Thoracic

Patient Care. Prior to surgery the care of the patient will depend on the specific operation to be done and the particular disorder requiring surgery. In general, the patient should be given an explanation of the operative procedure anticipated and the type of equipment that will be used in the postoperative period. The patient will be taught the proper method of coughing to remove secretions accumulated in the lungs. Although coughing may be painful in the immediate postoperative period and may require analgesic medication to relieve the discomfort, if the patient understands the need for coughing up the secretions he or she will be more cooperative. Special exercises may be given to preserve muscular action of the shoulder on the affected side and to maintain proper alignment of the upper portion of his or her body and arm. Usually the physical therapist supervises these exercises, but the nursing staff must coordinate them with other aspects of patient care.



Narcotics are rarely given before thoracic surgery because they can depress respiration. Usually the preoperative medication is atropine in combination with a barbiturate.

The development of intensive care units has sharply improved the care of the post-thoracotomy patient. The availability of monitors, ventilators, and special assist devices has increased not only the safety of the operation but also the comfort of the patient. Many patients return from the operating room with endotracheal tubes still in place, ventilated by machines, and monitored with such special equipment as Swan-Ganz catheters for observation of cardiac output, oxygenation, and level of hydration.

During the postoperative period, alteration in respiratory status is a major potential problem for patients having thoracic surgery. Impaired gas exchange can result from atelectasis, pneumothorax, mediastinal shift, bronchopulmonary fistula, pneumonia, pleural effusion, pulmonary edema, narcotics, or abdominal distention. To identify any change in respiratory status, the patient's arterial blood gases are serially monitored, breath sounds are auscultated, and the rate and character of respirations are assessed. To facilitate removal of obstructive mucus and other secretions in the air passages the patient is encouraged to deep breathe and cough every one to two hours. Chest physical therapy may be ordered to help mobilize the secretions so that they are more easily coughed up. The amount and character of sputum is noted and recorded. If necessary, nasotracheal suctioning may be done to help clear the air passages. Oxygen may be administered to prevent anoxia.

The patient is also periodically assessed for pain, abdominal distention, and alteration in cardiac function related to decreased cardiac output, arrhythmias, or cardiac tamponade. If the pericardial sac becomes filled with fluid and produces an acute cardiac tamponade, an emergency pericardiocentesis may be necessary.

Almost all patients having thoracic surgery will have chest tubes. (One exception is the patient who has had a lung removed. In this case fluid is deliberately allowed to accumulate in the pleural space to prevent mediastinal shift.) Chest tubes are attached to closed drainage systems to avoid pneumothorax and allow for drainage of the pleural space and gradual reexpansion of the lung. (See chest tube for care.)

As the operative site heals and the lung expands, the chest tubes can be safely removed. After their removal an airtight bandage is applied to the area. As a precaution against leakage of air into the chest cavity, the physician may apply petrolatum to the edges of the wound before applying the dressing.