preoperative preparation for thoracic surgery
TRANSCRIPT
Preoperative Patient Education
Saneesh P J
in Thoracic Surgery
Introduction
Modern-day health care
Scientifically perfect
Emotionally or psychologically unsatisfied patients
Surgeon
Anesthetist
Physicians
Nurses
Resp Therapist
s
Others
Patient
Coordinated activity
Initial visit•Recommendation for surgery•Sufficient time is allocated•Questions are encouraged
Subsequent visit•Review the planned procedure•Additional questions are answered•Preop anesthesia clinic visit
Content of preoperative teaching
Related to surgery (or thoracic surgery) in general
Issues related to a specific operation
Content of preoperative teachingGeneral preoperative education
Respiratory hygiene
Pain
Smoking cessation
Diet and nutrition
Wound care and drains
Postdischarge social issues
Contact numbers
General preoperative evaluation
Rapport
General preoperative evaluationUnderstanding of the planned procedure
Why it is being recommended
What its risks are
Whether there are alternatives
Role of active patient participation
Respiratory hygiene
Atelectasis
Pneumonia
Pulm embolism
Common complications of thoracic surgeryCan be prevented with active patient involvement
Respiratory hygiene
Coughing
Deep breathing
Using an incentive spirometer
Walking
Sitting to eat
Performing other seemingly minor activities
Decreased incidence of postoperative pneumonia
Respiratory hygiene
Coughing
Deep breathing
Using an incentive spirometer
Walking
Sitting to eat
Performing other seemingly minor activities
• Painful• ? Prevent pneumonia• Expectoration of sputum – desirable
• Teach method of splinting operative site to minimise pain with coughing
Respiratory hygiene
Coughing
Deep breathing
Using an incentive spirometer
Walking
Sitting to eat
Performing other seemingly minor activities
• Can open collapsed alveoli • Prevent overt atelectasis
Respiratory hygiene
Coughing
Deep breathing
Using an incentive spirometer
Walking
Sitting to eat
Performing other seemingly minor activities
• Improved aeration of the lungs • Avoidance of alveolar and segmental collapse
Respiratory hygiene
Coughing
Deep breathing
Using an incentive spirometer
Walking
Sitting to eat
Performing other seemingly minor activities
• Semirecumbent posture predisposes to aspiration and regurgitation
Respiratory hygiene
• Setting expectations is important• Far more effective preoperatively
than postoperatively when breathing is compromised by pain
• Baseline spirometry readings• Easy to convince target values in
postop period
Pain
Loss of personal control
Most frightening concerns by patients
Pain
Can allay these fears
Reduce anxiety
Realistic expectations - postop pain
Effective preoperative teaching
Pain
Discussion of narcotic analgesics, patient- controlled analgesia, nonsteroidal analgesics, and epidural anesthesia (continuous, intermittent, and patient controlled)
Side effects, including nausea, gastrointestinal dysfunction, and the potential for a lack of efficacy
Goal of postoperative analgesia pain control that provides patients with an ability to function and interact with their environment effectively
Goal
OptionsSide effects
Pain
Effective preoperative counseling
Sets the expectationsCan be reinforced in the postopeative period
Smoking cessationThoracic surgery mostly deals with smoking related pathology
May/may not quit smoking• addictive qualities of nicotine outweigh the intellectual
knowledge that smoking is harmful
May use smoking as a method of coping with anxiety and fear
Cigarette smoking impairs the mucociliary clearance mechanisms of the tracheobronchial tree and may predispose to postoperative pulmonary complications.
Smoking cessation
The optimal time for smoking cessation is unclear
Most surgeons encourage patients to stop smoking in preparation for thoracic surgery.
Whether surgery should be denied to patients who continue to smoke is controversial.
Every effort should be made preoperatively to persuade the patient to stop smoking.
Diet and Nutrition
Significant recent weight loss
Preoperative chemotherapy or radiation therapy
Nutritional deficiencies can be expected and consequently preempted.
Patient questions regarding nutritional supplementation to be addressed
Wound care & Drains
Patients often have negative expectations about wound care and often are pleasantly surprised to learn that care is usually minimal. Patients should be taught about the uses and benefits of percutaneous tubes and drains.
Post-discharge social issues
Family involvement in postoperative convalescence
Job-related concerns
Expectations regarding physical limitations, including appetite, sleep irregularity etc
Cultural sensitivity and family dynamics may play crucial roles in effecting a smooth post- operative recovery.
Contact numbers
Provide patients with a reliable method of contacting the surgeon or his or her designee.
Procedure-specific teaching
Pulmonary resection (lobectomy/pneumonectomy) Thoracoscopy Lung volume reduction surgery Esophagectomy Photodynamic therapy Transplantation
postthoracotomy pain – analgesia plans
potential for decreases in pulmonary reserve
Procedure-specific teaching
Pulmonary resection (lobectomy/pneumonectomy) Thoracoscopy Lung volume reduction surgery Esophagectomy Photodynamic therapy Transplantation
Often can be discharged the day after surgery
Presence of a chest tube often dictates an overnight stay
Procedure-specific teaching
Pulmonary resection (lobectomy/pneumonectomy) Thoracoscopy Lung volume reduction surgery Esophagectomy Photodynamic therapy Transplantation
Risk of prolonged air leaks.
Risks of pneumonia
Potential for postoperative mechanical ventilation
Use of one-way valves and the possibility of being discharged home with a chest tube in place can be discussed
Procedure-specific teaching
Pulmonary resection (lobectomy/pneumonectomy) Thoracoscopy Lung volume reduction surgery Esophagectomy Photodynamic therapy Transplantation
Prolonged cutaneous photosensitivity
Procedure-specific teaching
Pulmonary resection (lobectomy/pneumonectomy) Thoracoscopy Lung volume reduction surgery Esophagectomy Photodynamic therapy Transplantation
Lifelong involvement with the transplant center
Ongoing use of multiple medications
Need for periodic physiologic and pathologic assessment
Preoperative assessment frequently involves psychologists (or psychiatrists) and social workers
Preoperative teaching tools
Verbal instructio
n Written
material
Web-based
material
Audiovisual
material
Verbal instructions
Verbal instructi
on Written
material
Web-based material
Audiovisual material
Basic questions that they are reluctant to discuss with the surgeon
Multiple factors, such as language barriers, learning disabilities, and cultural barriers
The cornerstone tool to pre-operative teaching
Written materials / leaflets
Verbal instructio
n Written
material
Web-based material
Audiovisual material
Commercial product-specific patient education packets
“In-house” procedure-specific information booklets
Patient education materials, leaflets
Web-based materials
Verbal instructio
n Written
material
Web-based
material Audiovisual material
Help to choose right, authentic sources
Pharma websites also can help familiarize with specific products or procedures
Websites of authorised organisations can be of great help
Audiovisual materials
Verbal instructio
n
Written materi
al
Web-based materi
al Audiovisual
material
Better attention with patient’s own X ray, CT scan etc
Diagrams- hand-drawn or from books / web
Lung models to explain the disease
Summary
The goal of patient teaching is to improve patients’ understanding of their disease
process and the operation ensure their active participation in the treating
process The additional goal of obtaining informed
consent is an ingrained component to the current physician-patient relationship.
Summary
Team effort
Knowledgeable, Active Participant
Multiple modalities
Thank you