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THORACIC SURGERIES

DEFINITION
Thoracic surgery is the field of medicine involved in the surgicaltreatment of diseases affecting organs inside the thorax (the chest). Generally treatment of conditions of the lungs, chest wall, anddiaphragm. Thoracic surgery is often grouped with cardiac surgery and called cardiothoracic surgery.

TYPES OF PROCEDURES
TYPES Exploratory thoracotomy DESCRIPTION Internal ▪ view of Usually INDICATIONS lung May be used to confirm carcinoma posterolateral or for chest trauma (to detect source but could be of bleeding)

parascapular anterior

incision

▪ Chest tubes after procedure Lobectomy Lobe removal Used when pathology is limited to ▪ Thoracotomy incision at site one area of lung: bronchogenic of lobe removal carcinoma, giant emphysematous blebs or bullae, benign tumors, metastatic malignant tumors, ▪ Chest tubes after procedure

bronchiectasis and fungal infections Pneumonectomy Removal of an entire lung Performed chiefly for carcinoma, ▪ Posterolateral or anterolateral but may be used for lung abscesses, thoracotomy incision bronchiectasis, or extensive ▪ Sometimes there is a rib tuberculosis resection Note: Right lung is more vascular left; may cause more ▪ Normally no chest drains or than tubes because

fluid physiologic problems if removed

accumulation in empty space is desirable Segmentectomy Only certain segment of lung Used when pathology is localized

(segmental resection)

removed ▪ Segments function

(such as in bronchiectasis) and as when the patient has preexisting cardiopulmonary compromise

individual units Wedge resection

Small localized section of lung Performed for random lung biopsy tissue removed—usually pie- and shaped small peripheral nodules

Considered when less invasive tests

▪ Incision made without regard have failed to establish a diagnosis to segments May be used as a therapeutic procedure ▪ Chest tubes after procedure Thoracoscopy

Direct visualization of pleura VATS may be used for lung with thorascope via an biopsy, lobectomy, resection of nodules, repair of fistulas

intercostal incision ▪ Medical under sedation or local anesthesia; allows for visualization and biopsy ▪ Video assisted thorascopic surgery (VATS) under general anesthesia; multiple puncture sites and video screen allow for visualization and manipulation of the pleura, mediastinum, and lung parenchyma Decortication

Removal or stripping of thick Empyema fibrous membrane

unresponsive

to

from conservative management

visceral pleura ▪ Use of chest tube drainage system postoperatively Thoracotomy involving lungs not ▪ Incision into the thoracic Used for hiatal hernia repair, open cavity for surgical procedures heart surgery, esophageal surgery, on other structures tracheal resection, aortic aneurysm repair

Lung reduction (LVRS)

volume ▪

Involves

reducing

lung Performed in advanced bullous α1-antitrypsin

surgery volume by multiple wedge emphysema, excisions or VATS emphysema

Procedures Emergency thoracotomy A patient who has sustained truncal trauma but remains unstable or moribund despite adequate resuscitation by way of infusion, chest drainage and ventilation should be considered a candidate for emergency thoracotomy (ET). A penetrating injury anywhere between the nipples laterally, the sternal notch superiorly and the umbilicus inferiorly should be considered to have penetrated the heart till proven otherwise. Ideally Incision Incisions are adapted to the circumstances and the track of a weapon, the predicted injuries. Sometimes the presence of a protruding weapon will determine what approach is suitable. ET should be performed with the patient supine. If abdominal injuries are suspected, a separate laparotomy incision can be made in the supine patient without having to reposition him. For the patient who has circulatory collapse after a penetrating injury to the precordium amedian sternotomy because it gives access to all the major important structures. Anterior thoracotomy

1. 2. The accepted, standard, approach for emergency thoracotomy is via the left anterior fourth intercostal space. The image on the right is of a right hemiclamshell for a gunshot wound (visible in the axilla). He subsequently underwent a 'rooftop' incision to repair a liver injury.

open surgery is needed to diagnose and treat lung problems. This procedure removes only the affected tissue. A lobectomy removes an entire lobe. By removing the entire lobe. Wedge Resection A wedge resection can be performed if the tumor / mass is confined to one area of the lung. left hilum and the left lung. In certain cases. Surrounding lymph nodes may be removed at the same time in a procedure called a lymphadenectomy. . the mass can also be removed. surgery can help determine its cause. If a mass is found in the lung. Lobectomy The lungs are composed of sections called lobes.This incision allows good access to the cardiac ventricles. main pulmonary artery. If necessary. the lobectomy hopefully removes all traces of cancer cells.

 Teach an effective coughing technique. People often worry that their breathing will be compromised after lung removal. Take three short breaths. o o Splint the incision with hands or folded towel. o Contract abdominal muscles and cough twice forcefully with mouth open and tongue out. . and likelihood of postoperative atelectasis. Encourage deep breathing with the use of incentive spirometer to prevent atelectasis postoperatively. exhale in a quick distinct pant. by decreasing secretions and increasing oxygen saturation. Removal may be needed if cancer appears to have spread through one entire side of the lungs. Take a deep diaphragmatic breath and exhale forcefully against hand. o     Humidify the air to loosen secretions. Administer bronchodilators to reduce bronchospasm. . o Sit upright with knees flexed and body bending slightly forward (or lie on side with hips and knees flexed if unable to sit up). inhaling slowly and evenly through the nose. Alternate technique—huffing and coughing—is less painful.  Encourage the patient to stop smoking to restore bronchial ciliary action and to reduce the amount of sputum. followed by a deep inspiration. Administer antimicrobials for infection. but the exact location is hard to pinpoint.Pneumonectomy A pneumonectomy removes an entire lung. PREOPERATIVE MANAGEMENT Goal is to maximize respiratory function to improve the outcome postoperatively and reduce risk of complications.  Teach diaphragmatic breathing. but the remaining lung is usually more than sufficient.

infusions. pain control.V. and effort of respirations. depth. as prescribed.    Evaluate cardiovascular status for risk and prevention of complication. Carry out chest physical therapy and postural drainage to reduce pooling of lung secretions . suctioning.  Correct anemia.  Give prophylactic anticoagulant. o Orient the patient to events that will occur in the postoperative period — coughing and deep breathing. tube feedings. Make sure that patient fully understands surgery and is emotionally prepared for it. oxygen therapy. . verify that informed consent has been obtained NURSING DIAGNOSES     Ineffective Breathing Pattern related to wound closures Risk for Deficient Fluid Volume related to chest drainage and blood loss Acute Pain related to wound closure and presence of drainage tubes in the chest Impaired Physical Mobility of affected shoulder and arm related to wound closure and the presence of drainage tubes in the chest NURSING INTERVENTIONS MAINTAINING ADEQUATE BREATHING PATTERN   Monitor rate. chest tube and drainage system. consolidation. ventilator therapy. Administer medications and limit sodium and fluid to improve heart failure.  Monitor pulse oximetry and obtain ABG analysis and pulmonary function measurements as ordered. rhythm. Encourage activity to improve exercise tolerance.  Provide teaching and counseling. leg exercises and range-ofmotion (ROM) exercises for affected shoulder. and hypoproteinemia with I. to reduce perioperative incidence of deep vein thrombosis and pulmonary embolism. and blood transfusions as indicated. Auscultate chest for adequacy of air movement to detect bronchospasm. dehydration. if indicated.

placing the patient at risk for respiratory failure.   Suction. NURSING DIAGNOSES .  Encourage coughing and deep-breathing exercises and use of an incentive spirometer to prevent bronchospasm. retained secretions. Elevate the head of the bed 30 to 40 degrees when patient is oriented and BP is stabilized to improve movement of diaphragm and alleviate dyspnea. as needed. using meticulous aseptic technique. serum electrolytes. and coughing. Monitor LOC and inspiratory effort closely to begin weaning from ventilator as soon as possible. POST OPERATIVE MANAGEMENT POSTOPERATIVE ASSESSMENT  The nurse monitors the heart rate and rhythm by auscultation and electrocardiography because episodes of major dysrhythmias are common after thoracic and cardiac surgery.   Early extubation from mechanical ventilation can also lead to earlier removal of arterial lines 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. atelectasis. Central venous pressure monitoring devices are being used less frequently and for shorter periods of time than in the past. A preoperative FEV1 of more than 2 L or more than 70% of predicted value indicates a good lung reserve.   In the immediate postoperative period. turning. and arterial pressure.  Provide optimal pain relief to promote deep breathing. hemoglobin and hematocrit values. Central venous pressure may be monitored to detect early signs of fluid volume disturbances.This results in decreased tidal volumes. Patients who have a postoperative predicted FEV1 of less than 40% of predicted value have a higher incidence of morbidity and mortality . an arterial line may be maintained to allow frequent monitoring of arterial blood gases. and pneumonia.

then less frequently as the patient’s condition stabilizes. NURSING INTERVENTIONS IMPROVING GAS EXCHANGE AND BREATHING   Gas exchange is determined by evaluating oxygenation and ventilation. and the surgical procedure • Impaired physical mobility of the upper extremities related to thoracic surgery • Risk for imbalanced fluid volume related to the surgical procedure • Imbalanced nutrition. In the immediate postoperative period. drainage tubes. increased arm and shoulder mobility. understanding of self-care procedures. and pain • Acute pain related to incision. pulse. less than body requirements related to dyspnea and anorexia • Deficient knowledge about self-care procedures at home POTENTIAL COMPLICATIONS Based on assessment data. and bronchopleural fistula • Blood loss and hemorrhage • Pulmonary edema PLANNING AND GOALS The major goals for the patient may include improvement of gas exchange and breathing. and absence of complications. 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. improvement of airway clearance. . anesthesia. potential complications may include: • Respiratory distress • Dysrhythmias • Atelectasis.Based on the assessment data. relief of pain and discomfort. pneumothorax. and respirations) at least every 15 minutes for the first 1 to 2 hours. maintenance of adequate fluid volume and nutritional status.  Pulse oximetry is used for continuous monitoring of the adequacy of oxygenation. this is achieved by measuring vital signs (blood pressure.

. ! side frequently and moved from horizontal to semi-upright position as soon as tolerated. This facilitates ventilation. these measurements can help determine appropriate therapy.  The frequency with which postoperative arterial blood gases are measured depends on whether the patient is mechanically ventilated or exhibits signs of respiratory distress. such as diaphragmatic and pursed-lip breathing. and helps residual air to rise in the upper portion of the pleural space.  Another technique to improve ventilation is sustained maximal inspiration therapy or incentive spirometry. improves the cough mechanism. where it can be removed through the upper chest tube. promotes chest drainage from the lower chest tube. and allows early assessment of acute pulmonary changes. that were taught before surgery should be performed by the patient every 2 hours to expand the alveoli and prevent atelectasis. This technique promotes lung inflation. In general. Hemodynamic monitoring may be used to assess hemodynamic stability. There is controversy regarding the best side-lying position. the head of the bed is elevated 30 to 40 degrees during the immediate postoperative period. the patient should be positioned from back The manual vent should not be used to lower the water level in the water seal when the patient is on gravity drainage (no suction) because intrathoracic pressure is equal to the pressure in the water seal.  However.    It also is common practice for patients to have an arterial line in place to obtain blood for blood gas measurements and to monitor blood pressure closely. Most commonly. the patient is instructed to lie on the operative side. It is important to draw blood for arterial blood gas measurements early in the postoperative period to establish a baseline to assess the adequacy of oxygenation and ventilation and the possible retention of CO2.   The nurse should consult with the surgeon about patient positioning. Breathing techniques. When the patient is oriented and blood pressure is stabilized. the patient with unilateral lung pathology may not be able to turn well onto that side because of pain.   Positioning also improves breathing.

Turn the patient in log-roll fashion to prevent twisting at the waist and pain from possible pulling on the incision. Several techniques are used to maintain a patent airway. IMPROVING AIRWAY CLEARANCE  Retained secretions are a threat to the thoracotomy patient after surgery. pointing it in the direction toward which the patient is being turned.   Atelectasis. 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. If the secretions are retained. First. Have the patient grasp the side rail with the hand. the operated side should be dependent so that fluid in the pleural space remains below the level of the bronchial stump. In addition. and respiratory failure may result. and the other lung can fully expand. and diminished cough reflex all result in the accumulation of excessive secretions. Trauma to the tracheobronchial tree during surgery.  After a pneumonectomy. in turn. . Secretions continue to be removed by suctioning until the patient can cough up secretions effectively. 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. This. airway obstruction occurs.  The patient’s position is changed from horizontal to semi-upright as soon as possible. because remaining in one position tends to promote the retention of secretions in the dependent portion of the lungs. secretions are suctioned from the tracheobronchial tree before the endotracheal tube is discontinued.  Nasotracheal suctioning may be needed to stimulate a deep cough and aspirate secretions that the patient cannot cough up. causes the air in the alveoli distal to the obstruction to become absorbed and the affected portion of the lung to collapse. diminished  lung ventilation. pneumonia. The procedure for turning the patient is as follows:     Instruct the patient to bend the knees and use the feet to push.

to determine whether there are any changes in breath sounds. and percussion help to loosen and mobilize the secretions so that they can be coughed up or suctioned. vibration. with the feet resting on a chair. ineffective coughing results in exhaustion and retention of secretions .  Chest physiotherapy is the final technique for maintaining a patent airway. and controlled. To minimize incisional pain during coughing. then chest physiotherapy is started immediately (perhaps even before surgery). If a patient is identified as being at high risk for developing postoperative pulmonary complications. If audible crackles are present. anteriorly and posteriorly. the patient is helped to a sitting position on the edge of the bed. Coughing technique is another measure used in maintaining a patent airway. it may be necessary to use chest percussion with the cough routine until the lungs are clear. The patient is encouraged to cough effectively. the nurse should listen to both lungs.  However. Diminished breath sounds may indicate collapsed or hypoventilated alveoli. . deep. To be effective.  After helping the patient to cough. it should be used only after other methods to raise secretions have been unsuccessful .  Aerosol therapy is helpful in humidifying and mobilizing secretions so that they can easily be cleared with coughing.  The techniques of postural drainage. the nurse supports the incision or encourages the patient to do so. the cough must be low-pitched.  The patient should cough at least every hour during the first 24 hours and when necessary thereafter. Because it is difficult to cough in a supine position.

RELIEVING PAIN AND DISCOMFORT  Pain after a thoracotomy may be severe. and mobilization.   Bupivacaine is titrated to relieve postoperative pain while allowing the patient to cooperate in deep breathing. These medications are administered as topical transdermal analgesics that penetrate the skin. coughing. Deep inspiration is very painful after thoracotomy. depending on the type of incision and the patient’s reaction to and ability to cope with pain.  Lidocaine and prilocaine have also been found to be effective when used together.  Immediately after the surgical procedure and before the incision is closed. There is controversy about the effectiveness of injections of local anesthetic for pain relief after thoracotomy surgery. and if it further limits chest excursions so that ventilation becomes ineffective. Research has shown that bupivacaine was no more effective than saline injections in treating postoperative thoracotomy pain.  Lidocaine and prilocaine are local anesthetic agents used to treat pain at the site of the chest tube insertion. it is important to avoid depressing the respiratory system with excessive analgesia: the patient should not be so sedated as to be unable to cough. Sensorcaine). the surgeon may perform a nerve block with a longacting local anesthetic such as bupivacaine (Marcaine. However. Because of the need to maximize patient comfort without depressing the respiratory . Pain can lead to postoperative complications if it reduces the patient’s ability to breathe deeply and cough.

followed by a continuous intravenous infusion. With proper instruction. allows the patient to control the frequency and total dosage. PCA. the earlier the patient moves.drive. the patient is helped to get out of bed. PROMOTING MOBILITY AND SHOULDER EXERCISES  Because large shoulder girdle muscles are transected during a thoracotomy. patient-controlled analgesia (PCA) is often used. As soon as physiologically possible. Although this may be painful initially. the patient begins arm and shoulder exercises to restore movement and prevent painful stiffening of the affected arm and shoulder  MAINTAINING FLUID VOLUME AND NUTRITION Intravenous Therapy  During the surgical procedure or immediately after. In addition to getting out of bed. the arm and shoulder must be mobilized by full range of motion of the shoulder. the sooner the pain will subside. the patient may receive a transfusion of blood products. administered through an intravenous pump or an epidural catheter. usually within 8 to 12 hours. Preset limits on the pump avoid overdosage. Opioid analgesic agents such as morphine are commonly used. these methods are well tolerated and allow earlier mobilization and cooperation with the treatment regimen. .

tenderness. including swelling. The nurse should also monitor the infusion site for signs of infiltration.  Respiratory distress is treated by identifying and eliminating its cause while providing supplemental oxygen. eventually requiring weaning. the nurse monitors the patient at regular intervals for signs of respiratory distress or developing respiratory failure. and pulmonary infection. as well as intakeand output. In addition. and assessment of jugular vein distention. Therefore. often preceded by atelectasis. intubation and mechanical ventilation are necessary. hemorrhage and shock. Small. a period of physiologic adjustment is needed. and poor appetite. atelectasis. sputum production. bronchopleural fistula. 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. dysrhythmias. the patient is progressed toa full diet as soon as possible. and redness. it is especially important that adequate nutrition be provided.   The nurse performs careful respiratory and cardiovascular assessments. Diet  It is not unusual for patients undergoing thoracotomy to have poor nutritional status before surgery because of dyspnea. In the postoperative patient pneumothorax is often accompanied by hemothorax. MONITORING AND MANAGING POTENTIAL COMPLICATIONS  Complications after thoracic surgery are always a possibility and must be identified and managed early.    Dysrhythmias are often related to the effects of hypoxia or the surgical procedure. vital signs. frequent meals are better tolerated and are crucial to the recovery and maintenance of lung function.  A liquid diet is provided as soon as bowel sounds return. If the patient progresses to respiratory failure. They are treated with antiarrhythmic medication and supportive therapy Pulmonary infections or effusion. Failure of the chest drainage system will prevent return of negative pressure in the pleural cavity and result in pneumothorax. Because a reduction in lung capacity often occurs following thoracic surgery. may occur a few days into the postoperative course. . Fluids should be administered at a low hourly rate and titrated (as prescribed) to prevent overloading the vascular system and precipitating pulmonary edema.

as evidenced by normal vital signs and temperature. Maintains adequate fluid intake and maintains nutrition for healing 6. and pink. as evidenced by deep. breathing exercises. crackles.The early symptoms are dyspnea. Adheres to therapeutic program and home care 8. increased respiratory rate. demonstrates arm and shoulder exercises to relieve stiffening 5. Pulmonary edema from overinfusion of intravenous fluids is a significant danger. and increasing respiratory distress. Hemorrhage and shock are managed by treating the underlying cause. and use of incentive spirometry 2. The nurse maintains the chest drainage system and monitors the patient for signs and symptoms of pneumothorax: increasing shortness of breath. as reflected in arterial blood gas measurements. Evaluation 1. improved arterial blood gas measurements. Demonstrates improved gas exchange. clear lung sounds. Shows improved airway clearance. Exhibits less anxiety by using appropriate coping skills. tachycardia. and demonstrates a basic understanding of technology used in care 7. and adequate respiratory function . frothy sputum. it is treated with closed chest drainage. and possibly talc pleurodesis . Depending on its severity.    Bronchopleural fistula is a serious but rare complication preventing the return of negative intrathoracic pressure and lung reexpansion. bubbling sounds in the chest. tachycardia. controlled coughing and clear breath sounds or decreased presence of adventitious sounds 3. mechanical ventilation. This constitutes an emergency and must be reported and treated immediately. Has decreased pain and discomfort by splinting incision during coughing and increasing activity level 4. Is free of complications. Shows improved mobility of shoulder and arm. whether by reoperation or by administration of blood products or fluids.

and connected to a drainage apparatus to remove the residual air and fluid from the pleural or mediastinal space. Whenever the chest is opened. This assists in the reexpansion of remaining lung tissue. Therefore. sutured to the skin. during or immediately after thoracic surgery. or other substances in the thoracic cavity can compromise cardiopulmonary function and cause collapse of the lung. and/or help regain negative pressure. The collection of air.CHEST DRAINAGE Chest drainage is the insertion of a tube into the pleural space to evacuate air or fluid. there is loss of negative pressure in the pleural space. . chest tubes/catheters are positioned strategically in the pleural space. which can result in collapse of P. fluid. TABLE 10-3 Indications for Chest Tube Use INDICATION ACCUMULATING SUBSTANCE Pneumothorax Air Hemothorax Blood Pleural effusionFluid Chylothorax Empyema Lymphatic fluid Pus It is necessary to keep the pleural space evacuated postoperatively and to maintain negative pressure within this potential space.273 the lung.

and (3) the suction control chamber. For hemothorax (fluid)—sixth or seventh lateral interspace in the midaxillary line. on the mechanics of respiration and. if desired. (A) Strategic placement of a chest catheter in the pleural space. (C) A Pleur-evac operating system: (1) the collection chamber.  P. which permits drainage of air and fluid from the pleural space. The Pleurevac is a single unit with all three bottles identified as chambers. . Chest drainage can also be used to treat spontaneous pneumothorax or hemothorax/pneumothorax caused by trauma (see Table 10-3).FIGURE 10-7 Chest drainage systems. but does not allow air to move back into the chest. Functionally. on suction by the addition of controlled vacuum. Sites for chest tube placement are:  For pneumothorax (air)—second or third interspace along midclavicular or anterior axillary line.274 One-Bottle Water-Seal System  The end of the collecting tube is covered by a layer of water. (2) the water-seal chamber. (B) Three types of mechanical drainage systems. drainage depends on gravity.

except for the addition of a third bottle to control the amount of suction applied. it goes up when the patient inhales and down when the patient exhales. plus a fluidcollection bottle. Three-Bottle Water-Seal System  The three-bottle system is similar in all respects to the two-bottle system. the connection is made at the vent stem of the underwater-seal bottle. Two-Bottle Water-Seal System  The two-bottle system consists of the same water-seal chamber.  In the three-bottle system (as in the other two systems).  Effective drainage depends on gravity or on the amount of suction added to the system. When vacuum (suction) is added to the system from a vacuum source.  At the end of the drainage tube. Recent research has shown that suction may actually prolong an air leak by pulling air through the opening that would otherwise heal on its own. The water level fluctuates as the patient breathes.  The amount of suction is determined by the depth to which the tip of the venting glass tube is submerged in the water and level of water in the suction chamber or setting of a dial—depending on the system in use.  The amount of suction applied to the system is regulated by the wall gauge. drainage depends on gravity or the amount of suction applied. the underwater-seal system is not affected by the volume of the drainage. . Bubbling can mean either persistent leakage of air from the lung or other tissues or a leak in the system. bubbling may or may not be visible. There is a vent for the escape of any air that may be leaking from the lung. The tube from the patient extends approximately 1 inch (2. such as wall suction. except that when pleural fluid drains. The mechanical suction motor or wall suction creates and maintains a negative pressure throughout the entire closed drainage system.5 cm) below the level of the water in the container.  Drainage is similar to that of a single unit.

 Maintain integrity of insertion site. observing for drainage. Nursing and Patient Care Considerations   Assist with chest tube insertion (see Procedure Guidelines 10-23. no bubbling occurs. New chest tubes contain a nonthrombogenic coating.  Second chamber acts as the water-seal chamber with 2 cm of water acting as a oneway valve. This can be done by detaching the tubing from the suction port to provide a vent. The principles remain the same for the commercially available products as they do for the glass bottle system. The manometer bottle regulates the amount of negative pressure transmitted back to the patient from the suction/vacuum device. In a dry suction control system no water is used. This practice has been found to cause significant increases in intrapleural pressures and damage to the pleural tissue. the three bottles are contained in one unit and identified as “chambers” (see Figure 10-7C).  In the commercially available systems. pages 277 to 279). If patient is in pain. This is accomplished through the use of a water or dry system that downregulates the suction/vacuum applied.  First chamber acts as the collection chamber and receives fluid and air from the chest cavity through the collecting tube attached to the chest tube. allowing drainage out but preventing backflow of air or fluid into the patient. Assess patient's pain at insertion site and give medication appropriately. NURSING ALERT When the motor or the wall vacuum is turned off. chest excursion and lung inflation will be hampered. and a restrictive device or regulator is used to dial the desired negative pressure (up to 40 cm suction).  Third chamber applies controlled suction. impaired healing. The amount of suction is regulated by the volume of water (usually 20 cm) in the chamber not the amount of suction or bubbling with a water system.  Maintain chest tubes to provide drainage and enhance lung reinflation (see Procedure Guidelines 10-24. and subcutaneous emphysema. redness. the drainage system should be open to the atmosphere so that intrapleural air can escape from the system. thus decreasing . pages 275 to 277). NURSING ALERT Milking and stripping of chest tubes to maintain patency is no longer recommended.

Clamp only momentarily to change the drainage system. gown. P. Check for leaks to assess the patient's tolerance for removal of the chest tube (perhaps up to 24 hours). sterile drape. vacuum pump (if required)  Sterile water PROCEDURE P. and gloves Two large clamps Suture material Local anesthetic Chest tube (appropriate size). apply a gentle squeezeand-release motion to small segments of the chest tube between your fingers. collection bottles or commercial system.276 . connector Cap.275 PROCEDURE GUIDELINES 10-23 Assisting with Chest Tube Insertion EQUIPMENT             Tube thoracostomy tray Syringes Needles/trocar Basins/skin germicide Sponges Scalpel. gloves. NURSING ALERT Clamping of chest tubes is no longer recommended due to the increased danger of tension pneumothorax from rapid accumulation of air in the pleural space. mask. drapes Chest drainage system-connecting tubes and tubing. If it is necessary to help the drainage move through the tubing.the potential for clotting.

Using universal precautions. presence of respiratory distress. and draped. Use of universal precautions aspetic technique.To puncture the pleura and determine the presence of air or blood in the pleural cavity. 3. Other means of2. Performance phase Needle or intracath technique 1. Patient may muscles. 3.The IntraCath catheter is inserted through the needle into the pleural space. the patient's mobility. and the presence of coexisting conditions.Nursing Action Preparatory phase 1.Verify right patient and right location/procedure.Premedicate if indicated. 5. 2.Obtain a chest X-ray. feel pressure while tube is inserted. 6. during infiltration anesthesia. substance to be drained.An exploratory needle is inserted. 8. 4. and parietal pleura. anesthetized. hemothorax. A larger needle is used to and aseptic technique prevent infiltrate the subcutaneous tissue.Assemble drainage system.The area is anesthetized to make tube prepared. the skin is1. The needle is .Reassure the patient and explain the steps of7. using local insertion and manipulation relatively anesthetic with a short 25G needle and using painless.The patient can cope by remaining the procedure.The tube insertion site depends on the block or according to physician preference. 7. or fluoroscopic localization.Assess patient for pneumothorax. 2. Tell the patient to expect a immobile and doing relaxed breathing needle prick and a sensation of slight pressure during tube insertion. intercostal contamination of chest tube.Obtain informed consent.To evaluate extent of lung collapse or localization of pleural fluid include ultrasound amount of bleeding in pleural space.Position the patient as for an intercostal nerve8. Rationale 2.

may be4.removed. the2. Blunt dissection (with a hemostat) through the muscle planes in the interspace to the parietal pleura is performed. Hemostat technique using a large-bore chest tube Using universal precautions and aseptic technique. The chest tube clamp is removed once the chest tube is attached to the system.Using universal precautions. aseptic technique.The trocar is directed into the pleural space. an incision is made through the penetration of the intercostal muscles .There is a trocar catheter available cannula is removed.To prevent it from being dislodged out sutured to the chest wall and covered with a of the chest during patient movement or dressing. 1.The catheter is attached to a connector/tubing5. 4.The skin incision is usually made one and after skin preparation and anesthetic interspace below proposed site of infiltration. Trocar technique for chest tube insertion Using universal precautions and aseptic technique.To admit the diameter of the chest tube. and a chest tube is inserted equipped with an indwelling pointed rod into the pleural space and connected to a for ease of insertion. drainage system.1. seal or commercial system) and all connections taped.disconnection. and the catheter is pushed several centimeters into the pleural space.1.A small incision is made over the prepared. a large bore chest tube is used to drain blood or thick effusions from the pleural space. a trocar catheter is used for the insertion of a large-bore tube for removal of a moderate to large amount of air leak or for the evacuation of serous effusion. lung expansion.All connections are taped to prevent and attached to a drainage system (underwater. 2. 5.The catheter is taped to the skin. 1. anesthetized site.

Prevents dislodgment.The clamp is withdrawn and the chest tube is5. the blood is available for autotransfusion. Chest tubes open to air at the time of insertion will result in a pneumothorax. once connected to the drainage system. 5. 2. vasovagal response may occur with resulting hypotension. 3.Assess for bleeding.Catheter is attached to a connector/tube and to7.Secure a follow-up chest X-ray.1. All connections are taped.The tube is sutured in place and covered with a6.Clamps are removed from the chest tube the system. 3. cavity and the tissue is spread with the clamp. 3. infection.) tube into a bottle containing sterile normal saline.If a hemothorax is draining through a Observe for fluctuation in the tube on thoracostomy respiration.The tract is explored with an examining finger. 7.The tube is held by the hemostat and directed through the opening up over the ribs and into the pleural cavity. a and fluid around the tube. Follow-up phase 1. the proximal end for drainage of air or blood. (See page 274. and pleura. 2.A curved hemostat is inserted into the pleural2.skin and subcutaneous tissue.To make a tissue tract for the chest tube. leakage of air3. 2. Chest tube (tube thoracostomy) inserted via hemostat technique.The chest tube has multiple openings at connected to a chest drainage system.Observe the drainage system for blood and air. 6.To confirm correct chest tube placement and reexpansion of the lung.With too rapid removal of fluid.Digital examination helps confirm the presence of the tract and penetration of the pleural cavity. sterile dressing. Continued use of petroleum gauzes or ointment can irritate . 4.

Water-seal drainage provides for the escape space (the patient) to the of air and fluid into a drainage bottle. 2. The tube should be as straight as possible and coiled below level of chest without dependent loops. and to prevent backflow of drainage or air. Add sterile water to water-seal chambers as needed. patency of the tubes. Check the tube connections periodically. Vigorous bubbling is not indicated.Maintain integrity of the chest drainage system.2. Keep drainage system below level of chest. Adjust suction until bubbling is seen or set gauge as directed. sterile water) PROCEDURE P. Attach the chest tube from the pleural1. tight fit. collecting/drainage tubing and water-seal drainage system.the skin. a.277 PROCEDURE GUIDELINES 10-24 Managing the Patient with Water-Seal Chest Drainage EQUIPMENT     Closed chest drainage system Holder for drainage system (if needed) connector for emergency use Vacuum motor Sterile connector for emergency use (ie. 4. P. . The water acts as a seal and keeps the air from being drawn back into the pleural space.278 Nursing Action Performance phase Rationale 1. 4. Tube connections are checked to ensure Tape if necessary.Chest tube malposition is the most common complication.

Removal of 1. More frequent monitoring is required at the initiation of therapy and when warranted by patient's condition.200 mL of pleural once per shift. usually progressively after the first 24 hours. Surgical intervention may be necessary. The patient's position should be changed . pressure in the chest. of the tubing will decrease the negative pressure applied to the catheter. This marking will show the amount of fluid the outside of the drainage system. fluid at one time can result in hypotension and rebound pleural effusion. Grossly bloody drainage will appear in the bottle in the immediate postoperative period and. It serves as a basis for blood replacement. Do not let the patient lie on collecting/tubing drainage. Fluid collecting in the dependent segment interfere with the movements of the patient. Mark the original fluid level with tape on3. or pressure on the drainage tubing can produce back pressure. Report to physician immediately. or symptoms of hemorrhage. subcutaneous emphysema. thus possibly forcing drainage back into the pleural space or impeding drainage from the pleural space. cardiac tamponade. looping. incisional and pain. including tension pneumothorax. mediastinal shift. shallow breathing. Assess patient's clinical status at least4. if the fluid is blood. Make sure the tubing does not loop or5. if excessive. Encourage the patient to assume a6. cyanosis. hemorrhage. 6. 5. Observe and report immediately signs of rapid.b. Many clinical conditions may cause these signs and symptoms. 3. Kinking. Drainage may necessitate declines reoperation. loss and how fast fluid is collecting in the drainage bottle. pulmonary severe embolus. 4. Mark hourly and daily increments (date and time) at the drainage level.000 to 1.

adequate pain medication is indicated. 10. shoulder and assists in lessening postoperative pain and discomfort. and is a gauge of intrapleural pressure. Exercise helps to avoid ankylosis of the side through ROM exercises several times daily.Encourage the patient to breathe deeply11. 11.Leaking and trapping of air in the pleural system as indicated by constant bubbling in the water-seal bottle. provides a valuable indication of the patency of the drainage system. b. the intrapleural pressure. Encourage good body alignment.Watch for leaks of air in the drainage10. 9. Pain medication may be indicated to enhance comfort and deep breathing. a. 7. shows that there is effective communication between the pleural space and the drainage system.position of comfort. If there are signs of incisional pain. . a dependent loop develops. Proper positioning helps breathing and promotes better air exchange. Encourage the patient to change position frequently. space can result in tension pneumothorax. place a rolled towel under the tubing to protect it from the weight of the patient's body. Report excessive bubbling in the waterseal change immediately. 8. which allows emptying of any accumulation in the pleural space and removes secretions from the tracheobronchial tree so the lung expands. Fluctuations of fluid in the tubing will stop when: a. the lung has reexpanded. the tubing is obstructed by blood clots or fibrin. Make sure there is fluctuation (“tidaling”)8. frequently to promote drainage and body kept in good alignment to prevent postural deformity and contractures.Deep breathing and coughing help to raise and cough at frequent intervals. Some pain medication may be necessary. When the patient is in a lateral position. c. Put the arm and shoulder of the affected7. Fluctuation of the water level in the tube of the fluid level in the drainage system.

and reattach to the drainage system. removed. no residual air or fluid in chest X-ray. c.The drainage apparatus must be kept at a another area. Instruct the patient to perform a gentle Valsalva quietly. Follow-up phase 1.12. a small bandage is applied and made airtight with petroleum gauze covered by a 4″ × 4″ gauze and thoroughly covered and sealed with tape. Administer pain medication 30 minutes before removal of chest tube.When assisting with removal of the tube: 14. level lower than the patient's chest to prevent backflow of fluid into the pleural space. cut off the contaminated tips of the chest tube and tubing. Signs of reinflation include little or no drainage.If the patient has to be transported to12.If the tube becomes disconnected. d. Evidence Base could have reformation of pneumothorax after removal as well as infection at injection site. avoid a large sudden inspiratory effort. 14.The chest tube is removed as directed when a. Patient signs and symptoms of decompensation. b. no fluctuations in fluid in water-seal chamber. The chest tube is clamped and maneuver or to breathe the lung is reexpanded (usually 24 hours to several days). During the tube removal. place the drainage system below the chest level (as close to the floor as possible). absence of air leak. Otherwise. which may produce a pneumothorax. Monitor the patient's pulmonary status for1. do not clamp the chest tube during transport. insert a sterile connector in the chest tube and tubing. . Observe insertion site for signs of infection and changes in drainage. no noted respiratory distress. Simultaneously. 13.

cardiac.Coughlin. P. A. (2007). thoracic. M. (2006). home One-way flutter valve Evacuates air from the pleural space for trauma or blood Small size chest tube or pigtailPneumothorax catheter (smaller than standard 14F) Chronic drainage of fluid Chronic conditions Can be used for pleurodesis . esophageal surgery) Pneumothorax Hemothorax Pleural effusion Pleurodesis Smaller Portable CDU Drainage without use of suction For ambulatory patients Dry seal system that prevents airHome care leaks No lung reexpansion occurs 500 ml maximum drainage Emptied when used in home Indwelling Pleural Catheter Can be irrigated if occluded by healthNot care provider Less traumatic Heimlich Valve Removes air as patient exhalesUsed for emergency transport. C. Nursing 36(3):36-41. Go with the flow of chest tube therapy.279 TABLE 10-4 Chest Drainage Units (CDU) TYPES Standard CDU DESCRIPTION INDICATIONS FOR USE Drainage of pleural cavity for air orFollowing surgery that impacts on the any type of fluid with or without thecontinuity of suction of the thoracic use Up to 2. American Journal of Critical Care 16(6):609-612.000 ml capacity Replaced when full cavity (eg. Halm. To strip or not to strip? Physiological effects of chest tube manipulation. and Parchinsky..

and elevated BP. tachycardia. Cardiac dysrhythmias (usually occurring third to fourth postoperative day). atelectasis—monitor for fever. MI or heart failure. and hypotension. o o  Position with the operative side down.  A thoracotomy is a surgical procedure allowing the surgeon to access your lungs . bronchial stump leak.Valve opens when pleural spacecare.   Bronchopleural fistula from disruption of a bronchial suture or staple. dyspnea. Postoperative bleeding—monitor for restlessness. tachycardia. o Observe for sudden onset of respiratory distress or cough productive of serosanguineous fluid.  This information is a better intended to and provide understanding appreciation by our patients and their families of the events surrounding operations on the chest and lung. We hope you find it interesting and informative while helping you understand the importance you play in maintaining your good health. chest pain. Prepare for immediate chest tube insertion and/or surgical intervention. Pneumonia. and long-term care units pressure is greater than atmospheric pressure and closes when the reverse occurs COMPLICATIONS   Hypoxia—assess for restlessness. pallor. anxiety. tachypnea. changes in lung sounds on auscultation.

. The breathing tests you complete prior to surgery help ensure you will be able to tolerate a pulmonary resection. depending on the location of your lesion. the amount of lung tissue removed is contingent on the type. An incision will be made on the side of your chest.prior to removal of all or part of your lung (pulmonary resection). running behind your shoulder blade. Once your lung is exposed. size and location of the lesion.

and lower lobe. . middle. It is used most often if the lesion proves to be non-cancerous or if the lesion is small and peripherally located. Wedge Resection/Segmentectomy With this procedure. Often times Lobectomy an entire lobe of a lung must be removed. B. only a small part of the lung is removed. The left lung is divided into an upper and lower lobe.A. The right lung has an upper.

C. Pneumonectomy If there is concern that cancer may have spread throughout the left or right lung. the whole lung may need to be removed. or the lesion is located centrally.  .