Chest Tumor Nursing Management

 

TUMORS OF THE CHEST

A chest tumor may be primary, arising within the lung or the mediastinum or it may represent a metastasis from a primary tumor site elsewhere Metastatic tumors of the lungs occur frequently, since the bloodstream transports free cancer cells from primary cancers elsewhere in the body. Such tumors grow in and between the alveoli and the bronchi, which they push apart in their growth. This process may occur over a long period of time, causing few or no symptoms.

Primary tumors of the lungs may be benign or malignant. Most arise from the bronchial epithelium. Bronchial adenomas are slow growing, usually benign tumors, but they are very vascular and produce symptoms of bleeding and bronchial obstruction. Bronchogenic carcinoma is a malignant tumor arising from the bronchus. Such a tumor is epidermoid, usually located in the larger bronchi, or is an adenocarcinoma, arising farther out in the lung.

Lung Cancer

Bronchogenic cancer refers to a malignant tumor of the lung arising within the wall or epithelial lining of the bronchus.

Classification According to Cell Type

• Epidermoid (squamous cell) most common.
• Adenocarcinoma.
• Small cell (oat cell) carcinoma.
• Large cell (undifferentiated) carcinoma.

Staging

Refers to the anatomical extent of the tumor, spread to the regional lymph nodes and metastatic spread. Accomplished by tissue diagnosis, lymph node biopsy and mediastinoscopy.

Risk Factors

Cigarette smoking. radioactive substances, petroleum oil mists, coal tar products alone or in combination with tobacco smoke., Family history of carcinoma, (Hereditary)

Clinical Manifestations

Usually occur late and are related to size and location of tumor, extent of spread and involvement of other structures.

1. Cough, especially a new type or changing cough. Starts as a hacking non-productive cough, it later produces a thick purulent sputum

2. Dyspnea, wheezing (suggests partial bronchial obstruction)

3. Chest pain (poorly localized and aching)

4. Excessive sputum production, repeated upper respiratory tract infection.

5. Hemoptysis-

6. Malaise, fever, weight loss, fatigue, anorexia.

7. Symptoms of metastases bone pain, abdominal discomfort, nausea and vomiting from liver involvement, pancytopenia from bone marrow involvement, headache from CNS metastases.

8. Usual sites of metastases lymph nodes, bones, liver, brain, contra lateral lung and adrenal glands

Diagnostic evaluation

• Chest radiography.
• Cytologic examination of fresh sputum searches for malignant cells.
• Bronchoscopy allows a detailed study of bronchial segments and identifies the source of malignant cells.
• Fluorescent bronchofibroscopy - detects small, early bronchogenic cancers.
• Lung Scans.
• Bone scan or bone marrow study, liver scan, brain scan, computed tomography and other neurologic diagnostics.
• Mediastinoscopy.
• Pulmonary function tests combined with split- function perfusion scan to determine if patient will have adequate pulmonary reserve to withstand surgical procedure.

Management

1. Treatment may be used separately or in combination.
2. Surgery preferred method for patients with localized tumors with no evidence of metastatic spread and whose cardiopulmonary function is adequate.

3. For small, curable tumor of the lung is lobectomy. An entire lung may be removed (pneumonectomy) in combination with other surgical procedures such as resection of involved mediastinal lymph nodes.

   Radiation therapy

   It may be used as palliative treatment to decrease tumor size and relieve pressure on vital structures.

   With radiation therapy there is usually toxicity to normal tissue within the irradiation field.

   Complications

   Esophagitis, pneumonitis and radiation lung fibrosis. The patient should be monitored for signs of anaemia and infection.

   Chemotherapy

   Combinations of 2 or more drugs may be more beneficial than single -dose regimens. Various combinations of doxorubicin hydrochloride (Adriamycin), Cyclosphosphamide (Cytoxan), Vincristine (Oncovin) and Cisplatin (platinol) are used. These agents are toxic and have a narrow margin of safety, Chemotherapy may provide palliation, especially of pain, but does not cure and rarely prolongs life.

   Complications

   1. Superior vena cava syndrome.

   2. Hypercalcemia- commonly from home metastases.

   3. Syndrome of inappropriate antidiuretic hormone (SIADH) secretion with hyponatremia and abnormal water retention.

   4. Pleural effusion.

   5. Infectious complication especially upper respiratory infection.

   6. Brain metastasis, spinal cord compression.

   Nursing Management

   1. To improve breathing patterns

   
   
   • Elevate head of the bed to promote gravity drainage and prevent fluid collection in the upper body
   • Teach breathing exercises.
   • Give prescribed expectorant, antimicrobial agent.
   • Teach the patient to cough effectively to splint chest manually with hands, instruct patient to inspire fully and cough 2-3 times in 1 breath.
   • Provide humidifier to provide moisture to loosen secretion. Administer oxygen through a nasal cannula as prescribed.
   • Encourage energy conservation through decreasing activities.
   • Recognize anxiety and teach relaxation techniques.

   2. Improve nutritional status.

   • Encourage small amounts of high-calorie and high-protein foods frequently.
   • Suggest eating major meal in the morning (if rapidly becoming satiated. and feeling full are problems)
   • Ensure adequate protein intake milk, eggs, chicken, fish, cheese and oral nutritional supplements if patient cannot tolerate other meats.
   • Administer prescribed vitamin supplements, to avoid deficiency states, glossitis.
   • Provide a soft/liquid diet if patient has esophagitis from radiation therapy.
   • Give total parenteral nutrition for malnourished patient who is unable or unwilling to eat.

Controlling Pain

1. Assess pain
2. Administer prescribed drugs (usually starting with non-steroidal anti-inflammatory drugs and progressing to adjuvant analgesic and narcotic agents).
3. Consider alternative methods, such as cognitive and behavioral training, biofeedback, relaxation (to increase patients sense of control).

Minimize anxiety

Try to have the patient express any concerns.

Encourage the patient to communicate feelings to significant people in his or her life.