Which of the following nursing interventions should be instituted the day after surgery for the patient who h… - SCTIMST Staff Nurse - 2015 (Set-B)

SCTIMST Staff Nurse - 2015 (Set-B)

Medical Surgical Nursing

Hard

Appeared in: SCTIMST Staff Nurse - 2015 (Set-B)

Explanation

The day after a pneumonectomy, initiating gentle range-of-motion (ROM) exercises for the arm and shoulder on the operative side is a priority.
This intervention is crucial to prevent adhesive capsulitis, commonly known as "frozen shoulder," which is a significant risk after thoracotomy procedures due to pain and splinting.
Early mobility and ROM exercises also help improve overall circulation, reduce the risk of venous thromboembolism, and promote better respiratory mechanics by preventing chest wall tightness.

Option B: Stripping chest tubes creates a very high negative pressure, which is dangerous and can damage lung tissue. After a pneumonectomy, chest tubes (if present) are for gravity drainage to allow the empty space to fill, not for re-expanding a lung. Stripping could cause a life-threatening mediastinal shift.
Option C: Forcing fluids to 3500 ml/day is contraindicated. With only one lung, the patient's pulmonary circulation is handling the entire cardiac output, placing them at high risk for fluid overload and pulmonary edema. Fluids are typically restricted in the immediate postoperative period.
Option D: Intermittent Positive Pressure Breathing (IPPB) is not a routine postoperative intervention. It is used cautiously for specific indications like severe atelectasis unresponsive to other measures. Routine use of positive pressure can cause barotrauma to the remaining lung or a mediastinal shift.

Clinical Relevance

Nursing practice connection: Safe nursing care depends on performing Postoperative nursing care following a pneumonectomy in the correct sequence, documenting the action clearly, and monitoring for the expected response.
A key nursing role after pneumonectomy is preventing complications. Proactively starting ROM exercises prevents long-term disability from a frozen shoulder, which can significantly impact a patient's quality of life and ability to perform daily activities.
Nurses must understand that post-pneumonectomy care is unique. Interventions that are standard for other surgeries, like aggressive fluid resuscitation or certain chest tube management techniques, are dangerous in these patients.
What if the patient had a lobectomy (removal of a lobe) instead of a pneumonectomy? In that case, a chest tube with suction would likely be in place to help the remaining lobe(s) re-expand and fill the thoracic space. The focus would be on maintaining the patency and function of that chest tube system, which is a different goal than after a pneumonectomy.

How to Approach the Question

First, identify the core of the question: what is a safe and appropriate nursing intervention on the first day after a pneumonectomy?
Consider the specific pathophysiology of a pneumonectomy: one entire lung is removed, leaving an empty space that fills with fluid, and the entire circulatory and respiratory workload is on the remaining lung.
Evaluate each option based on this specific context. Ask yourself: 'Is this intervention safe for a patient with only one lung and an unstable mediastinum?'
Option A (ROM exercises): This addresses a common post-thoracotomy complication (stiffness) and is a low-risk mobility intervention. This is plausible.
Option B (Stripping chest tubes): This involves high pressure. Is that safe in a chest with no lung? No, it could shift the heart and great vessels. This is dangerous.
Option C (Forcing fluids): The patient has only one lung to handle gas exchange and fluid balance. Is fluid overload a risk? Yes, a major one. This is dangerous.

Concept Tested & Keywords

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