DQ Response

Sarah Kerkla

Posted Date

Mar 31, 2022, 5:10 AM

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AGACNPs have a pivotal role in the healthcare team and are proven assets as members of the surgical team. A literature review conducted of NPs in the orthopedic setting (but can logically be applied to other surgical specialties) discuss the growing concern of physician shortages in surgery specialties and legislation in the early 1990s that limits the hours residents can work (Spence et al., 2019). This left many surgical specialties with less clinicians to severe a large population of patients. NPs have helped fill that void. The AGANP is a skilled clinician that can take accurate medical history, order necessary tests, initiate a plan of can, and consult other services (Spence et al., 2019). There are several modules in which an AGANP can function in the surgical setting; however, they have important role in all aspects of perioperative care. In the postoperative period NPs round on patients, address concerns or issues, provide patient education, coordinate care, lead the interdisciplinary team, perform complex dressing changes/remove drains, and order additional testing as appropriate (Spence et al., 2019). This model allows for surgeons to operate and ensure their post-op patients are being safely managed (Spence et al., 2019). 

            In the presented scenario, increased/inadequate chest tube output, change in output color, or increased pain could indicate a potential complication (Columbus et al., 2017, p. 800). The first assessment should always be the patient rather than the device. The patient should be evaluated for respiratory distress and hemodynamic instability. The amount of drainage is highly variable depending on the reason for the chest tube. Occasionally in lobectomy patients, two chest tubes are used; one for lung re-expansion and the other for blood/fluid collection (Shintani et al., 2018). In this instance, it would be expected for one tube to have little to no drainage and the other to have larger amounts. Some lobectomy patients have massive air leaks, pleural effusions, or hemorrhage that require two chest tubes (Shintani et al., 2018). It’s important to note the characteristics of the drainage and if they’ve changed. Large amounts of sanguineous drainage would be cause for concern especially coupled with hemodynamic changes; serous drainage is expected as effusions are common in malignancy; and milky can be consistent with chyle which could be expected or a complication. An abrupt stoppage of drainage in the immediate post-op period is concerning for potential tube occlusion or migration, which can result in pneumothorax. 

            Tubes and drains are commonly placed in surgery as part of postoperative management. A chest tube can be placed in the pleural or mediastinal space for pneumothorax, hemothorax, and cardiac/thoracic surgeries (Columbus et al., 2017, Tables 45-1). GI tubes can be placed for feeding or decompression including: NG tube, gastrostomy tube, jejunostomy tube, or duodenal tube (Columbus et al., 2017, Tables 45-1). A Penrose is a small drain that is open at both ends and is intended to maintain a surgical tract for drainage (Columbus et al., 2017, pp. 45–1). Closed suction drain systems (Jackson-Pratt or Hemovac) are placed in the surgical space to facilitate drainage of blood and other fluids (Columbus et al., 2017, pp. 45–1). AGACNPs should be well versed in different drainage devices and be aware of potential complications. Depending on the specialty of the AGACNP, drains should not be manipulated without discussing it with the placing surgeon and all unexpected changes or concerns should be addressed with the surgeon (Columbus et al., 2017, p. 804). 

In the scenario, depending what the assessment demonstrated possible causes of large chest tube output are: hemorrhage, chylothorax, or expected high volume drainage. If the concern of the nurse was no output, possible causes are tube malposition or occlusion. In the scenario of large volume output, I’d expect to see hemodynamic instability with hypotension and tachycardia due to fluid loss or significant fluid shifts. In the case of low/no output, this could cause a pneumothorax or tension pneumothorax and the patient would have respiratory distress along with hypotension and tachycardia. 

In the case with sever hemorrhage the patient will likely need transfusion of blood products and taken back to OR for exploration for the source of the bleed. Chylothorax is a rare complication secondary to a thoracic duct injury (Chen et al., 2020). Treatment options are drug therapy with Somatostatin analogs, thoracic duct embolization, or possible surgical intervention (Chen et al., 2020). In some cases, high output may be expected from a large effusion. In this case no intervention is needed if the patient is stable. In the case of decreased output, chest x-ray would be need to verify placement and possible repositioning or clot evacuation may be necessary.  

References

Chen, C., Wang, Z., Hao, J., Zhou, J., Chen, N., Lui, L., & Pu, Q. (2020). Chylothorax after lung cancer surgery: A key factor influencing prognosis and quality of life. Annals of Thoracic and Cardiovascular Surgery26(6), 303–310. https://doi.org/10.5761%2Fatcs.ra.20-00039

Columbus, A., Havens, J. M., & Peetz, A. B. (2017). Surgical tubes and drains. In Principles and practice of hospital medicine (2nd ed., pp. 798–804). McGraw Hill.

Shintani, Y., Funaki, S., Ose, N., Kanou, T., Kanzaki, R., Minami, M., & Okumura, M. (2018). Chest tube management in patients undergoing lobectomy. Journal of Thoracic Disease10(12), 6432–6435. https://doi.org/10.21037%2Fjtd.2018.11.47

Spence, B. G., Ricci, J., & McCuaig, F. (2019). Nurse practitioners in orthopedic surgical settings. Orthopedic Nursing38(1), 17–24. https://doi.org/10.1097%2FNOR.0000000000000514

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