Reviewing The Chart
&
Abdominal Incisions
Week 8
REVIEWING THE CHART
Pre-Operative Check List
• Purpose:
Correct patient
Correct surgeon
Correct procedure
Correct location
The Pre-Op Check List
Process
• Patient Identification
Verbally
ID bracelet
• Reviewed
Nursing history
Assessment
History and Physical
NPO since…
MD orders
Consent
Site/Procedure verified
Metal pins, plates, joints
The Pre-op Check List
Continued
• Allergies
foods, medications,
latex, other
• Personal items
removed
• Lab values
• Diagnostic Imaging
• Electrodiagnostic
Studies
Laboratory Values
Serum/Blood
• CBC (complete blood count)
• Red blood cells (erythrocytes)
RBC levels: male
4.3 - 5.9
female
3.5 - 5
• Cells that deliver oxygen throughout the body and make blood look
red.
• A low RBC can indicate anemia, which can lead to fatigue.
• A high RBC may indicate congenital heart disease, dehydration,
obstructive lung disease, or bone marrow over-production.
WBC
5,000 - 10,000
White blood cell: One of the cells the body makes to help fight infections.
A low WBC is called leukopenia (decrease in the number of
these cells can place patients at increased risk for infection)
.
A high WBC is termed leukocytosis (very common in acutely
ill patients.) Although it may be a sign of illness,
leukocytosis in-and-of itself is not a disorder, nor is it a
disease. .
Hgb (hemoglobin) substance inside red blood cells that binds to oxygen and
carries it from the lungs to the tissues.
male
13.5 - 18
female
11.5 - 15.5
Hct (hematocrit) measures how much space in the blood is occupied by
red blood cells/the percentage of RBCs per volume of whole blood.
male
40 - 52%
female
35 - 46%
Plt (platelets) cells found in the whole blood that are needed to control
bleeding/allow blood to clot
130 – 400
Laboratory Values Continued
• PT (prothrombin time) is a blood test that
measures how long it takes blood to clot.
10 – 15 seconds in a normal adult
• PTT (partial thromboplastin time) Partial
thromboplastin time (PTT) is a clotting deficiency test. It
tests Factor III, a component that works with plts & fibrin
to create clot. It can help tell if you have bleeding or
clotting problems. If the person is taking blood thinners,
clotting takes up to two and a half times longer.
60 – 70 seconds in a normal adult
I hear INR instead….
• You will also here the term INR. INR =‘s
International Normalized Ratio
• Since PT and INR (PT/INR) evaluate the
ability of blood to clot properly, they can be
used to assess both bleeding and clotting
tendencies. One common use is to monitor
the effectiveness of blood thinning drugs
such as Warfarin (Coumadin).
INR levels
• Patients on anti-coagulant drugs should have an INR
of 2.0 to 3.0 for basic “blood-thinning” needs. For
some patients who have a high risk of clot formation,
the INR needs to be higher - about 2.5 to 3.5.
• Range usually is between 0.8 and 1.2. Normal is 1
whereas 3 would mean it takes 3 times as long as
normal to clot.
• If you hear your patients INR is above this range, your
case may be canceled, postponed or cell saver may be
called.
If you must do your case and INR
is too high…..
• Can give the patient FFP (Fresh Frozen Plasma) aka thawed plasma
which is the plasma taken from a unit of whole blood.
• Plasma transfusion is indicated in patients with documented
coagulation factor deficiencies and active bleeding, or who are about
to undergo an invasive procedure.
• Can also give Vitamin K (not potassium) as a reversal agent.
• Vitamin K is a fat-soluble vitamin. The vitamin K present in plant
foods is called phylloquinone; while the form of the vitamin present in
animal foods is called menaquinone. Both of these vitamins are
absorbed from the diet and converted to an active form called
dihydrovitamin K.
Laboratory Values Continued
• Blood Chemistry
K+
3.5 – 5.0
• Potassium to high =‘s Hyperkalemia which can be fatal
because it can cause cardiac arrest or kidney failure.
• Potassium to low =‘s you can become weak as cellular
processes are impaired, muscles would not move, heart
would not beat.
• The kidney is the main organ that controls the balance of
potassium. It removes excess potassium into the urine.
Na+
135 – 145
High sodium levels =‘s Hypernatremia. Symptoms = lethargy,
weakness, irritability, and edema. With more severe
elevations of the sodium level, seizures and coma may
occur.
Low sodium levels =‘s Hyponatremia ( aka water
intoxication) . Symptoms = nausea, vomiting, headache
and malaise. As the hyponatremia worsens, confusion,
diminished reflexes, convulsions, stupor or coma may
occur.
• Type & Crossmatch
Type- blood type (A, B, AB, O) and Rh
factor (positive or negative)
Crossmatch- determines compatibility of
donor
with recipient’s blood
Laboratory Values Continued
Urine
• UA (urinalysis)
color
clarity
odor
glucose
RBC
WBC
Diagnostic Imaging
• X-Rays
•
Identify abnormalities or foreign bodies
•
Find lost needle, sponge, instrument
•
Visualize fluid or air in cavities such as the
plural cavity or peritoneal cavity
•
Assist with broken bone realignment
•
Assist with implantation of prosthetics
•
Identify correct placement of catheters,
drains, or tubes
Diagnostic Imaging Continued
• Portable X-Ray equipment needed in the
OR
• A cassette will be placed under or beside the
area to be x-rayed
• Will be taken to radiology department and
read by a doctor of radiology
Diagnostic Imaging Continued
• Fluoroscopy
•
portable C-arm X-ray machine with a
monitor screen
•
allows for visualization of areas being
x-rayed by the surgeon as a procedure
is being done with the use of a contrast dye
•
Examples: ortho, neuro, vascular
procedures, cholangiograms, and urography
Diagnostic Studies For Vascular
and Heart Surgeries
•
•
•
•
Angiography
Stress Test
Cardiac Catheterization
Echocardiography
Electrodiagnostic Studies
• EKG or ECG (electrocardiogram)monitors and evaluates normal and
abnormal heart rhythm as well as how well
the heart is functioning
• EEG (electoencephalogram)-monitors and
evaluates brain activity
Abdominal Divisions
• Anatomy of the Abdomen
RUQ (right upper quadrant) contents:
liver
gallbladder
duodenum
head of pancreas
right kidney and adrenal
part of ascending and transverse colon
Anatomy of Abdomen Continued
• LUQ (left upper quadrant) contents:
stomach
spleen
left lobe of liver
body of pancreas
left kidney and adrenal
part of transverse and descending colon
Anatomy of Abdomen Continued
• RLQ (right lower quadrant) contents:
cecum
appendix
right ovary and fallopian tube
right ureter
right spermatic cord
Anatomy of Abdomen Continued
• LLQ (left lower quadrant) contents:
part of descending colon
sigmoid colon
left ovary and fallopian tube
left ureter
left spermatic cord
Anatomy of Abdomen Continued
• Midline of Abdomen:
Aorta
Uterus
Bladder
Anatomy of the Abdominal
Wall
• Subcuticular (skin)
• Subcutaneous (fatty/adipose layer)
• Anterior fascia (thin or thick membrane over the
muscle)
• Muscle
• Posterior fascia (thin or thick membrane under the
muscle)
• Peritoneum (shiny membrane covering the
abdominal cavity)
• Contents of abdominal cavity (organs)
Procedure for Opening
Abdominal Cavity
•
•
•
•
•
•
•
Skin incised
Blood vessels cauterized
Fascia incised
Muscle layers divided or separated
Fascia incised
Peritoneum incised
Abdominal cavity contents exposed
Abdominal Incisions
Abdominal tumor
Abdominal Incision Type
Considerations
• Surgeon selects incision that will best
expose the structure to be operated on
• Surgeon selects incision that will create
minimal trauma and post-operative pain
• Surgeon selects incision that will allow for
wound closure strength as closed by
primary wound healing
Abdominal Incision Types
• Right Subcostal
gallbladder, biliary system
• Left Subcostal
spleen
• Median Upper Abdominal
stomach, duodenum, pancreas
• Median Lower Abdominal
uterus, adnexa (ovaries, fallopian tubes),
bladder
Abdominal Incision Types
• Right Upper Paramedian
stomach, duodenum, pancreas
• Left Lower Paramedian
pelvic structures, colon
• McBurney
appendix
• Left Oblique Inguinal
hernia repair
• Lower Transverse (Pfannensteil)
uterus, ovaries, and fallopian tubes
Laparoscopy
• Port-Sites
Hernia
Appendectomy
Bowel Resection
• Equipment/Room-Set-Up
Anticipating Potential Problems
With Abdominal Surgery
• Any time you are cutting into the body there is a
risk of something being cut that was not meant to
be cut
• Depending on what structure is accidentally cut
into, will determine what is needed by the surgical
technologist
• Vascular structures will require sutures that are
non-absorbable such as silk, prolene or ticron on a
taper needle
• Other structures can often be repaired with
chromic, vicryl or dexon on a taper needle
Nursing Process
• Surgery is an on-going process of
assessment of needs, plan of action,
intervention or implementation of the
plan, and evaluation to determine what
could be done to better prepare next time
Summary
•
•
•
•
•
Reviewing the Chart
Pre-op Check List
History and Physical
Laboratory Values
Diagnostic Tests
• Abdominal Incisions
• Anatomy of Abdomen
• Anatomy of
Abdominal Wall
• Abdominal Incisions
• Laparoscopy
• Anticipation of
Potential Problems