A nurse is planning care for a client who was admitted to the intensive care unit hour ago following a left-sided pneumonectomy. Which of the following interventions should the nurse implement to minimize the risk of potential complications? Select all that apply.
- ATurn the client onto the right, non-operative side every hours to prevent dependent atelectasis.
- Palpate the client's neck to assess for tracheal deviation.Answer
- Instruct the client to perform deep breathing exercises and use an incentive spirometer.Answer
- Maintain the head of the bed elevated in a semi-Fowler's position.Answer
- EAdminister intravenous sodium bicarbonate if the client's arterial blood gas shows a pH of , of , and of .
- FAuscultate the abdomen for bowel sounds prior to assessing the respiratory system to establish a baseline.
Answer
The correct interventions are palpating the neck for tracheal deviation, instructing the client to use an incentive spirometer, and maintaining the head of the bed in a semi-Fowler's position.
Following a pneumonectomy, the client has only one functioning lung, which must be protected and its expansion maximized. Elevating the head of the bed to a semi-Fowler's position utilizes gravity to pull abdominal organs downward, promoting optimal diaphragmatic excursion and ventilation. Deep breathing exercises and incentive spirometry are critical aggressive therapies to prevent atelectasis and pneumonia in the remaining lung. Palpating the neck for tracheal deviation is a vital assessment, as a shift away from midline indicates a life-threatening mediastinal shift or tension pneumothorax that requires immediate emergency intervention.
Step-by-Step Solution
Key Concept
Post-pneumonectomy risk reduction involves prioritizing the expansion of the remaining lung, detecting life-threatening mediastinal shifts early, and strictly following the ABCs of assessment.