Invasive Procedures

-can be diagnostic and therapeutic to the patient. Pre-operative Intra-operative Post-operative

Thoracic Surgery
Diseases of the lungs that requires surgical procedures 1. Lung Cancer 2. Lung Abscess 3. Cysts 4. Chest Trauma 5. Lung Transplant Diagnosis/ Preparation Common incisional approach: 1. Sternotomy- incision through and down the breastbone 2. Thoracotomy- incision via the side of the chest 3. VATS (Video Assisted Thoracotomy) insertion of the thorascope and surgical instruments into the thorax through any of 3 to 4 small incision in the chest wall.

Thoracic surgeries and procedures

Lobectomy- surgical removal of one lobe of the lungs - indicated for patient with bronchogenic carcinoma, giant emphysematous blebs or bullae, benign tumors, metastatic malignant tumors, bronchoiectasis and fungus infecions. Pneumonectomy- removal of the entire lung - indicated for patient with lung cancer, lung abcess, bronchoiectasis, extensive unilateral tuberculosis

Exploratory Thoracotomy- internal view of the lung - used to confirm carcinoma or chest trauma Segmentectomy (Segmental Resection)- removal of section of a lobe of the lungs Wedge resection- small localized section of lung tissue removed - usually pie shaped - performed for random lung biopsy and small peripheral nodules

Pre- operative Management:

Maximize respiratory function and reduce risk of complications Chest auscultation Assess for retained secretion Pulmonary function studies ABG Bronchoscopic examination Chest X-ray MRI Blood test ECG Improving airway clearance Humidification Postural drainage Chest percussion after administration of bronchodilators

 Health teachings regarding the: Type of anesthesia Use of chest tubes and drainage system Administration of oxygen or possible use of ventilator Use of incentive spirometry Proper positioning Health teaching techniques: Coughing Splinting the incision site Pain management Relieving anxiety *huffing- deep breathing Giving prophylactic anticoagulant as prescribed to reduce peri-operative incidence of DVT and pulmonary embolism Ensure patient fully understands surgery and emotionally prepared, consent for the surgery

Post-operative Management:
Chest auscultation, suctioning of secretion Oxygen administration via mechanical ventilator, nasal cannula, or face mask V/S, intake and output monitoring hourly including CTT (amount, character of drainage) Proper positioning: Lobectomy- lying on the back/ turned to either side Pneumonectomy- lying on back/ turned toward the operative side (affected side) Segmental resection- lying on back/ turned onto non-operative side Assess for signs of complications: Cyanosis Dyspnea Acutes chest pain- may indicate atelectasis Elevated WBC- infection Pallor and increased pulse- internal hemorrhage Dressings are assessed for fresh bleeding Monitor ABG and Oxygen saturation frequently Begin ROM exercise of arm and shoulder of affected side (ankylosis)

 Respiratory insufficiency- if the rest of the lung cannot compensate for the loss of the lobe Pulmonary embolism- blood clot can lodge in the vessels of the lung DVT- lying in bed for long periods after surgery Cardiac arrhythmias- the hear beats irregularly and stops pumping blood as efficiently (3rd to 4th day post-operative) Bleeding and infection Bronchopleural fistula- connection of forms Nursing Diagnosis Ineffective Breathing Pattern related to wound closures Risk of Fluid Volume Deficit related to chest drainage and blood loss Pain related to wound closure and presence of drainage tubes in the chest Impaired Physical Mobility of affected shoulder and arm related to

Renal Surgery
Indication: For severe kidney damage such as: 1. Cancer of the kidney- renal cell carcinoma 2. Polycystic kidney disease 3. Serious kidney infections 4. Kidney transplantation

Types of nephrectomy 1. Radical nephrectomy- treatment of tumor can be removed - removal of the kidney tumor, adrenal gland, fatty tissue, lymph nodes 2. Simple nephrectomy- performed for living donor, transplant purposes requires removal of the kidney and section of the ureter 3. Laparoscopic nephrectomy- removal of kidney with small tumor -use of videoscope

Pre-operative Management
Patient is prepared for surgery and consent is witnessed Pre-operative antibiotics and bowel cleansing regimen are prescribed Application of anti-embolic stockings, and leg exercise are taught Blood samples for cross matching for possible transfusion Insertion of retention catheter Assess CP clearance

Positioning Lateral lumbar flank; transthoracic with affected side up Incision site: Flank (Posterior axillary line, beneath the 12th rib to suprapubic area)

Post-operative Management
Assess fluid and electrolytes status Monitor hemoglobin and hematocrit results and urine specific gravity and ECG Monitor amount and character of urine drainage every 1 hour Assess patency of urinary or wound drainage tube; reinforce or change dressings Assess pain location, intensity, and characteristics; assess bowel sounds

Health teachings: coughing, deep breathing exercises, use of incentive spirometry to prevent atelectasis and pulmonary complications Assist in turning because patient may experience pain and muscle soreness For Kidney Transplant- immunosuppressant drugs are ordered Monitor for kidney infection/ kidney rejection Increased temperature Decreased urine output Pain and tenderness Hypertension Blood exam (Creatinine) Home instructions: Teach patient to inspect and care for incision Activity and lifting restriction, driving and pain management Notify physician about problems like fever, breathing difficulty Advise to wear a medical alert bracelet Emotional support- loss of one kidney, dialysis

Complications: Infection Hemorrhage and shock Post-operative Pneumonia Thromboembolism Paralytic Ileus Obstruction of urinary drainage Injection of transplant Nursing Diagnosis Pain related to surgical incision site Altered Urinary Elimination related to urinary drainage tubes or catheter Risk for infection related to incision, potential pulmonary complications Risk for Fluid Volume Deficit or Excess related to fluid replacement needs

Prostate Surgery
Indication: Benign Prostatic Hyperplasia and Prostate Cancer Surgical approach depends on size of the gland: 1. Transurethral Resection of the Prostate (TURP)- the most common used to remove BPH. Retroscope is passed through the urethra to exercise and cauterize the excessive prostatic tissue 2. Suprapubic Prostatectomy- incision into suprapubic area and through bladder wall and prostate gland is removed from above 3. Retropubic Prostatectomy- incision can be made in the lower abdomen (at the level of symphysis pubis); useful when prostate is large 4. Perineal Prostatectomy- incision through the scrotum and rectum. Prostate gland is removed through an incision in the perineum. 5. Laparoscopic Radical Prostatectomy- preformed through 4-6 small incisions in the mid-abdomen. It reduces the risk of post-operative erectile and urinary dysfunction

Pre-operative Management:
Reducing anxiety Explain the nature of the procedure Discuss the complications of surgery 1. Incontinence of dribbling of urine 2. Retrograde ejaculation Bowel preparation is given and prophylactic antibiotics Providing instruction: turning, coughing, and breathing exercises Ensure that optimal cardiac, respiratory, and circulatory status have been achieved to decrease risk of complication Monitor Urinary Drainage- Continuous Bladder Irrigation (Cystoclysis) 1. Monitor urine character after prostatectomy a) Clear to pale pink- normal during entire hospital course b) Light red to red- normal or expected on the day of surgery c) Very dark red/ bright red- indicate venous/ arterial bleeding or inadequate CBI flow. d) Blood Clots- normal if they are occasional. Increase the CBI rate to prevent catheter obstruction

2. Offer fluids frequently to keep urine diluted and minimize infection and obstruction of the catheter. 3. When catheter is removed about 3-7 days after surgery, client should void within 5-6 hours. Normal for client to experience some urgency, frequency and dysuria. Incontinence is not normal and may be caused by bladder spasm.
Prevent Complications- most common are: 1. Hemorrhage- noted by copious, bright red blood in the urine. 2. Thrombus and embolism- prevent by turning and exercising the legs. 3. Bladder spasm- check for the patency of the catheter and irrigate it as ordered. Frequency of spasm should decrease in 24-48 hours. Discharge Instructions: 1. Healing- health habits of adequate nutrition and rest help promote healing. Perineal was used, sitz bath or warm compress should be applied to the perineum.

2.
3. 4.

Adjusting to changes in self-concept- client may have permanent/ temporary interference with sexual functioning. Do not any lifting or have intercourse of 6 weeks after surgery. Hematuria may continue but client should report bright red bleeding and inability to void.

Nursing Diagnosis
Altered Urinary Elimination related to surgical procedure and urinary catheter Risk for Infection related to surgical incision , immobility and catheter Pain related to surgical procedure Anxiety related to Urinary Incontinence difficulty voiding and erectile dysfunction

Breast Examination
Breast Cancer Screening- early detection is an important factor in the success of breast cancer treatment 3 Methods Commonly used for early detection are: 1. Breast self-examination (BSE) 2. Clinical Breast exam 3. Mammogram Purpose: - to detect any abnormalities in the breast - to identify signs of breast disease and then initiate early treatment - teach a woman to perform BSE Indications: - Patients practice of BSE - Palpable lumps - Nipple discharge - Pain or tenderness

When to do? Regularly monthly basis, 3- 7 days after the end of the menses For irregular period/ menopause women, do it on the same day same month
Equipments: Good lighting Small pillow Gloves (optional) Slide foe specimen (optional) Special Considerations: Breast assessment should also be a routine part of a complete male assessment Breast palpation requires practice and skill because the consistency of the breasts varies widely from client to client BSE should begin for women in 20s

Risk Factors Gender (female) Age (increasing with age) - 100x to develop breast cancer (60 y/o) Family history Personal history Early menarche and late menopause No natural children (nullipara and absence of breast feeding) First child born to mother with an older age Education and socioeconomic status Diet
Possible risk factors for mortality No (poor) BSE Poor Screening

Risk Reduction Tips Not delaying pregnancy until after age 30 Breastfeeding Knowledge about Breast cancer screening Exercise esp. in youth but also in adulthood
Breast Cancer Screening The type and frequency of breast cancer screening that is best for you, changes as you age. 1. Ages 18 to 39: You should have a clinical breast exam every 3 years 2. Ages 40 to 69: Annual clinical breast exams. Annual mammography is recommended for women older than age 50 3. Age 70 and over: If you are 70 or older talk to health care professional about mammography as regular part of your health care plan.

Malignancy of Mammary ducts (Pagets Disease) -early sign is erythema of areola and nipple; while the late sign are thickening, erosion
Inflammation of the breast (Acute Mastitis) -inflammation associated with lactation. Signs of nipple cracks and abrasion Peud orange of edema -associated with breast cancer with orange peel in color, enlargement of skin pores is noted esp. in areola

3 Patterns: Circular Up and down Wedge

Breast exam 41% upper, outer quadrant 14% upper, inner quadrant 5% lower, inner quadrant 6% lower, outer quadrant 34% in the area behind the nipple * Ductile carcinoma- originates from ducts * Lobular carcinoma- lobules

Breast Surgery
Indications: Breast tumor Breast cancer Breast augmentation Breast reduction Breast lift/ mastopexy Types of Mastectomy 1. Segmental mastectomy/ Lumpectomy- removes the tumor and a margin of breast tissue surrounding the tumor 2. Simple mastectomy- removal of the breast with some nearby axillary nodes 3. Modified Radical mastectomy removal of the entire breast and all axillary lymph nodes, chest wall muscles are not resected

4. Radical mastectomy removal of the entire breast, axillary lymph nodes and underlying chest wall muscles (pectoral muscles) 5. Breast reconstruction (Mammoplasty)- maybe performed at the time of mastectomy/ maybe done at a later time; can be accomplished through submuscular breast implant to improve the psychological coping to improve self- esteem
Implants (Prosthetic) at areola incision Silicone Saline (10 years) Flap grafts- transfer of skin, muscles and subcutaneous tissue from other part of the body to the mastectomy site 1. Latissimus dorsi flap graft 2. Transverse rectus abdominis myocutaneous (TRAM) flap

Clinical Staging - signs and symptoms that are present - Involves the physicians extimation of the size of breast tumor and extent of axillary lymph nodes involvement - Diagnostic test
Pathological Staging - Done when the pathologist examine the surgically excision and biopsy Stages of Breast Cancer Stage I: tumors are less than 2cm in diameter and confined to the breast Stage II: less than 5cm or tumors are smaller with mobile axillary lymph node involvement Stage III a: greater that 5cm or tumors are accompanied by enlarged axillary lymph nodes fixed to one another or to adjacent tissue Stage III b: advanced lesion with satellite nodules, fixation to the skin or chest wall, ulceration, edema or with supraclavicular or intraclavicular involvement Stage IV: all tumors with distant metastasis

Pre-operative Nursing interventions 1. Providing education and preparation about surgical treatment 2. Reducing fear and anxiety and improving coping ability 3. Promoting decision making ability Post-operative: 1. Relieving pain and discomfort a) Analgesic medication b) Provide alternative pain management c) Do not use arm operative side for BP taking, IV or injection 2. Managing post-operative sensation a) Reassure patient that this are normal part of healing and that these sensations are not indicative of a problem 3. Promoting positive body image a) Assess for readiness and provide gentle encouragement b) Maintain privacy while assisting her to view the incision c) Allow to express feelings, acknowledging her feelings d) Reassure that her feelings are normal response to breast cancer surgery e) Suggest clothing adjustments

4. Promote positive adjustment and coping a) Assisting the patient in identifying and mobilizing her support system b) Provide support, education and guidance to spouse or partner c) Involve family in patient care 5. Improving sexual function a) Encourage patient to openly discuss how she feels about herself and reasons in decrease libido b) Assume position that are comfortable c) Expressing affection using manual stimulation 6. Monitoring and managing complications 1) Lymphedema- inadequate lymphatic channel to ensure return flow as lymph fluid to general information a) Perform prescribed exercises, start with simple movement on affected side b) Elevate the arm above the heart several times a day c) General muscle pumping

2. Hematoma (Seroma formation)- collection of blood inside the cavity a) Warm shower b) Warm compress
Seroma- collection of serous fluid a) Unclogging the drain b) Manually aspirating the fluid with needle and syringe 3. Infection a) Monitor for signs and symptoms of infection b) Oral or IV antibiotics for 1-2 weeks c) Culture for foul smelling discharges Drainage Management a) Demonstrate how to empty and measure fluid from the drainage device b) Demonstrate how to milk clots through the tubing of the drainage device c) Note for observation requiring contacting the physician or nurse d) Identify when the drain is ready for removal- less than 30cc after 24 hours

Arm exercise Purpose: 1. To promote ROM 2. To increase circulation and muscle strength 3. Prevent joint stiffness and contraction
Nursing Considerations: 1. Initiated on the 2nd day post-operatively of after surgical drain is removed 2. Perform 3 times a day for 20 mins. at a time until ROM is restored 4-6 weeks 3. Take analgesics 30 mins. Before beginning exercises if patient has discomfort 4. Instruct to take warm shower before exercising to lose stiff muscle and provide comfort 5. Heavy lifting is avoided 4-6 weeks

Exercise after breast surgery 1. Wall hand climbing 2. Rope turning 3. Rod or broomstick lifting 4. Pulley tugging
Breast reconstruction Nursing Interventions: Nursing care to be provided to patients with TRAM flaps involves: Flap monitoring Pain management Drain monitoring Prevention of possible complications Home care training of the patient

Evaluate the flap are for temperature, blood flow, color, and capillary refill Pink- early stage Dark red- accumulation of blood or obstruction by a clot in donor site veins Petechia- indicates a reduced venous return and may require addition of fresh veins Ivory colored (pale) or mottled breast- indicates inadequate or reduced arterial perfusion Notify the surgeon immediately