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Under supervision of
Prof DR / Eman Mahmoud
DR/Boshra Mustafa
DR/Omnia Ahmed
2022
Outlines:
1. Introduction
2. Definition of lung cancer.
3. Epidemiology.
4. Causes & Risk factors of lung cancer.
5. Pathophysiology of lung cancer.
6. Types of lung cancer.
7. Signs and symptoms of lung cancer.
8. Stages of lung cancer.
9. Diagnosis of lung cancer.
10. Complications
11. Medical management of lung cancer.
12. Nursing management of lung cancer.
13. Prevention of lung cancer.
3
Introduction
Bed rest has been prescribed for a wide range of conditions, from acute
medical illnesses to postoperative convalescence. In intensive care units
(ICUs) bed rest is especially common. Immobility from prolonged bed
rest is associated with many complications, including muscle atrophy,
pressure ulcers, atelectasis, and bone demineralization.
DEFINITION
Immobility
Is a state in which the individual experiences or is at risk for experiencing
limitation of physical movement. Altered physical mobility can be a
result of prescribed bed rest, movement physically restricted by an
external device (e.g., a cast), voluntarily restricted movement, or impaired
or lost motor function.
Mobility is defined as the "ability to move freely, easily, rhythmically,
and purposefully in the environment. It is an essential part of living.
Epidemiology
 Lung cancer remains an important cause of cancer death
throughout the Western world, despite a recent decline.
 The epidemiology of lung cancer in the developing world is likely
to increase.
 Lung cancer is the number one cancer killer among men and
women.
 Lung cancer is increase at a greater rate in women than it is in men
due to breast cancer.
 Lung cancer is account of 70 % of elderly patient over 65 years
diagnosis.
 Less than 3% of cases occur in people under 45 years.
4
Causes & Risk factors
1. The major cause of lung cancer is tobacco smoking: 90 % of
all cases of lung cancer are thought to be caused by smoking.
Risk is determined by the pack–year history (number of pack
of cigarettes used each day times the number of years
smoked).
2. Passive smoking or second hand smoke.
3. Occupation exposure: chronic exposure to industrial
carcinogens such as asbestos, mustard gas, coke radiation
nickel……. etc has been associated with development lung
cancer.
4. Radon gases: A radioactive gas that occurs naturally and is
often found in the lower levels of buildings.
5. Poor dietary intake of fresh fruit and vegetables.
6. Family history of lung cancer.
7. Lung disease: There are certain disease such as chronic
pulmonary lung disease and tuberculosis have relationship of
lung cancer particular if patient smoker .
8. Air pollution: Prolonged exposure to high polluted air can
lead to developments of lung cancer
Pathophysiology:
Most lung cancers start in the bronchi, but they can also begin in
other areas such as the trachea, bronchioles, or alveoli. Lung cancers are
thought to develop over many years. A carcinogen bind to cell's DNA and
damage it. After that there's a cellular change and abnormal growth of
these cells. these pre-cancerous changes may progress to true cancer.
The cancer cells may make chemicals that cause new blood vessels to
form nearby.
5
These new blood vessels nourish the cancer cells, which can continue to
grow and form a tumor.
At some point, cells from the cancer may break away from the original
tumor and spread (metastasize) to other parts of the body.
Lung cancer cells can enter lymphatic vessels and begin to grow in
lymph nodes around the bronchi and in the mediastinum When lung
cancer cells have reached the lymph nodes, they are more likely to have
spread to other organs of the body as well.
6
Types of lung cancer
 Small cell lung cancer
 Non-small cell lung cancer
A. Small cell lung cancer
• About 10% to 15% of all lung cancers are small cell lung cancer
(SCLC), oat cell carcinoma, these cells grow rapidly and
metastasize early.
• SCLC often starts in the bronchi near the center of the chest and
The cancer cells can multiply quickly, form large tumors and
spread to lymph nodes and other organs, such as the bones, brain,
adrenal glands, and liver.
• Small cell lung cancer is almost always caused by smoking. It is
very rare for non smokers person.
B. Non-small cell lung cancer
1.About 85% to 90% of lung cancers are non-small cell lung cancer
(NSCLC).
There are 3 subtypes of NSCLC:
(a) Adenocarcinoma: most common type and include up to 50%
NSCLC associated with smoking and arise in the outer or peripheral
area of the lung.
(b) Squamous cell carcinoma: also known as epidemoid carcinoma
account for about 30% of NSCLC arise most frequently in central area
in the bronchi.
(C) Large cell carcinoma: referred to as undifferentiated carcinoma.
7
The cells in these subtypes differ in size, shape, and chemical make-up.
Stages of lung cancer
Non small cell lung cancer :
 Stage 1: In stage 1, the cancer is confined to the lung with highest
cure rate.
 Stage2 and 3 : In these stages, the cancer is confined to the chest
with larger and more invasive tumor.
 Stage 4 : The cancer has spread from the chest to other parts of the
body (metastasis).
Small cell lung cancer :
 Limited stage refer to cancer that is confined to its area origin in
the chest.
 Extensive stage: The cancer has spread behind the chest to other
parts of the body
Signs and symptoms of lung cancer:
Signs and symptoms of lung cancer depend on the location, size of
tumor and the degree of obstruction
• A cough that does not go away begin as dry persistent cough.
• Chest pain.
• Shortness of breath.
• Swelling of the neck and face.
• Significant weight loss that cannot be explained by other factors.
• Fatigue and loss of appetite.
• Bloody or brown-colored sputum.
8
• In some patients fever may occur as an early symptom in response
to Persistent infections, such as pneumonities distal to the tumor.
• If the cancer invaded nerves it may causes shoulder pain and
paralysis of the vocal cord lead to persistent hoarseness.
• Invasion of the esophagus lead to difficulty swallowing
(dysphagia).
• Cancer has spread to bone may produce pain at the site of bone.
• Cancer that has spread to brain that causes number of neurologic
symptoms include blurred vision, headaches and seizer.
• Additionally, lung tumors also may alter the production of
hormones (called Paraneoplastic syndrome) that regulate body
functions, causing: breast enlargement in males, bone and joint
pain Cushing's syndrome (overproduction of corticosteroid
hormones). Carcinoid syndrome (excess of serotonin hormone in
the body), Hyperkalemia cancer cells production of substance
similar to parathyroid hormone resulting in elevating level of
calcium in the blood stream.
Diagnosis :
 Take history and physical examination may reveal the present of
symptoms for lung cancer.
 Perform chest X ray is most common first diagnosis step.
 CT(computerized axial tomography scan) may be performed on
chest ,abdomen and brain to identify small nodule not visualized on
chest x-ray.
 MRI (magnetic resonance imaging) scans may be appropriate when
precise detail about tumor location is required.
9
 Cytological examination of fresh sputum performed to search for
malignant cells.
 Bone scan or bone narrow study is performed to determine bone
metastasis.
 Liver scanning to determined if the cancer has spread to the liver.
 Mediastinoscoy to determined if cancer has spread to lymph nodes
 Bronchoscopy allow for biopsies of suspicious area
 Blood tests they may reveal metabolic abnormalities in the body
accompany cancer such as liver enzymes
Complications
Lung cancer can cause complications, such as:
 Shortness of breath.
 Coughing up blood.
 Pain.
 Fluid in the chest (pleural effusion).
 Cancer that spreads to other parts of the body
 Cancer that spreads can cause pain, nausea, headaches, or other signs
and symptoms depending on what organ is affected. Once lung cancer
has spread beyond the lungs, it's generally not curable. Treatments are
available to decrease signs and symptoms and to help you live longer.
10
Medical treatment of lung cancer
Medical treatment depends on: The cell type, the stage of the
disease, and physiological status especially cardiac and pulmonary status
of the patient. In general, treatment may involve: surgery, radiation,
chemotherapy, and experimental therapy.
1.Surgical treatment:
• Surgical procedure primarily used for (NSCLC). There are three
types of lung resection may be performed;
1. Lobectomy (removal of one lobe).
2. Pneumonectomy (removal of an entire lung).
3. Lymphadenectomy (removal of lymph nodes in the region of
the lung).
Complication of lung cancer surgery :
 Respiratory failure especially when cardio pulmonary system is
compromised before surgery.
2. Radiation therapy:
May be as a treatment for both NSCLC and SCLC radiation
therapy use high energy of x ray or other type of radiation to kill dividing
cancer cell. Radiation may help relieve cough, chest pain, dyspnea,
hempotysis, and bone pain.
Complication of radiation therapy
Complication of radiation therapy include: Esophagitis,
pneumonitis, lung fibrosis, and effect of the heart; low blood platelets
levels leading to hemorrhage, reduce white blood cell count leading to the
increasing risk of infection, if radiation therapy affect digestive system
patient may complain nausea, vomiting and diarrhea.
11
3. Chemotherapy:
Chemotherapy may be as a treatment for both NSCLC and SCLC.
Chemo therapy refer to administration of drug as pills or iv these the drug
stop the growth of cancer cell by killing them or preventing them form
division.
Complication of chemotherapy:
Complication of chemotherapy include
 Damage to blood cells lead to increase patient susceptibility to
infection and difficult with blood clotting
 Fatigue, weight loss, hair loss, nausea, vomiting, diarrhea, and
mouth sore.
N.B: The side effects of chemotherapy vary according to dose and
combination of the drug.
4. Experimental therapies (Immunotherapy):
Experimental therapy is known as immunotherapy that involve the
use of vaccine related therapy that attempt to utilize the body's immune
system to fight cancer cells.
12
Nursing management
Nursing Care plan for patient with lung cancer
Nursing diagnosis Goal Nursing interventions
1. Ineffective way
air way clearance
related to the
bronchial
obstruction
Patient will
maintain a
potent air way
and adequate
air way
clearance.
 Assess the frequency, intensity,
duration, and precipitating factors
associated with your patient's cough.
 Monitor the amount and type of
sputum.
 Monitor for color change in sputum
indicating infection or bleeding.
 Give your patient anti-tussive
medications as ordered.
 Encourage fluid intake to resolve the
mucous secretion.
 Teach the patient to avoid lung irritants
and situations that promote coughing.
 Teach him to notify the doctor of a
change in cough or sputum production
or failure of anti-tussive agents to
control his cough.
2. Impaired gases
exchange related to
lung cancer
The patient
will maintain
optimal gas
exchange.
 Assess patient's breath sounds,
respiratory rate and depth, pulse
oxygenation each shift and as needed.
 Teach patients coughing, deep
breathing, and pursed-lip breathing
exercises.
 Position pt in comfort position
 Administer humidified oxygen as
ordered.
 Administer bronchodilators, anti-
tussive agents, and antibiotics as
ordered.
 Suction as needed.
 If patient has massive hemoptysis,
monitor his vital signs to detect
hypovolemia and administer blood
products as ordered.
 Provide emotional support by telling
the patient and his family what
measures will be used to manage
bleeding.
Nursing diagnosis Goal Nursing interventions
4. Altered comfort
related to lung
cancer
patient will
able to manage
pain
 Assess pain frequency, location,
intensity, precipitating and alleviating
factors, and the effective of the pain
 Develop a plan for analgesia
administration and implement
measures to counteract adverse effects.
 Manage expected constipation with
routine use of laxatives and stool
softeners.
 Teach your patient relaxation
techniques, distraction, or other
noninvasive methods to supplement
pain medications.
5-Altered of body
weight(weight loss)
related to chemo
therapy or radiation
pt will
maintain
optimal body
weight
 Assess the amount of weight lost and
the amount of food consumed.
 Assess the patient for nausea, vomiting,
constipation, pain, anxiety, and other
unrelieved symptoms that interfere
with appetite
 Weigh patient weekly.
 Consult with a nutritionist for meal
planning.
 Encourage the patient to rest after
meals.
 Perform mouth care before and after
meals.
 Teach the patient the importance of
good nutrition
 Modify the consistency of the patient's
diet to facilitate swallowing.
 Administer appetite stimulants and
nutritional supplements as ordered.
Prevention
There's no sure way to prevent lung cancer, but you can reduce your risk if
you:
 Don't smoke.
 Stop smoking.
 Avoid secondhand smoke.
 Test your home for radon.
 Avoid carcinogens at work.
 Eat a diet full of fruits and vegetables.
 Exercise most days of the week.
15
References
Smeltzer & Bare (2009): Brunner and Sauderth’s, Text book of medical-
Surgical Nursing, 10th
ed. Lippincott, Williams & Willkins.
Black, J.M. & Hawks, J.H. (2009): Medical Surgical Nursing, Clinical
Management for Positive Outcomes, 8th
ed., Philadelphia: W.B.
Saunders Co.
Detterbeck FC, et al(2013). Diagnosis and management of lung cancer,
3rd ed.: American College of Chest Physicians evidence-based clinical
practice guidelines. Chest. 2013; doi:10.1378/chest.12-2377.
Lung cancer prevention (PDQ). National Cancer Institute.
https://www.cancer.gov/types/lung/patient/lung-prevention-pdq.
Accessed March 14, 2020.
Warner KJ. Allscripts EPSi. Mayo Clinic. Jan. 13, 2020.
Antonia SJ, et al.(2017) Durvalumab after chemoradiotherapy in stage
III non–small-cell lung cancer. New England Journal of Medicine. 2017;
doi:10.1056/NEJMoa1709937.
Wang S, et al.(2019) Current diagnosis and management of small-cell
lung cancer. Mayo Clinic Proceedings. 2019;
doi:10.1016/j.mayocp.2019.01.034.
16

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lung cancer.doc

  • 1. Under supervision of Prof DR / Eman Mahmoud DR/Boshra Mustafa DR/Omnia Ahmed 2022
  • 2. Outlines: 1. Introduction 2. Definition of lung cancer. 3. Epidemiology. 4. Causes & Risk factors of lung cancer. 5. Pathophysiology of lung cancer. 6. Types of lung cancer. 7. Signs and symptoms of lung cancer. 8. Stages of lung cancer. 9. Diagnosis of lung cancer. 10. Complications 11. Medical management of lung cancer. 12. Nursing management of lung cancer. 13. Prevention of lung cancer. 3
  • 3. Introduction Bed rest has been prescribed for a wide range of conditions, from acute medical illnesses to postoperative convalescence. In intensive care units (ICUs) bed rest is especially common. Immobility from prolonged bed rest is associated with many complications, including muscle atrophy, pressure ulcers, atelectasis, and bone demineralization. DEFINITION Immobility Is a state in which the individual experiences or is at risk for experiencing limitation of physical movement. Altered physical mobility can be a result of prescribed bed rest, movement physically restricted by an external device (e.g., a cast), voluntarily restricted movement, or impaired or lost motor function. Mobility is defined as the "ability to move freely, easily, rhythmically, and purposefully in the environment. It is an essential part of living. Epidemiology  Lung cancer remains an important cause of cancer death throughout the Western world, despite a recent decline.  The epidemiology of lung cancer in the developing world is likely to increase.  Lung cancer is the number one cancer killer among men and women.  Lung cancer is increase at a greater rate in women than it is in men due to breast cancer.  Lung cancer is account of 70 % of elderly patient over 65 years diagnosis.  Less than 3% of cases occur in people under 45 years. 4
  • 4. Causes & Risk factors 1. The major cause of lung cancer is tobacco smoking: 90 % of all cases of lung cancer are thought to be caused by smoking. Risk is determined by the pack–year history (number of pack of cigarettes used each day times the number of years smoked). 2. Passive smoking or second hand smoke. 3. Occupation exposure: chronic exposure to industrial carcinogens such as asbestos, mustard gas, coke radiation nickel……. etc has been associated with development lung cancer. 4. Radon gases: A radioactive gas that occurs naturally and is often found in the lower levels of buildings. 5. Poor dietary intake of fresh fruit and vegetables. 6. Family history of lung cancer. 7. Lung disease: There are certain disease such as chronic pulmonary lung disease and tuberculosis have relationship of lung cancer particular if patient smoker . 8. Air pollution: Prolonged exposure to high polluted air can lead to developments of lung cancer Pathophysiology: Most lung cancers start in the bronchi, but they can also begin in other areas such as the trachea, bronchioles, or alveoli. Lung cancers are thought to develop over many years. A carcinogen bind to cell's DNA and damage it. After that there's a cellular change and abnormal growth of these cells. these pre-cancerous changes may progress to true cancer. The cancer cells may make chemicals that cause new blood vessels to form nearby. 5
  • 5. These new blood vessels nourish the cancer cells, which can continue to grow and form a tumor. At some point, cells from the cancer may break away from the original tumor and spread (metastasize) to other parts of the body. Lung cancer cells can enter lymphatic vessels and begin to grow in lymph nodes around the bronchi and in the mediastinum When lung cancer cells have reached the lymph nodes, they are more likely to have spread to other organs of the body as well. 6
  • 6. Types of lung cancer  Small cell lung cancer  Non-small cell lung cancer A. Small cell lung cancer • About 10% to 15% of all lung cancers are small cell lung cancer (SCLC), oat cell carcinoma, these cells grow rapidly and metastasize early. • SCLC often starts in the bronchi near the center of the chest and The cancer cells can multiply quickly, form large tumors and spread to lymph nodes and other organs, such as the bones, brain, adrenal glands, and liver. • Small cell lung cancer is almost always caused by smoking. It is very rare for non smokers person. B. Non-small cell lung cancer 1.About 85% to 90% of lung cancers are non-small cell lung cancer (NSCLC). There are 3 subtypes of NSCLC: (a) Adenocarcinoma: most common type and include up to 50% NSCLC associated with smoking and arise in the outer or peripheral area of the lung. (b) Squamous cell carcinoma: also known as epidemoid carcinoma account for about 30% of NSCLC arise most frequently in central area in the bronchi. (C) Large cell carcinoma: referred to as undifferentiated carcinoma. 7
  • 7. The cells in these subtypes differ in size, shape, and chemical make-up. Stages of lung cancer Non small cell lung cancer :  Stage 1: In stage 1, the cancer is confined to the lung with highest cure rate.  Stage2 and 3 : In these stages, the cancer is confined to the chest with larger and more invasive tumor.  Stage 4 : The cancer has spread from the chest to other parts of the body (metastasis). Small cell lung cancer :  Limited stage refer to cancer that is confined to its area origin in the chest.  Extensive stage: The cancer has spread behind the chest to other parts of the body Signs and symptoms of lung cancer: Signs and symptoms of lung cancer depend on the location, size of tumor and the degree of obstruction • A cough that does not go away begin as dry persistent cough. • Chest pain. • Shortness of breath. • Swelling of the neck and face. • Significant weight loss that cannot be explained by other factors. • Fatigue and loss of appetite. • Bloody or brown-colored sputum. 8
  • 8. • In some patients fever may occur as an early symptom in response to Persistent infections, such as pneumonities distal to the tumor. • If the cancer invaded nerves it may causes shoulder pain and paralysis of the vocal cord lead to persistent hoarseness. • Invasion of the esophagus lead to difficulty swallowing (dysphagia). • Cancer has spread to bone may produce pain at the site of bone. • Cancer that has spread to brain that causes number of neurologic symptoms include blurred vision, headaches and seizer. • Additionally, lung tumors also may alter the production of hormones (called Paraneoplastic syndrome) that regulate body functions, causing: breast enlargement in males, bone and joint pain Cushing's syndrome (overproduction of corticosteroid hormones). Carcinoid syndrome (excess of serotonin hormone in the body), Hyperkalemia cancer cells production of substance similar to parathyroid hormone resulting in elevating level of calcium in the blood stream. Diagnosis :  Take history and physical examination may reveal the present of symptoms for lung cancer.  Perform chest X ray is most common first diagnosis step.  CT(computerized axial tomography scan) may be performed on chest ,abdomen and brain to identify small nodule not visualized on chest x-ray.  MRI (magnetic resonance imaging) scans may be appropriate when precise detail about tumor location is required. 9
  • 9.  Cytological examination of fresh sputum performed to search for malignant cells.  Bone scan or bone narrow study is performed to determine bone metastasis.  Liver scanning to determined if the cancer has spread to the liver.  Mediastinoscoy to determined if cancer has spread to lymph nodes  Bronchoscopy allow for biopsies of suspicious area  Blood tests they may reveal metabolic abnormalities in the body accompany cancer such as liver enzymes Complications Lung cancer can cause complications, such as:  Shortness of breath.  Coughing up blood.  Pain.  Fluid in the chest (pleural effusion).  Cancer that spreads to other parts of the body  Cancer that spreads can cause pain, nausea, headaches, or other signs and symptoms depending on what organ is affected. Once lung cancer has spread beyond the lungs, it's generally not curable. Treatments are available to decrease signs and symptoms and to help you live longer. 10
  • 10. Medical treatment of lung cancer Medical treatment depends on: The cell type, the stage of the disease, and physiological status especially cardiac and pulmonary status of the patient. In general, treatment may involve: surgery, radiation, chemotherapy, and experimental therapy. 1.Surgical treatment: • Surgical procedure primarily used for (NSCLC). There are three types of lung resection may be performed; 1. Lobectomy (removal of one lobe). 2. Pneumonectomy (removal of an entire lung). 3. Lymphadenectomy (removal of lymph nodes in the region of the lung). Complication of lung cancer surgery :  Respiratory failure especially when cardio pulmonary system is compromised before surgery. 2. Radiation therapy: May be as a treatment for both NSCLC and SCLC radiation therapy use high energy of x ray or other type of radiation to kill dividing cancer cell. Radiation may help relieve cough, chest pain, dyspnea, hempotysis, and bone pain. Complication of radiation therapy Complication of radiation therapy include: Esophagitis, pneumonitis, lung fibrosis, and effect of the heart; low blood platelets levels leading to hemorrhage, reduce white blood cell count leading to the increasing risk of infection, if radiation therapy affect digestive system patient may complain nausea, vomiting and diarrhea. 11
  • 11. 3. Chemotherapy: Chemotherapy may be as a treatment for both NSCLC and SCLC. Chemo therapy refer to administration of drug as pills or iv these the drug stop the growth of cancer cell by killing them or preventing them form division. Complication of chemotherapy: Complication of chemotherapy include  Damage to blood cells lead to increase patient susceptibility to infection and difficult with blood clotting  Fatigue, weight loss, hair loss, nausea, vomiting, diarrhea, and mouth sore. N.B: The side effects of chemotherapy vary according to dose and combination of the drug. 4. Experimental therapies (Immunotherapy): Experimental therapy is known as immunotherapy that involve the use of vaccine related therapy that attempt to utilize the body's immune system to fight cancer cells. 12
  • 12. Nursing management Nursing Care plan for patient with lung cancer Nursing diagnosis Goal Nursing interventions 1. Ineffective way air way clearance related to the bronchial obstruction Patient will maintain a potent air way and adequate air way clearance.  Assess the frequency, intensity, duration, and precipitating factors associated with your patient's cough.  Monitor the amount and type of sputum.  Monitor for color change in sputum indicating infection or bleeding.  Give your patient anti-tussive medications as ordered.  Encourage fluid intake to resolve the mucous secretion.  Teach the patient to avoid lung irritants and situations that promote coughing.  Teach him to notify the doctor of a change in cough or sputum production or failure of anti-tussive agents to control his cough.
  • 13. 2. Impaired gases exchange related to lung cancer The patient will maintain optimal gas exchange.  Assess patient's breath sounds, respiratory rate and depth, pulse oxygenation each shift and as needed.  Teach patients coughing, deep breathing, and pursed-lip breathing exercises.  Position pt in comfort position  Administer humidified oxygen as ordered.  Administer bronchodilators, anti- tussive agents, and antibiotics as ordered.  Suction as needed.  If patient has massive hemoptysis, monitor his vital signs to detect hypovolemia and administer blood products as ordered.  Provide emotional support by telling the patient and his family what measures will be used to manage bleeding. Nursing diagnosis Goal Nursing interventions 4. Altered comfort related to lung cancer patient will able to manage pain  Assess pain frequency, location, intensity, precipitating and alleviating factors, and the effective of the pain  Develop a plan for analgesia administration and implement measures to counteract adverse effects.  Manage expected constipation with routine use of laxatives and stool softeners.  Teach your patient relaxation techniques, distraction, or other noninvasive methods to supplement pain medications.
  • 14. 5-Altered of body weight(weight loss) related to chemo therapy or radiation pt will maintain optimal body weight  Assess the amount of weight lost and the amount of food consumed.  Assess the patient for nausea, vomiting, constipation, pain, anxiety, and other unrelieved symptoms that interfere with appetite  Weigh patient weekly.  Consult with a nutritionist for meal planning.  Encourage the patient to rest after meals.  Perform mouth care before and after meals.  Teach the patient the importance of good nutrition  Modify the consistency of the patient's diet to facilitate swallowing.  Administer appetite stimulants and nutritional supplements as ordered. Prevention There's no sure way to prevent lung cancer, but you can reduce your risk if you:  Don't smoke.  Stop smoking.  Avoid secondhand smoke.  Test your home for radon.  Avoid carcinogens at work.  Eat a diet full of fruits and vegetables.  Exercise most days of the week. 15
  • 15. References Smeltzer & Bare (2009): Brunner and Sauderth’s, Text book of medical- Surgical Nursing, 10th ed. Lippincott, Williams & Willkins. Black, J.M. & Hawks, J.H. (2009): Medical Surgical Nursing, Clinical Management for Positive Outcomes, 8th ed., Philadelphia: W.B. Saunders Co. Detterbeck FC, et al(2013). Diagnosis and management of lung cancer, 3rd ed.: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013; doi:10.1378/chest.12-2377. Lung cancer prevention (PDQ). National Cancer Institute. https://www.cancer.gov/types/lung/patient/lung-prevention-pdq. Accessed March 14, 2020. Warner KJ. Allscripts EPSi. Mayo Clinic. Jan. 13, 2020. Antonia SJ, et al.(2017) Durvalumab after chemoradiotherapy in stage III non–small-cell lung cancer. New England Journal of Medicine. 2017; doi:10.1056/NEJMoa1709937. Wang S, et al.(2019) Current diagnosis and management of small-cell lung cancer. Mayo Clinic Proceedings. 2019; doi:10.1016/j.mayocp.2019.01.034. 16