8.

Describe the clinical manifestations, diagnostic findings and collaborative management of a client who has sustained a
thoracic trauma.

Table 30-21 in the Med-Surge textbook.

9. Chest Tubes
The purpose is to remove the air and fluid from the pleural space and to restore normal intrapleural pressure so that the lungs can re-
expand.
Chest Tube Insertion
Chest tubes can be inserted in the emergency department, at the patient's bedside, or in the operating room. In the operating room, the
chest tube is inserted via the thoracotomy incision. In the emergency department or at the bedside, the patient is placed in a sitting
position or is lying down with the affected side elevated. The area is prepared with antiseptic solution, and the site is infiltrated with a
local anaesthetic agent. After a small incision is made, one or two chest tubes are inserted into the pleural space. One catheter is placed
anteriorly through the second intercostals space to remove air. The other is placed posteriorly through the eighth or ninth intercostal
space to drain fluid and blood. The tubes are sutured to the chest wall, and the
puncture wound is covered with an airtight dressing. During insertion, the tubes are kept clamped. After the tubes are in place in the
pleural space, they are connected to drainage tubing and pleural drainage and the clamp is removed. More commonly, a Y-connector
is
used to attach both chest tubes to the same drainage system.
Complications
Chest tube malposition is the most common complication. Routine monitoring is done by the nurse to evaluate whether the chest
drainage is successful by observing for tidalling in the water-seal chamber, listening for breath sounds over the lung fields, and
measuring the amount of fluid drainage.
Re-expansion pulmonary edema can occur
after rapid expansion of a collapsed lung in patients with a pneumothorax or evacuation of large volumes of pleural fluid (>1 to 1.5 L).
A vasovagal response with symptomatic hypotension can occur from too rapid removal of fluid.
Infection at the skin site is also a concern. Meticulous sterile technique during dressing changes can reduce the incidence of infected
sites.
Pneumonia from not taking deep breaths, from not using spirometers, and by splinting on the affected side and (2) shoulder disuse
(frozen shoulder) from lack of range of motion exercises. Poor patient adherence or lack of patient teaching can contribute to these
complications.
Nurses can make a tremendous impact on preventing these complications. As with many procedures, the hospital may have policies
and procedures referring to the care of chest tubes. Ensure that these are reviewed and followed.
Chest Tube Removal
The patient with chest tubes may have chest radiographic studies to follow the course of lung expansion. The chest tubes are removed
when the lungs are re-expanded and fluid drainage has ceased. Generally, suction is discontinued and the patient is placed on gravity
drainage for a period of time before the tubes are removed. The tube is removed by cutting the sutures; applying a sterile petroleum
jelly gauze dressing; having the patient take a deep breath, exhale,
and bear down (Valsalva's manoeuvre); and then removing the tube. Pain medication is generally given before chest tube removal.
The site is covered with an airtight dressing, the pleura seals itself off, and the wound is healed in several days. A chest radiograph is
obtained after chest tube removal to evaluate for pneumothorax, reaccumulation of fluid, or both. The wound should be observed for
drainage and should be reinforced if necessary. The patient should be observed for respiratory distress, which may signify a recurrent
or new pneumothorax.

10. Describe the risk factors, clinical manifestations, diagnostic studies, collaborative care, and surgical management for a
client with lung cancer.

Surgical Therapy.
Surgical resection is considered the treatment of choice in NSCLC Stages I and II because the disease is potentially curable with
resection. For other NSCLC stages, surgery may be indicated in conjunction with radiation therapy and/or chemotherapy. In limited-
stage SCLC, which is rare, surgical resection, chemotherapy, and radiation therapy may be recommended. When the tumour is
considered operable with a potential for cure, the patient's cardiopulmonary status must be evaluated to determine the ability to
withstand surgery. This is done by clinical studies of pulmonary function, ABGs, and others, as indicated by the individual's status.
Contraindications for thoracotomy include hypercapnia, pulmonary hypertension, cor pulmonale, and markedly reduced lung function.
Coexisting conditions such as cardiac, renal, and liver disease may also be contraindications for surgery.
A tumour may be considered inoperable. If operable, the type of surgery performed is usually a lobectomy (removal of one or more
lobes of the lung) and, less often, a pneumonectomy (removal of one entire lung).
Radiation Therapy.
Radiation therapy is used as a curative approach in the individual who has a resectable tumour but who is considered a poor surgical
risk. Adenocarcinomas are the most radioresistant type of cancer cell. Although SCLCs are radiosensitive, radiation (even when used
in combination with chemotherapy) does not significantly improve the mortality rate because of the early metastases of this type of
cancer. Radiation therapy is also done as a palliative procedure to reduce distressing symptoms such as cough, hemoptysis, bronchial
obstruction, and superior vena cava syndrome. It can be used to treat pain that is caused by metastatic bone lesions or cerebral
metastasis. Radiation used as a preoperative or postoperative adjuvant measure has not been found to significantly increase survival in
the patient with lung cancer.
Stereotactic Radiotherapy.
Stereotactic radiotherapy is a type of radiation therapy that uses high doses of radiation delivered very accurately to the tumour. SRT
provides an option to elderly patients, patients with severe lung or heart disease, and other patients with poor health who are not good
candidates for surgery. SRT is an outpatient procedure that uses special positioning procedures and radiology techniques so that a
higher dose of radiation can be delivered to the tumour, and a smaller part of the healthy lung is exposed.
Chemotherapy.
Chemotherapy may be used in the treatment of nonresectable tumours or as adjuvant therapy to surgery in NSCLC with distant
metastases. A variety of chemotherapy drugs and multidrug regimens (i.e., protocols) including combination chemotherapy have been
used. These drugs include etoposide (VePesid), carboplatin, cisplatin, paclitaxel (Taxol), vinorelbine, cyclophosphamide (Procytox),
ifosfamide (Ifex), docetaxel (Taxotere), gemcitabine (Gemzar), topotecan (Hycamtin), and irinotecan (Camptosar). Chemotherapy has
improved survival in patients with advanced NSCLC and is now considered standard treatment.

Biological Therapy.
Biological (targeted) therapy as adjuvant therapy has been used in individuals with cancer, including malignant
lung tumours.
Prophylactic Cranial Radiation.
Brain metastasis is a common complication of SCLC. Most chemotherapy drugs do not adequately penetrate
the bloodbrain barrier. Prophylactic cranial radiation may be used as a potential way to improve the
prognosis of patients, especially those who have a complete response to chemotherapy. Toxicity of this
therapy may include scalp erythema, fatigue, and alopecia.
Bronchoscopic Laser Therapy.
Bronchoscopic laser therapy makes it possible to remove obstructing bronchial lesions. The thermal energy of
the laser is transmitted to the target tissue. It is a complicated procedure that often requires general anaesthesia
to control the patient's cough reflex. Relief of the symptoms from airway obstruction as a result of thermal
necrosis and shrinkage of the tumour can be dramatic. However, it is not a curative therapy for cancer.
Phototherapy.
Photodynamic therapy is a safe, nonsurgical therapy for lung cancer. Porfimer (Photofrin) is injected
intravenously and selectively concentrates in tumour cells. After a set time (usually 48!hr), the tumour is
exposed to laser light, producing a toxic form of oxygen that destroys tumour cells. Necrotic tissue is removed
through a bronchoscope.
Airway Stenting.
Stents can be used alone or in combination with other techniques for palliation of dyspnea, cough, or
respiratory insufficiency. The advantage of an airway stent is that it supports the airway wall against collapse
or external compression and can impede extension of the tumour into the airway lumen.
Cryotherapy.
Cryotherapy is a technique in which tissue is destroyed as a result of freezing. Bronchoscopic cryotherapy is
used to ablate (destroy) bronchogenic carcinomas, especially polypoid lesions. A repeat bronchoscope is
performed 8 to 10 days after the first session. The second examination enables assessment of cryodestruction,
removal of any slough, and repeat cryotherapy if required for the treatment of large lesions.

Nursing Implementation
Health Promotion
promoting smoking cessation programs and actively supporting education and policy changes related to smoking.
assist the smoker to stop smoking. RNAO Best Practice Guideline Integrating Smoking Cessation into Daily Nursing Practice
recommends nurses use the ask, advise, assist, arrange protocol to motivate smokers and other tobacco users to quit. The five
stages of change identified in smokers attempting to quit include precontemplation, contemplation, preparation, action, and
maintenance. For patients unwilling to quit, motivational interviewing is recommended. The Canadian Cancer Society (2007)
has a series of One Step at a Time guides for quitting smoking that are available at its Web site. Health Canada (2008) also
provides resources via a GoSmokeFree strategy. Because some patients relapse months or years after having stopped smoking,
nurses must continually provide interactions to prevent relapse. Nicotine's addictive properties make quitting a difficult task
that requires much support. Nicotine replacement significantly lessens the urge to smoke and increases the percentage of
smokers who successfully quit smoking. Support for the smoker includes education that smoking a few cigarettes during a
cessation attempt (a slip) is much different from resuming the full smoking habit (a relapse). Despite the slip, smokers should
be encouraged to continue the attempt at cessation without viewing the effort as a failure. Measures to assist an individual in
quitting should be directed toward the meaning that smoking has to that individual.
Acute Intervention
support and reassurance during the diagnostic evaluation.
help the patient and the family deal with the diagnosis of lung cancer.
The patient may feel guilty about cigarette smoking having caused the cancer and need to discuss this feeling with someone
who has a nonjudgemental attitude.
Questions regarding each patient's condition should be answered honestly.
Additional counselling from a social worker, psychologist, or member of the clergy may be needed.
A major role in providing patient comfort, teaching methods to reduce pain, assessing for signs and symptoms of progressive
or recurrent disease, and assessing indications for hospitalization.
Ambulatory and Home Care
Patient teaching needs to include signs and symptoms to report, such as hemoptysis, dysphagia, chest pain, and hoarseness.
The patient and caregivers should be encouraged to provide a smoke-free environment (smoking cessation for multiple family
members).
If the treatment plan includes the use of home oxygen, part of the teaching plan must include the safe use of oxygen.
The patient who has had a surgical resection with intent to cure should be followed up carefully for manifestations of
metastasis.The patient and family should be told to contact the physician if symptoms such as hemoptysis, dysphagia, chest
pain, and hoarseness develop
The patient and family or caregivers may need information about palliative care options in the community.
 Pathophysiology
More than 90% originate from the epithelium of Health teaching
the bronchus; grow slowly; primarily in the Smoking cessation
Lab and diagnostics segmental bronchi or beyond and have a Stay away from second-hand smoke
History and physical examination preference for the upper lobes of the lungs
Chest radiographic examination Safe use of oxygen
Types: nonsmall cell lung cancer
Sputum for cytological study Methods to reduce pain
(NSCLC, 75 to 80%) and small cell lung cancer
Bronchoscopy Report signs and symptoms of progressive or
(SCLC, 20 to 25%)
CT scan recurrent disease, such as hemoptysis, dysphagia,
Metastasize by direct extension and via the
MRI chest pain, and hoarseness.
blood and the lymph.
PET Indications for hospitalization
The common sites for
Spirometry (preoperative) Metastatic sites: liver, brain, bones, scalene
Mediastinoscopy lymph nodes, and adrenal glands.
VAT
Pulmonary angiography
Lung scan
Fine-needle aspiration
Pharmacology
Chemotherapy (PO, IV, injections)
Nursing interventions Targeted therapies (gefitinib (Iressa)
support and reassurance during the diagnostic LUNG CANCER and erlotinib (Tarceva)
evaluation Photodynamic therapy: medicine
help the patient and the family deal with the that gets absorbed by cancer cells,
diagnosis of lung cancer then doctors shine a high-energy laser
providing comfort, methods to reduce pain, light on you, which activates the
assessing for S&S, and assessing indications for medicine and helps it destroys the
Signs and symptoms cancer cells.
hospitalization
Mostly clinically silent https://www.lung.ca/lung-
Collaborative care Anorexia, nausea, vomiting, dysphagia (late symptom), weight health/lung-disease/lung-
Surgery loss cancer/treatment
Radiation therapy Persistent cough (productive or nonproductive), dyspnea,
Chemotherapy hemoptysis (late symptom)
Biological therapy Fatigue, fever, chills
Bronchoscopic laser therapy Chest pain or tightness, shoulder and arm pain; headache;
Phototherapy bone pain (late symptom) Patient history
Airway stenting Fever, neck and axillary lymphadenopathy, paraneoplastic long history of cigarette smoking;
Cryotherapy syndromes (e.g., SIADH secretion) environmental exposure to toxic
Fever, neck and axillary lymphadenopathy, paraneoplastic substances.
Risk factors syndromes (e.g., SIADH secretion) Demographics
Smoking, asbestos, radon, nickel, iron and Jaundice (liver metastasis); edema of neck and face (superior older than 50 years
iron oxides, uranium, polycyclic aromatic vena cava syndrome), digital clubbing most frequently in persons 40 to 75
hydrocarbons, chromates, arsenic, and air Wheezing, hoarseness, stridor, unilateral diaphragm paralysis, years of age, with peak incidence
pollution pleural effusions (late signs) between 55 and 65;
Pericardial effusion, cardiac tamponade, dysrhythmias (late More men than women diagnosed, die
signs) and have worse prognosis;