Thoracic Surgery
What are the three chambers in a three-chamber drainage system?
1) drainage collection 2) water seal 3) suction control (wet or dry)
How much tidaling in the water-seal chamber is considered normal?
2-6cm
What is pleural effusion?
A buildup of fluid in the pleural space
Lab tests used to diagnose pneumo-hemothorax:
ABG's (PaO2 <80%)
What is a hemothorax?
Accumulation of blood in the pleural cavity
What are the potential complications of thoracic surgery?
Allergy to local anesthetic Infection Aspiration Bronchospasm Hypoxemia Bleeding Perforation
What does continuous bubbling in the water seal chamber indicate?
An air leak
Where is a CT placed to remove air?
Anterior and superior
What is the FIRST and most appropriate intervention when a patients chest tube is accidentally removed?
Apply sterile gauze to the insertion site
Post-op care for thoracic surgery
Assess and provide routine post-op care Assess pain and adequate control Assess respiratory status FREQUENTLY Assist effective coughing, postural drainage, incentive spiro Assist with arm ROM Monitor/maintain effective ventilation Monitor for infection/use of aseptic technique Assess and maintain nutrition--strict I&O Maintain patent chest tubes/drains
Nursing interventions for thoracic surgery:
Assure adequate consent NPO 6hrs prior to surgery Explain procedure Administer meds Monitor for return of gag reflex after procedure Monitor respiratory status FREQUENTLY Monitor VS Discharge instructions
How can chest surgery cause a pneumothorax on the operated side?
Atmospheric air rushes into the pleural space as the parietal pleura is incised. The normally negative pressure in the pleural space changes to positive pressure, causing a collapse of the lung.
When performing a thoracentesis, what is very important to monitor?
BP; drop in BP could indicate shock
What is important to have in order to see that a patient is having post op complications?
Baseline vitals!
Risk factors for pneumo- and hemothorax
Blunt chest trauma Penetrating chest wounds Closed/occluded chest tube Older adults with decreased pulmonary reserves (normal) including decreased lung elasticity and thickening alveoli COPD
What is hard to do when there is fluid in the pleural space?
Breathe
Diagnostic procedures used in pneumo-hemothorax:
Chest x-ray to confirm pneumothorax Thoracentesis to confirm hemothorax
When you suspect an air leak in chest tube, what do you do?
Clamp the tubing just distal to the insertion site. If the leak stops, it is patient-centered. Place occlusive petroleum gauze around insertion site. If it continues, clamp tubing in a step-wise fashion to locate leak.
What does a patient have to do or not do when having thoracentesis?
DO NOT cough, move or deep breathe Lean over a bedside table
How do you explain what a patient will feel during thoracentesis?
Dsicomfort during local injection, only pressure when needle goes into the lung.
Specific symptoms of hemothorax:
Dull percussion
Why would a patient need to have surgery in the thoracic cavity?
Emergency Exploratory Relief of disease process
Specific symptoms of Pneumothorax:
Hyperresonance on percussion due to trapped air
Possible nursing diagnoses for a patient with a chest tube:
Ineffective Breathing Pattern Risk for trauma/suffocation Deficient knowledge Risk for infection
What is pleurisy/pleuritis?
Inflammation of the pleura that causes chest pain that worsens with breathing
Where is the pleural space?
Lies between the parietal pleura and the visceral pleura
What are four different surgical procedures done on the lung to remove cancerous tissue?
Lobectomy (most severe) Pneumonectomy Segmentectomy Wedge resection
Benzodiazepines (sedatives) used in thoracic surgery and the effects produced when taking:
Lorazepam or midazolam Amnesic effects, drowsiness, hypotension, respiratory distress
What is the procedure for chest tube removal?
Medicate patient 30 mins prior to removal Take deep breathe, exhale and bear down (Valsalva) Place airtight sterile petroleum jelly gauze dressing Obtain chest x-rays to confirm resolution of problem
Opioid agonists (pain medications) used in thoracic surgery and the effects produced when taking:
Morphine sulfate and Fentanyl Analgesia, respiratory depression (MONITOR), euphoria, sedation, decrease in GI motility
Why do lungs stay expanded?
Negative pressure in the pleural space
What is a tension pneumothorax?
Occurs when air enters the pleural space during inspiration and cannot exit. The trapped air causes pressure on the heart and lung, compressing vessels and limiting venous return. Air and tension rise in the pleural cavity, causing a mediastinal shift
What items should always be at the bedside of a patient with a chest tube?
Oxygen Sterile water Enclosed hemostats Occlusive dressing
What is done in thoracentesis?
Perforation of the chest wall and pleural space with a large bore needle
What thoracic surgery will not need a chest tube postop? With this procedure, what is crucial to watch for?
Pneumonectomy: there is not lung to re-expand! Watch for mediastinal shift
List five reasons that a patient may have a chest tube:
Pneumothorax Hemothorax Pleural effusion Post-op drainage Lung abscess (or pulmonary empyema: accumulation of pus in the pleural space)
Where is a CT placed to remove fluids and blood?
Posterior and inferior
What is a pneumothorax?
Presence of air or gas in the pleural space that causes the lung to collapse
What is a thoracentesis?
Removal of fluid in the pleural space
General signs and symptoms of pneumothorax, tension pneumothorax and hemothorax:
Respiratory distress (tachycardia, tachypnea, hypoxia, cyanosis, dyspnea, accessory muscle use) Reduced or absent breath sounds on affected side Asymmetrical chest wall movement Sub-Q emphysema
What are two things that could be indicative of a water seal chamber not bubbling?
The patient's lungs have completely expanded or There is an occlusion in the tube.
When is a chest tube placed?
To drain fluid, blood, or air; re-establish a negative pressure; facilitate lung expansion; restore normal intrapleural pressure.
Specific symptoms of tension pneumothorax:
Tracheal deviation to unaffected side
What is a thoracotomy?
Used for lung surgery and involves cutting into bone, muscle and cartilarge. (posterolateral or endoscopic)
What is a bronchoscopy?
Visualization of the larynx, trachea and bronchi
What is a thoracoscopy?
Visualzation of hte contents of the thoracic cavity
What needs to be monitored immediately after thoracentesis?
Vitals, SaO2, and insertion site.
When would a chest tube be removed?
When lungs have re-expanded or there is no more fluid drainage