(Relates to Chapter 28 “Nursing Management: Lower Respiratory Problems,” in the textbook) Focus on Lung Cancer Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Lung Cancer Leading cause of cancer-related deaths Leading cause of death in women Survival rates are lower than for most other cancers. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 2

Etiology Most important risk factor in 80% to 90% of all lung cancers is smoking.  Contains 60 carcinogens that interfere with cell development  Causes a change in bronchial epithelium Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 3

Etiology Lung cancer is related to total exposure to cigarette smoke measured by  Total number of cigarettes smoked  Age of smoking onset  Depth of inhalation  Tar and nicotine content  Use of unfiltered cigarettes Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 4

Etiology Environmental tobacco smoke (ETS) inhaled by nonsmokers poses 35% increased risk of developing lung cancer. Children are more vulnerable to ETS than adults. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 5

Etiology Other carcinogens pose risk for developing lung cancer.  Asbestos  Radon  Nickel  Iron/iron oxides  Uranium Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 6

Etiology Other carcinogens pose risk for developing lung cancer.  Polycyclic aromatic hydrocarbons  Arsenic  Chromates  Air pollution Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 7

Pathophysiology Most cancers originate from epithelium of bronchus. It takes 8 to 10 years for a tumor to reach 1 cm.  Smallest lesion detectable on x-ray Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 8

Pathophysiology Occur primarily in segmental bronchi and upper lobes Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 9

Lung Cancer Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 10 Fig Lung cancer (peripheral adenocarcinoma). The tumor shows prominent black pigmentation, suggestive of having evolved in an anthracotic scar.

Lung Carcinoma Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 11 Fig Lung carcinoma. The gray-white tumor tissue is infiltrating the lung. Histologically this tumor was identified as a squamous cell carcinoma.

Pathophysiology Pathologic changes in bronchial system  Hypersecretion of mucus  Desquamation of cells  Reactive hyperplasia of basal cells  Metaplasia of normal respiratory epithelium to stratified squamous cells Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 12

Pathophysiology Primary lung cancers categorized into two subtypes  Non–small-cell lung cancer (NSCLC) 80%  Small cell lung cancer (SCLC) 20% Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 13

Pathophysiology Lung cancers metastasize by  Direct extension  Blood circulation  Lymph system Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 14

Pathophysiology Common sites for metastatic growth  Liver  Brain  Bones  Scalene lymph nodes  Adrenal glands Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 15

Pathophysiology Paraneoplastic syndrome  Various systemic manifestations caused by factors produced by tumor cells  Commonly associated with SCLC Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 16

Clinical Manifestations Symptoms appear late in disease. Depend on type of primary lung cancer, location, and metastatic spread Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 17

Clinical Manifestations Pneumonitis Persistent cough with sputum (most common) Hemoptysis Chest pain Dyspnea Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 18

Clinical Manifestations Later manifestations  Anorexia  Fatigue  Nausea/vomiting  Hoarse voice  Unilateral paralysis of diaphragm  Dysphagia  Superior vena cava obstruction Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 19

Diagnostic Studies Chest x-ray CT scan Magnetic resonance imaging (MRI) Positron emission tomography (PET) Diagnosis identified by malignant cells Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 20

Diagnostic Studies Sputum specimens obtained for cytologic studies  Fiberoptic bronchoscope  Mediastinoscopy  Video-assisted thoracoscopy (VATS)  Pulmonary angiography Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 21

Diagnostic Studies Staging NSCLC staged according to TNM system T T denotes tumor size, location, and degree of invasion. N N indicates regional lymph node invasion. M M represents presence/absence of distant metastases. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 22

Diagnostic Studies Staging  SCLC Has not been useful because cancer has metastasized before diagnosis is made Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 23

Diagnostic Studies Screening  No current recommendations exist.  No difference in deaths between those screened and those who were not Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 24

Collaborative Care Surgical therapy  Surgical resection is contraindicated for small cell carcinomas.  NSCLC is likely treated with surgery. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 25

Collaborative Care Radiation therapy  Used as curative therapy, palliative therapy, or adjuvant therapy  Primary therapy for those unable to tolerate surgery  Some cancer cells are more radiosensitive than others.  Stereotactic radiotherapy Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 26

Collaborative Care Chemotherapy Primary treatment for SCLC Treatment of nonresectable tumors or adjuvant to surgery in NSCLC Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 27

Collaborative Care Biologic and targeted therapy Erlotinib (Tarceva): Blocks growth stimulating signals in NSCLC cells Bevacizumab (Avastin): Inhibits angiogenesis Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 28

Collaborative Care Other therapies  Prophylactic cranial therapy  Bronchoscopic laser therapy Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 29

Collaborative Care Other therapies  Photodynamic therapy  Airway stenting  Cryotherapy Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 30

Nursing Management Nursing Assessment Assess patient’s and family’s understanding of diagnostic tests, diagnosis, treatment options, and prognosis. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 31

Nursing Management Nursing Assessment Assess level of anxiety. Obtain subjective and objective data. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 32

Nursing Management Nursing Diagnoses Ineffective airway clearance Anxiety Acute pain Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 33

Nursing Management Nursing Diagnoses Imbalanced nutrition: Less than body requirements Ineffective health maintenance Ineffective breathing pattern Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 34

Nursing Management Planning Overall goals  Effective breathing pattern  Adequate airway clearance  Adequate oxygenation of tissues Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 35

Nursing Management Planning Overall goals  Minimal to no pain  Realistic attitude toward treatment and prognosis Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 36

Nursing Management Nursing Implementation Health promotion  Avoid smoking.  Promote smoking cessation programs.  Support education and smoking policies. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 37

Nursing Management Nursing Implementation Acute intervention  Offer support during diagnostic evaluation.  Monitor for side effects.  Provide comfort. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 38

Nursing Management Nursing Implementation Acute intervention  Teach methods to reduce pain.  Educate indications for hospitalization. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 39

Nursing Management Nursing Implementation Ambulatory and home care  Follow up carefully for manifestations of metastasis.  Educate patient on signs and symptoms of hemoptysis, dysphagia, chest pain, and hoarseness.  May need information about hospice Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 40

Case Study Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 41

Case Study 62-year-old man is diagnosed with stage IIB small cell cancer of the lungs. He has smoked 2 packs of cigarettes per day for past 40 years. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 42

Case Study He is the sole income provider for his wife and two grandchildren. He has not agreed to chemotherapy and radiation. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 43

1. How can you attempt to determine the patient’s goals and understanding of the diagnosis? 2. What is the most important thing that can improve the patient’s outcome? Discussion Questions Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 44

3. What can you do to help him with anticipatory guidance if he elects to get treatment? Discussion Questions Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 45