NSG210 Week 09 Lecture: Lung Cancer and Chest Drainage

Course: NSG210 Medical-Surgical Nursing, Fall 2026 Week: 09 (Oct 19-23), lecture Oct 21, Alterations in Protection Exam: Exam 3

Source: lecture deck raw/nsg210_wk09_LungCancer.ppt (20 slides, no speaker notes). Slide 14 is an image only. Where the slides differ from the textbook, the slide value is given with the textbook value noted.

Textbook: Hinkle Ch. 19, sections XV (Lung Cancer) and XVI (Thoracic Surgery): nsg210-hinkle-ch19-chest-lower-respiratory-disorders.

Objectives (slide 1)

1. Identify the types and prognosis of lung cancer
2. Identify the causes
3. Discuss clinical manifestations
4. Discuss collaborative management

Epidemiology and Risk Factors (slide 2)

• 2nd most common cancer in men and women; number 1 cancer killer in the US for both
• Most common over age 65
• Risk factors: smoking (90% of cases), secondhand smoke, radon, occupational pollutants, asbestos
• Smoking is the major and most preventable cause; risk rises with cigarettes per day and years smoked (pack-years)

Slide 2 says 90% of cases are from smoking and slide 7 says 85%. The textbook gives 85-90%.

Types and Prognosis (slide 3)

Textbook adds: adenocarcinoma is the most common type and peripheral; squamous cell is central; small cell is the most aggressive, almost always in smokers, and spreads early to brain, liver, and bone.

Clinical Manifestations (slides 4-6)

Early lung cancer is insidious; it is usually advanced at diagnosis.

Local:

• Cough (textbook: a change in a chronic cough is the most frequent sign)
• Hemoptysis
• Wheezing and dyspnea
• Chest pain, dull or pleuritic
• Hoarseness and dysphagia
• Pleural effusion
• Superior vena cava compression (swelling of face, neck, and arms)

General: weight loss, fever, anorexia.

Paraneoplastic syndromes (hormones or immune effects from the tumor, not from local spread):

Correction: slide 5 says “hypercalcemia/hyperphosphatemia.” It should be hypophosphatemia (low phosphate). The tumor makes PTH-related protein, which raises calcium and lowers phosphate. General association, not on the slides: SIADH and Cushing syndrome go with small cell, and hypercalcemia goes with squamous cell.

Collaborative Care (slide 7)

• Prevention is the primary goal; reducing tobacco use has the biggest impact on deaths
• Accurate diagnosis is the first step
• Treatment depends on tumor location, cell type, stage, and the patient’s ability to tolerate treatment
• Surgery is the only significant chance for cure in most forms

Diagnostic Tests (slide 8)

• Chest x-ray: often the first evidence
• Sputum cytology: collect on rising in the morning; positive if malignant cells are found
• CBC, liver function tests, electrolytes: look for metastasis or paraneoplastic syndromes
• CT and MRI
• Bronchoscopy: see the tumor and take a biopsy

Textbook adds: PET, CT-guided needle biopsy, and annual low-dose CT screening for ages 55-80 with 30 pack-years who smoke or quit within 15 years.

Treatment (slide 9)

The type of surgery depends on tumor size and location and the patient’s lung function and general health.

Surgical Procedures (slides 10-12)

Textbook adds: after pneumonectomy there is usually no chest tube, and the patient is turned only to the back or the operative side, never fully onto the unoperated side (prevents mediastinal shift). After lobectomy there are usually two chest tubes (upper for air, lower for fluid).

Postoperative Care (slide 13)

• Assess respiratory status often. Complications that impair gas exchange: pneumothorax, atelectasis, bronchospasm, pulmonary embolism, ARDS
• Coughing technique, postural drainage, incentive spirometry
• Suction as needed (surgery and anesthesia increase mucus)
• Keep chest tubes patent and the drainage system closed
• Check chest tube output every hour at first, then every 2-4 or 8 hours
• Notify the provider if output is 150 mL/hour or more, or bright red, warm, and free flowing (hemorrhage)

Chest Drainage System (slides 15-18)

Purpose: re-expand the lung and remove air, fluid, and blood.

Management:

• Mark the starting fluid level with tape on the outside of the unit
• Keep tubing free of kinks and loops and out of the patient’s way
• Gently milk the tubing toward the drainage chamber as needed
• Keep the unit below chest level
• Do not clamp the chest tube during transport

Tidaling (fluid in the water seal rising and falling with breathing) is expected. It stops when:

• The lung has fully re-expanded
• The tubing is blocked by clots, fibrin, or kinks
• A loop of tubing hangs below the rest
• Suction is not working

Air leaks:

• Constant bubbling in the water seal chamber or air leak detector means an air leak
• Look for a fixable leak in the system first
• Notify the provider right away of excess bubbling not caused by an external leak

Report immediately: rapid shallow breathing, cyanosis, chest pressure, subcutaneous emphysema, signs of hemorrhage, significant vital sign changes.

Subcutaneous emphysema: air that has leaked out of the lung or pleural space and become trapped under the skin. It feels like crackling or popping under your fingers (crepitus), like bubble wrap, usually around the chest tube site, chest wall, neck, or face. Mark the edges with a pen to track whether it is spreading. A small amount often absorbs on its own once the leak stops. Report it because it signals an air leak or a malfunctioning or displaced tube; rapid spread or swelling of the neck can threaten the airway. Not the same as the lung disease emphysema (COPD).

Also:

• Encourage deep breathing, coughing, and incentive spirometry; give enough pain medication so the patient can do them
• Chest tube removal: patient does a gentle Valsalva maneuver; cover the site with petrolatum gauze and a 4x4
• Watch for infection: incision, chest tube site, empyema, pneumonia
  • Empyema: pus collected in the pleural space (the space between the lung and chest wall). It is an infection, usually a complication of pneumonia, lung abscess, chest surgery, or a chest tube. Signs: fever, chills, chest pain, cough, dyspnea, decreased breath sounds on that side, cloudy or foul-smelling chest tube drainage. Treatment: drain the pus (thoracentesis or chest tube, sometimes surgery) plus 4-6 weeks of antibiotics
• Turn and ambulate as soon as possible
• Nutrition to support healing and prevent negative nitrogen balance

Home Care Teaching (slides 19-20)

• Smoking cessation, especially after surgery
• Information about planned chemotherapy or radiation
• Keep doing coughing and deep breathing at home
• Report: fever, increasing shortness of breath, cough, more or purulent sputum, or redness, pain, swelling, or drainage at the incision
• How to use prescribed medications
• Resources: hospice, home health, cancer support groups for patients and caregivers, American Cancer Society

End-of-life and hospice content connects to the Death and Dying Workshop: nsg210-death-dying-workshop.

Likely Exam Points

• Chest tube output 150 mL/hour or more, or bright red and warm: notify the provider
• Continuous bubbling in the water seal means an air leak; tidaling is normal
• Do not clamp a chest tube for transport; keep the unit below the chest
• Small cell is treated with chemotherapy; non-small cell with surgery
• Lobectomy is the procedure of choice for a tumor in one lobe
• Paraneoplastic syndromes: SIADH (hyponatremia), hypercalcemia with hypophosphatemia, Cushing syndrome, clubbing
• Collect sputum cytology first thing in the morning