P PREPARED BY
ALPHONSA SEBASTIAN
OR DEPARTMENT

NAME : MR.M. K. Z
AGE/SEX : 24YRS/MALE
DATE OF ADMISSION : 24/02/2013
DIAGNOSIS : HAEMOPERITONIUM
SURGERY ON : 24/02/2013
SURGICAL INTERVENTION : EXPLORATORY
LAPROTOMY WITH SPLEENECTOMY
DISCHARGED ON : 02/03/2013

• Patient is conscious.
• Looks weak and fatigue
• His vital signs are
• 120/67mmof hg
• P/R :82/mt
• RR : 22/mt
• SPO2 :98%

• Skin is warm .
• Light complexion.
• Warm to touch.
• Absence Of Dandruff.
• Able to move both eyes
• No redness.
•
• Hair Is Equally Disrtibuted.
Pupils reactive to light
.

•
Patients pinna is same colour as fascial.
• Skin,aligned with eye level .
• Able to hear sounds clearly .
• No discharges.
•
No ulcers present in the mouth.
• Oral cavity is pale in colour.
• Lips pale and dry.

• Teeth is propely aligned with no dentures.
• No tenderness of node .
•
The Thorax Is Symmetric On Inspection
• Tenderness Of Abdomen present on palpation.

.
• No deformities of upper and lower limbs .
•
Absence Of Chest Pain .
• Heart sounds are clear.
• Upon auscultation his Bp is 132/78mmofhg
• With foley catheter fr.16

.
Patient Is Mentally Alert And Oriented With
Circumstances.
• Able To Follow Commands.
• No neurovascular deficit.



•

INVESTIGATIONS RESULTS
CBC
WBC
NEUT
RBC
HB
PLT
PT
APTT
Urea
Creatinine
Sodium
Pottassium
Chloride
ABO RH
20.63
76.6
2.68
8.2
236
16.3
30
23.2
121
140
5.1
114
O +ve
NORMAL VALUE
4.23-9.07
34-67.9
4.63-6.08
13.7-17.5G/DL
163-337
10.9-16.3secs
27-39secs
3.2-7.1mmol/L
46-110mmol/L
137-145mmol/L
3.5-5.1mmol/L
98-107mmol/L

NAME OF THE
MEDICINE
DOSE
INJ.PREMOSAN
10mg
INJ.RISEK
40mg
INJ.CIPROXIN
200mg
INJ.FLAGYL
500mg
INJ.TRAMADOL
50mg
ROUTE&
FREEQENCY
IV /BID
ACTION
Antiemetic
IV/OD
IV/BID
IV/BID
IM/TID
H2receptor antagonist
Antibiotic
Antibiotic
Analgesic

TYPES OF SPLENECTOMY
1. Minimally invasive (laparoscopic) splenectomy
During laparoscopic splenectomy, the surgeon makes four small incisions in abdomen. A tube with a tiny video camera is inserted into abdomen through one of the incisions. Surgeon watches the video images on a monitor in the operating room as special surgical tools are inserted through the other incisions in abdomen and spleen is removed. The incisions are then closed.

2 . Traditional (open) splenectomy
.
During open splenectomy surgeon makes an incision in the middle of abdomen. Muscle and other tissue are moved aside to reveal spleen. surgeon then removes the spleen, and closes the incision.
Laparoscopic splenectomy isn't appropriate for everyone. A ruptured spleen usually requires open splenectomy. In some cases surgeon may begin with a laparoscopic approach and find it necessary to make a larger incision because of scar tissue from previous operations or other complications
.

•Receive blood transfusions before surgery to ensure have enough blood cells following removal of spleen.
•Receive a pneumococcal vaccine to help prevent infection after spleen is removed.
•Temporarily stop taking certain medications and supplements.
•Avoid eating or drinking for a certain amount of time before the surgery.

.

The spleen is a lymphatic organ interposed in the blood stream. The surface projection of the longitudinal axis of the spleen is the tenth rib. It is concealed anteriorly by the greater curvature of the stomach and the left colic
(splenic) flexure. Its weight varies from 50 to 250g.

HILUM
The hilum can be found on the inferomedial part of the gastric impression (see the image above). The hilum transmits the splenic vessels and nerves and provides attachment to the gastrosplenic and splenorenal (lienorenal) ligaments

PERITONEAL RELATIONS
The spleen is surrounded by peritoneum and is suspended by multiple ligaments, as follows
:
• The gastrosplenic ligament
The splenorenal ligament
• The phrenicocolic ligament
VISCERAL RELATIONS
The visceral surface of the spleen contacts the following organs:
• Anterior surface of the left kidney .
• Splenic flexure of the colon
• The fundus of the stomach
• Tail of pancreas

FUNCTIONS OF SPLEEN
There are three major functions of the spleen and these are handled by three different tissues within the spleen.
 Concerned with phagocytosis of erythrocytes and cell debris from the blood stream. This same tissue may produce foci of haemopoiesis when rbc's are needed.
 Along with the power of the spleen to contract, provides a method for expelling the contained blood to meet increased circulatory demands in certain animals.
 Provides lymphocytes and a source of plasma cells and hence antibodies for the cellular and humoral specific immune defenses

The splenic artery supplies blood to the spleen.This artery is the largest branch of the celiac trunk and reaches the spleen's hilum by passing through the splenorenal ligament. It divides into multiple branches at the hilum.It divides into straight vessels called penicillin ellipsoids, and arterial capillaries in the spleen.

Sympathetic fibers are derived from the celiac plexus.
LYMPHATIC DRAINAGE
Proper splenic tissue has no lymphatics; however,some arise from the capsule and trabeculae and drain to the pancreaticosplenic lymph nodes .
VENOUS DRAINAGE
The splenic vein provides the principal venous drainage of the spleen. It runs behind the pancreas (after forming at the hilum) before joining the superior mesenteric vein behind the neck of the pancreas to form the portal vein. The short gastric, left gastro-omental, pancreatic, and inferior mesenteric veins are its tributaries

•Ruptured spleen
.
If spleen ruptures due to a severe abdominal injury or because of enlargement of spleen (splenomegaly), the result may be life-threatening, internal bleeding.
•Blood disorder .
 Idiopathic thrombocytopenic purpura (ITP),
 Polycythemia vera,
 Thalassemia and sickle cell anemia
.
• Cancer.

Chronic lymphocytic leukemia,
 hodgkin lymphoma and non-hodgkin lymphoma
 Hairy cell leukemia.

• I nfection
.
 A severe infection or a large collection of pus surrounded by inflammation (abscess) within your spleen that doesn't respond to other treatment may require splenectomy
• Cyst or tumor
.
 Noncancerous cysts or tumors inside the spleen may
• require splenectomy if they become large or are difficult to remove completely .
 Aneurysm in the spleen's artery
 Blood clot in the spleen's blood vessels


• Streptococcus pneumonia
• Neisseria meningitides
• Haemophilus influenzae
These bacteria cause severe pneumonia , meningitis, and other serious infections.
Vaccinations to cover these bacteria should be given in patients without a spleen.

• Blood clot in the vein that carries blood to the liver
•
•
Hernia at the incision site
Infection at the incision site
• Inflammation of the pancreas (pancreatitis)
• Lung collapse
• Injury to the pancreas, stomach, and colon

:
Bleeding .
• Chills.
• Cough or shortness of breath.
• Difficulty eating or drinking.
• Increased swelling of the abdomen.
• Pain that doesn't go away with prescribed medications.
• Increasing redness, pain, or discharge (pus) at the incision site.
• Nausea or vomiting that persists.
• Fever over 101 degree .

Hospitalization for 2 days .
• Iv fluids .
• Antibiotics .
• To guard against infections, doctor may recommend a pneumonia vaccine, as well as yearly flu vaccines.
• Immunizations against pneumococcus species as a routine of postoperative management. Immunization should be administered anywhere from 24 hours after injury to 2 weeks.

• Tachypnea, ronchi, crackles, cloudy foul smelling urine, urgency frequency, irritation ulcers of oral, vaginal or other mucosa; redness or drainage from wound or invasive sites .
Hypotension, shock-like state. Indicates potential for meningeal infection .
Monitor, Describe, Record
• White blood cells increases, urine, blood and wound cultures and sensitivities. WBC of > 10,000 cu/mm positive cultures for infectious organisms.
• Immunoglobulins. IgM decreases, IgG ad IgA within normal ranges indicating deficiencies.
• Vital signs and temperature every four hours. Indicates presence of infection

• Antibiotics specific to identified infectious agent.
Antipyretic (acetaminophen.
•
Handwash techniques before giving care.
•
Aseptic technique for any invasive procedures .
Adequate fluids, nutritional and activity support .
• Meticulous mouth and perineal care.

High risk for infection related to inadequate secondary defenses by immunosuppresion resulting from decreased immunoglobulins
Acute pain related to surgical incision
Risk for defficient fluid volume related to heamorrhage caused by surgery of highly vascular organ.
Knowledge deficit regarding treatment regimen and post op care .

ASSESSMENT NSG DIAGNOSIS PLANNING
SUBJECTIVE
I have fever and chilling as verbalized by the patient
OBJECTIVE
• Elevated temperature
P/R-126/mt
TEMP-38.6C
RR-24/mt
High risk for infection related to inadequate secondary defenses by immunosuppr esion resulting from decreased immunoglobul ins .
After series of nursing interventions the client should manifest no signs of infection .
INTERVENTION
1.Asses for
Temperature elevation above 101 fh,chills
2.
Assess for tachypnea, crackles, cloudy foul smelling urine, urgency frequency.
3.Asses for hypotension, shocklike state.
RATIONALE
1.High grade fever indicates infection
2. Indicates pneumococcal infection or overwhelming infection.
3.Indicates potential for meningeal infection.
 Chills
 Tachypnea
4.Monitor urine, blood and wound cultures and sensitivities.
4.To identify the presence of infectious organisms.
• Cloudy foul smelling urine
• Redness or drainage from wound or invasive sites .
5.Administer specific antibiotics
{ INJ:CIPROXIN 200MG IV
,BID.
INJ:FLAGIL 500MG IV,BID}
6.Administered antipyretics
{ INJ:PERFALGAN 1GM
STAT}
5.Acts to destroy microorganisms by inhibiting cell wall synthesis.
6.Reduces fever by inhibiting heatregulating center.
EVALUATION
After 12 hrs of nursing interventions the goals were fully met as evidenced by…..
 Absence of infection evidenced by
1 .Temperature, white blood cell, urinalysis, cultures within normal ranges
[Temp-36.6c
Pr/82bpm,rr-20/mt
2.Breath sounds, urinary pattern, mucous membranes within baseline levels.
}

Instruct The Patient
• Take short walks on a level surface
• Don’t overexert to the point of fatigue.
• Limit stair climbing to no more than once or twice a day. Climb steps slowly and stop to rest every few steps
• Don’t lift anything heavier than 10 pounds or push a vacuum cleaner for 4 to 6 weeks after surgery.
•
Don’t drive until after first doctor’s appointment after surgery
• Get medical attention even for mild illnesses such as sinus problems or
• .
colds.
• Take antibiotic medication after surgery as directed by doctor

• Be sure to tell all your healthcare providers that he doesn’t have a spleen
• Wash incision site with soap and water and pat dry.
• Check incision every day for redness, drainage, swelling, or separation of the skin.
• Take the medications exactly as directed. Don’t skip doses.
• Don’t take any over-the-counter medication unless the doctor tells to do so.
• Check temperature each day for 1 week after surgery.
• Make a follow-up appointment as directed.

• A case of RTA patient who underwent splenectomy as an emergency procedure on 24/02/13.
• Splenectomy is a surgical procedure to remove spleen an organ that sits under rib cage on the left side of abdomen.
• The two types of splenectomy are open splenectomy and laproscopic splenectomy .
A ruptured spleen usually requires open splenectomy.
• Patient was discharged on 02/03/13 .
• He was instructed about the follow up care and has been explained he is prone to infection as he does not have a spleen.

Bibliography
• Lippincott manual of nursing practice 9 th edition
• www.mayoclinic
.com
• Wikipedia
• Grays anatomy and physiology