a. Usually develops within the wall or epithelium of the
b. Prolonged exposure to cancer-promoting agents causes
damage to ciliated cells and mucus-producing cells, leading
to genetic mutations and development of dysplastic cells.
II. Classification (Memorial Sloan-Kettering Cancer Center,
2008; National Cancer Institute, 2008)
a. Small cell lung cancers (SCLCs), or oat cell lung cancer
i. Represent about 15% to 25% of lung cancer cases
(Elias & Baldini, 2008)
ii. Occur almost exclusively in smokers
iii. Aggressive and fast growing with surgery seldom a
b. Non–small cell lung cancers (NSCLCs)
i. Most common type of lung cancer (75% to 85%, Elias
& Baldini, 2008)
ii. Include adenocarcinoma, squamous cell, and large cell
iii. Frequently associated with metastases, but are generally
III. Staging (National Cancer Institute, 2008)
a. Stage 0—cancer cells only found in the innermost lining of
b. Stage IA—tumor has grown through the innermost lining
of the lung into deeper lung tissue, but does not invade the
bronchus; no cancer cells found in nearby lymph nodes
c. Stage IB—tumor is larger, may be more than 3 cm across;
may have grown into the main bronchus; may have grown
into the pleura, but no cancer cells found in nearby lymph
d. Stage IIB—tumor has invaded the chest wall, diaphragm,
pleura, main bronchus, or tissue that surrounds the heart;
cancer cells found in nearby lymph nodes
e. Stage IIIA—tumor may be any size; cancer cells found in
the lymph nodes near the lungs and bronchi and between
the lungs on the same side of the chest as the tumor
f. Stage IIIB—tumor may be any size; cancer cells found on
the opposite side of the chest from the tumor, with possible
invasion into nearby organs
g. Stage IV—malignant growths may be found in more than
one lobe or may have metastasized to other organs
IV. Etiology (American Cancer Society, 2008)
a. Risk factors include cigarette smoking or being exposed to
secondhand smoke; radon, asbestos, other occupational
exposures, including radioactive ores such as uranium,
inhaled chemicals or minerals, such as nickel compounds,
silica, coal dust, and cromates, or diesel exhaust; high
levels of arsenic in drinking water; and family history of
b. Chronic obstructive pulmonary disease (COPD) and
pulmonary fibrosis may increase susceptibility.
a. Morbidity: Second most commonly diagnosed cancer
accounting for 13% of all cases (American Association
for Cancer Research, 2005) with new cases of lung
and bronchus cancer estimated at 172,570 for 2005
(Jemal et al, 2005).
b. Mortality: Number one cause of death in cancer patients;
in 2004, death rates for men and women were 89,575 and
68,431, respectively; results in more deaths than breast
cancer, prostate cancer, and colon cancer combined
(U.S. Cancer Statistics Worling Group, 2007).
c. Cost: $9.6 billion was spent for treatment in 2004.
VI. Treatment Options
a. Depends upon staging—generally the lower the stage, the
more favorable the prognosis
i. Surgery is primary treatment for NSCLC stage I and
stage II tumors.
ii. Selected stage III carcinomas may be operable if the
tumor is resectable.
b. Surgical procedures for operable tumors of the lung
i. Pneumonectomy—performed for lesions originating in
the main stem bronchus or lobar bronchus
ii. Lobectomy—preferred for peripheral carcinoma localized
in a lobe
iii.Wedge or segmental resection—performed for lesions
that are small and well contained within one segment
iv. Endoscopic laser resection—may be done on peripheral
tumors to reduce the necessity of cutting through ribs
v. Photodynamic therapy—reduces symptoms such as
bleeding or may be used to treat very small tumors
Client is treated in inpatient surgical and possibly subacute
1. Maintain or improve respiratory function.
2. Control or alleviate pain.
3. Support efforts to cope with diagnosis and situation.
4. Provide information about disease process, prognosis,
and therapeutic regimen.
1. Oxygenation and ventilation adequate to meet individual
2. Pain controlled.
3. Anxiety and fear decreased to manageable level.
4. Free of preventable complications.
5. Disease process, prognosis, and planned therapies
6. Plan in place to meet needs after discharge.
NURSING DIAGNOSIS: impaired Gas Exchange
May be related to
Removal of lung tissue
Altered oxygen supply—hypoventilation
Decreased oxygen-carrying capacity of blood—blood loss
Possibly evidenced by
Changes in mentation
Hypoxemia and hypercapnia
Desired Outcomes/Evaluation Criteria—Client Will
Respiratory Status: Gas Exchange
Demonstrate improved ventilation and adequate oxygenation of tissues by arterial blood gases (ABGs) within client’s normal
Be free of symptoms of respiratory distress.
Note respiratory rate, depth, and ease of respirations. Observe
for use of accessory muscles, pursed-lip breathing, or
changes in skin or mucous membrane color, such as pallor
Auscultate lungs for air movement and abnormal breath
Investigate restlessness and changes in mentation and level of
Assess client response to activity. Encourage rest periods,
limiting activities to client tolerance.
Note development of fever.
Maintain patent airway by positioning, suctioning, and use of
Reposition frequently, placing client in sitting and supine to
Avoid positioning client with a pneumonectomy on the operative
side; instead, favor the “good lung down” position.
Encourage and assist with deep-breathing exercises and
pursed-lip breathing, as appropriate.
Tube Care: Chest
Maintain patency of chest drainage system following
lobectomy and segmental wedge resection procedures.
Note changes in amount or type of chest tube drainage.
Observe for presence of bubbling in water-seal chamber.
Administer supplemental oxygen via nasal cannula, partial
rebreathing mask, or high-humidity face mask, as indicated.
Assist with and encourage use of incentive spirometer.
Monitor and graph ABGs and pulse oximetry readings. Note
hemoglobin (Hgb) levels.
Respirations may be increased as a result of pain or as an
initial compensatory mechanism to accommodate for loss
of lung tissue. However, increased work of breathing and
cyanosis may indicate increasing oxygen consumption and
energy expenditures or reduced respiratory reserve, for
example, in an elderly client or extensive COPD.
Consolidation and lack of air movement on operative side are
normal in the client who has had a pneumonectomy; however,
a client who has had a lobectomy should
demonstrate normal airflow in remaining lobes.
May indicate increased hypoxia or complications such as
mediastinal shift in a client who has had a pneumonectomy
when accompanied by tachypnea, tachycardia, and tracheal
Increased oxygen consumption and demand and stress of
surgery may result in increased dyspnea and changes in
vital signs with activity; however, early mobilization is
desired to help prevent pulmonary complications and to
obtain and maintain respiratory and circulatory efficiency.
Adequate rest balanced with activity can prevent
Fever within the first 24 hours after surgery is frequently due
to atelectasis. Temperature elevation within postoperative
day 5 to 10 usually indicates an infection, such as wound
Airway obstruction impedes ventilation, impairing gas
exchange. (Refer to ND: ineffective Airway Clearance.)
Maximizes lung expansion and drainage of secretions.
Research shows that positioning clients following lung surgery
with their “good lung down” maximizes oxygenation by
using gravity to enhance blood flow to the healthy lung,
thus creating the best possible match between ventilation
Promotes maximal ventilation and oxygenation and reduces
or prevents atelectasis.
Drains fluid from pleural cavity to promote reexpansion of
remaining lung segments.
Bloody drainage should decrease in amount and change to
a more serous composition as recovery progresses.
A sudden increase in amount of bloody drainage or return
to frank bleeding suggests thoracic bleeding or a hemothorax;
sudden cessation suggests blockage of tube, requiring
further evaluation and intervention.
Air leaks appearing immediately postoperatively are not
uncommon, especially following lobectomy or segmental
resection; however, this should diminish as healing
progresses. Prolonged or new leaks require evaluation to
identify problems in client versus a problem in the drainage
Maximizes available oxygen, especially while ventilation is
reduced because of anesthetic, depression, or pain, and
during period of compensatory physiological shift of
circulation to remaining functional alveolar units.
Prevents or reduces atelectasis and promotes reexpansion of
Decreasing PaO2 or increasing PaCO2 may indicate need for
ventilatory support. Significant blood loss results in
decreased oxygen-carrying capacity, reducing PaO2.