1. Nursing Care of the Lung Cancer Patient Ann Proctor RN, BSN, OCN Linda Farjo RN, BSN, OCN

2. Putting the Puzzle Together VATS Chest Tubes Nursing Care of the Brachytherapy Patient Pleur-x Catheters Oncology Emergencies and Lung Cancer EDUCATE UNDERSTAND RESPOND ANTICIPATE

3. VATS - VIDEO ASSISTED THORASCOPIC SURGERY

4. What is VATS? VATS – video assisted thorascopic surgery Minimally invasive procedure 3-4 small incisions Uses a small video camera introduced into the chest via a scope. Used for diagnosis and treatment A segment, lobe or entire lung can be removed, depending on the patient's condition and the extent of the cancer

5. Advantages of a VATS Procedure Less morbidity and shorter hospital stay Reduced injury to the chest wall muscles used in respiration Smaller incisions means less pain and fewer complications Return to work and daily activities much sooner

6. VATS Candidates People with cancer in the early stages of disease Not suitable for: –People receiving neoadjuvant chemo (given before surgery) –People with bulky areas of disease in the thorax –People whose surgery will exceed a certain threshold of complexity

7. Nursing Care of the VATS Patient Chest tube management Pain control Education –Surgery takes 1-2 hours –CT removed 1 day after surgery –Cough and deep breathe, IS –Ambulation –Skin below and in front of incision to be numb – up to 6 months after surgery –Discharge 1-2 days after surgery EDUCATE UNDERSTAND RESPOND ANTICIPATE

8. CHEST TUBES

9. Chest Anatomy

10. Why do we use chest tubes? Cardiac Surgery –Fluid drainage

11. Why do we use chest tubes? Thoracic Surgery Tension pneumothorax Signs and Symptoms of tension pneumothorax  Sudden chest pain  Chest tightness  SOB  Rapid heart rate  Bluish skin color  Pain in arm  Stabbing sensation in the back  Venous return and cardiac output impeded

12. Why do we use chest tubes? Malignant pleural effusion  Most common signs and symptoms of pleural effusions:  Chest pain  Shortness of breath  Mild pain  Dry cough  Pleuritic stabbing pain  No symptoms

13. Why do we use chest tubes? Pneumothorax

14. Why do we use chest tubes? Hemothorax

15. Chest Drainage System Components Collection Chamber Water Seal Chamber Suction control chamber

16. Care of the Chest Tube Drainage System Preparing the system for insertion –Step 1 - Fill water seal to 2 cm line –Step 2 - Connect chest drain to patient –Step 3 - Connect chest drain to suction –Step 4 - Turn suction on Care of the drainage unit –Place below the level of the patient’s chest –Swing floor stand open for secure placement on floor –Hang the system bedside with the hangers provided –Do not obstruct the positive pressure valve

17. Care of the Chest Tube Drainage System Care of the tubing –Do not tape connections –Avoid dependent loops in the tubing –Keep it above the chest drainage system –Do not clamp the tubing Care of the dressing site –Redress prn if wet using sterile technique

18. Heimlich valve

19. Nursing Assessment Know when and why the tube was inserted Patient Education Breath sounds Trachea position Respiratory rate and pattern Suction setting Drainage amount and color Dressing condition Check for air leaks EDUCATE UNDERSTAND RESPOND ANTICIPATE

20. Nursing Assessment Look for evidence of: –Fever –Hypoxia –Chest pain Pain assessment and response to pain relieving measures Evidence of subcutaneous emphysema –Palpate around chest tube area EDUCATE UNDERSTAND RESPOND ANTICIPATE

21. NURSING CARE OF THE BRACHYTHERAPY RADIATION PATIENT

22. Permanent Radiation Implants Prostate seed implants Little radiation precautions necessary –Radiation used has low energy and does not penetrate the patient’s body –Generally an out- patient procedure –Patient may be admitted for medical and not radiation reasons

23. Permanent Radiation Implants Cesium 131 Implants –Body sites for permanent implant therapies, such as lung, brain, head and neck, gynecological. –Patients are hospitalized for the post- operative care, not for the radiation care

24. Cesium 131 implants

26. Protection Basic Radiation Safety Rules –Minimize time with the patient –Maximize your distance –Use appropriate shielding

27. Room Preparation Private room with bathroom Equipment: –Long handled forceps or hemostat –Lead vial holder –Lead shield –Lead aprons (2) –Dosimeter badge Radiation Caution Sign outside of room Radiation Safety Officer (RSO) will tape the 3 foot safe distance area in the room.

28. Nursing Protection Always wear your radiation dosimeter badge. No one who is pregnant or suspects they are pregnant should enter the room unless an immediate need arises. –A lead shield will be available if a pregnant staff member must enter the room. Standard precautions are appropriate. Use a lead apron or stay behind the lead shield provided if contact closer than 3 ft of patient will be longer than 5 minutes. RSO will check radiation levels in room daily.

29. Housekeeping Housekeeping personnel may enter room for short intervals of time When the patient is transferred or discharged out of the room – RSO will check the room for radiation safety levels and notify the nursing staff when the room can be cleaned and occupied by another patient

30. Visitors Children and pregnant women are not permitted in the patient’s room. Minimum contact with the patient is permissible, however the time spent in close proximity to the patient (closer than 3 feet) should be minimized to less than 5 minutes per day for the first 10 days.

31. Nursing Care Nursing Assessment –Organize patient care to provide maximum care in minimal time –Work on side opposite seed implant if applicable –Be alert for seed implants which have become loose, particularly in cavities with access to the exterior Notify RSO of any dislodged implant Use long handled forceps or hemostats to pick radioactive source and place in leaded vial Do not touch the seed with hands EDUCATE UNDERSTAND RESPOND ANTICIPATE

32. Nursing Care Medication Administration –All equipment is not considered contaminated and may be removed from the room Dressing –Do not discard any old dressings or linens until they have been surveyed by the RSO –Linens and trash are considered contaminated because of potential lost seeds and should remain in the room until cleared by the RSO I&O –Body fluids are not radioactive- maintain standard nursing precautions EDUCATE UNDERSTAND RESPOND ANTICIPATE

33. Nursing Care Notify Radiation Oncology @ x18180 if any unusual event occurs such as: –Finding a seed –The patient requires additional surgery –The patient expires In an emergency –First priority is caring for the patient –Wear badges when with the patient –Notify RSO immediately EDUCATE UNDERSTAND RESPOND ANTICIPATE

34. PLEUR-X DRAINAGE CATHETERS

35. Indications Malignant Pleural Effusion Malignant Ascites

36. Benefits for Patients Easy set up and use Low rate of infection Helps eliminate hospital visits Palliation of symptoms Improved quality of life Simple placement procedure

37. Supplies Purchased by patient Hospice patient: supplies covered by hospice VNA patient: supplies covered by individual insuranceSupplies Drainage system kit includes everything necessary to drain (10 kits/box)

38. Drainage Instructions Getting started –Get drainage supplies ready and wash hands –Remove dressing from drainage site –Open all packages and prepare field Connecting the Drainage Bottle –Remove cover from access tip –Take valve cap off catheter –Clean around valve opening with alcohol pad –Insert access tip into catheter valve

39. Drainage Instructions Draining fluid –Insert plunger into drainage bottle –Release clap on drainage line to begin draining *** Chest drain – maximum of 1000 cc/day *** *** Abdomen drain - maximum 2000 cc/day *** –Inpatients can be connected to PleurX drainage system, pleuravac, foley bag, or wall suction Suction should be set at lowest possible setting (60 mm Hg)

40. Drainage Instructions Final Steps and Disposal –Clean around valve with alcohol pad and place new cap on catheter valve –Clean around catheter site with alcohol pad –Place dressing on site –Dispose of bottle

41. Chest drainage

42. Abdominal drainage

43. Nursing Care Assess patient’s comfort level : pain, shortness of breath Do not drain more than the amount indicated for the drain If patient experiences any distress, notify physician EDUCATE UNDERSTAND RESPOND ANTICIPATE

44. ONCOLOGY EMERGENCIES AND LUNG CANCER

45. Superior Vena Cava Syndrome (SVCS) Definition: –SVC obstruction is a narrowing or blockage of the superior vena cava -- the second largest vein in the human body. The superior vena cava moves blood from the upper half of the body to the heart. –The SVC is the main vein that drains blood back into the heart from the upper body, and it runs in the middle of the chest on the right side, where it is vulnerable to being compressed by a nearby lung cancer or enlarged lymph nodes, such as from lung cancer or lymphoma

46. SVCS

47. Symptoms of SVCS The leading symptoms of SVC syndrome are facial edema, distended veins in the neck and sometimes chest, arm edema, shortness of breath, cough, facial plethora/fullness, and less commonly wheezing, lightheadedness, headaches, and even confusion.

48. Causes of SVCS Malignant causes –Lung Cancer Small cell lung cancer –Lymphoma –Other metastatic cancers Mesothelioma Breast Germ cell Thymoma Non-malignant causes –Catheter related thrombus –TB –Goiter –Aortic aneurysm –Histoplamosis

49. Diagnosis of SVCS Chest X-ray CT scan of thorax MRI Ultrasound

50. Treatment of SVCS Radiation Therapy Chemotherapy Pharmacological Surgery

51. Nursing Interventions for SVCS Recognize high risk patients –Lung cancer –Lymphoma –Other metastatic disease Be aware of the signs and symptoms of SVCS –Assessment of respiratory, cardiac and neurologic systems –Intravenous fluids should not be given through the upper extremities - central venous access devices necessary and require diligent nursing care EDUCATE UNDERSTAND RESPOND ANTICIPATE

52. Spinal Cord Compression (SCC) Definition –The spinal cord is compressed by bone fragments from a vertebral fracture, a tumor, abscess, ruptured intervertebral disc or other lesion

53. Symptoms of SCC Can depend on where the compression is located New or worsening back pain Weakness Loss of sensation in affected limbs Decreased sense of the relative position of neighboring parts of the body Numbness / tingling / coldness Urinary retention / constipation Ataxia / Bowel / bladder incontinence Sexual dysfunction

54. Causes of SCC Most common tumors that cause spinal cord compression: Lung Breast Prostate

55. Causes of SCC Vertebral metastases –Vertebral metastases can directly invade the epidural space or cause bone destruction, with bone fragments leading to compression. –Edema and ischemia caused by compression of blood flow to the cord Cauda equina compression –The cauda equina is a bundle of nerves located at the bottom of the spinal cord, with nerves spreading out like a horse tail –Loss of bowel and/or bladder function –Loss of sensation in the buttocks, thighs and groin (saddle distribution).

56. Diagnosis of SCC MRI CT scan with myelography

57. Treatment of SCC The goal of therapy for SCC include pain control, avoidance of complications, preserving or improving neurologic functions or reversing impaired neurologic functions. –Corticosteroids –Radiation Therapy –Surgery –Other medications: Chemotherapy, Biphosphonates

58. Prognostic Factors for Functional Recovery Favorable prognostic factors: –Early recognition and diagnosis –Prompt initiation of therapy –Able to ambulate at presentation –Slow onset of motor weakness –Radiosensitive tumors – myeloma, lymphoma, breast, prostate –Responsive to steroid treatment –Female gender –Good performance status –Long interval between diagnosis and appearance of SCC

59. Prognostic Factors for Functional Recovery Poor prognostic factors: –Paraplegia prior to treatment –Urinary retention –Sphincter incontinence –Rapidly deteriorating neurologic function (in less than 72 hours) –Radioresistant tumors – lung, renal, GI, sarcoma, bladder –Extensive disease –Poor performance status

60. Nursing Interventions for SCC Early recognition –Know signs & symptoms –Know risk factors –Thorough assessment Pain Sensory and motor status Neurologic Bowel and bladder function Education EDUCATE UNDERSTAND RESPOND ANTICIPATE

61. Other Oncology Emergencies SIADH Hypercalcemia of Malignancy Cardiac Tamponade Malignant Pleural Effusion Sepsis and Septic Shock