Thoracotomy

A surgical incision into the thoracic cavity, a thoracotomy is done to locate and
examine abnormalities, such as tumors, bleeding sites, or thoracic injuries; to
perform a biopsy; or to remove diseased lung tissue. This procedure is most
commonly performed to remove part or all of a lung to spare healthy lung tissue
from disease. Lung excision may involve pneumonectomy, lobectomy, segmental
resection, or wedge resection.
A pneumonectomy is the excision of an entire lung. It's usually performed to
treat bronchogenic cancer but may also be used to treat tuberculosis (TB),
bronchiectasis, or lung abscess. It's used only when a less radical approach can't
remove all diseased tissue. After pneumonectomy, chest cavity pressures stabilize
and, over time, fluid fills the cavity where lung tissue was removed, preventing
significant mediastinal shift.
The removal of one of the five long lobes, lobectomy can be used to treat
bronchogenic cancer, TB, lung abscess, emphysematous blebs, benign tumors, or
localized fungal infections. After this surgery, the remaining lobes expand to fill
the entire pleural cavity.
Segmental resection is the removal of one or more lung segments and
preserves more functional tissue than lobectomy. It's commonly used to treat
bronchiectasis. Remaining lung tissue must be reexpanded.
The removal of a small portion of the lung without regard to segments,
wedge resection preserves the most functional tissue of all the surgeries but can
treat only a small, well-circumscribed lesion. Remaining lung tissue must be
reexpanded.
Complications
Hemorrhage
Infection
Tension pneumothorax
Bronchopleural fistula
Empyema

Assessment (only potential abnormalities listed)

NURSING HISTORY BY FUNCTIONAL HEALTH PATTERN
Health perception and management
Fear about serious nature of illness and impending major surgery
Family history of heart disease or lung conditions such as asthma
High-risk respiratory health patterns, such as stress, smoking, or exposure to
respiratory toxins
Nutrition and metabolism
Loss of appetite
Weight loss
Activity and exercise
Shortness of breath or labored breathing on exertion
Tiredness and less tolerance for exercise than usual
Difficulty in breathing at rest and during exercise
Weakness and fatigue
Self-perception and self-concept
Fear of disfigurement and scarring
Roles and relationships
Fear of inability to return to work after surgical procedure
PHYSICAL EXAMINATION
Physical findings may vary, depending on the nature of the condition requiring
the thoracotomy.
General appearance and nutrition
General debilitation
Integumentary
Cyanosis
Pallor
Abrasions or open wounds
Respiratory
Dyspnea
Shortness of breath
Tachypnea
Use of accessory muscles
Gurgles, wheezes, crackles
Possible open sucking wound, flail chest, paradoxical asymmetrical chest
movements, or orthopnea
Cardiovascular
Arrhythmias
 Chest pain
Hypotension
Tachycardia
DIAGNOSTIC STUDIES
Because of the various conditions for which thoracotomy may be performed, this
section instead presents monitoring tests.
Arterial blood gas (ABG) levels reveal oxygenation, ventilation, and acid-base
status.
Chest X-ray may reveal abnormalities of the chest structures and heart and lung
tissues.
Fluoroscopy may reveal mobility abnormalities of the intrathoracic structures.
Magnetic resonance imaging may reveal abnormalities of the thoracic
structures and organs.
Computed tomography scan may reveal abnormalities of the lung, such as
tumors, calcium deposits, or cavities.
Biopsy may aid in definitive diagnosis of lung problems.
Ventilation-perfusion pulmonary scan may reveal areas of nonventilation and
nonperfusion.
Pulmonary function tests reveal static and dynamic lung volumes and
capacities.
Bronchoscopy may reveal abnormalities of the pulmonary tree.
Sonography of the lung may reveal collections of fluid and may be used
postoperatively to locate the best site for thoracentesis.
Thoracentesis may reveal abnormal fluid or tissue specimens.
Bronchography may reveal abnormal airway structures or a tumor.

Nursing care plan

Nursing diagnosis
Deficient knowledge (treatment regimen) related to
lack of exposure to information about thoracotomy
Impaired gas exchange related to hypoventilation
Ineffective breathing pattern related to
pneumothorax, hemothorax, or mediastinal shift
secondary to malfunction or removal of chest
drainage system
Risk for infection related to surgical incision and
endotracheal intubation
Nursing priorities
Prepare the patient and his family preoperatively
for surgery and postoperative care.
Optimize ventilation and oxygenation.
Maintain patency of chest drainage system.
Observe for complications after chest tube
removal.
Prevent infection.
Other potential nursing diagnoses: Acute pain related to surgical incision Anxiety related to change in
health status Ineffective airway clearance related to incisional pain
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.
Suggested NOC Outcomes
Knowledge: Treatment regimen
NURSING INTERVENTIONS
Intervention type Intervention
Independent Provide information, reinforcing as
necessary, and document
teaching regarding the purpose
and goal of the surgical
procedure.
Independent Provide information, reinforcing as
necessary, and document
teaching regarding expected
location for recovery in the
immediate postoperative period.
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.
Independent Provide information, reinforcing as
necessary, and document
teaching regarding endotracheal
intubation and mechanical
ventilation, if appropriate.
Independent Provide information, reinforcing as
necessary, and document
teaching regarding deep
breathing, coughing, and using an
incentive spirometer, if
appropriate.
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
Rationale
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.
Telling the patient where recovery
will take place helps reduce
postoperative disorientation.
Providing information about
postoperative therapy may allay
fears and anxiety about the
unknown and help the patient
cooperate.
Explaining intubation and
mechanical ventilation, including
the temporary loss of speech, may
allay anxiety about this treatment.
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.
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
 coughing.
[Additional individualized
interventions]
Suggested NIC Interventions
Teaching: Preoperative; Teaching: Procedure/treatment
Impaired gas exchange related to hypoventilation
EXPECTED OUTCOME
The patient will maintain adequate gas exchange and normal ABG and oximetry
levels.
Suggested NOC Outcomes
Respiratory status: Gas exchange; Respiratory status: Ventilation; Tissue
perfusion: Pulmonary
NURSING INTERVENTIONS
Intervention type Intervention
Independent Assess respiratory status as
needed and according to unit
protocol.
Independent Document and notify the
practitioner of abnormal findings.
Independent Monitor ABG levels for changes in
respiratory status and notify the
practitioner if changes occur.
Collaborative Monitor and document arterial
oxygen levels using pulse
oximetry, as ordered.
Collaborative Provide humidified oxygen. as
ordered.
Collaborative Medicate for pain every 1 to 4
hours and as needed, as ordered.
Independent Encourage deep breathing and
coughing two to three times every
hour while awake.
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.
Collaborative Promote and document incentive
spirometer use, as ordered,
several times per hour while the
patient is awake.
perform coughing and deep-
breathing exercises.
Rationale
Frequent assessment of the
cardiopulmonary system may
reveal problems and permit timely
interventions.
Early notification can facilitate
treatment changes.
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.
Oximetry provides a noninvasive
way to monitor arterial oxygen
levels.
Oxygen therapy may be required
until the lungs are fully
reexpanded and the breathing
pattern and airway clearance are
more effective.
Pain relief promotes effective deep
breathing and coughing.
Regular deep breathing and
coughing promotes reexpansion of
the lungs, mobilizes secretions,
and prevents atelectasis.
Support over the incision may
decrease pain during deep
breathing and coughing.
Spirometers encourage deep
inspiratory efforts, which are
effective in reexpanding alveoli.
Independent Provide adequate hydration.
[Additional individualized
interventions]
Suggested NIC Interventions
Acid-base management; Chest physiotherapy; Fluid monitoring; Oxygen therapy;
Positioning; Respiratory monitoring
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.
Suggested NOC Outcomes
Respiratory status: Gas exchange; Respiratory status: Ventilation; Tissue
perfusion: Pulmonary
NURSING INTERVENTIONS
Intervention type Intervention
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.
Independent Observe for and document
fluctuation of water level in the
water-seal chamber during
respirations.
Independent Observe the water-seal chamber
for intermittent bubbling during
respiration. Document the amount
of bubbling and where in the
respiratory cycle it occurs.
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).
Adequate hydration promotes
liquid, easily removed lung
secretions.
Rationale
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.
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.
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.
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

Collaborative Assist with removal of chest tubes
3 to 4 days after surgery and
apply a sterile occlusive dressing.
Independent After chest tube removal, assess
the patient for signs and
symptoms of respiratory distress.
Collaborative If necessary, assist the physician
with reinsertion of the chest tubes
or thoracentesis.
[Additional individualized
interventions]
Suggested NIC Interventions
Respiratory monitoring; Surveillance: Safety; Tube care: Chest
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.
Suggested NOC Outcomes
Infection severity; Wound healing: Primary intention
NURSING INTERVENTIONS
Intervention type Intervention
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.
Independent Assess for signs and symptoms of
wound infection.
Collaborative Monitor culture and sensitivity test
results for wound drainage, as
ordered.
Independent Reinforce or change dressings as
pressure.
Chest tubes are removed when
the lungs have reexpanded.
A sterile occlusive dressing may
prevent infection and air leaks into
the pleural space.
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.
Rarely, the patient may
accumulate fluid or air and may
require reinsertion of chest tubes
or thoracentesis.
Rationale
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.
Regular assessment of the
incision may provide early warning
of infection.
Culture and sensitivity tests help
identify the infective organism and
the most effective antibiotic
treatment.
The dressing is usually reinforced,
 needed, using sterile technique. not changed, during the first 1 to 2
days after surgery to prevent
exposure to microorganisms.
[Additional individualized
interventions]
Suggested NIC Interventions
Incision site care; Infection control; Infection protection; Wound care

Teaching checklist
Surgical procedure, including expected postoperative course
Deep breathing, coughing, and spirometer use
Comfort measures
Range-of-motion and other exercises
Purpose and mechanism of chest drainage system
Purpose, dosage, administration schedule, and adverse effects of discharge
medications
Date, time, and location of follow-up appointments
Signs and symptoms to report to the practitioner and contact information