Lung Cancer

1. Lung Cancer By Holly Winn and Cathy Mac Donald

2. Objectives To provide a general overview of lung physiology To explore the types and classifications of lung cancer To provide causes and risk factors of lung cancer To 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

3. General Overview of Lung Physiology: Breathing

4. Healthy lung tissue

5. Diseased Lung Tissue

6. 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%)

7. Small Cell Lung Cancer

8. Non-small cell lung cancer • 1. Squamous cell carcinoma • 2. Adenocarcinoma • 3. Large cell carcinomas

9. Squamous cell carcinoma • 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

10. Adenocacinoma • Increasing in frequency. Most common type of Lung 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

11. Large cell carcinomas • makes up 15-20% of all lung cancers • Poorly differentiated cells • Tends to occur in the outer part (periphery) of lung, 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=3wzjqbhbesI.

12. Lung Cancer Re-cap Non-Small-Cell Lung Cancer Small Cell Lung Cancer Squamous cell Adenocarinoma

13. Causes and Risk factors of Lung Cancer

14. Signs and Symptoms of Lung Cancer • Sometimes lung cancer does not cause any symptoms and is only 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

15. 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.

16. 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

17. Generalized Signs and Symptoms • Bone pain • Headaches, mental status changes or neurologic findings • Abdominal pain, elevated liver function tests, enlarged liver, gastrointestinal disturbances (anorexia, cachexia), jaundice, hepatomegaly r/t liver involvement • Weight loss

18. Early/late Signs and Symptoms Of Lung Cancer

19. Diagnostic Tests • CXR • CT Scans • MRI • Sputum cytology • Fibreoptic bronchoscopy • Transthoracic fine needle aspiration

20. 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)

21. Biopsy

22. Endoscopy • Bronchoscopy • Mediastinoscopy • VATS (video assisted thoracoscopic surgery)

23. Bronchoscopy

24. Mediastinoscopy

25. VATS (video assisted thoracoscopic surgery)

26. Nursing Management for post endoscopic procedures

27. Post-op complications for those with lung cancer • 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

28. 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

29. Educating the patient • Inform the patient what to expect, from administration of 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

30. Cancer Staging

31. 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.

32. 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

33. Lung Cancer Staging Continued • T: Tx, T0, Tis, T1-T4 (T3-tumors greater than 7cm, T4 is a tumor of any size) • N: N0, N1, N2, N3 • M: M0, M1a, M1b

34. 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.

35. Side effects of treatments

36. Lung resections • Lobectomy: a single lobe of lung is removed • Bilobectomy: 2 lobes of the lung are removed (only on R 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

37. 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.

38. Complimentary Therapies cont’d • Foods: Green tea, N-acetyl cysteine, Curcumin, Garlic, Fish Oil, Lactobacillus, ginseng root

39. Complimentary Therapies cont’d • Mind-body: help to reduce anxiety, mood disturbance, or chronic pain in cancer patients (audiotapes, videotapes, books, music, relaxation, yoga, meditation). • Acupuncture • Hypnosis • Massage therapy

40. 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

41. Prevention: Primary • 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

42. Prevention: Secondary • Aim is to early diagnose high risk populations via screening • CXR, MRI, CT scans, sputum cytology

43. 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

44. Nurse’s Role with clients with lung cancer • 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

45. Nursing Interventions • Management of N/V, weakness, fatigue, wt loss, appetite loss, 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.

46. Nursing Diagnoses • Ineffective breathing pattern r/t loss of adequate ventilation • Impaired gas exchange r/t excessive or thick secretions 2 to 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”.

47. 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”.

48. 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’sTextbook 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. • 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