NSG 202: Cellular Regulation

Where is this Concept?

• Nursing 119

  • Intro to cancer

  
  

• Nursing 202

  • Lung CA

  • BPH/Prostate CA

  
  

• Nursing 207 (peds)

  • Leukemia

  • Sickle Cell Disease

Cellular Regulation

• Refers to all functions carried out in the cells to maintain homeostasis, including their responses to extracellular signals (hormones, cytokines and neurotransmitters) & the way each cell produces an intracellular response

Cellular Regulation Interrelated Concepts

Lung Cancer

• Second most common cause of cancer related death 

• Survival rate approximately 5 years

• Prognosis poor r/t late diagnosis 

• High potential for mets

Pathophysiology of Lung Cancer

• Tumors arise from mutated epithelial cells

• Carcinogens cause those cells to multiply

• Can take 8-10 years to reach 1cm

• May not show on x-ray right away

Metastasis

• Direct extension

  
  

• Via blood, lymph glands, vessels

  
  

• Interferes with gas exchange

  
  

• Lymph nodes, other tissue, bone, liver, brain & adrenal glands

Incidence/Prevalence

• Smoking responsible for 81% of lung cancer deaths 

• Second hand / third hand smoke

• E-cigarettes, vaping

• Hookah

• Chronic exposures

• Genetics

  • First degree relative

• Age

  • More exposure

Assessment

• Health hx

• Pack Years

• Physical exam

• ID risk factors

Clinical Manifestations of Lung Cancer

• Persistent cough with sputum (most common)

• Dyspnea

• Wheezing

• Hemoptysis

• Heart sounds

• Chest Pain

Later Manifestations of Lung Cancer

• Later manifestations:

  • Anorexia, fatigue, weight loss

  • N/V

  • Dysphagia

  • Superior vena cava syndrome - EMERGENCY

  • Mental status changes

Benign vs Malignant

• Benign

  • Slow Growing

  • Capsulated

  • Non-Invasive

  • Does not metastasize

  • Well Differentiated

• Malignant

  • Fast Growing

  • Non-Capsulated

  • Invasive & Infiltrates

  • Metastasizes

  • Poorly Differentiated

  • Suffix: "Carcinoma" or "Sarcoma"

Types

• Small Cell (SCLC)

  • Grows rapidly

  • Spreads quickly

  • Early metastasis

  • Poor prognosis

• Non-Small Cell Carcinoma (NSCLC)

  • Every other cancer that is not the small cell type

Non-Small Cell Carcinoma (NSCLC) Examples

• Squamous cell carcinoma

  • Slow growing

  • Early symptoms

  
  

• Adenocarcinoma

  • Moderate growing

  • Most common in non-smokers

  
  

• Large-cell carcinoma

  • Rapid growing

  • Highly metastatic

Staging of NSCLC

Diagnostic Testing

• Radiology

  • CXR

  • CT

  • MRI

  • Radionuclide scans

  
  

• Biopsy

  • Tissue

  • Pleural effusion fluid

  
  

• Thoracoscopy

  • Via VAT

  
  

• PET scan

Nonsurgical Management

• Chemotherapy

• Targeted Therapy for NSCLC

• Immunotherapy

• Radiation

• Photodynamic therapy (PDT)

Chemotherapy

• Primary tx for SCLC

  • Adjuvant therapy for NSCLC

  
  

• Destroys ALL cells

  • HIGH risk for infection

  • Reduces Immunity

  • Neutropenia (low WBC)

  • Thrombocytopenia (decreased platelets)

  • Nadir

Chemotherapy Side Effects

• Side effects

  • N/V

  • Alopecia

  • Mouth sores

  • Immunosuppression

  • Anemia

  • Altered bowel elimination

  • Cognitive changes

  • Sleep disturbances

  • Peripheral neuropathy

Targeted Therapy

• For NSCLC

  
  

• Focuses on specific molecules within cancer cells

  • Not the same as chemotherapy

  
  

• Very targeted to very specific cells only

  
  

• Immunotherapy

  • A type of targeted therapy

  • Pt's own immune system recognizes and attacks the cancer cells

  • Doesn't replace chemo or radiation

  • Is not a cure

Radiation Therapy

• For cancer confined to the chest

  • For SCLC and NSCLC

  
  

• Best used in conjunction with surgery and/or chemo

  
  

• May be used pre-op to reduce tumor mass for easier removal

  
  

• Side effects:

  • Skin irritation and peeling

  • Fatigue

  • Nausea

  • Taste changes

  
  

• No sun for 1 year

Stereotactic Body Radiotherapy (SBRT)

• High dose radiation accurately delivered to tumor

  
  

• Smaller part of healthy lung exposed

  
  

• Outpatient therapy over 1-3 days

Photodynamic Therapy (PDT)

• Uses photosensitizing agents & light to kill cancer cells

  
  

• Can be topical or injected into bloodstream

  
  

• Drug accumulates into cancer cell withing 48-72 hours

  
  

• Pt intubated and laser light is focused on tumor

  • Causes irreversible damage & death to cells that have retained the chemical

Surgical Management

• Tx of choice for stages 1 & 2 NSCLC

  
  

• May result in a cure

  
  

• May include:

  • Tumor removal only

  • Segmental, wedge or sleeve resection

  • Lobectomy

  • Pneumonectomy

  
  

• Open thoracotomy or minimally invasive

  • VATS

  
  

• May need chest tube post-op

Chest Tube

• Catheter in the pleural space

  • Allows lung expansion

  • Prevents air/fluid/blood from returning to the chest

• Closed chest drainage

  • Drains air

  • Drains fluid

• General Nursing Care

  • Ensure integrity of system

  • Promote comfort

  • Ensure tube patency

  • Prevent complications

Why a Chest Tube?

Water Seal & Dry Seal

Ongoing Nursing Implications

• Respiratory Status

  • Breath sounds

  • Work of breathing

  • SpO2 <90

  
  

• Drainage

  • Amount

  • Color

  • Character

  
  

• Water Seal Chamber

  • Tidaling = Normal

  • No Tidaling = lung re-expanded or a blockage

  • Continuous bubbling = possible air leak

  
  

• System Position

  • MUST be below chest level

  • Ensure: no dependent loops/no kinks/secure to bed or floor

  
  

• Insertion site

  • Dressing intact

  • So subcutaneous emphysema

Things to Not Do

• Do not clamp

• Do not strip

• Do not lift above chest

Chest Tube

Call the Provider When:

• Sudden bright red drainage

  
  

• System breaks

  
  

• New/worse respiratory distress

  
  

• Dislodged

  
  

• New continuous bubbling

Palliative Care Lung Cancer

• Oxygen therapy

  • When pt is hypoxemic and to help relieve dyspnea & anxiety

  
  

• Radiation therapy

  • Help with difficulty swallowing & pain

  
  

• Thoracentesis

  • For pleural effusion

  
  

• Dyspnea management

  • Keep pain free if possible

  • High fowlers

  • Oxygen

  
  

• Pain management

  • Oral, parenteral, transdermal

  • Around the clock with PRN analgesics for breakthrough pain

  
  

• Hospice

  • For pt in terminal phase

  • Offers support

• What is  a thoracentesis?

• What do you think would be the priority of care after the patient has a thoracentesis?

• What is  a thoracentesis?

• What do you think would be the priority of care after the patient has a thoracentesis?

Lung Cancer Nursing Diagnosis

• Ineffective breathing pattern

  
  

• Impaired gas exchange

  
  

• Ineffective self health management

Your post op patient has 2 chest tubes in place. The patient reports burning pain in his lower chest. On assessment, the nurse notes there is no bubbling on exhalation in the water seal chamber. The patient is hunched over at the middle of the bed. What action will the nurse perform first?

1. Immediately notify the rapid response team

2. Reposition the patient and reassess the water seal chamber for bubbling.

3. Administer the prescribed opioid analgesic immediately and then assess the chest tube system.

4. No action is needed because these responses are normal for the first post-op day after a lobectomy.