Atelectatic Right Lung Cancer
A 6o-year-old white man presents with an accelerated decline in lung function. Last year he was diagnosed with metastatic ling cancer. Today he is dyspneic, pale, and seems almost listless. He continues to smoke and his pack-year history is 40 years. He says “I am tired of this fight”.
CC: ”I have to sleep in my recliner because I can’t lie in bed, and I have no energy to do anything—I don’t even have energy to eat I just want to die.”
Physical exam: Blood pressure, 120/74; pulse rate, 120 beats/min; respiration rate, 36/min Height, 5’9”; weight, 130 lbs.
AP to lateral diameter: 1:1
Cough with clear mucoid sputum Diminished breath sounds
Dullness overright lower and middle lung fields on percussion and use of accessory muscles during respiration
Chest x-ray film. Mass noted RML and RLL, tracheal shift to left, no cardiomegaly Arterial blood gases: pH 7.2, PaO2 55, pCO2 60, HCO3 26
1. What additional subjective data do you think the patient will share*
2. What additional objective data will you be assessing for?
3. What National Guidelines are appropriate to consider?
4. What tests will you order?
5. Will you be looking for a consult? If so with whom?
6. What are the medical and nursing diagnoses?
7. Are there any legal/ethical considerations?
8. What is your plan of care*
- complementary therapies
9. Are there any Healthy People 2020 objectives that you should consider?
10. Using the Circle of Caring, what or who else should be involved to truly hear the patient‘s voice, getting him and the family involved in the care to reach optimal health?
11. What additional patient teaching may be needed7
12. What billing codes would you recommend?
Assignment 2: Right Lung Cancer with Atelectatic Lung
A 60-year-old white patient has presented to the office with an accelerated decline in lung function, dyspnea, paleness, and almost listless. His chief complaints are fatigue as he does not have any energy, and he sleeps in a recliner as he cannot lie on his bed. He was diagnosed with metastatic lung cancer last year. But, he continues smoking, and his pack-year smoking history is 40 years.
The common symptoms of the intrathoracic diseases are insidious and ambiguous comprising cough, dyspnea, wheezing, sputum production, post-obstructive pneumonia, chest pain, pleural effusions, and hemoptysis. Severe spasms of cough could also result in cough-induced fractures of the rib, emphysematous bleb ruptures, or syncope. Cough with the production of sputum are not definite indicators since most lung cancer patients experience emphysema and chronic bronchitis owing to the smoking of cigarettes. But, changes in the cough character, changes in quantity and quality of the sputum, and impassiveness to formerly effective drug therapy will raise the suspicion of the presence of tumor (Bickley et al., 2013). Most lung cancer patients have dyspnea due to compound disruptions in the physiological functioning of the respiratory system and underlying pulmonary disorders. The patient could have problems in airway clearance due to chest pain, muscle weakness, excessive tracheobronchial, and thick tenacious secretions. Lastly, chest pain with coughing or deep inspiration could be reported, along with anorexia and fatigue.
Auscultation could reveal wheezing if the airway has been partially obstructed. Also, the wheezing is monophonic, localized, and does not fade after coughing. The wheezing is heard on both exhalation and inhalation. The patient’s absent or decreasing breath sounds are listened to when the tumor has replaced the normal lung tissue, or there is pleural effusion. Also, percussion discloses reduced resonance over the lung tissues that have been affected by the tumor, pneumonia, and pleural effusions. The decrease in tactile fremitus is related to pleural effusion and pleural cavity tumors, while an increase in tactile fremitus indicates a mass. But, the most common peripheral indication is the clubbing of the fingers that are sometimes associated with Bamberger-Marie disease. The evidence of physical examination for surgical non-resectability comprises hoarseness, arm pain, facial edema, or change emotional and mental status.
The systemic symptoms are generalized weakness, cachexia, extreme fatigue, anorexia, anemia, and loss of weight. The extrathoracic metastatic spread happens in the lymph node, liver, suprarenal glands, brain, and bone. Bone pain triggered by metastasis occurs in about 25.0% to 40.0% of patients (Dunphy et al., 2019). Neurological symptoms from intracranial metastases are hemiplegia, confusion, epilepsy, speech defects, personality changes, nonspecific headache, and gait disturbances. The liver syndromes symptoms are an endocrine, cutaneous, cardiovascular, neurological, and skeletal manifestation. The metabolic manifestations are linked to secretions of endocrine and similar materials by the tumor. Hyperadrenocorticism is manifested as severe weakness, hypokalemia, hyperglycemia, loss of weight, edema, and hypertension. The inapt antidiuretic hormone secretion syndrome is resultant from antidiuretic hormone secretion manifested by water intoxication symptoms like anorexia, vomiting, and nausea. The low serum osmolality and hyponatremia symptoms are changes in mental status, lethargy, confusion, and seizures. Hypercalcemia is instigated by bony metastases, a tumor’s excessive secretion, or humoral hypercalcemia. Thus, manifestations resultant from the extrathoracic involvement include headache, pain in the bones, dizziness, disturbances of the CNS, gastrointestinal issues, jaundice, lymphadenopathy, hepatomegaly, and pain in the abdomen.
In the recent past, the low radiation dose screening of the chest has become the preferred standard of healthcare in the U.S for lung cancer, partly due to the National Lung Screening Trials results. The benefits and risks of the low radiation dose screening vary in magnitude and occurrence, but the conversion of an optimal balance of benefits and risks into medical practice is hard. The CHEST guidelines provide recommendations for diagnosis, evaluation, management, treatment, and follow up among patients with lung cancer. These guidelines cover the whole range of healthcare from the first diagnosis to palliative healthcare and end-of-life patient care (Alberts et al., 2013). Besides, the additional recommendations comprise screening for lung cancer, chemoprevention, as well as treatment of tobacco use among patients. In 2018, the Chest publication of American College of Chest Physicians offered an update on the evidence-based benefits, risks, and execution of low radiation dose screening (Mazzone et al., 2018). The evidence recommended that low radiation dose lung cancer screening has a favorable but unsubstantiated balancing of benefits and harms. Furthermore, the choice of patients who are qualified for screening, imaging quality and interpretation, management of screen results, and overall effectiveness of interventions like cessation of smoking has an impact on the balance.
The first recommendation is yearly screening for lung cancer for asymptomatic as well as former smokers who are aged between 55 and 77 years with a history exceeding 30 pack-years and are now smoking or have quit over the past 15 years. (Weak recommendation and moderate-quality evidence) Secondly, the routing low-dose chest CT screening for asymptomatic in addition to former smokers who do not match the smoking and age criterion but are considered as high risks for the development of lung cancer as per the clinical risk predictions. (weak recommendations and low-quality evidence) Guidance for no screening persons with an accumulation of below 30 pack smoking years or below 55 or higher 77 years or quit smoking for over 15 years, and absence of high risks of development of lung cancer (strong recommendation and moderate-quality evidence). Finally, low-dose chest CT screening cannot be done for persons having comorbidities that unfavorably influence their aptitude to tolerate the assessment of screen results or can tolerate treatment at the early-stage lung cancer or considerably hinder their life expectancy. (Strong recommendation and low-quality evidence).
The presently accepted system used in the staging is the tumor node-metastasis classification of codes where T represents the degree of the primary tumor (T0 to T4), N specifies the nodal involvement (N0 to N3), and M defines the range of metastasis (M0 or M1). The disease stage is based on an amalgamation of clinical staging (physical examination, and laboratory, and radiological) and pathological staging (biopsy of the lymph nodes, Mediastinoscopy, bronchoscopy, and paramedian sternotomy). The initial tests will comprise ordering a complete blood count since anemia can be linked to lung cancer. Besides, a basic metabolic and hepatic panels will be used to assess any irregularities in the K, Ca, Na, and other liver enzymes. The platelet count, prothrombin timing, and partial thromboplastin timing will assess coagulopathies. Also, an electrocardiogram and baseline pulmonary function tests should be done. The simplest technique for the identification of patients with lung cancer is the lateral and anterior-posterior chest x-ray films since the heart, as well as other thoracic organ structures, hide a portion of the lung tissue (Melnyk & Fineout-Overholt, 2011). Also, the chest x-ray film demonstrates asymptomatic cancer and is nearly anomalous when patients are symptomatic.
A computed tomography scan of the chest with infusions of contrast materials is extensively accepted as the principal cross-sectional modality for thorax evaluation that characterizes the tumor’s size and location and its relationship with other thoracic structures. The CT scan extends inferiorly to contain the liver as well as adrenal glands. Mediastinal changes on the chest radiograph could suggest pleural effusions or lymphadenopathy, and elevated diaphragm due to the phrenic nerve involvement.
Cytological sputum evaluation, bronchial brushings, bronchial washing, as well as fine-needle aspirations, tend to have high diagnostic value. Yet, the positive predictive and negative predictive values and diagnostic accuracy is dependent on sampling errors, processing quality, tissue preservation, and observer’s experience. The sputum cytology is a simple test that has a positive predictive value, which can approach 100 percent, but the sensitivity rate is 10 percent to 15 percent (Tobias & Hochhauser, 2015). Next, the flexible fiberoptic bronchoscopy is a key and standard method for evaluating patients who have pulmonary neoplasms and determines the endobronchial level of disease. When the lesions are detectible endobronchially, the bronchial washings diagnostic yield is about 90%; the samples of bronchial mucosal forceps biopsy and bronchial brushings provide a diagnosis of lung tissue in approximately 98% of the visualized tumors. The fine-needle aspiration biopsy can be used when the lung lesions are not visualized via bronchoscopy and are accessible percutaneously. The positive pleural fluid cytology demonstrates the spreading of malignancy into the pleural space. A combination of the pleural biopsy and thoracentesis offers up to 90 percent diagnostic yield among patients with malignancy.
Mediastinoscopy is a procedure used in diagnosing and staging lung cancer and is recommended when mediastinal lymph nodes on the chest CT scan are more than one cm for the patient with operable NSCLC. In addition, video-assisted thoracoscopic surgery can be used to diagnose and staging lung cancer when other less invasive techniques do not yield a diagnosis (Parrillo & Dellinger, 2019). The chest visualization, mediastinum, and evaluation of pleural effusions are superior as they improve the diagnostic accuracy. Thoracoscopy is beneficial for pleural evaluation but less expedient for assessment of the lung. It has 90% sensitivity for pleural-based malignancy and peripheral lung nodules diagnosis with a 99% specificity.
The lung cancer symptoms develop gradually and are often attributed to the smoker’s cold or cough and healthcare provider pulmonary infarction, tuberculosis, lung abscess, sarcoidosis tracheobronchitis, pneumonia, lung infarction, and influenza. The initial diagnosis seeks to differentiate the presence of a primary tumor or metastatic cancer that is evaluated on biopsy. The other differential diagnoses include hamartomas, lymphoma, mycobacterium avium complex, or foreign body aspiration. The age and smoking status provides a clue to if lung cancer is the likely cause of infiltrate on the lung X-ray for a possible diagnosis. The thoracic CT scan indicates the tumor growth rate through comparisons with earlier images. The massive calcification is improbable in lung cancer but is common in fungal granulomas, hamartomas, and tuberculomas. The invasion of adjacent organs is close to malignant growth and is observed at the top of the lung. Cavitation, multiplicity, and large size, either extrathoracic or intrathoracic, are additional signs of malignancy. Chest discomfort is associated with atelectasis, and the diagnosis is confirmed using the CT, oximetry, thorax ultrasound, and bronchoscopy diagnosis. The atelectasis develops with lung cancer secondary to the mechanical airway obstruction, lung tissue compression, and shallow breathing patterns.
The treatment plan for lung cancer consists of surgery, chemotherapy, or radiation, either alone or varying combinations. The form of treatment is determined by the stage, tissue type, and the performance status or other comorbid conditions (Sydney et al., 2018). The patient is critically sick since his ABG is very acidotic; the emergency treatment is cardiopulmonary resuscitation. If pCO2 is greater than 80 mmHg, mainly if pH < 7.10. There is a need for immediate mechanical ventilation and sedation. Since the patient is sedated, the volume control ventilation is used starting at an initial tidal volume of 4-6 ml/kg to preserve the peak pressure < 30 mmHg. The acidosis can be treated with sodium bicarbonate along with nebulizer treatments to ease the secretions. Metastatic lung cancer treatment will focus on controlling the growth of cancer and relieving the symptoms. Treatment options include biological therapy, radiation therapy, laser therapy, and drug therapy that addresses specific symptoms such as steroids, painkillers, and muscle relaxants.
The patient should be informed of probable symptoms and urged to contact their hospital when there is a development of new symptoms or a deterioration of pre-existing symptoms. Annual chest x-rays can be used to evaluate for possibly curable second primary cancers such as chest/abdomen X-rays, bronchoscopy, CBC, and other routine chemistries can be performed as indicated by the symptoms of the patient. Furthermore, a head CT scan with and with no infusion of contrast materials can be recommended for patients who have central nervous system disease symptoms only (Melnyk & Fineout-Overholt, 2011). Lastly, additional diagnostic tests include the adrenal biopsy, brain CT, bone scan, and liver biopsy.
Healthy People 2020
One of the goals is the reduction of the number of new cases of cancer, illnesses, disabilities, and death by cancer. This can be achieved through the continued developments in research, diagnosis, management, and treatment to lower death and incidence rates for all types of cancers. The Healthy People 2020’s cancer objectives support the monitoring of trends in the incidence, mortality rates, and survival for better assessment of the progress towards lessening the cancer burden in the U.S. This is a reflection of the significance of promotion of evidence-based screening and measurement of screening identified in the USPSTF recommendations. Besides, in an age of patient-centered health care, there is the need to maintain effective communications between clinicians, patients, and even family members to foster the sharing knowledge and better understanding resulting in medical decisions aligned with patient care values. Lastly, the objectives evaluate whether persons understand and recall information received about screening.
The assessment of educational needs and the provision of information is of paramount significance from the time of the first biopsy, between the diagnosis, evaluation, and treatment, and discharge. It is vital to assess the participation level in the decision-making to help direct the information interventions and decrease psychological distress and anxiety. Some of the interventions are smoking cessation, avoidance of occupation, and environmental exposure to carcinogenic substances. They are effective interventions for reducing the risks of second primary lung cancer. Since the patient has distant metastatic disease, there is a poor outlook; hence smoking cessation has minimal effects on overall prognosis but can improve the respiratory symptoms (Gately, 2013). In this case, a tapering nicotine patch has been attested to increase the probabilities of smoking cessation in combination with behavioral interventions.
Epidemiological studies recommend that individuals who consume large quantities of fruits and vegetables have a low risk of cancer and cardiovascular disease. The family members will need education with the demonstration of health care methods and opportunities for inquiries and articulation of feelings about caring for the patient. Finally, the Circle of Caring model advocates for collaborative planning for the patient and family in making informed choices and living in the moment.
Irrespective of the type of cell, the primary malignant neoplasm ICD-9-CM code for the lung is 162x, with 4th-digit subgroup classifying the specific site of cancer: 162.30, Upper lobe and bronchus and 162.40 middle lobe bronchus. The advanced lung cancer has metastasized to nearby lymph nodes and other chest tissues, including the left lung. In most cases, the lung cancer spread to other organs like the bone (198.50), brain (198.30), liver (197.70), and adrenal glands (198.70).
The follow up can aid in discovering the recurrence of lung cancer or a new primary tumor. There is a higher need for treatment for relieving symptoms; it is essential to request for the patient check-up every three months in the first two years and every six months after that till year 5, and annually thereafter. The follow-up concerning lung cancer complications should be conducted by the oncologist, thoracic surgeon, and lung specialist in 1 to 3 months after treatment. The resource-demanding exams could be avoided except for the work-up of clinical findings and new symptoms. This includes patient history, physical examination, blood tests, and image analysis of chest x-rays or chest CT scan. Notably, the checks could be completed at the local hospital, perhaps in dialogue with the primary doctor (West & Stanley, 2011). Finally, a good palliative treatment plan can be offered during the follow-up. When medical care progress from the curative into palliative care, the family should choose health care setting such as hospice care that provides familiar surroundings, sense normalcy, family involvement, and a more comfortable situation in readiness for the death activities.
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Bickley, L. S., Szilagyi, P. G., & Bates, B. (2013). Bates’ guide to physical examination and history taking. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
Dunphy, L. M. H., In Winland-Brown, J. E., In Porter, B. O., & In Thomas, D. J. (2019). Primary care: The art and science of advanced practice nursing. Philadelphia, PA: F.A. Davis Company.
Gately, K. (2013). Lung cancer: A comprehensive overview. New York: Nova Science.
Mazzone, P. J., Silvestri, G. A., Patel, S., Kanne, J. P., Kinsinger, L. S., Wiener, R. S., Wiener, R. S., Detterbeck, F. C. (April 01, 2018). Screening for Lung Cancer: CHEST Guideline and Expert Panel Report. Chest, 153, 4, 954-985.
Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidence-based practice in nursing & healthcare: A guide to best practice. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins.
Parrillo, J. E., & Dellinger, R. P. (2019). Critical care medicine: Principles of diagnosis and management in the adult. Philadelphia, PA. : Elsevier.
Sydney, E., In Weinstein, E., & In Rucker, L. M. (2018). Handbook of outpatient medicine. Cham, Switzerland: Springer.
Tobias, J. S., & Hochhauser, D. (2015). Cancer and its management. Chichester, West Sussex, UK: Wiley Blackwell.
West, B. S., & Stanley, D. R. (2011). Lung cancer treatment. New York: Nova Science Publishers.