THORACOTOMY Thoracotomy is a surgical incision into the thoracic cavity.

. This is done to locate and examine abnormalities such as tumors, bleeding sites or thoracic injuries; to perform biopsy; or to remove diseased lung tissue. It is most commonly done to remove part or all of a lung to spare healthy tissue from disease. A full thoracotomy is a major surgical procedure that requires careful preop and postop patient management and may require mechanical ventilation and closed chest drainage. Other types include: Exploratory thoracotomy done to examine the chest and pleural space in evaluating chest trauma and tumors. Decortication is used to help reexpand the lung in a patient with emphysema; involves the removal or stripping of the thick, fibrous membrane covering the visceral pleura. Thoracoplasty performed to remove part or all of one rib and to reduce the size of the chest cavity; decreases the risk of mediastinal shift when TB has reduced lung volume. INDICATIONS: Pulmonary conditions such as cancers, benign tumors, TB, abscesses or infection, bronchiectasis or blebs caused by emphysema or empyema. Cardiac conditions, such as arteriosclerotic coronary arteries, valvular diseases, mural wall defects, aortic aneurysm, cardiomyopathy, CHD Hiatal hernias or esophageal problems Chest trauma involving one or more of the vital chest structures (lungs, heart, aorta, trachea, esophagus, or superior or inferior vena cava) PROCEDURE: Administration of anesthesia Thoracotomy may be done in 3 approaches: 1. Posterolateral thoracotomy incision starts at the submammary folds of the anterior chest, is drawn below the scapular tip and along the ribs, and then is curved posteriorly and up to the spine of the scapula. Any type of lung excision calls for a posterolateral incision through the 4th, 5th, 6th, or 7th ICS. 2. Anterolateral thoracotomy incision begins below the breast and above the costal margins, extending from the anterior axillary line and then turning downward to avoid the axillary apex. 3. Median sternotomy involves a straight incision from the suprasternal notch to below the xiphoid process and requires the sternum to be transected with an electric or airdriven saw. Once the incision is made, the surgeon takes a biopsy, locates and ties off sources of bleeding, locates and repairs injuries within the thoracic cavity or spreads the ribs and exposes the lung area for excision.

 After completing the procedure requiring thoracotomy, the surgeon closes the chest cavity and applies a dressing. COMPLICATIONS: hemorrhage infection tension pneumothorax bronchopleural fistula empyema A lung excision may also cause a persistent air space that the remaining lung tissue doesnt expand to fill. Removal of 3 ribs may be necessary to reduce chest cavity size and allow lung tissue to fit the space. NSG. DX: Anxiety Impaired gas exchange Ineffective airway clearance Risk for infection

NSG. INTERVENTIONS: Explain procedure to the patient and inform him that hell receive GA. Prepare him psychologically accdg. to his condition. (Ex: A patient having a lung biopsy faces the fear of cancer as well as the fear of surgery and needs ongoing emotional support.) Inform patient that postoperatively, he may have chest tubes in place and may receive oxygen. NOTE: Chest tubes are placed postoperatively in order to drain fluid and blood from the thoracic cavity and to help lungs refill with air. It will be removed when drainage stops and no air is leaking from the incision usually 24 to a few days. Arrange for laboratory studies and tests as ordered. (Ex: PFT, ECG, CXR, ABG) Ensure that the patient or a responsible family member has signed a consent form. If patient had a pneumonectomy, make sure he lies only in his operative side or back until hes stabilized. (This prevents fluid from draining to the unaffected lung if the sutured bronchus opens.) If a patient has a chest tube in place, makes sure its functioning and monitor for s/sx of tension pneumothorax such as dyspnea, chest pain, an irritating cough, vertigo, syncope or anxiety. If he develops these symptoms: Palpate his neck, face and chest wall for subQ emphysema and palpate trachea for deviation from the midline. Auscultate lungs for decreased or absent breath sounds on the affected side. Then percuss for hyperresonance. If tension pneumothorax is suspected, notify the physician at once.

 Provide analgesics as ordered. Have the patient begin coughing, DBE, and incentive spirometry as soon as hes stabilized. Auscultate lungs, place him in semi-Fowlers position and have him splint his incision to facilitate coughing and deep breathing. Have him cough q2 until his breath sounds are clear. Perform passive ROM exercises the evening of surgery and 2-3 times daily thereafter. PATIENT TEACHING: Before surgery, teach him coughing and deep breathing techniques. Explain that hell use these after surgery to facilitate lung reexpansion. Also, teach him how to use an incentive spirometer; record the volumes he achieve s to provide a baseline. NOTE: Incentive spirometer is to be used 4x a day. Tell the patient to continue his coughing and DBE when he returns home to prevent complications. Advise him to report any changes in sputum characteristics to his physician. Instruct patient to continue performing ROM exercises to maintain mobility of his shoulder and chest wall. Tell patient to avoid contact with people who have URTIs and to refrain from smoking. Provide the patient with instructions for wound care and dressing changes and refer him to home health care as needed. Instruct patient that he cannot lift anything that weighs beyond 10-15 lbs for 6 weeks after surgery. Avoid pushing or pulling heavy objects. (These place pressure on the incision.) Maintain proper personal hygiene. Instruct to inspect incisions daily for s/sx of infection such as swelling, redness, or drainage.