2-49
2-49. THORACIC SURGERY
a. Pulmonary resection is removal of a significant portion of a lung. Resection in which a lobe of a lung is removed is referred to as lobectomy. Removal of the entire lung is referred to as pneumonectomy. These procedures are done to treat diseases such as tuberculosis and cancer or to deal with the consequences of trauma to the lungs.
b. These procedures involve opening the pleural cavity containing the affected lung. When the pleural cavity is opened, the affected lung will collapse. After completion of the desired surgical procedure, the surgeon will place a tube into the pleural cavity. The use of either an air-tight underwater seal or suction on the tube will help recreate the naturally existing partial vacuum in the pleural cavity and re-expand the remainder of the affected lung. The tube is withdrawn when the air and fluid has been removed from the pleural cavity.
c. In addition to the routine preoperative care given to any surgical patient, patients scheduled for thoracic surgery require special nursing considerations.
(1) Frequently, much time must be devoted to improving the patient's respiratory status prior to surgery. This will make the preoperative period longer than normal.
(2) The patient will be instructed in special exercises that will strengthen those muscles of the shoulders and chest that support respiratory movement. These exercises are routinely taught by the physical therapist. The nursing personnel, however, must be familiar with these exercises. It is a nursing responsibility to reinforce the teaching, observe, and assist the patient in correct procedure.
(3) Preoperative patient education must include preparing the patient and his family, the postoperative course of events, to include chest tubes, suctioning, and artificial ventilation, as appropriate.
(4) Preoperative education can be used to reduce the potential for complications. (For example, teaching the importance of active range of motion of the arms may prevent the patient from developing a "frozen" shoulder.) Always explain what must be done and why it is important. A patient will naturally be reluctant to perform a movement or exercise that is painful to him.
d. In addition to general postoperative nursing care, the following considerations for chest surgery patients must be noted.
(1) Intake and output must be strictly monitored.
(2) Intravenous fluids are routinely given slowly and in limited amounts (as ordered by the physician) to avoid fluid overload and pulmonary edema.
(3) Vigorous turning, coughing, and deep breathing must be done to expel secretions. If these secretions are not removed, atelectasis may occur. Secretions that cannot be removed by coughing must be removed by suctioning.
(4) Blood pressure, pulse, and respirations should be taken and recorded frequently for the first 24 hours postoperatively. Nursing personnel should note general appearance, skin color and temperature, character of respiration, and appearance of the wound site. Close observation must be made for signs of shock, hemorrhage, pulmonary edema, or respiratory embarrassment.
(5) Early ambulation of chest surgery patients is desired, with exercises as prescribed, to promote lung reinflation, good body posture, and maintenance of shoulder movement and muscle tone. Increase in ambulation will depend upon physician's orders, nursing assessment, and the patient's desire for independence.
(6) Proper positioning while bed resting is extremely important. The pneumonectomy patient should not be placed directly on his inoperative side. To do so will place additional strain on the already overtaxed remaining lung. Patients undergoing resection should not be placed on the operative side, as this interferes with the desired maximum expansion of the operative lung.
