video assisted thoracic surgery case analysis

7/27/2019 Video Assisted Thoracic Surgery Case Analysis

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Valerie Ann L. Miller CIs: Rowena S. Manzarate, RN, MAN/

3Nur7 RLE 2 Margaret Natividad, RN, M.Ed

Nursing Case Analysis: Myasthenia Gravis

I. AssessmentA. Demographics

A 34-year-old single male patient, residing in Cainta, Rizal was admitted in

University of Santo Tomas Hospital last July 1, 2013 to undergo Video Assisted

Thoracic Surgery with Thymectomy.

B. History of Present Illness8 months PTC, patient noticed difficulty chewing. Symptoms recurredintermittently throughout the day. 4 months PTC, patient was hospitalized for

tonsillitis and the fatigue with chewing disappeared. 3 months PTC, patient

experienced fatigue with chewing and difficulty in swallowing. 2 months PTC,

patient experienced double vision, blurring of vision, change in character of voice.

Persistence of symptoms prompted consult at UST-OPD.

C. PCR format on assessmentOn assessment, patient was conscious, coherent, ambulatory, not in

cardiorespiratory distress, pink peripheral conjunctiva, anicleric sclera, no cervical

lymphadenopathies, no neck mass, symmetric lung expansion, clear breath sounds,adynamic precordium, no murmurs, flat abdomen, normoactive bowel sounds, and

pulses full and equal. MMT 5/5 on all and no deformities.

D. Significant Laboratory and Diagnostic ExaminationsCBC : WBC: 13.33

CXR: (-) PTB

PFT: patient unable to tolerate full PFT

FEV13.65L FVC: 4.37L

FEV1/FVC- 88%

Spirometry: revealed moderate restrictive defect but patient unable to tolerate.

Blood bank: A positive


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E. Nurses NotesJuly 1, 2013

Admitted 34 year old male under the service of Dr. Sanchez; complaints of thymoma;

encouraged DBE and relaxation technique; mild anxiety related to incoming

thymectomy; (+) Myasthenia Gravis, for blood extraction; monitor VS every 4 hours;

started Omeprazole 40 mg

July 2, 2013

Scheduled for OR suite VATS thymectomy on July 3, 2013 TF 7am; Secured consent

and clearance; shifted Prednisone to 100mg/IV; NPO from 2am; IVF via g18 venflon,

sterofundin at 40 gtts/min; Cefuroxime 1.5 g/ IV skin test.

July 3, 2013

Started hydrocortisone(solucortef) 100mg/ IV q12; rescheduled OR for tomorrow

July 4,2013 7 am; NPO from 10 pm; IVF as previously ordered.

July 4, 2013

(endorsed to OR at 8 am)

II. Anatomy and PhysiologyThe skeletal muscle fibers are innervated by large myelinated nerve fibers that

originate from large motoneurons in the anterior horns of the spinal cord. Each nerve fiber

normally branches and stimulates from three to several hundred skeletal muscle fibers. Each

nerve ending makes a junction, called the neuromuscular junction, with the muscle fiber nearits midpoint. As shown in the figure below, the nerve fiber forms a complex of branching

nerve terminals that invaginate into the surface of the muscle fiber but lie outside the muscle

fiber plasma membrane. The entire structure is called the motor end plate.

To clearly visualize the relation of the muscle fiber to the nerve fiber, Figure 2 is also used.

This is where the junction between a single axon terminal and the muscle fiber membrane exists.

The invaginated membrane is called the synaptic gutter, and the space between the terminal and

the fiber membrane is called the synaptic cleft. At the bottom of the gutter are numerous smaller


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folds on the muscle membrane called subneural clefts, which increase the surface area at which

the synaptic transmitter can act.

In the axon terminal are many mitochondria that supply adenosine triphosphate (ATP),the energy source that is used for synthesis of an excitatory transmitter acetylcholine. The

acetylcholine in turn excites the muscle fiber membrane. Acetylcholine is synthesized in the

cytoplasm of the terminal, but it is absorbed rapidly into many small synaptic vesicles, about

300,000 of which are normally in the terminals of a single end plate. In the synaptic space are

large quantities of the enzyme acetylcholinesterase, which destroys acetylcholine a few

milliseconds after it has been released from the synaptic vesicles.

Acetylcholine Aids in Muscle Contraction

Normally, a nerve impulse reaches the neuromuscular junction which allows the release

of acetylcholine from the axon terminals into the synaptic cleft. In detail, acetylcholine is

released from the synaptic vesicles at the neural membrane of the neuromuscular junction which

contains voltage-gated calcium channels. These channels open and allow calcium ions to diffuse

from the synaptic cleft to the interior of the nerve terminal. The calcium ions attract the

acetylcholine vesicles, drawing them to the neural membrane adjacent to the dense bars. The


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vesicles then fuse with the neural membrane and empty their acetylcholine into the synaptic cleft

by the process of exocytosis. On the other hand, the muscle fiber membrane contains

acetylcholine receptors which are acetylcholine-gated ion channels. Its principal effect is to

allow large numbers of sodium ions to pour to the inside of the fiber, creating a local positive

potential change inside the muscle fiber membrane, called the end plate potential. In turn, this

end plate potential initiates an action potential that spreads along the muscle membrane and thus

causes muscle contraction.

Once the acetylcholine is released into the synaptic cleft, it continues to activate the

acetylcholine receptors. However, acetylcholine will be removed rapidly by the enzyme

acetylcholinesterase and the diffusion of the small amount of acetylcholine out of the synaptic

cleft, preventing it to act on the muscle fiber membrane. Fatigue of the neuromuscular junction

or the repetitive stimulation of the nerve fiber at rates greater than 100 times per second for

several minutes often diminishes the number of acetylcholine vesicles that it may fail to pass intothe muscle fiber.

III. Pathophysiology


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IV. Discussion for the OR ProcedureA. Rationale for the Surgery

Thymectomy is an effective, but radical therapy for myasthenia. Video-assisted

thoracic surgery (VATS) may allow a minimally invasive alternative to the

standard sternotomy approach. It allows surgeons to remove masses close to the

outside edges of the lung and to test them for cancer using a much smaller surgery

than doctors needed to use in the past. It is also useful for diagnosing certain

pneumonia infections, diagnosing infections or tumors of the chest wall, and

treating repeatedly collapsing lungs. Doctors are continuing to develop other uses

for VATS.

B. Pictures related to Surgery

C. Significant Discussion Related to SurgeryVATS is done in an operating room. You wear a hospital gown and have an IV

(intravenous) line placed in your arm so that you can receive medicines through it.

VATS is usually done with general anesthesia, which puts you to sleep so you are

unconscious during the procedure. General anesthesia is administered by an

anesthesiologist, who asks you to breathe a mixture of gases through a mask.After the anesthetic takes effect, a tube is put down your throat to help you

breathe. Your anesthesiologist can use this tube to make you breathe using only

one of your lungs. This way the other lung can be completely deflated and allowthe surgeon a full view of your chest cavity on that side during the procedure.

If VATS is being used only to evaluate a problem on the inside of the ribcage (notthe lung itself), then it can sometimes be done using regional anesthesia. With


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regional anesthesia, you are not asleep during the surgery, but are given medicines

that make you very groggy and that keep you from feeling pain in the chest. This

is done with either a spinal block or an epidural block, in which ananesthesiologist injects the anesthetic through a needle or tube in your back or

neck. You do your own breathing with this type of anesthesia, but one of your

lungs will be partly collapsed to allow the doctors to move instruments betweenthe lung and the chest wall.

A very small incision (less than an inch long) is made, usually between yourseventh and eighth ribs. Carbon dioxide gas is allowed to flow into your chest

through this opening, while your lung on that side is made to partly or completely

collapse. A tiny camera on a tube, called a thoracoscope, is then inserted through

the opening. Your doctor can see the work he or she is doing by watching a videoscreen.

If you are having a procedure more complicated than inspection of the chest and

lung, the doctor makes one or two other small incisions to allow additionalinstruments to reach into your chest. These additional incisions are usually made

in a curving line along your lower ribcage. A wide variety of instruments areuseful in VATS. These include instruments that can cut away a section of your

lung and seal the hole left in your lung using small staples, instruments that can

burn away scar tissue, and tools to remove small biopsy samples such as lymph

nodes from your chest.

At the end of your surgery, the instruments are removed, the lung is reinflated,

and all but one of the small incisions are stitched closed. For most patients, a tube(called a chest tube) is placed through the remaining opening to help drain any

leaking air or fluid that collects after the surgery.

If you are having general anesthesia, it is stopped so that you can wake up within

a few minutes of your VATS being finished, although you will remain drowsy for

a while afterward.

D. Positive and Negative Aspects Related to the SurgeryIt is easier for patients to recover from VATS compared with regular chestsurgery (often called "open" surgery) because the wounds from the incisions are

much smaller. You will have a small straight scar (less than an inch long)

wherever the instruments were inserted. There are some potentially serious risks

from VATS surgery. Air leaks from the lung that don't heal up quickly can keepyou in the hospital a longer time and occasionally require additional treatment.

About 1% of patients have significant bleeding requiring a transfusion or larger

operation.


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Sometimes, especially if cancer is diagnosed, your doctors will decide that you

need a larger surgery to treat your problem in the safest manner possible. Your

doctors might discuss this option with you ahead of time. That way, if necessary,the doctors can change over to a larger incision and do open chest surgery while

you are still under anesthesia. Death from complications of VATS surgery does

occur in rare cases, but less frequently than with open chest surgery.

General anesthesia is safe for most patients, but it is estimated to result in major

or minor complications in 3%-10% of people having surgery of all types. Thesecomplications are mostly heart and lung problems and infections.

Irritation of the diaphragm and chest wall can cause pain in the chest or shoulderfor a few days. Some patients experience some nausea from medicines used for

anesthesia or anxiety.

V. Drug AnalysisGeneric Name Specific

Brand Name

Mechanism of

Action

Rationale Nursing

Responsibilities

Pyridostigmine Mestinon Pyridostigmine isused to improve

muscle strength in

patients with a

certain muscle

disease (myasthenia

gravis). It works by

preventing the

breakdown of a

certain natural

substance

(acetylcholine) in

your body.

Acetylcholine is

needed for normal

muscle function.

It is used to

temporarily improveneuromuscular

transmission. These

agents prolong the

action of Ach at theneuromuscular

junction and

facilitate eating andswallowing.

*Report increasing

muscular weakness,cramps, or

fasciculations.Failure of patient toshow improvement

may reflect either

underdosage oroverdosage.

*Monitor vital

signs frequently,

especially

respiratory rate.*Be aware that

duration of drug

action may varywith physical and

emotional stress, as

well as withseverity of disease.*Report onset of

rash to physician.

Drug may bediscontinued.
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Prilosec Omeprazole An antisecretory

compound that is

a gastricacid pump

inhibitor.Suppresses gastricacid secretion by

inhibiting the H+,

K+-ATPaseenzyme system

[the acid (proton

H+) pump] in the

parietal cells.

*Report any

changes in urinary

elimination such as

pain or discomfort

associated withurination, or blood

in urine.

*Report severe

diarrhea; drug may

need to be

discontinued.

Prednisone Enters target cellsand binds tointracellular

corticosteroidreceptors, therebyinitiating manycomplex reactionsthat are responsible

for its anti-inflammatory andimmunosuppressiveeffects.

Glucocorticosteroids

are effective in

suppressing theimmune system.

Administer once-

a-day doses before

9 AM to mimicnormal peak

corticosteroid

blood levels.

Increase dosage

when patient is

subject to stress.

Taper doses when

discontinuing high-

dose or long-term

therapy.

Do not give live

virus vaccines with

immunosuppressive

doses of

corticosteroids.

Hydrocortisone Sulo Cortef Enters target cellsand binds tocytoplasmic

receptors; initiatesmany complexreactions that areresponsible for itsanti-inflammatory,

immunosuppressive(glucocorticoid),

and salt-retaining(mineralocorticoid)

Glucocorticosteroidsare effective in

suppressing the

immune system.

Administer once-

a-day doses before

9 AM to mimic

normal peak

corticosteroid

blood levels.

Increase dosage

when patient is

subject to stress.

Taper doses when


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actions. Some

actions may beundesirable,depending on drug

use.

discontinuing high-

dose or long-term

therapy.

Do not give live

virus vaccines with

immunosuppressive

doses of

corticosteroids.

VI. Nursing Care Plans

A. Pre-operativeCues and

Clues

Nursing

Diagnosis

Analysis Goal and

Objectives

Intervention

s

Rationale Eval-uation

*Impaired

vision: diplopia

and ptosis

due to

weakness

of ocular*Dysphagi

a due topharyngeal

and

laryngeal

weakness.

Nervous

systemdysfunction

The initial

manifest-tation of

myastheni

a gravis in

two thirds

of patientsinvolves

the ocularmuscles.

At the end

of theshift, the

patient will

be able to:

1. eat and

drinkwithout

havingdifficulty.

1.Adminis-

ter Mestinonas

prescribed.

1. It is used

totemporarily

improve

neuro-

muscular

transmission

At the end

of the shift,the patient:

1.can eat

and drink

without

difficulty.

(+)Myasthenia

Gravis

*weakness

*restless

Mildanxiety

related to

incoming

thymectomy

At the endof the shift

the patient

will:

1.Verbalize

awareness

of feelings

of anxiety2.Appear

relaxed

1. Establisha therapeutic

relationship,

conveying

empathy.2. Provide

comfort

measures.

1. Toidentify and

assess the

different

nursingintervention

s to be done.

2. To

providecomfort.

At the endof the shift,

the patient:

1.verbalize

dawareness

of feelings

of anxiety.

2.appearedrelaxed.


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B. Intra-operativeClues and

Clues

Nursing

Diagnosis

Analysis Goal and

Objectives

Intervention

s

Rational

e

Evaluation

*Incision*Ongoing

Surgery

Risk forbleeding At risk for adecrease in

blood volume

that maycompromise

health.

At the end ofsurgery, the

patient will:

1.have anormal range

of laboratory

results forclotting times

and factors

2.be free of

signs ofactive

bleeding or

excessive

blood loss.

1.Monitorclosely for

diffuse

oozing fromtubes,

incision.

2.beprepared

with blood

transfusion.

1.identify factors

that may

poten-tiate

blood

loss.2. to be

ready if

in case

ofexcessiv

e blood

loss

duringsurgery.

At the end ofsurgery, the

patient:

1.has normalrange of

laboratory

results.2.is free of

signs of

active

bleeding andexcessive

blood loss.

*Immuno

-

suppresio

n*Ongoing

surgery

Risk for

infection

At increased

risk for being

invaded by

pathogenicorganisms.

At the end of

the shift, the

health team

memberswill:

1.identify

interventionsto prevent or

reduce risk

of infection.

2.verbalizeunderstandin

g of

individualcausative or

risk factors.

1. Use

sterile

technique

duringscrubbing,

gowning,

and gloving.2.

Remember

and perform

the aseptictechnique

when

handling theinstruments

inside the

operating

room suite.

1.To

avoid

conta-

minationthat

maycaus

einfection

to the

patient.

At the end of

the shift, the

health team

members:1.identified

interventions

preventingrisk of

infection.

2.Verbalized

understanding of

individual

causative orrisk factors.

*ongoingsurgery

*more

than 10hours

surgery

Risk forInjury

At risk ofinjury as a

result of

environmental conditions

interacting

At the end ofthe surgery,

the patient

will:1. Be

free

1.Use ofstraps.

1.toprevent

the

patientfrom

falling

At the end ofthe surgery,

the patient:

1.is free ofinjury.


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with the

individualsadaptive and

defensive

resources.

of

injury

from the

OR bed.

C.Post-operativeCues and

Clues

Nursing

Diagnosis

Analysis Goal and

Objectives

Interventions Rationale Evaluation

*(+) facial

grimace

Pain related

to post

surgery

incision

Un-

pleasant

sensory

arisingfrom

actual or

potential

tissuedamage.

At the end of

the shift, the

patient will:

1.verbalizeminimal pain

from the

incision site.

1.Administer

analgesics as

prescribed.

2. Teachclient

divertional

activies.

1.

alleviate

pain

2. todivert

attention

from

pain.

At the end of

the shift, the

patient;

1.verbalizedminimal pain

from the

incision site.

*difficulty

in

swallowin

g*fatigue

in

chewing

Imbalanced

nutrition

less than

bodyrequirement

s

Many

patients

also

experience

weakness

ofthe

muscles

of the face

and throat(bulbar

symptoms

) andgeneralize

d

weakness.

At the end of

the shift, the

patient will

be able to:1.verbalize

understandin

g ofcausative

factors

2.Verbalize

Demonstration behaviors

and lifestyle

changes toregain and

maintain

appropriate

weight.

1.Assess

reflex cough

reflex and

swallowingdisorders

before

administration by mouth.

2. Record

intake and

output.3. Measure

the patient's

body weightevery day

1. to be

able to

know if

thepatient

can

toleratefeeding.

2. to

monitor

thepatients

nutrition

al intake.

At the end of

the shift, the

patient:

1.verbalizedunderstandin

g of

causativefactors.

2.Verbalized

demonstratio

n ofbehaviors

and lifestyle

changes toregain and

maintain

appropriate

weight.


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VII. References:Doenges, Moorhouse & Murr.Nurses Pocket Guide. Philadelphia, USA:FA

Davis Company,2010.

Gould, Barbara. Pathophysiology for the Health Professions. Singapore:

Elsevier,2007.

Smeltzer, Bare, Hinkle & Chiver. Medical Surgical Nursing.

Philadelphia,USA: Lippincott Williams and Wilkins, 2010.

http://www.ncbi.nlm.nih.gov/pubmed/12162392

http://www.health.harvard.edu/diagnostic-tests/video-assisted-thoracic-surgery.htm

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video assisted thoracic surgery case analysis

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