NURSING PROCESS: THE PATIENT UNDERGOING THORACIC SURGERY
The nurse monitors the heart rate and rhythm by auscultation and electrocardiography because episodes of major dysrhythmias are common after thoracic and cardiac surgery. In the immediate postoperative period, an arterial line may be maintained to allow frequent monitoring of arterial blood gases, serum electrolytes, hemoglobin and hematocrit values, and arterial pressure. Central venous pressure may be monitored to detect early signs of fluid volume disturbances. Central venous pressure monitoring devices are being used less frequently and for shorter periods of time than in the past. Early extubation from mechanical ventilation can also lead to earlier removal of arterial lines (Zevola & Maier, 1999). Another important component of postoperative assessment is to note the results of the preoperative evaluation of the patient’s lung reserve by pulmonary function testing. A preoperative FEV1 of more than 2 L or more than 70% of predicted value indicates a good lung reserve. Patients who have a postoperative predicted FEV1 of less than 40% of predicted value have a higher incidence of morbidity and mortality (Scanlan, Wilkins & Stoller, 1999). This results in decreased tidal volumes, placing the patient at risk for respiratory failure.
Based on the assessment data, the patient’s major postoperative nursing diagnoses may include:
· Impaired gas exchange related to lung impairment and surgery
· Ineffective airway clearance related to lung impairment, anesthesia, and pain
· Acute pain related to incision, drainage tubes, and the sur-gical procedure
· Impaired physical mobility of the upper extremities related to thoracic surgery
· Risk for imbalanced fluid volume related to the surgical pro-cedure
· Imbalanced nutrition, less than body requirements related to dyspnea and anorexia
· Deficient knowledge about self-care procedures at home
Based on assessment data, potential complications may include:
· Respiratory distress
· Atelectasis, pneumothorax, and bronchopleural fistula
· Blood loss and hemorrhage
· Pulmonary edema
The major goals for the patient may include improvement of gas exchange and breathing, improvement of airway clearance, relief of pain and discomfort, increased arm and shoulder mobility, main-tenance of adequate fluid volume and nutritional status, under-standing of self-care procedures, and absence of complications.
Gas exchange is determined by evaluating oxygenation and ven-tilation. In the immediate postoperative period, this is achieved by measuring vital signs (blood pressure, pulse, and respirations) at least every 15 minutes for the first 1 to 2 hours, then less fre-quently as the patient’s condition stabilizes.
Pulse oximetry is used for continuous monitoring of the ade-quacy of oxygenation. It is important to draw blood for arterial blood gas measurements early in the postoperative period to es-tablish a baseline to assess the adequacy of oxygenation and ven-tilation and the possible retention of CO2. The frequency with which postoperative arterial blood gases are measured depends on whether the patient is mechanically ventilated or exhibits signs of respiratory distress; these measurements can help determine ap-propriate therapy. It also is common practice for patients to have an arterial line in place to obtain blood for blood gas measure-ments and to monitor blood pressure closely. Hemodynamic monitoring may be used to assess hemodynamic stability.
Breathing techniques, such as diaphragmatic and pursed-lip breathing, that were taught before surgery should be performed by the patient every 2 hours to expand the alveoli and prevent at-electasis. Another technique to improve ventilation is sustained maximal inspiration therapy or incentive spirometry. This tech-nique promotes lung inflation, improves the cough mechanism, and allows early assessment of acute pulmonary changes. (See Charts 25-3 and 25-4 for more information.)
Positioning also improves breathing. When the patient is ori-ented and blood pressure is stabilized, the head of the bed is elevated 30 to 40 degrees during the immediate postoperative period. This facilitates ventilation, promotes chest drainage from the lower chest tube, and helps residual air to rise in the upper portion of the pleural space, where it can be removed through the upper chest tube.
The nurse should consult with the surgeon about patient po-sitioning. There is controversy regarding the best side-lying posi-tion. In general, the patient should be positioned from back to side frequently and moved from horizontal to semi-upright posi-tion as soon as tolerated. Most commonly, the patient is in-structed to lie on the operative side. However, the patient with unilateral lung pathology may not be able to turn well onto that side because of pain. In addition, positioning the patient with the “good lung” (the nonoperated lung) down allows a better match of ventilation and perfusion and therefore may actually improve oxygenation. The patient’s position is changed from horizontal to semi-upright as soon as possible, because remaining in one po-sition tends to promote the retention of secretions in the depen-dent portion of the lungs. After a pneumonectomy, the operated side should be dependent so that fluid in the pleural space re-mains below the level of the bronchial stump, and the other lung can fully expand.
The procedure for turning the patient is as follows:
· Instruct the patient to bend the knees and use the feet to push.
· Have the patient shift hips and shoulders to the opposite side of the bed while pushing with the feet.
· Bring the patient’s arm over the chest, pointing it in the di-rection toward which the patient is being turned. Have the patient grasp the side rail with the hand.
· Turn the patient in log-roll fashion to prevent twisting at the waist and pain from possible pulling on the incision.
Retained secretions are a threat to the thoracotomy patient after surgery. Trauma to the tracheobronchial tree during surgery, di-minished lung ventilation, and diminished cough reflex all result in the accumulation of excessive secretions. If the secretions are retained, airway obstruction occurs. This, in turn, causes the air in the alveoli distal to the obstruction to become absorbed and the affected portion of the lung to collapse. Atelectasis, pneumo-nia, and respiratory failure may result.
Several techniques are used to maintain a patent airway. First, secretions are suctioned from the tracheobronchial tree before the endotracheal tube is discontinued. Secretions continue to be re-moved by suctioning until the patient can cough up secretions ef-fectively. Nasotracheal suctioning may be needed to stimulate a deep cough and aspirate secretions that the patient cannot cough up. However, it should be used only after other methods to raise secretions have been unsuccessful (Chart 25-20).
Coughing technique is another measure used in maintaining a patent airway. The patient is encouraged to cough effectively; in-effective coughing results in exhaustion and retention of secretions (see Chart 25-5). To be effective, the cough must be low-pitched, deep, and controlled. Because it is difficult to cough in a supine position, the patient is helped to a sitting position on the edge of the bed, with the feet resting on a chair. The patient should cough at least every hour during the first 24 hours and when necessary thereafter. If audible crackles are present, it may be necessary to use chest percussion with the cough routine until the lungs are clear. Aerosol therapy is helpful in humidifying and mobilizing secretions so that they can easily be cleared with coughing. To min-imize incisional pain during coughing, the nurse supports the in-cision or encourages the patient to do so (Fig. 25-8).
After helping the patient to cough, the nurse should listen to both lungs, anteriorly and posteriorly, to determine whether there are any changes in breath sounds. Diminished breath sounds may indicate collapsed or hypoventilated alveoli.
Chest physiotherapy is the final technique for maintaining a patent airway. If a patient is identified as being at high risk for de-veloping postoperative pulmonary complications, then chest phys-iotherapy is started immediately (perhaps even before surgery). The techniques of postural drainage, vibration, and percussion help to loosen and mobilize the secretions so that they can be coughed up or suctioned.
Pain after a thoracotomy may be severe, depending on the type of incision and the patient’s reaction to and ability to cope with pain. Deep inspiration is very painful after thoracotomy. Pain can lead to postoperative complications if it reduces the patient’s abil-ity to breathe deeply and cough, and if it further limits chest ex-cursions so that ventilation becomes ineffective.
Immediately after the surgical procedure and before the incision is closed, the surgeon may perform a nerve block with a long-acting local anesthetic such as bupivacaine (Marcaine, Sensorcaine). Bupivacaine is titrated to relieve postoperative pain while allowing the patient to cooperate in deep breathing, coughing, and mobi-lization. However, it is important to avoid depressing the respira-tory system with excessive analgesia: the patient should not be so sedated as to be unable to cough. There is controversy about the ef-fectiveness of injections of local anesthetic for pain relief after tho-racotomy surgery. Research has shown that bupivacaine was no more effective than saline injections in treating postoperative tho-racotomy pain (Silomon et al., 2000).
Lidocaine and prilocaine are local anesthetic agents used to treat pain at the site of the chest tube insertion. These medica-tions are administered as topical transdermal analgesics that pen-etrate the skin. Lidocaine and prilocaine have also been found to be effective when used together. EMLA cream, which is a mix-ture of the two medications, has been found to be effective in treating pain from chest tube removal, and recent studies found it to be more effective than intravenous morphine (Valenzuela & Rosen, 1999).
Because of the need to maximize patient comfort without de-pressing the respiratory drive, patient-controlled analgesia (PCA) is often used. Opioid analgesic agents such as morphine are com-monly used. PCA, administered through an intravenous pump or an epidural catheter, allows the patient to control the frequency and total dosage. Preset limits on the pump avoid overdosage. With proper instruction, these methods are well tolerated and allow earlier mobilization and cooperation with the treatment regimen.
Because large shoulder girdle muscles are transected during a tho-racotomy, the arm and shoulder must be mobilized by full range of motion of the shoulder. As soon as physiologically possible, usually within 8 to 12 hours, the patient is helped to get out of bed. Although this may be painful initially, the earlier the patient moves, the sooner the pain will subside. In addition to getting out of bed, the patient begins arm and shoulder exercises to restore movement and prevent painful stiffening of the affected arm and shoulder (Chart 25-21).
During the surgical procedure or immediately after, the patient may receive a transfusion of blood products, followed by a contin-uous intravenous infusion. Because a reduction in lung capacity often occurs following thoracic surgery, a period of physiologic ad-justment is needed. Fluids should be administered at a low hourly rate and titrated (as prescribed) to prevent overloading the vascu-lar system and precipitating pulmonary edema. The nurse performs careful respiratory and cardiovascular assessments, as well as intake and output, vital signs, and assessment of jugular vein distention. The nurse should also monitor the infusion site for signs of infil-tration, including swelling, tenderness, and redness.
It is not unusual for patients undergoing thoracotomy to have poor nutritional status before surgery because of dyspnea, sputum pro-duction, and poor appetite. Therefore, it is especially important that adequate nutrition be provided. A liquid diet is provided as soon as bowel sounds return; the patient is progressed to a full diet as soon as possible. Small, frequent meals are better tolerated and are crucial to the recovery and maintenance of lung function.
Complications after thoracic surgery are always a possibility and must be identified and managed early. In addition, the nurse monitors the patient at regular intervals for signs of respiratory distress or developing respiratory failure, dysrhythmias, bron-chopleural fistula, hemorrhage and shock, atelectasis, and pul-monary infection.
Respiratory distress is treated by identifying and eliminating its cause while providing supplemental oxygen. If the patient pro-gresses to respiratory failure, intubation and mechanical ventila-tion are necessary, eventually requiring weaning.
Dysrhythmias are often related to the effects of hypoxia or the surgical procedure. They are treated with antiarrhythmic med-ication and supportive therapy. Pulmonary infections or effusion, often preceded by atelectasis, may occur a few days into the postoperative course.
Pneumothorax may occur following thoracic surgery if there is an air leak from the surgical site to the pleural cavity or from the pleural cavity to the environment. Failure of the chest drainage system will prevent return of negative pressure in the pleural cavity and result in pneumothorax. In the postoperative patient pneumothorax is often accompanied by hemothorax. The nurse maintains the chest drainage system and monitors the patient for signs and symptoms of pneumothorax: increasing shortness of breath, tachycardia, increased respiratory rate, and increasing res-piratory distress.
Bronchopleural fistula is a serious but rare complication pre-venting the return of negative intrathoracic pressure and lung re-expansion. Depending on its severity, it is treated with closed chest drainage, mechanical ventilation, and possibly talc pleu-rodesis.
Hemorrhage and shock are managed by treating the under-lying cause, whether by reoperation or by administration of blood products or fluids. Pulmonary edema from overinfusion of intra-venous fluids is a significant danger. The early symptoms are dyspnea, crackles, bubbling sounds in the chest, tachycardia, and pink, frothy sputum. This constitutes an emergency and must be reported and treated immediately.
The nurse instructs the patient and family about postoperative care that will be continued at home. The nurse explains signs and symptoms that should be reported to the physician. These include:
· Change in respiratory status: increasing shortness of breath, fever, increased restlessness or other changes in mental or cognitive status, increased respiratory rate, change in respi-ratory pattern, change in amount or color of sputum
· Bleeding or other drainage from the surgical incision or chest tube exit sites
· Increased chest pain
In addition, respiratory care and other treatment modalities (oxygen, incentive spirometer, chest physiotherapy, and oral, in-haled, or intravenous medications) may be continued at home. Therefore, the nurse needs to instruct the patient and family in their correct and safe use.
The nurse emphasizes the importance of progressively in-creased activity. The nurse instructs the patient to ambulate within limits and explains that return of strength is likely to be very gradual. Another important aspect of patient teaching ad-dresses shoulder exercises. It is important to instruct the patient to do these exercises five times daily. Additional patient teaching is described in Chart 25-22.
Depending on the patient’s physical status and the availability of family assistance, a home care referral may be indicated. The home care nurse assesses the patient’s recovery from surgery, with special attention to respiratory status, the surgical incision, chest drainage, pain control, ambulation, and nutritional sta-tus. The patient’s use of respiratory modalities should be as-sessed to ensure they are being used correctly and safely. In addition, the nurse assesses the patient’s compliance with the postoperative treatment plan and identifies acute or late post-operative complications.
The recovery process may be longer than the patient had ex-pected, and providing support to the patient is an important task for the home care nurse. Because of shorter hospital stays, at-tending follow-up physician appointments is essential. The nurse teaches the patient about the importance of keeping follow-up appointments and completing laboratory tests as prescribed to as-sist the physician in evaluating recovery. The home care nurse provides continuous encouragement and education to the patient and family during the process. As recovery progresses, the nurse also reminds the patient and family about the importance of par-ticipating in health promotion activities and recommended health screening.
Expected patient outcomes may include:
· Demonstrates improved gas exchange, as reflected in arte-rial blood gas measurements, breathing exercises, and use of incentive spirometry
· Shows improved airway clearance, as evidenced by deep, controlled coughing and clear breath sounds or decreased presence of adventitious sounds
· Has decreased pain and discomfort by splinting incision during coughing and increasing activity level
· Shows improved mobility of shoulder and arm; demon-strates arm and shoulder exercises to relieve stiffening
· Maintains adequate fluid intake and maintains nutrition for healing
· Exhibits less anxiety by using appropriate coping skills, and demonstrates a basic understanding of technology used in care
· Adheres to therapeutic program and home care
· Is free of complications, as evidenced by normal vital signs and temperature, improved arterial blood gas measure-ments, clear lung sounds, and adequate respiratory function
For a detailed plan of nursing care for the patient who has had a thoracotomy, see the Plan of Nursing Care.