INTENSIVE CARE SERVICE
NURSING POLICY& PROCEDURES
NAME OF POLICY: THORACOTOMY FOR PNEUMONECTOMY
GOAL: TO EFFECTIVLY CARE FOR A POST OPERATIVE
PNEUMONECTOMY
Introduction:
Pneumonectomy is the removal of an entire lung; a thoracotomy procedure is used to open the
thoracic cavity in order to remove the entire lung.
Pneumonectomy is commonly used in the treatment of bronchogenic cancer and can include
involvement of the lobar and hilar lymph nodes. It is occasionally used for extensive unilateral
tuberculosis, bronchiectasis or lung abscess.
Pre-operative care:
Tests including pulmonary function, chest x-rays and CT’s need to be attended. Pre-operative
teaching about the post operative period is imperative especially pulmonary hygiene, early
ambulation, arm/ shoulder exercises, patient control analgesia and the role of the chest drain.
Operative procedure:
Pneumonectomy is performed via the thoracotomy approach. The lung is removed at the main
bronchus bifurcation with the bronchus being sutured closed. Ligation of the pulmonary artery
and vein occurs. The adjacent lymph nodes are removed and phrenic nerve is severed on the
affected side. A three-bottle system (Thoraseal) is not necessary however a chest drain is
routinely inserted. Serous ooze from the chest is allowed to accumulate in the empty cavity (over
time this solidifies). This fluid and along with the surgeon adjusting pressure in the empty space
minimizes mediastinal shift. The chest drain allows for the assessment of bleeding and pressure
within the cavity to be adjusted.
Changes to the respiratory physiology post operatively
Pleural pressure will be more negative post-operative; this causes the remaining lung to be
hyperinflated and compliance is slightly reduced.
Diaphragm will rise on the affected side.
Inspired gas distribution will remain normal (i.e. greater at apex), ventilation-perfusion
relationship becomes more homogeneous but diffuse capacity decreases due to the reduced
alveolar area.
There is a reduced elasticity or compliance of the lung and thorax. This increases the work of
breathing, oxygen consumption and increases energy expenditure.
Increase in the rate and depth of breathing, this will increase the lung efficiency.
Arterial Blood gases will be normal.
Within the pneumonectomy space air is absorbed, fluids leak from the parietal pleura and
mediastinum, this fills the space over time.
Pulmonary artery pressures and right ventricular pressures are temporarily increased due to
the cardiopulmonary system compensating for reduced gas exchange and increased blood
flow through remaining lung.
Complications:
Bleeding: This can be severe and fatal. Pneumonectomy patients have an open space and no
lung tissue to place pressure on the internal bleeding site. A slipped ligature or vascular
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suture line can cause bleeding. Hypotension, reduced CVP, increased HR and mediastinal
shift are good indicators of bleeding. Because the chest drain is clamped bleeding can be
difficult to see. Unclamping the drain according to protocol may help detect this.
Mediastinal shift: Some mediastinal shift is expected. A mediastinal shift toward the good
lung can threaten a patient’s respiratory status and needs reporting.
Fluid overload: Pneumonectomy patients are at risk of fluid overload and pulmonary
oedema. Normally two lungs receive cardiac output now only one lung does. Strict fluid
balance, urine output and CVP monitoring need to be attended. Filling should be given with
caution.
Arrhythmias: Atrial fibrillation is most common.
Impaired ventilation and oxygenation: This can occur due to reduced lung volume,
ineffective pain management, sputum retention and fluid overload.
Broncho-pleural stump rupture: Not very common. It presents as a massive airleak into the
pneumonectomy space (sometimes with subcutaneous emphysema), excessive mediastinal
shift to the remaining lung, aspiration of space fluid into the remaining lung, and coughing
up the large volume of fluid in the space.
Nursing Responsibilities: Immediately post op.
Vital parameters as per setting should be ordered by the RMO
Inform pt. and relatives that the operation is over with a brief update, If applicable
Continuos cardiac, ABP (if insitu) CVP and SpO2 monitoring, If NIBP: ½ hourly blood
pressure for 2hrs, then hourly for 4 hrs then second hourly till 0600hrs post-operative day
1. Hourly RR and 4 hourly temperatures.
Assess respiratory status including air entry
Assess neurological status
ECG if pt has cardiac history or noted cardiac event intra-op
NBM, give IVI fluids as ordered
Right pneumonectomy patients will have an NG insitu. NG on free drainage, with 4/24
aspirates
1500ml fluid restriction
6-8L/min via Venturi mask, if Sats >95% then change to nasal prongs 4L/min
Ensure 2/24hr deep breathing and coughing, (ensure adequate sleeping time)
Hourly urine output ( ½ ml/kg/hr)
Hourly chest drain observation /management (see below)
Chest x-ray on return then 6hrs thereafter followed by daily
Ensure adequate analgesia (PCA protocol)
Maintain high fowlers position
Do not roll onto unoperative side
Wound remains intact, report abnormal ooze/bleeding
Antibiotics
Clexane
Digoxin- surgeons choice
Nebulizers if required
EUC & FBC attended, as per ‘Routine Blood Collection Protocol’. ABG’s PRN if arterial
line insitu
Physiotherapy- 2/24 hourly deep breathing and coughing exercises. Arm, shoulder and leg
exercises. All patients are on the night time physio list
Sponge and oral care
Chest tube management:
Drains are double clamped with NO suction
Use designated pneumonectomy form for management recording
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Every hour unclamp the drain for 2 minutes- DO NOT LEAVE THE PATIENTS SIDE
WHILE DRAINS UNCLAMPED
Monitor for air and drainage
Record air and drainage, report abnormal findings (drainage > 200mls)
Ensure all connection from patient to drainage bottle/tubing is secure
DAY ONE: As per surgeon’s orders and protocol (see below)
Inform patient, relative/significant others of the management plan
EUC & FBC attended, as per ‘Routine Blood Collection Protocol’
Continue drain management until surgeons review
Removal of chest drain after surgeons review
Chest x-ray after drain removal
QID- Temperature, HR, BP, RR SpO2
Oxygen reduced to maintain SpO2 > 95%
Removal of NG after surgeons review
Normal diet as tolerated- right pneumonectomy after surgeons review
1500ml fluid restriction
IV fluids ceased
Daily weight
Removal of IDC, ensure pt. has voided 6-8hr post removal
Adequate analgesia- PCA usually removed after drain removal. Pain team to review
patient
IV antibiotics changed to oral
Continue clexane
Nebulizers if required
Check wound sites, redress if applicable
Patient to sit out of bed, mobilize around bed space
DB+C, arm and shoulder exercises
Aperients- Record bowel activity
Pressure area care
DAY TWO:
Wound: if confeel insitu, leave. If Opsite insitu take down and assess the wound for
infection, re-dress if necessary
QID- Temperature, HR, BP, SpO2, RR
Daily chest x-ray
Daily weight
Full diet
1500ml fluid restriction
Anticipate ward transfer (see Discharge protocol)
REFERENCES:
Care of the patient after pneumonectomy. Written by Jocelyn McLean, (Case Manager for
Thoracic Surgery) for Concord Repatriation General Hospital.
Brenner, Z.R. and Addona, C. 1995. Caring for the Pneumonectomy Patient: Challenges and
Changes. Critical Care Nurse. October 1995.
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Occupational Health and Safety: Universal precautions taken in the preparation, administration of drug and
disposal of equipment and sharps.
Cross Referenced: RPAH Occ. Health & Safety Manual and Infection Control Manual
NSW Infection Control Policy 98/99
Written by: Morgan Smith (CNE cardiothoracic), February 2004
Reviewed by: Jocelyn McLean (Case manager thoracic)
Authorised by: Professor McCaughan
Revision Due: February 2006
With the introduction of Powerchart online ordering, a clinical agreement has been set up with the Director
of ICS and other Staff Specialists. Nursing Management, with the agreement of the hospital executive, have
made arrangement that allows all permanently employed RPAH Nursing Staff to place orders for a variety of
tests on their behalf. It is a Health Insurance Commission (HIC) directive that all orders placed by nursing
staff are countersigned by the responsible MO within 14 days.
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