Part 3: Abdominal Assessment

Part 3 : Abdominal assessment

The Emergency Physical Examination

• In an emergency, the routine of the physical examination must be altered to fit the circumstances • The history may be limited to a single sentence • Or there may be no history if patients is unconscious and there are no other informants • Although the details of an accident or injury may be very useful in the total appraisal of the patient, they may be left for later

The Emergency Physical Examination • The primary considerations are the following: • Is the patient breathing ? • Is the airway open ? • Is there a palpable pulse ? • Is there heart beating ? • Is there massive bleeding occurring ?

The Emergency Physical Examination • If the patient is not breathing, ►► airway obstruction must be ruled out by thrusting the fingers into the mouth and pulling the tongue forward • If the patient is unconscious, the respiratory tract should be intubated and mouth-to-mouth respiration started • If there no pulse or heartbeat,►► start cardiac resuscitation

The Emergency Physical Examination

• Serious external loss of blood from an extremity can be controlled by:

* elevation and * pressure Some injuries are life-threatening that action must be taking before even limited physical examination is done * Penetrating wound of the heart * Large open sucking wound of the chest * Massive external bleeding All require emergency treatment before any further examination can be done

Laboratory Examination (or Lab Test)

• ♂* Laboratory examination in surgery patients have the following objectives:

• 1) Screening for asymptomatic disease that may affect the surgical result (e.g., unsuspected anemia or diabetes) • 2) Appraisal of diseases that may contraindicate elective surgery or require treatment before surgery (e.g., diabetes, organ failure)

Laboratory Examination • 3) Diagnosis of disorder that require surgery (e.g., hyperparathyroidism, pheochromocytoma)

• 4) Evaluation of the nature and extend of metabolic or septic complications

Laboratory Examination • ♂► Remember • Anyway, patients undergoing major surgery, even though they seem to be in excellent health except for their surgical disease, should have a complete: blood • urine and • stool examination •

Imaging Studies • Modern patient care calls for a variety of critical radiologic examinations • The closest cooperation between the surgeon and the radiologist is essential if serious mistakes are to be avoided

Imaging Studies • When the radiologic diagnosis is definitive, the examinations must be repeated in the light of the history and physical examination

Special examinations • Special examinations such as cystoscopy, gastroscopy, esophagoscopy, colonoscopy, angiography, and bronchoscope are often required in the diagnosis appraisal of surgical disorders • The surgeon must be familiar with indications and limitations of these procedures and be prepared to consult with colleagues in internal medicine

Chapter 2: Care of the patient • The care of the patient with a major surgical problem commonly involves distinct phases of management that occur in the following sequence: • I) Preoperative care Preoperative evaluation)

(Diagnostic

work

up,

• II) Anesthesia and Operation Postoperative • III) observation, Intensive Convalescent care)

care (Postanesthetic care, Intermediate care,

• Preoperative care • Definition and Objective • The diagnostic work up is concerned primarily with determining the cause and extent of the present illness • Preoperative evaluation consists of an overall assessment of the patient’s general health in order to identify significant abnormalities that might increase operative risk or adversely influence recovery • Preoperative preparation includes intervention dictate by the findings on diagnostic workup and preoperative evaluation and by the nature of the expected operation

Preoperative care • Preoperative evaluation • General Health Assessment • The initial diagnosis workup of the surgical patient is concerned chiefly with determining the cause of the presenting complaints • This work up should be supplemented by a complete assessment of the patient’s general health • Seeks to identify abnormalities that may have a bearing on the patient’s future well-being

• Preoperative evaluation General Health Assessment Preoperative evaluation includes at least a complete: * history and * physical examination Patient over 40 should be also have: * complete blood cell count (CBCC)and * serum electrolyte measurement Patient over 50 should have: * chest x-rays and * electrocardiograms as well

Preoperative care • Preoperative evaluation • General Health Assessment • Open wounds and infections usually require culture and determination of antibiotic sensitivity

Preoperative care • Preoperative evaluation • General Health Assessment • ►Circulating blood volume • The adequacy of circulating blood volume needs to be evaluated and can be determined by the adequacy of Peripheral perfusion • such as: Blood pressure • Pulse • • Remember: • A hemoglobin of 8g/dl is generally safe for tissue oxygen delivery

Preoperative evaluation General Health Assessment ►Liver and kidney function: The adequacy of liver and kidney function should be tested if impairment is suspected ► Bleeding tendencies platelet count (PT) prothrombin time (PTT) ► Medications allergies reactions to antibiotics and other agents

Preoperative care • Preoperative evaluation • General Health Assessment • ► Psychiatric consultation • should be considered in patients with a past history of significant mental disorder

• • • •

Preoperative evaluation General Health Assessment ►Physical examination The physical examination should be thorough and must include neurologic examination and check of peripheral arterial pulses (carotid, radial, femoral, popliteal, posterior tibial, and dorsalis pedis)

• Peripheral arterial disease should be suspected if there is: transient ischemic attach, claudication, or diabetes • If a carotid bruit is found, other studies may be indicated to specifically assess stenosis

Preoperative care • • • •

Preoperative evaluation General Health Assessment ►Physical examination A rectal examination should always be done, and a pelvic examination should be performed unless contraindicated by: • * age • * virginity, • * or other valid reason

• Sigmoidoscopy is required for completeness of evaluation when there are rectal or colonic complaints

Preoperative care • Preoperative evaluation • General Health Assessment • ►Blood • If the procedure is planned that will or may require blood replacement, the preoperative preparation should include planning for that: • ► Appropriate strategies may include storing the patient’s blood in the week prior to operation to allow: * autologous transfusion * directed-donor blood storage for transfusion

Preoperative care • Preoperative evaluation • General Health Assessment • Specific Factors Affecting Operative Risk • a) Nutritional Assessment • It has been documented that malnutrition leads to a significant increase in the operative death rate •

It clear importance

that

dietary

history

is

of

major

Preoperative care

• b) Assessment of immune competence • Patients at high risk for immune deficiency include: Elderly patients Malnourishment patients Severe trauma Burns cancer AIDS patients

• c) Others factors increased infection

leading

to

• Remember • Certain drugs may reduce the patient’s resistance to infection such as: • ► Corticoids • ► Immunosuppressive agents • ► Cytotoxic drugs • ► Prolonged antibiotic therapy

B) Pulmonary Dysfunction The patient with compromised pulmonary function preoperatively is susceptible to postoperative pulmonary complication such as:

* hypoxia * atelectasis and * pneumonia

B) Pulmonary Dysfunction • Preoperative evaluation of the degree of respiratory impairment is necessary in patients at high risk for postoperative complications, these include: • • * a history of heavy smoking and cough • * obesity • * advanced age • * major intrathoracic surgery • * upper abdominal surgery • * Known pulmonary disease

B) Pulmonary Dysfunction ■ Pertinent factor in the history include the: ►presence and character of cough ►excessive sputum production ►history of wheezing ►exercise tolerance ■ Pertinent physical finding include the: presence of wheezing or prolonged expiration a chest x-ray ECG blood gas Should be evaluated before surgery

C) Delayed Wound Healing • Many factors have been alleged to influence wound healing • Important factors include: ► protein depletion ► ascorbic acid deficiency ► marked dehydration ► edema ► severe anemia ► diabetes mellitus ► smoking

E) Risks factor Thromboembolism • Increased risk factors for: • •

deep vein thrombophlebitis and pulmonary embolus

• include: Cancer Obesity Myocardial dysfunction Age over 45 years Prior history of thrombosis

F) The elderly patient • ►► The operative risk should be judged on the basis of physiological rather than chronologic age • ►Assume that every patient over 60 even in the absence of symptoms and signs ►► has some generalized arteriosclerosis and potential limitation of myocardial and renal reserve • ►Therefore, even minor gastrointestinal and other complaints should be thoroughly investigated by the physician

G) The Obese patients • The obese patients have an increased frequency of concomitant disease and a high incidence of postoperative wound complications • A controlled preoperative weight loss program is often beneficial before elective procedure

G) Consultation • The opinion of a qualified consultant should be obtained: When may of benefit to the patient When requested by the patient or family members When it may be of medicolegal importance

G) Consultation • ►►Anesthesia consultation is always requested prior to major surgery if an anesthesiologist is available • In poor-risk patients, this consultation should request several days in advance of operation if possible

G) Consultation • Anesthesia assessment classified the patients as follows: • • • • •

Class Class Class Class Class for 24

1: Healthy 2: Mild systemic disease 3: Severe but not incapacitating disease 4: Severe disease, constant threat to life 5: Moribund patient not expected to survive hours

Postoperative Care • The recovery from major surgery can be divided into three phases: • (1) an immediate, or postanesthesic phase (in the postanesthetic recovery room) • (2) an intermediate phase, encompassing the hospital period (ICU/ ward) • (3) a convalescent phase ( Ward/ discharged)

Postoperative Care ► The major causes of early complications and death following major surgery are: acute pulmonary cardiovascular and fluid derangements The postanesthetic recovery room is staffed by specially trained personnel and provided with equipment for early detection and treatment of these problems

Postoperative Care • ►In

the recovery room, the anesthesiologist generally exercises primary responsibility for the patient’s cardiopulmonary function

• ►The surgeon is responsible for: • * the operating operative site and • * the patient’s care not directly related to the effects of anesthesia

Postoperative Care ► The patient can be discharged from the recovery room when cardiovascular, pulmonary, and neurologic function have returned to baseline, which usually occurs 1-3 hours following operation

►Patients who require continuing ventilatory or circulatory support or who have other conditions that require frequent monitoring are transferred to ICU

Postoperative Care • Postoperative orders

• Detailed treatment orders should be written upon arrival in the recovery room

• Important orders should also be communicated to the nursing team orally

• The nursing team should also be advised of the nature of the operation and patient’s condition

• The postoperative orders should cover the following :

• • • •

A)

Monitoring Vital signs Central venous pressure Fluid balance

B) Respiratory care C) Position in bed and mobilization D) Diet E) Administration of fluid and electrolytes F) Drainage Tubes G) Medications H) laboratory examinations and imaging

The intermediated postoperative period • • • • • • • •

A) Care of the wound B) Management of the drains C) Postoperative Pulmonary care D) Respiratory failure E) Postoperative fluid and electrolyte management F) Postoperative care of the gastrointestinal tract G)Management of the pain

THANKS