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By: Cindy Stegman RN BSN Alverno College MSN 621 Spring 2010

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1 By: Cindy Stegman RN BSN Alverno College MSN 621 Spring 2010

2 How to navigate this tutorial: To advance to next slide click on box To advance to previous slide click on box To return to MAIN MENU click on box If you see the return button click on it to return to QUESTION slide. Hover over the underlined text for an explanation/definition

3 To educate RNs and LPNs on the pathophysiology of advanced lung cancer associated with dyspnea At the end of the tutorial the learner will be able to: Identify pathophysiology of advanced lung cancer associated with dyspnea Discuss key assessment components of the advanced lung cancer patients experiencing dyspnea Describe evidence-based interventions for the advanced lung cancer patients experiencing dyspnea PURPOSE & OUTCOMES

4 Clip art, 2010 Pathophysiology of advanced lung cancerAnatomy of normal lung function Causes of dyspnea Mechanisms of dyspneaGenetic relationship Evidence-Based Nursing Interventions Stress & Immune/Inflammatory response Nursing assessment Case Study Nursing-Sensitive Outcomes Content of Tutorial At any time during tutorial you may click to come to this screen and select next topic. Let’s get started… taking a DEEP breath and relax!

5 Anatomy of Normal Lung Function Click each circle in the diagram to recognize the anatomy of the lungs 1 2 3 5 4 Trachea: Is the tube that runs from your larynx to just above your lungs. The trachea divides into TWO large branches called the bronchi. Bronchi: Entering the lung, the bronchi divide into the left and right side of lung. They continue to branch & divide into smaller bronchi. Bronchioles: Smallest conducting airways at the terminal end of the bronchi. At the most distal end gas exchange takes place. Pleura: A thin serous membrane that lines the thoracic cavity & cushions the lungs. Alveolar sacs: Cup-shaped structures which are the smallest functional unit of the lungs. Porth, 2005

6 Physiology of Normal Breathing : -Automatic, quiet - Movement that control ventilation are integrated by neurons located in: - Medulla & Pons (Respiratory Center) GOAL of Breathing: Oxygenation of the blood and removal of Carbon dioxide. Scroll across each picture Porth, 2005)

7 What Stimulates your respiratory system to increase breathing? Receptors Click on star to receive answer

8 1)Chemoreceptors - Peripheral chemoreceptors: Located in the carotid and aortic bodiesPeripheral chemoreceptors: - Central chemoreceptors: Located in the Respiratory center in the Medulla & ponsCentral chemoreceptors 2) Lung & Chest wall Receptors - Stretch (smooth muscle) Stretch - Irritant (Airway of epithelial cells) Irritant - Juxtacapillary or J receptors (alveolar wall) Juxtacapillary or J receptors Jantarakupt, P. & Porock, D. (2005).

9 A nurse walks into a room and observes a patient breathing rapid and shallow. Respiratory rate is 32 breaths/min and pulse ox at 80% on room air. What receptors alerted the respiratory center to turn ON ? Incorrect. These receptors are located in the medulla & pons and stimulate the resp. center when there are high levels of carbon dioxide in the blood. Central Chemoreceptors Incorrect. These receptors are located in smooth muscle and do not stimulate the respiratory center when there is LOW oxygen in the blood. Incorrect In this situation because this scenario did not mention crackles in the lungs that would suggest pulmonary edema. Correct!! These receptors alert the respiratory center when there is LOW oxygen in the blood J Receptors Stretch Receptors Peripheral Chemoreceptors

10 What Causes Lung Cancer? Repeated EXPOSURE to Carcinogens Transforms: Normal cell into Malignant Clip Art, 2010 Hoffman, A. & Gift, A. (2007) Cells in the respiratory membrane that line the bronchi become THICK & HARDEN Cilia become Stiff (Unable to sweep debris away) Genetic Damage

11 Lung Cancer Cell Dividing - Lung cancer cells are highly invasive & may extend into the mediastinum or pleural cavity - Lung network is highly vascular and metastasis occurs early - Distant metastasis may occur in the brain, liver, bones, or kidneys Hoffman, A., & Gift, A. (2007) Permission from

12 What we know increases risk for development of Lung Cancer Active tobacco exposure Passive smoke exposure (Second hand) Shared environment Asbestos (school, home, work, person-person) Environmental exposure (Radon & heavy metals) Nickel, arsenic National Cancer Institute, 2010 Clip Art, 2010 Clip Art, 2007

13 Research in the works… Study produced by: National Cancer Institute National Human Genome Research Institute National Institutes of health Study that was printed in 2004 in the American Journal of Human Genetics Study involved: -52 families with a minimum of Three 1 st -degree family members affected by either lung, throat, or laryngeal cancer -Used 392 known genetic markers & compared the alleles of each affected and non-affected family member National Cancer Institute, 2010

14 Research in the works Cont… Discovered: A region on Chromosome 6 (susceptibility to Lung caner) WORK is needed to: Look closer in this REGION to find the exact GENE that causes this susceptibility National Cancer Institute, 2010 Clip Art, 2010

15 Mechanisms of Dyspnea Divided into 3 pathologies: Chemical Stimulation Neural Stimulation Emotional Stimulation Clip Art, 2007

16 Chemical Stimulation Central respiratory chemoreceptors Peripheral respiratory chemoreceptors PaCO2 PaO2 Eliminate Carbon Dioxide American Thoracic Society. (1998). Clip Art, 2007 Jantarakupt, P. & Porock, D. (2005)

17 Neural Stimulation Neural Pathways for breathing receive signals from receptors in: - Lungs - Skin - Muscles - Joints These receptors are called “Mechanoreceptors” - Stretch receptors in (trachea, bronchi) are stimulated with lung expansion - Irritant receptors (epithelium of airways) stimulated by smoke, pollens, fungi, cold air, & mold - Movement of lower and upper extremities stimulate receptors in muscles & joints - Painful stimuli will elicit mechanoreceptors within the skin Jantarakupt, P. & Porock, D. (2005) Once mechanoreceptors are stimulated they will cause an individual to breathe faster

18 Emotional Stimulation Emotional distress Anxiety Anger Depression THE CAUSE & EFFECT relationship is unclear but… Emotional changes CAN stimulate the respiratory center, which in turn AFFECTS the Individual’s breathing pattern Clip art, 2007 Jantarakupt, P. & Porock, D. (2005).

19 Dyspnea is a distressing and debilitating symptom that cancer patients may experience. - It is SUBJECTIVE (what the patient says) - An uncomfortable, frightening experience ( Clip art, 2007 Dyspnea is estimated to occur in 15-55% at the time of diagnosis and up to 18-79% during the last week of life Oncology Nursing Society. (2010).

20 Stress and Dyspnea: What’s the CONNECTION ? Stress response or General Adaptation Syndrome (GAS) is meant to protect an individual during ACUTE episodes stress. If the GAS is continually stimulated by chronic stressors, this can be a threat to an individual’s homeostasis. Porth, C., (2005) Clip Art, 2010

21 Stress and DYSPNEA Cont… Dyspnea: Acute or Chronic Advanced Lung Cancer PATIENT Physical & Psychological Stress ALERT: STRESS RESPONSE

22 Stress and Dyspnea Cont… Results : In release of catecholamines (such as epinephrine and norepinephrine) and cortisol, which: - Increases heart rate - Dilates the bronchioles Stress causes Vasoconstriction to… - Skin: which becomes Pallor and cold - GI tract: which causes nausea, No bowel sounds, & digestion stops - Kidneys: which decreases urinary output Porth, C., (2005)) Inflammatory and Immune response stops!

23 PhysicalBehavioral ADAPT to ACUTE STRESS WHAT factors AFFECT our ability to ADAPT to STRESS?? Endocrine-Neurotransmitter pathway… PRODUCE CHANGES

24 Click on each circle Severe emotional distress often disrupts physiological function and limits an individuals ability to make appropriate choices related to adaptive needs. If a dyspnea is present, this is causing emotional distress and affecting their ability to enjoy daily activities due to the stress of not being able to breathe. Sleep-Wake Cycles Hardiness Mental Health Status Nutrition Sleep is the most restorative function in which tissues are regenerated. If an individual cannot sleep at night, due to dyspnea, this is affecting their ability to restore their energy. Malnutrition is one of the most common causes of immunodeficiency. Most advanced lung cancer patients have major issues with nutrition due to loss of appetite & weight loss from treatment &/or disease process itself. A personality characteristic which includes: A sense of purpose in life and to view stressors as a challenge rather than a threat. If dyspnea is affecting their hardiness, the individual will see this stressor as a threat and slowly become susceptible to sadness. Porth, C. (2005)

25 What happens if DYSPNEA continues to stimulate our Stress Response??

26 Exhaustion OCCURS! Coping mechanisms are depleted. WEAR & TEAR on the System Chronic stress will occur & LEAD to: Loss of Appetite Sleep disturbance Depression What does this mean for an advanced lung cancer patient if this cycle continues ? Porth, C., 2005 Clip Art, 2007

27 Immune & Inflammatory responses diminish which means: The advanced lung cancer patient is at an increased risk for infections The AGING advanced AGING lung cancer patient has less ability to adapt to environmental stressors Decreases their immune responsiveness & ability to heal wounds Porth, C., 2005 Clip Art, 2007

28 Aging can be viewed as a low-grade chronic inflammatory state which is termed as “inflammaging”inflammaging Porth, C. 2005 & Franceschi, C. & Bonafe, M. 2003 If the GAS is constantly stimulated, what does this mean for the aged advanced lung cancer patient? Due to the thymus decreasing in size as we age, this affects T-Cell function within the body. Ultimately, compromises the immune system responsiveness to heal wounds.thymusT-Cell Due to inflammaging, this can cause chronic activation of inflammatory responses. Eventually, leads to the infiltration of macrophages, lymphocytes, & fibroblasts, which causes persistent swelling and scar formation to occur. Click on ARROW twice

29 Cancer-Related Causes of DYSPNEA: 1)Direct cause of the cancer 2)Indirect result of the cancer 3)Result of cancer treatment 4) Other

30 DIRECT -Primary or metastatic cancer to lung - Pleural tumor - Pericardial effusionPericardial effusion - Ascites Ascites Permission from Tyson, L. (2006) INDIRECT -AnemiaAnemia -PneumoniaPneumonia - Pulmonary emboliPulmonary emboli - Cachexia Cachexia

31 Dyspnea from Treatment 1) Surgery 2) Radiation (which can cause) - - Pulmonary PneumonitisPulmonary Pneumonitis - - Pulmonary fibrosisPulmonary fibrosis Polovich, M., Whitford, J., & Olsen, M. (2009). Clip Art, 2007 3) Chemotherapy agents that can either cause: - Pulmonary Edema Cytoxan, Gemzar, Methotrexate, Mitomycin - Pulmonary Pneumonitis/Fibrosis Cytoxan (later development), Gemzar (later sign of fibrosis), Bleomycin (Pneumonitis), Methotrexate, Carmustine

32 - ObesityObesity - Age - AsthmaAsthma - CHF or COPDCHFCOPD Co-Morbidities that cause Dysnpea Clip art, 2007 Other: - Anxiety DiSalvo, W., at el., (2008)

33 Oncology Nursing Society (ONS) In 2003, ONS developed their own definition of oncology nursing-sensitive patient outcomes (NSPO’s), which focused around: Oncology Nursing Society, 2003 -Patient’s problems are significantly affected by nursing interventions. -Interventions developed within the scope of nursing practice; are sensitive to nursing care and represent the consequences or effects of nursing interventions -Result in changes in patients' symptom experience, functional status, safety, psychological distress, and/or cost

34 NSPO’s for Dyspnea: 1)Symptom Management -Decrease in patient’s perception of breathlessness -Patient maintains activity level within capabilities -Respiratory rate remains at comfortable level -Patient is able to manage episodes of dyspnea 2) Psychosocial Distress - Promoting relaxation and stress reduction - Education and support to patients and their families Crowley. (2005) & ONS PEP, (2008)

35 ASSESSMENT 1)SUBJECTIVE (Pt’s own description, feeling, of breathlessness) - At rest - With activity - Assess dyspnea with a Visual Analog scale - Number Scale (1-10) - Mild-Moderate-Severe 2) VITAL SIGNS - Respiratory rate (Rate, Irregular, Depth) - Weight Clip Art, 2007

36 Assessment Cont… 3) CARDIOPULMONARY: - Accessory Muscle use - Edema - Tachycardia - Underlying cause (fever, etc.) - Auscultation -Wheezes, crackles, cough - Secretions (amount, consistency) 4) INTEGUMENTARY: - Pallor (Anemia) - Cyanosis (Low oxygen, hypoxia) Itano, J. & Taoka, K. (2005) Clip Art, 2007

37 Assessment Cont… 5) MENTAL STATUS - Restlessness - Confusion - Memory Difficulties 6) PSYCHOSOCIAL Distress: - Depression - Anxiety - Fear Clip art, 2007

38 G. S. is a 65 year-old man diagnosed with Stage IV Lung cancer in October 2009 - His presenting symptom at the time of diagnosis is rib pain. - During the next few weeks, G.S has received several radiation treatments to his ribs. - After his radiation treatment, G.S has also received system chemotherapy. (Up to this point, G.S. has tolerated this treatment fairly well) December of 2009 (post radiation/chemotherapy tx) G.S had a PET scan that showing worsening enlargement of primary tumor.PET January 2010 G.S. was switched to salvage Taxotere chemotherapy regimen Over the next few weeks to months G.S. is seen in the clinic with increased weakness, hypotension, nausea, and dehydration. Continued

39 Today March 2010, G.S is seen in the clinic: - G.S. is looking frail & ashen in color - Knees down bilateral has +3 pitting edema - Oxygen saturation measuring at 87% on room air - No appetite - Lost of five pounds since February - Denies any pain - C/o of shortness of breath with activity - Uses a walker to assist with ambulation - C/O of insomnia, due to trouble breathing at night - On auscultation: fine wheezes heard throughout bases of lungs HOME MEDICATION: - MS Contin 30 mg BIDMS Contin - Fluconazole 200 mgFluconazole - Ativan 0.5-1 mg every 8 hrs PRNAtivan - Oxycodone 5 mg (1-3) every 2 hrs PRN Oxycodone

40 These are all possible Nursing Interventions to help relieve G.S’s DYSPNEA. Click on all the buttons at the bottom to understand WHY? A)Suggest to G.S to get a prescription of Morphine Sulfate in an immediate release capsules to help relieve his dyspnea B)On assessment, heard audible wheezes in upper lung fields. Suggest an albuterol inhaler treatment C)Suggest to G.S to take his Ativan before strenuous activities & before sleep to help relieve his anxiety D)G.S. oxygen saturation on room air was 87%. Supplement oxygen to help relieve his dyspnea. E)Due to the edema (swelling) in his legs, ask his physician for an order of lasix F)Suggest to his wife to place a fan on G.S’s face and nose, as this might help relieve his dyspnea or use breathing techniques to slow down his breathing during periods of dyspnea. G)Educate G.S on relaxation techniques & encourage G.S to sleep in his recliner to keep upper body at least at 45-90 degree angel to help with sleep. ABCDEFG

41 Opioids on Cancer-Related Dyspnea Immediate-release oral agents Parenteral RECOMMENDED for Practice: Morphine (most common) Hydromorphone (Dilaudid) WHEN OXYGEN OR REST DO NOT RELIEVE DYSPNEA NCCN, 2010, DiSalvo, W., Joyce, M., Tyson, L., Culkin, A., & Mackay, K., 2008, & Oncology Nursing Society, 2008.

42 Theory of OPIATES Act at central/peripheral opioid receptors sites & central nervous system (Respiratory center) Respiratory drive at rest and activity Block respiratory responses to hypoxia & hypercapnia Wickham, R. (2002) & Gift, A. & Hoffman, A. (2007) MORPHINE Opioids have a depressant effect on the central nervous system, which alleviate dyspnea by blocking the neural signals to hypoxia & hypercapnia.hypoxiahypercapnia

43 Recommendations: Treating COUGH/DYSPNEA/ or AIR HUNGER - 2-10 mg Morphine orally every 4 hr prn - 1-4 mg Morphine IV every 4 hr prn 1) RE-ASSESS patient 2) SIDE EFFECTS: dysphoria, dizziness, drowsiness, urinary retention, constipation. Re-assure patient: Opiates will help them rest without the feeling of “suffocation” REMEMBER!! Naïve Vs Tolerant LOWER dose of Morphine used to treat Dyspnea, BUT Action of Morphine for dyspnea is shorter than its analgesic effects! Jantarakupt, P. & Porock, D. (2005), NCCN, 2010, & Wickham, R. (2002). NCCN, 2010

44 Patient/Family MYTHS & FEARS about OPIOIDs 1)ADDICTION - Reassure patient they are taking opioids to relieve their cancer-related dyspnea. Dyspnea can change from day to day depending on the progression of their disease state. As nurse providers, reassure patient that the dosage may increase in the future due to repeated administration of that opioid dose. The body will eventually build up a tolerance for that dose of opioids and the individual will not be receiving the desired effect. 2) Over SEDATION - Reassure patient we will be monitoring them while receiving opioids - This is for palliative treatment of dyspnea, so titrating the opioid dosage may be necessary to get the desired effect. - As the individual transitions from palliative care to hospice… Retain increased amounts of carbon dioxide Causes Sleep & a comatose state to occur with the dying patient regardless if opioids are administered or not DYING patient’s breathing is now more rapid & shallow Wickham, R. (2002) & Johnston, M. (2007). Clip Art, 2010

45 QUIZ 1)Are extended-release opioids just as effective as immediate-release? CORRECT! Immediate-release opioids have been shown to be effective in practice when treating dyspnea. Sorry  Extended-Release opioids have NOT been established to show effectiveness towards treating dyspnea FALSETRUE In the case of G.S, immediate-release opioids are an appropriate intervention, because he has already has been exposed to opioids. REMEMBER… he is opioid tolerant, so G.S. might need to repeat the dose more frequently to treat the DYSPNEA. As nurse providers, we need to console & support G.S. if he has any fears of using opiods, because sedation & addiction can be a fear patients have with opioid usage. KEEP the patient’s GOAL in mind & reassure G.S. that this intervention will be able to get him through tough periods of dyspnea to be able to endure certain activities.

46 Bronchodilators Inhaled or Nebulized -B2 –adrengergic agonist Albuterol decreases WORKLOAD of the lungs Nebulized Opioids?? Believed to “TARGET” stretch and irritant receptors in the lungs SYSTEMIC TOXICITY Jantarakupt, P. & Porock, D. (2005) & Kallet, R., (2007 ) NOT Recommend for Practice Due to: Insufficient Evidence Bronchodilators relaxes smooth muscles within the bronchioles

47 CORRECT On assessment you heard wheezing throughout lung fields to suggest vasoconstriction within bronchioles. An albuterol treatment would be an appropriate intervention for G.S’s dyspnea. Sorry  Short-Acting bronchodilators are more effective for patient’s who have either air flow obstruction such as COPD, asthma, or patient’s with lung cancer & is presenting with wheezing throughout lung fields to suggest vasoconstriction. Quiz 1)Which option is correct to suggest an albuterol inhaler to treat G.S’s dyspnea? G.S complained of shortness of breath while walking to the bathroom? On auscultation, you heard wheezes throughout G.S.’s lung fields Wickham, R. 2005

48 Benzodiazepines Lorazepam Diazepam Recommended Dosages: Ativan: 0.5-1 mg orally or IV q 4 hrs prn Diazepam: 2 mg po/SQ/IV q 12 hours (NCCN, 2010) Sedative action ANXIETY that stimulates dyspnea!! DO NOT WORK DIRECTLY ON THE LUNGS Jantarakupt, P., & Porock, D., (2005) & NCCN, (2010). & Wickham, R., (2002)

49 Sorry Benzodiazepines do not directly work on the lungs to relieve dyspnea. Benzodiazepines are used for their sedative use to decrease anxiety that is commonly associated with dyspnea. Quiz True or False: Do benzodiazepines work directly on the lungs to relieve Dyspnea? TRUE YES Benzodiazepines treat anxiety associated with dyspnea and do not directly treat dyspnea. In G.S’s case, this can help his anxiety & let him be able to sleep at night with out the fear of suffocation. FALSE

50 OXYGEN - Increase oxygen saturation (SaO2) - Hypoxia is present DYSPNEA Lowers respiratory RATE Lowers respiratory EFFORT Non-hypoxic Patients? FEAR and Anxiety Jantaarakupt, P. & Porock, D. (2005) Patient’s with advanced lung cancer have less ability to remove carbon dioxide or transport oxygen to other parts of the body due to the physical changes cancer makes within lung tissue. Patient’s with a history of COPD will be at higher risk of retaining CO2. CAUTION!! CO2 Retainers Click on box Clip Art, 2007

51 Quiz True or False Oxygen therapy is ONLY for patient’s who are truly hypoxic? Incorrect Oxygen therapy is primarily used for hypoxic patients, but in cases of advanced lung cancer patient’s who are experiencing dyspnea, oxygen has been proven to help relieve the feeling of shortness of breath. True Correct Oxygen therapy can be used for hypoxic & non-hypoxic advanced lung cancer patient’s experiencing dyspnea. CAUTION should be used when titrating oxygen if patient is a CO2 retainer. In the case of G.S. he is truly hypoxic when his oxygen saturation was at 87% on room air. Oxygen therapy would be an appropriate intervention to treat his dyspnea. False

52 OTHER Treatments: Steroids & NSAIDS Side effects of steroids: Gastric toxicity, fluid retention, hyperglycemia Lasix Given when a patient is experiencing: 1)Pulmonary congestion 2)Lower extremity edema INFLAMMATION in the LUNGS to relieve dyspnea Gift A. & Hoffman, A. (2007). More effective for patient’s with pre-existing conditions such as COPD LASIX is given for fluid overload to Decrease the demand on the heart Jantarakupt, P. & Porock, D., 2005 & Wickham, R. 2005

53 What is the relationship between G.S’s lower extremity edema and him experiencing DYSPNEA? In G.S.’s situation, there could be multiple factors causing his lower leg edema, such as malnutrition, medications, and/or worsening of his lung cancer involvement. The edema is causing his heart to pump harder to compensate for the extra fluid, which is causing G.S. to have dyspnea at rest &/or with activities. Lasix would be an appropriate short term fix to help with the edema in lower extremities & relieve dyspnea. CLICK ON Hoffman, A. & Gift, A. (2007)

54 1)Breathing Techniques -Pursed-lip and diaphragmatic breathing (Shown to optimize lung function, decrease stress, & relax the breathing for that patient) 2) Increase airflow (generated by a FAN) - Face - Nose (Gives the perception of more airflow to the individual, which may reduce the feeling of dyspnea) 3) Providing COOLER temperatures - Decrease the feeling of dyspnea DiSalvo, W., Joyce, M., & Belansky, H. (2009) Clip Art, 2007

55 4) Positioning - Sitting up (expansion of lungs) 5 ) Promoting Relaxation Stress Reduction - Massage - Reducing external noise (Decrease anxiety & stress associated with dyspnea) 6) Emotional & Psychosocial Support (Coaching and support have been shown to decrease the feeling and anxiety associated with dyspnea) Clip Art, 2007 Andry, J. (2008) & Tyson, L (2006)

56 Key Points to REMEMBER : -Dyspnea is a SUBJECTIVE feeling & a debilitating symptom that patients experience. - Key ASSESSMENT skills are crucial to help understand the underline cause of the dyspnea and/or the treatment options. -Be consciously aware of evidence-based interventions that are already incorporated into nursing practice, whether the dyspnea is oncology related or not. -Dyspnea is a symptom that can CHANGE from day to day. Reassure the patient of this and the multiple interventions we can help to relieve dyspnea. -Lastly, keep the patient’s GOAL in mind. Are the interventions appropriate and will the patient be able to enjoy certain activities with some of the side effects that may occur. Just remember to communicate & educate patients on these interventions and just maybe, we can give them a little relief from their dyspnea! KEY POINTS TO REMEMBER

57 REFERENCES: Guyton, A. & Hall, J. (2006). Blood Cells, Immunity, & Blood Clotting. Schmitt, W. & Gruliow, R. Medical Physiology (11 th e.d.) pp. 439-450. PA: Elsevier Inc DiSalvo, W., Joyce, M., Tyson, L., Culkin, A., & Mackay, K. (2008). Putting Evidence Into Practice: Evidence-Based Interventions for Cancer-Related Dyspnea. Clinical Journal of Oncology Nursing. 12(2) pp. 341-352. Jantarakupt, P. & Porock, D. (2005). Dyspnea Management in Lung Cancer: Applying the Evidence From Chronic Obstructive Pulmonary Disease. Oncology Nursing Forum. 32(4), pp. 785-795. Johnston, M. P. (2007). Oncology Nursing. In Langhorne, M., Fulton, J., & Otto, S. Pain. (5 th e.d. pp. 680-693). St. Louis: Elsevier Saunders. Kallet, R. (2007). The Role of Inhaled Opioids and Furosemide for the Treatment of Dyspnea. Respiratory Care. 52(7): pp. 900-910. Nation Cancer Institute, Retrieved on March 31, 2o10 from, National Comprehensive Cancer Network Practice Guidelines, Palliative Care, Version 1, 2010. Retrieved on April 22, 2010 from http://www.nccn.org Oncology Nursing Society, 2003. Retrieved on March 31, 2010 from, Oncology Nursing Society, 2008. Putting Evidence into Practice. Retrieved on April 2, 2010 from, Crowley, M. (2005). Core Curriculum for Oncology Nursing. In Itano, J. & Taoka, K (Eds.), Supportive Care: Dying and Death. (4 th ed., pp. 102-126) St. Louis: Elsevier Saunders About.Com. (2010). Smoking Cessation. Retrieved April 5, 2010 from, American Cancer Society. (2007). Retrieved February 23, 2010 from, American Thoracic Society. (1998). Dysnpea: Mechanisms, Assessment, & Management. A Consensus Statement. American Journal of Respiratory and Critical Care Medicine. (159) pp 321-340. Andry, J. (2008). Palliative Practices From A-Z for the Bedside Clinician. In Esper, P. & Kuebler, K. (Eds.). Dyspnea. (2 nd ed., pp. 117-122). ONS Publishing Division, PA: Pittsburgh. Hoffman, A. & Gift, A. (2007). Oncology Nursing. In Langhorne, M., Fulton, J., & Otto, S. Lung Cancer. (5 th e.d., pp. 258- 274). St. Louis: Elsevier Saunders. Franceschi, C. & Bonafe, M. (2003). Centenarians as a model for healthy aging. Biochemical Society Transactions. 31(2) pp: 457-461.

58 Polovich, M., Whitford, J., & Olsen, M. (2009). Chemotherapy and Biotherapy Guidelines and Recommendations for Practice. Oncology Nursing Society, pp. 234-244. Stedman’s Medical Dictionary for the Health Professions and Nursing. (2005). (5 th e.d.) Baltimore, MD: Lippincott Williams & Wilkins. Tyson, L. (2006). Dyspnea. Clinical Manual for the Oncology Advanced Practice Nurse. Sorrell-Camp, D. & Hawkins, R. (23) pp. 153-158. Wickham, R. (2002). Dyspnea: Recognizing and managing an invisible problem. Oncology Nursing Forum, 29, 925-933. Zerwekh, J. & Claborn, J. (2006). Illustrated Study Guide for the NCLEX-RN Exam. Respiratory System, pp. 281-316. MO: Elsevier Mosby.

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