Lung cancer is the leading cause of cancer death in the United States and usually develops within the wall or epithelium of the bronchial tree. The two major categories are small cell lung cancers (SCLC), such as oat cell; and non–small cell lung cancers (NSCLC), which include adenocarcinoma, squamous cell and large cell carcinomas.
Prognosis is generally poor, varying with the type of cancer and extent of involvement at the time of diagnosis.
Survival rates are better with NSCLC, especially if treated in early stages. Although NSCLC tumors are frequently associated with metastases, they are generally slow growing.
Treatment options can include combinations of surgery, radiation, and chemotherapy. Surgery is the primary treatment for stage I and stage II tumors. Selected stage III carcinomas may be operable if the tumor is resectable.
Surgical procedures for operable tumors of the lung include:
1. Pneumonectomy (removal of an entire lung), performed for lesions originating in the mainstem bronchus or lobar bronchus.
2. Lobectomy (removal of one lobe), preferred for peripheral carcinoma localized in a lobe.
3. Wedge or segmental resection, performed for lesions that are small and well contained within one segment.
4. Endoscopic laser resection may be done on peripheral tumors to reduce the necessity of cutting through ribs.
CARE SETTING
Inpatient surgical and possibly subacute units.
RELATED CONCERNS
Cancer
Hemothorax/pneumothorax
Psychosocial aspects of care
Radical neck surgery: laryngectomy (postoperative care)
Surgical intervention
Patient Assessment Database (Preoperative)
Findings depend on type, duration of cancer, and extent of metastasis.
ACTIVITY/REST
May report: Fatigue, inability to maintain usual routine, dyspnea with activity
May exhibit: Lassitude (usually in advanced stage)
CIRCULATION
May exhibit: Jugular venous distention (JVD) (with vena caval obstruction)
Heart sounds: Pericardial rub (indicating effusion)
Tachycardia/dysrhythmias
Clubbing of fingers
EGO INTEGRITY
May report: Frightened feelings, fear of outcome of surgery
Denial of severity of condition/potential for malignancy
May exhibit: Restlessness, insomnia, repetitive questioning
ELIMINATION
May report: Intermittent diarrhea (hormonal imbalance, SCLC)
Increased frequency/amount of urine (hormonal imbalance, epidermoid tumor)
FOOD/FLUID
May report: Weight loss, poor appetite, decreased food intake
Difficulty swallowing
Thirst/increased fluid intake
May exhibit: Thin, emaciated, or wasted appearance (late stages)
Edema of face/neck, chest, back (vena caval obstruction); facial/periorbital edema
(hormonal imbalance, SCLC)
Glucose in urine (hormonal imbalance, epidermoid tumor)
PAIN/DISCOMFORT
May report: Chest pain (not usually present in early stages and not always in advanced stages), which may/may not be affected by position change
Shoulder/arm pain (particularly with large cell or adenocarcinoma)
Bone/joint pain: Cartilage erosion secondary to increased growth hormones (large cell carcinoma or adenocarcinoma)
Intermittent abdominal pain
May exhibit: Distraction behaviors (restlessness, withdrawal)
Guarding/protective actions
RESPIRATION
May report: Mild cough or change in usual cough pattern and/or sputum production
Shortness of breath
Occupational exposure to pollutants, industrial dusts (e.g., asbestos, iron oxides, coal dust), radioactive material
Hoarseness/change in voice (vocal cord paralysis)
History of smoking
May exhibit: Dyspnea, aggravated by exertion
Increased tactile fremitus (indicating consolidation)
Brief crackles/wheezes on inspiration or expiration (impaired airflow)
Persistent crackles/wheezes; tracheal shift (space-occupying lesion)
Hemoptysis
SAFETY
May exhibit: Fever may be present (large cell carcinoma or adenocarcinoma)
Bruising, discoloration of skin (hormonal imbalance, SCLC)
SEXUALITY
May exhibit: Gynecomastia (neoplastic hormonal changes, large cell carcinoma)
Amenorrhea/impotence (hormonal imbalance, SCLC)
TEACHING/LEARNING
May report: Familial risk factors: Cancer (especially lung), tuberculosis
Failure to improve
Discharge plan
DRG projected mean length of inpatient stay: 9.9 days
Assistance with transportation, medications, treatments, self-care, homemaker/maintenance tasks.
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
Fiberoptic bronchoscopy: Allows for direct visualization, regional washings, and cytologic brushing of lesions (large percentage of bronchogenic carcinomas may be visualized).
Chest x-ray (PA[posteroanterior] and lateral), chest computed tomography (CT): Outlines shape, size, and location of lesion. May reveal mass of air in hilar region, pleural effusion, atelectasis, or erosion of ribs or vertebrae.
Positron emission tomography (PET): Useful diagnostic tool in early detection of cancer, allowing measurement of differential metabolic activity in normal and diseased tissues.
Magnetic resonance imaging (MRI) scan: May be used in combination or instead of CT scans to determine tumor size/location and for staging.
Cytologic examinations (sputum, pleural, or lymph node): Performed to assess presence/stage of carcinoma, and may identify tumors of the bronchial wall.
Needle or tissue biopsy: May be performed on scalene nodes, hilar lymph nodes, or pleura to establish diagnosis.
Mediastinoscopy: Used for staging of carcinoma and to examine for metastasis.
Pulmonary function studies and ABGs: Assess lung capacity to meet postoperative ventilatory needs.
Skin tests, absolute lymphocyte counts: May be done to evaluate for immunocompetence (common in lung cancers).
Bone scan; CT scan of brain, liver; gallium scan of liver, spleen, bone: Used to detect metastasis.
NURSING PRIORITIES
1. Maintain/improve respiratory function.
2. Control/alleviate pain.
3. Support efforts to cope with diagnosis/situation.
4. Provide information about disease process/prognosis and therapeutic regimen.
DISCHARGE GOALS
1. Oxygenation/ventilation adequate to meet individual activity needs.
2. Pain controlled.
3. Anxiety/fear decreased to manageable level.
4. Free of preventable complications.
5. Disease process/prognosis and planned therapies understood.
6. Plan in place to meet needs after discharge.
Prognosis is generally poor, varying with the type of cancer and extent of involvement at the time of diagnosis.
Survival rates are better with NSCLC, especially if treated in early stages. Although NSCLC tumors are frequently associated with metastases, they are generally slow growing.
Treatment options can include combinations of surgery, radiation, and chemotherapy. Surgery is the primary treatment for stage I and stage II tumors. Selected stage III carcinomas may be operable if the tumor is resectable.
Surgical procedures for operable tumors of the lung include:
1. Pneumonectomy (removal of an entire lung), performed for lesions originating in the mainstem bronchus or lobar bronchus.
2. Lobectomy (removal of one lobe), preferred for peripheral carcinoma localized in a lobe.
3. Wedge or segmental resection, performed for lesions that are small and well contained within one segment.
4. Endoscopic laser resection may be done on peripheral tumors to reduce the necessity of cutting through ribs.
CARE SETTING
Inpatient surgical and possibly subacute units.
RELATED CONCERNS
Cancer
Hemothorax/pneumothorax
Psychosocial aspects of care
Radical neck surgery: laryngectomy (postoperative care)
Surgical intervention
Patient Assessment Database (Preoperative)
Findings depend on type, duration of cancer, and extent of metastasis.
ACTIVITY/REST
May report: Fatigue, inability to maintain usual routine, dyspnea with activity
May exhibit: Lassitude (usually in advanced stage)
CIRCULATION
May exhibit: Jugular venous distention (JVD) (with vena caval obstruction)
Heart sounds: Pericardial rub (indicating effusion)
Tachycardia/dysrhythmias
Clubbing of fingers
EGO INTEGRITY
May report: Frightened feelings, fear of outcome of surgery
Denial of severity of condition/potential for malignancy
May exhibit: Restlessness, insomnia, repetitive questioning
ELIMINATION
May report: Intermittent diarrhea (hormonal imbalance, SCLC)
Increased frequency/amount of urine (hormonal imbalance, epidermoid tumor)
FOOD/FLUID
May report: Weight loss, poor appetite, decreased food intake
Difficulty swallowing
Thirst/increased fluid intake
May exhibit: Thin, emaciated, or wasted appearance (late stages)
Edema of face/neck, chest, back (vena caval obstruction); facial/periorbital edema
(hormonal imbalance, SCLC)
Glucose in urine (hormonal imbalance, epidermoid tumor)
PAIN/DISCOMFORT
May report: Chest pain (not usually present in early stages and not always in advanced stages), which may/may not be affected by position change
Shoulder/arm pain (particularly with large cell or adenocarcinoma)
Bone/joint pain: Cartilage erosion secondary to increased growth hormones (large cell carcinoma or adenocarcinoma)
Intermittent abdominal pain
May exhibit: Distraction behaviors (restlessness, withdrawal)
Guarding/protective actions
RESPIRATION
May report: Mild cough or change in usual cough pattern and/or sputum production
Shortness of breath
Occupational exposure to pollutants, industrial dusts (e.g., asbestos, iron oxides, coal dust), radioactive material
Hoarseness/change in voice (vocal cord paralysis)
History of smoking
May exhibit: Dyspnea, aggravated by exertion
Increased tactile fremitus (indicating consolidation)
Brief crackles/wheezes on inspiration or expiration (impaired airflow)
Persistent crackles/wheezes; tracheal shift (space-occupying lesion)
Hemoptysis
SAFETY
May exhibit: Fever may be present (large cell carcinoma or adenocarcinoma)
Bruising, discoloration of skin (hormonal imbalance, SCLC)
SEXUALITY
May exhibit: Gynecomastia (neoplastic hormonal changes, large cell carcinoma)
Amenorrhea/impotence (hormonal imbalance, SCLC)
TEACHING/LEARNING
May report: Familial risk factors: Cancer (especially lung), tuberculosis
Failure to improve
Discharge plan
DRG projected mean length of inpatient stay: 9.9 days
Assistance with transportation, medications, treatments, self-care, homemaker/maintenance tasks.
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
Fiberoptic bronchoscopy: Allows for direct visualization, regional washings, and cytologic brushing of lesions (large percentage of bronchogenic carcinomas may be visualized).
Chest x-ray (PA[posteroanterior] and lateral), chest computed tomography (CT): Outlines shape, size, and location of lesion. May reveal mass of air in hilar region, pleural effusion, atelectasis, or erosion of ribs or vertebrae.
Positron emission tomography (PET): Useful diagnostic tool in early detection of cancer, allowing measurement of differential metabolic activity in normal and diseased tissues.
Magnetic resonance imaging (MRI) scan: May be used in combination or instead of CT scans to determine tumor size/location and for staging.
Cytologic examinations (sputum, pleural, or lymph node): Performed to assess presence/stage of carcinoma, and may identify tumors of the bronchial wall.
Needle or tissue biopsy: May be performed on scalene nodes, hilar lymph nodes, or pleura to establish diagnosis.
Mediastinoscopy: Used for staging of carcinoma and to examine for metastasis.
Pulmonary function studies and ABGs: Assess lung capacity to meet postoperative ventilatory needs.
Skin tests, absolute lymphocyte counts: May be done to evaluate for immunocompetence (common in lung cancers).
Bone scan; CT scan of brain, liver; gallium scan of liver, spleen, bone: Used to detect metastasis.
NURSING PRIORITIES
1. Maintain/improve respiratory function.
2. Control/alleviate pain.
3. Support efforts to cope with diagnosis/situation.
4. Provide information about disease process/prognosis and therapeutic regimen.
DISCHARGE GOALS
1. Oxygenation/ventilation adequate to meet individual activity needs.
2. Pain controlled.
3. Anxiety/fear decreased to manageable level.
4. Free of preventable complications.
5. Disease process/prognosis and planned therapies understood.
6. Plan in place to meet needs after discharge.
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