Thoracic Surgery and Chest Tubes- 7 questions
What is the positioning for a thoracentesis surgery?
*orthopneic position*. sitting on the side of the bed, leaning over bedside table creating a c-curved back. - local analgesic is used (lidocaine) could be epinephrine
Chest Tubes: - What do you say if a patient asks why they have a chest tube? - why is there blood in the tubing?
- it is going to relieve air or fluid from lungs and make it easier to breathe - this is normal for it to start bloody red then turn serosanguinous
What is a thoracotomy?
-otomy means incision. It is an incision into the thoracic cavity (-ectomy means removal)
REVIEW: Indications for Thoracic Surgery (going in chest for something) 1. removal of empyema (pus in pleural space); abscess; chronic effusions; tumor/masses 2. tracheal/esophageal resection 3. lung reduction (emphysema)
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How long do CT and Heimlich stay in?
1-2 weeks until the leak is healed
T/F about a CT dressing? 1. it is changed weekly 2. It is a sterile dressing 3. serosanguinous drainage on the dressing is not a serious problem 4. the tubing should be secured a few inches below the main part of the dressing 5. you place vaseline on the gauze
1. F. it is changed daily or by protocol 2. T 3. T 4. T 5. F- dry dressing
What are the S&S of pleural effusion?
1. dyspnea 2. decreased chest wall movement on affected side 3. *dullness* on percussion (want to hear resonance) 4. absent or distant breath sounds
Describe each: 1. Wedge resection 2. Segmentectomy 3. Lobectomy 4. Pneumonectomy
1. just a small part to remove a mass 2. larger portion of the lobe in lungs 3. remove an entire lobe of lung 4. remove entire lung
What are the 2 types of thoracotomy?
1. median steronotomy 2. lateral thoracotomy (can be posterior or anterior)
*Preoperative care* of Thoracic Surgery: What are the 3 main teaching points?
1. pulmonary hygiene- cough and deep breathe. Use incentive spirometer and try to prevent atelectasis. Chest PT 2. pain control 3. *chest tubes*- container of blood draining is normal
what is the main difference between wet and dry chest tube drainage systems?
1. wet (atrium)- extra 3rd chamber filled with water to provide negative pressure 2. dry (oasis) has bellows to provide suction ... the water seal chamber still shows fluctuation and tidaling. air leak still shows up in water seal chamber
what is the needle size for a chest tube insertion?
14-16 g needle for aspiration (big needle) - premedicate if not emergency (percocet)
When is the dressing removed when you have a CT and heimlich?
48 hours after the CT is removed
what are the emergency equipment with CT?
4x4 sterile gauze adn NSS
If a patient refuses to deep breathe and cough what should you do as the nurse?
ASSESS PAIN LEVEL. then call the doctor. do not just leave patient and come back later. listen to lung sounds. - pain should not be a 0...
What is some postoperative care that goes along with thoracic surgery? - how often do you use incentive spirometry - when should the person be getting OOB? - what is the first electrolyte lost?
Assessment, VS, Pain control 1. *Pulmonary hygiene*- coughing and deep breathing. incentive spirometry done q2h 2. OOB *next day*. have them sit on the side of the bed first 3. Potassium (hypovolemic shock)
What is the main concept to think about when dealing with CT?
BREATHING AND LUNGS... pulse ox and respirations are important
How does the pressure work in a Heimlich valve during inspiration and expiration?
Inspiration: *negative intrapleural pressure* closes the valve and prevents air from entering pleural space Expiration: *positive pressure* opens valve and allows air/fluid to drain - not much drainage so home healthcare nurse just stops by to check on patient
can a chest tube be removed if there is an air leak? What do you do?
NO. you could possibly put them on Heimlich valve if they do not have any drainage but you can not remove CT with air leak present
What would you do... Your patient complains of extreme SOB and the pulse ox reads 90% about 20 minutes after the CT was pulled.
SBAR and call someone - all I could really do is put the patient on O2. The doctor has to place a new chest tube in.
What does SBAR stand for?
Situation Background Assessment Recommendation
Patient education: Heimlich valve What should you tell the patient about fluttering of the valve leaflet and/or honking or duck-like sounds?
THIS IS NORMAL
What is a Heimlich valve and when is it used?
Used when a patient has hardly any drainage in container but still needs to recreate negative pressure. They can go home on a Heimlich valve. GOAL: reexpand the chest
What is the diagnostic test to check and make sure the patient does not have a pneumo after thoracentesis surgery?
chest x-ray
what is the positioning for a thoracotomy?
depending on where the incision will be... but you want *arm stretched out above* if you are doing a posterior lateral incision. want to encourage active ROM for the arm.
Thoracotomy: Where is the incision for median sternotomy?
down the middle of chest
what is the different reasons for a chest tube being placed high and low?
high in the lung if draining air (simple pneumo) and low in the lung if draining blood or fluid (hemothorax or empyema).
After a thoracentesis surgery what does the incision site look like?
just a needle was put in. a small bandaid or gauze would be on it.
what is the first thing that should be assessed with a CT?
make sure it is plugged in and set to suction or just the water seal chamber
What is some postoperative that goes along with thoracic surgery? what is the incision/dressing like? 1. drainage? color and amount
microfoam tape that is occlusive over top (think of lab). split sponges underneath. dressing dry and intact. 1. serosanguinous (yellow/pink). small to moderate amount (if moderate then change every shift). Must reinforce dressing if drainage.
What is done to treat a pneumothorax? - what does this do?
needle throacostomy - releases the pressure on the lungs.
What is the purpose of the water seal chamber?
one way valve to allow fluid to drain but no air to re-enter
what is the difference between an open thoracotomy and VATS?
open thoracotomy is much more painful and takes 4-5 days recovery. VATS (video assisted thoracic surgery) is cheaper and less painful. Surgeon knows where they are going. Person stays for maybe 1 or 2 days.
What is an air leak?
positive pressure escapes from pleural psace
What type of pressure is suction?
provides *negative pressure* - you are pulling out fluid (positive pressure is an air leak)
What is a Thoracentesis surgery? - when is this done
putting a needle into the pleural space - used to suction fluid out (pleural effusion)
how often are vital signs done post-op?
q15 min for 1 hour. q30 min for 1 hour q4h for the rest
What is *flail chest*
segment of the rib cage is separated from the rest of the chest wall. *free-floating ribs* - segment does not contribute to lung expansion - *paradoxical chest movement* it is going the other way
*Preoperative care* of Thoracic Surgery: What should be encouraged?
smoking cessation
What does the Physician tell a patient to do when they are pulling out CT? - what should the physician be wearing?
tell the patient to "take a deep breath, blow out and hold it" and hummm... don't want inspiration to pull any positive pressure back into the lungs - goggles, gown, gloves, face mask and pad under patient. in case any fluid spills out and splatters
What if you are obtaining consent and the patient seems confused?
the procedure should have already been explained to them. If the patient seems unaware you need to have the doctor re-explain the procedure.
what is the main complication with thoracentesis? - what would the patient look like?
this involves thoracic cavity... think lungs... *pneumothorax* - dyspnic or tachypnic. should check pulse ox because this is a problem with oxygen.
*Preoperative care* of Thoracic Surgery: why are diagnostic tests done?
to determine baseline pulmonary and CV status
What is the overall purpose of a chest tube?
to recreate negative pressure
