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LUNG CANCER

 Also known as bronchogenic

carcinoma.  Development of neoplasm, usually within the wall or epithelium of bronchial tree
 For the 2008 Philippine population,

aggregated lung cancer incidence and mortality estimates were 10 871 cases and 9871 deaths.  it is estimated that 85% to 95% of lung cancer death rate is related to smoking

nickel. radioactive dust and uranium)  Genetic predisposition  underlying respiratory diseases (COPD & TB) . chromates.Risk Factors:  Tobacco/cigarette smoke  secondhand (passive)smoke  Exposure to carcinogenic and industrial air pollutants (asbestos. iron oxides. arsenic. coal dust.

adenocarcinoma (40%) .large cell carcinoma (15%) .bronchoalveolar carcinoma .Two major categories of lung cancer: • small cell lung cancer (20-25%) • non-small cell lung cancer (80%) .squamous cell carcinoma (20-30%) .

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cough .sputum production -dyspnea -Atelectasis -Wheezing -Hypercalcemia . skeleton and adrenal glands 2.Adenocarcinoma Moderate Early metastasis to CNS. -Pleural effusion Diagnostic tests Diagnostic test: -Fiberoptic bronchoscopy -Radiography -Electron microscopy -Sputum analysis -Biopsy -Immunohisto chemistry -Electron microscopy -Bronchoscopy 1.Squamous cell (epidermoid) Slow late metastasis to hilar lymph nodes. . chest wall and mediastinum Central lesion located in large bronchi.Common lung cancers: Type of cancer Rate of growth metastasis Presentation Signs and symptoms peripheral mass involving bronchi.

pneumonia – induced airway obstruction. cough.Type of cancer Rate of growth fast metastasis Presentation Signs and symptoms usually peripheral lesion that is larger than that associated with adenocarcinoma and tends to cavitate. -SIADH -Cushing’s syndrome .Sputum analysis . extensive metastasis 4. sputum production.Sputum analysis 3. chest wall pain. pleural effusion. hemoptysis. Small cell (oat cell) carcinoma Very Fast very early metastasis to mediastinum -Sputum analysis Immunohistoch emistry -Electron microscopy -Radiography -bronchoscopy . no cavitation.thrombophlebitis Diagnostic tests .early mediastinal involveme nt. Central lesion with hilar mass common. Large cell (anaplastic) early.Bronchoscopy .

Adenocarcinoma Squamous cell Small-cell Large –cell carcinoma .

Pathophysiology Inhalations of irritants or carcinogen Tissue trauma Epithelial cells continually replaces itself Cells develop chromosomal changes Cell becomes dysplastic Carcinogen binds to & damages the cell’s DNA Dysplastic cells turn into neoplastic carcinoma Start invading deeper tissues. .

neck. . Vena caval obstruction -edema of the face.Cancerous tissue cannot exchange O2 &carbon dioxide Impairs the functioning of the lung Tumor cells grow & invade surrounding lung tissue Eventually metastasize Bronchial obstruction -Hemoptysis. -atelectasis -pneumonitis -dyspnea Recurrent nerve invasion -hoarseness Chest wall invasion -piercing chest pain -increasing dyspnea -severe shoulder pain radiating down the arm. chest or back.

loss & fatigue Shoulder.Warning signals of lung cancer  Any changes in respiration  Persistent cough & sputum w/ blood     (hemoptysis) Wt. back or arm pain Recurring episodes of pleural effusion. pneumonia &bronchitis Unexplained dyspnea . chest.

(parietal pleura. spread to great vessels. invades visceral pleura.T4: any size. -T3: >7cm. mediastinum. local extension into adjacent structure. trachea. esophagus or malignant effusion (nonresectable) .T1: < or = 3cm -T2: 3-7cm. or has associated atelectasis or pneumonitis.Staging in NSCLC – TNM • Tumor size (T) . chest wall or within 2 cm of carina) .

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• Lymph node (N) -N 0: No involvement -N1 : hilar nodes -N2: mediastinal nodes -N3 : contralateral nodes or ipsilateral supraclavicular (nonresectable) .

• Metastasis (M) .M 0: no distant metastasis .M1: distant metastasis present .

Stage Stage IA Stage IB Stage IIA Stage IIB Stage IIIA Description T1 N0 MO T2 N0 MO (T > 3cm) T1 N1 M0 T2 N1 MO T3 N0 MO T3 N1 M0 T1-3 N2 M0 Any T N3 M0 T4 any N M0 any T any N M1 Treatment options Surgery Surgery Surgery Surgery Chemotherapy ff by radiation or surgery Combination of chemotherapy & radiation Chemotherapy only Sage IIIB Stage IV .

.  sputum cytology  microscopic examination of cells.Diagnostic tests:  chest x-ray  shows advanced lesions and can detect a lesion up to 2 yrs before signs and symptoms may appear  It may reveal tumor size and location. collected every morning. Obtained from a deep-cough sample of mucus in the lungs.

 Biopsy  The removal of a small sample of tissue for examination under a microscope by a pathologist.  can show whether a person has cancer. .  Fiberoptic Bronchoscopy  provides detailed study of the tracheobronchial tree and allows for washing and biopsies of suspicious areas.  cells or small samples of tissu can be taken through this tube.

 Thoracentesis  a procedure where a needle is used to take a sample of the fluid that surrounds the lungs to check for cancer cells.Fine-Needle aspiration Involves inserting a needle through the chest into the tumor to remove a sample of tissue. .

 CT scan  MRI  Bone scan  positron emission tomography (PET) scan .  to obtain biopsy specimen. Thoracotomy PET scan  a major operation where chest is opened.

 Radiation therapy  Chemotherapy  Palliative therapy .Management Medical management:  Early identification of lung cancer.

Early detection  Early detection is the key to improve survival rate for clients with lung cancer.  Early detection should be done when pre malignant changes occur. lesions are curable.  A tumor must be at least 1 cm in diameter & its detectable on a chest radiogarphy.  At this stage. .

Any cancer cells that may remain in the area after surgery. Symptoms – to reduce tumor size and dercrease symptoms.  Before surgery – To decrease the size of a tumor and make surgery more effective.  Both small-cell and non-small cell lung cancers are treated with radiotherapy. which is often combined with chemotherapy.  to tx.Radiation therapy  The delivery of high energy radiation to kill cancer cells and shrink tumor. When to used:  After surgery – To tx. surgery or both. .

Types of radiation therapy a. w/c delivers high-dose radiation. . External beam radiation therapy  Used most commonly and involves the use of an external machine.

To remove all metal objects (pins.  Explain that the areas to be treated will be mark w/ indelible ink & he must not scrub these areas bcoz it’s important to radiate the same areas each time. Is painless.  tell the pt. buttons. jewelry).  Reassure that the tx. . where radiation therapy takes place & introduce him to the radiation therapist.Nursing considerations on external radiation therapy:  Show the pt.

.  The radiation source is a solid in the form of seeds & capsules. Internal radiation therapy (brachytherapy)  A source of radiation is put inside the body.b. w/c are placed in body in or near the cancer cells.

 Use of drugs to kill bacteria. viruses.chemotherapy  Refer to cancer-killing drugs. fungi & cancer cells. .

Cisplatin.& vincristine.  Etoposide. doxorubicin. doxorubicin.Drugs combinations used in chemotherapy  Cyclophosphamide.  Cyclophosphamide. .  Become tired more easily  Bleed too much. even during everyday activities  Feel pain from damage to the nerves  Poor appetite and loose wt. & doxorubicin Side effects of chemotherapy  Are more likely to have infections. Cyclophosphamide.& vincristine & etoposide.

.  Pain management.  Evaluation & referral for hospice care are important in planning for comfortable and dignified end-oflife care for the patient & family. Compose of:  radiation therapy to shrink the tumor to provide pain relief.  Bronchoscopic interventions to open a narrowed bronchus or airway.Palliative therapy  Provide comfort.

Types of lung resection: .Surgical management:  Surgical resection.

. o Chest wall resection w/ removal of cancerous lung tissue: for cancers that have invaded the chest wall.Other Types of lung resection o Sleeve resectioncancerous lobe(s) is removed and a segment of the main bronchus is resected.

Nursing Diagnosis:     Ineffective breathing pattern.  Anxiety  Risk for infection . Acute and/or chronic pain Activity intolerance Imbalanced nutrition less than body requirements .

. to turn. cough & deepbreathing exercises for lung expansion & relaxation.  Assist & teach pt.NURSINGINTERVENTION: Improving breathing patterns:  Elevate head of bed to reduce pressure on the diaphragm & promote gravity drainage.

.  Administer oxygen as prescribed. Provide chest physiotherapy with percussion & postural drainage as needed or ordered to maintain airway patency & remove excess secretions.  Give prescribed tx. Such as bronchodilators to promote bronchial dilation.

Activity tolerance  Plan rest periods between activities and procedures bet. Activities & procedures to reduce oxygen demands and fatigue.  Assist postoperative client to increase activities gradually to improve exercise tolerance. . This helps conserve energy.  Keep frequently used objects within easy reach.

frequent meals (high calorie & high protein foods). eggs. . to eat small.  Ensure adequate protein intake: milk. fish.  Administer or encourage prescribed vitamin supplement.Improving nutritional status  Encourage pt. chicken. cheese.

such as massage .  Provide analgesics as needed to maintain comfort. positioning. These techniques promote relaxation and enhance pain relief. . best evaluated by the client. distraction and relaxation techniques.Controlling pain:  Assess & document pain using a standardized pain scale & objective data. Pain is a subjective experience.  Provide or assist with comfort measure.

encourage the patient to express fears and concerns. . Honestly reinforces reality and provides a sense of control over decisions to be made.Minimizing anxiety:  Provide emotional support.  Answer questions honestly: do not deny the probable outcome of the disease.

. such as insertion of an indwelling catheter. dressing changes & I.Nursing considerations Provide appropriate perioperative care  Explain expected postoperative procedures. deep breathing exercises and range of motion exercises .V therapy. use of an endotracheal tube or chest tube.  Teach pt how to perform coughing.

 Sputum will be thick & dark w/ blood.Provide appropriate care after thoracic surgery  Maintain a patent airway and monitor chest tubes to reestablish normal intrathoracic pressure and prevent postoperative and pulmonary complications  Monitor vital signs and report abnormal respiration and other changes  Suction patient often and encourage coughing and deep breathing. but w/in a day it should become thinner & grayish yellow. .

 position the patient on surgical side to promote drainage and lung reexpansion  Monitor intake and output  Maintain adequate hydration . Monitor closed chest drainage. keep chest tube patent and draining effectively.

and pulmonary embolus . atelectasis. shock. Apply antiembolism stocking and encourage ROM exercises to prevent pulmonary embolus  Watch for and treat infection.hemorrhage. dyspnea.

Which of the following statements regarding the epidemiology of lung cancer is correct? (A) Chronic obstructive pulmonary disease (COPD) is not associated with an increased risk of lung cancer (B) Cigar smoking is associated with an equal risk of lung cancer as compared with cigarette smoking (C) Occupational exposure to radon is associated with an increased risk of lung cancer (D)The risk of developing lung cancer for cigarette smokers exposed to asbestos is equal to that of those not exposed to asbestos .1.

Review Questions: .

 1. The appropriate nursing assessment of the client’s pain would include which of the following? a. The nurse’s impression of the client’s pain d. Nonverbal cues from the client c. Pain relief after appropriate nursing intervention . The client’s pain rating b. The home health care nurse is caring for a male client with cancer and the client is complaining of acute pain.

1. . but this option is not related to the subject of the question. Assessing pain relief is an important measure. The client’s self-report is a critical component of pain assessment. Nonverbal cues from the client are important but are not the most appropriate pain assessment measure. Answer A. The nurse should ask the client about the description of the pain and listen carefully to the client’s words used to describe the pain. The nurse’s impression of the client’s pain is not appropriate in determining the client’s level of pain.

When caring for the client. 2. Limit the time with the client to 1 hour per shift b. Individuals younger than 16 years old may be allowed to go in the room as long as they are 6 feet away from the client . the nurse should observe which of the following principles? a. Remove the dosimeter badge when entering the client’s room d. Do not allow pregnant women into the client’s room c. Nurse Joy is caring for a client with an internal radiation implant.

Answer B. . The time that the nurse spends in a room of a client with an internal radiation implant is 30 minutes per 8-hour shift.2. Children younger than 16 years of age and pregnant women are not allowed in the client’s room. The dosimeter badge must be worn when in the client’s room.

3. The nurse on the oncology unit enters the room of the client with lung cancer. Which action is most appropriate for the nurse to do first?
a) check the client's IV infusion pump and IV fluid rate b) take the client's blood pressure and pulse c) assess the client's mental status d) elevate the client's head of the bed

3. D

the client with lung cancer experiences difficulty of breathing. Therefore, the first action by the nurse is to facilitate the client's breathing by elevating the head of the bed.

4. A nurse is admitting a 63-year old male reporting hemoptysis and weight loss. The nurse identifies that the highest priority risk factor for lung cancer for this client is:
a) family history of lung cancer b) the client works in a chemical factory c) the client lives in a coal mining area d) the client uses chewing tobacco

4. . B the client who is exposed to chemicals for a long period of time is at highest risk to develop lung cancer.

The nurse would consider implementing neutropenic precautions if the client's white blood cell count was which of the following? a) 2.800 cells/mm3 c) 8.000 cells/mm3 b) 5.400 cells/mm3 d) 11.5.500 cells/mm3 . The nurse is caring for a client with a diagnosis of cancer who is immunosuppressed.

C.000/mm3. and D are normal values. The client who is immunosuppressed has a decrease in the number of circulating white blood cells.500 to 11. A the normal white blood cell count ranges from 4. . Options B. The nurse implements neutropenic precautions when the client's values fall sufficiency below the normal level. The specific value for implementing neutropenic precautionsusually is determined by agency policy.5.

Which of the following actions should the nurse take? a) Restrict visiting hours and ask the family to limit visitors to two at a time. c) If possible. keep the other bed in the room unassigned to provide privacy and comfort to the family. 6. A nurse is caring for an elderly Vietnamese patient in the terminal stages of lung cancer. d) Contact the physician to report the unusual rituals and activitie . Many family members are in the room around the clock performing unusual rituals and bringing ethnic foods. b) Notify visitors with a sign on the door that the patient is limited to clear fluids only with no solid food allowed.

it is important that the dying be surrounded by loved ones and not left alone. Traditional rituals and foods are thought to ease the transition to the next life. Answers A. it is most helpful for nursing staff to provide a culturally sensitive environment to the degree possible within the hospital routine. Answer: C When a family member is dying. When possible.6. In the Vietnamese culture. allowing the family privacy for this traditional behavior is best for them and the patient. and D are incorrect because they create unnecessary conflict with the patient and family . B.

7. the nurse discovers wheezing. and a respiratory rate of 10 breaths/minute. Hypoxia b. a home health nurse is visiting a home care client with advanced lung cancer. These signs are associated with which condition? a. bradycardia. Gina. Upon assessing the client. Hyperventilation d. Delirium c. Semiconsciousness .

producing wheezing. Hyperventilation (respiratory rate greater than that metabolically necessary for gas exchange) is marked by an increased respiratory rate or tidal volume. bradycardia. and a decreased respiratory rate. Delirium is a state of mental confusion characterized by disorientation to time and place. Semiconsciousness is a state of impaired consciousness characterized by limited motor and verbal responses and decreased orientation . hypoxia occurs. Answer A. or both.7. As the respiratory center in the brain becomes depressed.

localized area near the surface of the lung d. A segment of the lung. A client has been diagnosed with lung cancer & requires a wedge resection. One entire lung b. A lobe of the lung c. including a bronchiole & its alveoli . How much of the lung is removed? a. A small.8.

8. Answer C .

 9. The physician tells your assigned client that their chest X-ray shows they have lung cancer. which of the following reactions would you most expect from this client during the next day or two? a) b) c) d) Acceptance anger depression denial . Based on your understanding of the work of Kubler-Ross.

9. Answer D .

d.10. b. what should the nurse plan to do? a. Secure the chest tube with tape. c. Apply an occlusive dressing and notify the physician. Place the end of the chest tube in a container of sterile saline. . If the chest drainage system is accidentally disconnected. The nurse is caring for a male client with a chest tube. Clamp the chest tube immediately.

rather than taping it after it has been disconnected. The nurse shouldn’t clamp the chest tube because clamping increases the risk of tension pneumothorax. the nurse may place the end of the chest tube in a container of sterile saline or water to prevent air from entering the chest tube. thereby preventing negative respiratory pressure. Answer A If a chest drainage system is disconnected. The nurse should tape the chest tube securely to prevent it from being disconnected. The nurse should apply an occlusive dressing if the chest tube is pulled out — not if the system is disconnected.10. .