Minor Tonsillectomy Tonsillectomy is surgery to remove the tonsils. The tonsils help protect against infections.

But children with large tonsils may have many sore throats and ear infections. Preoperative Details Careful history taking is needed to evaluate for the following:
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Bleeding disorders or wish to avoid transfusion Anesthesia intolerance Obstructive sleep apnea

In patients with Down syndrome, order cervical spine images to evaluate for C1-C2 subluxation. Also, be aware of possible underlying cardiac disease. Sleep studies are recommended if the severity of the patient's symptoms is uncertain. Regarding admission planning, insurance plans are increasingly disallowing inpatient admission for tonsillectomy or adenoidectomy. Children who should be admitted are those with obstructive sleep apnea, those with significant comorbid disease such as hypotonia or neuromotor delays, and those younger than 3 years. Intraoperative Details Place the patient in the Rose position with a shoulder roll. Carefully, insert a mouth prop, and open and suspend it. Apply an Alyss clamp to the tonsil to allow for traction during dissection. Variations in dissection methods include the following:6,7 8,9
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Use of cold steel (eg, scissors, curettes) Monopolar cautery Bipolar cautery with or without a microscope Radiofrequency ablation, or coblation (can be used to shrink tonsils) Harmonic scalpel with vibrating titanium blades Powered instruments (eg, microdebrider) for an intracapsular technique

Variations in hemostasis methods include the following:

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Pressure with sponge for several minutes Use of bismuth subgallate Use of ties Suction cautery

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Bipolar cautery Leave the lingual tonsil in situ. Be cautious when suctioning the patient's airway.

Postoperative Details
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Use liquid acetaminophen (Tylenol) with or without codeine for pain control. (The unwillingness of parents to give analgesics is associated with children's refusal to eat, which results in dehydration, weight loss, and local infection.) Sutters et al conducted a study comparing scheduled postoperative opioid analgesia (acetaminophen and hydrocodone 167 mg/2.5 mg per 5 mL PO q4h for 3 d) with as needed (PRN) opioid analgesia in children aged 6-15 years undergoing outpatient tonsillectomy. Children in the scheduled-dose group received more analgesia compared with the PRN group (p <0.0001). Children in the PRN group had higher pain intensity scores (p=0.017). Pain intensity scores were higher in the morning compared with the evening (p <0.0001).10 Maintain good hydration. The patient should eat an adequate diet. No evidence suggests that a special diet is required; however, soft foods are more easily swallowed than hard foods. Administer antibiotics. Oral antibiotic use for the week after tonsillectomy is associated with improved outcomes in children.11,12 Instruct the patient to avoid smoking. Instruct the patient to avoid heavy lifting and exertion for 10 days. Warn patients that pain will abate during the first 3-5 days then increase for 1-2 days before completely disappearing. Most often, tonsillectomy is safely performed on an outpatient basis. Individuals who should not receive tonsillectomy as outpatients are those younger than 3 years, those with obstructive sleep apnea, those who live far away from the outpatient facility, those with Down syndrome, or those who have difficulty in complying with instructions.

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HYSTERECTOMY PREOPERATIVE CARE Assess the womans understanding of the procedure. Provide explanation, clarification, and emotional support as needed. Reassure that the anesthesia will eliminate any pain during surgery and that medication will be administered postoperatively to minimize discomfort. The woman who understands about the procedure to be performed and what to expect after surgery will be less anxious. Cleanse the abdominal and perineal area, and, if ordered, shave the perineal area. If ordered, administer a small cleansing enema and ask the woman to empty her bladder. This precaution helps prevent contamination from the bowel or bladder during surgery. Administer preoperative medications as ordered. Check the chart to ensure that the consent form has been signed. Intraoperative care
Proper positioning Preventing joint and nerve damage Surgical procedure Two separate back tables are used for sterile setups, one for the vaginal instruments and supplies and one for the laparoscopic abdominal portion. Supplies and instrumentation between the two tables can't be interchanged once the surgical procedure has started. After final verification of the correct patient, site, and procedure by all members of the surgical team, the surgeon will insert a weighted speculum into the vagina to expose the cervix. A uterine manipulator is inserted through the cervix into the uterus, allowing for manipulation of the uterus during the procedure. After the surgeon changes gloves, the laparoscopic component of the surgery will begin; the surgeon usually stands on the patient's left side. Video equipment should be placed at the foot of the bed and close enough to the patient to avoid stretching/pulling cords or connections. Monitors should be placed at the patient's feet and on her right side to allow unrestricted visibility for the surgeon and surgical team. A pneumoperitoneum must be created to distend the abdominal wall, create a working area, and to displace the bowel superiorly. The umbilicus is elevated, often with towel clips, and an incision is made into the umbilicus using a No. 11 blade. The umbilicus is elevated for the initial incision to prevent injury to the bowel prior to the creation of the pseudoperitoneum. A Verres needle is then inserted through the incisional site into the abdominal cavity to allow the attachment of insufflation tubing. The insufflation tubing is flushed with gas to decrease the risk of air embolism, then attached to the Verres needle.2,6 The pneumoperitoneum is created by infusing carbon dioxide into the abdominal cavity to a pressure of approximately 14 to 15 mmHg.2 Placing the patient in the Trendelenburg position will further displace the bowel superiorly. Once the pneumoperitoneum has been safely established, more incisions will be made into the abdomen. A 12 mm trocar sleeve is inserted through the umbilical incision into the abdomen for laparoscope insertion. Using the laparoscope to aid with visualization, two more incisions are made to accommodate 12 mm trocars: one in the left lower quadrant and one in the right lower quadrant. An incision is then made suprapubically to accommodate a 5 to 12 mm trocar. The uterus is manipulated to allow visualization of the infundibulopelvic (IP) ligament. The IP ligament, or suspensory ligament of the ovary, is a fold of peritoneum that extends out from the ovary to the wall of the pelvis. If the ovaries are to be preserved, the adnexa is separated from the uterus by either cautery, endoscopic

scissors, or stapled with an endoscopic gastrointestinal anastomosis (GIA). If the ovaries are being removed, grasping forceps are used to move the ovary and fallopian tube to allow better exposure of the IP ligament. After clearly identifying the left ureter and isolating the left IP ligament, the left IP ligament is cut. Endoscopic GIA staplers, endoscopic scissors, and cautery may be used for dissection. Tissue between the ovary and round ligament is divided by sharp dissection and the round ligament and the upper portion of the broad ligament are dissected, either by cautery, endoscopic scissors, or endoscopic GIA staplers.2,12 The right IP ligament is then excised in the same manner as the left, once again identifying the right ureter before cutting the ligament. The round and broad ligaments on the right side are dissected in the same manner. The vesicouterine peritoneum is divided to separate the bladder from the uterus.2,12 Once the supporting uterine ligaments have been ligated and the uterus is no longer supported within the pelvic cavity, the uterus can be removed through the vaginal canal, resembling a traditional vaginal hysterectomy. The movable stirrups are usually manipulated to place the patient in high lithotomy position, allowing greater exposure. The uterine fundus is pulled forward, both uterine arteries are clamped, ligated, cut, and tied with heavy suture ligatures. The uterus is removed, the vaginal cuff is closed, and, depending on surgeon preference, the vagina may be packed with antibiotic-impregnated vaginal packing. Before closing the vaginal cuff, sponge, needle, and instrument counts are performed as indicated per facility policy to ensure that no foreign bodies have been retained. After the uterus is removed, the patient's legs are lowered simultaneously to a modified lithotomy position, and the laparoscope is reinserted through the abdominal cavity trocar sleeve to check for any bleeding. The pelvic cavity is lavaged with copious amounts of lactated Ringer's solution. Upon ensuring hemostasis, insufflation gas should be removed from the pneumoperitonuem via the trocar sleeves. The incisions are then closed; some surgeons inject a local anesthetic with epinephrine into the puncture wounds before closing. Final sponge, needle, and instrument counts should be completed as indicated per facility policy, and abdominal and perineal dressings applied. To prevent joint injury and to minimize the risk of sudden BP changes, the legs are slowly lowered simultaneously from the stirrups to the operative table, and the safety strap is applied across the patient's thighs. The patient is covered with warm blankets as needed to ensure normothermia and then transferred to the PACU.

POSTOPERATIVE CARE Assess for signs of hemorrhage. Hemorrhage is more common after vaginal hysterectomy than after abdominal hysterectomy. Monitor vital signs every 4 hours, auscultate lungs every shift and measure intake and output. These data are important indicators of hemodynamic status and complications. Once the catheter has been removed, measure the amount of urine voided. Assess for complications, including infection, ileus, shock or hemorrhage, thrombophlebitis, and pulmonary embolus. Assess vaginal discharge; instruct the woman in perineal care. Assess incision and bowel sounds every shift. Encourage turning, coughing, deep breathing, and early ambulation. Encourage fluid intake. Teach to splint the abdomen and cough deeply.Teach the use of the incentive spirometer. Instruct to restrict physical activity for 4 to 6 weeks. Heavy lifting, stair climbing, douching, tampons, and sexual intercourse should be avoided. The woman should

shower, avoiding tub baths, until bleeding has ceased. Infection and hemorrhage are the greatest postoperative risks; restricting activities and preventing the introduction of any foreign material into the vagina helps reduce these risks. Explain to the woman that she may feel tired for several days after surgery and needs to rest periodically. Explain that appetite may be depressed and bowel elimination may be sluggish. These are aftereffects of general anesthesia, handling of the bowel during surgery, and loss of muscle tone in the bowel while empty. Teach the woman to recognize signs of complications that should be reported to the physician or nurse: a. Temperature greater than 100F (37.7C) b. Vaginal bleeding that is greater than a typical menstrual period or is bright red c. Urinary incontinence, urgency,burning, or frequency d. Severe pain Encourage the woman to express feelings that may signal a negative self-concept. Correct any misconceptions. Some women believe that hysterectomy means weight gain, the end of sexual activity,and the growth of facial hair. Provide information on risks and benefits of hormone replacement therapy, if indicated. If the ovaries have also been removed, the woman is immediately thrust into menopause and may want or need hormone replacement therapy. Reinforce the need to obtain gynecologic examinations regularly even after hysterectomy

Haemorrhoidectomy Haemorrhoidectomy simply means removal of the haemorrhoids. Piles (haemorrhoids) are the loose lining of skin that bulges out through the ring muscle which holds the back passage shut. They contain big blood vessels which can bleed or clot up and cause pain. The loose skin can produce irritating tags.

Preparation before surgery.The patient enters the hospital on the afternoon of the day preceding operation. A complete blood count and urinalysis and other necessary laboratory studies are made. An enema is given. A sedative is given, preferably a barbiturate, to ensure a good night's sleep. The perianal area is shaved and cleansed with an antiseptic detergent. Three hours before operation, the patient is asked to attempt a bowel evacuation. He then receives a second enema. Two hours before operation, the patient is given pre-anesthetic sedation consisting of a barbiturate, followed by morphine sulfate with scopolamine or atropine one hour later. Immediately before surgery, a skin antiseptic is applied and a long-lasting oil soluble anesthetic is injected perianally. It Relieves muscle spasm-a principal cause of postoperative pain and urinary retention [3]. Preoperative Procedures Preoperative tests may include blood and urine tests, a chest x-ray, and an EKG, depending on the patient's health. These tests are normally done a few days prior to surgery. Medications that "thin" the blood, including aspirin, are usually discontinued before a scheduled surgery. Some drugs, such as the prescription medication Coumadin (warfarin), usually must be withheld at least 3 or 4 days prior to a surgical procedure to avoid excessive bleeding during the surgery. If general anesthesia is going to be used, nothing may be eaten from midnight on the evening before surgery until the procedure is completed. This includes food, water, chewing gum, and candy. This necessary precaution decreases the possibility of vomiting during and after surgery. For local and spinal anesthesia, dietary restrictions vary. The surgeon may require patients to abstain from eating after midnight, and that should be clarified in advance. Hemorrhoidectomies are performed in a hospital or outpatient surgery center. Some patients go home the same day and others remain in the hospital. Check-in is usually the same day as the surgery and at this time an informed consent formmust be signed. This is a legal document acknowledging that the patient understands the procedure and its potential risks, and is aware of the medications they will receive.

The operation details The operation can be done using local or general anesthesia. Local anesthesia causes a loss of feeling in the area where the surgery is to be done but patient remains awake during the operation. General anesthesia causes the patient to become unconscious during the operation.

During the surgery, the patient is positioned so that the anal-rectal area is fully exposed. The hemorrhoids are simply clamped, tied off, and then cut away. Special care must be taken because there is a risk of damaging the muscles that control the anal opening. Hemorrhoidectomy has a high rate of success and the good news is that most patients have an easy recovery with no recurrence of the hemorrhoids.

Postoperative Care after Hemorrhoidectomy After surgery, the patient is taken to the postanesthesia care unit (PACU). Patients are closely monitored by the nursing staff and remain there until they are stable. The amount of time spent in the PACU depends on the patient's progress and the type of anesthesia received. General anesthesia must wear off and the patient must be awake and coherent before they leave the PACU. Outpatients are transferred to another room to finish their recovery, and inpatients are taken to their hospital room. The intravenous line remains in until clear liquids are taken and tolerated. This can be almost immediately following surgery, especially if local anesthesia was used. Sometimes general anesthesia induces nausea, which may delay taking oral fluids. Once clear liquids are tolerated, the diet progresses to solid foods. Spinal anesthesia usually wears off within a few hours. During the first hour following surgery, patients lie flat on their back to decrease the risk for an anesthesia-induced headache, which can be painful and prolonged. Before being discharged, the patient must regain full sensation in the lower part of the body. Because of swelling and the dressing, some patients have temporary difficulty urinating. If there is urgency, but the urine will not flow, a catheter is used to empty the bladder. Outpatients may need to stay overnight, if they are unable to urinate. Patients must be able to urinate on their own before being discharged. Even though the anesthesia has worn off, most patients remain groggy for the rest of the day. Patients must arrange for a family member or friend to be with them if they are being discharged the same day as the surgery. Patients experience pain and discomfort during the immediate postoperative period (i.e., about 10 days). Pain medication is prescribed and should be taken as directed. Sometimes relief can be achieved with an over-the-counter preparation such as Tylenol. If a pack was inserted into the rectum following surgery, the physician usually removes it in a day or two.

An ice pack can help reduce swelling. Soaking in a sitz bath (a shallow bath of warm water) several times a day helps ease the discomfort. Using a donut ring (cushion with a hole in the middle) can make sitting upright more comfortable. It is important to avoid constipation at this time so, the physician will prescribe stool softeners and a laxative. Eating a high-fiber diet and drinking plenty of liquids also helps. A small to moderate amount of bleeding, usually when having a bowel movement, may occur for a week or two following the surgery. This is normal and should stop when the anus and rectum heal. Complete recovery takes 6 weeks to 2 months. Most patients return to work within 10 days. Heavy lifting should be avoided for 2 to 3 weeks.

Adenoidectomy is the surgical procedure in which the adenoids are removed. Adenoids are lymphoid tissue located in the back of the nose. They are often not understood by the lay public or by physicians who are not otolaryngologists because they are not observed during routine physical examinations because of their location. Although the tissue composition of adenoids is the same as that of the tonsils, the diseases associated with infected adenoids differ from the diseases associated with infected tonsils, based on their location. This causes additional confusion because the adenoids are often simultaneously grouped with the tonsils when reporting outcomes in scientific journals. NURSING CARE FOLLOWING TONSILLECTOMY & ADENOIDECTOMY
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After operation, patient placed in sitting position. For patient undergone general anesthesia, patient placed in prome position and turned head on one side. Ice collar should be applied, kidney basin, gauze or tissue for the expectoration of blood and mucus. Always guard patient for any hemorrhage if he spit out bight fresh blood in large amount frequently, report to the doctor immediately. Vital signs should be monitored every thirty minutes for first eight hours then every hour. If no bleeding, give cracked ice if desired. Avoid too much talking and coughing. Diet should be liquid and semi-liquid after three days. Best offer is icecream and gellatine for dessert. Avoid citrus fruits and fruit juices or any acidic food that may causi pain on the operative site.

Prior to Surgery

It is very important that the patient avoid taking aspirin, Motrin, ibuprofen, Advil, Aleve or naproxen for two weeks before and two weeks after surgery as these

thin the blood and in-crease the chance for bleeding after surgery. Tylenol (acetaminophen) may be taken as directed.
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The Day of Surgery

On the day of surgery the patient should have nothing to eat or drink after midnight. Please check with your doctor to see if regular medication should be taken the morning of surgery. Failure to follow these directions may cause the anesthesiologist to cancel the surgery. You will need to arrive at the surgical facility well before the scheduled time of surgery. A day or two before surgery you will be called by someone from the surgical facility to tell you what time to arrive. After you arrive the nursing staff will take some information from you and someone from the anesthesia department will talk with you. Parents are usually allowed to go with their children to the operating room and stay with them while they go to sleep but not during the actual operation. If interested in this please request to do so as soon as you arrive to the surgical facility. Once in the operating room young children will go to sleep by breathing gas through a mask, they will then have an IV started. Older children and adults will usually have an IV started first, sometimes before going to the operating room. Once asleep, a breathing tube will be placed through the mouth. During surgery the patient will be kept completely asleep by breathing gas through this tube under the supervision of an anesthesiologist. Heart rhythm, blood pressure and oxygen levels will be closely monitored throughout the operation. The surgery is performed through the open mouth and takes about 45 minutes. The doctor will talk to you after surgery is done. Please stay in the waiting room the whole time the patient is in surgery. After surgery the patient will be in the recovery room for about 30 minutes. Parents may be able to sit with their child for part of this time. After this the family will stay with the patient in another recovery area for about 2 hours after surgery. For some patients with certain medical conditions plans will be made ahead of time to stay overnight after surgery.
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Once You Are Home

It is most important for the patient to take enough liquids. Good things early on include fruit juices, pop, popsicles, Gator-aide, ice cream, milkshakes, Instant Breakfast, yogurt, pudding Jell-O, applesauce, scrambled eggs, etc. Any soft foods are OK but sharp or hard foods should be avoided for 10 days. Children will require frequent, consistent, firm yet loving encouragement to eat and drink for up to 10 to 14 days after surgery. The patient will have significant pain in the THROAT as well as in the EARS (because the tonsils are straight in from the ears) and the back of the NECK or HEAD for up to 10 to 14 days

after surgery. Tylenol (acetaminophen follow bottle directions) or the prescription pain medicine (which usually contains a narcotic and Tylenol) should be taken every 4 hours as needed for pain. It helps to take it regularly for the first few days to stay ahead of the pain, after that taking it hour before meals is helpful. Remember not to take aspirin, Motrin, ibuprofen, Advil, Aleve or naproxen as these may cause bleeding. Usually a dose of steroids is given through the vein at the time of surgery to decrease pain and swelling early on. Pain often worsens when this wears off in 2 days. Pain can be worse at night so be sure to take pain medication at bedtime. Benadryl (follow bottle directions) can be given to help the patient sleep as well. Due to the swelling of the uvula it is common to have some snoring and rattling breathing for a while. Elevating the head of the bed by placing a pillow between the mattress and box spring helps keep pain and swelling down and also helps reduce the risk of bleeding. Avoid strenuous activity for 10 days after surgery as it increases the chance of bleeding. It is OK to go to a movie or a mall and to be up in the house but avoid driving especially when on prescription pain medication. Plan to miss 7 to 10 days of day care, school or work after surgery. It is common to have some blood tinged saliva but it is possible to have significant bleeding up to 10 days after surgery. Should significant bleeding occur (spitting out clots or continual dripping of blood) the patient should rinse the mouth with cold water and wait for 15 minutes as the bleeding will usually stop on its own. If bleeding persists call the office day or night and your surgeon or another ENT specialist will call you. In the unlikely event that you are unable to make contact with the doctor and significant bleeding persists, go to the ER. Due to the bacteria in the mouth there is always a low grade infection in the area where the tonsils were removed causing a white to yellow build up, foul breath and a fever of 101 or even 102 for 10 or more days after surgery. This will resolve on its own, however your surgeon may give you an antibiotic to take after surgery to help control this. You may also notice some voice changes and snoring after surgery for awhile due to swelling and the removal of enlarged tissue. This will resolve on its own usually in 3 to 4 weeks. If you have questions or problems please call the office. Please make an appointment now for your surgeon to check you 3 to4 weeks after surgery. There is no charge for this visit.

Rhinoplasty Perioperative Nursing Considerations 1. Do not allow prep solutions to pool in or around the eyes and ears. 2. Keep tissue specimens moistened in saline solution. 3. The table may be turned and flexed for ease of access and patient comfort. 4. The nasal preparation tray may be set up on a clean, nonsterile Mayo tray, according to surgeons preference.

Major Transurethral resection of the prostate Transurethral resection of the prostate (TURP) is surgery to remove all or part of the prostate gland, to treat anenlarged prostate. The prostate gland often grows larger as men get older. This is called benign prostatic hyperplasia (BPH). The larger prostate play causes problems with urinating. Removing part of the prostate gland can often make these symptoms better. Pre-operative Management: 1. Inform the patient about the procedure and the expected postoperative care, including catheter drainage, irrigation and monitoring of hematuria. 2. Discuss the complications of surgery which include: 3. Incontinence or dribbling of urine up to 1 year after surgery and that Kegels exercise will help alleviate this problem 4. Retrograde ejaculation 5. Bowel preparation is given. 6. Optimal cardiac, respiratory and circulatory status should be achieved to decrease risk of complications. 7. Prophylactic antibiotics are ordered. Intraoperative Care 1.Maintain Safety and Prevent Injury 2.Position in Client 3.Provide Equipment Safety 4.Maintain Surgical Asepsis 5.Assist in Wound Closure 6.Monitoring: V/S (Body temperature) Malignant Hyperthermia Cardiac Respiratory Arrest --Allergic Reactions Post-operative Management: 1. Urinary drainage is maintained and observed for signs of hemorrhage. 2. Maintain patency of urethral catheter. 3. Avoid overdistention of bladder, which could lead to hemorrhage. 4. Administer anti-cholinergic medications to reduce bladder spasms. 5. Maintain bed rest for the first 24 hours. 6. Encourage early ambulation, thereafter to prevent embolism, thrombosis and pneumonia.

7. Wound care is provided to prevent infection. 8. Administer pain medications. 9. Promote comfort through proper positioning. 10. Administer stool softeners to prevent straining that can lead to hemorrhage. 11. Reduce anxiety by providing realistic expectations about postoperative discomfort and overallprogress. 12. Encourage patient to express fears related to sexual dysfunctions and to discuss with partner. 13. Teach measures to regain urinary control.

Balloon Valvuloplasty Therapeutic dilatation of a narrowed heart valve using balloon catheters threaded into the heart via the venous or arterial system. Pre-procedure 1. Emphasize the doctors explanation of the procedure including the risks involved and other treatment alternatives. 2. Inform the patient that he will be awake throughout the procedure and be given a sedative and/or local anesthetic before the procedure. 3. Describe the expected sensation during local anesthesia administration and catheter insertion. With the injection of the contrast medium, a warm, flushed feeling will likely occur. 4. Instruct the patient to abstain from eating and drinking 6 hours before the procedure or as prescribed. (Usually NPO post midnight) 5. Tell the client that the procedure may last up to 4 hours. 6. Assess for any allergy to shellfish, iodine or contrast medium. 7. Check the informed consent for the clients signature, if over 18 years old or the parents if the patient is underage. 8. Baseline vital signs must be taken including peripheral pulses in all extremities. 9. Insert an intravenous line to provide entry for medications to be administered (Heparin). 10. Shave insertion sites and cleanse it using an antiseptic. 11. Check and collect the standard laboratory test results required by the doctor before the procedure such as ECG, chest x-rays and routine blood tests. 12. Place ECG electrodes precisely upon patients arrival in the cardiac catheterization laboratory and check the I.V. lines for patency. During the procedure 1. Administer oxygen via nasal cannula. 2. Under a local anesthesia the doctor will make a small cut in the femoral blood vessel in the upper part of the leg.

3. A guide wire is carefully passed through the needle and is gently pushed into thevessel towards the chest. A catheter tube is threaded along the wire until it reaches the heart. 4. The doctor then uses the catheter to inject the contrast medium to visualize the heart valvesand assess the degree of the narrowed part. 5. Heparin is also injected into the catheter to prevent it from clotting. 6. The physician positions the deflated balloon precisely at the midpoint of the affected area. The balloon is then inflated using a low pressure for about 12-30 seconds. Time and pressure gradually increases and if desired outcome is not seen, a larger balloon may be used. 7. A series of angiograms is obtained to evaluate the effectiveness of the treatment. 8. The doctor then sutures the guide catheter in place and removes it after the effect of heparin wears off. Post-procedure 1. Monitor insertion site frequently. Be alert for signs of hemorrhage. 2. Keep the affected leg straight and instruct the patient to avoid prevent excessive hip flexion. 3. Monitor vital signs with following order: Every 15 minutes x 1hour Every 30 minutes x 2 hours Every hour x 5 hours Unstable vital signs: every 5 minutes 1. Assess the peripheral pulses, color, sensation, temperature and capillary refill of the affected leg. 2. Closely observe the catheter site for bruising, hematoma and bleeding. If hematoma expands, mark the site for later evaluation and notify the physician immediately. 3. Assess for signs of fluid overload (due to contrast medium injection) such as distended neck veins, dyspnea, pulmonary congestion, tachycardia, hypertension, hypoxemia, atrial and ventricular gallop. 4. Monitor intake and output. 5. Increase IV fluid rate for at least 100 ml/hour to aid kidneys in excreting the contrast medium. 6. Encourage patient to do deep breathing exercises to prevent atelectasis. 7. Frequent heart function evaluation should be done by auscultation. Murmurs indicate a worsening valve insufficiency. 8. Be alert for signs and symptoms of cardiac tamponade such hypotension, decreased or absent peripheral pulses and pale or cyanotic skin. This condition requires immediate surgery. 9. Removal of guide catheter is usually 6-12 hours after the procedure. Direct pressure should be applied for at least 10 minutes to prevent bleeding. Nephrectomy The surgical removal of a kidney (partial or total). PREOPERATIVE CARE

 Provide routine preoperative care as outlined in Chapter 7. Report abnormal laboratory values to the surgeon. Bacteriuria, blood coagulation abnormalities, or other significant abnormal values may affect surgery and postoperative care. Discuss operative and postoperative expectations as indicated, including the location of the incision (Figure 274) and anticipated tubes, stents, and drains. Preoperative teaching about postoperative expectations reduces anxiety for the client and family during the early postoperative period. POSTOPERATIVE CARE Provide routine postoperative care as described in Chapter 7. Frequently assess urine color, amount, and character, noting any hematuria, pyuria, or sediment. Promptly report oliguria or anuria,as well as changes in urine color or clarity. Preserving function of the remaining kidney is critical; frequent assessment allows early intervention for potential problems. Note the placement, status, and drainage from ureteral catheters, stents, nephrostomy tubes, or drains. Label each clearly. Maintain gravity drainage; irrigate only as ordered. Maintaining drainage tube patency is vital to prevent potential hydronephrosis.Bright bleeding or unexpected drainage may indicate a surgical complication. Support the grieving process and adjustment to the loss of a kidney. Loss of a major organ leads to a body image change and grief response. When renal cancer is the underlying diagnosis, the client may also grieve the loss of health and potential loss of life. Provide the following home care instructions for the client and family. a. Teach the importance of protecting the remaining kidney by preventing UTI, renal calculi, and trauma. See Chapter 26 for measures to prevent UTI and calculi. Damage to the remaining kidney by UTI, renal calculi, or trauma can lead to renal failure. b. Maintain a fluid intake of 2000 to 2500 mL per day. This important measure helps prevent dehydration and maintain good urine flow. c. Gradually increase exercise to tolerance, avoiding heavy lifting for a year after surgery. Participation in contact sports is not recommended to reduce the risk of injury to the remaining kidney. Lifting is avoided to allow full tissue healing. Trauma to the remaining kidney could seriously jeopardize renal function. d. Teach care of the incision and any remaining drainage tubes, catheters, or stents. This routine postoperative instruction is vital to prepare the client for self-care and prevent complications. e. Instruct to report signs and symptoms to the physician, including manifestations of UTI (dysuria, frequency, urgency, nocturia, cloudy, malodorous urine) or systemic infection (fever, general malaise, fatigue), redness, swelling, pain, or drainage from the incision or any catheter or drain tube site. Prompt treatment of postoperative infection is vital to allow continued healing and prevent compromise of the remaining kidney

Gastrectomy is surgery to remove part or all of the stomach. Preoperative Procedures Prior to surgery, patients undergo preoperative testing, which may include x-rays, CT scans, ultrasonography, blood tests, urinalysis, and an EKG. Medications that "thin" the blood, such as aspirin, are discontinued several days prior to the operation. Other drugs, such as insulin for diabetes, may be withheld the day of surgery. As soon as the decision to undergo surgery is made, medication usage should be discussed with the physician. The stomach must be completely empty before the operation begins to avoid vomiting that can occur during the procedure. Patients must abstain from solid food and liquid after midnight on the evening before the operation. Upon arrival at the hospital (usually the day before surgery), patients must sign aninformed consent form acknowledging that the procedure and risks have been explained and that they are aware that they will receive anesthesia and possibly other medications. The anesthesiologist (i.e., doctor who administers anesthesia) speaks to the patient prior to surgery and performs a brief physical assessment. The anesthesiologist needs to know about medications being taken, any history of allergies, and previous adverse reactions to anesthesia. The patient's physical condition and history determines the choice and dosage of anesthesia and whether special precautions need to be taken. An intravenous (IV) is started in the patient's room or in the preoperative area. Sedation is given by injection or through the intravenous to induce relaxation and cause drowsiness. Anesthesia is administered in the operating room.

Intraoperative Phase
Maintenance of Safety
1. 2. 3. 4. 5. 6. Maintains aseptic, controlled environment. Effectively manages human resources, equipment, and supplies for individualized patient care. Transfer patient to operating room bed or table. Position the patient: function alignment, exposure of surgical site. Applies grounding device to patient. Ensure that the sponge, needle, and instrument counts are correct.

7.

Completes intraoperative documentation.

Physiologic Monitoring
1. 2. 3. Calculates effect on patient of excessive fluid loss or gain. Distinguishes normal from abnormal cardiopulmonary data. Reports changes in patients vital signs.

Postoperative Care After gastrectomy surgery, most patients are taken to the postanesthesia care unit (PACU) and are closely monitored by the nursing staff until the anesthesia wears off.They may spend several hours in the PACU, depending on how quickly they recover from the surgery. When they are stable, they are transferred to their room. Some patients need closer monitoring and attention. Those who are having respiratory problems, those who were very ill prior to the operation, and those who developed complications during the procedure are taken to the surgical intensive care unit until they are stable enough to be transferred to their hospital room. Upon waking from anesthesia, patients have an intravenous line, a urinary catheter, and a nasogastric tube. They are not allowed to eat or drink immediately following surgery. Oxygen may also be delivered through a plastic mask that fits over the mouth and nose, or through nasal prongs. Patients experience pain from the incision and medication is prescribed to provide relief. Pain medication is usually delivered intravenously. Intensive care patients are connected to a monitor that measures their heart rate and breathing. Their blood pressure and blood oxygen level are continuously monitored. Some patients require a respirator to breathe for them, and additional intravenous lines to deliver medication and fluids. Recovery is a gradual process. The nasogastric tube is attached to intermittant suction to keep the stomach empty. If the entire stomach has been removed, the tube goes directly to the small intestine and remains in place until bowel function returns. This generally takes between 2 and 3 days and is determined by listening to the abdomen with a stethoscope for bowel sounds (the passage of gas). A bowel movement also indicates healing. When bowel sounds return, clear liquids are offered. If they are tolerated, the nasogastric tube is removed and the diet is gradually advanced from liquids to soft foods, and then to more solid foods. Dietary adjustments may be necessary, as certain foods may now be difficult to digest. The urinary catheter is removed in a day or two, depending on recovery. When food and liquid are tolerated, and urine output is normal, the catheter is removed. The

intravenous may also be removed, but it remains in longer if medications, such as antibiotics and painkillers, have been prescribed. The day after surgery, most patients can get out of bed. Getting up and moving around is one of the best ways to prevent postoperative complications. Movement helps blood circulation return to normal, decreases the risk for a blood clot, helps bowel function normalize, and lowers the risk for lung infection. Getting out of bed can be painful and puts pressure on the incision. Pain medication is prescribed and can be given before the patient attempts to get up. Diet may present a challenge, especially for those whose entire stomach was removed. Food and liquids now enter the small intestine quickly, causing uncomfortable symptoms that can usually be relieved by eating several small meals, eating more protein and less sugar, and making other dietary changes. A nutritionist or dietician can help develop new eating habits. The dietary changes may be temporary, until the digestive system adjusts, or they may be permanent. Vitamin B12 is absorbed in the stomach and must be supplemented with regular injections by patients who underwent a total gastrectomy. Absorption may be impaired in those who still have part of their stomach, so it is necessary to have B12 levels checked periodically. Supplementation with folate, iron, and calcium may also be necessary to correct deficiencies caused by the surgery. The length of hospitalization varies. Full recovery may take several weeks or a few months, especially if the patient has gastrointestinal problems such as diarrhea, which can be debilitating. Recovery may also be prolonged by other treatments, such as chemotherapy. Craniotomy SCRUB NURSE Pre-operative Responsibilities 1. Assist with the preparation of the room for the designated surgical procedure, including gathering supplies for the procedure. 2. Scrub, dry hands, gown, and glove. 3. Assist person scrubbed in first position with: a. Setting up back table, mayo, and basins b. Arrangement of instruments c. Preparation of suture and needles d. Preparation and counting sponges e. Arrangement and preparation of other necessary items f. Gowning and gloving surgeon and assistants

g. Assist with draping h. Arrangement of sterile field Intra-operative Responsibilities 1. During the procedure, progress from double-scrubbed position. Train self to keep eyes on field, and learn steps of procedure. 2. Begin developing methods of anticipating needs of surgeon and assistant. 3. After closing the skin: a. Assist with care of instruments and counts if necessary b. Care of specimen c. Assist with dressing of wound Post-operative Responsibilities 1. After the completion of the Procedure: a. Assist with the gathering of all materials used during the procedure b. Discard items as necessary being careful to discard sharp items in designated places c. Return all items to respective area d. Assist with cleaning of room e. Clean the materials used properly and arrange them after drying 2. Perform any duties which will speed up the surgical procedure to follow in that room. CIRCULATING NURSE Pre-operative Responsibilities 1. Care for the patient before surgery by: a. Greeting patient and assist nurse with identification b. Checking patient's chart, preparation, etc. 2. Prepare the room by: a. Obtaining instruments, supplies, and equipment for the designated operative procedure b. Opening unsterile supplies c. Assisting in gowning

d. Observing breaks in sterile technique e. Assisting anesthesiologist as necessary f. Assisting with skin preparation and positioning g. Assisting with forming of the sterile field 3. Count the instruments, sharps and sponges before the procedure and confirm with scrub nurse. Intra-operative Responsibilities y 1. During the Procedure: a. Remain in room and dispense materials as necessary b. Observe procedure as closely as possible c. Begin establishing method of anticipating needs of surgical team d. Care of specimen as indicated e. Care of operative records as indicated f. Assist with application of dressing g. Monitor the instruments, sharps and sponges used and take note of additional instruments. 2. Before the closing of the organ or peritoneum, count all instruments, sharps and sponges and confirm with scrub nurse. 3. Inform the surgeon and assistant surgeon of a report of the instruments. Post-operative Responsibilities y y 1. Properly document all the necessary information on the patient s chart. 2. Assist in the cleaning of the Operation Room as necessary.

Prior to operation: y y y y A careful history and physical examination are performed Intravenous fluids are given to correct volume depletion and any electrolyte imbalances are measured and corrected. Monitor and regulate IVFs The nurse instructs the patient about the need to avoid smoking to enhance pulmonary recovery postoperatively and avoid respiratory complications. It is also important to instruct the patient to avoid the use of aspirin and other agents that can alter coagulation and other biochemical process

y y y y

On of the most important responsibility of the nurse is to let the patient sign an informed consent regarding the surgery. The patient is given anaesthesia prior to surgery and the patient is under NPO.

During the operation y y y y Monitoring the vital signs of the patient is one of the responsibilities of the nurse during the surgery. Assisting the anesthesia care provider during induction of general anesthesia Ensuring adequate oxygenation and hydration

After the operation y After recovery, the nurse places the patient in the low fowler s position. IV fluids may be given. Water and other fluids are given in about 24hours, and soft diet is started when bowel sounds returned.