Chapter 10: Nursing Management: Patients with Chest and Lower Respiratory Tract Disorders

Chapter 10: Nursing Management: Patients With Chest and Lower Respiratory Tract Disorders

*The following is a sample care plan meant for adaptation. Always revise to meet your facility’s protocols and the latest research and nursing diagnoses.

PLAN OF NURSING CARE Care of the Patient After Thoracotomy NURSING DIAGNOSIS: Impaired gas exchange related to lung impairment and surgery GOAL: Improvement of gas exchange and breathing Nursing Interventions Rationale Expected Outcomes 1. Monitor pulmonary status as 1. Changes in pulmonary status ● Lungs are clear on auscultation

directed and as needed: indicate improvement or onset of ● Respiratory rate is within

a. Auscultate breath sounds. complications. acceptable range with no episodes

of dyspnea b. Check rate, depth, and pattern ● Vital signs are stable

of respirations. ● Arrhythmias are not present or are

c. Assess blood gases for signs of under control

hypoxemia or CO2 retention. ● Demonstrates deep, controlled,

d. Evaluate patient’s color for effective breathing to allow maximal

cyanosis. lung expansion 2. Monitor and record blood pressure, 2. Aid in evaluating effect of surgery ● Uses incentive spirometer every 2

apical pulse, and temperature on cardiac status. hours while awake

every 2–4 hours, central venous ● Demonstrates deep, effective

pressure (if indicated) every 2 coughing technique

hours. ● Lungs are expanded to capacity 3. Monitor continuous 3. Arrhythmias (especially atrial (evidenced by chest x-ray) electrocardiogram for pattern and fibrillation and atrial flutter) are

Arrhythmias. more frequently seen after thoracic

surgery. A patient with total

pneumonectomy is especially

prone to cardiac irregularity. 4. Elevate head of bed 30–40 degrees 4. Maximum lung excursion is

when patient is oriented and achieved when patient is as close

hemodynamic status is stable. to upright as possible. 5. Encourage deep-breathing 5. Helps to achieve maximal lung

exercises (see section on Breathing inflation and to open closed

Retraining) and effective use of airways. incentive spirometer (sustained

maximal inspiration). 6. Encourage and promote an 6. Coughing is necessary to remove

effective cough routine to be retained secretions.

performed every 1–2 hours during

first 24 hours. 7. Assess and monitor the chest 7. System is used to eliminate any

drainage system* residual air or fluid after

a. Assess for leaks and patency as thoracotomy.

needed (See Chart 25–19).

b. Monitor amount and character

of drainage and document every

2 hours. Notify health care

provider if drainage is 150 mL/h

or greater. NURSING DIAGNOSIS: Ineffective airway clearance related to lung impairment, anesthesia, and pain GOAL: Improvement of airway clearance and achievement of a patent airway Nursing Interventions Rationale Expected Outcomes 1. Maintain an open airway. 1. Provides for adequate ventilation ● Airway is patent

and gas exchange. ● Coughs effectively 2. Perform endotracheal suctioning 2. Endotracheal secretions are ● Splints incision while coughing until patient can raise secretions present in excessive amounts in ● Sputum is clear or colorless effectively. postthoracotomy patients due to ● Lungs are clear on auscultation trauma to the tracheo-bronchial

tree during surgery, diminished

lung ventilation, and cough reflex. 3. Assess and medicate for pain. 3. Helps to achieve maximal lung

Encourage deep-breathing and inflation and to open closed

coughing exercises. Help splint airways. Coughing is painful;

incision during coughing. incision needs to be supported. 4. Monitor amount, viscosity, color, 4. Changes in sputum suggest

and odor of sputum. Notify health presence of infection or change in

care provider if sputum is excessive pulmonary status. Colorless sputum

or contains bright-red blood. is not unusual; opacification or

coloring of sputum may indicate dehydration or infection. 5. Administer humidification and mini- 5. Secretions must be moistened and

nebulizer therapy as prescribed. thinned if they are to be raised from

the chest with the least amount of

effort. 6. Perform postural drainage, 6. Chest physiotherapy uses gravity to

percussion, and vibration as help remove secretions from the

prescribed. Do not percuss or lung.

vibrate directly over operative site. 7. Auscultate both sides of chest to 7. Indications for tracheal suctioning

determine changes in breath are determined by chest

sounds. auscultation. NURSING DIAGNOSIS: Acute pain related to incision, drainage tubes, and the surgical procedure GOAL: Relief of pain and discomfort Nursing Interventions Rationale Expected Outcomes 1. Evaluate location, character, 1. Pain limits chest excursions and ● Asks for pain medication, but

quality, and severity of pain. thereby decreases ventilation. verbalizes that he or she expects

Administer analgesic medication as some discomfort while deep

prescribed and as needed. breathing and coughing

Observe for respiratory effect of ● Verbalizes that he or she is

opioid. Is patient too somnolent to comfortable and not in acute

cough? Are respirations distress

depressed? ● No signs of incisional infection

evident 2. Maintain care postoperatively in 2. The patient who is comfortable and

positioning the patient: free of pain will be less likely to

a. Place patient in semi-Fowler’s splint the chest while breathing. A

position. semi-Fowler’s position permits

b. Patients with limited respiratory residual air in the pleural space to

reserve may not be able to turn rise to upper portion of pleural

on unoperated side. space and be removed via the

c. Assist or turn patient every 2 upper chest catheter.

hours. 3. Assess incision area every 8 hours 3. These signs indicate possible

for redness, heat, induration, infection.

swelling, separation, and drainage. 4. Request order for patient-controlled 4. Allowing patient control over

analgesia pump if appropriate for frequency and dose improves

patient. comfort and compliance with

treatment regimen. NURSING DIAGNOSIS: Anxiety related to outcomes of surgery, pain, technology GOAL: Reduction of anxiety to a manageable level Nursing Interventions Rationale Expected Outcomes 1. Explain all procedures in 1. Explaining what can be expected in ● States that anxiety is at a

understandable language. understandable terms decreases manageable level

anxiety and increases cooperation. ● Participates with health care team 2. Assess for pain and medicate, 2. Premedication before painful in treatment regimen especially before potentially painful procedures or activities improves ● Uses appropriate coping skills procedures. comfort and minimizes undue (verbalization, pain relief strategies, anxiety. 3. Silence all unnecessary alarms on 3. Unnecessary alarms increase the use of support systems such as

technology (monitors, ventilators). risk of sensory overload and may family, clergy)

increase anxiety. Essential alarms ● Demonstrates basic understanding

must be turned on at all times. of technology used in care 4. Encourage and support patient 4. Positive reinforcement improves

while increasing activity level. patient motivation and

independence. 5. Mobilize resources (family, clergy, 5. A multidisciplinary approach

social worker) to help patient cope promotes the patient’s strengths

with outcomes of surgery and coping mechanisms. (diagnosis, change in functional

abilities). NURSING DIAGNOSIS: Impaired physical mobility of the upper extremities related to thoracic surgery GOAL: Increased mobility of the affected shoulder and arm Nursing Interventions Rationale Expected Outcomes 1. Assist patient with normal range of 1. Necessary to regain normal mobility ● Demonstrates arm and shoulder

motion and function of shoulder of arm and shoulder and to speed exercises and verbalizes intent to

and trunk: recovery and minimize discomfort. perform them on discharge

a. Teach breathing exercises to ● Regains previous range of motion

mobilize thorax. in shoulder and arm

b. Encourage skeletal exercises to

promote abduction and

mobilization of shoulder (see

Chart 25-22). c. Assist out of bed to chair as

soon as pulmonary and

circulatory systems are stable

(usually by evening of surgery). 2. Encourage progressive activities 2. Increases patient’s use of affected according to level of fatigue. shoulder and arm. NURSING DIAGNOSIS: Risk for imbalanced fluid volume related to the surgical procedure GOAL: Maintenance of adequate fluid volume Nursing Interventions Rationale Expected Outcomes 1. Monitor and record hourly intake 1. Fluid management may be altered ● Patient is adequately hydrated, as

and output. Urine output should be before, during, and after surgery, evidenced by:

at least 30 mL/h after surgery. and patient’s response to and need ● Urine output greater than 30

for fluid management must be mL/h

assessed. ● Vital signs stable, heart rate, 2. Administer blood component 2. Pulmonary edema due to and central venous pressure therapy and parenteral fluids and/or transfusion or fluid overload is an approaching normal diuretics as prescribed to restore ever-present threat; after ● No excessive peripheral edema and maintain fluid volume. pneumonectomy, the pulmonary

vascular system has been greatly

reduced. NURSING DIAGNOSIS: Deficient knowledge of home care procedures GOAL: Increased ability to carry out care procedures at home Nursing Interventions Rationale Expected Outcomes 1. Encourage patient to practice arm 1. Exercise accelerates recovery of ● Demonstrates arm and shoulder

and shoulder exercises five times muscle function and reduces long- exercises

daily at home. term pain and discomfort. ● Verbalizes need to try to assume 2. Instruct patient to practice 2. Practice will help restore normal an erect posture assuming a functionally erect posture. ● Verbalizes the importance of position in front of a full-length relieving discomfort, alternating mirror. 3. Instruct patient about home care 3. Knowing what to expect facilitates walking and rest, performing

(see chart 25-3). recovery. breathing exercises, avoiding heavy

lifting, avoiding undue fatigue,

avoiding bronchial irritants,

preventing colds or lung infections,

getting influenza vaccine, keeping

follow-up visits, and stopping

smoking *A patient with a pneumonectomy usually does not have water seal chest drainage because it is desirable that the pleural

space fill with an effusion, which eventually obliterates this space. Some surgeons do use a modified water seal system.