The Patient Undergoing Thoracic Surgery
Assessment and management are particularly important in the patient undergoing thoracic surgery. Frequently, patients under-going such surgery also have obstructive pulmonary disease with compromised breathing. Preoperative preparation and careful postoperative management are crucial for successful patient out-comes because these patients may have a narrow range between their physical tolerance for certain activities and their limitations, which, if exceeded, can lead to distress. Various types of thoracic surgical procedures are performed to relieve disease conditions such as lung abscesses, lung cancer, cysts, and benign tumors (Chart 25-16). An exploratory thoracotomy (creation of a surgi-cal opening into the thoracic cavity) may be performed to diag-nose lung or chest disease. A biopsy may be performed in this procedure with a small amount of lung tissue removed for analy-sis; the chest incision is then closed.
The objectives of preoperative care for the patient undergoing thoracic surgery are to ascertain the patient’s functional reserve to determine if the patient can survive the surgery and to ensure that the patient is in optimal condition for surgery.
The nurse performs chest auscultation to assess breath sounds in the different regions of the lungs. It is important to note if breath sounds are normal, indicating a free flow of air in and out of the lungs. (In the patient with emphysema, the breath sounds may be markedly decreased or even absent on aus-cultation.) The nurse notes crackles and wheezes and assesses for hyperresonance and decreased diaphragmatic motion. Unilateral diminished breath sounds and rhonchi can be the result of oc-clusion of the bronchi by mucus plugs. The nurse assesses for re-tained secretions during auscultation by asking the patient to cough. It is important to note any signs of rhonchi or wheezing.
The patient history and assessment should include the following questions:
· What signs and symptoms are present (cough, sputum ex-pectorated [amount and color], hemoptysis, chest pain, dyspnea)?
· If there is a smoking history, how long has the patient smoked? Does the patient smoke currently? How many packs a day?
· What is the patient’s cardiopulmonary tolerance while rest-ing, eating, bathing, and walking?
· What is the patient’s breathing pattern? How much exer-tion is required to produce dyspnea?
· Does the patient need to sleep in an upright position or with more than two pillows?
· What is the patient’s physiologic status (eg, general appear-ance, mental alertness, behavior, nutritional status)?
· What other medical conditions exist (eg, allergies, cardiac disorders, diabetes)?
A number of tests are performed to determine the patient’s preoperative status and to assess the patient’s physical assets and limitations. Many patients are seen by their surgeons in the of-fice, and many tests and examinations are performed on an out-patient basis. The decision to perform any pulmonary resection is based on the patient’s cardiovascular status and pulmonary reserve. Pulmonary function studies (especially lung volume and vital capacity) are performed to determine whether the planned resection will leave sufficient functioning lung tissue. Arterial blood gas values are assessed to provide a more com-plete picture of the functional capacity of the lung. Exercise tol-erance tests are useful to determine if the patient who is a candidate for pneumonectomy can tolerate removal of one of the lungs.
Preoperative studies are performed to provide a baseline for comparison during the postoperative period and to detect any un-suspected abnormalities. These studies may include a broncho-scopic examination (a lighted scope is inserted into the airways to examine the bronchi), chest x-ray, electrocardiogram (for arte-riosclerotic heart disease, conduction defects), nutritional assess-ment, determination of blood urea nitrogen and serum creatinine (renal function), glucose tolerance or blood glucose (diabetes), as-sessment of serum electrolytes and protein levels, blood volume determinations, and complete blood cell count.
The underlying lung condition often is associated with increased respiratory secretions. Before surgery, the airway is cleared of se-cretions to reduce the possibility of postoperative atelectasis or in-fection. Risk factors for postoperative atelectasis and pneumonia are listed in Chart 25-17. Strategies to reduce the risk for atelec-tasis and infection include humidification, postural drainage, and chest percussion after bronchodilators are administered, if pre-scribed. The nurse estimates the volume of sputum if the patient expectorates large amounts of secretions. Such measurements are carried out to determine if and when the amount decreases. An-tibiotics are administered as prescribed for infection, which may be causing the excessive secretions.
Increasingly, patients are admitted on the day of surgery, which does not provide much time for the acute care nurse to talk with the patient. Nurses in all settings must take an active role in ed-ucating the patient and relieving anxiety. The nurse informs the patient what to expect, from administration of anesthesia to thoracotomy and the likely use of chest tubes and a drainage system in the postoperative period. The patient is also informed about the usual postoperative administration of oxygen to fa-cilitate breathing, and the possible use of a ventilator. It is es-sential to explain the importance of frequent turning to promote drainage of lung secretions. Instruction in the use of incentive spirometry begins before surgery to familiarize the pa-tient with its correct use. The nurse should teach diaphragmatic and pursed-lip breathing, and the patient should begin practic-ing these techniques (see Chart 25-3, “Breathing Exercises,” and Chart 25-4, “Assisting the Patient to Perform Incentive Spirometry”).
Because a coughing schedule will be necessary in the postop-erative period to promote the clearance or removal of secretions, the nurse instructs the patient in the technique of coughing and warns the patient that the coughing routine may be uncomfort-able. The nurse teaches the patient to splint the incision with the hands, a pillow, or a folded towel (see Chart 25-5).
Another technique, “huffing,” may be helpful for the patient with diminished expiratory flow rates or for the patient who re-fuses to cough because of severe pain. Huffing is the expulsion of air through an open glottis. This type of forced expiration technique (FET) stimulates pulmonary expansion and assists in alveolar inflation. The nurse instructs the patient as follows:
· Take a deep diaphragmatic breath and exhale forcefully against your hand in a quick, distinct pant, or huff.
· Practice doing small huffs and progress to one strong huff during exhalation.
Patients should be informed preoperatively that blood and other fluids may be administered, oxygen will be administered, and vital signs will be checked often for several hours after surgery. If a chest tube is needed, the patient should be informed that it will drain the fluid and air that normally accumulate after chest surgery. The patient and family are informed that the pa-tient may be admitted to the intensive care unit for 1 to 2 days after surgery, that the patient may experience pain at the incision site, and that medication is available to relieve pain and discom-fort (Finkelmeier, 2000).
The nurse listens to the patient to evaluate his or her feelings about the illness and proposed treatment. The nurse also deter-mines the patient’s motivation to return to normal or baseline function. The patient may reveal significant concerns: fear of hemorrhage because of bloody sputum, fear of discomfort from a chronic cough and chest pain, fear of ventilator dependence, or fear of death because of dyspnea and the underlying disease (eg, tumor).
The nurse helps the patient to overcome these fears and to cope with the stress of surgery by correcting any misconceptions, supporting the patient’s decision to undergo surgery, reassuring the patient that the incision will “hold,” and dealing honestly with questions about pain and discomfort and their treatment. The management and control of pain begin before surgery, when the nurse informs the patient that many postoperative problems can be overcome by following certain routines related to deep breathing, coughing, turning, and moving. If patient-controlled analgesia or epidural analgesia is to be used after surgery, the nurse instructs the patient in its use.
After surgery the vital signs are checked frequently. Oxygen is administered by a mechanical ventilator, nasal cannula, or mask for as long as necessary. A reduction in lung capacity requires a period of physiologic adjustment, and fluids may be given at a low hourly rate to prevent fluid overload and pulmonary edema. When the patient is conscious and the vital signs have stabilized, the head of the bed may be elevated 30 to 45 degrees. Careful positioning of the patient is important. Following pneumonectomy, a patient is usually turned every hour from the back to the operative side and should not be completely turned to the unoperated side. This allows the fluid left in the space to consolidate and prevents the remaining lung and the heart from shifting (mediastinal shift) toward the operative side. The patient with a lobectomy may be turned to either side, and a patient with a segmental resection usually is not turned onto the operative side unless the surgeon prescribes this position (Finkelmeier, 2000).
Medication for pain is needed for several days after surgery. Because coughing can be painful, patients should be taught to splint the chest. Exercises are resumed early in the postoperative period to facilitate lung ventilation. The nurse assesses for signs of complications, including cyanosis, dyspnea, and acute chest pain. These may indicate atelectasis and should be reported im-mediately. Increased temperature or white blood cell count may indicate an infection, and pallor and increased pulse may indi-cate internal hemorrhage. Dressings should be assessed for fresh bleeding.
Depending on the nature of the surgery, the patient’s underly-ing condition, the intraoperative course, and the depth of anes-thesia, the patient may require mechanical ventilation after surgery. The physician is responsible for determining the venti-lator settings and modes, as well as determining the overall method and pace of weaning. However, the physician, nurse, and respiratory therapist work together closely to assess the pa-tient’s tolerance and weaning progress. Early extubation from mechanical ventilation can also lead to earlier removal of arter-ial lines (Zevola & Maier, 1999).
A crucial intervention for improving gas exchange and breathing in the postoperative period is the proper management of chest drainage and the chest drainage system. After thoracic surgery, chest tubes and a closed drainage system are used to re-expand the involved lung and to remove excess air, fluid, and blood. Chest drainage systems also are used in treatment of spontaneous pneu-mothorax and trauma resulting in pneumothorax. Table 25-3 describes and compares the main features of these systems. Management of chest drainage systems is explained in Chart 25-18. Prevention of cardiopulmonary complications following tho-racic surgery is discussed in Chart 25-19.
The normal breathing mechanism operates on the principle of negative pressure; that is, the pressure in the chest cavity normally is lower than the pressure of the atmosphere, causing air to move into the lungs during inspiration. Whenever the chest is opened, there is a loss of negative pressure, which can result in the collapse of the lung. The collection of air, fluid, or other substances in the chest can compromise cardiopulmonary function and can also cause the lung to collapse. Pathologic substances that collect in the pleural space include fibrin, or clotted blood; liquids (serous fluids, blood, pus, chyle); and gases (air from the lung, tracheo-bronchial tree, or esophagus).
Chest tubes may be inserted to drain fluid or air from any of the three compartments of the thorax (the right and left pleural spaces and the mediastinum). The pleural space, located between the visceral and parietal pleura, normally contains 20 mL or less of fluid, which helps to lubricate the visceral and parietal pleura. Surgical incision of the chest wall almost always causes some de-gree of pneumothorax (air accumulating in the pleural space) or hemothorax (build-up of serous fluid or blood in the pleural space). Air and fluid collect in the pleural space, restricting lung expansion and reducing gas exchange. Placement of a chest tube in the pleural space restores the negative intrathoracic pressure needed for lung re-expansion following surgery or trauma.
The mediastinal space is an extrapleural space that lies be-tween the right and left thoracic cavities. Mediastinal chest tubes promote the removal of blood or other fluid from around the heart (Finkelmeier, 2000). Accumulating fluid can stop the heart from beating if it is not drained. A mediastinal tube can be in-serted either anteriorly or posteriorly to the heart to drain blood after surgery or trauma. Without a tube, compression of the heart could occur, leading to death (Carroll, 2000).
There are two types of chest tubes: small-bore and large-bore catheters. Small-bore catheters (7F to 12F) have a one-way valve apparatus to prevent air from moving back into the patient. They can be inserted through a small skin incision. Large-bore catheters,which range in size up to 40F, are usually connected to a chest drainage system to collect any pleural fluid and monitor for air leaks (Scanlan, Wilkins & Stoller, 1999). After the chest tube is positioned, it is sutured to the skin and connected to a drainage apparatus to remove the residual air and fluid from the pleural or mediastinal space. This results in the re-expansion of remaining lung tissue.
Chest drainage systems have a suction source, a collection chamber for pleural drainage, and a mechanism to prevent air from reentering the chest with inhalation.
Various types of chest drainage systems are available for use in removal of air and fluid from the pleural space and re-expansion of the lungs. Chest drainage systems come with either wet (water seal) or dry suction control. In wet suction systems, the amount of suction is determined by the amount of water instilled in the suction chamber. The amount of bubbling in the suction chamber in-dicates how strong the suction is. Wet systems use a water seal to prevent air from moving back into the chest on inspiration. Dry systems use a one-way valve and a suction control dial in place of the water needed with wet or water seal system. Both systems can operate by gravity drainage, without a suction source.
Water Seal Chest Drainage Systems. The traditional water sealchest drainage system (or wet suction) has three chambers: a collection chamber, a water seal chamber, and a wet suction control chamber. The collection chamber acts as a reservoir for fluid draining from the chest tube. It is graduated to permit easy measurement of drainage. Suction may be added to create neg-ative pressure and promote drainage of fluid and removal of air. The suction control chamber regulates the amount of negative pressure applied to the chest. The amount of suction is deter-mined by the water level. It is generally set at 20-cm water; adding more fluid results in more suction. After the suction is turned on, bubbling appears in the suction chamber. A positive-pressure valve is located at the top of the suction chamber that automatically opens with increases in positive pressure within the system. Air will automatically be released through a posi-tive-pressure relief valve if the suction tubing is inadvertently clamped or kinked.
The water seal chamber has a one-way valve or water seal that prevents air from moving back into the chest when the patient inhales. There will be an increase in the water level with inspiration and a return to the baseline level during exhalation; this is referred to as tidaling. Intermittent bubbling in the water seal chamber is normal, but continuous bubbling can indicate an air leak. Bub-bling and tidaling do not occur when the tube is placed in the me-diastinal space; however, fluid may pulsate with the patient’s heartbeat. If the chest tube is connected to gravity drainage only, suction is not used. The pressure is equal to the water seal only. Two-chamber chest drainage systems (water seal chamber and collection chamber) are available for use with patients who need only gravity drainage.
The water level in the water seal chamber reflects the negative pressure present in the intrathoracic cavity. A rise in the water level indicates negative pressure in the pleural or mediastinal space. Excessive negative pressure can cause trauma to tissue (Bar-El, Ross, Kablawi & Egenburg, 2001). Most chest drainage systems have an automatic means to prevent excessive negative pressure. By pressing and holding a manual high-negativity vent (usually located on the top of the chest drainage system) until the water level in the water seal chamber returns to the 2-cm mark, excessive negative pressure is avoided, preventing damage to tissue.
Dry Suction Water Seal Systems. Dry suction water seal systems,also referred to as dry suction, have a collection chamber for drainage, a water seal chamber, and a dry suction control cham-ber. The water seal chamber is filled with water to the 2-cm level. Bubbling in this area can indicate an air leak. The dry suction control chamber contains a regulator dial that conveniently reg-ulates vacuum to the chest drain. Water is not needed for suction as it is in the wet system. Without the bubbling in the suction chamber, the machine is quieter.
Once the tube is connected to the suction source, the regula-tor dial allows the desired level of suction to be dialed in; the suc-tion is increased until an indicator appears. The indicator has the same function as the bubbling in the traditional water seal sys-tem; that is, it indicates that the vacuum is adequate to maintain the desired level of suction. Some drainage systems use a bellows (a chamber that can be expanded or contracted) or an orange-colored float device as an indicator of when the suction control regulator is set.
When the water in the water seal rises above the 2-cm level, intrathoracic pressure increases. Dry suction water seal systems have a manual high-negativity vent located on top of the drain. Pressing the manual high-negativity vent until the indicator ap-pears (either a float device or bellows) and the water level in the water seal returns to the desired level, intrathoracic pressure is decreased.
Dry Suction with a One-Way Valve System. A third type of chestdrainage system is dry suction with a one-way mechanical valve. This system has a collection chamber, a one-way mechanical valve, and a dry suction control chamber. The valve acts in the same way as a water seal and permits air to leave the chest but prevents it from moving back into the pleural space. This model lacks a water seal chamber and therefore has the advantage of a system that operates without water. For example, it can be set up quickly in emergency situations, and the dry control drain will still work even if it is knocked over. If the wet suction drain is knocked over, the water seal could be lost. This makes the dry suction systems useful for the patient who is ambulating or being transported. However, without the water seal chamber, there is no way to tell by inspection if the pressure in the chest has changed. An air leak indicator is present so that the system can be checked for air leaks. If an air leak is sus-pected, 30 mL of water are injected into the air leak indicator. Bub-bles will appear if a leak is present (Carroll, 2000).
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