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 ListProcess

• 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 ListContinued

• Allergies foods,

medications, latex, other• Personal items

removed

• Lab values• Diagnostic Imaging• Electrodiagnostic

Studies

Laboratory ValuesSerum/Blood

• CBC (complete blood count)• Red blood cells (erythrocytes - RBC) 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. male 40 - 52%

female 35 - 46% Plt (platelets) cells found in the blood that are needed to

control bleeding 130 – 400

Laboratory Values Continued• PT (prothrombin time) is a blood test that measures

how long it takes blood to clot by measuring the activity of prothrombin. Used in initiating and maintaining oral anti-coagulant therapy (Coumadin (Warfarin)).

10 – 15 seconds in a normal adult• PTT (partial thromboplastin time) Partial

thromboplastin time (PTT) is a clotting deficiency/disorder test. Often used to determine if heparin therapy is effective. If a person is taking blood thinners, clotting takes up to two and a half times longer.

60 – 70 seconds in a normal adult

Clotting Cascade• Site of injury• Platelets arrive first and begin to dam up the

breach• Fibrin is formed through a combination of various

processes including 12 clotting factors• The fibrin acts to roll the platelets up like they are

being spun into a sticky web• The web acts to collect RBCs, WBCs and other

platelets floating by creating a solid clot to staunch the bleeding

I hear INR instead….• You will also here the term INR. INR =‘s

• International Normalized Ratio• Normal is 1 for healthy patients• Range 0.08-1.2• 2-3 in patients on anti-coagulants• 3-4 patients with mechanical heart valves• Measures the time it takes blood to clot and compares

it to an average.• The higher, the longer it takes blood to clot which can

lead to uncontrolled bleeding• The lower, the greater chance of clot and

complications such as stroke or PEs

INR levels

• So for someone with a 2, 3 or 4, their clotting time is 2, 3, or 4 times longer than a normal person’s

• If you hear your patients INR is above this range, your case may be canceled, postponed or cell saver may be called as bleeding will be a problem intra-operatively.

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 Hypokalemia - 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 – 145High 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 ContinuedUrine

• 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 (electroencephalogram)-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 IncisionsAbdominal 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 (lower), duodenum, pancreas• Left Upper Paramedian stomach, duodenum, pancreas• Left Lower Paramedian pelvic structures, colon• McBurney appendix• Left Oblique Inguinal 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 tapered needle

• Other structures can often be repaired with chromic, vicryl or dexon on a tapered 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