Upload
emman-ramos
View
240
Download
0
Embed Size (px)
Citation preview
7/31/2019 Reviewer RLE
1/30
Invasive Procedures
-can be diagnostic and therapeutic to the
patient.
Pre-operative
Intra-operative
Post-operative
7/31/2019 Reviewer RLE
2/30
Thoracic Surgery
Diseases of the lungs that requires surgical procedures
1. Lung Cancer
2. Lung Abscess
3. Cysts
4. Chest Trauma5. Lung Transplant
Diagnosis/ Preparation
Common incisional approach:
1. Sternotomy- incision through and down the breastbone2. Thoracotomy- incision via the side of the chest
3. VATS (Video Assisted Thoracotomy) insertion of the thorascope and surgical
instruments into the thorax through any of 3 to 4 small incision in the chest wall.
7/31/2019 Reviewer RLE
3/30
Thoracic surgeries and procedures
Lobectomy- surgical removal of one lobe of the lungs
- indicated for patient with bronchogenic carcinoma, giantemphysematous blebs or bullae, benign tumors, metastatic malignanttumors, bronchoiectasis and fungus infecions.
Pneumonectomy- removal of the entire lung
- indicated for patient with lung cancer, lung abcess, bronchoiectasis,
extensive unilateral tuberculosis
Exploratory Thoracotomy- internal view of the lung
- used to confirm carcinoma or chest trauma
Segmentectomy (Segmental Resection)- removal of section of a lobe of the lungs
Wedge resection- small localized section of lung tissue removed
- usually pie shaped
- performed for random lung biopsy and small peripheral nodules
7/31/2019 Reviewer RLE
4/30
Pre- operative Management:
Maximize respiratory function and reduce risk of complications
Chest auscultation
Assess for retained secretion
Pulmonary function studies
ABG
Bronchoscopic examination
Chest X-ray
MRI Blood test
ECG
Improving airway clearance
Humidification
Postural drainage
Chest percussion after administration of bronchodilators
7/31/2019 Reviewer RLE
5/30
Health teachings regarding the:
Type of anesthesia
Use of chest tubes and drainage system
Administration of oxygen or possible use of ventilator
Use of incentive spirometry
Proper positioning
Health teaching techniques:
Coughing
Splinting the incision site
Pain management
Relieving anxiety
*huffing- deep breathing
Giving prophylactic anticoagulant as prescribed to reduce peri-operative incidence
of DVT and pulmonary embolism
Ensure patient fully understands surgery and emotionally prepared, consent for
the surgery
7/31/2019 Reviewer RLE
6/30
Post-operative Management:
Chest auscultation, suctioning of secretion
Oxygen administration via mechanical ventilator, nasal cannula, or face mask
V/S, intake and output monitoring hourly including CTT (amount, character ofdrainage)
Proper positioning:
Lobectomy- lying on the back/ turned to either side
Pneumonectomy- lying on back/ turned toward the operative side (affected side)
Segmental resection- lying on back/ turned onto non-operative side
Assess for signs of complications:
Cyanosis
Dyspnea
Acutes chest pain- may indicate atelectasis
Elevated WBC- infection
Pallor and increased pulse- internal hemorrhage
Dressings are assessed for fresh bleeding
Monitor ABG and Oxygen saturation frequently
Begin ROM exercise of arm and shoulder of affected side (ankylosis)
7/31/2019 Reviewer RLE
7/30
Respiratory insufficiency- if the rest of the lung cannot compensate for the loss of
the lobe
Pulmonary embolism- blood clot can lodge in the vessels of the lung
DVT- lying in bed for long periods after surgery
Cardiac arrhythmias- the hear beats irregularly and stops pumping blood as
efficiently (3rd to 4th day post-operative)
Bleeding and infection
Bronchopleural fistula- connection of forms
Nursing Diagnosis
Ineffective Breathing Pattern related to wound closures
Risk of Fluid Volume Deficit related to chest drainage and blood loss
Pain related to wound closure and presence of drainage tubes in the chest
Impaired Physical Mobility of affected shoulder and arm related to
7/31/2019 Reviewer RLE
8/30
Renal Surgery
Indication: For severe kidney damage such as:1. Cancer of the kidney- renal cell carcinoma
2. Polycystic kidney disease
3. Serious kidney infections
4. Kidney transplantation
Types of nephrectomy
1. Radical nephrectomy- treatment of tumor can be removed
- removal of the kidney tumor, adrenal gland, fatty tissue,
lymph nodes
2. Simple nephrectomy- performed for living donor, transplant purposes requiresremoval of the kidney and section of the ureter
3. Laparoscopic nephrectomy- removal of kidney with small tumor
-use of videoscope
7/31/2019 Reviewer RLE
9/30
Pre-operative Management
Patient is prepared for surgery and consent is witnessed
Pre-operative antibiotics and bowel cleansing regimen are prescribed
Application of anti-embolic stockings, and leg exercise are taught Blood samples for cross matching for possible transfusion
Insertion of retention catheter
Assess CP clearance
Positioning
Lateral lumbar flank; transthoracic with affected side up
Incision site: Flank (Posterior axillary line, beneath the 12th rib to suprapubic area)
Post-operative Management
Assess fluid and electrolytes status
Monitor hemoglobin and hematocrit results and urine specific gravity and ECG
Monitor amount and character of urine drainage every 1 hour
Assess patency of urinary or wound drainage tube; reinforce or change dressings
Assess pain location, intensity, and characteristics; assess bowel sounds
7/31/2019 Reviewer RLE
10/30
Health teachings: coughing, deep breathing exercises, use of incentive spirometry
to prevent atelectasis and pulmonary complications
- Assist in turning because patient may experience pain and muscle soreness
For Kidney Transplant- immunosuppressant drugs are ordered Monitor for kidney infection/ kidney rejection
Increased temperature
Decreased urine output
Pain and tenderness
Hypertension Blood exam (Creatinine)
Home instructions:
Teach patient to inspect and care for incision
Activity and lifting restriction, driving and pain management
Notify physician about problems like fever, breathing difficulty
Advise to wear a medical alert bracelet
Emotional support- loss of one kidney, dialysis
7/31/2019 Reviewer RLE
11/30
Complications:
Infection
Hemorrhage and shock
Post-operative Pneumonia Thromboembolism
Paralytic Ileus
Obstruction of urinary drainage
Injection of transplant
Nursing Diagnosis
Pain related to surgical incision site
Altered Urinary Elimination related to urinary drainage tubes or catheter
Risk for infection related to incision, potential pulmonary complications
Risk for Fluid Volume Deficit or Excess related to fluid replacement needs
7/31/2019 Reviewer RLE
12/30
Prostate Surgery
Indication: Benign Prostatic Hyperplasia and Prostate Cancer
Surgical approach depends on size of the gland:
1. Transurethral Resection of the Prostate (TURP)- the most common used to remove
BPH. Retroscope is passed through the urethra to exercise and cauterize the
excessive prostatic tissue
2. Suprapubic Prostatectomy- incision into suprapubic area and through bladder wall
and prostate gland is removed from above
3. Retropubic Prostatectomy- incision can be made in the lower abdomen (at the
level of symphysis pubis); useful when prostate is large
4. Perineal Prostatectomy- incision through the scrotum and rectum. Prostate gland
is removed through an incision in the perineum.5. Laparoscopic Radical Prostatectomy- preformed through 4-6 small incisions in the
mid-abdomen. It reduces the risk of post-operative erectile and urinary
dysfunction
7/31/2019 Reviewer RLE
13/30
Pre-operative Management:
Reducing anxiety
Explain the nature of the procedure
Discuss the complications of surgery1. Incontinence of dribbling of urine
2. Retrograde ejaculation
Bowel preparation is given and prophylactic antibiotics
Providing instruction: turning, coughing, and breathing exercises
Ensure that optimal cardiac, respiratory, and circulatory status have been achievedto decrease risk of complication
Monitor Urinary Drainage- Continuous Bladder Irrigation (Cystoclysis)
1. Monitor urine character after prostatectomy
a) Clear to pale pink- normal during entire hospital course
b) Light red to red- normal or expected on the day of surgery
c) Very dark red/ bright red- indicate venous/ arterial bleeding or inadequate CBIflow.
d) Blood Clots- normal if they are occasional. Increase the CBI rate to preventcatheter obstruction
7/31/2019 Reviewer RLE
14/30
2. Offer fluids frequently to keep urine diluted and minimize infection and
obstruction of the catheter.
3. When catheter is removed about 3-7 days after surgery, client should void within
5-6 hours. Normal for client to experience some urgency, frequency and dysuria.Incontinence is not normal and may be caused by bladder spasm.
Prevent Complications- most common are:
1. Hemorrhage- noted by copious, bright red blood in the urine.
2. Thrombus and embolism- prevent by turning and exercising the legs.3. Bladder spasm- check for the patency of the catheter and irrigate it as
ordered. Frequency of spasm should decrease in 24-48 hours.
Discharge Instructions:
1. Healing- health habits of adequate nutrition and rest help promote healing.Perineal was used, sitz bath or warm compress should be applied to the
perineum.
7/31/2019 Reviewer RLE
15/30
2. Adjusting to changes in self-concept- client may have permanent/temporary interference with sexual functioning.
3. Do not any lifting or have intercourse of 6 weeks after surgery.
4. Hematuria may continue but client should report bright red bleedingand inability to void.
Nursing Diagnosis
Altered Urinary Elimination related to surgical procedure and urinary catheter
Risk for Infection related to surgical incision , immobility and catheter
Pain related to surgical procedure
Anxiety related to Urinary Incontinence difficulty voiding and erectile dysfunction
7/31/2019 Reviewer RLE
16/30
Breast Examination
Breast Cancer Screening- early detection is an important factor in the success ofbreast cancer treatment
3 Methods Commonly used for early detection are:
1. Breast self-examination (BSE)
2. Clinical Breast exam
3. MammogramPurpose:
- to detect any abnormalities in the breast
- to identify signs of breast disease and then initiate early treatment
- teach a woman to perform BSE
Indications:
- Patients practice of BSE
- Palpable lumps
- Nipple discharge
- Pain or tenderness
7/31/2019 Reviewer RLE
17/30
When to do?
Regularly monthly basis, 3- 7 days after the end of the menses
For irregular period/ menopause women, do it on the same day same month
Equipments:
Good lighting
Small pillow
Gloves (optional)
Slide foe specimen (optional)
Special Considerations:
Breast assessment should also be a routine part of a complete male assessment
Breast palpation requires practice and skill because the consistency of thebreasts varies widely from client to client
BSE should begin for women in 20s
7/31/2019 Reviewer RLE
18/30
Risk Factors
Gender (female)
Age (increasing with age)
- 100x to develop breast cancer (60 y/o)
Family history
Personal history
Early menarche and late menopause
No natural children (nullipara and absence of breast feeding)
First child born to mother with an older age
Education and socioeconomic status
Diet
Possible risk factors for mortality
No (poor) BSE
Poor Screening
7/31/2019 Reviewer RLE
19/30
Risk Reduction Tips
Not delaying pregnancy until after age 30
Breastfeeding
Knowledge about Breast cancer screening
Exercise esp. in youth but also in adulthood
Breast Cancer Screening
The type and frequency of breast cancer screening that is best for you, changes as
you age.
1. Ages 18 to 39: You should have a clinical breast exam every 3 years
2. Ages 40 to 69: Annual clinical breast exams. Annual mammography is
recommended for women older than age 50
3. Age 70 and over: If you are 70 or older talk to health care professional about
mammography as regular part of your health care plan.
7/31/2019 Reviewer RLE
20/30
Malignancy of Mammary ducts (Pagets Disease)
-early sign is erythema of areola and nipple; while the late sign are thickening,
erosion
Inflammation of the breast (Acute Mastitis)
-inflammation associated with lactation. Signs of nipple cracks and abrasion
Peud orange ofedema
-associated with breast cancer with orange peel in color, enlargement of skin pores
is noted esp. in areola
3 Patterns:
Circular
Up and down
Wedge
7/31/2019 Reviewer RLE
21/30
Breast exam
41% upper, outer quadrant
14% upper, inner quadrant
5% lower, inner quadrant
6% lower, outer quadrant
34% in the area behind the nipple
* Ductile carcinoma- originates from ducts
* Lobular carcinoma- lobules
7/31/2019 Reviewer RLE
22/30
Breast Surgery
Indications: Breast tumor
Breast cancer
Breast augmentation
Breast reduction
Breast lift/ mastopexy
Types of Mastectomy
1. Segmental mastectomy/ Lumpectomy- removes the tumor and a margin of breast
tissue surrounding the tumor
2. Simple mastectomy- removal of the breast with some nearby axillary nodes3. Modified Radical mastectomy removal of the entire breast and all axillary lymph
nodes, chest wall muscles are not resected
7/31/2019 Reviewer RLE
23/30
4. Radical mastectomy removal of the entire breast, axillary lymph nodes and
underlying chest wall muscles (pectoral muscles)
5. Breast reconstruction (Mammoplasty)- maybe performed at the time of
mastectomy/ maybe done at a later time; can be accomplished throughsubmuscular breast implant
to improve the psychological coping
to improve self- esteem
Implants (Prosthetic) at areola incision Silicone
Saline (10 years)
Flap grafts- transfer of skin, muscles and subcutaneous tissue from other part of
the body to the mastectomy site
1. Latissimus dorsi flap graft2. Transverse rectus abdominis myocutaneous (TRAM) flap
7/31/2019 Reviewer RLE
24/30
Clinical Staging
- signs and symptoms that are present
- Involves the physicians extimation of the size of breast tumor and extent ofaxillary lymph nodes involvement
- Diagnostic test
Pathological Staging
- Done when the pathologist examine the surgically excision and biopsy
Stages of Breast Cancer Stage I: tumors are less than 2cm in diameter and confined to the breast
Stage II: less than 5cm or tumors are smaller with mobile axillary lymph nodeinvolvement
Stage III a: greater that 5cm or tumors are accompanied by enlarged axillarylymph nodes fixed to one another or to adjacent tissue
Stage III b: advanced lesion with satellite nodules, fixation to the skin or chestwall, ulceration, edema or with supraclavicular or intraclavicular involvement
Stage IV: all tumors with distant metastasis
7/31/2019 Reviewer RLE
25/30
Pre-operative Nursing interventions
1. Providing education and preparation about surgical treatment
2. Reducing fear and anxiety and improving coping ability
3. Promoting decision making abilityPost-operative:
1. Relieving pain and discomfort
a) Analgesic medication
b) Provide alternative pain management
c) Do not use arm operative side for BP taking, IV or injection2. Managing post-operative sensation
a) Reassure patient that this are normal part of healing and that these sensations
are not indicative of a problem
3. Promoting positive body image
a) Assess for readiness and provide gentle encouragementb) Maintain privacy while assisting her to view the incision
c) Allow to express feelings, acknowledging her feelings
d) Reassure that her feelings are normal response to breast cancer surgery
e) Suggest clothing adjustments
7/31/2019 Reviewer RLE
26/30
4. Promote positive adjustment and coping
a) Assisting the patient in identifying and mobilizing her support system
b) Provide support, education and guidance to spouse or partner
c) Involve family in patient care5. Improving sexual function
a) Encourage patient to openly discuss how she feels about herself and reasons
in decrease libido
b) Assume position that are comfortable
c) Expressing affection using manual stimulation6. Monitoring and managing complications
1) Lymphedema- inadequate lymphatic channel to ensure return flow as lymph
fluid to general information
a) Perform prescribed exercises, start with simple movement on affected
sideb) Elevate the arm above the heart several times a day
c) General muscle pumping
7/31/2019 Reviewer RLE
27/30
2. Hematoma (Seroma formation)- collection of blood inside the cavity
a) Warm shower
b) Warm compress
Seroma- collection of serous fluid
a) Unclogging the drain
b) Manually aspirating the fluid with needle and syringe
3. Infection
a) Monitor for signs and symptoms of infection
b) Oral or IV antibiotics for 1-2 weeks
c) Culture for foul smelling discharges
Drainage Management
a) Demonstrate how to empty and measure fluid from the drainage device
b) Demonstrate how to milk clots through the tubing of the drainage device
c) Note for observation requiring contacting the physician or nurse
d) Identify when the drain is ready for removal- less than 30cc after 24 hours
7/31/2019 Reviewer RLE
28/30
Arm exercise
Purpose:
1. To promote ROM
2. To increase circulation and muscle strength3. Prevent joint stiffness and contraction
Nursing Considerations:
1. Initiated on the 2nd day post-operatively of after surgical drain is removed
2. Perform 3 times a day for 20 mins. at a time until ROM is restored 4-6 weeks3. Take analgesics 30 mins. Before beginning exercises if patient has discomfort
4. Instruct to take warm shower before exercising to lose stiff muscle and provide
comfort
5. Heavy lifting is avoided 4-6 weeks
7/31/2019 Reviewer RLE
29/30
Exercise after breast surgery
1. Wall hand climbing
2. Rope turning
3. Rod or broomstick lifting
4. Pulley tugging
Breast reconstruction
Nursing Interventions:
Nursing care to be provided to patients with TRAM flaps involves:
Flap monitoring
Pain management
Drain monitoring
Prevention of possible complications
Home care training of the patient
7/31/2019 Reviewer RLE
30/30
Evaluate the flap are for temperature, blood flow, color, and capillary refill
Pink- early stage
Dark red- accumulation of blood or obstruction by a clot in donor site veins
Petechia- indicates a reduced venous return and may require addition of freshveins
Ivory colored (pale) or mottled breast- indicates inadequate or reduced arterial
perfusion
Notify the surgeon immediately