Nursing Assignment: Post-Operative Care Plan for Lung Cancer Patient

This nursing assignment analyzes the case of Mr. Joseph Bailey, a 66-year-old patient who underwent a thoracotomy and right upper lobe lobectomy due to lung cancer. The report delves into the potential post-operative complications, including pulmonary issues, and identifies associated risk factors...Read More

Running head: NURSING ASSIGNMENT
Introduction
Thoracic surgeries due to lung cancer can bring about several complications following the
surgery. If left unchecked, might cause abut severity of the condition. This paper is about Mr.
Joseph Bailey, a 66 years old gentleman, who had been admitted into the surgical ward after a
thoracotomy and right upper lobe lobectomy. This report will discuss the risk factors and the
complications followed by a potential postoperative complication. A care plan has been
developed based on 4 complications. Finally the role of the physiotherapist and the education
that should be given to the patient while discharge has been analyzed.
Post-operative complications and risk factors
After thoracotomy, pulmonary complications can be one of the major cause of mortality
in patients, thoracotomy in the postoperative period after surgery. The type and the severity of
the complication depend upon the type and the severity of the surgery. It also depends upon the
condition of the patient in the pre-operative period. Risk stratification can be done for assessing
the type of risks in the peri-operative period (Sengupt, 2015). Certain airway complications
might develop after thoracic surgery. The bronchopleural fistulae, injuries in the vocal cord,
pulmonary edema are some of the postoperative complications that might have occurred in Mr.
Bailey. Some of the major pulmonary complications that have been recorded are bronchospasms,
pneumonia, and atelectasis that might cause respiratory failure. Furthermore, the case study
revealed that the patient has past history of chronic bronchitis. Long-standing chronic bronchitis
has been found to be increasing the chance of lung cancer (Sengupta, 2015). Hence, chronic
bronchitis might have been an important risk factor for lobectomy.

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Old age has always been the most important risk factor for any kind of clinical complications. As
the population ages, more and more lung cancers are found among the elderly population
(Agostini et al.., 2018). Age can be a risk factor for complications after thoracic surgery. A study
has demonstrated that lung cancer elderly patients have a high risk of developing post-operative
pneumonia and emphysema (Kelkar, 2015). Some of the other complications that can include are
lower preoperative arterial PO2 value, a higher difference in oxygen and a longer time for
surgery. Elderly individuals often have other comorbidities and have poor physical health statue
due to the presence of cancer or due to some pre-existing chronic diseases like arthritis and
chronic bronchitis (Agostini et al.., 2018).
Again, to get adequate post-operative pain therapy can be challenging for elderly patients.
Untreated pain can have a negative impact on the health and the quality of life of the elderly,
sleep disturbances and mobility (Shiono, Abiko & Sato, 2013). Apart from the other post-
operative complications, it can lead to depression, social isolation, and anxiety. Elderly patients
with long term indwelling urinary catheter are at risk of developing urinary tract infection. Using
a catheter can introduce bacteria into the bladder and can cause UTI (Dietz et al., 2016). The case
study states that there is no drainage in the incision site, but surgical sites act as portals of entry
for the infection-causing bacteria.
Post-operative complication based on the Roper Logan Tierney model
In this section, the Roper Logan Tierney model will be used to analyze one of the
postoperative complications of Mr. Bailey. The Roper Logan Tierney is a model of nursing that
focuses on the management of the daily activities of living for achieving the optimal status of
wellbeing and health (Holland & Jenkins, 2019). Nursing is mainly concerned with the problem

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arising every day because of some serious medical condition. Illness impairs the ability of a
person to carry out certain activities of living. All the activities are interrelated and do not have
many distinct boundaries (Dietz et al., 2016).
The postoperative complication that has been chosen for Mr. Bailey is the pulmonary
complications. A pulmonary complication in a patient can certainly affect the daily activities of
living. Pulmonary complications might cause labored breathing and chronic cough. Chronic
cough and congestion might cause breathing trouble in the patient. After the surgery is it is
natural to build up mucus in the lungs that can cause trouble breathing. The patient might feel
hurt too deeply push the air in or deeply push the air out.
There is a risk for infection after the surgery. It can be due to the indwelling catheter or
the surgical site infection (Webster & Osborne, 2015). Colonization of harmful bacteria might
occur in the surgical site. Hence, it necessary to keep an eye on the dressing or the amount and
the color of discharge or whether there are any incidents of oozing. Elderly patients feel tired and
fatigued and lacked strength for some time afterward. Hence, it can be very difficult on the
patients part to keep an eye on the dressing and the incision wound. Hence, it is the duty of the
nurse to maintain a safe and clean environment to prevent any complications (Avitabile et al.,
2016). The health care professionals should categorize the patients as per the risk of respiratory
morbidity and mortality. Certain tools can be used in the post-operative management of the
patients undergoing thoracotomy.
Communication
One of the main purpose of communication is to maintain a therapeutic relationship with the
client. For a nurse, effective communication is an essential element for assisting patients to retain

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or regain their optimal level of functioning in every day’s life. There are various factors that can
impede the process of communication. Severe dyspnea and fatigue might refrain patients from
communicating with health care professionals (Leo et al., 2016). It is evident from this case
scenario that the patient is oriented to time and space, hence, nurses can indulge in conversation
with the client by using short necessary words in order to understand the grievances of the
patients. Nurses are also accountable to maintain a safe environment to prevent infections and
falls and should also ensure that the right dosage of medications is given at the given time.
Eating and drinking
Mr. Bailey can have bowel’s problem soon after the surgery. The patient can become
constipated after the patient starts mobilization. Fluids has to be given after the surgery to
maintain hydration. Painkillers like morphine, dihydrocodeine can cause constipation. After the
patient reaches home, ample amount of fruits and the vegetables needs to be taken. Symptoms of
aspiration are patients might occur after eating or drinking. Breathing conditions might make
eating a challenging job. In such a case, the patient can be made to eat sitting up for making
space for the lungs and diaphragm to expand, facilitating easier breathing. Since the patient is
likely to experience fatigue while eating, nurses and other health care workers might help
patients in consume food. Again individuals suffering from pulmonary complications might need
to have a restricted water intake, as water intake above 10 liters can cause acute pulmonary lung
edema (Narcı, 2013). In this way, pulmonary complication affects the daily activities like eating
and drinking (Narcı, 2013).

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Eliminating
Abdominal bloating after surgery is common. Abdominal bloating can affect the diaphragm,
which is a muscular partitioning between the abdomen and chest. The diaphragm actually helps
in breathing. Bloating generates pressure in the abdomen that is enough to restrict the movement
of the diaphragm causing breathlessness (Leo et al., 2016). Bloating and shortness of breath can
thus cause problems in the bowel movements.
Personal cleansing and dressing
Mr. Bailey might get breathless, while doing the things like the washing or dressing. An
OT can teach certain breathing exercises for eased breathing. An occupational therapist can help
the patient in mobility by the recommendation of lightweight transit wheelchairs or by
recommending certain home modifications (Agostini et al., 2013). The patient can be advised to
wear loose fitted clothing, as the body might be sore from the surgery (White, 2016).
Controlling body temperature
The blood gas homeostasis is an important factor that a nurse should always keep a note
of, as it is the partial pressure of the blood gases that reflects those occurring within the alveoli of
the lungs (Avitabile et al., 2016). Hence, the homeostasis is necessary for controlling the lung
function if the tissue functions have to be supported. Monitoring the pulse rate and the
temperature of the body is required.

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Sexuality
Breathlessness and complicated lung problems can get in the way of sexuality and
relationships. The health care professionals should educate the patients about the sexual activities
that need to be restricted or the ones that can be resumed after the wounds are healed.
Working and playing
Working and playing within a few days after the surgery is non-permissible, although some
incidental exercises can be done only under if it is recommended by the physician. The patient
needs to be educated about few precautions that has to be taken to ensure smooth mobility. It is
advised that heavy substances should not be lifted for a few days.
Sleeping
Obstruction of the airways might cause episodes of dyspnea and can cause sleep problems in the
patient.
Care plan
ADL 1
Bathing after the surgery
Nursing Assessment and intervention (1)
As referred by the physician
A bed bath is needed after the surgery and not a shower. Wet wipes can be used
Rationale: Direct shower or use of soap might irritate the wound (Veje et al., 2018).

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Nursing Assessment and intervention (2)
Physical examination
Chlorohexidine wash used
Rationale : Noto et al., (2013) have supported that cholorohexidine wash during bath helps to
prevent healthcare associated infections.
Nursing Assessment and intervention (3)
Physical examination
Using a shower seat for comfortable showering
Rationale: This will allow the patient to sit while bathing.
ADL 2
Pain management
Nursing Assessment and intervention (1)
Assessing the characteristics and the severity of pain.
Provision of comfort backrubs, change of the position, massage and low music.
Rationale: According to Gelinas et al., (2013) non-pharmacological measures like a gentle touch
of healing might reduce the discomfort in the patient.
Nursing Assessment and intervention (2)
Monitoring the vital signs
Assisting the patient in the chest splinting techniques at the time of the coughing episodes.

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Rationale: It helps in controlling the chest discomfort during enhancing the effectiveness of the
effort of coughing.
Nursing Assessment and intervention (3)
Using an optic analog scale
Administration of analgesics like opioid or NSAIDs for the management of pain
Rationale: The study by Peng et al., (2013) have demonstrated the effect of analgesics in the
management of pain
ADL 3
To cope up the patient with dysphagia (difficulty in swallowing)
Nursing Assessment and intervention (1)
Observation of any signs and symptoms of swallowing difficulty
Determining the safest and the most appropriate route of nutrition and hydration intake.
Rationale: In case of severe swallowing problem, a feeding tube can helps to bypass the food
(Howard et al, 2017).
Nursing Assessment and intervention (2)
Observation of planned and routine mealtime situations.
The patient needs to be provided with liquid food instead of solid food, as solid food can be
difficult to swallow for a patient who had just undergone a surgery and was under intubation.
Rationale: Howard et al., (2017) have proposed the use of liquid diet in patients after intubation.

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Nursing Assessment and intervention (3)
Administration of a questionnaire addressing the perception of the patient regarding the concern
with swallowing.
There are certain exercises that can help coordinating the swallowing muscles that help to
stimulate the nerves that will trigger the swallowing reflex.
Rationale: Howard et al, (2017) have proposed the use of textured food in order to manage with
dysphagia.
ADL 4
Physical mobility
Nursing Assessment and intervention (1)
Determining the response of the patient towards any activity.
After the thoracic surgery, the functional residual capacity can be increased by proper
positioning of the patient.
Rationale: Shiono, Abiko and Sato, (2013) have suggested that functional residual capacity and
lung atelectasis can be prevented by positioning the patient.
Nursing Assessment and intervention (2)
Bedside mobility assessment tool
For the safety of the patient, ambulation can be done by using assistive devices like a mechanical
lift.

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Rationale: The study by Makhabah, Martino and Ambrosino, (2013) had suggested the use of
assistive devices for early ambulation of the patients.
Nursing Assessment and intervention (3)
Assessment of balance of the patient
Mild exercises can be taught to the patient that will increase the strength and gait.
Rationale: Mild relaxation exercises helps in building strength and can help the patient to cope
up faster( Pouwels et al., 2018)
Role of physiotherapist in the post-operative period
Physiotherapy has currently become an essential part of the recovery protocol in the post-
surgical period after thoracic surgery. some of the presenting challenges faced by the patients
involve the improper positioning of the patient, the chest drain, the incision site, reduced volume
of the lungs, cough and pulmonary lung complications, that can be non –infectious or infectious,
frozen shoulders or the postural abnormalities and persistent tightness of the chest wall. All these
problems, if untreated can delay the recovery of the patients, hospital readmission and increased
rate of mortality and the morbidity (Agostini et al., 2017). Physiotherapy needs to be
implemented routinely after a thoracotomy. Proper post-operative physiotherapy can only be
designed based on the accurate initial assessment of post-operative patients (Agostini et al.,
2017). Physiotherapy can be used for the management of pain, by using transcutaneous electrical
nerve stimulation (Leo et al., 2016). This is a complementary post-operative analgesic modality,

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which safe and effective in alleviating post-operative pain and improving the recovery process of
the patient.
A physiotherapist might also apply cold therapy. After surgery, the application of ice
packs over the incision during the first 24 hours after the surgery produces a remarkable effect on
the management of pain (Liu & Petrini, 2015). Cold therapy given by the physiotherapist reduces
the sensitivity of the nerve endings by inducing the vasoconstriction, ultimately reducing the
swelling and the inflammation (Makhabah, Martino & Ambrosino, 2013). One of the important
role of the physiotherapist is to position the patient appropriately, as it increases the functional
residual capacity and prevents lung atelectasis.
Education required by Mrs Bailey during the discharge of Mr. Bailey
Before the discharge, the hospital staff will educate the patient and his carers about two
weeks supply of medicine and proper dosage of the painkillers. The discharge letter and an entire
summary for the operation should be provided (Avitabile et al., 2016). It is necessary to educate
the informal caregiver, in this case Mrs. Bailey and the patient about the occurrence of hospital-
acquired blood clots. The patient would be educated about the chest drain information and the
necessary equipment if required. The surgical wound and chest drainage would take some time
to heal. Mirrors can be used to check the wound regularly (Boynton, Kelly, Amber Perez, &
Miller, (2014). The practice nurse should give information about the drain stitch that has to be
removed five to seven days after the drains have been removed. Other education involves
bathing information, such as avoiding the direct application soap above the wound, as direct
contact might cause irritation of the wound . Education about the type of food that has to be
consumed is also necessary to give to the patients. Eating more fruits vegetables, high fiber food

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can be recommended. After a major operation, it is normal to feel a bit “down”, which can be
due to the impact of the surgery, lack of money or energy. Hence, the nurse might counsel these
patients and should assure them.
Conclusion
Thoracotomy and lobectomy pose a huge physical burden on the patients, which needs to
be addressed in order to bring back the patient to the normal pace of life. One of the most
important complications that might arise after thoracic surgery is pulmonary complication that
can act both as a physical as well as an emotional burden as it largely affects the functionality of
an individual. How pulmonary complication will affect the daily activities of living has been
described in the lens of the Roper Logan Tierney model. Physiotherapists play an important role
in managing pain by using non-phamacological ways such as cold therapy and physiotherapies.
Finally, before discharging the patient, the patient should be educated about the medicines, the
movements that are permissible, the precautionary measures that need to be taken, checking for
the signs and symptoms for preventing infections. An occupational therapist might visit patients
to help him cope up with the movement.

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