RELATED CONCERNS
Cancer, general considerations, page 945 Pneumothorax/hemothorax, page 169 Psychosocial aspects of care, page 835
Radical neck surgery: laryngectomy (postoperative care), see DavisPlus
Surgical intervention, page 873
CARE SETTING
Primary Health Care Settings— aimed at health education, prevention (Stop Smoking and Clean Air Campaigns), early diagnosis, and follow-up care
Secondary Health Care Settings— referral to specialists in pulmonology, thoracic surgery, oncology, radiology, nutrition, occupational therapy, outpatient/ambulatory surgery, hospice, and home care
Tertiary Health Care Settings— inpatient medical- surgical unit, ICU
Adenocarcinomas: Are the most common type of NSCLC in the United States and comprise up to 40% of lung cancer cases. While adenocarcinomas are associated with smoking like other lung cancers, this type is also seen in nonsmokers— especially women— who develop lung cancer (Ratini, 2016).
Cryosurgery: Freezing of tumor in its original location (in situ). Sometimes used for NSCLC patients who can’t tolerate surgery.
Hemoptysis: Expectoration of blood or of blood- stained sputum.
Lobectomy: Removal of one lobe.
Pneumonectomy: Removal of an entire lung.
Staging: Classifi cation as to the extent of disease, based on pathology report from tissue obtained during bronchos- copy, needle (or other) biopsy, bloodwork, and imaging studies to rule out distant metastases.
Video- assisted thoracoscopic surgery (VATS): Less invasive type of surgery used when pos si ble for treatment of early stage NSCLC.
Wedge or segmental resection: Removal of the tumor and a small part of the lung.
G L O S S A R Y
Findings depend on type, duration of cancer, and extent of metastasis.
C L I E N T A S S E S S M E N T D A T A B A S E ( P R E O P E R A T I V E )
D I A G N O S T I C D I V I S I O N
M A Y R E P O R T M A Y E X H I B I T
Activity/Rest
• Fatigue, inability to maintain usual routine • Lassitude— usually in advanced stage
• Dyspnea with activity
Circulation
• Swelling of extremities
• Swelling in neck lymph nodes
• Fast heart rate
• Jugular vein distention (JVD), with vena caval obstruction
• Swelling of face
• Swollen lymph nodes above collar bone
• Expanded veins in arms, chest, or neck
• Tachycardia and dysrhythmias
• Pericardial rub, indicating effusion
• Clubbing of fi n gers
Ego Integrity
• Frightened feelings, fear of outcome of surgery • Restlessness
• Denial of severity of condition and potential for malignancy • Repetitive questioning
Elimination
• Intermittent diarrhea, due to hormonal imbalance, small cell lung cancer (SCLC)
• Increased frequency and amount of urine, due to hormonal imbalance (epidermoid tumor)
M A Y R E P O R T (continued) M A Y E X H I B I T (continued)
Food/Fluid
• Weight loss • Thin, emaciated, or wasted appearance in late stages
• Poor appetite, decreased food intake
• Diffi culty swallowing (late symptom)
• Thirst, increased fl uid intake
• Edema of face or neck, chest, back, due to vena caval obstruc- tion; facial or periorbital edema, due to hormonal imbalance (SCLC)
• Glucose in urine, due to hormonal imbalance (epidermoid tumor)
Pain/Discomfort
• Chest pain— not usually pres ent in early stages and not always pres ent in advanced stages. When pres ent, pain may be described as dull, aching, per sis tent
• Shoulder or arm pain, particularly with large cell carcinoma or adenocarcinoma
• Bone and joint pain— cartilage erosion secondary to increased growth hormones (large cell carcinoma or adenocarcinoma)
• Intermittent abdominal pain
• Guarding and protective actions
• Distraction be hav iors, such as restlessness, withdrawal
Respiration
• History of smoking; occupational exposure to pollutants, industrial dusts, such as asbestos, iron oxides, coal dust, or to radioactive materials
• Mild cough or change in usual cough pattern, sputum production
• Shortness of breath
• Weak breathing
• Hoarseness or change in voice (late symptom)
• Dyspnea, aggravated by exertion
• Increased tactile fremitus, indicating consolidation
• Dullness when chest is tapped
• Brief crackles or wheezes on inspiration or expiration
• Per sis tent crackles or wheezes; tracheal shift (space- occupying lesion)
• Hemoptysis
Safety
• Fever may be pres ent, with large cell carcinoma or adenocarcinoma
• Bruising, discoloration of skin, due to hormonal imbalance (SCLC)
Sexuality
• Gynecomastia, due to neoplastic hormonal changes (large cell carcinoma)
• Amenorrhea, impotence, due to hormonal imbalance (SCLC)
Teaching/Learning
• Familial risk factors— cancer, especially lung, tuberculosis
• Failure to improve
• Use of vitamins or herbal supplements, such as vitamins A, C, E; ribofl avin; folic acid; ashwagandha; birch; yellow doc; milk thistle; turmeric; ginger; red clover; echinacea; astragalus;
reishi and shiitake mushrooms; zedoary
Discharge Plan Considerations
• Assistance with transportation, medi cations, treatments, self- care, homemaker and maintenance tasks
➧ Refer to section at end of plan for postdischarge considerations.
CHAPTER 3Respiratory: Lung Cancer
T E S T
W H Y I T I S D O N E W H A T I T T E L L S M E
• Carcinoembryonic antigen (CEA, also called carcinogenic antigen): A cancer- specifi c immune system protein that is pres ent in many adenocarcinomas, including lung adenocarcinoma.
Increased preoperative levels of CEA usually suggest a poor prognosis. A CEA level greater than 50 may indicate advanced- stage lung cancer.
• Parathyroid protein- related hormone (PTHrP): Mea sures the release of a protein— similar to parathyroid hormone—
produced by some cancers, including all lung cancers.
Blood levels of PTHrP may help to distinguish lung cancer from cancer of the pleura or other diseases, is responsible for the clinical syndrome of hypercalcemia of malignancy, may stimulate proliferation of cancer cells, and is a factor in development of bone metastasis.
• Lymphocyte count: Determines number of white blood cells pres ent.
Lymphocytopenia or decreased level of cells can occur with surgical procedures and is associated with shorter survival times for clients with advanced lung cancer.
• Sputum cytology: Examines a sample of sputum (mucus) under a microscope to determine whether abnormal cells are pres ent.
Sputum is produced in the lungs and in the airways leading to the lungs. Sputum cytology may be done when lung cancer is suspected.
• Chest x- ray, posteroanterior (PA) and lateral: Evaluates organs or structures within the chest.
Lung cancer is often discovered on chest x- ray. Size and location of mass can be determined. Peripheral nodules and hilar and mediastinal changes may suggest lymphadenopathy. Pleural effusions and endobronchial obstruction may be seen.
• Thoracic CT: An imaging method that uses x- rays to create cross- sectional pictures of the chest and upper abdomen.
A CT scan is frequently the second step either to follow up on an abnormal chest x- ray fi nding or to evaluate troublesome symptoms in those with a normal chest x- ray.
• Positron emission tomography (PET) scan: Nuclear imaging scan used to evaluate and stage lung cancer.
Identifi es occult metastatic disease in the mediastinum and distant sites. More sensitive and specifi c than CT scan and may be used in combination with, or instead of, CT to determine tumor size and location and for staging.
• Magnetic resonance imaging (MRI) scan: Uses magnetic fi elds to produce two- or three- dimensional images of organs inside the body.
Used to confi rm abnormalities seen on chest x- ray, to detect early (<1 cm) lesions not vis i ble on chest x- ray, and to assess spread to the mediastinum. Outlines shape, size, and location of lesion. May reveal erosion of ribs or vertebrae.
• Pulmonary function studies, including total lung capacity (TLC), functional residual capacity (FRC), and residual volume (RV): Provide information on the extent of the pulmonary abnormality and if there is air- trapping in the lungs.
Volumes may be increased, indicating air- trapping, especially advanced disease. If airways are blocked by tumor, an obstructive pattern of pulmonary disease may lead to changes in FRC.
• Biopsy: May be performed using forceps or needle, or may be via open surgical incision. Allows for direct and microscopic examination of tissue for presence of malignant cells.
Needle biopsy may be performed on scalene nodes, hilar lymph nodes, or pleura to establish diagnosis. Tissue biopsy of metastatic sites is used to stage disease and determine prognosis and treatment.
• Bronchoscopy: Procedure used to look inside the lungs’
airways, or bronchi and bronchioles, by means of a thin tube inserted through the mouth or nose.
Samples may be taken from fl uid (bronchoalveolar lavage), tissue (transbronchial biopsy), or lymph nodes (transbronchial needle aspiration) to diagnose or stage certain cancers.
• Thoracentesis: Procedure in which a needle is used to remove excess fl uid in the pleural space (space between the lungs and the chest wall).
If fl uid is pres ent in the lining of the lung, removal of the fl uid may help diagnose cancer, as well as improve breathing symptoms.
• Endoscopic ultrasound: Minimally invasive procedure to assess gastrointestinal and lung diseases. It uses high- frequency sound waves to produce detailed images of the lining and walls of digestive tract and chest, as well as nearby organs. May be combined with fi ne- needle aspiration (FNA) of tissue or fl uids.
May be done to stage cancer, if pres ent, or determine if cancer has metastasized to lymph nodes or other organs. Also done to provide precise information about NSCLC, to guide treatment.