NU 236 Care of the Adult II: Surgical Respiratory

Lung cancer

second most common type of cancer and #1 cancer killer worldwide, with a 5-year survival rate of 28.6%

Risks: Lung Cancer

Cigarette smoking (85-95%)

Prolonged exposure to secondhand smoke, asbestos, radiation, air pollution, chemicals, or coal mining

Primary Prevention: Lung Cancer

NO smoking

Avoid radon, asbestos, and secondary smoke

Second-Hand Smoke

environmental tobacco smoke; increases risk of lung cancer in non-smokers, SIDs, heart disease, and asthma in children

Adolescents and Tobacco

often use flavored vapes; can help quit with tobacco control programs such as mass media campaigns, higher prices, smoke-free laws, policies, evidence-based school programs, and bans

Three Steps to Quitting Smoking

Want IT (set a QUIT date and stick to it)

Plan IT (make a list of triggers and find something to distract you)

Do IT (reward yoruself when you do not smoke)

Stages of Change

1. Precontemplation

2. Contemplation

3. Preparation

4. Action

5. Maintenance

When teaching smokers, always meet them ________ using the stages of change.

where they are at!

Smoking Cessation Options

Counseling/support groups

Nicotine patches, gum, inhalers, zyban, Chantix

Secondary Prevention: Lung Cancer

Often asymptomatic early

Screenings ONLY for smokers

Screenings for Lung Cancer

recommended is annual CT screening of current/former smokers aged 50-80 with 20 pack/yr history, and applies to those who have quit within the past 15 years

Clinical Manifestations: Lung Cancer

Persistent cough

Hemoptysis

Chest pain

Recurring pneumonia/bronchitis

Anorexia

Weight loss

Fatigue

Dyspnea

Hoarseness

Hemoptysis

bloody sputum

Diagnosis: Lung Cancer

Sputum for cytology

Biopsy via bronchoscopy

Transthoracic needle biopsy

Bronchoscopy

the visual examination of the bronchi using a bronchoscope, often to obtain a biopsy

Pre-Procedure: Bronchoscopy

Informed consent and IV access

NPO unless emergent

Post-Procedure: Bronchoscopy

NPO until swallow reflex returns d/t risk of aspiration from numbness

No driving 24hr

Complications: Bronchoscopy

Frank bleeding (NOT blood-streaked sputum, expected)

Vitals, O2 sat, and lung sounds

Possible pneumothorax

Transthoracic needle biopsy

technique of obtaining a biopsy specimen of lung tissue by which a needle is passed through the chest, often guided by CT imaging to create a culture for analysis

When else are transthoracic needles used?

pleural effusion to remove fluid

Pleural Effusion

abnormal accumulation of fluid in the pleural space, decreasing the ability of the lungs to expand

Causes: Pleural Effusion

HEART FAILURE

Bacterial pneumonia

Malignancies

Cirrhosis with ascites

Pancreatitis

TB

Signs and Symptoms: Pleural Effusion

SHORTNESS OF BREATH

Chest pain (sharp or stabbing) and increased with deep inspiration

May have other local/systemic symptoms and may look like TB, bacterial pnuemonia, or CHF

Assessment: Pleural Effusion

Decreased or absent breath sounds

Dullness upon percussion

Decreased fremitus/resonance

Abnormal CXR/CT

Labs

Thoracentesis

Pleural biopsy

Labs: Pleural Effusion

Cytology for malignancy (may not always show cancer)

WBC/RBC

Blood and pleural fluid cultures

Presence of proteins, amylase, glucose

Thoracentesis

surgical puncture to remove fluid from the pleural space with immediate relief; done from the back where the pleural gutter is deepest

Positioning: Thoracentesis

sitting on the side of the bed and leaning over the table with head down

Complications: Thoracentesis

Pneumothorax (d/t lung puncture)

Bleeding

Pneumothorax

atmospheric air enters the pleural lining, causing lung collapse

Max amount of fluid removed in a thoracentesis is..

1L at a time

Nursing Interventions: Thoracentesis

Informed consent and explanation

Pre-procedure x-ray

Proper positioning and remain still

Vitals, especially O2 sat, and skin color throughout procedure

Apply dressing post-op, monitor vitals, and encourage deep breathing

Mediastinoscopy

visual examination of the mediastinal structures, including the heart, trachea, esophagus, bronchus, thymus, and lymph nodes

Thoroscopy

visual examination of the thoracic cavity

Pack Years

# of packs/day X # of years smoked

TNM Staging for Lung Cancer

T = primary tumor

N = regional lymph nodes

M = distant metastasis

Used to determine extent of disease and prognosis, and the patterns of spread depend on type of lung cancer and location (Stage I and II are surgical)

Types of Lung Cancer

Non-small cell lung cancer (NSCLC)

Small cell lung cancer (oat cell) (VERY aggressive)

Non-Small Cell Cancers

adenocarcinoma, squamous cell, large cell; first treated with usual respiratory interventions and possible surgery, radiation, and chemotherapy

Surgeries: NSCLC

Thoracotomy

Wedge resection

Lobectomy

Pneumoectomy

Post-Op: Lung Surgery

Assess cardiac/respiratory status

O2 admin

Incentive spirometry q1-2 hrs

Pain management

NO positioning on operative side

Turn, cough, deep breath

HOB > 30-45

Active range of motion to shoulder

Chest tube drainage system

Chest Tube

catheter inserted through the thorax into the chest cavity for removing air or fluid; used after chest or heart surgery or pneumothorax.

Hemothorax

a collection of blood in the pleural cavity

3 Chambers of Chest Tubes

Collection (measurement)

Water seal (one-way valve)

Suction (wall)

Chest Tube Assessment

Air leak

Bubbling

Crepitus

Dependant loops

Proper seal

Drainage measurement every shift

Below chest level

Is bubbling right after insertion expected? What about after three days?

YES, as fluid is being removed; NO, this means that there is a leak

Crepitus

air in the subcutaneous tissue

What should be kept at the bedside for a patient with a chest tube?

Bottle of unopened sterile water

Clamps

Sterile 4X4

Sterile vaseline gauze

Tape

Sterile basin

Always make sure chest tube systems are ___________ and ________.

connected, taped

How often do you get a CXR with a chest tube?

Before placement and after placement

1x/day

Chest Tube Dislodgement

Cover with a dry sterile dressing taped on 3 sides

If there is an air leak tape the dressing on 3 sides only to allow air to escape and prevent the formation of a tension pneumothorax

Notify HCP and prepare for reinsertion

Chest Tube Disconnection

DO NOT CLAMP

Immediately place end of chest tube in container of sterile saline or water until a new drainage system can be connected

Why do we place the chest tube in sterile water?

acts as a temporary one-way water seal that lets air and fluid escape from the pleural space while blocking outside air from rushing back into the chest

Concerns: Lung Cancer

Dyspnea

Pain

Anxiety

Coping

Altered nutrition

Activity intolerance

Stigma/judgment

D/C Teaching: Lung Cancer

Symptom management

When to call MD (pain, fever)

Safe use of O2 and narcotics at home

Smoking cessation

Facilitate expression of fears/death and referrals to hospice/home care

Smoking Cessation Teaching

done at EVERY encounter, provide resources

Laryngeal Cancer

cancer of the throat (vocal chords, larynx, or other areas of the throat and often occurs between ages 50-65 years and is 9x more common in men than women

Risks: Laryngeal Cancer

SMOKING

Alcohol abuse

Exposure to pollutants/radiation

Voice strain

Clinical Manifestations: Laryngeal Cancer

Persistent hoarseness or sore throat

Painless neck mass

"Lump in throat"

Burning of throat

Dysphagia

Change in voice quality

Dyspnea

Hemoptysis

Weakness

Foul breath

Diagnostics: Laryngeal Cancer

Laryngoscopy

Biopsy

Chest x-ray to rule out lung mets

Treatment: Laryngeal Cancer

Radiation and chemotherapy

Surgery (partial laryngectomy and total laryngectomy)

Partial laryngectomy

surgical removal of part of the larynx for small tumors; patient can STILL speak

Total laryngectomy

surgical removal of the entire larynx for large tumors; patient will NOT be able to speak and will have a stoma

Radical Neck Dissection

surgical removal of lymph nodes in the neck

Pre-Op: Total Laryngectomy

Establish a method of communication and encourage expression of feelings about changes of body image/voice loss

Rehab/trach care and suctioning

Post-Op: Total Laryngectomy

Position on side with HOB < 30-45

Humidification to trach site/stoma

Maintain airway and suction PRN

Monitor pulse ox, lung sounds, sputum, etc.

Administer TPN/G-Tube feeds

Patient education

Speech therapy

Communication Options: Post Laryngectomy

Lip motions

White board

Communication board

Esophageal speech

Mechanical devices (electrolarynx/implantable)

Visit from a laryngectomee

Safety: Laryngectomy

Teach self-care for trach/suctioning technique

Caution swimming, showering, aerosol sprays

How to use humidity at home

ROM with arms/shoulders/neck

Fluid intake 3000mL/day

Medic alert bracelet

Tracheostomy

surgical creation of an opening into the trachea through the neck that can be temporary or permanent; required when client is on vent for > 7 days and uses local/general anesthesia in 2-10 minutes

Types of Tracheostomies

Cuffed

Uncuffed

Metal

Plastic

Single or double lumen

Stoma

surgically created during surgery for total laryngectomy and can take 8-10 hours and is done under general anesthesia; required to remove ALL cancerous tissue and is always permanent

Metal laryngectomy tube or plastic button at site

initially keeps stoma open

What should you keep at the bedside for a trach?

Suture removal set

Suction

Additional trach (current size/smaller)

Obterator

Indications: Tracheostomy

Acute airway obstruction when oral/nasal intubation is not feasible

Severe OSA

Prolonged intubation and need for mechanical ventilation

Airway reconstruction post-laryngeal trauma/cancer surgery

____________ is always preferred to suctioning.

coughing

Suctioning

indicated for noisy secretions, dyspnea, falling O2 sat, crackles, restlessness, tachypnea, client request and can be done nasopharyngeal, oral, trach, or stoma

Suctioning Technique

Apply suction no longer than 5-10 sec.

Wait 1-2 mins between suction passes

Risks: Suctioning

Hypoxia

Trauma

infection

Vagal stimulation

Bronchospasm

Nursing Concerns: Stoma

Alteration in airway clearance

Impaired communication

Pain

Anxiety

Care for stoma

Key Points: Surgical Respiratory

Positioning is IMPORTANT post-op

Immediate post-op/LT care of stoma/trach

Primary concern is airway, but do not lose sight of pain, emotional support, teaching, and communication