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2017 PNLE REVIEW MATERIALS FOR SALE

Sunday, July 1, 2012

NCP: Thoracotomy



Deficient knowledge (treatment regimen) related to lack of exposure to information about thoracotomy


Expected Outcome
The patient will explain the purpose and goal of thoracotomy and describe the general procedure and will verbalize or demonstrate understanding of preoperative and postoperative thoracotomy care.


Intervention type
Intervention
Rationale
Independent
Provide information, reinforcing as necessary, and   document teaching regarding the purpose and goal of the surgical procedure.
A general understanding of the purpose and goal of a thoracotomy and what the procedure will be like will help orient the patient to upcoming nursing and medical care.
Independent
Provide information, reinforcing as necessary, and   document teaching regarding expected location for recovery in the immediate postoperative period.
Telling the patient where recovery will take place helps reduce postoperative disorientation.
Independent
Provide information, reinforcing as necessary, and   document teaching regarding invasive lines and tubes that might be present postoperatively, including I.V. lines, oxygen administration devices, chest tubes, nasogastric tube, and indwelling urinary catheter.
Providing information about postoperative therapy may allay fears and anxiety about the unknown and help the patient cooperate.
Independent
Provide information, reinforcing as necessary, and   document teaching regarding endotracheal intubation and mechanical ventilation, if appropriate.
Explaining intubation and mechanical ventilation, including the temporary loss of speech, may allay anxiety about this treatment.
Independent
Provide information, reinforcing as necessary, and   document teaching regarding deep breathing, coughing, and using an incentive spirometer, if appropriate.
The patient's postoperative efforts to reexpand the lungs,   remove secretions, and participate in respiratory function measurements may be more successful if practiced preoperatively, when the patient is under less stress and is free from pain.
Independent
Provide information, reinforcing as necessary, and   document teaching regarding postoperative pain control, including using analgesic medications and splinting the incision with a pillow during deep breathing and coughing.
The patient may be reassured to learn that pain relief is an important part of therapy. Explanations about the timely use of pain medication and pillow splinting may increase the patient's willingness to initiate and perform coughing and deep-breathing exercises.

[Additional individualized interventions]




Impaired gas exchange related to hypoventilation


Expected Outcome
The patient will maintain adequate gas exchange and normal ABG and oximetry levels.

Intervention type
Intervention
Rationale
Independent
Assess respiratory status as needed and according to unit   protocol.
Frequent assessment of the cardiopulmonary system may   reveal problems and permit timely interventions.
Independent
Document and notify the practitioner of abnormal findings.
Early notification can facilitate treatment changes.
Independent
Monitor ABG levels for changes in respiratory status and notify the practitioner if changes occur.
ABG levels reflect general oxygenation levels. Low partial pressure of arterial oxygen levels may indicate a need for increased oxygen therapy and more vigorous pulmonary hygiene.
Collaborative
Monitor and document arterial oxygen levels using pulse oximetry, as ordered.
Oximetry provides a noninvasive way to monitor arterial oxygen levels.
Collaborative
Provide humidified oxygen. as ordered.
Oxygen therapy may be required until the lungs are fully reexpanded and the breathing pattern and airway clearance are more effective.
Collaborative
Medicate for pain every 1 to 4 hours and as needed, as ordered.
Pain relief promotes effective deep breathing and coughing.
Independent
Encourage deep breathing and coughing two to three times every hour while awake.
Regular deep breathing and coughing promotes reexpansion of the lungs, mobilizes secretions, and prevents atelectasis.
Independent
Instruct the patient how to support the incision with his hands or a small, hard pillow, as needed, during deep-breathing and coughing   efforts.
Support over the incision may decrease pain during deep breathing and coughing.
Collaborative
Promote and document incentive spirometer use, as ordered, several times per hour while the patient is awake.
Spirometers encourage deep inspiratory efforts, which are   effective in reexpanding alveoli.
Independent
Provide adequate hydration.
Adequate hydration promotes liquid, easily removed lung secretions.

[Additional individualized interventions]



Ineffective breathing pattern related to pneumothorax, hemothorax, or mediastinal shift secondary to malfunction or removal of chest drainage system



Expected Outcome
The patient will have a properly functioning chest drainage system, will be free from air and fluid in the pleural space, will display no dyspnea, and will have normal respiratory status.

Intervention type
Intervention
Rationale
Independent
Maintain an intact water‑seal drainage system. Ensure that   the chest drainage system is positioned securely below the patient's chest level, that the tubing is free from kinks and clots, and suction is set correctly.
Positioning the chest tube below chest level allows gravity to assist in drainage of the chest and prevents backflow. Keeping the tube clear ensures patency. The correct suction level also aids in drainage.
Independent
Observe for and document fluctuation of water level in the water‑seal chamber during respirations.
Tidaling indicates a functioning, airtight system between the pleura and the drainage receptacle. Absence of fluctuation may indicate a   blocked chest tube or complete lung expansion.
Independent
Observe the water‑seal chamber for intermittent bubbling during respiration. Document the amount of bubbling and where in the respiratory cycle it occurs.
Intermittent bubbling represents drainage of air from within the pleural spaces. Bubbling occurs normally during expiration with spontaneous ventilation or during inspiration with mechanical ventilation.
Independent
Monitor the amount, color, and consistency of chest tube drainage. Notify the practitioner if large amounts of drainage occur (more than 200 ml/hour for 3 hours).
Large amounts of drainage may indicate bleeding and require immediate intervention. Absence of drainage, particularly in the immediate postoperative period, may indicate a plugged chest tube, which could cause a dangerous increase in intrapleural pressure.
Collaborative
Assist with removal of chest tubes 3 to 4 days after surgery and apply a sterile occlusive dressing.
Chest tubes are removed when the lungs have reexpanded.
A sterile occlusive dressing may prevent infection and air   leaks into the pleural space.
Independent
After chest tube removal, assess the patient for signs and symptoms of respiratory distress.
Rarely, the patient may develop such complications as pneumothorax, hemothorax, or mediastinal shift, which may compromise the respiratory and cardiac systems. Careful assessment allows early identification and intervention.
Collaborative
If necessary, assist the physician with reinsertion of the chest tubes or thoracentesis.
Rarely, the patient may accumulate fluid or air and may require reinsertion of chest tubes or thoracentesis.

[Additional individualized interventions]



Risk for infection related to surgical incision and endotracheal intubation


Expected Outcome
The patient will have a clean, dry, and healing wound; will display a normal white blood cell count and sedimentation rate; and will have clear breath sounds, normal fremitus, and normal resonance to percussion, as appropriate to type of surgery.


Intervention type
Intervention
Rationale
Independent
Monitor for and document signs of pneumonia, including fever, tachypnea, bronchial or bronchovesicular breath sounds in the periphery, increased vocal fremitus, increased dullness, and dyspnea. Notify the practitioner if any of these signs occur.
Invasive chest surgery and endotracheal intubation place   the patient at high risk for pneumonia. Treatment may require aggressive pulmonary hygiene, antibiotics, and positive‑pressure breathing treatments.
Independent
Assess for signs and symptoms of wound infection.
Regular assessment of the incision may provide early warning of infection.
Collaborative
Monitor culture and sensitivity test results for wound drainage, as ordered.
Culture and sensitivity tests help identify the infective organism and the most effective antibiotic treatment.
Independent
Reinforce or change dressings as needed, using sterile technique.
The dressing is usually reinforced, not changed, during the first 1 to 2 days after surgery to prevent exposure to microorganisms.

[Additional individualized interventions]


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