Lung cancer picture
Lung cancers can arise in any part of the lung, but 90%-95% of cancers of the lung are thought to arise from the epithelial cells, the cells lining the larger and smaller airways (bronchi and bronchioles); for this reason, lung cancers are sometimes called bronchogenic cancers or bronchogenic carcinomas. (Carcinoma is another term for cancer.) Cancers also can arise from the pleura (called
mesotheliomas) or rarely from supporting tissues within the lungs, for example, the blood vessels.
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LUNG CANCER: POSTOPERATIVE CARE
I. Pathophysiology
a. Usually develops within the wall or epithelium of the bronchial tree
b. Prolonged exposure to cancer-promoting agents causes damage to ciliated cells and mucus-producing cells, leading
to genetic mutations and development of dysplastic cells.
II. Classification (Memorial Sloan-Kettering Cancer Center, 2008; National Cancer Institute, 2008)
a. Small cell lung cancers (SCLCs), or oat cell lung cancer
i. Represent about 15% to 25% of lung cancer cases (Elias & Baldini, 2008)
ii. Occur almost exclusively in smokers
iii. Aggressive and fast growing with surgery seldom a treatment option
b. Non–small cell lung cancers (NSCLCs)
i. Most common type of lung cancer (75% to 85%, Elias & Baldini, 2008)
ii. Include adenocarcinoma, squamous cell, and large cell carcinomas
iii. Frequently associated with metastases, but are generally slow growing
III. Staging (National Cancer Institute, 2008)
a. Stage 0—cancer cells only found in the innermost lining of the lung
b. Stage IA—tumor has grown through the innermost lining of the lung into deeper lung tissue, but does not invade the
bronchus; no cancer cells found in nearby lymph nodes
c. Stage IB—tumor is larger, may be more than 3 cm across; may have grown into the main bronchus; may have grown
into the pleura, but no cancer cells found in nearby lymph nodes
d. Stage IIB—tumor has invaded the chest wall, diaphragm, pleura, main bronchus, or tissue that surrounds the heart;
cancer cells found in nearby lymph nodes
e. Stage IIIA—tumor may be any size; cancer cells found in the lymph nodes near the lungs and bronchi and between
the lungs on the same side of the chest as the tumor
f. Stage IIIB—tumor may be any size; cancer cells found on the opposite side of the chest from the tumor, with possible
invasion into nearby organs
g. Stage IV—malignant growths may be found in more than one lobe or may have metastasized to other organs
IV. Etiology (American Cancer Society, 2008)
a. Risk factors include cigarette smoking or being exposed to secondhand smoke; radon, asbestos, other occupational
exposures, including radioactive ores such as uranium, inhaled chemicals or minerals, such as nickel compounds, silica, coal dust, and cromates, or diesel exhaust; high levels of arsenic in drinking water; and family history of lung cancer.
b. Chronic obstructive pulmonary disease (COPD) and pulmonary fibrosis may increase susceptibility.
V. Statistics
a. Morbidity: Second most commonly diagnosed cancer accounting for 13% of all cases (American Association
for Cancer Research, 2005) with new cases of lung and bronchus cancer estimated at 172,570 for 2005 (Jemal et al, 2005).
b. Mortality: Number one cause of death in cancer patients; in 2004, death rates for men and women were 89,575 and 68,431, respectively; results in more deaths than breast cancer, prostate cancer, and colon cancer combined (U.S. Cancer Statistics Worling Group, 2007).
c. Cost: $9.6 billion was spent for treatment in 2004.
VI. Treatment Options
a. Depends upon staging—generally the lower the stage, the more favorable the prognosis
i. Surgery is primary treatment for NSCLC stage I and stage II tumors.
ii. Selected stage III carcinomas may be operable if the tumor is resectable.
b. Surgical procedures for operable tumors of the lung include:
i. Pneumonectomy—performed for lesions originating in the main stem bronchus or lobar bronchus
ii. Lobectomy—preferred for peripheral carcinoma localized in a lobe
iii.Wedge or segmental resection—performed for lesions that are small and well contained within one segment
iv. Endoscopic laser resection—may be done on peripheral tumors to reduce the necessity of cutting through ribs
v. Photodynamic therapy—reduces symptoms such as bleeding or may be used to treat very small tumors
Care Setting
Client is treated in inpatient surgical and possibly subacute units.
Nursing Priorities
1. Maintain or improve respiratory function.
2. Control or alleviate pain.
3. Support efforts to cope with diagnosis and situation.
4. Provide information about disease process, prognosis, and therapeutic regimen.
Discharge Goals
1. Oxygenation and ventilation adequate to meet individual activity needs.
2. Pain controlled.
3. Anxiety and fear decreased to manageable level.
4. Free of preventable complications.
5. Disease process, prognosis, and planned therapies understood.
6. Plan in place to meet needs after discharge.
NURSING DIAGNOSIS: impaired Gas Exchange
May be related to
Removal of lung tissue
Altered oxygen supply—hypoventilation
Decreased oxygen-carrying capacity of blood—blood loss
Possibly evidenced by
Dyspnea
Restlessness
Changes in mentation
Hypoxemia and hypercapnia
Cyanosis
Desired Outcomes/Evaluation Criteria—Client Will
Respiratory Status: Gas Exchange
Demonstrate improved ventilation and adequate oxygenation of tissues by arterial blood gases (ABGs) within client’s normal range.
Be free of symptoms of respiratory distress.
ACTIONS/INTERVENTIONS
Respiratory Management
Independent
Note respiratory rate, depth, and ease of respirations. Observe for use of accessory muscles, pursed-lip breathing, or changes in skin or mucous membrane color, such as pallor and cyanosis.
Auscultate lungs for air movement and abnormal breath sounds.
Investigate restlessness and changes in mentation and level of consciousness.
Assess client response to activity. Encourage rest periods, limiting activities to client tolerance.
Note development of fever.
Airway Management
Maintain patent airway by positioning, suctioning, and use of airway adjuncts.
Reposition frequently, placing client in sitting and supine to side positions.
Avoid positioning client with a pneumonectomy on the operative side; instead, favor the “good lung down” position.
Encourage and assist with deep-breathing exercises and pursed-lip breathing, as appropriate.
Tube Care: Chest
Maintain patency of chest drainage system following lobectomy and segmental wedge resection procedures.
Note changes in amount or type of chest tube drainage.
Observe for presence of bubbling in water-seal chamber.
Airway Management
Collaborative
Administer supplemental oxygen via nasal cannula, partial rebreathing mask, or high-humidity face mask, as indicated.
Assist with and encourage use of incentive spirometer.
Monitor and graph ABGs and pulse oximetry readings. Note hemoglobin (Hgb) levels.
RATIONALE
Respirations may be increased as a result of pain or as an initial compensatory mechanism to accommodate for loss of lung tissue. However, increased work of breathing and cyanosis may indicate increasing oxygen consumption and energy expenditures or reduced respiratory reserve, for example, in an elderly client or extensive COPD.
Consolidation and lack of air movement on operative side are normal in the client who has had a pneumonectomy; however, a client who has had a lobectomy should demonstrate normal airflow in remaining lobes.
May indicate increased hypoxia or complications such as mediastinal shift in a client who has had a pneumonectomy when accompanied by tachypnea, tachycardia, and tracheal deviation.
Increased oxygen consumption and demand and stress of surgery may result in increased dyspnea and changes in vital signs with activity; however, early mobilization is desired to help prevent pulmonary complications and to obtain and maintain respiratory and circulatory efficiency.
Adequate rest balanced with activity can prevent respiratory compromise.
Fever within the first 24 hours after surgery is frequently due to atelectasis. Temperature elevation within postoperative day 5 to 10 usually indicates an infection, such as wound or systemic.
Airway obstruction impedes ventilation, impairing gas exchange. (Refer to ND: ineffective Airway Clearance.)
Maximizes lung expansion and drainage of secretions.
Research shows that positioning clients following lung surgery with their “good lung down” maximizes oxygenation by using gravity to enhance blood flow to the healthy lung, thus creating the best possible match between ventilation and perfusion.
Promotes maximal ventilation and oxygenation and reduces or prevents atelectasis.
Drains fluid from pleural cavity to promote reexpansion of remaining lung segments.
Bloody drainage should decrease in amount and change to a more serous composition as recovery progresses.
A sudden increase in amount of bloody drainage or return to frank bleeding suggests thoracic bleeding or a hemothorax; sudden cessation suggests blockage of tube, requiring further evaluation and intervention.
Air leaks appearing immediately postoperatively are not uncommon, especially following lobectomy or segmental resection; however, this should diminish as healing progresses. Prolonged or new leaks require evaluation to identify problems in client versus a problem in the drainage system.
Maximizes available oxygen, especially while ventilation is reduced because of anesthetic, depression, or pain, and during period of compensatory physiological shift of circulation to remaining functional alveolar units.
Prevents or reduces atelectasis and promotes reexpansion of small airways.
Decreasing PaO2 or increasing PaCO2 may indicate need for ventilatory support. Significant blood loss results in decreased oxygen-carrying capacity, reducing PaO2.
