Virtual Surgery Reflection of Thoracotomy

Virtual surgery reflection of Thoracotomy

Background Inquiry

The patient is a 54-year-old male with a long history of smoking about one pack of cigarettes a day. Patient has a history of nodular lymphoma involving lymph nodes of multiple sites. Also, about four years ago patient had a CVA leaving him left sided weakness. Patient's last surgery was to neck dissection to remove the lymphoma. Patient's last chest x-ray noticed that there was a large mass on his right upper lung. Patient is in the operating room for a right thoracotomy with a possible resection. A major health condition that is going to impact the surgery is the fact that the patient already has an impaired airway due to previous cancer which will make it harder to intubate him. The second factor is that because of the patients damage to his lungs the anesthesiologist is really going to have to watch the patient breathing, oxygen status, because his impaired lung is going to have to do double work while surgery is occurring.

Pathophysiology

In this patient cancer was most likely caused by the carcinogens found in tobacco smoke. What happens is that as you continue to smoke over the years, your normal cells in the body will slowly transform or mutate into malignant or cancer cells (Black, 2005). The first step that happens in this process is called initiation. This stage is when the carcinogens start to change the structure and function at the cellular level (Black, 2005). If the person does not make lifestyle changes to stop smoking, then the cells will mutate further and eventually will become malignant. If cancer is not noticed at this point it will eventually metastasize and spread throughout the body. A symptom associated with lung cancer is a persistent cough. This occurs because the cancerous cells that are lining the airway will be able to detect anything foreign such as a tumor mass and this will cause the patient to cough, because the body is trying to get rid of this foreign substance. Coughs are seen from 20 to 80 percent of cases (Scott, 2000). Another symptom sometimes seen is that the patient will cough up blood due to the surface of the tumor bleeding (Scott, 2000). Wheezing can also occur from a partially blocked airway due to a tumor. If the cancer spreads to the chest you may see symptoms such as chest pain, hoarse voice, drooping eyelid, and shortness of breath.

Pre-op medications

There were two pre-op medications that were given to the patient. The first medication was midazolam hydrochloride, trade name is Versed. This drug was used to induce sleepiness and to help relieve apprehension. This drug is usually given one hour prior to surgery and dose recommendation is 0.07-0.08mg/kg I.M. Side affects that are seen in the CNS with this drug is headache, over sedation, involuntary movements, amnesia, and combativeness. Cardiovascular side affects include hypotension, bradycardia, and cardiac arrest. GI side affects to look for include nausea and vomiting. This drug should not be given is person is an alcoholic and grapefruit juice should be avoided. The action that this drug has on the body is that it may depress the central nervous system by potentiating effects of GABA. This drug will promote calmness and sleep in the patient. Special implications for this drug are that it is very important that you have resuscitation equipment available in case of severe respiratory depression. This drug should not be given to alcoholics.

The second pre-op medication that was given was cefazolin sodium, trade name Ancef. This drug is commonly given pre-op in prevention of a disease associated with contamination from surgery. This drug is classified as a cephlosporin antibiotic. The action of this drug is to inhibit cell wall synthesis, which will hinder or kill bacteria (Lippincott, 2006). Adverse reactions that can be seen with this drug involving the CNS are dizziness, headache, malaise, and paresthia. GI reactions to look for are genital pruritis, vaginitis, anemia, and thrombocytopenia. Respiratory effects are dyspnea. You can see skin rashes and other hypersensitivity reactions occur also. Nursing implications is that we need to monitor the hydration of the patient.

Operative Phase

The surgical suite environment is a lot different then you would expect it to be. You walk in and there are two doors to enter and exit the room. The room is very small; the reason that this particular room is so small is that it was made in the fifties when there was only a major and minor tray for surgery. Today we used a lot more equipment then we did fifty years ago. In this particular room there was equipment such as a crash cart, monitors for the anestheologist to monitor vital signs and oxygen levels, a sterile field, and a bandage cart with numerous supplies on it. It is also extremely cold. " The operating room is maintained at a standard cool level of 60-70 F." (Black, 2005) There are two reason why the operating room is always this cold first it is to allow the surgeons to not become overheated because of all the clothing layers that they have on. Second, warmer temperatures will allow bacteria to grow.

There are many people involved with the surgery each playing a very important role. In the operating room there was an attending surgeon, surgeon, surgeon intern, two circulating nurses, anesthesiologist, anesthesiologist intern, scrub nurse in training and a trained scrubbed nurse. The role of the attending surgeon was mainly making decisions about the procedures. The other surgeon and his intern assisted with the operation and helped to make proper decisions and mention any observations that may have been missed by the attending surgeon. The anesthesiologist and intern were responsible for placing an AV line, IV therapy, administering a epidural, giving medications to alleviate pain and promote relaxation for the surgery, intubating the client, maintaining proper gas exchange, documenting fluid losses and monitoring circulation and vitals. The nurses scrubbed were there to set up the sterile field and organize the proper instruments that were needed for the procedure. The circulating nurses did many tasks such as answer phone calls, look for breaks in sterile technique, handled specimens, inserted catheter, documented care on the computer, and helped the other personal with anything they could assist with. These nurses were also responsible for the client's safety.

When the surgeons and anesthesiologists were ready the circulating nurse went to get the patient. When the client entered the room the nurses asked the patient how he was doing today, and if he had any last second questions. The