Reviewer RLE

7/31/2019 Reviewer RLE

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Invasive Procedures

-can be diagnostic and therapeutic to the

patient.

Pre-operative

Intra-operative

Post-operative


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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.


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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


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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


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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


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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)


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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


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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


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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


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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


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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


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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


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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


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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.


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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


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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


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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


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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


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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.


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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


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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

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Reviewer RLE

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