NURS 443 Lecture Notes - Lecture 12: Hypercalcaemia, Ifosfamide, Radiofrequency Ablation

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6 May 2018
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Lung cancer
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Lung cancer is the leading cause of cancer-related deaths in the United States and accounts for 28% of all cancer
deaths. Female smokers have a higher risk of developing lung cancers than male smokers.
■Smoking is the greatest risk factor for lung cancer. Smoking is responsible for approximately 80% to
90% of all lung cancers. Tobacco smoke contains 60 carcinogens and causes a change in the bronchial
epithelium, which usually returns to normal when smoking is discontinued.
Assessment of lung cancer risk is divided into three categories: (1) smokers, people who are currently smoking; (2)
nonsmokers, people who formerly smoked; and (3) never smokers. The risk of developing lung cancer is directly
related to total exposure to tobacco smoke, measured by total number of cigarettes smoked in a lifetime, age of
smoking onset, depth of inhalation, tar and nicotine content, and the use of unfiltered cigarettes. Sidestream smoke
(smoke from burning cigarettes, cigars) contains the same carcinogens found in mainstream smoke (smoke inhaled
and exhaled from the smoker).
■Other causes of lung cancer include high levels of pollution, radiation (especially radon exposure),
and asbestos. Heavy or prolonged exposure to industrial agents such as ionizingradiation, coal dust,
uranium, formaldehyde, and arsenic can also increase the risk of lung cancer.
■It is also theorized that people have different genetic carcinogen-metabolizing pathways. This may
explain why some smokers develop lung cancer and others do not.
Pathophysiology
Most primary lung tumors are believed to arise from mutated epithelial cells. The development of mutations that are
caused by carcinogens is influenced by various genetic factors. Once started, tumor development is promoted by
epidermal growth factor. These cells grow slowly, taking 8 to 10 years for a tumor to reach 1 cm in size, the smallest
lesion detectable on an x-ray. Lung cancers occur primarily in the segmental bronchi or beyond and have a
preference for the upper lobes of the lungs.
Primary lung cancers are categorized into two broad types: nonsmall cell lung cancer (NSCLC) (80%) and small
cell lung cancer (SCLC) (20%). Lung cancer metastasizes primarily by direct extension and by way of the blood and
lymph system. Common sites for metastasis are the liver, brain, bones, lymph nodes, and adrenal glands.
Clinical manifestations
Manifestations are usually nonspecific, appear late in the disease process, and depend on the type of primary lung
cancer, its location, and metastatic spread.
■One of the most common first symptoms reported is a persistent cough. Blood-tinged sputum may be
produced because of bleeding caused by the malignancy.
■The patient may complain of dyspnea or wheezing. Chest pain, if present, may be localized or
unilateral, ranging from mild to severe.
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Later manifestations include nonspecific symptoms such as anorexia, fatigue, weight loss, and nausea and vomiting.
Hoarseness may be present as a result of laryngeal nerve involvement. Unilateral paralysis of the diaphragm,
dysphagia, and superior vena cava obstruction may occur because of intrathoracic spread of malignancy. There may
be palpable lymph nodes in the neck or axillae. Mediastinal involvement may lead to pericardial effusion, cardiac
tamponade, and dysrhythmias.
Paraneoplastic syndrome is caused by humoral factors (hormones, cytokines) excreted by tumor cells or by an
immune response against the tumor. SCLCs are most often associated with the paraneoplastic syndrome. Symptoms
of paraneoplastic syndrome may manifest before the diagnosis of a malignancy.
■Examples of paraneoplastic syndrome include hypercalcemia, syndrome of inappropriate antidiuretic
hormone (SIADH) secretion, hematologic disorders, and neurologic syndromes. These conditions may
stabilize with treatment of the underlying neoplasm.
Diagnostic studies
■ Chest x-ray is used for diagnosis and assessing for metastasis.
■ Biopsy is necessary for a definitive diagnosis. If thoracentesis is performed to relieve a pleural
effusion, the fluid is also analyzed for malignant cells.
■ Additional diagnostic tests include bone scans, CT scans, MRI, positron emission tomography (PET),
blood tests, renal function tests, and pulmonary function tests.
Staging of NSCLC is performed according to the TNM staging system (see TNM Classification System, p. 777).
Collaborative care
Surgical resection is the treatment of choice in NSCLC stages I and IIIA without mediastinal involvement because
the disease is potentially curable with resection. The 5-year survival in stage I and II disease ranges from 30% to
50%. For other NSCLC stages, patients may require surgery in conjunction with radiation therapy and/or
chemotherapy. Fifty percent of NSCLCs are not resectable at the time of diagnosis. Surgical procedures that may be
performed include pneumonectomy (removal of one entire lung), lobectomy (removal of one or more lung lobes), or
segmental or wedge resection procedures.
Radiation therapy may be used as treatment for both NSCLC and SCLC (see Radiation Therapy, p. 730).
■Radiation relieves symptoms of dyspnea and hemoptysis from bronchial obstruction tumors and treats
superior vena cava syndrome.
■Radiation can be used to treat the pain of metastatic bone lesions or cerebral metastasis, to reduce
tumor mass preoperatively, or as an adjuvant measure postoperatively.
A newer type of radiation therapy is stereotactic radiotherapy (SRT), which uses high doses of radiation delivered
accurately to the tumor. SRT provides an option for patients with early-stage lung cancers who are not surgical
candidates for other medical reasons.
Chemotherapy is the primary treatment for SCLC. It may be used for nonresectable tumors or as an adjuvant therapy
to surgery in NSCLC. A variety of chemotherapy drugs and multidrug regimens (i.e., protocols) have been used (see
Chemotherapy, p. 694).
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One type of targeted therapy for patients with NSCLC is erlotinib (Tarceva), which blocks signals for growth in
cancer cells. Other drugs, such as bevacizumab (Avastin), inhibit new blood vessel growth (angiogenesis).
Nursing management
Goals
The patient with lung cancer will have effective breathing patterns, adequate airway clearance, adequate
oxygenation of tissues, minimal to no pain, and a realistic attitude toward treatment and prognosis.
Nursing diagnoses
■ Ineffective airway clearance
■ Anxiety
■ Ineffective self-health management
■ Ineffective breathing pattern
■ Impaired gas exchange
Nursing interventions
Care of the patient with lung cancer initially involves support and reassurance during the diagnostic evaluation.
Individualized care will depend on the plan for treatment.
■Assessment and intervention in symptom management are pivotal.
■For many individuals who have lung cancer, little can be done to significantly prolong their lives.
Radiation therapy and chemotherapy can provide palliative relief from distressing symptoms. Constant
pain may become a major problem.
■Provide patient comfort, monitor for side effects of prescribed medications, foster appropriate coping
strategies for patient and caregiver, assess smoking cessation readiness, and help patients access
resources to deal with the illness.
patient and caregiver teaching
■ A wealth of material is available to the smoker who is interested in smoking cessation. The Centers
for Disease Control and Prevention (CDC) provides an index of
tools(www.cdc.gov/tobacco/quit_smoking/cessation/index.htm). Also see Chapter 11 in Lewis et
al.,Medical-Surgical Nursing, ed. 9.
■ The patient and family should be encouraged to provide a smoke-free environment. This may include
smoking cessation for multiple family members. If the treatment plan includes the use of home oxygen,
instruct the patient and family on the safe use of oxygen.
■ Teach the patient to recognize signs and symptoms that may indicate progression or recurrence of
disease.
Lung Cancer
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Document Summary

Lung cancer is the leading cause of cancer-related deaths in the united states and accounts for 28% of all cancer deaths. Female smokers have a higher risk of developing lung cancers than male smokers. Smoking is the greatest risk factor for lung cancer. Tobacco smoke contains 60 carcinogens and causes a change in the bronchial epithelium, which usually returns to normal when smoking is discontinued. Assessment of lung cancer risk is divided into three categories: (1) smokers, people who are currently smoking; (2) nonsmokers, people who formerly smoked; and (3) never smokers. Sidestream smoke (smoke from burning cigarettes, cigars) contains the same carcinogens found in mainstream smoke (smoke inhaled and exhaled from the smoker). Other causes of lung cancer include high levels of pollution, radiation (especially radon exposure), and asbestos. Heavy or prolonged exposure to industrial agents such as ionizingradiation, coal dust, uranium, formaldehyde, and arsenic can also increase the risk of lung cancer.

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