Lung cancer is the leading cause of cancer death among both men and women. Annually, over 163,500 deaths from lung cancer occur, which are 28% of all cancer deaths. Lung cancer accounts for more deaths than prostate, breast, and colon cancer combined. The 1-year survival rate remains approximately 41%, and the 5-year survival rate is 15%. Only 16% of lung cancers are found at an early, localized stage, when the 5-year survival rate is 49%. The survival rate for lung cancer has not improved over the last 10 years.
There are two major types of lung cancer: small cell lung cancer (SCLC) and non–small cell lung cancer (NSCLC). Sometimes a lung cancer shows characteristics of both types and is labeled small cell/large cell carcinoma. Both types have the capacity to synthesize bioactive products and produce paraneoplastic syndromes such as the syndrome of inappropriate antidiuretic hormones (SIADH), Cushing’s syndrome, and Eaton-Lambert syndrome of neuromuscular disorder.
SCLC accounts for 13% of all lung cancers and is almost always caused by smoking. SCLC is characterized by small, round to oval cells generally beginning in the neuroendocrine cells of the bronchoepithelium of the lungs. They start multiplying quickly into large tumors and can spread to the lymph nodes and other organs. At the time of diagnosis, approximately 70% have already metastasized, often to the brain. SCLC is sometimes called small cell undifferentiated carcinoma and oat cell carcinoma.
NSCLC accounts for almost 87% of all lung cancers and includes three subtypes: squamous cell carcinoma, adenocarcinoma, and large cell undifferentiated carcinoma. Squamous cell carcinoma, also associated with smoking, tends to be located centrally, near a bronchus, and accounts for approximately 25% to 30% of all lung cancers. Adenocarcinoma, accounting for 40% of all large cell carcinoma, is usually found in the outer region of the lung. One type of adenocarcinoma, bronchioloalveolar carcinoma, tends to produce a better prognosis than other types of lung cancer and is sometimes associated with areas of scarring. Large cell undifferentiated carcinoma starts in any part of the lung, grows quickly, and results in a poor prognosis owing to early metastasis; approximately 10% to 15% of lung cancers are large cell undifferentiated carcinoma.
The hilus of the lung, close to the larger divisions of the bronchi, is the most frequent site of lung cancer. Abnormal cells divide and accumulate over time. As the cells grow into a carcinoma, they make the bronchial lining irregular and uneven. The tumor may penetrate the lung wall and surrounding tissue or grow into the opening (lumen) of the bronchus. In more than 50% of patients, the tumor spreads into the lymph nodes and then into other organs.
Systemic effects of the lung tumor that are unrelated to metastasis may affect the endocrine, hematologic, neuromuscular, and dermatologic systems. These changes may cause connective tissue and vascular abnormalities, referred to as paraneoplastic syndromes. In lung cancer, the most common endocrine syndromes are SIADH, Cushing’s syndrome, and gynecomastia. Complications of lung cancer include emphysema, bronchial obstruction, atelectasis, pulmonary abscesses, pleuritis, bronchitis, and compression on the vena cava.
Approximately 80% of lung cancers are related to cigarette smoking. Lung cancer is 10 times more common in smokers than in nonsmokers. In particular, squamous cell and small cell carcinoma are associated with smoking. Other risk factors include exposure to carcinogenic industrial and air pollutants—such as asbestos, coal dust, radon, and arsenic—and family history.
Nursing care plan assessment and physical examination
Establish a history of persistent cough, chest pain, dyspnea, weight loss, or hemoptysis. Ask if the patient has experienced a change in normal respiratory patterns or hoarseness. Some patients initially report pneumonia, bronchitis, epigastric pain, symptoms of brain metastasis, arm or shoulder pain, or swelling of the upper body. Ask if the sputum has changed color, especially to a bloody, rusty, or purulent hue. Elicit a history of exposure to risk factors by determining if the patient has been exposed to industrial or air pollutants. Check the patient’s family history for incidence of lung cancer.
The clinical manifestations of lung cancer depend on the type and location of the tumor. Because the early stages of this disease usually produce no symptoms, it is most often diagnosed when the disease is at an advanced stage. In 10% to 20% of patients, lung cancer is diagnosed without any symptoms, usually from an abnormal finding on a routine chest x-ray. The clinical findings of lung cancer may be localized to the lung or may result from the regional or distant spread of the disease. Auscultation may reveal a wheeze if partial bronchial obstruction has occurred. Auscultate for decreased breath sounds, rales, or rhonchi. Note rapid, shallow breathing and signs of an airway obstruction, such as extreme shortness of breath, the use of accessory muscles, abnormal retractions, and stridor. Tumor involvement of the pleura and chest wall may cause pleural effusion. Typically, pleural effusion causes dullness on percussion and breath sounds that are decreased below the effusion and increased above it. Monitor the patient for oxygenation problems, such as increased heart rate, decreased blood pressure, or an increased duskiness of the oral mucous membranes. Metastases to the mediastinal lymph nodes may involve the laryngeal nerve and may lead to hoarseness and vocal cord paralysis. The superior vena cava may become occluded with enlarged lymph nodes and cause superior vena cava syndrome; note edema of the face, neck, upper extremities, and thorax.
The patient undergoes major lifestyle changes as a result of the physical side effects of cancer and its treatment. Interpersonal, social, and work role relationships change. The patient is faced with a psychological adjustment to the diagnosis of a chronic illness that frequently results in death. Evaluate the patient for evidence of altered moods such as depression or anxiety, and assess the patient’s coping mechanisms and support system.
Nursing care plan primary nursing diagnosis: Ineffective airway clearance related to obstruction caused by secretions or tumor.
Nursing care plan intervention and treatment plan
The treatment of lung cancer depends on the type of cancer and the stage of the disease. Surgery, radiation therapy, and chemotherapy are all used. Unless the tumor is small without metastasis or nodes when discovered, it is often not curable.
Surgical treatment ranges from segmentectomy or wedge resection (removal of a part of a lobe) to lobectomy (removal of a section of the lung) to pneumonectomy (removal of an entire lung). These procedures all require general anesthesia and a thoracotomy (surgical incision in the chest). If patients are unable to undergo a thoracotomy because of other serious medical problems or widespread cancer, laser surgery may be performed to relieve blocked airways and diminish the threat of pneumonia or shortness of breath. Chemotherapy is used for cancer that has metastasized beyond the lungs. It is used both as a primary treatment and an adjuvant treatment to surgery. The chemotherapy most often uses a combination of anticancer drugs; different combinations are used to treat NSCLC and SCLC.
Radiation therapy is sometimes the primary treatment for lung cancer, particularly in patients who are unable to undergo surgery. It is also used palliatively to alleviate symptoms of lung cancer. In conjunction with surgery, radiation is sometimes used to kill deposits of cancer that are too small to be seen and thus to be surgically removed. Radiation therapy takes two forms: External beam therapy delivers radiation from outside the body and focuses on the cancer and is most frequently used to treat a primary lung cancer or its metastases to other organs; brachytherapy uses a small pellet of radioactive material that is placed directly into the cancer or into the nearby airway.
Maintain a patent airway. Position the head of the bed at 30 to 45 degrees. Increase the patient’s fluid intake, if possible, to assist in liquefying lung secretions. Provide humidified air. Suction the patient’s airway if necessary. Assist the patient in controlling pain and managing dyspnea. Assist the patient with positioning and pursed-lip breathing. Allow extra time to accomplish the activities of daily living. Teach the patient to use guided imagery, diversional activities, and relaxation techniques. Provide periods of rest between activities.
Discuss the expected preoperative and postoperative procedures with patients who are undergoing surgical intervention. Emphasize the importance of coughing and deep breathing after surgery. Splinting the patient’s incision may decrease the amount of discomfort the patient feels during these activities. Monitor closely the patency of the chest tubes and the amount of chest tube drainage. Notify the physician if the chest tube drainage is greater than 200 mL/hr for more than 2 to 3 hours, which may indicate a postoperative hemorrhage. Early in the postoperative period, begin increasing the patient’s activity. Help the patient sit up in the bedside chair, and assist the patient to ambulate as soon as possible.
Explain the possible side effects of radiation or chemotherapy. Secretions may become thick and difficult to expectorate when the patient is having radiation therapy. Encourage the patient to drink fluids to stay hydrated. Percussion, postural drainage, and vibration can be used to aid in clearing secretions.
The patient may experience less anxiety if allowed as much control as possible over his or her daily schedule. Explaining procedures and keeping the patient informed about the treatment plan and condition may also decrease anxiety. If the patient enters the final phases of lung cancer, provide emotional support. Refer the patient and family to the hospice staff or the hospital chaplain. Encourage them to verbalize their feelings surrounding impending death. Allow for the time needed to adjust while you help the patient and family begin the grieving process. Assist in the identification of tasks to be completed before death, such as making a will; seeing specific relatives and friends; or attending an approaching wedding, birthday, or anniversary celebration. Urge the patient to verbalize specific funeral requests to family members.
Nursing care plan discharge and home health care guidelines
Teach the patient to recognize the signs and symptoms of infection at the incision site, including redness, warmth, swelling, and drainage. Explain the need to contact the physician immediately. Be sure the patient understands any medication prescribed, including dosage, route, action, and side effects. Provide the patient with the names, addresses, and phone numbers of support groups, such as the American Cancer Society, the National Cancer Institute, local hospice, the Alliance for Lung Cancer Advocacy, Support & Education (ALCASE), and the Visiting Nurses Association. Teach the patient how to maximize her or his respiratory effort.