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98 Cards in this Set

  • Front
  • Back
What is the leading cause of cancer-related deaths worldwide?
Lung cancer
What is the overall 5-year survival rate for all clients with lung cancer?
14%
Why is there a poor long-term survival rate for lung cancer?
Due to the fact that most lung cancers are diagnosed at a late stage, when metastasis is present
What % of clients have small tumors and localized disease at the time of diagnosis?
Only 15%
What is the treatment for lung cancer?
Treatment of lung cancer is often aimed toward relieving symptoms (palliation) rather than cure, because of the presence of metastasis
Where does lung cancer arise from?
More than 90% of all primary lung cancers arise from the bronchial epithelium
What are bronchogenic carcinomas?
Cancers that arise from the bronchial epithelium
How are lung cancers classified?
Classified according to their histologic cell type
What are the classifications of lung cancer?
1. Small cell lung cancer (SCLC)

2. Epidermoid (squamous cell) cancer

3. Adenocarcinoma

4. Large cell cancer

**The last three types are now referred to as non-small cell lung cancer (NSCLC) because of their similar responses to treatment.
What endocrine paraneoplastic syndromes are associated with lung cancer?
1. Cushing's syndrome

2. Syndrome of appropriate antidiuretic hormone (SIADH)

3. Gynecomastia

4. Hypercalcemia

5. Hypoglycemia
How does lung cancer metastasize?
By direct extension, through the blood and invading lymph glands and vessels
What complications can arise from tumors in the bronchial tubes?
Tumors can grow and obstruct the bronchus partially or completely
What complications can arise from tumors in other areas of lung tissue?
Tumors can grow so large that they can cause airway obstruction by compressing the airway
What complications can arise from tumors in the edges of the lungs?
Tumors spread and can compress the alveoli, nerves, blood vessels, and lymph vessels
What do the patterns of metastasis depend on?
1. The type of tumor cell and the location of the tumor

2. Lung lymph nodes, as well as more distant lymph nodes, can be invaded
What causes hematogenous (bloodborne) metastasis of lung cancer?
The invasion of blood vessels in the lungs and tumor pieces (emboli) spread to distant body areas
What are the sites of metastasis?
1. Bone
2. Liver
3. Brain
4. Adrenal glands
What is the purpose of staging lung cancer?
1. Lung cancer is staged at diagnosis to assess the size and extent of the disease

2. These factors are correlated to survival rate
How is lung cancer staged?
TNM system:

1. T, primary tumor
2. N, regional lymph nodes
3. M, distant metastasis
What are the TMN stage groupings of lung cancer?
1. Occult carcinoma
2. Stage 0
2. Stage I
3. Stage II
4. Stage IIIa
5. Stage IIIb
6. Stage IV
What is occult carcinoma?
Tx, N0, M0
What is Stage 0 lung cancer?
Tumor Tis
Carcinoma in situ
What is Stage I lung cancer?
T1, N0, M0

or

T2, N0, M0
What is Stage II lung cancer?
T1, N1, M0

or

T2, N1, M0
What is Stage IIIa lung cancer?
T3, N0, M0

or

T3, N1, M0

or

T1-3, N2, M0
What is Stage IIIb lung cancer?
Any T, N3, M0

or

T4, Any N, M0
What is Stage IV lung cancer?
Any T, Any N, M1
What is the incidence/prevalence of lung cancer?
13% of new cancer cases in men and women
What is the primary prevention for lung cancer?
Directed at reducing tobacco smoking
What is the nurse's role in lung cancer prevention?
1. Encouraging nonsmokers not to begin to smoke

2. Promoting smoking cessation programs

3. Establishing a smoke-free environment

4. Encouraging nonsmokers to avoid passive, or secondhand, smoke by avoiding environmental exposure
What are the risk factors of lung cancer?
1. Repeated exposure to inhaled substances that cause chronic tissue irritation or inflammation

2. Cigarette smoking

3. Pipe and cigar smoking

4. Nonsmokers exposed to "passive," or "secondhand," smoke. Passive smoke has many of the carcinogens found in inhaled, or "mainstream," tobacco smoke.

5. Chronic exposure to asbestos, beryllium, chromium, coal distillates, cobalt, iron oxide, mustard gas, petroleum distillates, radiation, tar, nickel, and uranium

6. Air pollution that contains benzopyrenes and hydrocarbons
What are the genetic considerations of lung cancer?
One of the P450 enzymes, CYP2D6, activates carcinogens present in tobacco. People who have a mutated CYP2D6 gene do not activate the tobacco carcinogen and are less susceptible to lung cancer even if they smoke. About 10% of the U.S. population has this "resistance to lung cancer" gene. Another enzyme, glutathione S transferase, detoxifies and clears carcinogens from the body. Women who are missing this active enzyme are less able to clear carcinogens and are thus at greater risk for lung cancer if they are exposed to tobacco smoke. Men missing this enzyme do not have a greater risk for lung cancer.
What enzymes are associated with a genetic risk for lung cancer?
1. CYP2D6

2. Glutathione S transferase
What are the warning signals associated with lung cancer?
1. Hoarseness
2. Change in respiratory pattern
3. Persistent cough or change in cough
4. Blood-streaked sputum
5. Rust-colored or purulent sputum
6. Frank hemoptysis
7. Chest pain or chest tightness
8. Shoulder, arm, or chest wall pain
9. Recurring episodes of pleural effusion, pneumonia, or bronchitis
10. Dyspnea
11. Fever associated with one or two other signs
12. Wheezing
13. Weight loss
14. Clubbing of the fingers
What findings are associated with lung cancer upon palpation?
1. Possible areas of tenderness or masses when palpating the chest wall

2. Increased vibrations felt on the chest wall (fremitus) indicate areas of the lung where airspaces are replaced with tumor or fluid. Fremitus is decreased or absent when the bronchus is obstructed.

3. The trachea may be displaced from midline if a mass is present in the area
What findings are associated with lung cancer upon percussion?
Lung areas with masses sound dull or flat rather than hollow or resonant on chest percussion
What findings are associated with lung cancer upon auscultation?
1. Wheezes

2. Decreased or absent breath sounds

3. Increased loudness or sound intensity of the voice while listening to breath sounds

4. A pleural friction rub
What does wheezing indicate?
Partial obstruction of airflow in passages narrowed by tumors
What do decreased or absent breath sounds indicate?
Complete obstruction of an airway by a tumor or fluid
What does increased loudness or sound intensity of the voice while listening to breath sounds indicate?
Increased density of lung tissue from tumor compression
What does a pleural friction rub indicate?
Inflammation is also present
What are the nonpulmonary clinical manifestations of lung cancer?
1. Heart sounds may be muffled by a tumor or fluid around the heart (cardiac tamponade)

2. Dysrhythmias may occur as a result of hypoxemia or direct pressure of the tumor on the heart

3. Cyanosis of the lips and fingertips or clubbing of the fingers may be present

4. Bones become thin with tumor invasion and break easily

5. Superior vena cava syndrome may result from tumor pressure in or around the vena cava

6. Lethargy and somnolence may develop, and the client may have confusion or personality changes as a result of brain metastasis

7. Bowel and bladder tone or function may be affected by tumor spread to the spine and spinal cord
What are the late clinical manifestations of lung cancer?
1. Fatigue
2. Weight loss
3. Anorexia
4. Dysphagia
5. Nausea and vomiting
What are the diagnostic tests for lung cancer?
1. Chest x-rays
2. Computed tomography (CT)
3. Fiberoptic bronchoscopy
4. Specimens and bronchial brushings
5. Needle biopsy during bronchoscopy
6. Thoracoscopy
7. Mediastinoscopy
8. Direct surgical biopsy
9. Thoracentesis with pleural biopsy
10. Magnetic resonance imaging (MRI)
11. Radionuclide scans
12. Pulmonary function tests
13. Arterial blood gas (ABG) analysis
14. Positron emission tomography (PET)
What is the treatment of choice for lung cancers (especially small cell lung cancer)?
Chemotherapy
What are the common agents used in combination for treatment of lung cancer?
1. Carboplatin (Paraplatin)
2. Cisplatin (Platinol)
3. Docetaxel (Taxotere)
4. Gemcitabine (Gemzar)
5. Irinotecan (Camptosar)
6. Paclitaxel (Taxol)
7. Vinorelbine (Navelbine)
What are the side effects of chemotherapy?
1. Alopecia (hair loss)
2. Nausea and vomiting
3. Open sores on mucous membranes (mucositis)
4. Immunosuppression
5. Anemia
6. Thrombocytopenia (decreased numbers of platelets)
What is the management for mucositis?
1. Good, frequent oral hygiene, including tooth cleaning and mouth rinsing

2. Use of soft-bristled toothbrushes or disposable mouth sponges

3. Avoid using dental floss and water-pressure gum cleaners (such as a WaterPik)
What is the management for immunosuppression?
Biological response modifiers (BRMs) to stimulate bone marrow production of immune system cells
What is an effective treatment for locally advanced lung cancers confined to the chest?
Radiation therapy
What is the precaution regarding radiation therapy?
Skin is more sensitive to sun damage, clients should avoid direct skin exposure to the sun during treatment and for at least 1 year after radiation is completed
What is the main treatment for stage I and stage II non-small cell lung cancer (NSCLC)?
Surgery
What are the goals of preoperative care?
1. Relieve anxiety - encourage the client to express fears and concerns

2. Promote client's participation
What are the types of operative incisions?
Depending on the location of the cancer:

1. Posterolateral
2. Anterolateral
3. Median sternotomy
What is a segmentectomy?
A segmental resection of the lung that includes the bronchus, pulmonary artery and vein, and tissue of the involved lung segment or segments
What is a wedge resection?
Removal of the peripheral portion of small, localized areas of disease
What is a lobectomy?
The removal of an entire lung lobe
What is a pneumonectomy?
Removal of an entire lung, including all blood vessels. The bronchus to that lung is severed and sutured.
What is a chest tube?
A drain placed in the pleural space to restore intrapleural pressure, allows re-expansion of the lung
What are the functions of the chest tube?
1. Restore intrapleural pressure
2. Allow re-expansion of the lung
3. Prevents air and fluid from returning to the chest
How does the chest tube work?
1. The drainage system consists of one or more chest tubes or drains, a collection container placed below the chest level, and a water seal to keep air from entering the chest

2. The drainage system may use actual bottles or, more often, a disposable self-contained system

3. The basic principles of gravity and pressure are the same with both systems
Where is the tip of the chest tube placed in order to drain air from the lung?
Near the front lung apex
Where is the tip of the chest tube placed in order to drain fluid from the lung?
On the side near the base of the lung
What is the placement of chest tube after lung surgery?
After lung surgery, two tubes, anterior and posterior, are used. The puncture wounds are covered with airtight dressings.
What is used to drain air or fluid from the pleural space?
Gravity
What does the chest drainage system use?
Water seal mechanism
What is the purpose of the water seal mechanism?
Acts as a one-way valve to prevent air or liquid from moving back into the chest cavity
What is the three-bottle chest drainage system?
The three bottles are connected to one another. The tube(s) from the client is(are) connected to the first bottle (or chamber) in the series of three. This bottle (chamber) is the collection container. The second bottle (chamber) in the series is the water seal to prevent air from moving back up the tubing system and into the chest. The third bottle (chamber), when suction is applied, is the suction regulator.
What is the first bottle used for?
Bottle (chamber) one collects the fluid draining from the client. This fluid is measured hourly during the first 24 hours.
What is the second bottle used for?
Bottle two is the water seal that prevents air from entering the client's pleural space
What is the third bottle used for?
The third bottle is the suction control bottle of the system
What are chest drainage units?
Self-contained units that work in exactly the same way that the three-bottle system does. From right to left, the system contains chambers for drainage, a water seal, and suction control.
What is the plastic device on the chest drainage unit used for?
Reduce the risk of breakage or contamination of the drainage system and allow the client increased mobility
What is the management of chest drainage units?
1. Check hourly to ensure the sterility and patency of any chest drainage system

2. Tape tubing junctions to prevent accidental disconnections, and keep an occlusive dressing at the chest tube insertion site

3. Keep sterile gauze at the bedside to cover the insertion site immediately if the chest tube becomes dislodged

4. Keep padded clamps at the bedside for use if the drainage system is interrupted
What technique is used to move blood clots and prevent obstruction of the chest drainage units?
Gentle milking of the tube
What is the normal amount of drainage from the chest?
Less than 100mL/hr

(Notify the physician of drainage if more than 100 mL/hr occurs)
When is the observation of bubbling considered normal?
Bubbling is normal during forceful expiration or coughing because air in the chest is being expelled
When should the physician be notified of bubbling?
If bubbling occurs continuously in the water seal bottle or chamber
What does continuous bubbling indicate?
An air leak that must be identified
What is the management for continuous bubbling?
On the physician's prescription, gently apply a padded clamp on the drainage tubing close to the occlusive dressing
What if the bubbling stops with the application of a padded clamp?
If the bubbling stops, the air leak may be at the chest tube insertion site or within the chest, requiring physician intervention
What if the bubbling does not stop with the application of a padded clamp?
Air bubbling that does not cease when you apply a padded clamp indicates that the air leak is between the clamp and the drainage system
What happens after a pneumonectomy?
The pleural cavity on the affected side is an empty space (because the lung has been removed)
What is placed in the empty pleural cavity?
The surgeon sometimes inserts a clamped chest tube for only a day post-op
What is the purpose of the clamped chest tube?
Prevent mediastinal shift toward the affected side because serous fluid may accumulate in the empty space and create adhesions
What are the complications of a pneumonectomy?
1. Empyema

2. Development of a bronchopleural fistula
How are patients positioned after a pneumonectomy?
1. Positioning of the client after pneumonectomy varies according to surgeon preference and the client's comfort

2. Some surgeons want the client placed on the nonoperative side immediately after a pneumonectomy to reduce stress on the bronchial stump incision

3. Others prefer that the client be placed on the operative side to allow fluids to fill in the space formerly taken up by the lungs
What are the interventions for palliative care of lung cancer?
1. Oxygen Therapy
2. Drug Therapy
3. Radiation Therapy
4. Laser Therapy
5. Thoracentesis and Pleurodesis
6. Dyspnea Management
7. Pain Management
8. Hospice and End-of-Life Issues
What is the oxygen therapy for palliation for lung cancer?
1. If the client is hypoxemic, supplemental oxygen is provided

2. Even if the client is not overtly hypoxemic, the physician may prescribe oxygen to relieve dyspnea and anxiety

3. Humidification is used with oxygen therapy for the client with lung cancer
What is the drug therapy for palliation for lung cancer?
1. Bronchodilators and corticosteroids are prescribed for the client with bronchospasm to decrease bronchospasm, inflammation, and edema

2. Mucolytics may be of use to ease removal of thick mucus and sputum

3. Bacterial infections are treated with the appropriate antibiotic therapy
What is the purpose of radiation therapy for palliation for lung cancer?
1. Radiation therapy can help relieve hemoptysis, obstruction of the bronchi and great veins (superior vena cava syndrome), dysphagia (difficulty swallowing) from esophageal compression, and pain resulting from bone metastasis

2. Usually radiation for palliation uses higher doses for shorter periods of time

3. Skin care issues and fatigue are the same as those occurring with radiation therapy for cure
What is the purpose of laser therapy for palliation for lung cancer?
1. Lasers may be used to remove bronchial obstruction when tumors are accessible by bronchoscopy

2. The obstruction is debulked, and the airway is reopened

3. Laser therapy does not cause systemic or toxic effects and is usually well tolerated
What is thoracentesis?
Removal of fluid rapidly through suction after the placement of a large needle or catheter into the intrapleural space to treat pleural effusion and temporarily relieve hypoxia
What is pleurodesis?
An inflammation that causes the pleura to stick to the chest wall and prevent formation of effusion fluid
How is dyspnea managed?
1. The client with lung cancer tires easily and is often most comfortable resting in a semi-Fowler's position

2. Dyspnea is reduced with oxygen, use of a morphine drip, and positioning for comfort

3. The severely dyspneic client may be most comfortable sitting in a lounge chair or reclining chair
What are the nonpharmacologic measures of pain management?
1. Positioning
2. Hot or cold compresses
3. Distractions
4. Guided imagery
What services are provided by hospice programs?
Provide support to the terminally ill client and the family by meeting physical and psychosocial needs, adjusting the palliative care regimen as needed, making home visits, and providing volunteers for errands and respite care
What is the best practice for the client undergoing pleurodesis?
1. Reinforce explanation of the pleurodesis and inform the client that medication will be provided to promote comfort before the procedure. (The physician may administer IV analgesia/sedation immediately before the procedure.)

2. Ensure that the chest tube is clamped after instillation of the sclerosing agent

3. Monitor vital signs and respiratory status at the completion of the procedure and then at least every 30 minutes until the effects of the IV medication have dissipated

4. Thereafter, monitor vital signs every 4 hours for 24 hours. (The client may experience a low-grade fever. Pleurodesis creates pleuritis between the visceral and parietal layers, thus preventing reaccumulation of fluid.)

5. If a rotation schedule is ordered, assist the client to the correct position for appropriate time frames and provide reassurance

6. Unclamp the chest tube after completion of the rotation schedule or at the specified time ordered by the physician

7. Assess chest tube drainage and document the amount and character of the drainage

8. Perform a complete respiratory assessment every 2 hours and observe for manifestations of distress, including those of pneumothorax

9. Analgesics may be administered as needed to promote the client's comfort

10. When drainage has decreased (<150 mL in 12 to 24 hours), the physician may remove the chest tube. Maintain an occlusive dressing at the insertion site for a minimum of 48 hours