LUNG

CANCER

GROUP 4
 ◦ C.P. is a 71-year-old married farmer, with a past medical
history of hernia surgery in 1986 and prostate surgery in
2005 for benign prostatic hyperplasia. C.P. does not drink,
but he has smoked for 40 years; the past 3 years he has
smoked two to three packs per day. Two weeks ago, C.P.
visited the local rural health clinic with complaints of a
progressive cough and chest congestion. Despite a week of
antibiotic therapy, C.P. continued to worsen; he
experienced progressive dyspnea and productive cough,

SCENARIO and he began to have night sweats. C.P. refused to be

admitted to the hospital because “there's no one to look
after the cows,” but he agreed to go for a chest x-ray
(CXR). The radiologist reads C.P.'s CXR as “left hilar lung
mass, probable lung cancer.” C.P. is scheduled for a
diagnostic fiberoptic bronchoscopy with endobronchial
lung biopsy as an outpatient this morning to confirm the
diagnosis.
1. What is fiberoptic bronchoscopy, and what information will fiberoptic
bronchoscopy with endobronchial lung biopsy provide?

A fiberoptic bronchoscopy is a procedure that allows your physician to examine

the breathing passages (airways) of the lungs. This procedure can either be for
diagnostic reasons, to find out more about a problem or for therapeutic reasons,
to treat an existing problem.

The instrument used to examine the airways is called a bronchoscope. A

bronchoscope is a small flexible lighted tube that has an eyepiece that allows
your doctor to look inside your lungs.

They will be able to visualize the tumor and possibly stage it. The biopsy is
needed to test the tissue to determine for sure if the tumor is cancerous.
 2.As the nurse who
works with the
pulmonologist, it is
your responsibility to
prepare C.P. for the ◦ The patient will need to be NPO at least 6-8
fiberoptic hours before the procedure. It should be an
bronchoscopy outpatient procedure if there are no
procedure. What will complications.
you include in your
teaching plan?
3.What is your
responsibility ◦ Monitor the patients' vital signs and make sure they
are stable. You will need to check their gag reflux
during and before you send them home in case, they have
immediately trouble swallowing after the procedure.

after the
bronchoscopy?
4.C.P. tolerates the procedure
well. He returns to the office ◦ To support the patient during this time of bad
in 4 days to learn the results
of his test. The pulmonologist news. They may be angry and confused. The
tells C.P. and his wife that he patient may have more questions so you can
has poorly differentiated oat provide them with resources for information or
cell lung cancer and explains
contact the doctor to ask questions. He may
that it is a very fast-growing
cancer with a poor prognosis. want to know about his treatment option. Since
This kind of lung cancer is this is a poor prognosis the patient may want to
directly related to C.P.'s consider palliative car
history of smoking. What is
your role at this time?
5.What does
poorly ◦ The tumor has grown so fast and is in the
tissue so deep that you can’t easily define the
differentiated borders of the tumor.

mean?
 CASE ◦ C.P. undergoes a metastatic workup and is found to have
STUDY disease in a number of lymph nodes. The physician tells
C.P. and his wife that surgery is not an option and
PROGRESS schedules C.P. to begin combination chemotherapy.
6.How would
you explain ◦ The chemo attacks the different cells in the
combination tumor at different times increasing the
effectiveness of the therapy. They could also
chemotherapy refer to this as using chemo or radiation to
and how it shrink the tumor small enough to remove it
during surgery
works to C.P.
and his wife?
 7.C.P. says he doesn't
know if he should take ◦ Receiving chemotherapy may reduce pain
chemotherapy if he “isn't and make patient more comfortable. This
going to live anyway.” also known as palliative care.
What are the goals of Chemotherapy treatment is being done to
administering control cancer cells from growing and
chemotherapy in patients dividing.
such as C.P.?
8. C.P.'s wife tells
you she's heard ◦ Chemo uses medication toxic to the cells to
that treat liquid and solid tumors. Because of this
the chemo not only kills the cancer cells it is
chemotherapy also toxic to the normal cells. This causes the
makes you really patient to feel very fatigued and sometimes
sick. How would have an upset stomach.
you explain
chemotherapy
side effects?
 9.C.P. agrees to • Nadir is the point in time between chemotherapy cycles in which you
chemotherapy and is experience low blood counts.

scheduled to receive
cisplatin (Platinol) 60 mg
in 100 ml normal saline
(NS) IV over 1 to 2 hours Cisplatin's nadir is 18-23 days, with recovery in 39 days

daily, and etoposide

(VePesid) 200 mg in 250
mL NS IV over 1 to 2
hours daily, both during Etoposide's nadir is 7 to 14 days, with recovery in 21 to 28 days. (the ability
to conceive a child may be affected by etoposide)
the first 3 days of each
month. What is the nadir
for each drug, and what C.P. is receiving a dose of each drug on the first 3 days of each month; his
implications does the blood counts will never return to optimal levels between doses. Etoposide
peaks in 1 to 2 weeks, and cisplatin peaks in 2 to 3 weeks. This means that
nadir have for C.P.? C.P. will be maximally immunosuppressed for 2 weeks out of every month.
He is likely to be most susceptible to infection and most fatigued during that
time.
 Administer Administer Anti-nausea mediation before chemo is started.

10.Based on your Increase Increase magnesium, calcium, and potassium in his diet.

knowledge of the most

common side effects of Brush Brush teeth with a soft bristle toothbrush.
cisplatin (Platinol) and
etoposide (VePesid), list
at least seven Serve Serve food room temperature because of a decreased appetite

interventions that
should be incorporated Make Make sure mouth gets cleaned frequently because he is at a high risk for mouth
sores
into C.P.'s care plan.
Maintain Maintain a good fluid intake to help avoid kidney damage

Avoid crowds or sick people because of an increased risk for infection, practice
Avoid good hygiene as well.
11.C.P. plans to continue to work the farm as long as possible and says his brother-in-law has promised to help
him. C.P. needs to have a working understanding of how to balance his treatment with his work. You sit down
with C.P. to plan a daily work, activity, rest schedule to accommodate his treatments and side effects. List at least
four concepts you would emphasize

Farming is not an easy work for people, it

needs too much effort and time to this
work that have injury or infection potential
Patient needs to have fluid to dehydration
for someone receiving chemotherapy. In Patient must do the following while
and may need to consider the ease of
doing this work patient C.P may need to working in the following:
accessing a bathroom.
allow for sufficient rest and safety
precaution is observed all the time to
achieve long term positive outcome.

Patient will not be able to maintain his

Patient must not do the driving or
farm by himself. C.P. may be able to have
operating machine, due to many antiemetic
local kids come help him work the farm
Patient should take frequent breaks or rest. and analgesic agents have sedative
for volunteer hours or he may need to
components which can cause dizziness or
consider hiring people to work for him if
headache.
he can afford it.
 CASE STUDY PROGRESS

A month later, when C.P. returns for his second round of chemotherapy, he complains of
shortness of breath, chest tightness, and palpitations. He looks exhausted. An ECG
reveals new onset atrial fibrillation, and a CXR suggests a large left lower lobe pleural
effusion. C.P. is admitted to the hospital for supportive care. The pulmonologist performs
a thoracentesis and drains 985 mL of fluid, immediately relieving some of C.P.'s dypsnea
and chest discomfort.
 Laboratory Test Values

WBC 2500 /mm3

RBC 4.9 millions/mm3

Hgb 12.7 g/dL

Chart View Hct 37.6%

Platelets 152,000 /mm3

Sodium 131 mmol/L

Potassium 4.2 mmol/L

Chloride 90 mmol/L
12. What do
these lab ◦ Due to patient C.P. had chemotherapy the patient is
immunocompromised or the immune system's defenses
values are low, affecting its ability to fight off infections and
diseases and he is also slightly anemic
indicate?
 a. has a small amount of serosanguineous drainage on the dressing.

13. You assess b. complains of occasional chest pain when taking deep breaths.

C.P. 2 hours after c. has a blood pressure of 90/50 mm Hg and some increase in dyspnea.

the thoracentesis. d. states that he has some burning and stinging at the thoracentesis site.

Which ANS: C
information is
important to You would need to monitor VS, lung sounds, and chest movements and
immediately report any hypotension, dyspnea, and asymmetrical chest
movements.
report to the Some bleeding at the site is normal, as are continued complaints of some
pleuritic pain.

physician? C.P.: Although burning and stinging typically are present during the procedure, C.P.
might have some residual discomfort.

You would need to continue to assess C.P. and monitor for the development of
any problems
 14.C.P. tells you he doesn't
want to live like this and that
he would like to stop ◦ You can offer him other resources for his care.
chemotherapy, but his He can see a palliative or hospice doctor. You
physician wants him to can’t tell the patient what to do but you can
continue with aggressive
give them resources to make their own
therapy. Discuss the pros and
cons of continuing therapy decision
and what role you can play in
helping him.
 CASE ◦ C.P. refuses the second round of
STUDY chemotherapy and is discharged to home.
He receives no further treatment and dies 3
OUTCOME weeks later with his wife at his side.
THANK YOU!