Acute Care Flashcards
Thoracic Surgery
Performed & Types of Sx & Types of Incisions
Performed in order to remove an ireversible damaged area of the lungs
Types of Sx:
1. Pneumonectomy: Removal of a lung
2. Lobectomoy: Removal of a lobe of the lung
3. Segmental Resection: Removal of a segment of a lobe
4. Wedge Resection: Removal of a portion of a lung (not limited to an anatomical region)
5. Lung volume reduction Sx & Bullectomy: Removal of large emphysematous tissue
Bullectomy: pocket of air trapping - remove b/c it has the potential to rupture - can lead to a pneumothorax (COPD)
ALSO, area is occuping space of what can be good ventilated area > lung can expand optimally w/ removal of bullae > less risk of atelectasis b/c lung can fully expand
Types of Incisions:
1. Median Sternotomy - cut through the sternum
2. Thoracotomy - cut through the intercostal space
Thoracotomy
Characteristics (4) + Chest Tube Considerations
Commonly performed for lung resections or to remove an irreversibly damaged area of the lung
- Posterolateral thoracotomy is the most common procedure
- Incision follows the path of the 4th intercostal space (~nipple height)
- Muscles incised:
1. Latissimus dorsi
2. SA
3. External intercostals
4. Internal intercostals
5. Mid trapezius
6. Rhomboids
Chest Tubes - are placed to evacuate air & fluid from pleural space
Positioning:
- Lying on side of chest tube is NOT contraindicated, as long as the tube is kinked or pulled, but is often avoided by patients
- It is important to change positions as with all surgeries, in order to avoid pressure ulcers
- ** In Pneumonectomy, avoid lying with surgical side up until further notice from the surgeon
Potential to have saline (harden) leak from the surgicial tie into the remaining lung & hardened > leading to atelectasis & other complications
Thoracic Sx: Pre & Post-Op Education
(9)
- Deep breathing - prevent atelectasis > lung collapse
Incentive spirometer for visual representation - Supportive coughing manuevers (splinting)
Less vibrations of coughing = more tolerable (Regression = huff) - Lines - education; may attempt to remove
- Scar management (preventing infection) - keep it clean, mobilize?
- Relaxation
- Bed mobility
- Positioning - frequent changes to prevent skin breakdown
- Transfers - contraindications/safety
- Early mobilization
Potential Complications of Pulmonary Surgery
(6)
- Aspiration
- INC pain
- Phrenic nerve impairment
Diaphragm on affected side will elevate & compress the lung tissue - Atelectasis
Not taking DB, secretion retention (non-effective cough) - Ulcers - pressure sore
- DVT
Deep Vein Thrombosis
Characteristics (5)
A thrombus (blood clot) that forms in a deep vein in the body
- DVT in legs is most common
- Thrombus may partially or completely block flood flow
- Thrombus may potentially dislodge & travel to the lungs (PE), heart, or brain which may be fatal
- Venous stasis d/t immobility post-op can INC risk of DVT, along with hypercoagulation & changes to blood vessel wall
DVT: S/S
(6)
- Leg pain - suspect DVT, espeically post-op
- Tenderness
- Ankle edema
- Calf swelling
- Dilated veins
- Positive Homan’s Sign
- Take ankle & put it into DF to see if it reproduces/provokes pain
- Poor test: 50% specificity BUT know for the test
DVT: Prevention
(4)
- Early mobilization
- Ankle Pumps
- Anti-coagulants
- Graduated compression stockings - PREVENTION NOT Tx
What do you do if you suspect your patient has a DVT?
(3)
- Stop treatment which may be contraindicated until further notice (ie stop exercises - walking)
- Alert the surgeon, doctor, nurse
Doppler ultrasound/ test is a noninvasive test that can be used to estimate the blood flow through your blood vessels by bouncing high-frequency sound waves (ultrasound) off circulating red blood cells - Document your findings (2nd priority)
Cardiovascular Sx
Characteristics & CV Sx (2)
A specialized thoracic Sx involving the heart & great vessels
- Patient is placed on an extracorpal membrane oxygenator (bypass machine) d/t interrupted blood flow during procedure
*Takes over function of the lungs & the heart - oxygenate the blood & pump it out to the body
Common CV Sx:
Heart Surgery
1. CABG (Coronary Artery Bypass Graft)
Saphenous Vein Graft
- Mobility & leg exercises restricted until doctor’s notice
- Aware that mobility & leg exercises may be delayed d/t healing
Internal Thoracic Graft / Internal Mammillary Artery (supplies ANT chest wall & breast tissue)
Radial Artery Gradt
2. Valve Replacements (aortic & mitral valve replacement)
3. Heart Transplant
** Heart becomes deinnervated > lacks PNS/SNS input > resting HR ~90-100 bpm
Will NOT respond to exercise > will be delayed & not INC as much - may INC a little bit d/t epipherine (hormonal input)
** Do not want to use HR as an intensity guage instead use RPE
CAN EXERCISE
Surgery on Great Vessels:
1. Aortic Aneurysm repair
2. Abdominal Aortic Aneurysm (AAA) repair (laparotomy)
Sternal Precautions
Timeline & Restrictions (6)
Timeline: Sternum takes 6-8 weeks to heal
Limit UE exercise while sternal incisions are healing
- No pushing
Do not push through arms when transferring, lying to sit, or sit to stand
Engaging pec muscles - which attach to sternum - No pulling
ie. opening a heavy door - No lifting one arm above 90 degrees
- No hand behind back
ie. tucking in shirt, toliet hygiene, etc - No driving for 4 weeks
Driving (steering a wheel) requires horizontal adduction = engagement of pecs - No lifting >10lbs (some sources say 5 lbs) for 6 weeks
Benefits of Early Mobilization
8 + 6
- Improves breathing
- Chest mobility
- Secretion clearance
- Assists GI function/ bowel motility
- Improves conditioning & activity tolerance
- Allows increased independence
- Improves mood
8 Prevents:
- Aspiration
- Thrombus formation
- Muscle atrophy
- Contractures
- Pressure sores
- Neuropathy
