July 27, 2009 Exploratory Laparotomy And Transverse Loop Colostomy 1.

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 semiliquid 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,

established intervals by hospital policy.

pus,

warmth,

and

edema)

at

•

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 catheterassociated 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.