Lung Cancer
By Holly Winn and Cathy Mac Donald
Objectives
To
To
To
To
provide a general overview of lung physiology
explore the types and classifications of lung cancer
provide causes and risk factors of lung cancer
present the signs and symptoms of lung cancer in throughout
its progression
To explore assessment and diagnostic information of lung cancer
To introduce diagnostic staging specific to lung cancer
To discuss treatments and side effects of lung cancer
To present post-op complications for clients with lung cancer
To explore the nurses role and nursing interventions for a client
with lung cancer
To explain preventive health strategies regarding lung cancer
To present appropriate nursing diagnoses for clients living with
lung cancer
To provide and critically discuss a case study
General Overview of Lung
Physiology: Breathing
Healthy lung tissue
Diseased Lung Tissue
Types of Lung Cancer
Two main Types of Lung Cancer:
Small Cell Lung Cancer
(20-25% of all lung cancers)
Non Small Cell Lung Cancer (most common ~80%)
Small Cell Lung Cancer
Non-small cell lung cancer
• 1. Squamous cell carcinoma
• 2. Adenocarcinoma
• 3. Large cell carcinomas
Squamous cell carcinoma
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Moderate to poor differentiation
makes up 30-40% of all lung cancers
more common in males
most occur centrally in the large bronchi
Uncommon metastasis that is slow effects the liver,
adrenal glands and lymph nodes.
• Associated with smoking
• Not easily visualized on xray (may delay dx)
• Most likely presents as a Pancoasts tumor
Adenocacinoma
• Increasing in frequency. Most common type of Lung
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cancer (40-50% of all lung cancers).
Clearly defined peripheral lesions (RLL lesion)
Glandular appearance under a microscope
Easily seen on a CXR
Can occur in non-smokers
Highly metastatic in nature
– Pts present with or develop brain, liver,
adrenal or bone metastasis
Large cell carcinomas
• makes up 15-20% of all lung cancers
• Poorly differentiated cells
• Tends to occur in the outer part (periphery) of lung,
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invading sub-segmental bronchi or larger airways
Metastasis is slow BUT
Early metastasis occurs to the kidney, liver organs as
well as the adrenal glands
http://www.youtube.com/watch?v=3wzjqbh
besI.
Lung Cancer Re-cap
Small Cell Lung Cancer
Non-Small-Cell Lung Cancer
Squamous cell
Adenocarinoma
Causes and Risk factors of Lung
Cancer
Signs and Symptoms of Lung
Cancer
• Sometimes lung cancer does not cause any symptoms and is only
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found in a routine x-ray.
If a person with lung cancer does have symptoms, they will depend
on the location of the tumour in their lung.
It is also imperative to note that the same symptoms can be caused
by other conditions, so may not necessarily mean cancer.
Therefore it is important to consult a doctor when symptoms are
present.
Signs and symptoms also depend upon the location, size of the
tumor, degree of obstruction and existence of metastases
Signs and Symptoms of Lung
Cancer
There are two types of signs and
symptoms of lung cancer:
1) Localized – involving the lung.
2) Generalized – involves other areas
throughout the body if the cancer has
spread.
Localized Signs and Symptoms
Cough
Breathing Problems, SOB, stridor
Change in phlegm
Lung infection, hemoptysis
Hoarseness, Hiccups
Wt loss
Chest Pain and tightness
Pancoats Syndrome
Horner’s Syndrome
Pleural Effusion
Superior Vena Cava Syndrome
Fatigue
Generalized Signs and
Symptoms
• Bone pain
• Headaches, mental status changes or neurologic
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findings
Abdominal pain, elevated liver function tests,
enlarged liver, gastrointestinal disturbances
(anorexia, cachexia), jaundice, hepatomegaly r/t
liver involvement
Weight loss
Early/late Signs and Symptoms Of
Lung Cancer
Early Signs
Late signs
Cough/chronic cough
Bone pain, spinal cord
compression
Dyspnea
Chest pain/tightness
Hemoptysis
Dysphagia
Chest/shoulder pain
Head and neck edema
Recurring temperature
Blurred vision, headaches
Recurring respiratory
infections
Weakness, anorexia,
weight-loss, cachexia
Pleural effusion
Liver metastasis/regional
spread
Diagnostic Tests
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CXR
CT Scans
MRI
Sputum cytology
Fibreoptic bronchoscopy
Transthoracic fine needle aspiration
Laboratory Tests
 Blood Tests
*CBC-to check red/white blood cell & platelets
-to check bone marrow and organ function
*Blood Chemistry Test-to assess how organs
are functioning such as liver and kidney
 Biopsy-to determine if the tumor is cancer or not
-to determine the type of cancer
-to determine the grade of cancer (slow
or fast)
Biopsy
Endoscopy
• Bronchoscopy
• Mediastinoscopy
• VATS (video assisted thoracoscopic surgery)
Bronchoscopy
Mediastinoscopy
VATS (video assisted
thoracoscopic surgery)
Nursing Management for post
endoscopic procedures
Bronchoscopy
Mediastinoscopy
VATS
Monitor V/S; NPO status
maintained until return
of gag reflex.
Monitor VS; potential for
bleeding, infection and
dyspnea; NPO status
until return of gag reflex
Monitor V/S; potential
for bleeding, infection
and dyspnea; NPO status
until return of gag reflex
Fever up to 101F can be
expected afterwards
Post-op complications for those
with lung cancer
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Airway obstruction, dyspnea, hypoxemia, respiratory failure
Anesthesia side effects (N/V)
Bleeding (hypotension, cardiogenic shock)
Cardiac dysthymias, CHF, fluid overload
Fever, sepsis
Pneumonia
Pneumothorax
Pulmonary embolus
Wound dehiscence
Prolonged hospitalization
Death
Nursing pulmonary post-op
considerations/interventions
• Positioning in bed, Monitor V/S
• Prevention of respiratory complications
– Early ambulation, DB&C, incentive spirometer, managing
dyspnea
Prevention of deep vein thrombosis
– Early ambulation
• Pain management
• Infection control
Educating the patient
• Inform the patient what to expect, from administration of
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anesthesia to thoracotomy and the likely use of chest tubes and a
drainage system postoperatively.
Tell the patient about the administration of oxygen postoperatively
and the possible use of a ventilator.
Explain the importance of frequent turning to promote drainage of
lung secretions.
Instruct the proper use of an incentive spirometry and how to
perform diaphragmatic and pursed-lip breathing techniques.
Teach the patient to splint the incision site with hands, a pillow or a
folded towel to avoid discomfort
Cancer Staging
Clinical Staging
Pathological
• based on findings gathered by
the doctor
• used to plan the initial therapy
• may be modified by additional
information found during
pathological examination
• Based on the examination of the
tissue samples obtained from the
primary tumor, nodes or metastasis
• Helpful in planning additional
treatment and follow-up
Cancer Staging Systems
• The most common staging system for lung
cancer is the TNM System developed by the
International Union Against Cancer (UICC).
• Guides best course of treatment
• Estimates prognosis
• It is only useful in staging
NSCLC, when surgery is
considered.
TMN Staging system for Lung
Cancer
T= Tumors : tumor size,
(local invasion)
N= Node : node
involvement (size and
type)
M= Metastasis : general
involvement in organs and
tissues
Lung Cancer Staging Continued
• T: Tx, T0, Tis, T1-T4 (T3•
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tumors greater than 7cm,
T4 is a tumor of any size)
N: N0, N1, N2, N3
M: M0, M1a, M1b
Medical Management
The three main cancer treatments
are:
*surgery (lung resections)
*radiation therapy
*chemotherapy
Other types of treatment that are
used to treat certain cancers are
hormonal therapy, biological
therapy or stem cell transplant.
Side effects of treatments
Surgery
Radiation
Chemotherapy
Pain
fatigue
Anemia,
thrombocytopenia
Hemotomas
Decreased nutritional
intake
Fatigue
Hemmorhage
Radiodermatitis
Alopecia, SOB
Altered respiratory
function
Decreased hematopoietic Cold, pale
function
Risk for atelectasis,
pneumonia, hypoxia
Risk for Pneumonitis,
esophagitis, cough
Tingling
Risk for DVT
N/V
Irritable
Grief
Dizzy, weak
Lung resections
• Lobectomy: a single lobe of lung is removed
• Bilobectomy: 2 lobes of the lung are removed (only on R
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side)
Sleeve resection: cancerous lobe is removed and
segment of the main bronchus is resected
Pneumonectomy: removal of entire lung
Segmentectomy: a segment of the lung is removed
Wedge resection: removal of a small, pie-shaped area of
the segment
Chest wall resection with removal of cancerous lung
tissue: for cancers that have invaded the chest wall
Complimentary Therapies
• Includes acupuncture and massage and pharmacological approaches
such as vitamins and herbal medicine.
• One study showed that herbal medicine is used by approximately
48% of lung cancer patients in China.
• These herbal therapies combined with chemotherapy increases
survival in non-small-cell lung cancer by up to 42%, compared with
chemotherapy alone.
Complimentary Therapies cont’d
• Foods: Green tea, N-acetyl cysteine,
Curcumin, Garlic, Fish Oil, Lactobacillus,
ginseng root
Complimentary Therapies cont’d
• Mind-body: help to reduce anxiety, mood
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disturbance, or chronic pain in cancer patients
(audiotapes, videotapes, books, music,
relaxation, yoga, meditation).
Acupuncture
Hypnosis
Massage therapy
Prognostic Factors
 The best estimate on how a patient will do based on:
*type of cancer cells
*grade of the cancer
*size or location of the tumor
*stage of the cancer at the time of diagnosis
*age of the person
*gender
*results of blood or other tests
*a persons specific response to treatment
*overall health and physical condition
Prevention: Primary
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Avoid the use of tobacco smoke
Personal and family hx are important risk factors
Know environmental carcinogens that increase risk
Chemoprevention:
– Consuming carotenoids, Vit A, retinoids Vit E, selenium, Vit C, fat
Prevention: Secondary
• Aim is to early diagnose high risk
populations via screening
• CXR, MRI, CT scans, sputum cytology
Prevention: Tertiary
• Targeted at people who survived a cancer
disease
• Assists them to retain an optimal level of
functioning regardless of their potential
debilitating disease
Nurse’s Role with clients with lung
cancer
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Coping with diagnosis
Pre/post treatment education
Education on managing breathlessness
Referrals for ‘stop smoking advisor’
Referring to services such as hospice care, dietitian,
massage therapy, counselors
• Advocate for appointments, scans etc.
• Educate client and family about disease process,
treatment options and S/E
• Provide resources for support groups and where
information and be sought
Nursing Interventions
• Management of N/V, weakness, fatigue, wt loss, appetite loss,
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altered taste
Pain management, education to avoid concern about addiction,
pharmacological and non-pharmacological
Elevate HOB
Splinting to aid in coughing
Teach breathing exercises to ↑ diaphragmatic excursion and ↓ WOB
DB&C
Provide a vaporizer
Relaxation techniques to ↓ anxiety r/t SOB
Encourage energy conservation
Encourage small amts of high-calorie and Pn foods freq.
Nursing Diagnoses
• Ineffective breathing pattern r/t loss of adequate ventilation
• Impaired gas exchange r/t excessive or thick secretions 2 to
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smoking; r/t decreased passage of gases between alveoli of
lungs and vascular system
Chronic pain related to Stage IV NSCLC diagnosis as evidenced
by client reporting “pain in right chest and lower ribs”.
Risk of infection related to altered immune system secondary to
effects of cytotoxic drugs.
Risk for disturbed self concept related to changes in lifestyle.
Nausea related to effects of chemotherapy as evidenced by
client reporting feeling nauseated.
Risk for deficient fluid volume related to gastrointestinal fluid
loss secondary to vomiting.
Fatigue related to chemotherapy secondary to stage IV NSCLC
as evidenced by client reporting he “ no longer has the energy to
play with his grandchildren or visit his friends”.
Case Study & QUESTIONS
 John is a 44 year old man from NFLD. He worked in a machine shop
since he was 18. He was laid off for 6 months, has a new girlfriend
and custody of 3 kids from a previous marriage. They live in a low
SES neighborhood and is stressed about not having work to support
his family. He can’t afford to move out west and doesn’t want to
leave his children. Both of his parents have passed away. (Mum
from lung cancer and father from prostate cancer). Smoking helps
to manage his stress. He has smoked about a pack a day since he
was 16. Growing up, both of Johnathan’s parents smoked as well as
most of his aunts and uncles. His girlfriend is always complaining at
him because he is coughing and is sick all of the time. He says its
“just from the smokes”. Johnathan also noticed that he is becoming
short of breath and can’t play with his kids like he used too. The
past 4 months he has coughed up blood in the sink but attributes
that to getting older and coughing “too hard”.
References
• Carpenito-Moyet, L.J. (2009). Nursing Diagnosis; Application to clinical
practice (13th ed.). Philadelphia, P.A.: Lippincott Williams & Wilkins
• Cassileth, B., Deng, G., Gomez, J., Johnstone, P., Kumar, N., Vickers, A.
• Day, R.A., Paul, P., Williams, B. Smeltzer, S.C., Bare, B. (2010). Brunner &
Suddarth’s Textbook of Canadian Medical-Surgical Nursing (2nd ed.).
Philadelphia, P.A.: Lippincott Williams & Wilkins.
• Otto, S. (2001). Oncology Nursing (4th ed.). St. Louis, Missouri: Mosby Inc.
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http://nursingcrib.com/nursing-notes-reviewer/lung-cancer/
http://news.bbc.co.uk/2/hi/health/7130216.stm
http://news.bbc.co.uk/2/hi/health/7130216.stm
www.cancer.ca