Adult Medical-Surgical Nursing

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Adult Medical-Surgical Nursing

• Respiratory Module
• Lung Cancer

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Bronchogenic Carcinoma (Lung Cancer) Description

• Bronchogenic carcinoma is a major cancer killer
  for both men and women
• Often by the time of diagnosis malignancy has
  spread to regional lymphatics
• Therefore the long-term survival rate for lung
  cancer even with treatment is low

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Lung Cancer

• Lung cancer comprises
• Primary bronchial carcinoma
• Lung metastases secondary to a primary malignancy
  elsewhere in the body eg the breast

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Lung Cancer and Smoking

• 85 of lung cancer is related to cell mutation
  from carcinogenic chemical inhalation, especially
  from smoking
• Primary inhalation (x 10 incidence than in
  non-smokers)
• Secondary passive smoking in a smoke-filled room
• Risk is associated with number of packs smoked
  daily, years smoking, filtration, tar

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Lung CancerAetiology/ Risk Factors

• Smoking
• Environmental / occupational hazards
• Urban areas (? pollutants)
• Industrial carcinogens (asbestos, coal smoke,
  radiation)
• Genetic pre-disposition ? risk x 3 whether
  smoker or not
• Dietary factors diet low in fruit and vegetable,
  especially vitamin A and C

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Lung Cancer Classification

• Non-small Cell Carcinoma (75)
• Squamous cell (bronchial epithelium)
• Adenocarcinoma (peripheral tumours ? metastases)
• Large cell (peripheral, rapid growing)
• Bronchio-alveolar cell (terminal bronchi)
• Small Cell Carcinoma (25) rapid infiltration
  and metastases

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Lung Cancer Pathophysiology

• A single epithelial or gland cell of the
  tracheo-bronchial airways is damaged through
  binding of carcinogenic chemicals to the cell DNA
  ?
• Cellular changes (mutation) occur and abnormal
  cell growth ? malignant cell
• Damaged DNA is unstable and passes on changes to
  daughter cells
• This is the start of invasive carcinoma

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Lung Cancer Progression

• Insidious progression
• The condition is usually well-developed before
  symptoms appear

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Lung Cancer Clinical Manifestations

• Chronic cough (dry persistent or purulent) a
  cough which changes in character should be
  investigated
• Wheezing, chest tightness, hoarseness, dysphagia
• Haemoptysis
• Pain pleuritic, shoulder, rib (metastases)
• Weakness, fatigue, weight loss, anorexia
• Fever (if pneumonia develops)

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Lung CancerDiagnosis

• History and physical assessment
• Chest Xray
• CT scan
• Sputum cytology
• Bronchoscopy examination, brushings, washings,
  biopsy
• Trans-thoracic fine needle aspiration
  (fluoroscopic guidance) occasionally

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Lung Cancer Other Assessment in Diagnosis

• Presence of metastases
• Bone scan
• Abdominal scan
• Liver scan
• Brain scan
• (MRI)
• Assessment of lung impairment and function
• PFT, ABG, VQ ratio, treadmill, ECG

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Lung CancerStaging

• In addition to histology of bronchial carcinoma,
  staging assists the treatment plan
• Carcinoma in situ
• Localised infiltration
• Metastases to other organs

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Lung Cancer Management

• Separately or in combination
• Surgery
• Radiation
• Chemotherapy
• Determined by
• Type of tumour and staging
• General condition of the patient

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• Surgery

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Surgery

• Surgical resection is the preferred treatment if
• There is no evidence of metastases
• Patients general condition would tolerate
• Surgery is used for non-small cell carcinoma with
  no infiltration (small cell infiltrates through
  the lymphatics early)
• Often a patient presents with metastases already
  and surgery would not be useful

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Surgery

• Procedures include
• Lobectomy
• Pneumonectomy
• (Both involve Thoracotomy)

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Surgery Pre-operative Management and Nursing Care

• Pre-operative assessment
• PFT, ABG, VQ ratio, treadmill, ECG
• LFT, KFT, RBS, CBC, Group X-match
• Chest physiotherapy use of nebulised
  bronchodilators and postural drainage to
  encourage expectoration leg exercises
• Patient teaching breathing/ coughing technique,
  site and extent of wound, chest drains, possible
  ventilation, relieve anxiety

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Surgery Post-operative Management

• ICU ventilator if required
• Humidified O2 nebulised bronchodilators
• IVI IV antibiotics/ medications
• Chest drains
• ABG serum electrolytes
• Chest physio
• Prophylactic Heparin anti-embolism stockings

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Surgery Post-operative Nursing Care

• ICU ventilator if required
• Position patient semi-sitting once able, pillows
  to support (thoracotomy wound)
• Monitor vital signs, especially respirations
• Care of O2, IVI, wound dressing, chest drains,
  mouth, pressure areas, urination
• Adequate pain relief emotional support
• Breathing, leg, arm, shoulder exercises

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• Radiotherapy

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Radiotherapy Indications

• Radiation therapy is useful for neoplasms which
  are
• Difficult to resect
• Small-cell infiltrating
• Also used pre- or post-surgery ?

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Lung Cancer Radiotherapy and Surgery

• Radiation pre- or post-surgery
• Radiation inhibits cell growth, reducing the size
  of a tumour ?
• More accessible for surgery
• Reduces symptoms of pressure therefore
• Relieves dyspnoea, cough, chest pain,
  haemoptysis, bone pain
• Improves quality of life

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Lung Cancer Radiotherapy Protocol

• Usually almost daily sessions for 4 weeks
• Area to be treated is marked and kept dry and
  cool
• Careful monitoring of blood count and general
  well-being throughout the treatment period

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Radiotherapy Side Effects

• Radiotherapy is toxic to good cells
• May lead to oesophagitis, pneumonitis, fibrosis
  and impaired VQ ratio
• Other side effects are related to bone marrow
  depression
• Anaemia, fatigue, bruising, ? immune response and
  infection (including opportunistic infection as
  candida)

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• Chemotherapy

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Lung Cancer Chemotherapy

• Chemotherapy may be used in combination with the
  other 2 more major treatments
• Affects cell growth and multiplication therefore
  reduces tumour size and relieves symptoms as
  radiotherapy
• Side effects as radiotherapy
• (Chemotherapy and nursing care previously
  discussed see Leukaemia 1 lecture, Haematology
  Module)