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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
EDUCATE
UNDERSTAND
RESPOND
ANTICIPATE
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
UNDERSTAND
RESPOND
ANTICIPATE
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
ANTICIPATE
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
ANTICIPATE
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
UNDERSTAND
RESPOND
ANTICIPATE
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
UNDERSTAND
RESPOND
ANTICIPATE
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
UNDERSTAND
RESPOND
ANTICIPATE
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
EDUCATE
UNDERSTAND
RESPOND
ANTICIPATE
Other Oncology Emergencies
• SIADH• Hypercalcemia of Malignancy• Cardiac Tamponade• Malignant Pleural Effusion• Sepsis and Septic Shock