MEDICAL AND NURSING MANAGEMENT

1. AMANDEEP KAUR
MMCON
Lung Cancer

2. Respiratory system.

3. Organs of respiratiory system
 Upper respiratory tracts
 Nose
 Pharynx
 Larynx
 Trachea
 Lower respiratory tracts
 Two bronchi (one bronchus to each lung) Bronchioles
and smaller air passage
 Two lungs and their covering pleura

4. Normal Physiology Of Respiration
 Normal respiration begins by inhaling air through the
mouth and nose.
 This air flows down into trachea, which divides into
the left and right bronchi, and then to the alveoli.
 The alveoli are responsible for oxygenating the blood
for circulation as well as removing carbon dioxide
from the blood.

5. Lung Cancer
 Most common cause of cancer death for men
and women.
 Tobacco use accounts for 87% of lung cancer.
 Lung cancer affect primarily in 5 or 6th decade
of life.
 In 70% of lung cancer patient , disease has
spread to distant organs.

6. Definition
 Cancer: An abnormal growth of cells which tend to
proliferate in an uncontrolled way and, in some cases,
to metastasize (spread). Cancer is not one disease. It
is a group of more than 100 different and distinctive
diseases.

7. Healthy Lung Tissue

8. Diseased Lung Tissue

9. Types of Lung Cancer
Two main Types of Lung Cancer:
Small Cell Lung Cancer (20-25% of all lung cancers)
Non Small Cell Lung Cancer (most common
~80%)

10. Small Cell Lung Cancer
 Small Cell Lung Cancer is the most aggressive
form of lung cancer.
 It usually starts in the bronchi and then effects the
whole lung.
 These cancer cells are small and are considered to
be quite aggressive in nature and they have a large
growth factors.

11. Contd..
 Because of these reasons, at the time of
diagnosis, (60% of the time), these tumors have
often metastasize to other parts of the body
(brain, liver, and bone marrow)
 SCLC accounts for 20-25% of all lung cancers.

12. Contd..

13. Non Small Cell Lung Cancer
 NSCLC is any type of epithelial lung cancer
other than small cell lung cancer.
 Non-small cell lung Ca usually grows and
spreads more slowly than SCLC.

14. Types of NSCL
 Squamous cell carcinomas usually arise centrally in
larger bronchi
 Adenocarcinoma : formed from grandular structure in
epithelial tissues (mucus secreting glands) are often found
in the periphery of the lungs
 Large cell carcinomas can occur in any part of the lung
and tend to grow and spread faster than the other two
types

15. Squamous Cell Carcinoma
 Moderate to poor differentiation
 Makes up 30-40% of all lung cancers
 More common in males
 Most occur centrally in the large bronchi
 Uncommon metastasis that is slow effects the liver,
adrenal glands and lymph nodes.
 Associated with smoking
 Not easily visualized on x-ray.

16. Adenocacinoma
 Increasing in frequency. Most common type
of Lung cancer (40-50% of all lung cancers).
 Clearly defined peripheral lesions
 Glandular appearance under a microscope
 Easily seen on a CXR
 Can occur in non-smokers
 Slow metastatic in nature
 Pts present with or develop brain,
Liver, adrenal or bone metastasis

17. Large Cell Carcinomas
 Makes up 15-20% of all lung cancers
 Poorly differentiated cells
 Tends to occur in the outer part (periphery) of lung,
invading sub-segmental bronchi or larger airways
 Metastasis is slow BUT
 Early metastasis occurs to the kidney, liver organs as
well as the adrenal glands.

18. Causes and risk factors
 Gender
 Smoking history
Active smoking=85-87%
Passive smoking=3-5%
 Older age
 Presence of airflow obstruction
 Genetic predisposition.

19. Cont...
 Pollution and occupational exposure
 Industry work due to asbestos(heat resistant fibrous).
 Lung Disease like T.B
 family History
 Diet (low in fruits and vegetables)

20. Patho-physiology
Carcinogens like smoking, occupational and
environmental agents, genetics.
Binds with cell’s DNA and damage the cells.
Cellular changes and abnormal cell growth
occur.

21. Cont...
Malignant transformation of pulmonary epithelial
cells.
Abnormal proliferation of the lung cell. These
cells grow slowly and covers the segmental
bronchi and lobes of the lung.
Non specific inflammatory changes with
hypersecretion of mucus, desquamation of the
cells.

22. Cont...
Lesions formation in the lung’s tissues involving
the bronchi, bronchioles or even alveoli
Bronchogenic carcinoma.

23. Signs and Symptoms
There are two types of signs and symptoms of
lung cancer:
1) Localized – involving the lung.
2) Generalized – involves other areas throughout
the body if the cancer has spread.

24. Localized Signs and Symptoms
 Cough and fatigue
 Breathing Problems, stridor
 blood in phlegm
 Lung infection, hemoptysis
 Hoarseness, Hiccups
 Weight loss
 Chest Pain and tightness
 Pleural Effusion

25. Generalized Signs and Symptoms
 Bone pain
 Headaches, mental status changes or neurologic
findings
 Abdominal pain, elevated liver function tests,
enlarged liver, gastrointestinal disturbances
(anorexia, cachexia), jaundice, hepatomegaly
 Weight loss

26. Early/late Signs and Symptoms Of Lung
Cancer
Early Signs Late signs
Cough/chronic cough Bone pain, spinal cord compression
Dyspnea Chest pain/tightness
Hemoptysis Dysphagia
Chest/shoulder pain Head and neck edema
Recurring temperature Blurred vision, headaches
Recurring respiratory
infections
Weakness, anorexia, weight-loss,
cachexia
Pleural effusion
Liver metastasis/regional spread

27. Diagnostic Tests
 CXR
 CT Scans
 MRI
 Sputum cytology
 Fibreoptic bronchoscopy
 Transthoracic fine needle aspiration

28. Laboratory Tests
Blood Tests
*CBC- to check red/white blood cell & platelets
-to check bone marrow and organ function
*Blood Chemistry Test- to assess how organs are
functioning such as liver and kidney
Biopsy-to determine if the tumor is cancer or not
-to determine the type of cancer
-to determine the grade of cancer (slow
or fast)

29. Bronchoscopy

30.  Endoscopy
 Mediastinoscopy
 VATS (video assisted thoracoscopic surgery)

31. Mediastinoscopy

32. VATS (Video Assisted
Thoracoscopic Surgery)

33. Nursing Management for post endoscopic
procedures
Bronchoscopy Mediastinoscopy VATS
Monitor V/S; NPO
status maintained
until return of gag
reflex.
(Fever up to 1010F
can be expected
afterwards).
Monitor VS;
potential for
bleeding, infection
and dyspnea; NPO
status until return
of gag reflex
Monitor V/S;
potential for
bleeding,
infection and
dyspnea; NPO
status until return
of gag reflex

34. Post-op complications for those
with lung cancer
 Airway obstruction, dyspnea, hypoxemia, respiratory failure
 Anesthesia side effects (N/V)
 Bleeding (hypotension, cardiogenic shock)
 Cardiac dysthymias, CHF, fluid overload
 Fever, sepsis
 Pneumonia
 Pneumothorax
 Pulmonary embolus
 Wound dehiscence
 Prolonged hospitalization
 Death

35. Cancer Staging Systems
 The most common staging system for lung cancer is
the TNM System developed by the International
Union Against Cancer (UICC).
 Guides best course of treatment
 Estimates prognosis
 It is only useful in staging NSCLC, when surgery is
considered.

36. TMN Staging system for Lung Cancer
T= Tumors : tumor size,
(local invasion)
N= Node : node involvement
(size and type)
M= Metastasis : general
involvement in organs and
tissues

37. Tumor size
 Tx – The tumor size is unknown, or cancer cells are
only found in sputum.
 T0 – The tumor is present only in the cells lining the
airway
 T1 – Tumors less than or equal to 3 cm
 T2- Tumors size is 4-7 cm.
 T3 – Tumors greater than 7 cm
T4 – tumor that invades structures in the chest such
as the heart, major blood vessels near the heart, the
trachea, the esophagus.

38. Nodal involvement
 N0 – No nodes are involved.
 N1 – The tumor has spread to nearby nodes on the same
side of the body.
 N2 – The tumor has spread to nodes farther away, but
on the same side of the chest.
 N3 – The tumor has spread to lymph nodes on the other
side of the chest from the original tumor, or has spread
to nodes near the collarbone or neck muscles.

39. Metastasis
 M0 - The tumor has not spread to distant regions.
 M1:
 M1a – The tumor has spread to the opposite
lung, to the lung lining
 M1b – The tumor has spread to distant regions
of the body, such as the brain or bones.

40. Staging
Stage 1. Tumor is small and localised to lung, no lymph
node involvement
 A-Tumor <3 cm
 B-Tumor >3 cm and invading surrounding local area
Stage 2.
 A-Tumor <3cm with invasion of lymph nodes.
 Tumor >3 cm involving the bronchus and lymph nodes
on the same side of chest and tissue of local organs.

41. Contd..
Stage 3.
 A. Tumor spread to the nearby structure and
regional lymph nodes
 B. Tumor involving heart, trachea, esophagus,
mediastinum and lymph nodes.
Stage 4- distant metastasis

42. Medical Management
The three main cancer treatments are:
*surgery (lung resections)
*Radiation therapy
*chemotherapy
Other types of treatment that are used to treat certain
cancers are hormonal therapy, biological therapy or
stem cell transplant.

43. Surgical treatment
 Lobectomy: a single lobe of lung is removed
 Bilobectomy: 2 lobes of the lung are removed (only on R
side)
 Sleeve resection: cancerous lobe is removed and segment
of the main bronchus is resected
 Pneumonectomy: removal of entire lung
 Segmentectomy: a segment of the lung is removed
 Wedge resection: removal of a small, pie-shaped area of
the segment
 Chest wall resection with removal of cancerous lung
tissue: for cancers that have invaded the chest wall

44. Radiation treatment
 Useful in controlling the neoplasm that can not be
surgically removed.
 Used to reduce the size of the tumor
 May help to remove the symptoms like cough, chest
pain, dyspnea and hemoptysis etc.

45. Chemotherapy
Is used to alter tumor growth and to treat the patient with
metastasis.
 Non small cell:
 Two drug regimen.
 Cis/Carbo platin + 1 other
(Taxol/Taxotere/Gemcitabine)
 Small cell:
 Cisplatin / Etoposide

46. Contd..
Other drugs involved like-
 Etoposide
 Paclitaxel
 Cyclophosphamide
 Doxorubicin
 Vinblastin

47. Side effects of treatments
SURGERY RADIATION CHEMOTHERAPY
Pain fatigue Anemia,
thrombocytopenia
Hemotomas Decreased nutritional
intake
Fatigue
Hemmorhage Radiodermatitis Alopecia
Altered respiratory
function
Decreased
hematopoietic function
Cold, pale skin
Risk for atelectasis,
pneumonia, hypoxia
Risk for Pneumonitis,
esophagitis, cough
Tingling
Risk for DVT Lung fibrosis Irritable
Grief Dizziness, weakness

48. Complimentary Therapies
 Includes ACUPUNCTURE and MASSAGE and
pharmacological approaches such as vitamins and
herbal medicine.
 These herbal therapies combined with chemotherapy
increases survival in non-small-cell lung cancer by up
to 42%, compared with chemotherapy alone.

49. Complimentary Therapies cont…
 Foods: Green tea, Garlic, Fish Oil,
Lactobacillus.

50. Complimentary Therapies cont’d
 Mind-body: help to reduce anxiety, mood
disturbance, or chronic pain in cancer patients
(audiotapes, videotapes, books, music,
relaxation, yoga, meditation).
 Acupuncture
 Hypnosis
 Massage therapy

51. Prognostic Factors
The best estimate on how a patient will do
based on:
*Type of cancer cells
*Size or location of the tumor
*Stage of the cancer at the time of diagnosis
*Age of the person
*Gender
*Results of blood or other tests
*A persons specific response to treatment
*Overall health and physical condition

52. Prevention: Primary
 Avoid the use of tobacco smoke
 Know environmental carcinogens that increase risk
 Chemoprevention:
 Consuming Vit. A, Vit E,, Vit C.

53. Prevention: Secondary
 Aim is to early diagnose high risk populations via
screening
 Chest X-Ray, MRI, CT scans, sputum cytology

54. Prevention: Tertiary
 Targeted at people who survived a cancer disease
 Assists them to retain an optimal level of functioning
regardless of their potential debilitating disease

55. Nursing assessment
 Subjective data-
 Past health history
 Exposure to smoke, air born carcinogens, any
respiratory diseases and pollutants
 Nutritional habbits
 Symptoms like anorexia, nausea , vomiting, cough
and hemoptysis.

56. Contd..
 Objective data-
 Vitals monitoring
 Respiratory-assess for wheezing, stridor, hoarseness,
pleural effusion
 CVS- assess for cardiac temponade, dysrhythmias,
pericardial effusion
 Findings- chest X- ray, MRI, CT scan, CBC.

57. Nursing Diagnoses
1. Ineffective breathing pattern r/t loss of
adequate ventilation as evidenced by
overexertion of pt. during respiration.
2. Impaired gas exchange r/t excessive or thick
secretions or r/t decreased passage of gases
between alveoli of lungs and vascular system
as evidenced by decreased SPo2 level of pt.

58. 3. Chronic pain related to Stage IV NSCLC diagnosis
as evidenced by client reporting “pain in right chest
and lower ribs”.
4. Risk of infection related to altered immune system
secondary to effects of cytotoxic drugs as evidenced
by side effects of the drug/chemotherapy.
5. Risk for disturbed self concept related to changes in
lifestyle.

59.  Nausea related to effects of chemotherapy as
evidenced by
client reporting feeling nauseated.
 Risk for deficient fluid volume related to
gastrointestinal fluid loss secondary to vomiting.
 Fatigue related to chemotherapy secondary to stage IV
NSCLC as evidenced by client reporting he “ no
longer has the energy to play with his grandchildren or
visit his friends”.

60. Ineffective breathing pattern
 Teach patient about deep breathing exercises
 Encourage alternating activity with rest periods
 Chest physiotherpy
 Suctioning
 Bronchodilator medication
 O2 administration, if required

61. Impaired gas exchange
 Instruct the patient to stop smoking
 Semi-fowler position
 Administered antibiotics as prescribed
 Adequate hydration
 Deep breathing exercises
 Nebulisation
 Suctioning, as required

62. Chronic pain
 Relaxation techniques
 Diversional therapy
 Frequant massage
 Encourage energy conservation
 Comfortable position
 Education to avoid concern about pharmacological
and non- pharmacological therapies
 Medication , as prescribed.

63. Risk of infection
 Monitor the client body temp. routinely
 Encourage the patient to do regular ADL like
brushing, bathing, eating, toileting
 Provide a high calorie, high protein diet
 Hand washing before and after taking food
 Antibiotics, as prescribed

64. Risk of disturbed self concept
 Provide psychological support
 Encourage the family members in caring of the
patient
 Encourage the communication with the patient
 Diversional therapy
 Ask the client to identify personal strenght and
talent.

65. Risk of deficit fluid volume
 Encourage the patient to take fluids (2-3 l/day)
 Small and frequent diet
 I/V fluid administration, if prescribed
 Intake- output charting
 Administer skin care, apply hydrating lotion
 Weight recording

66. References
 Brunner and sudderth’s, a textbook of medical- surgical
nursing, smeltzer bare, 10th edition, page no-554-557.
 Lewis’s , a text book of medical surgical nursing, chintamani,
7th edition, page no. 585-588.
 Potter.perry, a text book of fundamental of nursing, 7th
edition, page no. 1066, 865.
 Posther KE, Harpole DH. The surgical management of lung
cancer. Cancer Investigation, 2006;24:56–67.
 National Comprehensive Cancer Network. NCCN Clinical
Practice Guidelines in Oncology: . Accessed at
www.nccn.org/professionals/physician_gls/PDF/nscl.pdf on
March 18, 2013.