The American Cancer Society estimates that 234,580 new cases of lung cancer (116,310 men and 118,270 women) will be diagnosed in the United States in 2024 [2]. Lung cancer deaths for the same year are estimated to be 125,070 (65,790 men and 59,280 women), accounting for approximately 20.5% of all cancer deaths [2].

In addition to asbestos, many other materials have been linked to the development of lung cancer, including [9,12,15]:

SCLC accounts for approximately 10% to 15% of all lung cancers [32,35]. It initiates in the basal cell lining of the bronchial mucosa, often in the central part of the chest. Because the cells resemble oat grains, SCLC was once called "oat cell carcinoma." SCLC is aggressive and grows rapidly, causing postobstructive pneumonia and atelectasis. It produces arginine vasopressin (AVP) and ACTH, which causes Lambert-Eaton syndrome, the syndrome of inappropriate antidiuretic hormone secretion (SIADH), and Cushing syndrome. SCLC metastasizes very early and to distant sites such as the brain, liver, and bone marrow. It is more responsive to chemotherapy and radiation than other types of lung cancer; however, because it has a tendency to be widely disseminated by the time of diagnosis, it is difficult to cure [36,37].

SCLC accounts for approximately 10% to 15% of all lung cancers [32,35]. It initiates in the basal cell lining of the bronchial mucosa, often in the central part of the chest. Because the cells resemble oat grains, SCLC was once called "oat cell carcinoma." SCLC is aggressive and grows rapidly, causing postobstructive pneumonia and atelectasis. It produces arginine vasopressin (AVP) and ACTH, which causes Lambert-Eaton syndrome, the syndrome of inappropriate antidiuretic hormone secretion (SIADH), and Cushing syndrome. SCLC metastasizes very early and to distant sites such as the brain, liver, and bone marrow. It is more responsive to chemotherapy and radiation than other types of lung cancer; however, because it has a tendency to be widely disseminated by the time of diagnosis, it is difficult to cure [36,37].

One of the most common symptoms experienced by patients with lung cancer is cough, which occurs when the airways become irritated (as from smoking) [2,32,36]. Those patients who have a cough related to their smoking may recognize a change in the type of cough but are not as likely to realize the significance of that change, particularly if the change occurs slowly over decades [36]. The cough may be more frequent, more irritating, of a different tone, or may feel as if it is arising from a different site than a normal cough. A cough that has always been dry may suddenly become productive as the obstructed bronchus develops an infection [2,36,41]. Persistent wheezing that occurs in one location in a smoker may also indicate lung cancer [36,41].

Metastasis has been shown to produce hoarseness, vocal cord paralysis, dysphagia, head and neck swelling, weakness, weight loss, loss of appetite, anorexia, and anemia [42]. Other symptoms that are indicative of metastatic spread of the disease include Horner syndrome, abdominal discomfort, nausea and vomiting, unexplained fever, jaundice, and cardiac symptoms. Elevated liver function tests may be signs of liver metastasis. Bone pain may signify bone metastasis, and severe, unrelenting headache may be caused by increased intracranial pressure from metastasis to the brain [42].

Mediastinoscopy and mediastinotomy may be done in instances when mediastinal lymph nodes must be assessed for possible metastasis. These are invasive procedures, involving incisions made over the sternal notch to allow access into the mediastinum with a mediastinoscope. The primary difference between the two procedures is in the size and location of the incision [32]. Biopsies may be taken from the nodes or other suspicious structures. Mediastinoscopy is considered to be the long-standing "criterion standard" for evaluating mediastinal lymph nodes; however, it is a high-risk procedure, typically used prior to surgery to confirm or exclude the presence of tumor in enlarged nodes [24,68,69,70]. Studies have shown that mediastinoscopy may be replaced by newer, more well-tolerated technologies, such as EBUS, which are safer and generally preferred by patients. Training to either maintain mediastinoscopy procedures skills or to elevate levels of accuracy for technologies such as EBUS is necessary to ensure a consistent level of accuracy between mediastinoscopy and other evaluation options [71].

Adenocarcinoma is the most common lung cancer. It represents approximately 40% of all cases and is increasing in frequency [33,39,80]. It is easy to diagnose, as it is most often located peripherally and can be readily visualized on chest x-rays. Adenocarcinoma metastasizes rapidly, and patients are often found to have distant lesions at the time of diagnosis [39]. Common sites for metastasis include the brain, bone, liver, kidneys, and the other lung [15]. A subtype of adenocarcinoma, adenocarcinoma in situ, is characterized by pneumonia-type infiltrates present on chest x-ray films. Patients with this subtype often have a better prognosis than those with other types of lung cancer [33].

The surgical procedures used to remove lung cancers include wedge resection, lobectomy, pneumonectomy, and sleeve resection. Wedge resection removes the tumor and a small amount of the normal surrounding tissue (called "segmental resection" or "segmentectomy" when more tissue is taken). Lobectomy removes the affected lobe of the lung, whereas pneumonectomy removes an entire lung. The sleeve resection removes only part of the bronchus [24,38]. According to the American College of Surgeons Oncology Group, a complete mediastinal lymphadenectomy should obtain one or more lymph nodes from each mediastinal station [86]. For cancers on the right side, lymph nodes should be removed from stations 2R, 4R, 7, 8, and 9; in cases of left-sided cancers, stations 4L, 5, 6, 7, 8 and 9 should be sampled.

Chemotherapeutic drugs are considered to be either cell cycle phase-specific or cell cycle phase nonspecific. The cell cycle phase-specific drugs work on cells undergoing cell division and are therefore more efficient in cases of rapid cell division. This class includes antimetabolites and vinca plant alkaloids. Examples of cell cycle phase-nonspecific drugs are alkylating agents, antitumor agents, hormones, and nitrosoureas. This class of chemotherapy is generally indicated for cells with longer division times. Some drugs may be both specific and nonspecific. Corticosteroids are often used concomitantly with other chemotherapeutic medications due to their anti-inflammatory and appetite stimulatory effects [113]. Chemotherapeutic agents that are cell cycle phase specific are given on a schedule to maximize their effect on the particular cell being treated. Some are given daily for one to three weeks, then stopped for one week before repeating the schedule again. Others are given daily for longer periods of time.

Although extensive research has been undertaken in an effort to minimize the adverse effects of chemotherapy, nausea and vomiting remain among the stressful side effects of treatment. Antiemetics are generally given immediately prior to the chemotherapy infusion; they may also be ordered after treatment to help prevent delayed emesis. It is often helpful for patients to avoid foods with strong scents or spiciness, as they may encourage nausea [36]. It is important that patients be made aware of the seriousness of dehydration. If unable to keep food or fluids down, they should notify a physician to begin intravenous rehydration. Adequate hydration is of particular importance when patients are receiving cisplatin, which is nephrotoxic. Patients receiving cisplatin should be encouraged to increase fluid intake to at least 2,000 cc per day [25]. Cisplatin, vinorelbine, docetaxel, or paclitaxel may damage nerves, which can lead to peripheral neuropathy [32].

Radiation therapy may cause a variety of side effects, including [123,124]:

As treatment continues, moist desquamation may occur in areas where skin surfaces meet. When this is the case, patients should be given a few days break from radiation therapy in order to allow for normal tissue healing. Desquamated areas are potential sites of infection and should be kept as clean as possible. The area can be gently irrigated with normal saline, and an ointment may be applied to soothe the exposed skin surfaces. The following are general skin care guidelines for patients receiving radiation therapy [124,127]:

The clinical course and outcomes for patients diagnosed with lung cancer may vary widely from one patient to another. Prognosis is dependent on the extent of the disease, the cell type, and the patient's physical condition at the time of diagnosis.

Progressive lung cancer ultimately involves respiratory distress of some degree. Obstruction of airways and/or restriction of lung expansion results in dyspnea. Also, postobstructive pneumonitis, atelectasis, or pleural effusions may occur.

Analgesics may be administered in many ways. Oral administration is preferred because it is noninvasive and convenient. If the patient is unable to swallow, the medications may also be given in the form of rectal suppositories or infusions, transdermal patches, subcutaneous injections, intravenous drips, patient-controlled analgesia (PCA), or intramuscular injections [146]. Due to the pain and unreliable absorption associated with intramuscular administration, it is not usually used. If one route does not prove effective, another may be tried.

Nonpharmacologic techniques for relief of pain include cutaneous stimulation, applications of heat and cold, transcutaneous electrical nerve stimulation (TENS), relaxation techniques, distraction, humor, music, prayer, biofeedback, and hypnosis. Other, more invasive techniques, in the form of nerve blocks, alcohol injections, or acupuncture, may also be employed to control pain [146].

Nontunneled catheters are inserted through neck or chest veins and include central venous catheters (CVCs), subclavian catheters, and central venous pressure (CVP) lines. They are inserted in the neck area into the high internal jugular, external jugular, low internal jugular, supraclavicular, or infraclavicular veins. The lines are then sutured in place and are used for a maximum of two to three months. They may have single, double, or triple lumens and may be used for multi-infusional therapy when the capabilities of an existing CVC or implantable port has been exceeded. They are often used when emergency CVC is needed and they may augment existing VADs that have been dedicated for acute care or long-term use [152].

Peripherally inserted central catheters (PICCs) may be used long-term (i.e., several weeks to months) to fill the gap that exists between the trauma of subclavian catheters and the cost of long-term tunneled catheters or ports. PICCs are the most easily inserted long-term CVC; however, they require one-handed self-care capabilities, or a caregiver, which may limit patient mobility. PICCs are small-gauge, thin-walled catheters that are inserted through the peripheral venous system of the hand, arm, or foot into the cephalic or basilic vein. Some state boards of registered nursing permit nurses to insert PICC lines if they have had appropriate education and training. Advantages of these catheters include: a nurse may insert them; elimination of the risk of neck and chest insertions; easy removal at completion of therapy; and no surgery is required [152]. Midline catheters are used for intermediate-term therapy when a short-term IV is either unavailable or not advisable. No surgery is required [152].

Tunneled central venous catheters (i.e., Broviac, Hickman, Groshong, Neostar) are radiopaque silicone rubber catheters characterized by a cuff that holds the line in place. These catheters are tunneled into the subcutaneous tissue, which begins to adhere to the line in 7 to 10 days, providing a mechanical barrier against infection. Tunneled central venous catheters are available in single, double, or triple lumens. Advantages of this type of catheter are secure placement, safe and reliable long-term access, decreased risk of infection (due to its unique design features), use without pain (due to external access site), ease of removal when no longer needed for care, and swimming and bathing may be allowed. Disadvantages include the external portion of the catheter is visible outside the chest, the need for daily dressing changes and heparin flushes, and the cost of equipment (i.e., needles, syringes, heparin or saline, dressing materials) [152].

Tunneled central venous catheters (i.e., Broviac, Hickman, Groshong, Neostar) are radiopaque silicone rubber catheters characterized by a cuff that holds the line in place. These catheters are tunneled into the subcutaneous tissue, which begins to adhere to the line in 7 to 10 days, providing a mechanical barrier against infection. Tunneled central venous catheters are available in single, double, or triple lumens. Advantages of this type of catheter are secure placement, safe and reliable long-term access, decreased risk of infection (due to its unique design features), use without pain (due to external access site), ease of removal when no longer needed for care, and swimming and bathing may be allowed. Disadvantages include the external portion of the catheter is visible outside the chest, the need for daily dressing changes and heparin flushes, and the cost of equipment (i.e., needles, syringes, heparin or saline, dressing materials) [152].

Learning about and recognizing the stages of grief may be helpful in developing a deeper understanding of death and dying. Dr. Elizabeth Kübler-Ross has identified the five stages of grief as [155]:

These emotions do not necessarily occur in any particular order, and a patient may move back and forth between stages within a relatively short period of time [156].

Denial is, however, often the first response. It may be the initial reason there was a delay in seeking medical treatment or assessment. Patients may have known that their cough was very different from anything they had ever before experienced; they also know their smoking history and may be acquainted with others who have been diagnosed with cancer. Delays in treatment regardless of this knowledge may, in many cases, be attributed to denial. Patients who are deeply in denial may have a difficult time making wise decisions about health care. Ideally, patients will work through this stage quickly, so that there is time to accomplish goals before dying.

The durable power of attorney for health care allows the patient to authorize another individual, called a proxy or agent, to make healthcare decisions if the patient becomes incapacitated. Some states restrict the ability of the agent to carry out some requests (e.g., to stop feeding). The durable power of attorney must specifically list the designated person(s) by name. It must also be in writing, signed by the patient choosing the proxy, and witnessed. A backup proxy is often named in case the first choice becomes unable or unwilling to act on the patient's behalf [157,158].

Physician directives (also referred to as living wills) are designed to control future healthcare decisions at a time when the patient is unable to make them. They are guides for physicians that are meant to ensure that the care the patient desires is provided. Physician directives may specify that all measures be taken to save the patient's life, or they may allow the physician to stop trying to prolong life in a terminally ill patient. If a patient has hope of recovery, the living will generally does not apply. There are endless variations on this, but the more specific a directive is, the easier it is to follow. Most states require that the document be witnessed and notarized by someone other than heirs, the attending physician, or employees of the healthcare facility. Where no written advance directive exists, some states recognize oral advance directives; others require a written and notarized form [157].

The term hospice is used in this country to refer to a program, not necessarily an institution. Hospice is a type of care provided not only to the terminally ill patient, but to the patient's family as well. Hospice strives to meet physical, psychologic, and spiritual needs through an interdisciplinary team of physicians, nurses, social workers, therapists, and volunteers. The goal of hospice is to allow the patient to die comfortably, surrounded by family, with the support that is needed to provide the best possible quality of life and death. Hospice nurses are adept in aggressive pain management and also in communicating effectively with family [154,162].

Hospice has certain rules for participation, but they are not rigid rules and may be adapted to a patient's special needs. The entrance requirements state that the patient's physician must certify that the disease is terminal and that the patient is in the last six months of life [154,162]. The six-month time frame is simply an attempt to define the type of patient participating in the program; if a patient lives seven months, the hospice service is not cut off.

Managed care is a method of delivering health care that is focused on cost-effective, patient outcome-oriented concepts. It keeps costs under control and manages resources while continuing to strive for good quality in patient care. It encompasses the health maintenance organization, the preferred provider organization, and other methods of healthcare delivery [163].

Whether they are called clinical pathways, critical pathways, case management plans, treatment plans, or care maps, they are all similar methods for managing patient care. As a vital part of the managed care environment, clinical pathways have often been the catalyst for hospitals to move to a case management type of nursing. It is important to note that the clinical pathway may or may not be part of the medical record.

Clinical pathways are multidisciplinary, sequential guides to patient care that are created through a collaboration of healthcare professionals. Anticipated events are included in a day-by-day grid, allowing the nurse, patient, and family members to know what can be expected on any given day [163]. This serves many purposes:

Although each of these factors may vary to meet the specific needs of the individual hospital, they all have certain common traits.

The pathway is usually posted within patients' rooms, so they and their families can follow along to see if their progress is as expected. It is motivating to a patient to see, for example, that he or she is expected to walk from the bed to the bathroom the afternoon of surgery or to successfully self-administer an insulin injection by the third day of instruction. Whatever the task, most patients make an effort to do what is expected of them.

The pathway may also be useful to the nurse case manager. For example, a patient's culture and sensitivity report comes back from the laboratory indicating that the patient is receiving the incorrect antibiotic. The report is ordinarily left on the patient's chart for the physician to review during the next rounds, but this might not occur for several hours or into the next day. However, if the nurse sees on the pathway that the patient is expected to be afebrile by the next day and homeward bound the day after, the nurse might be motivated to contact the physician for orders for a new antibiotic.

Clinical pathways are also particularly helpful to the relief nurse. It is always difficult to be the nurse called in to substitute for a nurse who has the day off, is ill, or is on vacation. The patients are new to the relief nurse, and it takes time to learn about the idiosyncrasies and needs of each one. The clinical pathway provides a way for the relief nurse to quickly determine each patient's point on the route to recovery.

Preoperative teaching can be done prior to admission. In the past, patients were admitted the evening before surgery, partially in order to carry out teaching before the patient went to surgery. Now, with patients being admitted the morning of surgery, very little time is available for teaching, let alone for allowing patients to absorb and understand what to expect. A better time for patient teaching is at the preoperative visit, when the electrocardiogram (EKG), lab work, and other testing are done. Nurses can use this visit as an opportunity to meet with the patient, begin preoperative teaching, and obtain useful history, which can assist in an early start to discharge planning. It has been found that preoperative patient teaching is very useful and comforting for the patient. This establishes a connection that will continue through future admissions as well.

Prior to discharge, it is important to reinforce several teaching points. Primarily, patients should know which medications have been prescribed for them at the time of discharge, their purpose, the correct dosage, administration schedule, and side effects. Signs of possible complications, emergency telephone numbers, and other safety information should also be provided.