SURGERIES

July 27, 2009

EXPLORATORY LAPAROTOMY AND TRANSVERSE LOOP COLOSTOMY

1. EXPLORATORY LAPAROTOMY

It is a method of abdominal exploration, a diagnostic tool that allows

physicians to examine the abdominal organs. The patient is usually placed

under general anesthesia for the duration of surgery. The advantages to

general anesthesia are that the patient remains unconscious during the

procedure, no pain will be experienced nor will the patient have any memory

of the procedure, and the patient's muscles remain completely relaxed,

allowing safer surgery.

During laparoscopy, organs that might have disease will be explored.

The doctor will examine you using the tools that have been passed through

the incisions. A television will be used to project the images. The surgeon may

take samples (biopsies) from suspicious areas. These will then be sent to the

lab.

*1-4 hours (depending on how hard it is to make a diagnosis)

PRE-OPERATIVE CARE

Do not take aspirin or other anti-inflammatory drugs for one week before

surgery, unless told otherwise by your doctor. You may also need to stop

taking blood-thinning medications. Examples include clopidogrel (Plavix),

warfarin (Coumadin), or ticlopidine (Ticlid). Talk to your doctor.

POST-0PERATIVE CARE

The patient will remain in the postoperative recovery room for several

hours where his or her recovery can be closely monitored.

Monitor for signs and symptoms of:

Bleeding or discharge from the incisions

Fever

Increasing pain or pain that doesn't go away

Nausea or vomiting

Constipation beyond the first few days

Pain or swelling in your legs

Cough or difficulty breathing

Pain or difficulty with urination

2. TRANSVERSE LOOP COLOSTOMY

Transverse loop colostomy is a simple, fast, and relatively easy

procedure used for those patients with pelvic disease in whom a temporary

fecal diversion is needed and who are not candidates for an end sigmoid

colostomy because of medical or technical reasons.

The transverse colostomy is in the upper abdomen, either in the middle

or toward the right side of the body. Some conditions of the colon such as

those caused by diverticulitis, inflammatory bowel disease, cancer,

obstruction, injury, or birth defects can lead to a transverse colostomy.

This type of colostomy allows the feces to exit from the colon before

they reach the descending colon. When conditions such as those listed are

present in the lower bowel, it may be necessary to give the affected portion of

the bowel a rest. A transverse colostomy may be created for a period of time

to prevent feces from passing through the area of the colon that is inflamed,

infected, diseased or newly operated on, thus allowing healing to occur.

There are two types of transverse colostomies: “loop transverse

colostomy” and “double-barrel transverse colostomy.

PRE OPERATIVE CARE

Preparation for colon surgery begins a few days prior to the procedure

unless the surgery is being done on an emergency basis, such as for an

injury or intestinal bleeding. Most patients have undergone a colonoscopy,

sigmoidoscopy, or barium enema to diagnose the disease. These tests

generally are not repeated. Prior to the operation, blood tests, a chest x-

ray, an EKG, and an abdominal CT scan may be ordered.

The colon contains bacteria and waste products that can cause infection if

they leak into the abdomen during surgery and precautions are taken to

reduce this risk. Oral antibiotics are started several days before the

operation is scheduled and the colon must be as empty as possible.

The procedure for colon cleansing depends on the physician, the patient's

health and diagnosis, and the facility where the procedure is being

performed. Generally, for 2 or 3 days prior to surgery, a soft or semi-liquid

diet (i.e., foods that are quickly and easily digested) is ordered. For some

patients, only clear liquids are permitted. These include fruit juice, sports

drinks, clear broth, and gelatin. All patients must go on a clear liquid diet

24 hours prior to surgery. After midnight, the night before surgery, nothing

may be taken by mouth.

Cleansing solutions and laxatives are used to cleanse the colon before

surgery. Patients are given a laxative solution to drink that can cause

severe diarrhea, so they may be admitted to the hospital the day before

the surgery to receive intravenous fluids that prevent dehydration.

If the patient is unable to comply with this regimen, it is necessary to

inform the physician as soon as possible. It may be unsafe to do the

surgery as scheduled and it may have to be postponed.

During this period, it may not be possible to continue prescription

medications. Blood "thinning" medications, including aspirin, must be

discontinued one week before the operation to avoid excessive bleeding

during the procedure.

An informed consent form must be signed acknowledging that the patient

understands the procedure, the potential risks, and that they will receive

certain medications.

The patient is then taken to a preoperative holding area and must remain

in bed except to use the bathroom. An intravenous (IV) is started for fluids

and medication, if one is not already in place. A sedative is given through

the intravenous to induce drowsiness. Anesthesia is administered in the

operating room.

POST OPERATIVE CARE

After surgery, the patient is taken to the postanesthesia care unit (PACU)

and is closely monitored by the nursing staff until the anesthesia wears off.

If no problems are observed in the PACU, the patient is transferred to a

hospital room after about 2 hours.

The catheter that was inserted prior to surgery and the IV remain in place.

The catheter is removed in a day or so, depending on recovery. Food and

fluid cannot immediately be taken by mouth, so the intravenous keeps the

patient nourished and hydrated. Medication is delivered through the IV.

Postsurgical abdominal pain is common, and medication is given to relieve

it. If the pain is unusually severe and the medication does not provide

relief, the doctor must be notified as soon as possible because this may

indicate a complication.

Nothing may be taken by mouth until it is certain that normal bowel

function has resumed. This is determined by listening through the

abdomen for bowel sounds (the passage of gas). Bowel sounds indicate

that the normal movement inside the colon has returned. The passage of

stool is another indication that the colon is healing.

In some cases, a nasogastric tube is passed through the nose and into the

stomach during surgery and may remain for several days until bowel

function returns. After bowel function returns, clear liquids are given and

the nasogastric tube is removed. Once clear liquids are tolerated, the diet

slowly progresses to solid foods.

On the day after surgery, most patients get out of bed and walk around. It

is important to get up as soon as possible to stimulate bowel function and

help blood circulation return to normal.

The most difficult part of the postoperative period is adjusting to the

colostomy. The opening is on the right or left side, depending on where the

removed section of colon was located. The stoma is red and, immediately

after surgery, there may be a bandage covering it. When stool starts to

come out through the stoma, the colon is healing.

Stools from a stoma are generally softer and looser. The opening must

always be kept covered by a special pouch designed to hold the stool. The

pouch is changed after a bowel movement.

An enterostomal therapist teaches the patient how to care for the

colostomy and provide assistance with any problems that occur with an

ostomy. It is vital that patients and/or their family members learn proper

care of the colostomy before the patient is discharged from the hospital.

Hospitalization ranges from 3 to 10 days, and normal activity can usually

be resumed within 1 to 3 weeks. It takes longer for the body to heal

completely and strenuous exertion and heavy lifting must be avoided for 4

to 6 weeks.

Having a colostomy puts few restrictions on the patient, once initial

healing has occurred. There are usually no limitations on diet, sports,

activities, work, or travel. Sports that involve rough and frequent body

contact and jobs involving very heavy lifting are not advised.

Postoperative Complications

Complications that may occur with a colostomy are:

bleeding,

infection,

leakage around the stoma, and

injury to surrounding organs during the procedure.

If there is drainage, bleeding, or swelling at the incision site, pain that

is not relieved by medication and comfort measures, a sudden fever, or

rectal bleeding, the surgeon must be contacted immediately. If the

stoma is painful to the touch, draining blood, or swollen, infection or

other complications may be indicated.

August 22, 2009

INSERTION OF IV CATHETER AND DEBRIDEMENT

3. INSERTION OF INTRAVENOUS CATHETER

Etymology: L, intra, within, vena, vein; Gk, katheter, a thing inserted

a catheter that is inserted into a vein for supplying medications or nutrients

directly into the bloodstream or for diagnostic purposes such as studying

blood pressure.

POST OPERATIVE CARE

IV catheter and skin junction sites should be assessed for potential

complications (redness, tenderness, pus, warmth, and edema) at

established intervals by hospital policy.

The HCW should change gauze dressings routinely every 48 hours on

peripheral and central catheter sites and immediately if the integrity of the

dressing is compromised.

If gauze is used in combination with a transparent dressing, it is

considered a gauze dressing and should be changed every 48 hours.

If transparent semi-permeable dressings are used on peripheral IV sites

and as long as the integrity of the dressing is maintained, then the

dressing is changed at the same time as the 72-hour catheter site rotation

is done.

Tubing continuous primary and secondary administration sets should be

changed every 48 hours if there is an increase in the incidence of phlebitis

above recommended levels and/or if an increase in catheter-associated

infections is noted.

Primary intermittent or intermittent secondary tubing continues to be

changed every 24 hours.

Add-on devices, such as tubing extensions, filters, stop-cocks, and

needleless devices, should be changed when the administration sets are

changed.

4. DEBRIDEMENT

Debridement is the process of removing dead (necrotic) tissue or

foreign material from and around a wound to expose healthy tissue.

An open wound or ulcer can not be properly evaluated until the dead

tissue or foreign matter is removed. Wounds that contain necrotic and

ischemic (low oxygen content) tissue take longer to close and heal. This is

because necrotic tissue provides an ideal growth medium for bacteria,

especially for Bacteroides spp. and Clostridium perfringens that causes the

gas gangrene so feared in military medical practice. Though a wound may not

necessarily be infected, the bacteria can cause inflammation and strain the

body's ability to fight infection. Debridement is also used to treat pockets of

pus called abscesses. Abscesses can develop into a general infection that may

invade the bloodstream (sepsis) and lead to amputation and even death.

The four major debridement techniques are surgical, mechanical,

chemical, and autolytic.

Surgical debridement

Surgical debridement (also known as sharp debridement) uses a

scalpel, scissors, or other instrument to cut necrotic tissue from a wound. It is

the quickest and most efficient method of debridement. It is the preferred

method if there is rapidly developing inflammation of the body's connective

tissues (cellulitis) or a more generalized alized infection (sepsis) that has

entered the bloodstream. The physician starts by flushing the area with a

saline (salt water) solution, and then applies a topical anesthetic or antalgic

gel to the edges of the wound to minimize pain. Using forceps to grip the dead

tissue, the physician cuts it away bit by bit with a scalpel or scissors.

Sometimes it is necessary to leave some dead tissue behind rather than

disturb living tissue. The physician may repeat the process again at another

session.

PRE OPERATIVE CARE

assessing the need for debridement:

the nature of the necrotic or ischaemic tissue and the best

debridement procedure to follow

the risk of spreading infection and the use of antibiotics

the presence of underlying medical conditions causing the wound

the extent of ischaemia in the wound tissues

the location of the wound in the body

the type of pain management to be used during the procedure

Before surgical or mechanical debridement, the area may be flushed with

a saline solution, and an antalgic cream or injection may be applied. If the

antalgic cream is used, it is usually applied over the exposed area some 90

minutes before the procedure.

POST OPERATIVE CARE

After surgical debridement, the wound is usually packed with a dry

dressing for a day to control bleeding.

Afterward, moist dressings are applied to promote wound healing. Moist

dressings are also used after mechanical, chemical, and autolytic

debridement.

Many factors contribute to wound healing, which frequently can take

considerable time. Debridement may need to be repeated.