Nursing Care of the Lung Cancer

Patient

Ann Proctor RN, BSN, OCNLinda Farjo RN, BSN, OCN

Putting the Puzzle Together

• VATS• Chest Tubes• Nursing Care of the

Brachytherapy Patient

• Pleur-x Catheters• Oncology

Emergencies and Lung Cancer

• EDUCATE

• UNDERSTAND

• RESPOND

• ANTICIPATE

VATS - VIDEO ASSISTED THORASCOPIC SURGERY

What is VATS?

• VATS – video assisted thorascopic surgery

• Minimally invasive procedure• 3-4 small incisions• Uses a small video camera introduced

into the chest via a scope. Used for diagnosis and treatment

• A segment, lobe or entire lung can be removed, depending on the patient's condition and the extent of the cancer

Advantages of a VATS Procedure

• Less morbidity and shorter hospital stay

• Reduced injury to the chest wall muscles used in respiration

• Smaller incisions means less pain and fewer complications

• Return to work and daily activities much sooner

VATS Candidates

• People with cancer in the early stages of disease

• Not suitable for:– People receiving neoadjuvant chemo (given before

surgery) – People with bulky areas of disease in the thorax– People whose surgery will exceed a certain

threshold of complexity

Nursing Care of the VATS Patient

• Chest tube management• Pain control• Education

– Surgery takes 1-2 hours– CT removed 1 day after surgery– Cough and deep breathe, IS– Ambulation– Skin below and in front of incision to be numb – up

to 6 months after surgery– Discharge 1-2 days after surgery

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CHEST TUBES

Chest Anatomy

Why do we use chest tubes?• Cardiac Surgery

– Fluid drainage

Why do we use chest tubes?

• Thoracic Surgery• Tension pneumothorax

Signs and Symptoms of tension pneumothorax Sudden chest pain Chest tightness SOB Rapid heart rate Bluish skin color Pain in arm Stabbing sensation in the backVenous return and cardiac output impeded

Why do we use chest tubes?

• Malignant pleural effusion Most common signs and symptoms of pleural effusions: Chest pain Shortness of breath

Mild pain Dry cough Pleuritic stabbing pain No symptoms

Why do we use chest tubes?

• Pneumothorax

Why do we use chest tubes?

• Hemothorax

Chest Drainage System Components

Collection Chamber

Water Seal Chamber

Suction control chamber

Care of the Chest Tube Drainage System

• Preparing the system for insertion– Step 1 - Fill water seal to 2 cm line– Step 2 - Connect chest drain to patient– Step 3 - Connect chest drain to suction

– Step 4 - Turn suction on

• Care of the drainage unit– Place below the level of the patient’s chest– Swing floor stand open for secure placement on floor – Hang the system bedside with the hangers provided– Do not obstruct the positive pressure valve

Care of the Chest Tube Drainage System

• Care of the tubing– Do not tape connections– Avoid dependent loops in the tubing– Keep it above the chest drainage system– Do not clamp the tubing

• Care of the dressing site– Redress prn if wet using sterile technique

Heimlich valve

Nursing Assessment

• Know when and why the tube

was inserted• Patient Education• Breath sounds• Trachea position• Respiratory rate and pattern• Suction setting• Drainage amount and color• Dressing condition• Check for air leaks

EDUCATE

UNDERSTAND

RESPOND

ANTICIPATE

Nursing Assessment

• Look for evidence of:– Fever– Hypoxia– Chest pain

• Pain assessment and response

to pain relieving measures• Evidence of subcutaneous emphysema

– Palpate around chest tube area

EDUCATE

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NURSING CARE OF THE BRACHYTHERAPY RADIATION

PATIENT

Permanent Radiation Implants

• Prostate seed implants

• Little radiation precautions necessary– Radiation used has

low energy and does not penetrate the patient’s body

– Generally an out-patient procedure

– Patient may be admitted for medical and not radiation reasons

Permanent Radiation Implants

• Cesium 131 Implants

– Body sites for permanent implant therapies, such as lung, brain, head and neck, gynecological.

– Patients are hospitalized for the post-operative care, not for the radiation care

Cesium 131 implants

Cesium 131 implants

Protection

• Basic Radiation Safety Rules

– Minimize time with the patient

– Maximize your distance

– Use appropriate shielding

Room Preparation

• Private room with bathroom• Equipment:

– Long handled forceps or hemostat– Lead vial holder – Lead shield– Lead aprons (2)– Dosimeter badge

• Radiation Caution Sign outside of room• Radiation Safety Officer (RSO) will tape the 3

foot safe distance area in the room.

Nursing Protection• Always wear your radiation dosimeter badge.

• No one who is pregnant or suspects they are pregnant should enter the room unless an immediate need arises. – A lead shield will be available if a pregnant staff

member must enter the room.

• Standard precautions are appropriate.

• Use a lead apron or stay behind the lead shield provided if contact closer than 3 ft of patient will be longer than 5 minutes.

• RSO will check radiation levels in room daily.

Housekeeping

• Housekeeping personnel may enter room for short intervals of time

• When the patient is transferred or discharged out of the room – RSO will check the room for radiation safety levels and notify the nursing staff when the room can be cleaned and occupied by another patient

Visitors

• Children and pregnant women are not permitted in the patient’s room.

• Minimum contact with the patient is permissible, however the time spent in close proximity to the patient (closer than 3 feet) should be minimized to less than 5 minutes per day for the first 10 days.

Nursing Care

• Nursing Assessment– Organize patient care to provide maximum care in

minimal time– Work on side opposite seed implant if applicable– Be alert for seed implants which have become

loose, particularly in cavities with access to the exterior• Notify RSO of any dislodged implant• Use long handled forceps or hemostats to pick

radioactive source and place in leaded vial• Do not touch the seed with hands

EDUCATE

UNDERSTAND

RESPOND

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Nursing Care• Medication Administration

– All equipment is not considered contaminated and may be removed from the room

• Dressing– Do not discard any old dressings or linens until they

have been surveyed by the RSO– Linens and trash are considered contaminated

because of potential lost seeds and should remain in the room until cleared by the RSO

• I&O– Body fluids are not radioactive- maintain standard

nursing precautions

EDUCATE

UNDERSTAND

RESPOND

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Nursing Care

• Notify Radiation Oncology

@ x18180 if any unusual event occurs such as:

– Finding a seed– The patient requires additional surgery– The patient expires

• In an emergency– First priority is caring for the patient– Wear badges when with the patient– Notify RSO immediately

EDUCATE

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PLEUR-X DRAINAGE CATHETERS

Indications

• Malignant Pleural Effusion

• Malignant Ascites

Benefits for Patients

• Easy set up and use• Low rate of infection• Helps eliminate hospital visits• Palliation of symptoms• Improved quality of life• Simple placement procedure

Supplies

• Purchased by patient• Hospice patient: supplies

covered by hospice• VNA patient: supplies

covered by individual insuranceSupplies

• Drainage system kit includes everything necessary to drain (10 kits/box)

Drainage Instructions

• Getting started– Get drainage supplies ready and wash hands– Remove dressing from drainage site– Open all packages and prepare field

• Connecting the Drainage Bottle– Remove cover from access tip– Take valve cap off catheter– Clean around valve opening with alcohol pad– Insert access tip into catheter valve

Drainage Instructions

• Draining fluid– Insert plunger into drainage bottle– Release clap on drainage line to begin draining

*** Chest drain – maximum of 1000 cc/day ***

*** Abdomen drain - maximum 2000 cc/day ***– Inpatients can be connected to PleurX drainage

system, pleuravac, foley bag, or wall suction• Suction should be set at lowest possible setting

(60 mm Hg)

Drainage Instructions

• Final Steps and Disposal– Clean around valve with alcohol pad and place new

cap on catheter valve– Clean around catheter site with alcohol pad– Place dressing on site– Dispose of bottle

Chest drainage

Abdominal drainage

Nursing Care

• Assess patient’s comfort level : pain, shortness of breath

• Do not drain more than the amount indicated for the drain

• If patient experiences any distress, notify physician

EDUCATE

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ONCOLOGY EMERGENCIES AND

LUNG CANCER

Superior Vena Cava Syndrome(SVCS)

Definition:

– SVC obstruction is a narrowing or blockage of the superior vena cava -- the second largest vein in the human body. The superior vena cava moves blood from the upper half of the body to the heart.

– The SVC is the main vein that drains blood back into the heart from the upper body, and it runs in the middle of the chest on the right side, where it is vulnerable to being compressed by a nearby lung cancer or enlarged lymph nodes, such as from lung cancer or lymphoma

SVCS

Symptoms of SVCS

• The leading symptoms of SVC syndrome are facial edema, distended veins in the neck and sometimes chest, arm edema, shortness of breath, cough, facial plethora/fullness, and less commonly wheezing, lightheadedness, headaches, and even confusion. 

Causes of SVCS

Malignant causes

– Lung Cancer• Small cell lung cancer

– Lymphoma– Other metastatic cancers

• Mesothelioma• Breast• Germ cell• Thymoma

Non-malignant causes

– Catheter related thrombus– TB– Goiter– Aortic aneurysm– Histoplamosis

Diagnosis of SVCS

• Chest X-ray

• CT scan of thorax

• MRI

• Ultrasound

Treatment of SVCS

• Radiation Therapy

• Chemotherapy

• Pharmacological

• Surgery

Nursing Interventions for SVCS

• Recognize high risk patients– Lung cancer– Lymphoma– Other metastatic disease

• Be aware of the signs and symptoms of SVCS– Assessment of respiratory, cardiac and neurologic systems– Intravenous fluids should not be given through the upper

extremities - central venous access devices necessary and require diligent nursing care

EDUCATE

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Spinal Cord Compression(SCC)

Definition– The spinal cord is compressed by bone fragments

from a vertebral fracture, a tumor, abscess, ruptured intervertebral disc or other lesion

Symptoms of SCC• Can depend on where the compression is

located• New or worsening back pain • Weakness • Loss of sensation in affected limbs • Decreased sense of the relative position of

neighboring parts of the body • Numbness / tingling / coldness • Urinary retention / constipation • Ataxia / Bowel / bladder incontinence • Sexual dysfunction

Causes of SCC

Most common tumors that cause spinal cord compression:

• Lung

• Breast

• Prostate

Causes of SCC

Vertebral metastases

– Vertebral metastases can directly invade the epidural space or cause bone destruction, with bone fragments leading to compression.

– Edema and ischemia caused by compression of blood flow to the cord

Cauda equina compression

– The cauda equina is a bundle of nerves located at the bottom of the spinal cord, with nerves spreading out like a horse tail

– Loss of bowel and/or bladder function

– Loss of sensation in the buttocks, thighs and groin (saddle distribution).

Diagnosis of SCC

• MRI• CT scan with myelography

Treatment of SCC

• The goal of therapy for SCC include pain control, avoidance of complications, preserving or improving neurologic functions or reversing impaired neurologic functions.

– Corticosteroids– Radiation Therapy– Surgery– Other medications: Chemotherapy, Biphosphonates

Prognostic Factors for Functional Recovery

• Favorable prognostic factors:– Early recognition and diagnosis– Prompt initiation of therapy– Able to ambulate at presentation – Slow onset of motor weakness– Radiosensitive tumors – myeloma, lymphoma, breast, prostate– Responsive to steroid treatment– Female gender– Good performance status– Long interval between diagnosis and appearance of SCC

Prognostic Factors for Functional Recovery

• Poor prognostic factors:– Paraplegia prior to treatment – Urinary retention– Sphincter incontinence– Rapidly deteriorating neurologic function

(in less than 72 hours)– Radioresistant tumors – lung, renal, GI, sarcoma, bladder– Extensive disease– Poor performance status

Nursing Interventions for SCC

• Early recognition

– Know signs & symptoms– Know risk factors– Thorough assessment

• Pain• Sensory and motor status• Neurologic• Bowel and bladder function

• Education

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UNDERSTAND

RESPOND

ANTICIPATE

Other Oncology Emergencies

• SIADH• Hypercalcemia of Malignancy• Cardiac Tamponade• Malignant Pleural Effusion• Sepsis and Septic Shock