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  • Subject Name : Nursing

Non-Small Cell Lung Cancer

Overview of The Study

The case discusses Mrs. DI Michiel, who is 81 years old and admitted to hospital because of shingles, lumbar plexopathy, and metastatic non-small cell lung cancer (NSCLC). She has got a history of hypercholesterolemia, depression, GORD, and autoimmune polygenic rheumatoid arthritis. She has been brought conscious and she was alert and oriented. The patient has advanced care plan. The patient is allergic to the Celecoxib drug which is used to relieve osteoarthritis pain, tenderness, stiffness, and swelling. The patient was assessed for the pain and stated that she does not have any pain. Her medical history describes about the subcutaneously administered anticoagulants. The patient next of kin are her sons Mr. Brett and Mr. Mark.

Pathophysiology of Metastatic NSCLC

Metastatic NSCLC is the biggest cause of mortality due to cancer globally, which is a fatal illness that results in a high symptom burden and poor quality of life. NSCLC type of lung cancer accounts for 80 per cent to 90 per cent of total lung cancers, while in other countries, small cell lung cancer (SCLC) has increased in prevalence over the past 2 decades (Herbst et al., 2018). NSCLC is an epithelial lung cancer and is different from small cell lung carcinoma (SCLC). As a class of cancers, NSCLCs are fairly resistant to chemotherapy. Where appropriate, they are generally treated with curative purpose by surgical resection, though pre-operative and post-operative chemotherapy has been increasingly used (Brody et al., 2017).

Lung cancer pathophysiology is highly complex and is incompletely understood. Repeated exposure to carcinogens, cigarette smoke in-particular, is believed to contribute to lung epithelium dysplasia (Basu, 2018). If the exposure continues it will lead to genetic mutations and affect the synthesis of proteins. Pollutants are among the most important causes of lung cancers. Among those who develop lung cancer, the environmental damage is also exacerbated by genetic susceptibility. NSCLC's pathogenesis is like other forms of cancer, starting with initiation events induced by carcinogens, followed by a long period of development and advancement in a multistep process (Basu, 2018). The genetic mutations happen and then further exposure to smoke enables the accumulation of additional mutations due to the development of persistent inflammation.

Levitt-Jones Clinical Reasoning for Nursing Priorities

The nursing team discussed the case study for the treatment of Mrs. DI Michiel using the Levitt-Jones clinical reasoning process. This method of reasoning helps to respond to her health condition in the medical ward during her hospitalization and to ensure that she as a patient gets the best possible positive outcome in less time. Developing clinical understanding and critical reasoning in nurses helps to promote open-minded patient safety and holistic treatment which is the positive side of this profession (Papathanasiou et al., 2014). This reflection cycle helps in the management skills and timely interventions in the acute hospital settings. The two nursing care priorities selected are cardiovascular and respiratory management.

Cardiovascular Management

Because the patient has NSCLS, and cytotoxic agents are used as medicines. These cytotoxic agents may mainly cause complications to the vascular system, including the venous or thromboembolic arterial events. Many medications used in NSCLC are those drugs that block VEGF-dependent pathways, contributing to the production of pulmonary hypertension. Suppression of VEGF-dependent pathways contributes to microvascular degradation, decreases the endothelial growth and the probability of capillary vessel formation (Zaborowska-Szmit et al., 2020). Treatment of NSCLC patients could be linked to effects on the cardiovascular events. Autoimmune myocarditis can also occur in the patient. Cancerous lung cells may find them into the bloodstream. One way that cancer travels from the lungs to other organs is the circulatory system (Bonaca et al., 2019).

When the patient coughs up blood, there can be leakage of tumors in the airway. When bleeding is serious there should be medications available to manage it. Treatments can involve embolization of the palliative radiation or bronchial arteries. When embolizing the bronchial artery, the doctors must use a catheter to find a leaking artery and seal it. Lung cancer patient is at elevated risk of blood clots. A blood clot going into the lung is called a pulmonary embolism. This is an occurrence that is potentially life-threatening (Li et al., 2018). This situation does not happen frequently, but the lung cancer can spread to the heart or pericardial sac. The tissue surrounding the heart is the pericardial sac. Damage to the heart can be evident instantly, but diagnosis often takes years. The patient must also be checked for any abnormalities in the vital signs and the caregiver should be prepared to deal with these circumstances.

Respiratory Management

The care givers should take the respiratory care as one of the important nursing priorities. The patient having lung cancer will certainly have respiratory problems so that the patient is monitored for the rate of respiration. Lung cancer patient suffers recurrent cough and occasionally blood cough. Due to the recurrent comorbidities found in these patients, the diagnosis protocols and care can be difficult. Many of the other health disorders inpatient is also a risk factor (Socinski et al., 2013). The risk factors are related to smoking and while others are unrelated to smoking but are commonly found within the general population. Such comorbidities need to be investigated carefully before any diagnostic tests or any treatment procedures are taken near the lung cancer. The patient gets cough which can be chronic or recurrent. Intense coughing results in the production of mucus. The mucus further changes color or has blood in it as the disease progresses. A serious cough that hacks can lead to pain in the throat and chest. During breathing or coughing, chest pain can get worse. A typical symptom of advanced lung cancer during respiration is shortness of breath, wheeze, or other noises. Breathing becomes more difficult, as cancerous tumors begin to obstruct airways (Harle et al., 2018). Fluid can accumulate around the lungs that limit the expansion of the lungs. Even moderate physical exercise will cause the breathing pressure.

Health Education to Manage the Nursing Priorities

Cardiovascular diseases occur in 23 per cent of lung cancer patients (Jones et al., 2018). Patients usually have short survival and limited treatment options. The patient has to be educated about the symptoms and treatments. As the patient is likely to cough blood so they are supposed to consult the doctor immediately. The patient can be briefed about the treatment options if the bleeding is severe. The treatment options include palliative radiation or bronchial artery embolization. The patient can also be warned against smoking as it will deteriorate the patient conditions further (Jones et al., 2018).

The Patient Will Be Educated About Lung Cancer

As a part of education, the different stages of cancer it causes, interventions, and treatment should be explained to the patient. The initial stages of lung cancer might not show symptoms, but it is vital to have early diagnosis and care to ensure the best outcome. The patient must be aware of the procedures like surgery, radiation, and chemotherapy that can be used to treat lung cancer (Johnson et al., 2018). The patient must be told not to exercise rigorously because they will cough up the blood and/or regularly develop bronchitis and pneumonia. The cancer signs include persistent coughing that do not stop away but exacerbate into a severe cough, like a cough from a smoker. The patient can feel the changes including wheezing and shortness of breath and chest pain while breathing. The nursing care plan for such patients will include self-management where they can keep a check on their appetite and less common signs include problems in swallowing the food or saliva, change of voice, backache, pain in joints, weakness, and drooping of the face with swelling on the face.

Pharmacokinetics of The Drugs

Pantoprazole is widely metabolized in the liver, has a minimum 0.1 l/h/kg serum clearance, and have a half-life of around 1.1 h from removal from serum, and an approximate 0.15 l/kg delivery rate. The drug is 98 per cent bound to proteins of serum. Half-life, clearance, and distribution volume are independent of the dose (Shakhnovich et al., 2018). Demethylation at the 4-position, in the pyridine ring, is the principal serum metabolite, followed by conjugation with sulphate. Approximately 80 per cent of an oral or IV dosage is excreted in urine as metabolites; the remainder is contained in faeces and arises from biliary secretion. Pantoprazole pharmacokinetics is unchanged in patients with renal insufficiency. For patients with extreme hepatic cirrhosis, the reduced metabolism rate results in a 7-9 h half-life. Pantoprazole clearance is only marginally affected by age; in the elderly, its half-life is approximately 1.25 h.

OxyContin is an extended-release version of oxycodone which is approved by the FDA to treat mild to extreme pain. In the western world, it is a controlled drug with a long history of violent commercial marketing, as well as misuse and diversion. The oral administration OxyContin pharmacokinetic studies show a mean terminal half-life (t1/2) of approximately 4.5 to 6.5 hours, mean time to maximum concentration (Tmax) of 2.5 to 5 hours, and oral absorption comparable to fast dissolving oxycodone. Oxycodone is metabolized to noroxycodone, its primary metabolite, through N-demethylation through the cytochrome P (Harris et al., 2014).

References for Mrs. DI Michiel Case Study

Basu A. K. (2018). DNA damage, mutagenesis, and cancer. International Journal of Molecular Sciences19(4), 970. https://doi.org/10.3390/ijms19040970

Bonaca, M. P., Olenchock, B. A., Salem, J. E., Wiviott, S. D., Ederhy, S., Cohen, A., Stewart, G. C., Choueiri, T. K., Di Carli, M., Allenbach, Y., et al. (2019). Myocarditis in the setting of cancer therapeutics: proposed case definitions for emerging clinical syndromes in cardio-oncology. Circulation. 140:80–91. doi: 10.1161/CIRCULATIONAHA.118.034497. 

Brody, R., Zhang, Y., Ballas, M., Siddiqui, M. K., Gupta, P., Barker, C., Midha, A., & Walker, J. (2017). PD-L1 expression in advanced NSCLC: Insights into risk stratification and treatment selection from a systematic literature review. Lung Cancer (Amsterdam, Netherlands)112, 200–215. https://doi.org/10.1016/j.lungcan.2017.08.005

Harle, A. S. M., Blackhall, F. H., Molassiotis, A. Yuill, D., Baker, K. & Smith, J. A. (2018). Cough in patients with lung cancer. Original Research: Signs And Symptoms Of Chest Diseases 155(1), 103-113.  

Harris, S. C., Perrino, P. J., Smith, I., Shram, M. J., Colucci, S. V., Bartlett, C., & Sellers, E. M. (2014). Abuse potential, pharmacokinetics, pharmacodynamics, and safety of intranasally administered crushed oxycodone HCl abuse-deterrent controlled-release tablets in recreational opioid users. Journal of Clinical Pharmacology54(4), 468–477.

Herbst, R. S., Morgensztern, D., & Boshoff, C. (2018). The biology and management of non-small cell lung cancer. Nature553(7689), 446–454. https://doi.org/10.1038/nature25183

Johnson, D. H., Schiller, J. H., & Bunn, P. A., Jr (2014). Recent clinical advances in lung cancer management. Journal of Clinical Oncology : Official Journal of the American Society of Clinical Oncology32(10), 973–982. https://doi.org/10.1200/JCO.2013.53.1228

Jones, G. S., & Baldwin, D. R. (2018). Recent advances in the management of lung cancer. Clinical Medicine (London, England)18(Suppl 2), s41–s46. https://doi.org/10.7861/clinmedicine.18-2-s41https://doi.org/10.1002/jcph.235

Li, Y., Shang, Y., Wang, W., Ning, S., & Chen, H. (2018). Lung cancer and pulmonary embolism: What is the relationship? A Review. Journal of Cancer9(17), 3046–3057. https://doi.org/10.7150/jca.26008

Papathanasiou, I. V., Kleisiaris, C. F., Fradelos, E. C., Kakou, K., & Kourkouta, L. (2014). Critical thinking: The development of an essential skill for nursing students. Acta informatica medica : AIM : journal of the Society for Medical Informatics of Bosnia & Herzegovina : casopis Drustva za medicinsku informatiku BiH22(4), 283–286. https://doi.org/10.5455/aim.2014.22.283-286

Shakhnovich, V., Brian Smith, P., Guptill, J.T. et al. A population-based pharmacokinetic model approach to pantoprazole dosing for obese children and adolescents. Pediatr Drugs 20, 483–495 (2018). https://doi.org/10.1007/s40272-018-0305-1

Socinski, M. A., Evans, T., Gettinger, S., Hensing, T. A., VanDam Sequist, L., Ireland, B., & Stinchcombe, T. E. (2013). Treatment of stage IV non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest143(5 Suppl), e341S–e368S. https://doi.org/10.1378/chest.12-2361

Zaborowska-Szmit, M., Krzakowski, M., Kowalski, D. M., & Szmit, S. (2020). Cardiovascular complications of systemic therapy in non-small-cell lung cancer. Journal of Clinical Medicine9(5), 1268. https://doi.org/10.3390/jcm9051268

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