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Lung cancer

  1. 1. AMANDEEP KAUR MMCON Lung Cancer
  2. 2. Respiratory system.
  3. 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. 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. 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. 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. 7. Healthy Lung Tissue
  8. 8. Diseased Lung Tissue
  9. 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. 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. 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. 12. Contd..
  13. 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. 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. 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. 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. 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. 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. 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. 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. 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. 22. Cont... Lesions formation in the lung’s tissues involving the bronchi, bronchioles or even alveoli Bronchogenic carcinoma.
  23. 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. 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. 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. 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. 27. Diagnostic Tests  CXR  CT Scans  MRI  Sputum cytology  Fibreoptic bronchoscopy  Transthoracic fine needle aspiration
  28. 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. 29. Bronchoscopy
  30. 30.  Endoscopy  Mediastinoscopy  VATS (video assisted thoracoscopic surgery)
  31. 31. Mediastinoscopy
  32. 32. VATS (Video Assisted Thoracoscopic Surgery)
  33. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 46. Contd.. Other drugs involved like-  Etoposide  Paclitaxel  Cyclophosphamide  Doxorubicin  Vinblastin
  47. 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. 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. 49. Complimentary Therapies cont…  Foods: Green tea, Garlic, Fish Oil, Lactobacillus.
  50. 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. 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. 52. Prevention: Primary  Avoid the use of tobacco smoke  Know environmental carcinogens that increase risk  Chemoprevention:  Consuming Vit. A, Vit E,, Vit C.
  53. 53. Prevention: Secondary  Aim is to early diagnose high risk populations via screening  Chest X-Ray, MRI, CT scans, sputum cytology
  54. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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.

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