Sie sind auf Seite 1von 35

By Marian Jeffries, APRN,BC, FNP,C, MSN; Rachel Townsend, RN, AND; and Emily Horrigan, RN,C, BSN

Nursing2007, December

Earn 2.0 ANCC/AACN contact hours Online:

2007 Lippincott Williams & Wilkins


Identify the two major types of lung cancer. Identify the presenting signs and symptoms of lung cancer. Indicate postoperative nursing measures for a person with lung cancer.



Most common malignancy in the world Affects over 3 million people Causes more deaths in the United States than breast, prostate, and colon cancers combined Only about 16% are found in early stages 49% survival when detected at localized stage
The American Cancer Society estimates that 213,380 new cases of cancer of the lung and bronchus will be diagnosed in the United States and that 160,390 people will die of the disease in 2007.

Current or previous tobacco smoking Preexisting lung disease Genetic predisposition Environmental exposure

Air pollution Secondhand smoke Toxic chemicals or fumes Radon gas Asbestos fibers The combination of smoking and asbestos exposure greatly Talc dust increases the risk of lung cancer. Radiation

Chest x-ray can detect lesions 1 cm Sputum cytology can detect malignant cells Spiral low-dose computed tomography (LDCT) has successfully detected early lung cancers in smokers and former smokers, but also detects other lesions that are later determined nonmalignant
The American College of Chest Physicians recommends against screening for lung cancer with LDCT, chest X-ray, or sputum cytology, except in the context of a well-designed clinical trial.

Small cell lung cancer (SCLC)

Small cell carcinoma (oat cell carcinoma) Mixed small cell/large cell carcinoma Combined small cell carcinoma

Non-small cell lung cancer (NSCLC)

Squamous cell carcinoma Adenocarcinoma Large cell carcinoma

Accounts for 15% of all lung cancers Strongly linked to cigarette smoking Spreads quickly Patients commonly have signs and symptoms of metastasis before cancer is detected Poor prognosis Treated with chemotherapy and radiation Surgery not an option

Accounts for 25% to 30% of all lung cancers in the United States. Linked to smoking history Arises from the epithelium covering and lining organ surfaces Commonly found centrally, near a bronchus Tends to grow and metastasize slowly

Responsible for about 40% of lung cancers in the United States Commonly affects nonsmokers and women Bronchioloalveolar carcinoma, a subtype, forms deep in the lungs air sacs


Accounts for 10% to 15% of all lung cancers in the United States. Most often affects smaller bronchioles near the surface of outer edges of the lungs Grows and metastasizes quickly


Difficult or labored breathing Shortness of breath Hoarseness Stridor Chronic fatigue Loss of appetite Bone pain, aching joints Unexplained weight loss

Cough > 2 weeks Persistent chest, shoulder, or back pain aggravated by deep breathing or coughing Change in sputum color or volume Blood in sputum Wheezing Recurrent pneumonia or bronchitis


Chest X-ray
Pinpoints consolidation, obstructive pneumonitis, or pneumothorax

Spiral computed tomography (CT)

Shows tumor mass and enlarged lymph nodes Lymph nodes >1 cm are suspicious; nodes <1 cm have 7% chance of malignancy

Fluorine-18-deoxyglucose positron emission tomography (FDG-PET)

Highlights areas of greater glucose metabolism, indicating malignancy False-positives possible

Integrated PET/CT
Potentially a more sensitive and accurate test for early stage

Endobronchial ultrasound
Assesses the depth of tumor invasion, especially with tumors close to the trachea, carina, and main bronchus

Magnetic resonance imaging (MRI)

Rarely used for diagnosis Helps detect vascular and chest wall invasion Helps detect metastases to the brain or spinal cord

Sputum cytology

To identify cancer cells in mucous coughed up from the lungs

Mediastinoscopy Needle biopsy

To visualize a tumor or obstruction Can biopsy specimen or tissue washings for pathology To visualize areas between the lungs, examine the lymph nodes, and get biopsy specimens
To collect fluid or tissue

Positive tissue biopsy from primary tumor confirms diagnosis Microscopic examination differentiates the cell type Staging is based on
Cell type Primary tumor size and location Lymph node involvement Presence of distant metastases



Staged as limited or extensive Limited stage typically means that cancer is present in one lung and possibly the lymph nodes on the same side Staged using the TNM system:
Extent of the primary Tumor Involvement of regional lymph Nodes Presence of Metastases



Surgery Radiation therapy Chemotherapy Adjuvant therapy Palliative care

The patient may undergo more than one type of therapy at the same time or consecutively.


Complete removal of tumors offers the best chance of survival for patients with NSCLC. Approach depends on
Type of lesion Location Patients age and overall health Surgeons preference


Video-assisted thorascopic surgery


Two to five small incisions Can be used to remove smaller lesions or one or more lung lobes


Incision through the chest wall Posterior approach for pneumonectomy Anterior or unilateral approach for any procedure requiring increased visualization clamshell incision a bilateral anterior approach for bilateral excisions of multiple nodules or segments
Incision through the sternum Access to bilateral pulmonary lesions, the heart, major blood vessels, and lymph nodes



Bronchoscopic coring or debulking

Collar incision To visually assess the mediastinum and the anterior surface of the lungs To biopsy the paratracheal lymph nodes Improves ventilation when tumor is blocking the airway Palliative technique Bolsters the tracheal or bronchial airway with a silicone stent to improve ventilation

Bronchial stent placement


Shrinks tumors by damaging DNA in the cancer cells to kill them Can be administered before or after surgery, as a single modality, or with chemotherapy Shrinking a tumor before surgery can improve resectability, but changes in local tissue can complicate postoperative healing


External beam radiation

Divided doses given once or twice a day over a period of weeks

Intensity modulated radiation therapy

Computer-programmed dosing delivered in three dimensions Causes less damage to surrounding tissues

Proton beam therapy

Targets very small tumors with very high radiation doses to minimize damage to healthy tissue Commonly used to destroy metastatic lesions in the brain, head, and neck and to treat children


Delivers radiation internally via an implant Spares noncancerous tissues Occasionally reduces the need for surgery Can help relieve symptoms but isnt a cure


Can help slow tumor growth Most common treatment for SCLC Also used to manage advanced stages of NSCLC Can be used in conjunction with radiation for a greater effect
Work by overwhelming the cancer cells capacity to repair DNA damage, resulting in cell death Attempt to localize damage to cells and tissues associated with the cancer, but noncancerous stem cells in the bone marrow are generally affected also


Drug selection varies with tumor type and stage Randomized trials show better survival rates for patients who receive combined regimens given simultaneously or sequentially Platinum-based combination preferred because of efficacy and toxicity profiles


Drugs to treat SCLC

cisplatin etoposide topotecan

Drugs to treat NSCLC

cisplatin or carboplatin combined with paclitaxel, docetaxel, gemcitabine, vinorelbine, irinotecan, etoposide, vinblastine, or bevacizumab


Interfere with specific molecules needed for carcinogenesis and tumor growth Target the epidermal growth factor receptor (EGFR) thats evident in many cases of NSCLC Examples:
gefitinib (Iressa) erlotinib (Tarceva) 2nd-line agent for advanced cases


Monitor level of consciousness and vital signs every 2-4 hours or more often Evaluate pulmonary status
Color Breath sounds Respiratory rate, depth, and pattern Arterial blood gases

Perform continuous cardiac monitoring (at risk for dysrhythmias, especially atrial fibrillation) Reposition the patient to optimize gas exchange

Elevate head of bed 30 to 45 Get patient out of bed Ambulate patient Turn patient from side to side while in bed if he had pneumonectomy, keep his operative side down


Administer supplemental oxygen via a face mask with humidification Help patient mobilize secretions
Provide pain management Coughing and deep breathing (every 1-2 hours for first 24 hours) Incentive spirometry Examine system Assess amount and characteristics of drainage Notify the surgeon if >150 mL/hr of drainage Reinforce dressing as needed

Care for chest tubes


Assess pain every 2 hours and administer analgesics as ordered

Continuous epidural infusion of an opioid is preferred PCA is also an option Most switch to nonopioid 48-72 hours postop Graduated compression stockings or intermittent pneumatic compression Anticoagulants

Help prevent venous thromboembolism

Clean and protect incision site and monitor drainage

Observe for signs of nonhealing, dehiscence, or infections If no drainage after 24 hours, surgeon may remove the dressing and leave the wound open to air


Help patient sit, stand, and ambulate within first 24 hours Monitor intake and output
Obtain and monitor daily serum electrolytes Advance diet based on tolerance, aspiration risk, bowel sounds, and special requirements Follow prescribed bowel regimen Remove indwelling catheter as soon as possible
Urine output should be at least 0.5 mL/kg/hour Administer fluids and diuretics as ordered


Activity, pain management, and incision care

If he smokes, urge him to quit and tell him to limit exposure to secondhand smoke Pain should gradually diminish over 3 to 6 weeks Follow-up with surgeon, typically in 3 weeks

Call surgeon if redness, swelling, or drainage of incision increases or if he develops fever, increased pain, or shortness of breath No lifting anything heavier than a half gallon of milk for 6 weeks


Chemotherapy, radiation, and surgery can be used to relieve signs and symptoms Radiofrequency ablation
Delivers current that heats and destroys tumor cells Minimally invasive Commonly done as an outpatient

Photodynamic therapy

For an obstructing endobronchial tumor thats untreatable by surgery or radiation Photosensitizing drug injected which binds to lipoproteins in his blood for transport to lipoprotein-hungry cancer cells 40-50 hours after injection, laser light is applied via bronchoscopy which activates the drug and disrupts cancer cells Can be performed as an outpatient and may be repeated Patient must avoid sunlight and bright indoor light for 6 weeks because of extreme photosensitivity


Differentiate from anxiety Treatment measures
Nebulizer treatments Secretion-clearance techniques Positioning Decreasing oxygen requirements by limiting physical activity Morphine via nebulization Low-dose opioids with positioning and muscle relaxation techniques Noninvasive positive-pressure ventilation



Address needs as his comfort level changes Usual plan is to gradually reduce opioids over 3 weeks and supplement them with NSAIDs or acetaminophen Complementary and alternative therapies
Acupuncture Massage therapy Relaxation techniques Support groups Reiki therapy Vitamin and dietary supplements Herbal products