Lung Cancer

Lung cancer remains the most common cause of cancer death among men and women in the United States. National Cancer Institute statistics indicate that 90% of lung cancer deaths in men and 86% in women may be attributed to smoking cigarettes, cigars or pipes. Secondhand tobacco smoke is responsible for 3400 deaths per year. Other risk factors are hookah smoking, radon exposure, which is the leading cause of lung cancer among nonsmokers, radiation therapy to the chest, and automobile pollution. Despite treatment advances in surgery, chemotherapy, and radiation therapy, the cure rate remains low. Although exposure to certain known carcinogens such as radon and asbestos may cause lung cancer, the greatest number of lung cancer cases is linked to tobacco smoking or exposure to secondhand smoke.

Most cases of lung cancer are classified as small cell or non–small cell cancer, but a small portion of lung cancer cases consists of mesotheliomas, bronchial gland tumors, or carcinoids. The cell type, diagnosed via biopsy and pathologic staging, determines the appropriate treatment. Depending on the stage of lung cancer at presentation, surgery, chemotherapy, and/or radiation therapy may be part of the medical treatment plan. For patients with advanced disease for whom cure is not foreseen, palliative care should be initiated concurrently with other treatment modalities, but actually palliation may be the only truly appropriate treatment course.

Nervous System Tumors

Tumors of the nervous system may be primary or secondary tumors of the central nervous system (CNS), which includes the brain and spinal cord. These tumors are classified according to their cell of origin and graded according to their malignant behavior. Although histologically the tumor may be benign, the enclosed nature of the CNS may result in tumor effects causing significant damage or even death.

The primary CNS tumor, whether benign or malignant, can manifest with interrupted neuronal function, compression of the spinal cord or brain and surrounding vasculature, cerebrospinal fluid (CSF) obstruction with resulting increased intracranial pressure, or degeneration of surrounding tissue. Treatment is initially surgical if the tumor site is accessible. The surgical approach may be conventional open skull, or minimally invasive keyhole surgery via the nose or the eyebrow. For some tumors, complete resection is tantamount to cure. For very aggressive tumors or when residual tumor is present postoperatively, radiation therapy and chemotherapy may be implemented.

Surgical excision of metastatic CNS tumors may be an option, but these tumors are more often treated with radiation therapy, including stereotactic radiosurgery, in which a system of three-dimensional coordinates is used to locate the site for irradiation. Chemotherapy also may be an option for control.

Gastrointestinal Malignancies

Malignancies of the gastrointestinal (GI) system include carcinomas of the stomach, esophagus, bowel, anus, rectum, pancreas, liver, and gallbladder. Each disease site has its own staging criteria and prognostic factors. Most early-stage tumors of all sites are surgically treated. Many treatment plans now begin with preoperative chemotherapy and/or concurrent radiation therapy in the weeks preceding surgery. This approach may eliminate the need for extensive surgeries, increase the chances for cure, or in the case of the anorectal-sparing approach, eliminate the necessity for a colostomy. Radiation therapy is less common in gastric, colon, and liver tumors because of the toxicities associated with irradiating these areas. Radiofrequency ablation is an interventional radiologic approach that is sometimes successful in managing metastatic liver tumors.

Neoplastic Diseases of the Hematopoietic System

Hematopoietic system cancers include lymphomas, leukemias, plasma cell disorders, and myeloproliferative disorders.

Lymphomas

Depending on cellular type, lymphomas are classified as Hodgkin or non-Hodgkin and are characterized by abnormal proliferation of lymphocytes. In addition to characteristic lymph node enlargement, involvement of other lymphoid organs such as the liver, spleen, and bone marrow does occur. Treatment planning, based on disease stage, usually involves chemotherapy and sometimes radiation therapy for eradication of local disease. Patients with Hodgkin lymphoma may have a chance for cure, whereas patients with certain grades of non-Hodgkin lymphoma may be given treatment to simply prolong survival.

Head and Neck Cancers

Head and neck cancers include tumors of the tonsils, larynx, pharynx, tongue, and oral cavity. Incidence is greatest in men over age 50 yr, and incidence rates in men are double those in women. By far the greatest risk factors are tobacco consumption through smoking or smokeless tobacco and alcohol consumption.

Breast Cancer

According to the ACS, the incidence of breast cancer continues to rise; the disease occurs in one out of seven women (lifetime risk) in the United States. Several factors must be taken into consideration to determine disease stage and prognosis and to establish a treatment plan upon diagnosis. Tumor differentiation is a prognostic factor, with poorly differentiated tumors boding a worse prognosis. Other factors considered in treatment and prognosis are rate of tumor growth (S-phase), DNA characteristics (ploidy), estrogen and progesterone receptors, other biochemical changes (e.g., HER-2/neu), lymph node metastases, and distant metastases. Treatment may include any, all, or a combination of the following: surgery, chemotherapy, radiation therapy, hormonal treatment, and biologic therapy. Metastatic breast cancer, considered a chronic disease in some women, may result in therapy spanning several years.

Genitourinary Cancers

Nursing Diagnoses and Interventions for General Cancer Care

The following nursing diagnoses, desired outcomes, and interventions relate to generalized cancer care. Those for care specific to chemotherapy, immunotherapy, and radiation therapy are discussed in the following major subsection, beginning on p. 672.

Ineffective breathing pattern

related to decreased lung expansion secondary to fluid accumulation in the lungs (pleural effusion)

For desired outcome and interventions, see this nursing diagnosis in “Pleural Effusion,” p. 69. Patients at increased risk for pleural effusion are those with malignancies, including lymphoma, leukemia, mesothelioma, lung and breast cancers, and metastasis to the lung from other primary cancers.

Ineffective breathing pattern

related to decreased lung expansion secondary to pulmonary fibrosis, cellular damage, and decreased lung capacity (pneumonectomy or lobectomy)

For desired outcome and interventions, see this nursing diagnosis in “Perioperative Care,” p. 5. Some chemotherapeutic agents (BOX 12-1) can cause pulmonary toxicity, an inflammatory reaction that results in fibrotic lung changes, cellular damage, and decreased lung capacity. Radiation therapy also can cause pulmonary damage and changes resulting in decreased lung capacity.

BOX 12-1 CHEMOTHERAPEUTIC DRUGS THAT MAY CAUSE PULMONARY TOXICITY

Bleomycin

Busulfan

Carmustine

Cyclophosphamide

Cytarabine

Fludarabine

Interferon alfa-2b

Interleukin-2

Melphalan

Methotrexate

Mitomycin C

Ineffective breathing pattern

related to dyspnea secondary to anemia, pulmonary tumors, pneumonia, pulmonary emboli, pulmonary atelectasis, ascites, radiation, pericardial effusion, superior vena cava syndrome, or hepatomegaly

For desired outcomes and interventions, see this nursing diagnosis in “Atelectasis,” p. 58. See Impaired gas exchange, p. 64, in “Pneumonia.”

Constipation

related to treatment with certain chemotherapy agents, opioids, tranquilizers, and antidepressants; less than adequate intake of food and fluids because of anorexia, nausea, or dysphagia; hypercalcemia; spinal cord compression; mental status changes; decreased mobility; or colonic disorders

For desired outcomes and interventions, see “Perioperative Care” for Constipation, p. 9; “Prolonged Bed Rest” for Constipation, p. 29; and “General Care of Patients with Neurologic Disorders” for Constipation, p. 363. Patients with cancer should not go more than 2 days without having a bowel movement. Patients receiving vinca alkaloids are at risk for ileus in addition to constipation. Preventive measures such as use of senna products or docusate calcium with casanthranol, especially for patients taking opioids, are highly recommended. In addition, all individuals taking opioids should receive a prophylactic bowel regimen.

Diarrhea

related to chemotherapeutic agents; biologic agents; antacids containing magnesium; radiation therapy to the abdomen or pelvis; tube feedings; food intolerance; and bowel dysfunction such as tumors, Crohn’s disease, ulcerative colitis, and fecal impaction

For desired outcomes and interventions, see “Malabsorption/Maldigestion” for Diarrhea, p. 456; and Risk for deficient fluid volume related to diarrhea, p. 457; “Ulcerative Colitis” for Diarrhea, p. 482, and Risk for impaired perineal/perianal skin integrity related to persistent diarrhea, p. 482; “Caring for Patients with Human Immunodeficiency Virus Disease” for Diarrhea, p. 650; and “Nutritional Support Modalities” for Diarrhea, p. 706. For patients receiving chemotherapy with potential to cause diarrhea (e.g., 5-fluorouracil, irinotecan), instruct patient regarding need to have appropriate antidiarrheal medications available and other methods used to combat the effects of diarrhea (fluid replacement, addition of psyllium to the diet to provide bulk to stool, perineal hygiene). Instruct patient to notify health care provider if experiencing more than six loose stools per day.

Risk for disuse syndrome

related to upper extremity immobilization secondary to discomfort, lymphedema, treatment or disease-related injury, or infection after breast surgery

Desired outcomes

Before surgery, patient verbalizes knowledge about importance of and rationale for upper extremity movements and exercises. Upon recovery, patient has full ROM of the upper extremity.

Nursing Interventions

♦ Consult surgeon before the breast surgery to determine type of surgery anticipated. With the surgeon, develop an individualized exercise plan specific to patient’s needs, considering factors of wound healing, suture lines, and extent of surgical procedure.

♦ Encourage finger, wrist, and elbow movement to aid circulation and help minimize edema.

♦ Elevate extremity as tolerated to decrease edema.

♦ Encourage progressive exercise to regain preoperative ROM and use of affected arm. Have patient use affected arm for personal hygiene and activities of daily living (ADL). Other exercises (e.g., clasping hands behind the head and “walking” fingers up the wall) should be added as soon as patient is ready. After drains and sutures have been removed (usually 7-10 days postoperatively), patient should begin exercises that will enhance external rotation and abduction of the shoulder. Patient should be able to achieve maximum shoulder flexion by touching fingertips together behind her back if patient was capable of performing this activity before surgery.

♦ Patients who have had an axillary dissection involving loss of lymph nodes are at increased risk for infection. To minimize risk of lymphedema and infection, avoid giving injections in, measuring BP on, or taking blood samples from affected arm. Remind patient about lowered resistance to infection and importance of promptly treating any breaks in the skin. To help prevent infection after hospital discharge, advise patient to treat minor injuries with soap and water and to notify health care provider if signs of infection occur.

♦ Advise patient to wear a MedicAlert bracelet that cautions against injections and tests in the involved arm, to decrease risk of infection.

♦ To protect hand and arm from injury, advise patient to wear a thimble when sewing and a protective glove when gardening or doing chores that require exposure to harsh chemicals such as cleaning fluids. Explain that cutting cuticles should be avoided and lotion should be used to keep the skin soft. An electric razor should be used for shaving the axilla.

Urinary stress incontinence

related to loss of muscle tone in the urethral sphincter after radical prostatectomy

Desired outcome

Within the 24-hr period before hospital discharge, patient relates understanding of incontinence cause and suggested regimen to promote bladder control.

Nursing Interventions

♦ Explain to patient that there is potential for permanent urinary incontinence after prostatectomy but that it may resolve within 6 months. Describe the reason for the incontinence, and use aids such as anatomic illustrations.

♦ Encourage patient to maintain adequate fluid intake of at least 2-3 L/day (unless contraindicated), and explain that dilute urine is less irritating to the prostatic fossa.

♦ Establish a bladder routine with patient before hospital discharge (see “Urinary Incontinence,” p. 207).

♦ Teach patient Kegel exercises to enhance sphincter control (see “Urinary Incontinence,” p. 213).

♦ Remind patient to discuss any incontinence problems with health care provider during follow-up examinations.

Deficient knowledge

related to side effects of antiandrogen therapy or bilateral orchiectomy

Desired outcome

Within the 24-hr period before hospital discharge, patient verbalizes knowledge about the extent and duration of body changes.

Nursing Interventions

♦ Assess patient’s facility with language, and engage an interpreter or provide language-appropriate written materials if necessary.

♦ Inform patient of side effects of estrogen therapy and orchiectomy (e.g., breast enlargement, breast tenderness, loss of sexual desire, hot flashes).

♦ For patients taking estrogen therapy, provide instruction about symptoms related to complications of thromboembolic disorders and myocardial infarction, which should be reported to health care provider (e.g., shortness of breath; orthopnea; dyspnea; pedal edema; unilateral leg swelling or pain; left arm, left jaw, or left-sided chest pain).

♦ Provide reassurance that discontinuance of therapy, when it occurs, will result in resolution of most side effects.

♦ If appropriate, explain to patient that before initiating estrogen therapy, health care provider may prescribe radiation therapy to areolae of the breasts to minimize painful gynecomastia. However, this procedure will not decrease other side effects.

Deficient knowledge

related to purpose, type, and management of venous access device (VAD)

Desired outcome

Within the 24-hr period before hospital discharge, patient and significant other/caregiver verbalize understanding regarding the VAD, including its purpose, appropriate management measures, and reportable complications.

Nursing Interventions

♦ Three types of VADs are generally used: tunneled catheters, nontunneled catheters, and implanted ports.

• Nontunneled catheters (peripheral or central): Inserted by venipuncture into the vessel of choice, usually basilic, cephalic, or medial cubital vein, near or at the antecubital area, or jugular or subclavian vein in the upper thorax. A peripherally inserted central catheter (PICC) is an example of a nontunneled catheter. Maintenance involves flushing daily and after each use with normal saline and/or heparinized solution. Sterile dressing and cap changes are necessary. Refer to institutional policies for specific instructions.

• Tunneled central venous catheters: Inserted into a central vein with a portion of the catheter tunneled through subcutaneous tissue and exiting the body at a convenient area, usually the chest. A Dacron cuff encircles the catheter about 2 inches from the exiting end of the catheter. Tissue grows into this cuff and helps to prevent catheter dislodgment, as well as decreasing risk of microorganisms migrating along the catheter surface and entering the bloodstream. Single-lumen or multilumen catheters are available. Examples of tunneled central venous catheters include Broviac, Hickman, and Groshong. Maintenance involves flushing per institutional protocol and after each use with saline and/or heparinized saline solution. A sterile dressing change is performed 24 hr after insertion and then every 5 to 7 days until healed. Cap changes are performed using sterile technique. Refer to institutional policies for specific instructions.

• Implanted venous access ports: Consist of a catheter attached to a plastic or metal port inserted into a central or peripheral vein and then sutured in place in a surgically created subcutaneous pocket, most commonly on the chest. Venous access ports are completely embedded under the skin and may have single or dual access ports. Access to the port may be from the top or side, depending on port style. Noncoring needles must be used to access the port, to allow the system to reseal when the needle is removed. Do not flush catheter with any syringe smaller than 10 mL because of excess pressures generated by smaller syringes. When removing needle, apply pressure to sides of the port to promote ease of removal and patient comfort. Maintenance involves preparation of the site for access with an antibacterial preparation solution (e.g., povidone-iodine solution), optional local anesthetic, and flushing at least monthly or after each use with normal saline and/or heparinized solution. Refer to institutional policies for specific instructions. Dressings are not required after healing of the insertion site. There is a wide variety of catheter types, and the type of catheter determines the proper flushing solution. Before flushing a catheter, the nurse must be certain of catheter type and recommended flushing solution. Patients should be instructed always to carry the card provided by the manufacturer that identifies the type of catheter and recommended flushing solution.

♦ Determine patient’s and caregiver’s level of understanding of the VAD’s purpose. As appropriate, explain that the device can be used for venipunctures and administration of drugs, fluids, and blood products.

♦ Show a model of the device, and explain insertion procedure. Nontunneled catheters may be inserted at the bedside or in the clinic under local anesthesia. Tunneled central venous catheters and implanted ports are inserted in the operating room with local anesthesia. There may be mild discomfort, similar to a toothache, for 48 hr after the procedure. Reassure patient that discomfort responds readily to pain medication.

♦ If possible, introduce patient and caregiver to another individual who has the device so they may discuss their concerns with someone who has experienced insertion and care of a VAD.

♦ Teach VAD maintenance care. Provide both verbal and written instructions, including educational materials provided by the VAD manufacturer. Have patient or caregiver demonstrate dressing care, flushing technique, and cap-changing routine before hospital discharge. Provide a 24-hr emergency number to call in the event of problems.

♦ Discuss the following potential complications associated with VADs, along with appropriate self-management measures:

• Infection: Teach how to check for fever (temperature higher than 38° C [100.4° F]) and how to assess exit site for erythema, swelling, local increased temperature, discomfort, and purulent drainage.

• Bleeding: Teach how to apply pressure to the site. Instruct patient and caregiver to notify health care team member if bleeding does not stop in 5 min.

• Clot in the catheter: Teach how to flush catheter without using excessive pressure, which could damage or dislodge catheter (particularly an implanted port). If flushing does not dislodge the clot, instruct patient and caregiver to notify health care team member. It is not unusual for small blood clots or fibrin sheaths to develop on the end of the catheter. The most common manifestation of a fibrin sheath is ability to infuse fluids with inability to aspirate blood. Both fibrin sheaths and small blood clots respond readily to urokinase therapy. Instill after obtaining a medical directive and reviewing institutional procedure.

• Disconnected cap: Teach how to tape all connections and importance of always carrying hemostats or alligator clamps with padded blades to prevent catheter from tearing. Teach measures to take if the cap becomes disconnected.

• Fractured catheters: If the patient has an external catheter, teach appropriate method for clamping a fractured catheter and provide the clamps. Instruct patient to seek skilled assistance immediately.

• Extravasation: Although this is a relatively rare complication, it can cause severe damage if a chemotherapy agent with vesicant properties is involved. Instruct patient to report pain, burning, and stinging in the chest, clavicle, and port pocket or along the subcutaneous tunnel during drug administration.

Acute pain

related to disease process, surgical intervention, or treatment effects

For desired outcome and interventions, see this nursing diagnosis in “Pain,” p. 13.

Chronic pain

related to direct tumor involvement such as infiltration of tumor into nerves, bones, or hollow viscus; postchemotherapy pain syndromes (peripheral neuropathy, avascular necrosis of femoral or humeral heads, or plexopathy); or postradiation syndrome (plexopathy, radiation myelopathy, radiation-induced enteritis or proctitis, burning perineum syndrome, or osteoradionecrosis)

Desired outcome

Patient participates in a prescribed pain regimen and reports that pain and side effects associated with the prescribed therapy are reduced to level of 3 or less within 1-2 hr of intervention, based on pain assessment tool (e.g., descriptive, numeric [on a scale of 1-10], or visual scale).

Nursing Interventions

♦ Nociceptive pain refers to the body’s perception of pain and its corresponding response. It begins when tissue is threatened or damaged by mechanical or thermal stimuli that activate the peripheral endings of sensory neurons known as nociceptors. In contrast, neuropathic pain is caused by damage to CNS or peripheral nervous system tissue or results from altered processing of pain in the CNS. The resulting pain is chronic, may be difficult to manage, and is often described differently (burning, electric, tingling, numbness, pricking, shooting) from nociceptive pain.

♦ After patient has undergone a complete medical evaluation for the causes of pain (BOXES 12-2 and 12-3) and the most effective strategies for pain relief, review evaluation and pain relief strategies with patient and caregivers to determine level of understanding. Empower patient as much as possible to participate in controlling his or her pain.

♦ Never ignore a patient’s report of pain; remember that a patient’s definition of pain may be different from that of the assessing nurse.

♦ Ongoing assessment of pain is essential and should occur at frequently scheduled intervals. Promptly report any change in pain pattern or new complaints of pain to health care provider.

♦ Be aware that neuropathic pain may present differently from nociceptive pain. Patients with neuropathic pain may not describe their discomfort as pain; therefore, be sure to question them regarding their level of “discomfort” or abnormal sensations in addition to your usual pain queries. Include the following in your pain assessments:

• Characteristics (e.g., “burning” or “shooting” often describes nerve pain).

• Location and sites of radiation.

• Onset and duration.

• Severity: Use a pain scale that is comfortable for patient (e.g., descriptive, numeric, or visual scale).

• Aggravating and relieving factors.

• Previous use of strategies that have worked to relieve pain.

♦ Assess patient’s and caregiver’s attitudes and knowledge about the pain medication regimen. Many patients and their families have fears related to patient’s ultimate addiction to narcotics. Dispel any misperceptions about narcotic-induced addiction when chronic pain therapy is necessary.

♦ Pharmacologic management of pain is often the mainstay of treatment of chronic cancer pain. Incorporate the following principles:

• Administer nonopioid and opioid analgesics in the correct dose, at the correct frequency, and via the correct route. Chronic cancer analgesia is often administered orally. If pain is present most of the day, analgesia should be given at scheduled intervals around the clock (ATC), rather than as needed (prn).

• Recognize and treat side effects of opioid analgesia early. Side effects include nausea and vomiting, constipation, sedation, itching, and respiratory depression. The presence of these side effects does not necessarily preclude continued use of the drug.

• Use prescribed adjuvant medications to help increase efficacy of opioids. See Box 1-3, p. 15.

• Monitor for signs and symptoms of tolerance, and when tolerance occurs discuss treatment with health care provider. Patients with chronic pain often require increasing doses of opioids. Respiratory depression occurs rarely in these individuals.

• Be aware of the potential for physical dependence in patients taking opioids for a prolonged period. Opioids should not be stopped abruptly but rather tapered slowly in these patients, to prevent withdrawal discomfort.

• Evaluate effectiveness of analgesics at regular and frequent intervals after administration, particularly after initial dose.

• Use nonpharmacologic approaches (see Box 1-6, p. 22) when appropriate. See discussion in Acute pain, p. 13.

BOX 12-2 PHYSIOLOGIC CAUSES OF ACUTE PAIN IN CANCER PATIENTS

Nerve compression or infiltration of nerves by tumor

Obstruction of hollow viscera or ductal system by tumor

Infiltration/obstruction of blood vessels

Exacerbation of altered body functions unrelated to cancer (e.g., preexisting conditions such as chronic headaches, arthritis)

Extravasation of vesicant drug

Mucositis

Pain preceding appearance of herpes zoster lesions

Central nervous system neoplasm/metastases (e.g., impending spinal cord compression, intracranial metastases, leptomeningeal metastases)

Bone pain from metastatic lesions or fractures at sites of metastases

Tumor infiltration of brachial or lumbar plexus

Deep vein thrombosis

Pulmonary embolism

BOX 12-3 PHYSIOLOGIC CAUSES OF CHRONIC PAIN IN CANCER PATIENTS

Tumor unresponsive to therapy

Postsurgical pain (e.g., postmastectomy pain, post–radical neck dissection pain, postthoracotomy pain, phantom pains)

Postchemotherapy pain (peripheral neuropathies, avascular necrosis of femoral or humeral head, plexopathies)

Paraneoplastic syndromes (gynecomastia)

Postradiation pain (plexopathy, radiation myelopathy, radiation-induced enteritis or proctitis, osteoradionecrosis)

Postherpetic neuralgia

Altered body functions (e.g., chronic arthritis, back pain, or any musculoskeletal disorder)

Bone pain (metastatic lesions and fractures)

Impaired physical mobility

related to musculoskeletal or neuromuscular impairment secondary to bone metastasis or spinal cord compression, pain and discomfort; intolerance to activity, or perceptual or cognitive impairment

For desired outcome and interventions, see this nursing diagnosis in “Osteoarthritis,” p. 589, and “Osteomyelitis,” p. 571. See discussions on care of patients at risk for pressure ulcers, p. 722.

Sexual dysfunction (erectile dysfunction, body changes, decreased libido, impaired sexual self-concept, infertility secondary to treatment)

related to the disease process; psychosocial issues; radiation therapy to the lower abdomen, pelvis, and gonads; chemotherapeutic agents; or surgery

Desired outcome

Following instruction, patient identifies potential treatment side effects on sexual and reproductive function and acceptable methods of contraception during treatment.

Nursing Interventions

♦ Determine patient’s readiness to discuss sexual concerns.

♦ Initiate discussion about effects of treatment on sexuality and reproduction. The PLISSIT model provides an excellent framework for discussion. This four-step model includes the following: (1) Permission—give the patient permission to discuss issues of concern; (2) Limited Information—provide patient with information about expected treatment effects on sexual and reproductive function, without going into complete detail; (3) Specific Suggestions—provide suggestions for managing common problems that occur during treatment; and (4) Intensive Therapy—although most individuals can be managed by nurses using the first three steps in this model, some patients may require referral to a counselor expert in sexuality.

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