2261 midterm 1: study guide ORTHOPEDIC SURGERY stages of bone healing stage 1: inflammation (72hrs – 3 weeks) stage 2 reparative primary soft callus collagen (2-3 weeks); callus mineralization (4-16 weeks) stage 3: remodelling (months to years) fracture: clinical manifestations swelling pain and tenderness muscle spasm deformity skin discolouration loss of function crepitation (grating) – air into joint or injury that causes a sound numbness/tingling arthritic clients may experience similar symptoms treatment immobilization half splints, cast, traction closed reduction non-surgical realignment of the bone by traction to restore position, length, and alignment under anaesthesia o the injury is them immobilized by cast, splint, traction, brace, or external fixation open reduction (ORIF) surgically realigned and supported with screws, plates, wires, pins, and rods external fixation used for extensive trauma when tissue trauma or wound is present (allows access to the surface) fractured hip a) femoral neck (subcapital and transcervical) b) intertrochanteric c) subtrochanteric d) pathological hip fracture risk factors age: decreasing bone density, decreasing vision, decreasing balance, slower reaction time, weaker muscles chronic medical conditions: o Osteoporosis, osteoarthritis o Rheumatoid arthritis o Hyperthyroidism - bone fragility o Parkinson’s – falls risk gender: 80% female physical inactivity and nutrition are linked to bone fragility alcohol and tobacco interfere with bone building medications: corticosteroids clinical manifestations of hip fracture external rotation, shortening of extremity, pain, muscle spasm, inability to use limb or walk displaced femoral neck fractures can cause serious interruption in blood supply and lead to avascular necrosis hip surgeries 1. femoral neck fracture – metal screws 2. hemiarthroplasty (partial hip replacement) – remove head of femur, replace with prosthesis 3. total hip replacement – hip socket, head and neck of femur are replaced 4. intertrochanteric fracture – metal screws and plates arthroplasty arthroplasty is the reconstruction or replacement of a joint to relieve pain, improve mobility, or correct deformity hemi-arthroplasty is the reconstruction of replacement of part of a joint total joint replacement generally lasts 10-15 years total hip arthroplasty (THA) Is the reconstruction or replacement of a joint to relieve pain, improve ROM, and correct deformity in patient with OA or RA. Lasts usually 10-15 years Cemented THA – attached to existing bone with glue, recommended for older, less active adults as it lessens the lifetime of the prosthesis. Will require revisions due to wear & tear Uncemented THA – attached using porous coating that allows bone to adhere to artificial joint, - provide longer implant stability as it facilitates biological in growth of new bone tissue into the porous surface of the prosthesis, used for younger patients THA hip precautions keep a pillow between knees when in bed hips cannot be lower than knees o use a raised toilet seat and chair risers to avoid 90° limit o don’t reach for items: use a reaching device to maintain proper hip and pelvic alignment o don’t bend over to put shoes or socks on o keep knees apart – do not cross legs and do not cross legs when sitting o lay on unaffected side total knee arthroplasty for severe destruction of the knee joint damaged part of the joint removed, surfaces reshaped, artificial joint attached with cement/adhesive material minimally invasive surgery – smaller incision (3-5 cm), does not cut tendon, works between fibers of quadricep muscles - Robert jones bandage put on in OR, which stabilizes the knee for first 24hrs (bulky soft roll bandage that covers ¾ of leg to reduce swelling POST-OP NURSING CARE OF JOINT REPLACEMENTS neurovascular assessment pain management nausea, constipation control deep breathing and cough no dressing changes: monitor for bleeding monitor Hgb and WBC use ice pack to decrease swelling and pain low molecular weight heparin – self injection mobility PT to mobilize for the first time and practice activities within limits of restrictions, then mobilize +++ Mobilise per prescriber’s order: FWB - full weight bearing PWB - partial weight bearing, amount determined by MD or PT NWB - non weight bearing Feather WB (or TTO) – also known as toe touch only cast care plaster of paris – 72hrs fiberglass – 3 hrs ( must be dried immediately after getting wet) patent teaching o must keep dry o protect from bangs that could crack the cast and misalign the fracture o protect fingers or toes by using a covering (sock) o wiggle fingers or toes to promote circulation o initial cast removal may occur at 3 weeks nursing interventions o preform frequent neurovascular assessments o elevate limb whenever possible, above the heart, especially for the first 48 hrs return to ER if: o fingers or toes become numb, painful, or discoloured o the cast feels too tight or loose o the cast cracks o unpleasant smell or drainage from cast orthopaedic surgery complications delayed union, non-union, mal union infection/osteomyelitis compartment syndrome fat embolism DVT post traumatic arthritis growth abnormality if fracture in growth plate causes of complications age site – site with mobility gets more stress during healing blood supply – consider impact of PVD, cardiac disease infection movement and immobility - underlying disease: osteoporosis, rheumatoid arthritis, diabetes, cardiac disease anesthetic, length of surgery hormones can affect bone strength (estrogen) prevention of fractures comfortable shoes with good support maintain BMI Chronic osteomyelitis: The infection starts with the formation of an intramedullary abscess, which then penetrates into the cortical bone to form a sequestrum (an area of necrotic bone within a compromised soft tissue envelope [periosteum]). After extensive surgical debridement, curettage, and sequestrectomy. The surgery involves the removal of large quantities of bone, which can affect bone stability. Moreover, it is impossible to remove all the infected tissue. The placement of a locked intramedullary nail is required to ensure bone stability compartment syndrome An emergency that can occur after injury, surgery, or repetitive muscle use Increased pressure within a confined space impairs the blood supply Increased pressure within the compartment exerts pressure on the blood vessels, which compromises muscle and nerve viability The body releases histamines, which exacerbates the compression by causing vasodilation and increased edema and pressure Irreversible muscle & nerve damage and loss of function Requires immediate fasciotomy * position limb at the level of the heart to decrease pressure *remove or loosen anything constrictive *fasciotomy: incision into the skin and fascia to release pressure incision left open for several days and wet dressing applied 3-5 days later the patient will need surgery to close the open fascia, may need skin graft compartment syndrome: 6 P’s Early signs: pressing on nerve and blood supply 1. Pain: progressive severe pain that is out of proportion to the injury and not relieved with analgesics 2. Pressure: skin is tight & shiny, swollen, burning, can feel hard to touch 3. Paresthesia: decreased sensation or tingling sensation due to pressure on nerves Late signs: 4. Paralysis: progressive motor weakness and decreased movement 5. Pallor: prolonged capillary refill, skin pale & cold due to decreased perfusion 6. Pulselessness: very weak or absent pulses due to lack of arterial perfusion how to prevent compartment syndrome frequent neurovascular checks pain assessment and management assess for swelling or tightness around the cast monitor urine for myoglobin which can indicate muscle injury o CK increases and urine becomes brown – kidney has trouble filtering myoglobin general surgery complications paralytic ileus – lack of GI motility post op nausea and vomiting delirium post-op bleeding pain over-sedation hemodynamic instability atelectasis, pneumonia shock GI SYSTEM psychological and emotional factors influence GI functioning crohn’s disease chronic IBD of unknown origin that can affect any part of the GI tract terminal ileum, jejunum, colon clinical manifestations diarrhea rectal bleeding fever mouth ulcers night sweats irregular menstrual cycle perianal disease inflammation of the skin, eyes, joints, and bile ducts *S&S will vary according to the location of disease diagnostics barium x-ray, colonoscopy, EGD low Hgb, high WBC and ESR treatment anti-inflammatories, steroids immunosuppressants antibiotics anti-diarrheal surgical removal of a portion of the intestines colonoscopy – patient teaching diagnostic to examine rectum and sigmoid colon prep is cleansing the bowel o 10-36 hours prior o clear fluid restriction o laxatives (polyethylene glycol) o stay very close to the toilet esophagogastroduodenoscopy to visualize the esophagus, stomach, and duodenum NPO 6 hrs prior conscious sedation ulcerative colitis inflammation of the large intestines swelling kills cells causing ulcers on top layer of digestive tract lining if untreated, increases cancer risk, often after the 10 year mark clinical manifestations bloody diarrhea abdominal cramps anemia hair loss anorexia and weight loss diagnostics colonoscopy, stool sample low Hgb, high WBCs treatment amino salicylates corticosteroids immunomodulators proctocolectomy (curable – removal of a portion of the intestine) gastritis inflammation of the stomach lining, which may be acute or chronic causes of acute gastritis: excessive alcohol consumption and NSAIDs causes of chronic gastritis: autoimmune, diffuse antral, multifocal risk factors: drug related, diet, H. Pylori clinical manifestations abdominal pain indigestion dark stool anorexia nausea/vomiting, including blood or coffee ground emesis diagnostics UGI blood and stool test gastroscopy H. Pylori test treatment diet modification (small bland meals) antacids upper GI bleed - represent a significant clinical and societal burden bc of high mortality (5-14%) as well as recurrence hematemesis: blood vomit appearing as fresh blood or coffee grounds (digested blood) melena: black, tarry stool occult bleeding: small amounts of blood in gastric secretions, vomit, or stool; not visible to plain eye o detectable by guaiac test causes of upper GI bleeds GERD Mallory Weiss tear esophageal/gastric CA esophagitis esophageal varices liver disease corticosteroids, NSAIDs, anticoagulants alcohol, smoking peptic ulcer disease gastritis clinical manifestations dark, tarry stool hematemesis hemodynamic instability epigastric pain syncope anemia medical management of UGIB 1. identify cause: gastroscopy or EGD; biopsy if indicated 2. treat: o banding, clamping, gluing, cauterizing o proton pump inhibitors o octreotide (reduce blood flow to cells near esophagus - vasoconstriction) 3. manage complications: o blood products and fluid balance nursing management of UGIB vitals, CBC, electrolytes, PTT, INR, liver enzymes melena stool or frank bleeding nausea and vomiting abdominal assessment type and cross match send stool of OB NPO or clear fluids strict ins and outs discharge planning; patient should… understand disease and how to prevent it understand the purpose of meds and instruction for use avoid NSAIDs lifestyle changes (stop drinking and smoking) when to go to ER lower GI bleed usually less acute than upper GI bleeds clinical manifestations frank blood frequent sanguineous stools hypotension, tachy, dizziness, lethargy syncope shock causes of lower GI bleeds crohn’s and ulcerative colitis diverticulitis trauma polyps hemorrhoids diagnostic tests duodenal ulcer colorectal cancer medical management of LGIB – similar to LGIB except for colonoscopy instead of EGD 1. identify cause o colonoscopy and biopsy if indicated 2. treat cause o banding, clamping, gluing, cauterizing o proton pump inhibitors o no octreotide (only used for esophageal bleeds) 3. manage complications o blood products o fluid balance referral to dietitian colorectal cancer risk factors over 50 yrs excessive alcohol >4 drinks/week chronic IBD smoking, obesity colorectal polyps familial adenomatous polyposis – inherited disorder that causes early polyps and colorectal cancer family history of colorectal cancer Hx of ovarian or endometrial cancer consumption of red meat clinical manifestations symptoms depend on which part of the colon is affected – signs are subtle, a colonoscopy is an important screening tool bowel surgeries laparotomy large incision through skin and muscle of the abdomen for exploration and repair right hemicolectomy disease located in cecum, ascending colon, hepatic flexure, or transverse colon portion of the terminal ileum, ileocecal valve and appendix removed – ileotransverse anastomosis created left hemicolectomy disease located in left transverse colon, splenic flexure, descending colon, sigmoid colon, upper rectum abdominal perineal resection disease located withing 5 cm of anus rectum must be removed - creation of a permanent colostomy from proximal sigmoid removal of distal sigmoid, rectum, and anus nursing management: bowel surgery monitor VS and assessments Hgb, WBC, electrolytes dressing & drains NG tube: confirm suction order and observe drainage IV fluids assess careful thorough abdominal assessment manage pain and nausea deep breathing and coughing mobilize IV fluids strict I&Os NPO or clear fluids bowel surgery complications paralytic ileus – initial bowel sounds followed by none infection – increased WBC, signs near incision malabsorption depending on what par removed gas, pain, nausea, vomiting dehiscence malabsorption syndrome results from impaired absorption of fats, carbs, proteins, minerals, and vitamins possible causes enzyme deficiency bacteria proliferation disruption of small intestine mucosa (IBD) disturbed lymphatic and vascular circulation surface area loss from surgery nausea and vomiting: age related considerations more likely to have cardiac or renal insufficiency and are at risk for fluid and electrolyte imbalances excessive fluid and electrolyte replacement can have adverse effects for these older adults bowel obstructions Causes: Mechanical causes -**most common cause** – occlusion of intestinal tract lumen by cancer, stool, volvulus, diverticular disease, adhesions, narcotics Non-mechanical causes – neuromuscular or vascular disorder, i.e. paralytic ileus Medical management: NPO, IV fluids, possible NG for decompression, possible TPN Medications – antibiotics, gastric acid suppression, anti nausea Bowel resection with anastomosis, partial or total colectomy with colostomy or ileostomy (if obstruction extensive or necrotic) types of ostomies - Ileostomy: from ileum (small intestines) permanent for IBD and temporary for lower abdominal resections to protect distal anastomosis – liquid output skin breakdown due to digestive enzymes Drainage is liquid and constant. Use a proper fitting device and empty when half full to prevent seal from breaking Loss of fluid and electrolytes; patient needs to have 1.5-2 L fluid daily Little odor Need to modify diet Colostomy: from colon can be used temporarily or permanently for bowel obstruction, trauma, volvulus, perforated diverticulitis No enzymes, but bacteria present Stool will eventually return to pre-surgical consistency 1-2 bowel movements/day Increased odor A sigmoid colostomy maintains most normal functioning of the bowel No need to modify diet* pre op care for bowel surgery with ostomy assess physical, psychological, social needs Ensure patient understands surgical procedure, risks Complete Surgical Checklist ; ensure consent is signed Educate the patient about post-operative pain. This may help to decrease anxiety Arrange consult with ostomy nurse Visit from member of Ostomy support group, if patient requests Administer bowel cleanse (GoLytely) goals of care post op Adjusting to the altered body image Managing pain and discomfort Ensuring skin integrity Managing care independently post op nursing management assessment Vital Signs Lab values: CBC, electrolytes Stoma assessment Q4H Stoma should appear dark red with mild to moderate edema and a scant amount of bleeding Volume, colour and consistency of ostomy drainage Peristomal skin and surgical dressing NG tube – placement, drainage Urine output interventions - Administer IV fluids and medications as ordered Thorough, focused abdominal assessments Manage pain and nausea DB&C exercises Monitor tubes, lines, drains Monitor urine output Keep strict ins and outs Increase diet as per orders from NPO to CF Consult/refer to ostomy nurse Consult/refer to dietitian potential complications Hemorrhage Malnutrition Bowel Obstruction Abdominal Distention Perforation Peritonitis Paralytic ileus Prolapsed stoma Retracted stoma Hernia care of peristomal skin Use only warm water and a cloth No soaps or cleanser – can be irritating Change in morning, prior to breakfast Don’t use waterproof tape to patch Shave hair around peristomal area* Consult enterostomal nurse clinician if problems occur ostomies and diet All patients should have a dietitian referral Colostomy patients have no diet restrictions once regular post-op diet is established Ileostomy patients – need to drink 1.5-2 L water daily to accommodate increased output Chew food well; no laxatives Need high calorie, high protein diet Ensure adequate vitamin intake odor producing foods eggs, garlic, onions, fish, asparagus, cabbage, broccoli, cauliflower, alcohol, spicy foods gas forming foods beans, legumes, onions, beer, carbonated drinks, strong cheese, cabbage diarrhea causing foods alcohol, cabbage, spinach, green beans, coffee, spicy foods, raw fruits and vegetables obstruction causing foods nuts, raisins, popcorn, seeds, raw fruits and vegetables, celery, corn ostomy discharge planning Prior to discharge, ensure the patient can: 1. Understand the type and function of ostomy – drain colon contents 2. Understand and demonstrate how to empty a pouch – empty when ½ to 2/3 full, wipe it clean, and clamp pouch 3. Understand how often to change ostomy appliance & pouch – 5-7 days 4. Understand normal stoma and peristomal skin appearance – pink/red, non-tender, dry and intact 5. . Understand and describe ostomy supplies used 6. 6. Understand methods to control odor and gas Ensure the patient knows when to seek medical care: Vomiting New or worse belly pain. Fever Cannot pass stools or gas Stoma turns pale or changes colour or swells or bleeds RESPIRATORY CONDITIONS AND SURGERIES pneumonia acute inflammation of the lung parenchyma caused by viruses or bacteria that can lead to alveolar consolidation and infiltrates risk increases with age and comorbidities (CV and lung disease, DM, cancer post-op patients who received general anesthetic are at risk community acquired S&S cough, fever, chest x-ray infiltrates risk factors age extremes alcohol misuse chronic corticosteroid use HIV/AIDS immunosuppression preceding flu tobacco use cardiac disease, liver disease, pulmonary disease, renal disease health care acquired S&S fever, leukocytosis, increased respiratory secretions, chest x-ray infiltrates risk factors aspiration risk o supine position o dysphagia o tracheal intubation o tracheostomy elevated gastric pH ICU admission immunosuppression poor glycemic control mechanical ventilation oropharyngeal microbial colonization general anesthesia diagnostics chest x-ray - sputum for C&S CBC procalcitonin is an acute phase reactant that is more specific for infection (pneumonia and sepsis) than C reactive protein or ESR – inflammation with be present after surgery but not necessarily due to pneumonia renal function – Cr, urea, GFR electrolytes may be abnormal with dehydration ABG if severe prevention of HAP “I COUGH” protocol head of bed elevated 30° oral care 3X a day patient hand hygiene deep breathing and coughing 5X/hour early and progressive ambulation healing initiatives monitor LOC, VS, and assessment findings monitor SOB, chest expansion, breath sounds, and sputum oxygen may be required but do not over oxygenate antipyretics as prescribed monitor intake and output ensure hydration to liquify sputum ensure adequate nutrition roll pt onto opposite side of pneumonia – encourages blood perfusion (good lung down) abx – monitor for efficacy (WBC) and adverse effects treat pain - pleural chest pain may prevent full lung expansion, coughing, and expectoration instruct pt about cause and prevention COPD emphysema alveoli stop working and expand but cannot deflate; air is stuck and cannot exhale chronic bronchitis inflammation and mucus in the airways caused by significant exposure to noxious stimuli, characterized by: o limited air flow o dyspnea, cough, mucus production o periods of exacerbations Dx. is made on the basis of medical history of risk factors, S&S, and pulmonary function tests S&S dyspnea, cough, sputum production functional decline barrel chest (late stage) pulmonary cachexia recurrent lower lung infections abnormal hypoxic drive in pts with COPD and chronically high CO2 levels, the stimuli to adjust respirations is lost through accommodation CO2/pH mechanism in the medulla is suppressed and the only stimulus for breathing is hypoxia (usually in late stages) diagnosis chest x-ray, CT, MRI forced expiratory volume forced vital capacity FEV1 and FVC ratio sputum, CBC, ABG, lytes renal function, cardiac disease GOLD classification uses exacerbation history and symptoms to classify future exacerbation risk strategies healing initiatives Monitor LOC, VS, and assessment findings monitor work of breathing, chest expansion and breath sounds, sputum Oxygen therapy may be required for hypoxic patients but titrated to SpO2 88-92% Position in semi-fowlers pursed lip breathing, diaphragmatic breathing education: inhalers promote influenza and pneumococcal vaccinations Monitor efficacy and adverse effects of drug therapies: β-2agonists relax smooth muscle airways SABA (salbutamol, Ventolin, albuterol) o should not be taking every hour (monitor use of inhaler) LABA (severest) Antimuscarinics block bronchoconstriction SAMA (ipratropium) LAMA (Spiriva) glucocorticoids inhaled; oral agents play a role in managing exacerbations Asthma airway inflammation, intermittent airflow obstruction, and bronchial hyperresponsiveness severity of asthma is classified as o intermittent o mild persistent o moderate persistent o severe persistent people have different biomarkers causing them to have only certain phenotypes even if they have the same symptoms – treated differently clinical presentation recurrent episodes of coughing particularly at night and in the morning – when sleeping, airways constrict and relax and mucus accumulates wheezing, chest tightness, SOB Symptoms worsen in the presence of allergens, irritants or exercise History of allergic rhinitis or atopic dermatitis diagnostics sputum – eosinophils CBC, lytes renal function ABG if severe pulmonary function test methacholine challenge (known asthma trigger) allergy testing – may worsen with certain foods provocative testing for exercise and cold-induced asthma healing initiatives Monitor LOC, VS, and assessment findings Identify asthma pattern of symptoms, including symptom nature, timing, triggersand response to treatment Closely monitor work of breathing, chest expansion and breath sounds, sputum Position to promote ease of breathing, semi-fowlers, tripod Oxygen therapy PRN titrated to prescribed SpO2 promote updated influenza and other vaccinations Leukotriene receptor antagonist - leukotrienes cause bronchospasm, increased vascular permeability, mucosal edema and inflammatory cell infiltration. These agents block these effects (e.g. montelukas) breathing problems are often associated with anxiety lung cancer Lung cancer primarily affects those over 55 years often diagnosed in late stage and has poor prognosis risk factors Primary smoking Second-hand smoke Radon exposure - naturally occurring radioactive gas that results from the breakdown of uranium in soil and rocks Asbestos exposure Radiation exposure Arsenic in drinking water Air pollution Lupus Family history of lung cancer Beta-carotene supplements in smokers clinical presentation Chronic and often worsening cough Expectorating blood or rust-coloured sputum Chest pain that is often worse with deep breathing, coughing or laughing Hoarseness Loss of appetite Unexplained weight loss Shortness of breath Fatigue Reoccurring infections such as bronchitis and pneumonia New onset of wheezing diagnostics Imaging – x-ray, CT, MRI Bronchoscopy – performed under moderate/procedural sedation maintain O2 stat, able to breath on own, bleeding, inflammation of the airway, aspiration Biopsy Sputum cytology Molecular tests – to determine specific gene changes in the cancer cells that could be treated with targeted drug therapies non-small cell lung cancer (85%) Adenocarcinoma - most common form Squamous cell carcinoma - accounts for about 25% of cases Large cell carcinoma – accounts for about 10% of cases less responsive to treatment; slower growing small cell lung cancer (15%) This form tends to grow more quickly than non-small cell lung cancer tumors, but tends to be more responsive to chemotherapy high risks VTE Malignancy-associated hypercalcemia results from increased bone resorption and release of calcium from bone secondary to underlying malignant processes. Bisphosphonate therapy which blocks osteoclastic bone resorption is the main and most effective long-term treatment of malignancy-associated hypercalcemia and is usually initiated in patients with mild to severe hypercalcemia on presentation Hyponatremia – most common type is Syndrome of Inappropriate Antidiuretic Hormone (SIADH) due to ectopic production of ADH by tumor cells particularly associated with non-small cell lung cancer staging TNM system o tumour o node o metastasis number staging 1. cancer is in lungs only 2. cancer is in lungs and lymph nodes inside the lungs 3. cancer is in lungs and lymph nodes outside the lungs 4. cancer has spread to areas around the ling or distant organs immunotherapy agents - Cancer cells have the unique ability to avoid detection by the body’s immune system because of specialized surface proteins Immunotherapy agents block these surface proteins, allowing the body’s T cells to recognize the tumour as foreign and respond to cancer cells appropriately It is important to note, that while these agents show great promise, they can also accelerate the body’s immune response to healthy tissue (high risk for other infections) skin rash, flu like symptoms, SOB, cough, leg edema, sinus congestion, headaches, weigh gain, diarrhea radiation therapy Radiation therapy is used in all stages of lung cancer treatment from curative to palliative Highly precise targeting, delivers high dose with minimized effects on nearby healthy tissue adverse effects of radiation o Skin dryness, itching, blistering or peeling o Fatigue o Difficulty swallowing o Shortness of breath o Breast or nipple soreness o Shoulder stiffness o Cough, fever, and fullness of the chest, known as radiation pneumonitis – usually occurs between 2 weeks and 6 months after therapy o Radiation fibrosis, which causes permanent lung scars from untreated radiation pneumonitis chemotherapy adverse effects: Chemo-brain - problems with memory and concentration Fatigue Hair loss Oral mucositis Nausea and vomiting Diarrhea Ototoxicity (cisplatin) Neuropathy Pain Rash Weight gain or loss - usually weight loss, but drugs like steroids will cause weight gain surgical interventions wedge resection lobectomy pneumonectomy sleeve resection (cancerous part of the bronchus is removed and reconnected to healthy ends) Video-assisted thoracoscopic surgery (VATS) has be shown to decrease reduce operative time, morbidity, post-operative pain and length of hospital stay. Used in combination with ultrasound which improves detection of pulmonary nodules and enlarged lymph nodes that may be visually undetectable chest tubes - - - After lung surgery, one or more chest tubes may be inserted to drain fluid/blood and promote lung reexpansion Depending on hospital and device may use dry or wet suction (although ongoing research suggests the use of suction may be harmful) Review the patient chart for the reason for the chest tube, its location and insertion date Position patient in semi-fowler’s to promote ease of breathing and promotes draining Assess vital signs and SpO2, chest expansion and breath sounds chest tube management Assess for pain and provide adequate analgesia. A patient who is free from pain, to the degree that an effective cough can be produced, will generate a much higher pressure than can safely be produced with suction Encourage the patient to perform deep breathing, coughing and incentive spirometry. Assist with repositioning or ambulation as required Check the insertion site, insertion level of tube (cm), chest tube securement, dressing and palpate the surrounding area for subcutaneous emphysema make sure there is no bubble wrap feeling under skin watch for trachea deviation towards good lung Evidence supports dry sterile dressing or transparent dressing and change only when indicated. Transparent dressings allow direct inspection of the site Ensure all tubing connections are tight and secure Ensure that there are no kinks or dependent loops in the tubing which can dramatically increase intrathoracic pressure in just a few minutes. Dependent loops can change pleural pressure from -18 cm H2O to + 8 cm H2O and decrease fluid drained to zero in less than 30 minutes Do NOT strip or milk the tubing. Stripping produces dangerously high pressures (- 400 cm H2O) Do NOT clamp a chest tube, except momentarily when replacing the chest drainage unit, assessing for an air leak, or assessing the patient’s tolerance of chest tube removal and during chest tube removal - - - - - - Ensure that the chest tube system is below the level of the patient and is stabilized to prevent it from tipping over The water seal chamber and suction control chamber provide intrathoracic pressure monitoring. Remember that in gravity drainage without suction the level of water in the water seal chamber = intrathoracic pressure When ordered, ensure the suction control dial is set to ordered level and the system is Make sure the water-seal chamber is filled with sterile water to the level specified by the manufacturer. You should see fluctuation (tidaling) of the fluid level in the water-seal chamber. The water level increases during spontaneous inspiration and decreases with expiration. If you don’t see tidaling, the system may not be patent or working properly, or the patient’s lung may have re-expanded to wall suction Look for constant or intermittent bubbling in the waterseal chamber, which indicates leaks in the drainage system. Identify and correct external leaks. The chest tube, connecting tubing, system and a patient's wound should be examined for any loose connections or dislodgement of the tube (fenestrated holes should not be outside of the body) Slow, gradual rise in water level over time means more negative pressure in pleural space and signals healing. Goal is to return to −8 cm H2O Assess the amount, color, and consistency of drainage in the drainage tubing and in the collection chamber. Mark the drainage level on the outside of the collection chamber (with date, time, and initials) every 8 hours or more frequently if indicated. Report drainage that is excessive, cloudy, or unexpectedly bloody healing initiative following lung surgery Closely monitor work of breathing, chest expansion and breath sounds, sputum Many thoracic surgery patients are present or past smokers. Oxygen and nebulizer therapy are common Arrhythmias, specifically atrial fibrillation, is the most common cardiac complication after thoracic surgery Monitor for bleeding. Monitor Hg and HCT I&O, IV fluids, electrolytes signs/symptoms of operative site, intrathoracic and systemic infection. Monitor WBC Monitor pain and efficacy of analgesia. Epidural in combination with or followed by oral. Pre-emptive analgesia for activities known to increase pain Administer VTE prophylaxis Assess and maintain nutritional status Provide ongoing emotional and psychologic support for the patient and family. In addition to facing surgery, the patient is adjusting to a new diagnosis of cancer and the possibility that surgical intervention will be only partially successful -
