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STAFF The clinical treatments described and recom-

mended in this publication are based on re-
Executive Publisher search and consultation with nursing, medical,
Judith A. Schilling McCann, RN, MSN and legal authorities. To the best of our knowl-
edge, these procedures reflect currently accept-
Editorial Director ed practice. Nevertheless, they cant be consid-
H. Nancy Holmes ered absolute and universal recommendations.
For individual applications, all recommenda-
Clinical Director
tions must be considered in light of the pa-
Joan M. Robinson, RN, MSN tients clinical condition and, before adminis-
Senior Art Director tration of new or infrequently used drugs, in
light of the latest package-insert information.
Arlene Putterman The authors and publisher disclaim any re-
Art Director sponsibility for any adverse effects resulting
from the suggested procedures, from any unde-
Elaine Kasmer
tected errors, or from the readers misunder-
Editorial Project Manager standing of the text.
Jennifer Kowalak 2007 by Lippincott Williams & Wilkins. All
rights reserved. This book is protected by copy-
Clinical Project Manager right. No part of it may be reproduced, stored in
Carol A. Saunderson, RN, BA, BS a retrieval system, or transmitted, in any form
or by any meanselectronic, mechanical, pho-
tocopy, recording, or otherwisewithout prior
Naina D. Chohan, Julie Munden written permission of the publisher, except for
Clinical Editors brief quotations embodied in critical articles
and reviews and testing and evaluation materi-
Joanne M. Bartelmo, RN, MSN; Collette als provided by publisher to instructors whose
Bishop Hendler, RN, BS, CCRN; Jennifer schools have adopted its accompanying text-
Meyering, RN, MS, CCRN; Kate McGovern book. Printed in the United States of America.
Stout, RN, MSN, CCRN; Beverly Ann For information, write Lippincott Williams &
Tscheschlog, RN, BS Wilkins, 323 Norristown Road, Suite 200,
Ambler, PA 19002-2756.
Copy Editors
Kimberly Bilotta (supervisor), Scotti Cohn,
Tom DeZego, Heather Ditch, Amy Furman, Library of Congress
Pamela Wingrod Cataloging-in-Publication Data
Designers Nurse's 5-minute clinical consult treatments.
Jan Greenberg (project manager), BJ Crim, p. ; cm.
Joseph John Clark Includes bibliographical references and index.
1. NursingHandbooks, manuals, etc. 2.
Digital Composition Services Clinical medicineHandbooks, manuals, etc. I.
Diane Paluba (manager), Joyce Rossi Biletz, Lippincott Williams & Wilkins. II. Title: Nurse's
Donald G. Knauss, Donna S. Morris five-minute clinical consult treatments.
[DNLM: 1. Nursing CaremethodsHand-
Manufacturing books. 2. Clinical MedicineHandbooks. 3.
Beth J. Welsh TherapeuticsHandbooks. WY 49 N972955
Editorial Assistants RT51.N87 2007
Megan L. Aldinger, Karen J. Kirk, 610.73dc22
Linda K. Ruhf ISBN 1-58255-512-5 (alk. paper) 2006017482

Barbara Hodgson
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Contributors and consultants iv

Appendices 477
Alternative and complementary treatments 478
Cosmetic treatments 481
Index 485

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Contributors and consultants

Lillian Craig, RN, MSN, FNP-C Ann S. McQueen, RNC, MSN, CRNP
Instructor Family Nurse Practitioner
Oklahoma Panhandle State University Health Link Medical Center
Goodwell Southampton, Pa.
Colleen Davenport, RN,C, MSN Noel C. Piano, RN, MS
Consultant Instructor Lafayette School of Practical
Renton, Wash. Nursing
Adjunct Faculty
Vivian Gamblian, RN, MSN Thomas Nelson Community College
Professor of Nursing
Williamsburg, Va.
Collin County Community College
District Kendra S. Seiler, RN, MSN
McKinney, Tex. Nursing Instructor
Rio Hondo College
Timothy Hudson, RN, BSN, MS, MEd
Whittier, Calif.
Chief Nurse, 274th Forward Surgical Team
U.S. Army Kelley Straub, RN, BSN, CCRN, RCIS
Fort Bragg, N.C. Critical Care Nurse
Julia A. Isen, RN, MS, FNP-C Bala Cynwyd, Pa.
Nurse Practitioner (primary care)
Assistant Clinical Professor Allison J. Terry, RN, MSN, PhD
University of California Director, Center for Nursing
San Francisco Alabama Board of Nursing
Patricia Lemelle-Wright, RN, MS
Staff Nurse/Clinical Instructor-Educator Brenda Williams, MSN
University of Chicago Hospital and Director of Student Health/Assistant
Malcolm X Community College Professor
Albany (Ga.) State University

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Abdominal aortic aneurysm repair or resection

fluid and blood and possible adminis-
OVERVIEW PROCEDURE tration of I.V. propranolol (Inderal) to
reduce myocardial contractility. An
Abdominal aortic aneurysm (AAA): OPEN SURGICAL REPAIR arterial line and indwelling urinary
abnormal widening of the distal de- AAAs usually require resection and catheter are also placed.
scending part of the aorta; descend- replacement of the aortic section Left-sided heart failure
ing aorta subdivided into thoracic with a vascular (patients or donor Arrhythmias
(above diaphragm) and abdominal vein) or polymer (polytetrafluoroeth- Myocardial infarction
(below diaphragm down to iliac ar- ylene, Dacron, Teflon, or Gore-Tex) Renal failure
teries) synthetic graft. Acute tubular necrosis
May be saccular (outpouching), Surgery requires general anesthesia. Ileus or bowel rupture
fusiform (spindle shaped), or dissect- Abdominal incision is made to ex- Pancreatitis
ing in form pose the aneurysm site, and clamps Ischemia of the left colon
95% of AAAs caused by pattern of in- are applied to the aorta above and Paralysis due to spinal cord ischemia
flammatory changes within the arte- below the aneurysm. Lower-extremity ischemia or em-
rial walls with weakening of the mus- The aneurysm sac is opened and the bolization
cular architecture (which can resem- aneurysm is resected. Infection such as peritonitis, catheter
ble atherosclerotic changes); re- A prosthetic graft is sewn into place insertion site
maining AAAs the result of congeni- and carefully tested for leakage. Aortic dissection or perforation
tal cystic medial necrosis, trauma, Endovascular graft migration
syphilis, or other inflammatory or in- ENDOVASCULAR REPAIR
fectious disease processes Uncomplicated AAAs beginning be-
Mortality greatly reduced by repair low the left renal artery may be re-
and resection techniques, which can paired endovascular grafting.
be performed by open surgery or This procedure is performed under
minimally invasive (endovascular) fluoroscopy with a local or regional
surgery anesthetic. Repairing an AAA with
The access site in the femoral or iliac endovascular grafting
INDICATIONS artery is prepared.
Large (greater than 4 cm diameter) or A delivery catheter with an attached Endovascular grafting (shown below) is a
symptomatic aneurysms (symptoms compressed graft is inserted over a minimally invasive procedure for the pa-
may be result of aneurysmal infec- guide wire. tient who requires repair of an abdominal
tion, adherence to or bleeding into The delivery catheter is advanced to aortic aneurysm (AAA).
nearby abdominal organs, or slow or the aorta, where its positioned The patient is instructed to walk the first
rapid leaking into the abdominal day after surgery and is discharged from
across the aneurysm.
cavity) the hospital in 1 to 3 days.
A balloon inside the graft expands
the aortic and right femoral seg-
ments and affixes them to the vessel
walls where theyre sewn in place.
(See Repairing an AAA with endovas-
cular grafting.)
Before elective surgery, such medica-
tions as I.V. nitroprusside (Nitro-
press) to maintain blood pressure at
100 to 120 mm Hg systolic and an
analgesic to relieve pain may be re-

Hemorrhage and shock from
aneurysm repair or rupture
WARNING Rupture of an AAA is a
medical emergency requiring
prompt surgical intervention. Other
emergency procedures initiated before
or during surgery are replacement of

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Insert an arterial line to allow for

NURSING DIAGNOSES continuous blood pressure monitor- PATIENT TEACHING
Acute pain Assist with insertion of a pulmonary GENERAL
Ineffective tissue perfusion: artery catheter to assess hemody- Provide psychological support for the
Peripheral namic balance if ordered. patient and his family.
Risk for infection Observe the patient for signs of rup- Reinforce instructions for controlling
ture, including decreasing blood hypertension; stress the importance
EXPECTED OUTCOMES pressure; increasing pulse and respi- of medication and diet therapy and
The patient will: ratory rates; cool, clammy skin; rest- the need for smoking cessation.
express feelings of comfort and relief lessness; and decreased sensorium. Instruct the patient to take all med-
from pain Prepare the patient for preoperative ications as prescribed and to carry a
maintain present and strong periph- abdominal computed tomography list of them at all times in case of an
eral pulses without skin color or tem- scan, magnetic resonance imaging, emergency.
perature change or angiography to assist the surgeon Advise the patient about activity
show no evidence of infection. in locating landmarks and involve- restrictions, such as no pushing,
ment of other nearby tissues. pulling, or lifting heavy objects, until
Administer ordered medications to the physician allows him to do so.
PRETREATMENT CARE prevent aneurysm progression.
Provide an analgesic to relieve pain, RESOURCES
if present. Organizations
Explain the treatment and prepara-
If rupture occurs, insert a large-bore American College of Surgeons:
tion to the patient and his family. On
I.V. catheter, begin fluid resuscita- www.facs.org
admission to the critical care unit,
tion, and administer propranolol I.V. Society of Vascular Surgery:
help ease their fears about this type
to reduce left ventricular ejection ve- www.vascularweb.org
of care, the threat of impending rup-
locity as ordered. Expect to adminis-
ture, and planned surgery. Take time
to provide appropriate explanations
ter additional doses every 4 to 6 Selected references
hours until oral medications can be Kukreja, N. Randomized Clinical Trial of
and to answer questions.
used. Vertical or Transverse Laparotomy for
Verify that the patient has signed an
Prepare the patient for elective sur- Abdominal Aortic Aneurysm Repair,
appropriate consent form. British Journal of Surgery 93(2):251,
gery, as indicated, or emergency sur-
Assess the patients vital signs, espe- February 2006.
gery if rupture occurs.
cially blood pressure, every 2 to 4 Kunihara, T., et al. The Less Incisional
hours or more frequently, depending Retroperitoneal Approach for Abdomi-
on the severity of his condition. nal Aortic Aneurysm Repair to Prevent
Monitor blood pressure and pulses POSTTREATMENT CARE Postoperative Flank Bulge, Journal of
in the extremities, and compare Cardiovascular Surgery (Torino)
findings bilaterally. If the difference Perform pulmonary hygiene meas- 46(6):527-31, December 2005.
in systolic blood pressure exceeds ures, including suctioning, chest Nano, G., et al. Sac Enlargement Due to
10 mm Hg, notify the physician im- physiotherapy, and deep-breathing Seroma After Endovascular Abdominal
exercises. Aortic Aneurysm Repair with the En-
Provide continuous cardiac monitor- dologix PowerLink Device, Journal of
Assess heart rate and rhythm fre-
ing. Vascular Surgery 43(1):169-71, January
quently via telemetry; obtain 12-lead 2006.
electrocardiogram results and car- Assess urine output hourly.
diac enzyme levels. Maintain nasogastric tube patency to
Monitor kidney function by obtain- ensure gastric decompression.
ing blood urea nitrogen, creatinine, Assist with serial Doppler examina-
and electrolyte levels and measuring tion of extremities to ensure that the
intake and output regularly. vascular area is healing properly and
Monitor complete blood count for that no emboli are present.
evidence of blood loss as indicated Monitor the patient for signs and
by a decrease in hemoglobin level, symptoms of poor arterial perfusion,
hematocrit, and red blood cell count. such as pain, paresthesia, pallor,
Monitor liver function test results for pulselessness, paralysis, and cold-
signs of impaired perfusion. ness.
Obtain an arterial sample for arterial
blood gas analysis as ordered.

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Abdominal myomectomy
AGE FACTOR Uterine fibroids
OVERVIEW may cause complications, in- PROCEDURE
cluding spontaneous abortion,
Surgery to remove large or sympto- preterm labor, malposition of the A low horizontal (bikini) incision is
matic uterine leiomyomastumors uterus, and secondary infertility made in the abdomen, and the
composed of smooth muscle that (rare), in a woman of childbearing uterus is lifted through it.
usually occur in the uterine body, al- age. The uterus is palpated to identify fi-
though may appear on the cervix or Patients usually discharged from broids deep inside that may not be
on the round or broad ligament; also hospital within 48 hours of surgery visible.
called fibroids, myomas, and fibro- Recovery varied; women whose work A vasoconstrictive drug is injected
myomas and are classified according doesnt require heavy lifting can re- into the uterus to shrink the blood
to location turn to work in 4 to 6 weeks vessels, and then a laser is used to in-
Location and removal of fibroids: cise the uterus so the fibroids can be
Submucosal: inner surface of the INDICATIONS removed.
uterus; usually removed hystero- Abnormal and extensive uterine Each fibroid is carefully dissected
scopically (vaginally with a resecto- bleeding from the muscular portion of the
scope) Abdominal pressure and impinge- uterus (myometrium) until the blood
Subserosal: outer surface of the ment on adjacent viscera resulting in supply to the fibroid can be identi-
uterus; may be pedunculated mild hydronephrosis, bladder com- fied. Special care is taken in tying,
(stemmed; on a stalk), commonly re- pression, or bowel obstruction cauterizing, and suturing these ves-
moved laparoscopically, through sev- Abdominal pain associated with tor- sels to prevent bleeding.
eral small incisions in the abdomen sion of a pedunculated subserous fi- The uterine walls are sutured togeth-
Intramural: deep within the muscu- broid or a fibroid undergoing degen- er with dissolving sutures. This is
lar wall of the uterus; generally re- eration done in many layers to ensure
moved by abdominal myomectomy; Anemia secondary to excessive greater strength of the repair.
for the patient not concerned about bleeding A special nonadhesive cloth barrier
future childbearing, hysteroscopic Infection (if tumor protrudes out of to prevent adhesions is wrapped
myomectomy (alternative surgery) the vaginal opening) around the uterus. This material dis-
performed vaginally (see Under- integrates in about 2 weeks, when
standing hysteroscopic myomectomy) sufficient healing has occurred to
Preserves uterus for future childbear- prevent most adhesions.
ing as opposed to hysterectomy for The uterus is replaced into the ab-
fibroids domen and the incision is closed.

Understanding hysteroscopic myomectomy Excessive bleeding and hemorrhage
Ruptured uterus during pregnancy
Submucosal (and some in- if inadequate surgical closing (in-
tramural) myomas can be creased risk with laparoscopic proce-
removed by inserting a re- dure)
sectoscope, a special type Submucosal Resectoscope Accidental laceration or perforation
of hysteroscope, through fibroid loop of nearby organs
the vagina and cervix and Smaller fibroids, which may likely be
into the uterus. The resecto- left behind if a laparoscopic ap-
scope has a wire loop or a proach is used
roller-type tip that directs Adhesion formation
high-frequency electrical
Ureter damage from laceration, inad-
energy to ablate the fibroid.
vertent ligation of the ureter, com-
The fibroid tissue can be
seen through the resecto- pression, or puncture (rare)
scopes telescopic-like lens. Blood clot formation
Continued menorrhagia despite
Resectoscope Infertility

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Acute pain Explain the treatment and prepara- GENERAL
Deficient knowledge (disorder and tion to the patient and her family. Be sure to cover the importance of
treatment) Verify that the patient has signed an reporting abnormal bleeding or
Risk for deficient fluid volume appropriate consent form. pelvic pain immediately, and the im-
Send a blood sample for type and portance of receiving regular gyneco-
EXPECTED OUTCOMES cross-matching because blood trans- logic examinations.
The patient will: fusions may be necessary. Reassure the patient that abdominal
report increased comfort and de- Administer a gonadotropin-releasing myomectomy doesnt cause prema-
creased pain hormone agonist to suppress pitu- ture menopause because the ovaries
verbalize an understanding of the itary gonadotropin release, reducing are left intact.
disorder and its treatment the size of the uterine fibroid if or- Review prescribed medications with
maintain normal blood pressure and dered. her, including dosage and possible
heart rate, intake and output, and Reinforce teaching about the proce- adverse effects; in a patient with se-
adequate peripheral pulses. dure and posttreatment care. vere anemia from excessive bleeding,
an iron supplement may be adminis-
POSTTREATMENT CARE Reassure women of childbearing age
that pregnancy may still be possible
Monitor the patient for signs of if desired. Explain, however, that a
bleeding. cesarean delivery may be necessary.
Monitor laboratory results, especially Advise the patient about complica-
hemoglobin level and hematocrit. tions of blood transfusions.
Administer an analgesic, as ordered,
for pain. RESOURCES
Maintain patency of I.V. line. Record Organizations
intake and output, and monitor hy- American College of Obstetrics and
dration. Gynecology: www.acog.org
Monitor the patients vital signs, and Obstetrics, Gynecology, Infertility, and
report changes in trends. Womens Health: www.obgyn.net

Selected references
Damiani, A., et al. Laparoscopic Myo-
mectomy for Very Large Myomas Using
an Isobaric (Gasless) Technique, Jour-
nal of the Society of Laparoendoscopic
Surgeons 9(4):434-38, October-Decem-
ber 2005.
Huang, J.Y., et al. Failure of Uterine Fi-
broid Embolization, Fertility and
Sterility 85(1):30-35, January 2006.
West, S., et al. Abdominal Myomectomy
in Women with Very Large Uterine
Size, Fertility and Sterility 85(1):36-39,
January 2006.

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Ablation therapy for arrhythmias

OVERVIEW Atrial fibrillation PROCEDURE
Atrial flutter
Destroys (ablates) heart tissue thats Supraventricular tachycardia, includ- The procedure is typically performed
creating a heart beat originating out- ing atrioventricular (AV) nodal under conscious sedation with an I.V.
side the sinoatrial node (an ectopic reentry and Wolff-Parkinson-White tranquilizer and opioid. General
foci) or permitting conduction of syndrome, and certain types of ven- anesthesia is used in children and se-
such foci (see Types of cardiac abla- tricular tachycardia lected adults undergoing surgical ab-
tion) lation.
Type of ablation performed depend- A nonsurgical procedure generally
ent on the type of arrhythmia and takes place in the electrophysiology
the presence of other heart disease laboratory. The patients groin area is
shaved and his neck, upper chest,
arm, and groin are cleaned with anti-
Types of cardiac ablation septic. Sterile drapes are placed over
the patient.
Cardiac ablation therapy depends on the ectopic foci in the heart muscle, obliterating The physician numbs the insertion
specific ablative method and type of medical small portions of abnormal tissue by heat. site with an anesthetic.
procedure required. Heres a list of common These areas also scar, permanently blocking Two to five electrode catheters are in-
types of cardiac ablation: abnormal conduction. Newer radiofrequency serted via the femoral or internal
Surgical ablation: This term is generally used ablation equipment comes with the capacity to jugular vein into the left side of the
to specify that the patient will be undergoing direct cooled saline to the area to reduce ex- heart, the right side of the heart, or
surgical opening of the chest. It can refer to cessive heat production, making the procedure
both. The coronary sinus may also be
open heart with cardiopulmonary bypass or any more comfortable and safer. Most of these
of the newer techniques for open chest or procedures are carried out with minimally
entered to evaluate for left-sided ab-
minimally invasive chest procedures. The invasive techniques through peripheral access normal conduction.
ablation technique itself may not involve direct sites, but can be done during other cardiac Anticoagulation with I.V. heparin is
surgical incision of the heart. surgery as well. used to reduce the risk of thrombo-
Minimally invasive ablation: Although this Microwave and ultrasound techniques: embolism.
term can be used as above, it generally means Microwave and high-frequency sound waves The patient is connected to monitors
a procedure where peripheral access (femoral, are being used in several research hospitals to for electrocardiography, heart rate,
brachial, subclavian) to a vein is obtained determine if either of these methods of tissue blood pressure, pulse oximetry and,
followed by placement of several specialized destruction reduce the risks of ablation, such as possibly, hemodynamic monitoring.
catheters that provide intracardiac rhythm damage to adjacent tissues or stenosing of After the catheters are in place, the
monitoring and a source of energy for ablation veins or arteries proximal to the ectopic tissue. hearts conduction system is assessed
of the cardiac tissue. This procedure generally These procedures are primarily done via
and present rhythm confirmed.
takes place in the electrophysiology laboratory peripheral access sites and specialized cathe-
During traditional ablation, the
instead of the operating suite. ters and monitoring leads.
The Maze or Cox-Maze III procedure: The Laser ablation: The increased technology of
physician uses a pacemaker to initi-
gold standard for arrhythmia treatment, in- laser use has made delicate procedures, such ate the arrhythmia. Then the physi-
cluding atrial fibrillation, this procedure was as cardiac ablation, possible with small, very cian moves the catheters around the
originally only done during open heart surgery focused laser beams. The essential goals of the heart to determine the area of origin.
with cardiopulmonary bypass. The procedure procedure remain the same. Theres hope that When the physician finds the area,
can now be done in some patients via mini- this technique will be particularly useful for energy is applied to ablate the
mally invasive access to the beating heart atrial fibrillation by reducing the risk of pulmo- source.
through a smaller chest incision where endo- nary vein stenosis. The procedure can be done WARNING The patient may feel
scopes guide the surgical treatment. However, by peripheral access or during cardiac surgery. some discomfort or a burning
not all arrhythmias can be treated with this Cryoablation: This technique uses a special
sensation in the chest when the tissue
more limited access. extremely cold catheter tip to freeze and
is being destroyed, which may provoke
The surgeon makes several small, destroy tiny amounts of abnormally conducting
specifically located cuts in the heart muscle cardiac tissue. Still being studied extensively,
anxiety; determine if the patient
where abnormal impulses are originating based preliminary results show equal results com- would like extra pain medication. Also
on intracardiac monitoring leads, leaving the pared to the Maze procedure, and equal com- remind him that the discomfort is
normal conduction pathways open. The cut plication rates. Cryoablation has been done by normal and ask him to lie quietly and
areas form scar tissue that then prevents the peripheral access and during other cardiac avoid taking deep breaths.
abnormal impulses from being conducted surgical procedures. Atrial fibrillation is commonly treat-
through the heart. ed with pulmonary vein ablation
Radiofrequency ablation: Instead of surgical where the tissue circling each en-
incisions, radio waves are directed to the trance to the four pulmonary veins is

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ablated. Other ectopic foci for atrial

fibrillation are also ablated. PRETREATMENT CARE PATIENT TEACHING
To facilitate the ablation process,
three-dimensional electroanatomical Explain the treatment and prepara- GENERAL
mapping systems are projected on tion to the patient and his family. Review insertion site care with the
monitors. Intracardiac echocardiog- Verify that the patient has signed an patient. Emphasize the importance
raphy may also be used. appropriate consent form. of keeping the area clean and dry.
When the ablation is complete, the Obtain a 12-lead ECG, blood samples Tell the patient to call the physician if
physician monitors the electrocardi- for complete blood count, laboratory redness, swelling, or drainage at the
ogram (ECG) to verify correction of studies, and complete chemistry incision site occurs.
the arrhythmic trigger. panel if not done before admission. Instruct the patient to report signs
The physician removes the catheters Other tests, such as an echocardio- and symptoms indicating that his ar-
from the groin and pressure is ap- gram, exercise stress testing, or car- rhythmia is recurring. Inform him
plied to the site. diac catheterization, may have been that healing after ablation may take 6
done before admission to assist the to 8 weeks.
COMPLICATIONS physician in diagnosis and treatment Review with the patient his pre-
Death (rare) planning. scribed medications, including
Cardiac complications: high-grade Confirm that cardiac drugs with elec- dosage and possible adverse effects.
AV block, cardiac tamponade, coro- trophysiologic effects, such as beta- Review with the patient how to take
nary artery spasm or thrombosis, adrenergic blockers, calcium channel his pulse and keep a record for the
pericarditis blockers, digoxin, and class I and III physician.
Retroperitoneal bleeding antiarrhythmics, were reduced or Teach the patient with ablation along
Hematoma discontinued as instructed. Verify the tricuspid or mitral valve annulus,
Vascular injury that warfarin (Coumadin) therapy that antibiotics to prevent endocardi-
Thromboembolism has also been stopped as ordered, tis may be recommended for up to 12
Hypotension and obtain serum coagulation test- weeks postablation.
Transient ischemic attack or stroke ing.
Pulmonary hypertension from steno- Ask the woman of childbearing age if RESOURCES
sis of the treated pulmonary veins its possible that she could be preg- Organizations
Pneumothorax nant, and notify the physician of re- American College of Cardiology:
Left atrial-esophageal fistula sults because exposure to radiation www.acc.org
Acute pyloric spasm or gastric hypo- should be avoided. American Medical Association:
motility Confirm that the patient has had no www.ama-assn.org
Phrenic nerve paralysis food or fluids since 12 a.m. the day of
Infection at access site the procedure. Selected references
New or recurrent arrhythmias WARNING Left atrial ablation Chen, M.C., et al. Clinical Determinants
and ablation for persistent atri- of Sinus Conversion by Radiofre-
al flutter are contraindicated if an quency Maze Procedure for Persistent
NURSING DIAGNOSES atrial thrombus is present. Left ven- Atrial Fibrillation in Patients Under-
going Concomitant Mitral Valvular
tricular ablation is contraindicated if
a left ventricular thrombus is found. Surgery, American Journal of Card-
Activity intolerance iology 96(11):1553-557, December
Decreased cardiac output
Ablation catheters usually arent in-
Ineffective tissue perfusion: Cardio-
serted through a mechanical prosthet- Nattel, S., and Opie, L.H. Controversies
pulmonary ic heart. in Atrial Fibrillation, Lancet 367(9506):
262-72, January 2006.
Rao, B.H., et al. Successful Radiofrequen-
The patient will:
POSTTREATMENT CARE cy Catheter Ablation of Recurrent Atri-
al Fibrillation Due to Left Inferior Pul-
carry out activities of daily living
Enforce bed rest for 1 to 6 hours, as monary Vein Tachycardia, Indian
without excess fatigue or decreased Heart Journal 57(4):339-42, July-August
energy ordered, with the operative leg ex-
maintain adequate cardiac output
tended during this time to prevent
maintain normal blood pressure,
Monitor telemetry for arrhythmias,
heart and respiratory rate, and clear
lung sounds. as indicated.
Initiate aspirin therapy to prevent
thromboembolic aftereffects.

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Involves surgical removal of one or Decreased cardiac output TO COUNTERACT SHOCK
both adrenal glands, partially or Ineffective tissue perfusion: Cardio- Administer an I.V. vasopressor; adjust
completely pulmonary the dosage based on the patients
Surgery done laparoscopically or Risk for infection blood pressure response as ordered.
through abdominal incision Increase the I.V. fluid rate as ordered.
Laparoscopic approach not used for EXPECTED OUTCOMES Administer an I.V. glucocorticoid as
malignant tumors or tumors larger The patient will: ordered.
than 4 (10 cm) in diameter maintain adequate cardiac output Administer an analgesic as ordered.
maintain normal heart rate and
Adrenal hyperfunction remain free from infection. Monitor the patients vital signs
Hyperaldosteronism and intake and output, and report
Benign or malignant adrenal tumor changes.
Secondary treatment of neoplasms PRETREATMENT CARE Monitor invasive arterial pressure for
or corticotropin oversecretion signs of hemorrhage, acute adrenal
Pheochromocytoma Explain the treatment and prepara- crisis, or adrenal hypofunction (hy-
tion to the patient and his family. potension).
Verify that the patient has signed an Administer glucocorticoids and min-
PROCEDURE appropriate consent form. eralocorticoids as ordered.
Administer ordered drugs to control Report trends in serum electrolyte
After the patient is anesthetized, an edema, diabetes, cardiovascular levels and glucose levels; administer
anterior (transperitoneal) or a poste- symptoms, and as prophylaxis glucose and electrolytes as ordered.
rior (lumbar) approach is used. against infection. Assess and provide care for the surgi-
The adrenal gland is identified and Administer an aldosterone antago- cal wound and dressings.
dissected free from the upper pole of nist to control hypertension and sup- Monitor the patient for abdominal
the kidney. plemental potassium as ordered. distention and return of bowel
Wound closure follows. Give a glucocorticoid on the morning sounds.
If adrenalectomy is done because of of surgery as ordered. Keep the patients room cool.
a tumor, the glands are explored first, Draw blood samples for laboratory
and then the tumor is resected or tests as ordered.
one or both glands is removed.
In pheochromocytoma, the affected FOR PATIENT WITH
adrenal gland is excised, and the ab- PHEOCHROMOCYTOMA
dominal organs are palpated for oth- Between 1 and 2 weeks before sur-
er tumors. gery, administer an alpha-adrenergic
blocker, as ordered, followed by a
COMPLICATIONS beta-adrenergic blocker (when sta-
Acute life-threatening adrenal crisis ble) to control hypertension and
with hypoglycemia and electrolyte tachycardia.
disturbances Monitor the patient for arrhythmias,
Hemorrhage palpitations, severe headache, hyper-
Poor wound healing tension, hyperglycemia, nausea,
Pancreatic injury vomiting, diaphoresis, and vision
Hypotension (with gland removal) or disturbances.
hypertension (with gland manipula-

5125A.qxd 8/15/08 9:57 AM Page 9

during stress or illness. (See Prevent- RESOURCES

PATIENT TEACHING ing adrenal crisis.) Organizations
Tell the patient treated for adrenal American College of Surgeons:
GENERAL hyperfunction to expect improve- www.facs.org
Review the prescribed medications, ment of signs and symptoms within National Adrenal Diseases Foundation:
including the dosage and possible a few months. www.medhelp.org/nadf
adverse effects. Provide wound assessment and care
Teach the patient not to stop steroid instructions and review signs and Selected references
therapy abruptly. symptoms of infection. Hara, I., et al. Clinical Outcomes of La-
Teach the patient about stress-reduc- paroscopic Adrenalectomy According
Review potential complications, in-
tion techniques if appropriate. to Tumor Size, International Journal
cluding adrenal insufficiency, with
of Urology 12(12):1022-1027, Decem-
the patient and when to notify the Reiterate the importance of wearing
ber 2005.
practitioner. medical identification. Li, H., et al. Role of Adrenalectomy in
Tell the patient that an increase in Ectopic ACTH Syndrome, Endocrine
the steroid dosage may be necessary Journal 52(6):721-26, December 2005.


Preventing adrenal crisis

Dear Patient,
Even though you follow your treatment plan carefully, unexpected situations can create stress and worsen your condition.
Because your adrenal glands cant respond to increased demands, youll need to prepare for stressful situations and know
what to do to prevent adrenal crisis.
TAKE PRECAUTIONS Follow your health care providers pallor or cool, clammy skin
directions for increasing your daily fever
Always wear or carry medical
doses of prescribed streroids during increased breathing and pulse rates
identification with your name, the name
stressful times emotional crisis, unusual fatigue or weakness
of your disorder, and the phone numbers
overexertion, infection, illness, or injury. loss of appetite, stomach cramps,
of your health care provider and a
diarrhea, nausea, and vomiting
responsible person.
WATCH YOUR DIET AND GET dehydration or reduced urine output.
Always carry a clearly labeled
ADEQUATE REST If you cant reach your health care
emergency kit, especially when you
provider or get to a hospital at once,
travel. Double-check to make sure that Eat regularly. Dont skip meals or go
give yourself a subcutaneous injection
the kit contains a syringe and needle, for a long time without food.
of 100 milligrams of hydrocortisone.
100 milligrams of hydrocortisone, and Be sure to follow a high-carbohy-
Then seek medical help.
instructions for use. drate, high-protein diet with up to 8
grams of salt (sodium) dailymore if
you perspire a lot.
Balance active periods with rest. Instruct a family member or friend to
give you a subcutaneous injection of
RECOGNIZE WARNING SIGNS 100 milligrams of hydrocortisone if he
finds you unconscious or physically
Notify your health care provider
unable to take your medicine by mouth.
immediately (or go directly to the
He should then seek medical help
nearest hospital emergency department)
if you have any of the warning signs of
Avoid physical activity in hot, humid
adrenal crisis: This patient-teaching aid may be reproduced by office copier
weather. If you begin to perspire heavily,
apathy or restlessness, apprehen- for distribution to patients. 2007 Lippincott Williams &
drink more fluids and add salt to your Wilkins.
siveness, confusion, dizziness, head-

5125A.qxd 8/15/08 9:57 AM Page 10

Amniocentesis, therapeutic
Needle aspiration of amniotic fluid Ultrasonography is performed to lo- Anxiety
(also called amnioreduction); used cate the fetuses, the placenta, and Risk for imbalanced fluid volume
when placental blood flow is com- the amniotic sacs. Risk for injury
promised in multiple gestational Maintaining sterility, the patients ab-
pregnancy dominal skin is cleaned with an anti- EXPECTED OUTCOMES
septic solution, and the physician The patient will:
INDICATIONS administers a local anesthetic to the express feelings of reduced anxiety
Twin-to-twin transfusion syndrome appropriate site. exhibit no signs or symptoms of ma-
(TTTS): The physician, guided by continued ternal or fetal bleeding
occurring when twin or multiple fe- ultrasonographic imaging, inserts exhibit no signs of maternal or fetal
tuses share a single placenta that de- the needle and stylet through the ab- injury.
velops abnormal anastamoses be- domen and uterine wall into the am-
tween each fatal circulatory system niotic sac. The stylet is removed and
despite each fetus developing in a the presence of amniotic fluid is con-
separate amniotic sac firmed. Amniotic fluid is then aspi-
resulting in a pressure gradient be- rated by a syringe.
tween the two circulatory systems re- If specimens are needed for study,
sulting in one fetus having too much fluid is transferred to appropriate
amniotic fluid and blood volume and tubes.
one not enough Monitoring for signs and symptoms
removing excess amniotic fluid from of supine hypotension (light-headed-
the enlarged sac allows pressure to ness, nausea, diaphoresis, low blood
normalize and increases blood flow pressure) is done throughout the
to the fetus with insufficient blood process. Fetal heart rates (FHRs) are
supply and amniotic fluid also monitored.
generally done repeatedly through- The needle is withdrawn; an adhe-
out the pregnancy sive bandage is placed over the inser-
tion site.

Amniotic fluid embolism
Hemorrhage or infection
Premature labor or birth
Abruptio placentae
Placental or umbilical cord trauma
Bladder or intestinal puncture
Rh isoimmunization
Intrauterine fetal death
Amniotic fluid leakage
Fetal bleeding
Spontaneous abortion
Merging of the two amniotic sacs to-
gether, increasing the risk of cord en-
tanglement and fetal death

5125A.qxd 8/15/08 9:57 AM Page 11


Explain the procedure to the patient, Assist the patient who is in the third GENERAL
and verify that a consent form has trimester to lie on her side to avoid Instruct the patient to report signs
been signed. hypotension from pressure of the and symptoms of complications:
Assist the patient when she voids to gravid uterus on the vena cava. vaginal discharge (fluid or blood),
reduce the risk of bladder puncture. Assess maternal vital signs every 15 decreased fetal movement, contrac-
Place the patient in a supine posi- minutes for 30 minutes and regularly tions, or fever and chills.
tion. thereafter to detect changes from Review with the patient the high pro-
Obtain baseline maternal vital signs baseline. tein supplements and bed rest re-
and FHRs. Continuously monitor the patient quirements associated with TTTS.
electronically for uterine irritability Instruct the patient to report a rapid
until discharge. increase in uterine size and weight
Monitor FHRs electronically for a few gain or difficulty breathing to the
hours after the procedure to allow physician promptly.
early intervention if complications
WARNING Changes in FHR, such Organizations
as tachycardia and bradycardia, Obstetrics, Gynecology, Infertility and
signal distress. If these signs appear, Womens Health: www.obgyn.net
notify the physician and continue to The Twin to Twin Transfusion Syndrome
monitor the FHRs. Foundation: www.tttsfoundation.org

Selected references
Galea, P.T., et al. Insights into the Patho-
physiology of Twin-Twin Transfusion
Syndrome, Prenatal Diagnosis 25(9):
777-85, September 2005.
Harkness, U.F., and Crombleholme, T.M.
Twin-Twin Transfusion Syndrome:
Where Do We Go From Here? Semi-
nars in Perinatology 29(5):296-304,
October 2005.
Quintero, R.A., et al. Management of
Twin-twin Transfusion Syndrome in
Pregnancies with Iatrogenic Detach-
ment of Membranes Following Thera-
peutic Amniocentesis and the Role of
Interim Amniopatch, Ultrasound in
Obstetrics & Gynecology 26(6):628-33,
November 2005.

5125A.qxd 8/15/08 9:57 AM Page 12

COMPLICATIONS Provide cast care if a rigid plaster
OVERVIEW Infection dressing has been applied.
Contractures Maintain the patient in proper body
Involves surgical removal of an ex- Skin breakdown, necrosis, or alignment.
tremity hematoma formation Reinforce physical therapy instruc-
In closed amputation: skin flaps used Phantom pain in the residual limb tions and activities.
to cover the bone end Chest pain, myocardial infarction, or Encourage frequent ambulation, as
In guillotine (open) amputation: tis- stroke appropriate.
sue and bone cut flush and wound is Encourage active or passive range-
left open to be repaired in a second of-motion exercises.
operation NURSING DIAGNOSES Help the patient with turning and
positioning without propping the
INDICATIONS Acute pain limb on a pillow.
Preservation of the function of a re- Impaired physical mobility Monitor the patients vital signs and
maining part Ineffective tissue perfusion: intake and output, and report
Severe trauma Peripheral changes.
Gangrene Observe the surgical wound, and re-
inforce or change dressings as or-
Vascular disease dered.
The patient will:
Congenital deformity Monitor and record amount of
express feelings of increased comfort
Thermal injury bleeding, patency of drains, and
attain the highest degree of mobility
amount and type of drainage.
possible within the confines of injury
Provide emotional support.
exhibit adequate tissue perfusion
PROCEDURE and pulses proximal to the amputa-
Encourage the patient to stop smok-
ing, if appropriate.
tion, with no evidence of skin break-
The patient receives general or local down.
Tissue is excised to the bone, leaving GENERAL
Review with the patient prescribed
sufficient skin to cover the limb end. Explain the treatment and prepara-
Bleeding is controlled by tying off the tion to the patient and his family. medications, including the dosage
bleeding vessels above the site. Verify that the patient or a family and possible adverse effects.
The bone (or joint) is sawed and Review postoperative care and reha-
member has signed an appropriate
filed, with the periosteum removed consent form. bilitation.
about 1/4 (0.5 cm) from the bone Review use and care of the prosthesis
Provide emotional support.
end. If possible, arrange for the patient to and phantom limb sensation.
All vessels are ligated and the nerves Reiterate the importance of daily ex-
meet with someone else who has un-
divided. dergone amputation and has adjust- amination of the distal limb and de-
Opposing muscles are sutured over ed well to the life changes that it scribe daily limb care and dressings
the bone end and periosteum. brings. as well as daily care after healing is
Skin flaps are closed and an incision Demonstrate prescribed exercises. complete.
Review signs and symptoms of infec-
drain may be placed. Administer a broad-spectrum antibi-
Soft dressings are applied; rigid otic as ordered. tion and skin breakdown.
dressings may be used in below-the- Review complications, and tell the
knee amputation. An elastic shrinker patient when to notify the physician.
may be applied to reduce edema and POSTTREATMENT CARE Review use of elastic bandages or a
limb shrinker. (See Wrapping your
residual limb.)
Elevate the affected limb as ordered.
Teach proper use of crutches as ap-
GUILLOTINE AMPUTATION Provide an analgesic as ordered and
A perpendicular incision is made comfort measures for pain.
Review activities to strengthen the
through the bone and all tissue. Keep the residual limb wrapped
residual limb and toughen the skin.
The wound isnt sutured closed. properly with elastic compression
Emphasize the importance of follow-
A large, bulky dressing is applied. bandages or an elastic shrinker as
up care.

5125A.qxd 8/15/08 9:57 AM Page 13

Assist the patient with finding a local Amputation Coalition of America: Walker, J.L., et al. Femoral Lengthening
support group or obtaining a referral www.amputee-coalition.org after Transfemoral Amputation, Or-
for psychological counseling. thopedics 29(1):53-59, January 2006.
Selected references Wang, J.N., et al. Salvage of Amputated
Poljak-Guberina, R., et al. The Amputees Upper Extremities with Temporary Ec-
RESOURCES and Quality of Life, Collegium Antro- topic Implantation Followed by Re-
Organizations pologicum 29(2):603-609, December plantation at a Second Stage, Journal
American College of Emergency Physi- 2005. of Reconstructive Microsurgery
cians: www.acep.org 22(1):15-20, January 2006.

Wrapping your residual limb

Dear Patient,
Wrapping your residual limb with an elastic bandage will promote healing and provide a comfortable fit for your prosthesis.

BEFORE YOU START 4. Now bring the bandage around the front of your body. The bandage should
back again. Keep it as close to your make an X over your thigh.
1. Assemble the supplies youll
groin as you can.
need skin care articles, 6 (15-
centimeter) wide elastic bandage (you
may need two rolls), and fasteners
(adhesive tape, safety pins, or clips).
Now do the skin care you learned in
the hospital. For comfort, wear only
lightweight or no underclothing while
8. Now bring the bandage down toward
applying the bandage.
the inside surface of your residual limb
2. Have an elastic bandage ready. Sit in 5. Next, place the bandage toward the
once again and around the back in an
a chair with your one foot resting flat on lower inside surface of your limb
upward diagonal. Continue wrapping
the floor. Now raise your limb about 6 slightly to one side of the last wrap.
diagonally until your limb is covered.
off the seat. Starting at the top front, Continue around to the back, wrapping
Secure the bandage with clips, pins, or
wrap the bandage diagonally toward the diagonally downward.
lower inside of your residual limb.

3. Wrap the bandage around the back. 6. Bring the bandage forward just below INSPECTING THE BANDAGE
Then bring it diagonally upward and the last wrap, then up and across to the
across the front and center of your limb. opposite hip. Make sure that all limb areas are
Be sure to secure the end of the covered, the bandage is wrinkle-free,
bandage. and every turn is diagonal. The bandage
should appear smooth and rounded and
fit snugly at the bottom of the residual
limb. If the bandage fails your inspec-
tion, you may need to re-wrap it.

This patient-teaching aid may be reproduced by office copier

7. Take the bandage around your back for distribution to patients. 2007 Lippincott Williams &
at waist level, and bring it around to the Wilkins.

5125A.qxd 8/15/08 9:57 AM Page 14

Angioplasty, percutaneous transluminal coronary

Stenosis that narrows the arterial lu- The expanding balloon compresses
OVERVIEW men by 70% or more the plaque, expanding the arterial lu-
men and pressure gradients across
Nonsurgical alternative to coronary the stenotic area.
artery bypass surgery PROCEDURE The balloon is inflated repeatedly
Uses a tiny balloon catheter to dilate until the residual gradient decreases
a coronary artery thats been nar- The catheter insertion site, usually to about 20% or until the pressure
rowed by atherosclerotic plaque; femoral, is prepared and anesthe- gradient measures less than 16 mm
usually includes atherectomy tized. Hg. The stent is fixed to the vessel
May include placement of a regular A guide wire is inserted into the wall during this procedure.
or drug-eluting stent femoral artery using a percutaneous Angiography is repeated.
or cutdown approach, and the The catheter may be left in place or
INDICATIONS catheter is guided fluoroscopically. removed, and the patient is taken to
Documented myocardial ischemia The lesion is confirmed using an- the intensive care unit or to a post-
and angina giography. anesthesia care unit for monitoring.
Proximal lesion in a single coronary A small, double-lumen, balloon- (See Relieving occlusions with angio-
artery tipped catheter with or without a plasty.)
Acute myocardial infarction stent over the balloon is inserted over
Postthrombolytic therapy with high- the guide wire and positioned prop- COMPLICATIONS
grade stenosis erly, and the balloon is inflated re- Arterial dissection
Previous coronary artery bypass sur- peatedly with normal saline solution Coronary artery rupture
gery and contrast medium for 15 to 30 Cardiac tamponade
Poor surgical candidate for coronary seconds, to a pressure of 6 atmo- Myocardial ischemia or infarction
artery bypass surgery spheres. Atherectomy may be per-
formed before balloon insertion.

Relieving occlusions with angioplasty

Percutaneous transluminal coronary angioplasty can open an occluded catheter through the guide catheter and directs the balloon through the
coronary without opening the chestan important advantage over bypass occlusion (shown below center). A marked pressure gradient will be
surgery. First, the physician confirms the presence and location of the obvious.
arterial occlusion using coronary angiography. Then the physician threads a The physician alternately inflates and deflates the balloon until an
guide catheter through the patients femoral artery into the coronary artery angiogram verifies successful arterial dilation (shown below right) and the
under fluoroscopic guidance (shown below left). pressure gradient has decreased.
When angiography shows the guide catheter positioned at the occlusion
site, the phyisician carefully inserts a smaller double-lumen balloon

Guide catheter

Plaque Flattened

Deflated balloon Inflated


Balloon catheter at occlusion

in coronary artery

5125A.qxd 8/15/08 9:57 AM Page 15

Abrupt reclosure of the affected ar- Insert I.V. line and arterial line if or-
tery (occurring within a few hours of dered; apply electrocardiogram PATIENT TEACHING
the procedure) (ECG) monitoring leads, automatic
Restenosis (usually occurring within blood pressure cuff, and pulse GENERAL
30 days to 6 months) oximetry monitor. Review with the patient the pre-
Coronary artery spasm Locate, mark, and record the ampli- scribed medications, such as anti-
Arrhythmias tude of bilateral distal pulses. platelets, including the dosage and
Bleeding Administer a sedative as ordered. possible adverse effects.
Hematoma Instruct the patient to tell the surgi- Discuss with the patient puncture
Thromboembolism cal team immediately if he has site care, activity restrictions if appli-
Adverse reactions to the contrast breathing difficulties, sweating, cable, and follow-up care and testing.
medium numbness, itching, nausea, vomit- Tell the patient to report signs and
ing, chills, or heart palpitations dur- symptoms of bleeding, infection,
ing the procedure. restenosis, or complications, and
NURSING DIAGNOSES when to notify the physician.
Teach the patient that a low choles-
Activity intolerance POSTTREATMENT CARE terol diet and regular exercise plus
Decreased cardiac output stress reduction and smoking cessa-
Ineffective tissue perfusion: Cardio- Administer an anticoagulant, I.V. ni- tion if appropriate reduces the risk of
pulmonary troglycerin, and I.V. fluids as ordered. recurrence.
Keep the affected extremity straight,
EXPECTED OUTCOMES and elevate the head of the bed no RESOURCES
The patient will: more than 15 degrees as ordered. Organizations
carry out activities of daily living If an expanding ecchymosis appears, American College of Cardiology:
without excess fatigue or decreased mark the area, and obtain hemoglo- www.acc.org
energy bin and hematocrit samples as or- American Heart Association:
maintain adequate cardiac output dered. www.americanheart.org
Monitor for hematoma formation, American Medical Association:
maintain normal blood pressure,
ecchymosis, or bleeding at the www.ama-assn.org
heart and respiratory rate, and clear
lung sounds. catheter insertion site. Report bleed-
ing sites to the surgeon and apply di- Selected references
rect pressure to them. Marret, E., et al. Thrombosis after Im-
plantation of Drug-Eluting Stents,
PRETREATMENT CARE After the sheath is removed, apply di-
JAMA 295(1):36, January 2006.
rect pressure to the insertion site un-
Mitka, M. Progress in Percutaneous
Explain the treatment and prepara-
til hemostasis occurs. Apply a pres- Heart Procedures Leads to Update
tion and verify that an appropriate sure dressing as ordered. in Clinical Guidelines, JAMA 295(3):
Monitor the patients vital signs and 263-64, January 2006.
consent form is signed.
Tell the patient that contrast medium intake and output, and report Oliver, B., et al. Open New Care Pathways
injection may cause a flushing sensa- changes. With Drug-Eluting Stents, Nursing
Continually monitor heart rate and Management 37(2):33-39, February
tion or transient nausea. Ask him
rhythm, invasive arterial pressures if 2006.
whether he has had reactions to
ordered, peripheral pulses, and neu-
shellfish, iodine, or contrast medium
rovascular status of extremities as in-
in the past. Also determine if he has
had a reaction to aspirin products or
Report ECG monitoring and 12-lead
antiplatelet drugs. Notify the surgeon
ECG results, particularly changes in
if the patient reports a reaction to
ST segments indicating ischemia or
any of these items.
Restrict food and fluid intake for at infarction.
Provide analgesia as needed.
least 6 hours before the procedure.
WARNING Immediately report
Obtain results of coagulation studies,
signs and symptoms of angina
complete blood count, serum elec-
(including chest pain), infection, fluid
trolyte levels, blood urea nitrogen
overload (tachycardia, dyspnea, ede-
and creatinine levels, and blood typ-
ma), and abrupt arterial reclosure
ing and crossmatching, as ordered.
Obtain the patients weight. (chest pain, ECG changes).

5125A.qxd 8/15/08 9:57 AM Page 16

Involves surgical removal of an in- The patient receives general anesthe- Acute pain
flamed vermiform appendix to pre- sia. Imbalanced nutrition: Less than
vent imminent rupture or perfora- The surgeon makes an incision in the body requirements
tion of the organ right lower abdominal quadrant to Ineffective tissue perfusion: GI
Laparoscopy: may be used to help di- expose the appendix.
agnose the condition In laparoscopic appendectomy, three EXPECTED OUTCOMES
or four small abdominal incisions are The patient will:
INDICATIONS made. express feelings of comfort
Acute appendicitis The base of the appendix is ligated. resume a normal diet by discharge
A purse-string suture is placed in the have normal bowel sounds and func-
cecum. tion by discharge.
Excess fluid or tissue debris is re-
moved from the abdominal cavity.
The incision is closed.
If perforation occurs, one or more
Penrose drains or abdominal sump
tubes, or both, are placed and the in-
cision may or may not be closed.

Paralytic ileus

With perforation
Local or general peritonitis
Paralytic ileus
Intestinal obstruction

5125A.qxd 8/15/08 9:57 AM Page 17


Explain the treatment and prepara- Place the patient in Fowlers position GENERAL
tion to the patient and his family. after the anesthesia wears off. Review with the patient prescribed
Verify that the patient has signed an Maintain patency of drainage medications and possible adverse
appropriate consent form. catheters and tubes. effects.
Administer a prophylactic antibiotic Encourage the patient to ambulate as Review with the patient signs and
as ordered. soon as possible. symptoms of infection and intestinal
Administer I.V. fluids as ordered. Encourage the patient to cough, obstruction and when to notify the
Insert a nasogastric (NG) tube as or- breathe deeply, and change positions physician.
dered. frequently. Teach the patient about wound care
Place the patient in Fowlers position. Auscultate for bowel sounds in all and activity restrictions.
Avoid giving an analgesic, a cathartic, four quadrants. Emphasize the importance of follow-
or an enema, and avoid applying Help the patient gradually resume up care.
heat to the abdomen. oral intake after NG tube removal.
Provide reassurance. Assist with emergency treatment of RESOURCES
peritonitis if needed. Organizations
Monitor the patients vital signs and American Academy of Pediatrics:
intake and output, and report www.aap.org
changes. American College of Gastroenterology:
Monitor surgical wounds and dress- www.acg.gi.org
ings. Harold D. Portnoy, MD, editor:
Report signs or symptoms of peri- www.yoursurgery.com
tonitis or other complications.
Record the type and amount of Selected references
drainage. Acosta, R., et al. CT Can Reduce Hospi-
talization for Observation in Children
with Suspected Appendicitis, Pedi-
atric Radiology 35(5):495-500, May
Bristow, N. Treatment and Management
of Acute Appendicitis, Nursing Times
100(43):34-36, October-November,
Dalal, I., et al. Serum and Peritoneal In-
flammatory Mediators in Children
with Suspected Acute Appendicitis,
Archives of Surgery 140(2):169-73,
February 2005.
Filewood, F. Improving Diagnosis and
Treatment for Appendicitis, Nursing
Times 101(17):41, April-May, 2005.

5125A.qxd 8/15/08 9:57 AM Page 18

Minor bleeding into the joint
Procedure in which a sterile needle The skin over the joint is sterilized Loss of pigment in the skin entered
and syringe are used to drain fluid using a liquid iodine solution or an- by the needle
from the joint; also called joint aspi- other antiseptic. Infection of the joint (septic arthritis)
ration Local anesthetic is used in the area of If a cortisone medication (a corti-
Although any joint in the body may the joint, either by injection, topical costeroid) is injected into the joint, ad-
be aspirated, arthrocentesis more liquid freezing, or both. ditional complications include:
commonly performed on larger ones, A needle with a syringe attached is inflammation in the joint as a result
such as the knees and shoulders inserted into the affected joint; fluid of the medication crystallizing
Typically performed as an office pro- is then aspirated back into the sy- increased blood glucose level (rare)
cedure or at the bedside of hospital- ringe. For certain conditions, the aggravation of preexisting infection
ized patients physician will also inject cortisone elsewhere in the body.
Possible injection of cortisone into into the joint after fluid removal.
the joint during the aspiration to rap- The needle is then removed and an
idly relieve joint inflammation and adhesive dressing is applied over the
further reduce symptoms entry point. (See Using arthrocentesis
to obtain fluid from a joint.)
Joint swelling and pain (removal of
fluid removes the white blood cells
that are sources of enzymes that can
be destructive to the joint)

Using arthrocentesis to obtain fluid from a joint

Arthrocentesis is aspiration
of the fluid from an
affected joint. Its
commonly used as a
diagnostic procedure, but
Ligament Fibrous
its also performed to
remove fluid from the joint
as a treatment.

Synovial cavity Synovial

containing membrane
synovial fluid



5125A.qxd 8/15/08 9:57 AM Page 19


Acute pain Review the procedure with the pa- GENERAL
Impaired physical mobility tient and review his medical history. Review with the patient the pre-
Risk for infection Assess the patient for reactions to scribed pain medications, including
steroids or current usage of steroids the dosage and possible adverse ef-
EXPECTED OUTCOMES systemically. fects.
The patient will: WARNING Before arthrocentesis, Tell the patient to avoid stressing the
express feelings of increased comfort check the patients history for a joint; activities may be resumed ac-
attain the highest degree of mobility preexisting bleeding disorder, use of cording to the physicians orders.
possible within the confines of the an anticoagulant with poorly con- Activities are usually restricted to al-
injury trolled blood levels, and allergic reac- low time for the joint to rest, as deter-
experience no fever, reddening, heat, tion to local anesthetic to avoid fur- mined by the physician.
recurrent swelling, increased pain, or ther complications. Review the need for follow-up care.
drainage at the puncture site in the Diagnostic studies may include an Tell the patient to report signs and
joint. X-ray of the joint or magnetic reso- symptoms of complications: recur-
nance imaging to confirm diagnosis rence of joint fluid, swelling,
and presence of joint fluid. drainage from the puncture area,
fever, increasing pain even though an
analgesic is taken, and signs and
POSTTREATMENT CARE symptoms of joint infection (redness
and warmth).
Ice may be applied to the joint for 20
to 30 minutes every 3 to 4 hours for RESOURCES
the first 24 hours after treatment. Organizations
The physician may apply an elastic American Academy of Orthopedic Sur-
bandage to help support the joint. geons:www.aaos.org
American College of Rheumatology:
Arthritis Foundation: www.arthritis.org

Selected references
Ostergaard, M., et al. Magnetic Reso-
nance Imaging in Rheumatoid Arthri-
tis Advances and Research Priorities,
Journal of Rheumatology 32(12):2462-
464, December 2005.
Sharp, J.T., et al. Measurement of Joint
Space Width and Erosion Size, Journal
of Rheumatology 32(12):2456-461, De-
cember 2005.
Tanaka, N., et al. Volume of a Wash and
the Other Conditions for Maximum
Therapeutic Effect of Arthroscopic
Lavage in Rheumatoid Knees, Clinical
Rheumatology 25(1):65-69, February

5125B.qxd 8/15/08 10:25 AM Page 20

Biliopancreatic diversion
retained, maintaining some diges-
OVERVIEW tion in the stomach as well as the PROCEDURE
normal flow of food through the py-
Procedure that restricts both food in- loric sphincter. This duodenal area is BPD
take and the amount of calories and then connected to the ileum. The patient is placed under general
nutrients the body absorbs to However, the remaining portion of anesthesia. If hes undergoing an
achieve long-term, major weight loss the stomach, duodenum, and je- open procedure, a large incision is
in individuals weighing more than junum are reconnected to the lower made in the abdomen. Alternatively,
100 lb (45 kg) over their ideal body end of the ileum, permitting gastric if a laparoscopic approach is being
weight juices as well as bile salts and pancre- used, several small incisions are
Stomach capacity: 4 to 5 oz after bil- atic digestive enzymes to aid absorp- made, carbon dioxide gas is insufflat-
iopancreatic diversion (BPD), com- tion of more fats and other nutrients ed into the abdomen to separate the
pared with 1 oz after standard gastric than in BPD alone. organs from each other, and smaller
bypass operation, making it a less re- Ghrelin, a hormone secreted by the instruments and a camera are used
strictive option stomach and responsible for the sen- to guide the surgery.
Two types of BPD surgery: sation of hunger, along with the re- All but a portion of the stomach is re-
in BPD, the stomach is removed just duced capacity to hold food, giving moved.
below the esophagus forming a small the patient a feeling of fullness after The stomach pouch is connected di-
pouch. The remaining pouch is con- eating 1 cup of food rectly to the ileum, through an open-
nected to the ileum, restricting ab- Removal of the gallbladder may be ing made in the mesothelium.
sorption of fats and other nutrients. done prophylactically The bypassed portions of the intes-
The freed duodenal and jejunal limbs tine are anastomosed to the final 2 to
of the small intestine are then con- INDICATIONS 4(1.2 m) of ileum, forming a com-
nected to the lower end of the ileum, Obesity for at least 5 years without a mon channel before entering the
allowing the biliary and pancreatic history of alcohol abuse, untreated colon.
digestive juices to mix with food just depression, or another major psychi- The newly anastomosed sites are
before entering the colon to permit atric disorder checked for leakage by being filled
digestion of some fats, vitamins, and Body mass index (BMI) 40 or higher with sterile saline solution.
minerals. (See Understanding bilio- despite repeated attempts to lose
pancreatic diversion.) weight BPD/DS
in BPD with duodenal switch BMI 35 to 40 and presence of a life- In BPD/DS, the pyloric valve and
(BPD/DS), less of the stomach is re- threatening or disabling condition about 2 (5 cm) of the proximal duo-
moved, and the pyloric valve and a related to weight denum is preserved, as a large por-
small segment of the duodenum are tion of the stomach is excised, paral-
lel to the greater curvature.
An opening in the mesothelium is
created and the ileum is attached to
Understanding biliopancreatic diversion the residual duodenum.
The detached stomach, duodenum,
In a biliopancreatic diversion, and jejunum are connected to the fi-
a portion of the stomach is Remainder of partially
removed stomach nal 2 to 4 (0.6 to 1.2 m) of the distal
removed and the remainder is
ileum, as in BPD, and similarly
connected to the lower Illeum
portion of the small intestine.
checked for leakage.
The food bypasses much of
the small intestine, resulting COMPLICATIONS
in fewer calories absorbed Loose stools or dumping syndrome
and weight loss. (mainly with BPD)
Malodorous gas
Serious deficiencies in protein, fat,
calcium, iron, or vitamins B12, A, D,
Colon E, and K due to malabsorption
Paralytic ileus
Stomal ulcers (rare with BPD/DS)
Infection or poor wound healing at
the incision site

5125B.qxd 8/15/08 10:25 AM Page 21

Peritonitis Reinforce the lifestyle changes that

Embolization of the large bowel or POSTTREATMENT CARE are needed, such as consuming only
lungs small portions of food high in pro-
Gallstones due to rapid weight loss Maintain I.V. replacement therapy as tein, vitamins, and minerals and
Osteoporosis ordered. minimizing carbohydrates. Remind
Coagulopathy due to reduced vita- Keep the NG tube patent, but dont the patient that initially his appetite
min K absorption reposition it. is suppressd so he may have to
Death (rare)NURSING DINOSES Monitor drainage from incisions and schedule meals.
provide care of incisions and skin Tell the patient that his taste and tol-
folds, as indicated. erance for different foods may com-
NURSING DIAGNOSES Encourage regular coughing and pletely change.
deep-breathing exercises. Tell the patient that because part of
Acute pain Teach the patient to splint the inci- the intestine is bypassed, deficiencies
Imbalanced nutrition: Less than sion site as necessary. may occur in iron, calcium, magne-
body requirements Monitor the patients vital signs, in- sium, or vitamins. Inform the patient
Ineffective tissue perfusion: GI take and output, and daily weight. that lifelong fat-soluble (A, D, E, K)
Assist with early ambulation. vitamin supplementation is neces-
EXPECTED OUTCOMES WARNING Monitor the patient sary to prevent severe anemia, bone
The patient will: for and immediately report signs loss, and nerve problems and that he
express feelings of comfort
and symptoms of anastomotic leak- may need to work with a dietitian to
have laboratory values within normal
age, including low-grade fever, mal- plan meals.
aise, slight leukocytosis, abdominal Emphasize the need for repeated
parameters and verbalize an under-
distention, tenderness, hemorrhage, laboratory studies, such as measur-
standing of the need for nutritional
hypovolemic shock, bloody stool, and ing protein stores. Oral protein sup-
supplementation for life
show no signs of peritonitis or bowel
wound drainage. plementation may be necessary.
Administer medications as ordered. Be sure to review the prescribed
Assess the patient for abdominal medications, including dosage and
pain or cramps and shoulder pain. possible adverse effects; incision site
PRETREATMENT CARE Explain that bloating or abdominal
fullness from laparoscopy will sub-
care; signs and symptoms of infec-
tion; complications; and when to no-
side as the infused gas is absorbed. tify the practitioner.
Verify that the patient has signed an
Administer analgesics as required.
informed consent form.
Instruct the patient not to have any-
Provide comfort measures. RESOURCES
thing to eat or drink after midnight
American College of Gastroenterology:

before the surgery.
Insert an I.V. access device
PATIENT TEACHING www.acg.gi.org
American College of Surgeons:
Check that preoperative testing re- www.facs.org
sults are available. GENERAL
American Society for Bariatric Surgery:
Verify that the patient completed Tell the patient to avoid abdominal
preoperative bowel cleansing and straining and lifting until the practi-
administer an antibiotic, as ordered. tioner approves.
Selected references
Explain the treatment, preparation, Tell the patient to return to activities
Crookes, P.F. Surgical Treatment of Mor-
and postoperative care to the patient as directed, usually within 3 to 5 bid Obesity, Annual Review of Medi-
and his family. weeks. cine 57:243-64, February 2006.
Tell the patient that a nasogastric Tell the patient to keep follow-up ap- Parikh, M.S., et al. Objective Comparison
(NG) tube will be in place after sur- pointments with the surgeon. of Complications Resulting from La-
gery and will be removed in a few Discuss dumping syndrome and how paroscopic Bariatric Procedures, Jour-
days. to minimize it: nal of the American College of Surgeons
occurs when food moves too quickly 202(2):252-61, February 2006.
Prepare the patient for early post-
through the GI, tract causing nausea, Vaidya, V. (ed.) Health and Treatment
operative ambulation.
weakness, sweating, faintness and, Strategies in Obesity, Advances in Psy-
Tell the patient to expect to have an
possibly, diarrhea soon after eating chosomatic Medicine 27:1-93, 2006.
I.V. line and possibly abdominal
drains after surgery.POSTTMENT commonly triggered by eating highly
CARE refined, high-calorie carbohydrates.

5125B.qxd 8/15/08 10:25 AM Page 22

Bladder and bowel retraining

May be needed to treat such elimina- BLADDER RETRAINING Bowel incontinence
tion problems as bladder and fecal Make sure that the patient maintains Risk for situational low self-esteem
incontinence (especially in elderly adequate daily fluid intake. Total urinary incontinence
patients) Frequently assess the patients men-
Incontinence: can have serious psy- tal and functional status. EXPECTED OUTCOMES
chosocial effects and threaten a pa- Encourage or assist the patient to The patient will:
tients ability to live independently void every 2 hours (or more frequent- demonstrate bowel continence with
ly to maintain dryness between void- a schedule
INDICATIONS ings). demonstrate urinary continence
Loss or impairment of urinary or Respond to patient calls promptly, with a schedule
anal sphincter control and help him get to the bathroom as express feelings of positive self-worth
Age- or disease-related changes in quickly as possible. about continence issues.
genitourinary (GU) or GI system Implement an exercise program for
function or, less commonly, in other strengthening pelvic floor muscles
body systems, such as the muscu- such as Kegel exercises.
loskeletal and nervous systems Suggest biofeedback to reinforce
Fecal stasis and impaction pelvic muscle contraction as needed.
When the patient can stay dry for 2
hours, increase the time between
voidings by 30 minutes each day un-
til a 3- to 4-hour voiding schedule is
Have the patient empty his bladder
completely before bedtime.

Remind or help the patient to get to
the toilet or commode 15 to 20 min-
utes before his usual bowel move-
ment time.
Ask the patient if the bowel move-
ment felt complete, allowing more
time if needed and tolerated.
Encourage the patient to alternately
contract and release his abdominal
muscles, sway back and forth on the
toilet, or take a large breath, hold
briefly while bearing down, and then
release it to stimulate peristalsis.
AGE FACTOR Stay with a patient
who has dementia and reinforce
the need to remain on the toilet.
Encourage a fiber-rich diet that in-
cludes raw, leafy vegetables, un-
peeled fruits, and whole grains, such
as bran cereals.
Encourage adequate daily fluid in-
Promote regular exercise.

Skin breakdown

5125B.qxd 8/15/08 10:25 AM Page 23


Explain the treatment and prepara- Praise the patients successful efforts. GENERAL
tion to the patient and his family. Encourage persistence, tolerance, Teach the patient and caregiver how
Perform careful assessment of diet, and a positive attitude. to manage the steps of retraining.
fluid status, dentition and swallow- Be sensitive to the patients feelings (See Retraining your bladder, pages
ing, usual bowel and bladder pat- of embarrassment and low self- 24 and 25.)
terns in the past and presently, laxa- confidence. Explain that periodic incontinence
tive use, ability to comprehend and Maximize the patients independ- doesnt mean program failure.
follow instructions, and abdominal ence while minimizing risks to his Explain the need for gradual elimina-
physical findings. self-esteem. tion of laxative use, if necessary, and
Assess the patient for signs and Regularly reassess food and fluid in- how to transition to the use of natu-
symptoms of urinary tract infection take, character and patterns of void- ral laxatives, such as prunes or prune
(UTI). ing, and mental capacity to respond juice.
Provide support and help the patient to the treatment program. Review medications, such as antibi-
deal with feelings of shame, embar- otics for UTI, and potential adverse
rassment, or powerlessness caused reactions.
by loss of control. Review signs and symptoms of infec-
Monitor the patients vital signs, fluid tion and when to notify the physi-
intake and output, and diet patterns cian.
to determine baseline values. Emphasize the importance of follow-
Assess the patient for signs of infec- up care.
tion or incomplete elimination.
Refer the patient for dental, GU, RESOURCES
physical, and speech therapy (for Organizations
swallowing), as needed to improve American Association of Clinical Urolo-
contributing factors and proper in- gists: www.aacuweb.org
take before initiating the therapy American Society of Colon and Rectal
program. Surgeons: www.fascrs.org
National Association for Continence:

Selected references
Bharucha, A.E. Update of Tests of Colon
and Rectal Structure and Function,
Journal of Clinical Gastroenterology
40(2):96-103, February 2006.
Jumadilova, Z., et al. Urinary Inconti-
nence in the Nursing Home: Resident
Characteristics and Prevalence of Drug
Treatment, American Journal of Man-
aged Care 11(Suppl 4):S112-120, July
Karon, S. A Team Approach to Bladder
Retraining: A Pilot Study, Urological
Nursing 25(4):269-76, August 2005.


5125B.qxd 8/15/08 10:25 AM Page 24


Retraining your bladder

Dear Patient,
You can retrain your bladder and correct or manage incontinence by reestablishing a normal urination pattern.
First youll keep a careful record of your fluid intake and urination pattern. Then youll schedule urination at regular intervals
and increase the time between urinations gradually. Your goal will be to urinate no more than once every 3 to 4 hours.


Do your accidental urinations follow a pattern? Youll know at After a few days, your chart will show when youre most
a glance by recording your fluid intake, how you urinated likely to become incontinent for example, after meals or
(intentionally or by accident), and why you think an accident during the night. Your chart will also help your health care
occurred. Keep a chart (like the one shown) throughout your provider evaluate your progress and adjust your treatment, if
retraining program. Record exact times and amounts. Make necessary.


6 to 8 a.m.

8 to 10 a.m.

10 a.m. to noon

Noon to 2 p.m.

2 to 4 p.m.

4 to 6 p.m.

6 to 8 p.m.

8 to 10 p.m.

10 p.m. to midnight

Midnight to 2 a.m.

2 to 4 a.m.

4 to 6 a.m.

5125B.qxd 8/15/08 10:25 AM Page 25

Retraining your bladder (continued)


Next, schedule specific times to urinate. Practice this Set an alarm clock to remind you when to use the toilet,
technique at home, where youre relaxed and close to the including once or twice during the night.
bathroom. Start by urinating every 112 to 2 hours, whether or Make sure that you can reach the bathroom or portable
not you feel the need. If you have the need to urinate sooner, toilet easily.
practice holding it by relaxing, concentrating, and taking Walk to the bathroom slowly.
three slow, deep breaths until the urge decreases or goes Always urinate just before bedtime.
away. Wait 5 minutes. Then go to the bathroom and Ask your nurse to teach you Kegel exercises, which help
urinate even if the urge has passed. Otherwise, your next increase bladder tone.
urge may be very strong and difficult to control. Avoid drinks that contan caffeine or alcohol.
If you have an accident before the 5 minutes have passed, Drink between eight and ten 8-ounce (240-milliliter)
shorten your next waiting time to 3 minutes. After a week of glasses of fluid every day. This helps prevent urinary tract
training, if waiting 5 minutes is easy, increase your waiting infection and constipation, which also can cause inconti-
time to 10 minutes. Using the method above, gradually nence. To prevent nighttime accidents, drink most of your
increse the intervals between urinations. Strive for 3- or 4- fluids before 6 p.m. Remember to count foods containing
hour intervals. Dont get discouraged if you have an accident. mostly liquid (such as ice cream, soup, and gelatin) as fluids.

This patient-teaching aid may be reproduced by office copier for distribution to patients.
2007 Lippincott Williams & Wilkins.

5125B.qxd 8/15/08 10:25 AM Page 26

Blood and plasma product transfusion

To prevent errors and a potentially Platelets to treat thrombocytopenia
OVERVIEW fatal reaction, two nurses or practi- caused by decreased platelet produc-
tioners required (per the Joint tion, increased platelet destruction,
Whole blood: blood with all blood Commission on Accreditation of or massive transfusion of stored
components intact Healthcare Organization standards blood; to treat acute leukemia and
Packed red blood cells (RBCs): whole and most facility policies) to identify marrow aplasia; and to improve
blood with 80% of the plasma re- the patient by two criteria and to platelet count preoperatively in a pa-
moved; volume usually 250 ml double check the blood product tient whose count is 100,000/l or
Leukocyte-poor RBCs: same as compatibility before transfusion less
packed RBCs with about 95% of the If the patient is a Jehovahs Witness, FFP to correct an undetermined co-
leukocytes removed; volume about special written permission required agulation factor deficiency; to re-
200 ml Alternatives to blood transfusions place a specific factor when it isnt
Each unit of whole blood or RBCs: when specific blood components are available; and to correct factor defi-
contains enough hemoglobin (Hb) to adequate but volume has been lost: ciencies resulting from hepatic dis-
raise the Hb level in an average-size normal saline or lactated Ringers so- ease
adult by 1 g/dl (by about 3%) lution, albumin or purified protein WARNING FFP is no longer in-
White blood cells (WBCs or leuko- fractions, hydroxyethyl starch or dex- dicated for use as a volume
cytes): whole blood with all RBCs and trans expander due to its high load of clot-
about 80% of the plasma removed; ting factors. Its also contraindicated
volume usually 150 ml INDICATIONS as prophylaxis after cardiopulmonary
Platelets: platelet sediment from Whole blood (rarely used) to rapidly bypass surgery or with massive blood
RBCs or plasma; volume 35 to 50 ml/ restore blood volume and oxygen- transfusions.
unit; 1 unit of platelets equal to 107 of carrying capability of blood as from Albumin to replace volume lost be-
platelets hemorrhage cause of shock from burns, trauma,
Above products requiring the pa- Packed RBCs to maintain or boost surgery, or infections; to replace vol-
tients blood to be identified by ABO oxygen-carrying capability of the ume and prevent marked hemocon-
and Rh type and crossmatched for blood, such as from blood loss from centration; and to treat hypopro-
antibodies so a matching product GI bleeding or surgery or RBC de- teinemia (with or without edema)
can be given struction from chemotherapy Factor VIII to treat hemophilia A; to
Fresh frozen plasma (FFP): uncoagu- Packed RBCs by exchange transfu- control bleeding associated with fac-
lated plasma separated from RBCs sion every 3 to 4 weeks in high-risk tor VIII deficiency; and to replace fib-
and rich in coagulation factors V, VIII, children with sickle cell anemia to rinogen or deficient factor VIII
and IX; volume 200 to 250 ml keep sickled hemoglobin below 30% Factors II, VII, IX, and X complex to
Albumin 5% (buffered saline) and al- and reduce incidence of stroke treat a congenital factor V deficiency
bumin 25% (salt-poor saline): small Leukocyte-poor RBCs for the patient and other bleeding disorders result-
plasma protein prepared by fraction- who has had a febrile, nonhemolytic ing from an acquired deficiency of
ating pooled plasma; volume of 5%, transfusion reaction, caused by WBC factors II, VII, IX, and X
12.5 g/250 ml; volume of 25%, 12.5 g/ antigens reacting with the patients WARNING Factors II,VII, IX, and
50 ml WBC antibodies or platelets X complex transfusions are con-
Factor VIII: insoluble portion of plas- WBCs used to treat sepsis unrespon- traindicated in patients who have he-
ma recovered from FFP; volume sive to antibiotics (especially if the patic disease resulting in fibrinolysis
about 30 ml (freeze-dried) patient has positive blood cultures or and in patients who have disseminat-
Factors II, VII, IX, and X complex a persistent fever exceeding 101 F ed intravascular coagulation and
(prothrombin complex): lyophilized, [38.3 C] and granulocytopenia arent undergoing heparin therapy.
commercially prepared solutions [granulocyte count usually less than
drawn from pooled plasma 500/l])

5125B.qxd 8/15/08 10:25 AM Page 27

Because a WBC infusion induces WARNING If signs of a reaction

PROCEDURE fever and chills, administer an anti- develop, stop the transfusion
pyretic if fever occurs. Dont discon- and record the patients vital signs.
Put on gloves, a gown, and a face tinue the transfusion; instead, reduce Infuse normal saline solution through
shield as appropriate. the flow rate, as ordered, for patient a new I.V. line at a moderately slow in-
If the patient doesnt have an I.V. line comfort. fusion rate, and notify the physician.
in place, perform a venipuncture us- Agitate the WBC container to prevent Save the blood product bag for return
ing a 20G or larger-diameter catheter. settling, thus preventing the delivery to the blood bank. Obtain a urine and
AGE FACTOR Pediatric and eld- of a bolus infusion of WBCs. blood sample and send them to the
erly patients require a smaller- Platelets require a component drip laboratory.
diameter catheter, such as 20G, to administration set to infuse 100 ml If no signs of a reaction appear with-
transfuse RBCs because they have over 15 minutes. As prescribed, pre- in 15 minutes, adjust the flow to the
smaller veins. medicate with an antipyretic and an ordered infusion rate, which should
Prepare a bag of normal saline solu- antihistamine if the patients history be as rapid as the circulatory system
tion to flush the line before and after includes a platelet transfusion reac- can tolerate.
transfusion or keep the vein open tion. If the patient has a fever before
during a reaction or between transfu- administration, notify the practition- COMPLICATIONS
sions. er for probable delay of the transfu- Transfusion reaction
Obtain an infusion pump suitable for sion. Infectious disease transmission
administering blood per facility poli- For FFP, use a straight-line I.V. set, Hepatitis C
cy. Obtain a blood warmer, if or- and administer the infusion rapidly. Circulatory overload
dered, to prevent hypothermia from For albumin, use a straight-line I.V. Hemolytic reactions
rapid infusion of large volumes of set with rate and volume dictated by Coagulation disturbances
blood. the patients condition and response. Citrate intoxication
WARNING Only normal saline so- For factor VIII, use the administra- Hyperkalemia
lution is compatible with blood tion set supplied by the manufactur- Acid-base imbalance
and plasma products. Never start a er. Administer with a filter; the stan- Allergic, febrile, and pyogenic reac-
transfusion in an I.V. line that has dard dose recommended for the tions
been used for another infusion with- treatment of acute bleeding episodes Hypothermia
out flushing the line completely with in patients with hemophilia is 15 to
saline. 20 units/kg.
Give whole blood or packed RBCs Factors II, VII, IX, and X complex are
through a Y-type I.V. set with a 170- administered with a straight-line I.V.
micron filter unless a 20- to 40- set, basing the dose on the desired
micron filter (for microaggregates factor level and the patients weight.
from degenerating platelets and fib- Adjust the flow rate as appropriate
rin strands) is ordered. for the component transfusion; re-
Administer leukocyte-poor RBCs main with the patient and reassess
with a straight-line or Y-type I.V. set his vital signs and blood pressure, fa-
to infuse blood over 112 to 4 hours. cial color, and any complaints fre-
Use a 40-micron filter suitable for quently for the initial 15 minutes, ac-
hard-spun, leukocyte-poor RBCs. cording to facility policy.
Administer WBCs using a straight-
line I.V. set with a standard in-line
blood filter to provide 1 unit daily for
5 days or until the infection resolves.


5125B.qxd 8/15/08 10:25 AM Page 28


Activity intolerance Explain the procedure to the patient After completing the transfusion, put
Deficient fluid volume and verify that he has signed the ap- on gloves and remove and discard
Ineffective tissue perfusion: Renal, propriate consent form. the used infusion equipment in the
cerebral, cardiopulmonary Record the patients baseline vital biohazard material receptacle.
signs. Reconnect the original I.V. fluid, if
EXPECTED OUTCOMES Obtain the blood product from the necessary, or discontinue the I.V. in-
The patient will: blood bank no more than 30 minutes fusion.
demonstrate increased ability to per- before starting the transfusion. Return the empty component bag to
form activities of daily living Check the expiration date on the the blood bank, if facility policy dic-
maintain adequate fluid volume component bag, and watch for ab- tates.
maintain adequate intake and out- normal color, clumping, gas bubbles, Record the patients vital signs.
put, vital signs, and blood pressure and extraneous material. Prepare to draw blood for a platelet
without deterioration in his level of Return outdated or abnormal com- count, as ordered, 1 hour after
consciousness. ponents to the blood bank. platelet administration to determine
Compare the name and medical platelet transfusion increments.
record number on the patients wrist Large-volume transfusions of FFP
band with those on the component may require correction for hypocal-
bag label. cemia because citric acid in FFP
Check the component bag identifica- binds calcium.
tion number, ABO blood group, and The half-life of factor VII is 8 to10
Rh compatibility, as appropriate. hours, which necessitates repeated
Compare the patients blood bank transfusions at specified intervals to
identification number, if present, maintain normal levels.
with the number on the blood bag.
WARNING ABO incompatibility
from mistakes in blood product
labeling or patient identification is
the major cause of fatal hemolytic
transfusion reactions.
Identification of blood and blood
products is performed at the pa-
tients bedside by two licensed pro-
fessionals, according to policy.
When administering WBCs, premed-
icate with diphenhydramine (Bena-
dryl) as prescribed.
WARNING Keep in mind that al-
bumin is contraindicated in pa-
tients with severe anemia and admin-
istered cautiously to those with car-
diac or pulmonary disease due to the
risk of heart failure from circulatory
Draw blood for a coagulation assay
before administration of factors II,
VII, IX, and X complex and at suitable
intervals during treatment.

5125B.qxd 8/15/08 10:25 AM Page 29

American College of Emergency Physi-
GENERAL cians: www.acep.org
Teach the patient to immediately re- American Medical Association:
port the following complaints to the www.ama-assn.org
National Heart, Lung, and Blood Institute,
National Institutes of Health:
flushing, feverish feeling, chills, nau- www.nhlbi.nih.gov
sea, and headache (transfusion reac-
Selected references
palpitations (with hypotension, ar-
Blajchman, M.A. The Clinical Benefits
rhythmia, and shaking chills; may be of the Leukoreduction of Blood Pro-
sign of hypothermia) ducts, The Journal of Trauma 60(Sup-
difficulty swallowing or breathing pl 6):S83-90, June 2006.
(possible anaphylaxis) Newman, B.H., and Roth, A.J. Estimating
tingling in the fingers, muscle the Probability of a Blood Donation
cramps, nausea and vomiting, faint- Adverse Event Based on 1000 Inter-
ness (with hypotension, arrhythmia, viewed Whole-Blood Donors, Trans-
and seizures; may signal hypocal- fusion 45(11):1715-721, November
cemia from citrate toxicity or liver 2005.
impairment) Sapatnekar, S., et al. Acute Hemolytic
Transfusion Reaction in a Pediatric
intestinal colic, diarrhea, muscle
Patient Following Transfusion of Aphe-
weakness (with irritability, oliguria,
resis Platelets, Journal of Clinical
T-wave changes on the electrocardio- Apheresis 20(4):225-29, December
gram, and bradycardia; may signal 2005.
hyperkalemia from large-volume

5125B.qxd 8/15/08 10:25 AM Page 30

Bone grafting
moval of scar tissue and dead or site with a needle or by open, inci-
OVERVIEW poorly vascularized tissue from graft sional surgery. (See Autogenous bone
site that might interfere with healing grafting.)
Refers to many surgical methods As an alternative, biological prod-
augmenting or stimulating the for- INDICATIONS ucts, such as bone graft extenders or
mation of new bone where needed Stimulation of healing for fractures bone graft replacements, may be
Used during orthopedic procedures that are fresh or those that have used. An allograft is bone harvested
to stimulate the bone to heal and to failed to heal after an initial treat- from a cadaver or an organ donor.
provide support to the skeleton by ment attempt The bone may be demineralized in
filling in gaps between two bones Stimulation of healing between two which some of the proteins that
A portion of bone graft placed into a bones across a diseased joint stimulate bone formation are ex-
space helps support the structure, (arthrodesis or fusion) tracted and readily used as an exten-
holding the bones apart while the Regeneration of bone thats lost or der to the patients own bone.
body grows to the bone graft at either missing as a result of trauma, infec- Other options include ceramics, cal-
end; over time, the entire piece of tion, or disease cium phosphates, and other synthet-
bone that was grafted is remodeled Improvement of bone healing re- ic materials, which have similar bio-
and replaced with new bone sponse and regeneration of bone tis- mechanical properties and structure
Bone taken from the patients body sue around surgically implanted de- to that of cadaver bone; however,
known as an autograft or an autoge- vices (artificial joint replacements or these substances arent biologically
nous bone graft; bone graft taken plates and screws) active, nor do they stimulate a spinal
from someone elses body, such as an fusion by themselves. Although
organ donor, known as an allograft; adding the patients bone marrow
some major spine fusions need a lot PROCEDURE cells to these compounds can give
of bone graft, so the surgeon may them more biological activity, this
mix allografts with autografts In an autogenous bone graft, the sur-
approach is still being tested.
When donated bone tissue is Platelet gels may be used because
geon makes a separate incision and
crushed into powder and placed theyre easily removed from the pa-
takes a small piece of bone from an-
around a fracture or fusion site, tients blood with few complications.
other area of the body (such as the
chemicals in the bone tissue stimu- The major disadvantages are that
pelvis or iliac crest). The surgeon
late healing; with an autograft, living they dont contain osteoinductive
transfers the bone graft to the graft
bone cells (called osteocytes) survive proteins and they arent powerful
after transfer to a new location and
continue making new bone
Artificial bone graft materials have Autogenous bone grafting
been developed, such as sea coral
harvested from the ocean; success-
During an autogenous
fully used as the basis for a structural bone graft, bone is har-
bone replacement Popliteal
vested from the patients artery
Demineralized bone matrix (a type of own body such as the iliac
allograft) has been developed from crest. Sometimes the Posterior
cadaver bones in a bone bank; the Bone graft
blood vessels supplying Fibula tibial artery
bone (with calcium removed) can be the bone graft are kept
made into a putty, sheet, or gel and with it and attached to the Fibular
then added to a graft site to improve blood vessels surrounding artery
fusion (Bone morphogenetic protein the recipient site. (The fib-
is an additional chemical thats ula is commonly a source
of vascularized bone
added to bone graft and enhances
grafts.) The graft is then
bone growth when added to a fusion Tibia
placed into the surgical
site.) site required.
Minimally invasive bone grafting
(when bone marrow or other graft
materials are delivered by injection)
available; however, most methods re-
quire open implantation to ensure
adequate space and proper position-
ing of graft material and allow for re-

5125B.qxd 8/15/08 10:25 AM Page 31

enough stimulants to induce bone Instruct the patient not to eat or

formation. They can be used as graft drink anything after midnight. PATIENT TEACHING
extenders but not graft replacements. Have the patient remove all jewelry,
Bone morphogenetic proteins have body piercings, makeup, nail polish, GENERAL
been produced, concentrated, and hairpins, and contact lenses before Tell the patient to follow a nutritious
placed in the body in areas where surgery. diet and exercise the nonaffected
bone formation is needed. Theyre Start an I.V. line and administer fluids muscle groups to maintain overall
powerful enough to stimulate bone as ordered. health during the recovery process.
formation without the patients bone. Administer medications, such as a Advise the patient to avoid smoking,
Several of these proteins are found prophylactic antiemetic, as ordered. because nicotine can inhibit fracture
naturally in the body and play a role healing. The patient should also
in bone formation. The most promis- avoid radiation therapy, chemothera-
ing ones are BMP-2 and BMP-7. POSTTREATMENT CARE py, NSAIDs, and systemic cortico-
steroids because all of these treat-
COMPLICATIONS Monitor the patients vital signs and ments are known to slow bone heal-
Nerve injury intake and output. ing.
Infection Report laboratory results. Tell the patient that the physician
Bleeding Assess the patient for such complica- will use an X-ray to determine
Stiffness tions as infection, hemorrhage, and whether the fracture has fully healed.
Pain and soreness that last well after graft-versus-host disease, as indicat- Advise and provide instructions
the surgery, and increased blood loss ed. about weight bearing as ordered.
(autografts) Assist with electrical current as indi- Activity at home depends on instruc-
Graft rejection (allografts) cated; this is known to stimulate tions as ordered.
bone growth, so many surgeons use
electrical stimulation devices during RESOURCES
NURSING DIAGNOSES the first weeks after surgery to speed Organizations
up a fusion. American Academy of Orthopedic Sur-
Acute pain Elevate the patients upper body as geons: www.aaos.org
Impaired physical mobility ordered. American Medical Association:
Ineffective tissue perfusion: Administer an analgesic, as ordered, www.ama-assn.org
Peripheral for pain.
Provide cast care, as indicated. Selected references
Monitor the patient for adequate cir- Chougle, A., et al. Long-Term Survival of
EXPECTED OUTCOMES the Acetabular Component after Total
The patient will: culation distally, signs of bleeding,
compartment syndrome, and infec- Hip Arthroplasty With Cement in Pa-
express feelings of increased comfort tients with Developmental Dysplasia
attain the highest degree of mobility
of the Hip, The Journal of Bone and
Apply heat to the injured area, as or-
possible within the confines of the Joint Surgery 88(1):71-79, January 2006.
dered, to improve blood circulation
injury Phipatanakul, W.P., and Norris, T.R.
exhibit adequate tissue perfusion
and promote healing. Treatment of Glenoid Loosening and
After the cast is removed, massage Bone Loss due to Osteolysis with Gle-
and pulses distally.
the injured area with ice. noid Bone Grafting, The Journal of
Shoulder and Elbow Surgery 15(1):84-
PRETREATMENT CARE 87, January-February 2006.
Yen, C.Y., et al. Osteonecrosis of the
Femoral Head: Comparison of Clinical
Explain the treatment and patient Results for Vascularized Iliac and Fibu-
preparation. la Bone Grafting, Journal of Recon-
Verify that the patient has signed the structive Microsurgery 22(1):21-24,
appropriate consent form. January 2006.
Make sure that prescribed preopera-
tive tests and laboratory work have
been completed.
Tell the patient to refrain from taking
aspirin and nonsteroidal anti-
inflammatory drugs (NSAIDs) 1 week
before surgery.

5125B.qxd 8/15/08 10:25 AM Page 32

Bone growth stimulation, electrical

physicians preference, or the pa- flammation. Use caution in patients
OVERVIEW tients ability and willingness to com- sensitive to nickel or chromium be-
ply with the treatment cause both are present in the electrical
Initiates or accelerates the healing Fully implantable device requiring bone stimulation system.
process in a fractured bone that fails little or no patient management
to heal properly Semi-invasive and noninvasive tech-
Failure to heal: occurs in about 1 in niques requiring patient to manage PROCEDURE
20 fractures as a result of infection, his own treatment schedule and
insufficient reduction or fixation, maintain the equipment DIRECT CURRENT STIMULATION
pseudarthrosis, or severe tissue trau- Treatment time averaging 3 to 6 Implantation is performed with the
ma around the fracture months patient under general anesthesia.
Stimulates osteogenesis by imitating A small generator and leadwires that
the bodys natural electrical forces INDICATIONS connect to a titanium cathode wire
Three electrical stimulation tech- Treating spinal fusions surgically implanted into a nonunit-
niques: fully implantable direct cur- Promoting healing of fractures ed bone site are used.
rent stimulation, semi-invasive per- WARNING Electromagnetic coils The physician may apply a cast or ex-
cutaneous stimulation, and noninva- are contraindicated in pregnant ternal fixator to immobilize the limb.
sive electromagnetic coil stimulation patients, patients with tumors, and The patient is usually hospitalized for
(see Stimulating bone growth with patients with arm fractures who also 2 to 3 days after implantation.
electric current) have a pacemaker. Percutaneous elec-
Choice of technique dependent on trical bone stimulation is contraindi- PERCUTANEOUS STIMULATION
the fracture type and location, the cated if the patient has any kind of in- Remove excessive hair from the in-
jury site.
An external anode skin pad is applied

Stimulating bone growth with electric current with a leadwire and lithium battery
pack. The surgeon implants 1 to 4
Teflon-coated stainless steel cathode
Stimulating bone growth with electric current can be invasive or noninvasive.
wires within the site.
An invasive system involves placing a Anode pulling on the anode wire.
spiral cathode inside the bone at the
fracture site. A wire leads from the ELECTROMAGNETIC STIMULATION
cathode to a battery-powered genera- Generator A generator is plugged into a stan-
tor, also implanted in local tissues. The dard 110-volt outlet.
patients body completes the circuit. Two strong electromagnetic coils are
placed on either side of the injured
area. The coils can be incorporated
into a cast, cuff, or orthotic device.

NONINVASIVE SYSTEM Infection (with direct current electri-
cal bone stimulation equipment)
A noninvasive system may include a
Local irritation or skin ulceration
cufflike transducer or fitted ring that
wraps around the patients limb at the around cathode pin sites (with per-
level of the injury. Electric current cutaneous devices)
penetrates the limb. No known complications with elec-
Transducer tromagnetic coils


5125B.qxd 8/15/08 10:25 AM Page 33


Impaired physical mobility Weight bearing may be ordered as Teach the patient how to care for his
Ineffective tissue perfusion: tolerated. cast or external fixation devices.
Peripheral After the bone fragments join, the Tell the patient how to care for the
generator and leadwire can be re- electrical generator.
EXPECTED OUTCOMES moved while the patient is under lo- Urge the patient to follow treatment
The patient will: cal anesthesia. The titanium cathode instructions.
express feelings of increased comfort remains implanted. Tell the patient to report increasing
attain the highest degree of mobility WARNING A patient with direct discomfort from the procedure as
possible within the confines of the current electrical bone stimula- well as signs of infection or circulato-
injury tion shouldnt undergo electrocauteri- ry compromise.
exhibit adequate tissue perfusion zation, diathermy, or magnetic reso- Review activity restrictions with the
and pulses distally. nance imaging (MRI). Electrocautery patient.
may short the system. Diathermy Teach the patient with a direct cur-
may potentiate the electrical current, rent implant to inform all health care
PRETREATMENT CARE possibly causing tissue damage. MRI providers of the implant, and not to
will interfere with or stop the current. have MRI testing or diathermy treat-
Follow instructions provided by the ments, or any procedure where
manufacturer. PERCUTANEOUS STIMULATION blood vessels might be treated elec-
Make sure that all parts are included Instruct the patient to change the trically.
and sterilized according to facility anode pad every 48 hours.
policy and procedure. Tell the patient to report local pain to RESOURCES
Discuss with the patient the use of his physician and not to bear weight Organizations
anesthetics. on the limb for the duration of treat- American Academy of Orthopedic
ment. Surgeons: www.aaos.org
American Medical Association:
Show the patient where to place the
coils, and tell him to apply them for 3
Selected references
Cowan, C.M., et al. Nell-1 Induced Bone
to 10 hours each day or as ordered.
Formation within the Distracted Inter-
Many patients find it most conven- maxillary Suture, Bone 38(1):48-58,
ient to perform the procedure at January 2006.
night. Harle, J., et al. Effects of Ultrasound on
Advise the patient not to interrupt Transforming Growth Factor-Beta
the treatments for more than 10 min- Genes in Bone Cells, European Cells &
utes at a time. Materials (electronic resource) 10:70-
Teach the patient how to use and 76; discussion 76, December 2005.
care for the generator. Weinraub, G.M. Orthobiologics: A Survey
Restate the physicians instructions of Materials and Techniques, Clinics
for weight bearing. The physician in Podiatric Medicine and Surgery of
North America 22(4):509-19, v. Review,
usually advises against bearing
October 2005.
weight until evidence of healing ap-
pears on X-rays.

5125B.qxd 8/15/08 10:25 AM Page 34

Bowel resection
Kock ileostomy
OVERVIEW PROCEDURE The surgeon removes the colon, rec-
tum, and anus, and closes the anus.
In bowel resection with ostomy: dis- All procedures are performed under A reservoir is constructed from a
eased bowel excised and stoma cre- general anesthesia loop of the terminal ileum.
ated on the outer abdominal wall for A portion of the ileum is intussus-
feces elimination; laparoscopic ap- BOWEL RESECTION WITH cepted to form a nipple valve.
proach possible for standard colosto- OSTOMY The upper part of the sutured and
my and end-ileostomy The surgeon makes an incision in the cut ileum is pulled down and sutured
In bowel resection with anastomosis: abdominal wall. (The location de- to form a pouch.
diseased intestinal tissue surgically pends on the bowel area to be resect- The nipple valve is used to create a
resected and remaining segments ed and type of ostomy required.) stoma by pulling it through the ab-
connected or anastomosed (pre- The diseased bowel segment is re- dominal wall and suturing it flush
ferred surgical technique for treating sected, possibly along with several with the skin. A catheter is placed in
localized bowel cancer) more inches of bowel. the stoma.
The surgeon creates a stoma.
Bowel resection with ostomy Abdominoperineal resection ANASTOMOSIS
Inflammatory bowel disease A low abdominal incision is made An abdominal incision is made, de-
Familial adenomatous polyposis and the sigmoid colon is divided. pending on location of the lesion.
Diverticulitis The proximal end of the colon is The diseased area is resected, along
Advanced colorectal cancer brought out through another, smaller with a wide margin of surrounding
abdominal incision to create an end normal tissue.
Bowel resection with anastomosis stoma. Remaining bowel segments are anas-
Localized obstructive disorders sec- A wide perineal incision is made and tomosed end-to-end or side-to-side.
ondary to diverticulitis, intestinal the anus, rectum, and distal portion The incision is closed.
polyps, adhesions, or malignant or of the sigmoid colon are resected. A sterile dressing is applied.
benign intestinal lesions The abdominal wound is closed and
abdominal drains are placed. COMPLICATIONS
The perineal wound may be left Hemorrhage
open, packed with gauze, or closed; Sepsis
several Penrose drains are placed. Ileus
Fluid and electrolyte imbalance
Ileostomy Skin excoriation
The surgeon resects all or part of the Pelvic abscess
colon and rectum (proctocolecto- Incompetent nipple valve (with a
my). Kock ileostomy)
A permanent ileostomy is created by Bleeding or leakage from the anasto-
bringing the end of the ileum out mosis site
through a small abdominal incision Peritonitis, postresection obstruc-
in the right lower quadrant to create tion, wound infection, or atelectasis
a stoma. Psychological problems

Ileoanal reservoir
A colectomy is performed and an
ileal loop or the distal ileum is used
to create a stoma for a temporary
The rectal mucosal layer is removed
and an internal pouch is made with a
portion of the ileum.
A pouch-anal anastomosis is per-
The temporary ileostomy is usually
closed after 3 to 4 months.

5125B.qxd 8/15/08 10:25 AM Page 35

Check catheter patency regularly,

NURSING DIAGNOSES and irrigate with 20 to 30 ml of nor- PATIENT TEACHING
mal saline solution as ordered.
Acute pain Assess pouch drainage and advance GENERAL
Anxiety the patients diet as ordered. Review prescribed medications, in-
Ineffective tissue perfusion: GI Clamp and unclamp the pouch cluding the dosage and possible ad-
catheter to increase its capacity as verse effects.
EXPECTED OUTCOMES ordered. Explain ostomy type and function
The patient will: Encourage the patient to express and review care of ostomy appli-
demonstrate or express feelings of feelings and concerns. ances.
increased comfort Arrange for a consultation with an Discuss resumption of sexual inter-
verbalize and show signs of de- enterostomal therapist as appropri- course.
creased anxiety ate. Review stoma and skin care.
regain regular bowel movements. Arrange for the patient to meet with Explain dietary restrictions and em-
a well-adjusted ostomy patient if phasize the importance of a high flu-
possible. id intake.
PRETREATMENT CARE Monitor the patients vital signs and Explain the need for avoidance of al-
intake and output. cohol, laxatives, and diuretics (unless
Assess the patient for dehydration approved by the physician).
Explain preoperative and postopera-
and electrolyte imbalance. Review bowel retraining for appro-
tive procedures and equipment to
Assess stoma appearance and drain- priate ostomy patients.
the patient and his family.
age. Look for skin irritation and exco- Review the use of sitz baths (after ab-
Discuss postoperative analgesia.
riation. dominoperineal resection).
Verify that the patient has signed the
Monitor the patient for signs of infec- Review the signs and symptoms of
appropriate consent form.
tion, peritonitis, and sepsis. inflammation and infection and
Tell the patient what to expect for fe-
WARNING Immediately report when to notify the physician.
cal drainage and bowel movement
excessive blood or mucus drain- Emphasize the need for follow-up
control for the type of ostomy per-
ing from the stoma, which could indi- care.
cate hemorrhage or infection.
Provide total parenteral nutrition as
Encourage deep-breathing and RESOURCES
coughing exercises. Encourage Organizations
Administer an antibiotic and other
splinting of the incision site as neces- American College of Gastroenterology:
medications as ordered.
sary. www.acg.gi.org
Monitor the patients vital signs, nu-
For anastomosis patients, encourage American College of Surgeons:
tritional status, fluid and electrolyte
oral fluid intake and give stool sof- www.facs.org
status, intake and output, and daily
teners and laxatives as ordered.
WARNING Monitor for and im- Selected references
mediately report signs and Chan, K.Y., et al. Chylous Ascites after
symptoms of anastomotic leakage, in-
POSTTREATMENT CARE cluding low-grade fever, malaise,
Anterior Resection for Rectal Carcino-
ma: A Rare but Significant Incident,
slight leukocytosis, abdominal disten- Asian Journal of Surgery 29(1):46-48,
Provide meticulous wound care. tion, tenderness, hemorrhage, hypo- January 2006.
Administer an analgesic as ordered. volemic shock, and bloody stool or Chang, R.W., et al. Serial Transverse En-
Maintain I.V. replacement therapy as wound drainage. teroplasty Enhances Intestinal Func-
ordered. tion in a Model of Short Bowel Syn-
Keep the nasogastric tube patent, but drome, Annals of Surgery
dont reposition it. 243(2):223-28, February 2006.
After an abdominoperineal resec- OKeefe, S.J., et al. Short Bowel Syn-
drome and Intestinal Failure: Con-
tion, irrigate the perineal area as or-
sensus Definitions and Overview,
dered. Clinical Gastroenterology and Hepa-
If the patient has a Kock pouch with tology 4(1):6-10, January 2006.
a catheter inserted in the stoma:
Connect the catheter to low intermit-
tent suction or to straight drainage as

5125B.qxd 8/15/08 10:25 AM Page 36

Breast reconstruction
OVERVIEW To rebuild the breast after mastecto- In one type of flap surgery, the tissue
my remains attached to its original site,
One of several methods used to re- retaining its blood supply. The flap,
build the breast after mastectomy, consisting of the skin, fat, and mus-
depending on the patients needs; PROCEDURE cle with its blood supply, is tunneled
method of surgery also dependent beneath the skin to the chest by the
on choice of a flap (or expander) and SKIN EXPANSION surgeon, creating a pocket for an im-
implant Following mastectomy, the surgeon plant. It can also be made to create
With breast reconstruction under the inserts a balloon expander beneath the breast mound itself, without the
skin: breast tissue removed but skin the skin and chest muscle. need for an implant.
and nipple preserved; implant then Through a tiny valve mechanism Another flap technique uses tissue
placed beneath skin to replace lost buried beneath the skin, the physi- thats surgically removed from the
breast tissue (suitable only for cian periodically injects saline solu- abdomen, thighs, or buttocks and
women with fairly small breasts) tion to gradually fill the expander then transplanted to the chest by re-
With breast reconstruction under the over several weeks or months. connecting the blood vessels to new
muscle: implant placed beneath the After the skin has stretched enough, ones in that region. This procedure
muscles covering the chest; ap- the expander is removed in a second requires the skill of a plastic surgeon
proach suitable only for women with operation and a more permanent whos experienced in microvascular
fairly small breasts and impossible if implant is inserted. Some expanders surgery as well. (See Reconstructing
the patient underwent radical mas- are designed to be left in place as the the breast with a flap.)
tectomy, in which the chest muscle final implant.
has been taken away or if the patient The nipple and the areola are recon- FOLLOW-UP PROCEDURE
has received radiotherapy, in which structed in a subsequent procedure. Follow-up surgery may be required
the muscles and skin are unlikely to Some patients dont require prelimi- to replace a tissue expander with an
stretch nary tissue expansion before receiv- implant or to reconstruct the nipple
Breast reconstruction involving tis- ing an implant. Instead, the surgeon and areola.
sue expansion: makes use of the abil- inserts an implant as the first step.
ity of the skin and muscle to stretch
through the use of an expandable
implant with a valve for filling it; ex-
pansion takes place over a few Reconstructing the breast with a flap
months by injecting a sterile saline
solution into the implant through a Flaps may be taken from large muscles of the body. In this breast reconstruction, the latissimus
valve thats just under the skin of the dorsi muscle is taken and moved to its new location.
armpit; process continues until size
is slightly larger than the remaining LATISSIMUS DORSI MUSCLE SITE IN RECONSTRUCTION
breast, thus permitting insertion of a
permanent implant
Another option: using areas of mus-
cle and skin (known as flaps) that are
taken from the back (latissimus dor-
si) or abdomen (rectus abdominis)
(These areas of the body contain very
large muscles, providing enough
skin, fat, and muscle with a good
blood supply to create the shape of a
breast on the chest wall. Its appro-
priate when tissue expansion is un-
suitable because a lot of skin and
muscle needs to be removedor has
been removedfrom the breast. Its
also useful where previous radiother-
apy has made the skin unsuitable for
tissue expansion or when recon-
structing large breasts.)

5125B.qxd 8/15/08 10:25 AM Page 37

Many surgeons recommend an addi-

tional operation to enlarge, reduce, PRETREATMENT CARE PATIENT TEACHING
or lift the natural breast to match the
reconstructed breast. Women with other health conditions, GENERAL
such as obesity, high blood pressure, Advise the patient to stop smoking;
COMPLICATIONS or smoking, may be advised to wait nicotine can delay healing, resulting
Bleeding until these conditions are under con- in conspicuous scars and prolonged
Fluid collection and swelling trol. recovery. Occasionally, these compli-
Bruising Explain the treatment and prepara- cations are severe enough to require
Excessive scar tissue tion to the patient and her family. a second operation.
Numbness or change in feeling Verify that the patient has signed the Tell the patient that the surgical drain
Infection from the implant (the im- appropriate consent form to remove excess fluids from the site
plant may need to be removed for Explain postoperative care. is removed within the first week or
several months until the infection Provide emotional support. two after surgery. Most stitches are
clears; a new implant can later be in- removed in 7 to 10 days.
serted) Review the prescribed medications,
Capsular contracture (the scar or POSTTREATMENT CARE including the dosage and possible
capsule around the implant begins to adverse effects.
tighten) Monitor the patients vital signs and Tell the patient which signs and
Complications with flap source site intake and output. symptoms she should report to the
(limited movement) Monitor drainage from the wound physician, such as infection or in-
and provide skin care. creasing pain.
Assess the patient for pain and pro- Review exercises, as ordered, and
NURSING DIAGNOSES vide an analgesic as ordered. care of the operative site.
Monitor the patient for infection, Tell the patient to have venipunc-
Acute pain hemorrhage, and other signs of com- tures, injections, and blood pressure
Impaired tissue integrity plications. measurements in the unaffected arm
Risk for infection Elevate the patients arm on a pillow; only.
position it to facilitate drainage, en-
EXPECTED OUTCOMES suring also that the patient is com- RESOURCES
The patient will: fortable. Organizations
Initiate flexion and extension arm ex- American Cancer Society:
verbalize or demonstrate feelings of
ercises as ordered. www.cancer.org
Place a sign in the patients room in- American College of Surgeons:
demonstrate healing of wounds
dicating that no blood pressure read- www.facs.org
show no signs of infection. American Society of Plastic Surgeons:
ings, injections, or venipunctures
should be performed on the affected www.plasticsurgery.org
Selected references
Chan, L.K., et al. Smoking and Wound
Healing Problems in Reduction
Mammaplasty: Is the Introduction of
Urine Nicotine Testing Justified? An-
nals of Plastic Surgery 56(2):111-15,
February 2006.
Christian, C.K., et al. A Multi-Institution-
al Analysis of the Socioeconomic De-
terminants of Breast Reconstruction: A
Study of the National Comprehensive
Cancer Network, Annals of Surgery
243(2):241-49, February 2006.
Shafir, R., and Gur, E. Defining the Gold
Standard in Breast Reconstruction
with Abdominal Tissue, Plastic Recon-
structive Surgery 117(1):315-17, Janu-
ary 2006.

5125B.qxd 8/15/08 10:25 AM Page 38

Involves direct visualization of the The patient is properly positioned Impaired gas exchange
larynx, trachea, and bronchi using a and given supplemental oxygen if or- Ineffective breathing pattern
rigid or fiber-optic bronchoscope dered. Ineffective tissue perfusion: Cardio-
Flexible fiber-optic bronchoscope: Pulse oximetry, vital signs, and car- pulmonary
allows a better view of the segmental diac rhythm are monitored.
and subsegmental bronchi with less Local anesthetic is sprayed into the EXPECTED OUTCOMES
risk of trauma mouth and throat. The patient will:
Large, rigid bronchoscope: used to The bronchoscope is inserted maintain adequate ventilation
remove foreign objects, excise endo- through the mouth or nose; a bite exhibit normal breathing pattern
bronchial lesions, and control mas- block is placed in the mouth if using maintain normal heart and respira-
sive hemoptysis (requires general the oral approach. tory rates, blood pressure, and have
anesthesia) When the bronchoscope is just above pink nail beds and mucosa.
the vocal cords, 3 to 4 ml of 2% to 4%
INDICATIONS lidocaine is flushed through the in-
Visual examination of tumors, ob- ner channel to the vocal cords.
structions, secretions, or foreign bod- A fiber-optic camera is used to take
ies in the tracheobronchial tree photographs for documentation.
Diagnosis of bronchogenic carcino- Tissue specimens are obtained from
ma, tuberculosis, interstitial pul- suspect areas.
monary disease, and fungal or para- A suction apparatus may remove for-
sitic pulmonary infections eign bodies or mucus plugs.
Specimens for microbiological and Bronchoalveolar lavage may remove
cytologic examination thickened secretions or may aid in
Bleeding sites in the tracheobron- the diagnosis of infectious causes of
chial tree infiltrates.
Removal of foreign bodies, malignant Specimens are properly prepared
or benign tumors, mucus plugs, and and immediately sent to the labora-
excessive secretions from the tra- tory.
cheobronchial tree
Subcutaneous crepitus, which may
indicate tracheal or bronchial perfo-
ration or pneumothorax
Laryngeal edema or laryngospasm
causing stridor and dyspnea
Cardiac arrhythmias

5125B.qxd 8/15/08 10:25 AM Page 39


Review with the patient the purpose If the patient is conscious, position GENERAL
of the test and how its performed, him in semi-Fowlers position. If the Tell the patient that hoarseness, loss
including who will perform it and patient is unconscious, position him of voice, hemoptysis, and sore throat
where. on one side with the head of his bed may occur.
Reassure the patient that the airway slightly elevated.
isnt blocked during the test. Instruct the patient to spit out saliva RESOURCES
Verify that the patient has signed the rather than swallow it. Organizations
appropriate consent form and note Observe the patient for bleeding. American College of Chest Physicians:
any allergies. Maintain nothing-by-mouth status www.chestnet.org
Instruct the patient to fast for 6 to 12 until the gag reflex returns. American College of Emergency Physi-
hours before the test. Help the patient resume his usual cians: www.acep.org
Obtain the patients vital signs and diet, beginning with sips of clear liq- American Medical Association:
results of preprocedure studies. uid or ice chips, when the gag reflex www.ama-assn.org
Report abnormal results. returns.
Administer an I.V. sedative as or- Provide lozenges or a soothing liquid Selected references
dered. gargle to ease discomfort when the Kvale, P.A. Chronic Cough Due to Lung
Remove the patients dentures. gag reflex returns. Tumors: ACCP Evidence-Based Clini-
Inform the patient that his airway Check the follow-up chest X-ray for cal Practice Guidelines, Chest
wont be blocked and that hoarse- pneumothorax. 129(Suppl 1):147S-153S, January 2006.
ness, loss of voice, hemoptysis, and Monitor the patients vital signs, spu- Moorthy, S.S., et al. Management of Air-
way in Patients with Laryngeal Tu-
sore throat may occur. tum characteristics, and respiratory
mors, Journal of Clinical Anesthesia
17(8):604-609, December 2005.
WARNING Immediately report Tomaske, M., et al. Anesthesia and Peri-
subcutaneous crepitus around interventional Morbidity of Rigid
the patients face, neck, or chest be- Bronchoscopy for Tracheobronchial
cause these may indicate tracheal or Foreign Body Diagnosis and Removal,
bronchial perforation or pneumotho- Paediatric Anaesthesia 16(2):123-29,
rax. February 2006.
WARNING Watch for and imme-
diately report signs and symp-
toms of respiratory difficulty associat-
ed with laryngeal edema or laryn-
gospasm, such as laryngeal stridor
and dyspnea.

5125C.qxd 8/15/08 10:50 AM Page 40

Surgical procedure in which the pa- The surgeon dissects a portion of the Activity intolerance
tients skeletal muscleusually the left latissimus dorsi muscle from its Decreased cardiac output
latissimus dorsiis wrapped around surrounding tissues, leaving the neu- Ineffective tissue perfusion: Cardio-
weakened heart muscle to provide rovascular supply intact. pulmonary
support Two stimulation electrodes are at-
After wrapping: a pulse generator tached to the muscle flap. EXPECTED OUTCOMES
implanted near the abdomen stimu- The muscle flap is then transposed The patient will:
lates the implanted muscle to con- into the left thoracic cavity through a carry out activities of daily living
tract simultaneously with the heart; window created by a partial resection without excess fatigue or decreased
skeletal muscle eventually becoming of the second rib. energy
resistant to fatigue A median sternotomy is performed maintain adequate cardiac output
Still considered experimental (left to open the pericardium and access maintain adequate tissue perfusion.
ventricular assist devices usually the heart. Sensing electrodes are
used); performed only at a few well- then implanted into the right and left
established heart centers in the ventricles.
country, with variable results The muscle flap is then rotated in-
In some patients, produces a small ward and wrapped around the ven-
increase in left ventricular ejection tricular surface of the heart and is
fraction, thus a reduction of symp- then attached to the pericardium
toms for a few months after surgery; with sutures.
however, latissimus dorsi muscle The pacing and sending electrodes
may not be able to sustain beneficial are then attached to a special pace-
effect over time maker thats implanted in an epigas-
Also known as cardiac wrap and tric pocket.
muscle-flap procedure After a 2-week postoperative period,
to allow for adhesion between the
INDICATIONS latissimus dorsi and the heart, the
Advanced heart failure skeletal muscle is electrostimulated
Ischemic or dilated cardiomyopathy and conditioned to pace synchro-
nously with the heart.
WARNING Cardiomyoplasty re-
quires the use of a unique pace-
maker manufactured by Medtronic
(the Transform Cardiomyostim-
ulator); however, to date, it hasnt yet
received Food and Drug Administr-
ation (FDA) approval.Therefore, the
procedure is offered only in an FDA
investigational device exemption tri-
al; clinical trials are ongoing.

Cardiac tamponade
Failure of graft procedure and return
of heart failure symptoms
Hemothorax, pneumothorax

5125C.qxd 8/15/08 10:50 AM Page 41


Review the procedure with the pa- Monitor the patients vital signs and GENERAL
tient, and verify that he has signed a mental status. Inform the patient about the signs
consent form. Monitor hemodynamic status and and symptoms of heart failure and
Monitor the patients vital signs, in- report changes in trends. when to notify the practitioner.
take and output, and hemodynamic Monitor for signs of complications Refer the patient for follow-up care.
status. and report symptoms as indicated.
Obtain laboratory results and notify Monitor the electrocardiogram for RESOURCES
the surgeon of the results. new-onset arrhythmias and report Organizations
as indicated. American College of Cardiology:
Monitor intake and output. www.acc.org
Monitor the patient for and report American Medical Association:
abnormal heart and breath sounds www.ama-assn.org
immediately. HeartCenterOnline:
Monitor results of laboratory studies. www.heartcenteronline.com
Maintain patency of I.V. lines and
maintain fluids as ordered. Selected references
Maintain patency of chest tubes and Bosen, D.M. New Strategies for Treating
monitor drainage; report signs of Patients with Heart Failure, Nursing
bleeding or alterations in pulmonary 33(12):44-47, December 2003.
status. Egerod, I., and Hansen, G.M. Evidence-
Based Practice among Danish Cardiac
Provide wound care and assess
Nurses: A National Survey, Journal of
dressings as indicated. Advanced Nursing 51(5):465-73, Sep-
Maintain oxygenation status, and tember 2005.
suction as indicated. Nesher, N., et al. Thermo-Wrap Technol-
Monitor for pain and effects of pain ogy Preserves Normothermia Better
medication as ordered. than Routine Thermal Care in Patients
Undergoing Off-Pump Coronary Ar-
tery Bypass and is Associated with
Lower Immune Response and Lesser
Myocardial Damage, Journal of
Thoracic and Cardiovascular Surgery
129(6):1371-78, June 2005.
Odim, J., et al. Results of Aortic Valve-
Sparing and Restoration with Autolog-
ous Pericardial Leaflet Extensions in
Congenital Heart Disease, Annals of
Thoracic Surgery 80(2):647-53, August
Olearchyk, A.S. Congenital Bicuspid
Aortic Valve and an Aneurysm of
the Ascending Aorta, Journal of
Cardiovascular Surgery 19(5):462-63,
September-October 2004.

5125C.qxd 8/15/08 10:50 AM Page 42

Cardioversion, synchronized
or may cause an airway obstruction. Discharge the current by pushing the
OVERVIEW If they may cause an obstruction, re- DISCHARGE buttons of both paddles
move them. simultaneously or pressing the
Used to treat tachyarrhythmias; de- Place the patient in the supine posi- SHOCK button on the mahcine; dont
livers an electric charge to the my- tion and assess his vital signs, level of remove the paddles from the pa-
ocardium at the peak of the R wave, consciousness (LOC), cardiac tients chest until the device dis-
which causes immediate depolariza- rhythm, and peripheral pulses. charges. (Unlike in defibrillation, the
tion, interrupting reentry circuits and Remove any oxygen delivery device discharge wont occur immediately;
allowing the sinoatrial node to re- just before cardioversion to avoid youll notice a slight delay while the
sume control possible combustion. machine synchronizes with the R
Also treatment of choice for arrhyth- Have emergency cardiac medica- wave.)
mias that dont respond to vagal tions at the patients bedside. Hold the paddles in place and wait
maneuvers or drug therapy, such as Make sure that the resuscitation bag for the energy to be discharged
atrial tachycardia, atrial flutter, atrial is at the patients bedside. the machine has to synchronize the
fibrillation, and symptomatic mono- Administer a sedative as ordered. The discharge with the QRS complex.
morphic ventricular tachycardia patient should be sedated but still Check the waveform on the monitor.
Synchronizes electric charge with able to breathe adequately. If the arrhythmia fails to convert, re-
R wave to ensure that current wont Carefully monitor the patients blood peat the procedure. Gradually in-
be delivered on the vulnerable pressure and respiratory rate until he crease the energy level to a maxi-
T wave and, thus, disrupt repolar- recovers from the sedation. mum of 360 joules with each addi-
ization Press the POWER button to turn on the tional countershock.
May be an elective or urgent proce- defibrillator. WARNING Be aware that improp-
dure, depending on how well the pa- Push the SYNC button to synchronize er synchronization may result if
tient tolerates the arrhythmia; for the machine with the patients QRS the patients electrocardiogram (ECG)
example, with hemodynamically un- complexes. Make sure that the SYNC tracing contains artifact-like spikes,
stable patient, immediate cardiover- button flashes with each of the pa- such as peaked T waves or bundle-
sion needed tients QRS complexes. You should branch heart blocks when the R wave
also see a marker on the monitor to may be taller than the R wave.
INDICATIONS signify correct synchronization.
Unstable supraventricular tachycar- Turn the ENERGY SELECT dial to the or- COMPLICATIONS
dia due to reentry dered amount of energy. Advanced Transient, harmless arrhythmias,
Atrial fibrillation cardiac life support protocols call for such as atrial, ventricular, and junc-
Atrial flutter an initial monophasic energy dose of tional premature beats
Unstable monomorphic ventricular 50 to 100 joules for a patient with un- Serious ventricular arrhythmias such
tachycardia stable supraventricular tachycardia, as ventricular fibrillation
100 to 200 joules for a patient with WARNING Ventricular fibrilla-
atrial fibrillation, 50 to 100 joules for tion is more likely to result from
PROCEDURE a patient with atrial flutter, and 100 high amounts of electrical energy,
joules for a patient who has ventricu- digoxin toxicity, severe heart disease,
lar tachycardia with a pulse (or clini- electrolyte imbalance, or improper
Verify the patients identity using two
cally equivalent biphasic energy synchronization with the R wave.
patient identifiers according to facili-
dose). Increase the second and sub-
ty policy.
sequent shock doses as needed.
Consider administering oxygen for 5
Remove the paddles from the ma-
to 10 minutes before the cardiover-
chine, and prepare them as you
sion to promote myocardial oxy-
would if you were defibrillating the
Connect the patient to a pulse
Place the conductive gel pads or pad-
oximeter and automatic blood pres-
dles in the same positions as you
sure cuff, if available.
would to defibrillate.
WARNING Remember that when
WARNING To prevent damage to
preparing for cardioversion, the
an implanted pacemaker, avoid
patients condition can deteriorate
placing the paddles directly over the
quickly, necessitating immediate de-
Make sure that everyone stands away
If the patient wears dentures, evalu-
from the bed, and move equipment
ate whether they support his airway
thats touching the bed or patient.

5125C.qxd 8/15/08 10:50 AM Page 43


Decreased cardiac output Explain the procedure to the patient, GENERAL
Impaired gas exchange reinforce the practitioners explana- Review with the patient how to take
Ineffective tissue perfusion: Cardio- tion of the procedure, and verify that his pulse and record it for the practi-
pulmonary, cerebral, peripheral the patient has signed a consent tioner to review on follow-up visits.
form. Review signs and symptoms to re-
EXPECTED OUTCOMES Check the patients recent serum port (recurrence of previous rhythm).
The patient will: potassium and magnesium levels, ar-
demonstrate hemodynamic stability terial blood gas levels, and recent RESOURCES
maintain adequate oxygenation and digoxin levels. Organizations
perfusion WARNING If the patient takes American College of Cardiology:
maintain adequate blood pressure, digoxin, reduce or withhold the www.acc.org
heart rate, and peripheral pulses. dose on the day of the procedure to American Medical Association:
avoid induction of ventricular ar- www.ama-assn.org
rhythmias. HeartCenterOnline:
Withhold food and fluids for 6 to 12 www.heartcenteronline.com
hours before the procedure.
If the cardioversion is urgent, with- Selected references
hold the previous meal. Critical Care: Ablation Helps Some Pa-
Obtain a 12-lead ECG to serve as a tients with Atrial Fibrillation and Heart
baseline. Failure, Nursing 2005 35(1):32cc8-
Check to see if the practitioner has
32cc8, January 2005.
Frodsham R. Cardiac Resynchronisation
ordered administration of any car-
Therapy for Patients with Heart Fail-
diac drugs before the procedure. ure, Nursing Standard: Official News-
Verify that the patient has a patent paper of the Royal College of Nursing
I.V. site in case drug administration 19(45):46-50, July 2005.
becomes necessary. Quinn T. The Role of Nurses in Improv-
ing Emergency Cardiac Care, Nursing
Standard: Official Newspaper of the
POSTTREATMENT CARE Royal College of Nursing 19(48):41-48,
August 2005.
Thompson, E.J. Radiofrequency Ablation
After the cardioversion, frequently
in the Pulmonary Veins for Paroxysmal,
assess the patients LOC and respira-
Drug-Resistant Atrial Fibrillation,
tory status, including airway patency, Dimensions of Critical Care Nursing
respiratory rate and depth, and the 23(6):255-63, November-December
need for supplemental oxygen. 2004.
WARNING Because the patient is Wickliffe, A.C., and Leon, A.R. Pacing
sedated, he may require airway and Heart Failure: Should all Patients
support. Receive a Biventricular Device?
Record a postcardioversion 12-lead Current Heart Failure Report 2(1):35-
ECG, and monitor the patients ECG 59, March 2005.
Check the patients chest for electri-
cal burns.

5125C.qxd 8/15/08 10:50 AM Page 44

Carpal tunnel release

Surgery to decompress the median
OVERVIEW nerve that relieves pain and restores PROCEDURE
function in the wrist and hand (see
Carpal tunnel syndrome: most com- Relieving symptoms of carpal tunnel The procedure may be performed as
mon nerve entrapment syndrome; syndrome) outpatient surgery using local anes-
results from compression of the me- thesia.
dian nerve in the wrist where it pass- INDICATIONS The surgeon can choose from several
es though the carpal tunnel, causing Carpal tunnel syndrome unrelieved approaches to perform carpal tunnel
loss of movement and sensation in by splinting or medication release. However, entire transverse
the wrist, hand, and fingers (see carpal tunnel ligament must be tran-
Locating the carpal tunnel) sected to ensure adequate decom-
pression of the median nerve.
The surgeon makes an incision
around the thenar eminence to ex-
Locating the carpal tunnel pose the flexor retinaculum, which
he then transects to relieve pressure
on the median nerve. Depending on
The carpal tunnel lies between the longitudinal tendons of the hand-flexing forearm muscles (not
the extent of nerve compression, he
shown) and the transverse carpal ligament. Note the median nerve and flexor tendons passing
may perform neurolysis to free flat-
through the tunnel on their way from the forearm to the hand.
tened nerve fibers. Neurolysis in-
volves stretching the nerve, which re-
lieves tension and loosens surround-
ing adhesions.
Decompression of the median nerve
can also be accomplished through a
Median Ulnar small incision in a puncture site via
Radial endoscopic carpal tunnel release. In
nerve nerve
the endoscopic procedure, which
Carpal tunnel
may be single portal or double por-
tal, the carpal tunnel is approached
through small incisions that allow
Flexor tendons the passage of the endoscope along
of fingers
the ulnar border of the transverse
carpal ligament. The ligament is
sharply divided after transverse
fibers are well visualized. The ante-
Transverse brachial fascia proximally is divided
carpal ligament
under direct vision.
WARNING Contraindications to
the procedure include rheuma-
toid arthritis, mass lesions, and repeat

Hematoma formation
Painful scar formation
Flexor tendons
of fingers Tenosynovitis
Nerve damage

5125C.qxd 8/15/08 10:51 AM Page 45


Relieving symptoms of carpal tunnel syndrome

Dear Patient,
If youre having symptoms of carpal tunnel syndrome, you know how disabling they can be. You know, too, that strain on your
wrist nerve triggers your discomfort. To get relief and prevent permanent damage, you need to stop or cut back on the activity
producing the strain.
Of course, thats easier said than done. If the activities that produce strain are related to your job or hobbies, stopping or de-
creasing them takes careful planning. Use the following suggestions to help.


Modify your work habits and work area. Wear a splint or a specially designed If fluid retention aggravates your symp-
If you work on an assembly line, do glove when you perform repetitive activ- toms, ask your health care provider
piecework, or have a repetitive job, ask itiesor all the time, if your health care about taking diuretics to relieve some
your supervisor to help you change or provider advises. These devices are of the swelling in the carpal tunnel. Or
eliminate activities that strain your available by prescription from medical drink plenty of fluids. Coffee or tea are
wrist. For example: supply stores. natural diuretics (increasing urination).
Make sure that the tools you use fit Elevating your hand may also help re-
your hand correctly so you dont need to SLOW DOWN lieve swelling temporarily.
twist your wrist too much when turning,
Slow down when performing repetitive This patient-teaching aid may be reproduced by office copier
gripping, or squeezing objects.
activities with your hands. For example, for distribution to patients. 2007 Lippincott Williams &
If you must lift and move objects, use Wilkins.
if knitting causes symptoms, you can
both hands rather than the hand with
knit at a slower pace. But if you do
carpal tunnel syndrome.
piecework or if you work on an assem-
Install a padded armrest at your
bly line and a machine paces your work,
workstation to relieve stress on your
discuss the problem with your supervi-
hands, wrists, and shoulders.
sor or union representative.
Arrange to rotate your duties, or find
a different technique for doing your job
that puts less stress on your wrist.
If you work at a typewriter, computer, Your health care provider will teach you
or another type of terminal, try lowering special exercises to strengthen all your
the height of your work table to hand and wrist muscles. If all your mus-
decrease the angle of wrist flexion. cles are strong, youll put less strain on
Raise your chair or sit on a pillow if one particular muscle or group of mus-
you cant adjust your work table. Just be cles.
sure to support your feet to promote
good posture and good circulation in
your lower legs.


5125C.qxd 8/15/08 10:51 AM Page 46


Acute pain Reinforce the purpose of the planned After the patient returns from sur-
Disturbed sensory perception surgery. Tell the patient that the pro- gery, monitor his vital signs and care-
(tactile) cedure should relieve pain in his fully assess circulation and sensory
Impaired physical mobility wrist and help him regain full use of and motor function in the affected
his hand. arm and hand.
EXPECTED OUTCOMES Outline the steps of surgery, tailoring Keep the hand elevated to reduce
The patient will: your explanation to the particular swelling and discomfort.
verbalize relief from pain procedure the surgeon has chosen as Check the dressing often for unusual
exhibit improved or normal sensory well as to the patients level of under- drainage or bleeding, which may in-
perception standing. dicate infection.
demonstrate stability or improve- Explain to the patient that before Assess for pain and provide anal-
ment in mobility. surgery, the affected arm will be gesics as needed.
shaved and cleaned and that hell be WARNING Report severe, persist-
given a local anesthetic. Reassure ent pain or tenderness, which
him that although he may feel some may indicate tenosynovitis or forma-
pressure, the anesthetic will ensure a tion of a hematoma.
pain-free operation. Encourage the patient to perform his
Discuss postoperative care measures. wrist and finger exercises daily to
Point out that hell have a dressing improve circulation and enhance
wrapped around his hand and lower muscle tone. If these exercises are
arm, which usually will remain in painful, have him perform them
place for 1 or 2 days after surgery. with his wrist and hand immersed
Explain that although he may experi- in warm water. (Have him wear a
ence pain when the anesthetic wears surgical glove if his dressing is still
off, analgesics will be available. in place.)
Teach the patient the rehabilitative Assess the need for home care and
exercises that hell be asked to do follow-up with activities of daily liv-
during the recovery period: gentle ing, especially if the patient lives
range-of-motion exercises with the alone.
wrist and fingers to prevent muscle WARNING Patients who had very
atrophy. Demonstrate these exercis- numb fingers or wasting of the
es, and have him perform a return thumb muscles before surgery will
demonstration. However, be aware probably never regain full nerve func-
that severe pain may prevent him tion. Recovery can be slow (6 to 12
from doing so. months). As the nerves grow back, the
fingers can actually feel tingly or even

5125C.qxd 8/15/08 10:51 AM Page 47

Selected references
PATIENT TEACHING Bland, J.D. Carpal Tunnel Syndrome,
Current Opinions in Neurology
GENERAL 18(5):581-85, October 2005.
Dunn, D. Preventing Perioperative
Discuss the medication prescribed,
Complications in Special Populations,
dosage, and adverse effects.
Nursing2005 35(11):36-43, November
Emphasize the importance of follow- 2005.
up care. Eskandari, M.M., et al. Effect of Patient
Refer the patient for resource and Age and Symptom Duration on
support services. Subjective and Objective Outcomes of
Inform the patient about caring for Carpal Tunnel Surgery, Orthopedics
the incision site. Tell him to keep the 28(6):600-602, June 2005.
incision site clean and dry, and to Hopp, P.T. Carpal Tunnel Syndrome
cover it with a surgical or rubber The Role of Psychosocial Factors in
glove when immersing it in water for Recovery, JAAOHN 52(11):458-60,
exercise or when taking a bath or November 2004.
Teach the patient how to change the
dressing; instruct him to do so once
daily until healing is complete.
Tell the patient to notify the surgeon
if redness, swelling, pain, or excessive
drainage persists at the operative
Encourage the patient to continue
daily wrist and finger exercises. Warn
him against overusing the affected
wrist or lifting an object heavier than
a thin magazine.
If the patients condition is job relat-
ed, suggest that he seek occupational
counseling to help him find more
suitable employment.
Inform the patient that keeping the
hand elevated is important to pre-
vent swelling and stiffness of the fin-
gers. Remind the patient not to walk
with the hand dangling or to sit with
the hand held in the lap.

American Academy of Orthopedic
Surgeons: www.aaos.org
American Medical Association:
Carpal Tunnel Syndrome:

5125C.qxd 8/15/08 10:51 AM Page 48

thus is more difficult to mold, but
OVERVIEW can bear body weight immediately, if PROCEDURE
Defined as a hard mold that encases Practitioner applies cast; nurse pre- Begin preparing the equipment by
a body part, usually an extremity, to pares patient and equipment and as- gently squeezing the packaged cast-
provide immobilization of bones and sists during the procedure (although ing material to make that sure the
surrounding tissue nurse may apply or change standard envelopes dont have air leaks.
Can be used to treat injuries (includ- cast after fracture reduced and set by Humid air can enter leaks and cause
ing fractures), correct orthopedic orthopedist) plaster to become stale, which could
conditions (such as deformities), or WARNING Contraindications in- make it set too quickly, form lumps,
promote healing after general or clude skin diseases, peripheral fail to bond with lower layers, or set
plastic surgery, amputation, or nerve vascular disease, diabetes mellitus, as a soft, friable mass.
and vascular repair (see Types of open or draining wounds, overwhelm- Follow the manufacturers directions
cylindrical casts) ing edema, and susceptibility to skin for water temperature when prepar-
May be constructed of plaster, Fiber- irritations. However, these arent strict ing plaster.
glas, or other synthetic materials contraindications; the practitioner Usually, room temperature or slightly
Plaster (commonly used): inexpen- must weigh the potential risks and warmer water is best because it al-
sive, nontoxic, nonflammable, easy benefits for each patient. lows the cast to set in about 7 min-
to mold, and rarely causes allergic re- utes without excessive exothermia.
actions or skin irritation INDICATIONS Cold water slows the rate of setting
Fiberglas: lighter, stronger, and more Fractures and may be used to facilitate difficult
resilient than plaster; dries rapidly, molding; warm water speeds the rate

Types of cylindrical casts

Made of plaster, Fiberglas, or synthetic material, casts may be applied almost anywhere on the body to support a single finger or the entire body.
Common casts are shown below.






5125C.qxd 8/15/08 10:51 AM Page 49

of setting and raises skin tempera- PREPARING A COTTON AND

Help the practitioner position the WARNING Open these casting
limb as ordered; its usually immobi- materials one roll at a time be- Acute pain
lized in the neutral position. cause cotton and polyester casting Impaired physical mobility
Support the limb in the prescribed must be applied within 3 minutes Ineffective tissue perfusion:
position while the practitioner ap- before humidity in the air hardens the Peripheral
plies the tubular stockinette and tape.
sheet wadding. Immerse the roll in cold water, and EXPECTED OUTCOMES
The stockinette, if used, should ex- squeeze it four times to ensure uni- The patient will:
tend beyond the ends of the cast to form wetness. express feelings of increased comfort
pad the edges. If the patient has an Remove the dripping wet material attain the highest degree of mobility
open wound or a severe contusion, from the bucket. possible within the confines of injury
the practitioner may decide to not Tell the patient that it will be applied exhibit adequate tissue perfusion
use the stockinette. immediately. Forewarn him that the and pulses distally.
The practitioner then wraps the limb material will feel warm and give off
in sheet wadding, starting at the dis- heat as it sets.
tal end, and applies extra wadding to PRETREATMENT CARE
the distal and proximal ends of the PREPARING A FIBERGLAS CAST
cast area as well as any points of If youre using water-activated Explain the procedure to the patient.
prominence. Fiberglas, immerse the tape rolls in If plaster is being used, make sure
Check for wrinkles as the practitioner tepid water for 10 to 15 minutes to that the patient understands that
applies the sheet wadding. initiate the chemical reaction that heat will build under the cast be-
Prepare the various cast materials as causes the cast to harden. cause of a chemical reaction between
ordered. Open one roll at a time. Avoid the water and plaster.
squeezing out excess water before Also begin explaining aspects of
PREPARING A PLASTER CAST application. If youre using light- proper cast care to prepare him for
Place a roll of plaster casting on its cured Fiberglas, you can unroll the patient teaching and to assess his
end in the bucket of water, immers- material more slowly. It remains soft knowledge level.
ing it completely. and malleable until its exposed to ul- Cover the appropriate parts of the
When air bubbles stop rising from traviolet light, which sets it. patients bedding and gown with a
the roll, remove it, gently squeeze out linen-saver pad.
the excess water, and hand the cast- COMPLICATIONS If the cast is applied to the wrist or
ing material to the practitioner, who Compartment syndrome arm, remove rings that may interfere
will begin applying it to the extremi- Palsy with circulation in the fingers.
ty. As he applies the first roll, prepare Paresthesia Assess the condition of the skin in
a second roll in the same manner. Ischemia the affected area, noting redness,
Stay at least one roll ahead of the Ischemic myositis contusions, or open wounds. This
practitioner during the procedure. Pressure necrosis will make it easier to evaluate any
After the practitioner applies each complaints the patient may have af-
Misalignment or nonunion of frac-
roll, hell smooth it to remove wrin- tured bones ter the cast is applied.
kles, spread the plaster into the cloth If the patient has an open wound,
webbing, and empty air pockets. If prepare him for a local anesthetic if
hes using plaster splints, hell apply the practitioner will administer one.
them in the middle layers of the cast. Clean the wound.
Before wrapping the last roll, hell Assist the practitioner as he closes
pull the ends of the tubular stock- the wound and applies a dressing.
inette over the cast edges to create To establish baseline measurements,
padded ends, prevent cast crum- assess the patients neurovascular
bling, and reduce skin irritation. status. Palpate the distal pulses; as-
The practitioner will then use the fi- sess the color, temperature, and cap-
nal roll to keep the ends of the stock- illary refill of the appropriate fingers
inette in place. or toes; and check neurologic func-
tion, including sensation and motion
in the affected and unaffected ex-

5125C.qxd 8/15/08 10:51 AM Page 50

Elevate the limb above heart level ing can result, causing pressure
POSTTREATMENT CARE with pillows or bath blankets, as or- necrosis of underlying tissue.
dered, to facilitate venous return and Also, dont use rubber- or plastic-
COMPLETING THE CAST reduce edema. covered pillows before the cast hard-
As necessary, petal the casts edges The practitioner will then send the ens because they can trap heat under
to reduce roughness and to cushion patient for X-rays to ensure proper the cast.
pressure points. positioning. If a cast is applied after surgery or
Use a cast stand or your palm to sup- Instruct the patient to notify the traumatic injury, remember that the
port the cast in the therapeutic posi- practitioner if any pain, foul odor, most accurate way to assess for
tion until it becomes firm to the drainage, or burning sensation under bleeding is to monitor the patients
touch (usually 6 to 8 minutes) to pre- the cast occurs. vital signs.
vent indentations in the cast. After the cast hardens, the practition- WARNING A visible blood spot on
Place the cast on a firm, smooth sur- er may cut a window in it to inspect the cast can be misleading: One
face to continue drying. the painful or burning area. drop of blood can produce a circle 3
Place pillows under joints to main- Dispose of materials appropriately; (7.6 cm) in diameter.
tain flexion, if necessary. pour water from the plaster bucket Casts may need to be opened to as-
To check circulation in the casted into a sink containing a plaster trap. sess underlying skin or pulses or to
limb, palpate the distal pulse and as- WARNING Dont use a regular relieve pressure in a specific area.
sess the color, temperature, and cap- sink because plaster will block In a windowed cast, a specific area is
illary refill of the fingers or toes. the plumbing. cut out to allow inspection of under-
Determine neurologic status by ask- Care consists of monitoring for lying skin or to relieve pressure.
ing the patient if hes experiencing changes in the drainage pattern, pre- A bivalved cast is split medially and
paresthesia in the extremity or de- venting skin breakdown near the laterally, creating anterior and poste-
creased motion of the extremitys un- cast, and averting the complications rior sections. One of the sections may
covered joints. Assess the unaffected of immobility. be removed to relieve pressure while
extremity in the same manner and Never use the bed or a table to sup- the remaining section maintains im-
compare findings. port the cast as it sets because mold- mobilization. (See Removing a plas-
ter cast.)

Removing a plaster cast

Typically, a cast is removed when a fracture heals or requires further manipulation. Less common indications include cast damage, a pressure ulcer under
the cast, excessive drainage or bleeding, and a constrictive cast.
Explain the procedure to the patient. Tell him hell feel some heat and vibration as the cast is split with the cast saw. If the patient is a child, tell him that
the saw is very noisy but wont cut the skin beneath. Warn the patient that when the padding is cut, hell see discolored skin and signs of poor muscle tone.
Reassure him that youll stay with him. The illustrations below show how a plaster cast is removed.

The practitioner cuts one side of the cast, then Next, the practitioner opens the cast pieces with Finally, using cast scissors, the practitioner cuts
the other. As he does so, closely monitor the a spreader. through the cast padding.
patients anxiety level.

When the cast is removed, provide skin care to remove accumulated dead skin and to begin restoring the extremitys normal appearance.

5125C.qxd 8/15/08 10:51 AM Page 51

Tell the patient to notify the practi-

PATIENT TEACHING tioner if the cast needs repair (if it
loosens, cracks, or breaks) or if he
GENERAL has questions about caring for the
Tell the patient that a Fiberglas cast cast.
dries immediately after application; a Warn the patient not to get the cast
plaster extremity cast dries in about wet because moisture will weaken or
24 to 48 hours; and a plaster spica or destroy it. If the practitioner ap-
body cast in 48 to 72 hours. proves, have the patient cover the
During this drying period, tell the pa- cast with a plastic bag or cast cover
tient that the cast must be properly for showering or bathing.
positioned to prevent a surface de- Urge the patient not to insert any-
pression that could cause pressure thing (such as a back scratcher or
areas or dependent edema. powder) into the cast to relieve itch-
Instruct the patient on how to moni- ing because it can damage the skin
tor his neurovascular status, and cause an infection.
drainage, and condition of the cast. Tell the patient that he can apply al-
Inform the patient that after the cast cohol on the skin at the cast edges.
dries completely, it looks white and WARNING Warn the patient not
shiny and no longer feels damp or to chip, crush, cut, or otherwise
soft. break any area of the cast and not to
Tell the patient that the practitioner bear weight on the cast unless in-
usually removes the cast at the ap- structed to do so by the practitioner.
propriate time, with the assistance of Tell the patient who needs crutches
a nurse. to have throw rugs removed from the
Tell the patient that when the cast is floor and have furniture rearranged
removed, his casted limb will appear to reduce the risk of tripping or
thinner and flabbier than the uncast- falling.
ed limb and his skin will appear yel- Inform the patient who has a cast on
lowish or gray from the accumulated his dominant arm that he may need
dead skin and oils from the glands help with bathing, toileting, eating,
near the skin surface. and dressing.
Reassure the patient that with exer-
cise and good skin care, his limb will RESOURCES
return to normal. Organizations
Before the patient is discharged, American Academy of Orthopedic
teach him how to care for his cast. Surgeons: www.aaos.org
Tell him to keep the casted limb ele- American Medical Association:
vated above heart level to minimize www.ama-assn.org
swelling. Raise a casted leg by having
the patient lie in a supine position Selected references
with his leg on top of pillows. Prop a Altizer L. Casting for Immobilization,
casted arm so that the hand and el- Orthopedic Nursing 23(2):136-41,
bow are higher than the shoulder. March-April 2004.
Berkowitz, M.J., and Kim, D.H. Process
(See Caring for your cast, pages 52
and Tubercle Fractures of the Hind-
and 53.) foot, Journal of the American Academy
WARNING Instruct the patient to of Orthopedic Surgery 13(8):492-502,
call the practitioner if he cant December 2005.
move his fingers or toes, has numbness Faulks, S., and Luther, B. Changing
or tingling in the affected limb, or if he Paradigm for the Treatment of
has symptoms of infection, such as a Clubfeet, Orthopedic Nursing
fever, unusual pain, or a foul odor 24(1):25-30, January-February 2005.
from the cast.
Advise the patient to maintain mus-
cle strength by continuing recom-
mended exercises.

5125C.qxd 8/15/08 10:51 AM Page 52


Caring for your cast

Dear Patient,
Think of your new cast as a temporary body partone that needs the same attentive care as the rest of you. While you wear
your cast, follow these guidelines.
SPEEDING UP DRYING TIME 2 hoursusing your palms, not your Hold the carpet in place with a large
fingertips. You can have someone else sock or slipper sock. Extending the car-
Your health care provider may apply a
move the cast for you. pet out beyond the toes a little will also
cast made of plaster, Fiberglas, or a
To avoid creating bumps inside the help prevent bumped or stubbed toes.
synthetic material. The wet material
castbumps that could cause skin irri-
must dry thoroughly and evenly for the
tation or soresdont poke at the cast PREVENTING SNAGS
cast to support your broken bone prop-
with your fingers while its wet. Also, be
erly. (At first, your wet cast will feel To keep an arm cast from snagging
careful not to dent the cast while its still
heavy and warm, but dont worryit clothing and furniture, make a cast cov-
will get lighter as it dries.) er from an old nylon stocking. Cut off
To speed drying, keep the cast ex- the stockings toe, and cut a hole in the
posed to the air. (Fiberglas and synthetic heel.
casts dry soon after application, but After your cast dries, you can remove Then pull the stocking over the cast
plaster casts dont. A plaster arm or leg dirt and stains with a damp cloth and to cover it.
cast dries in about 24 to 48 hours.) powdered kitchen cleaner. Use as little Extend your fingers through the cut-
When you raise the cast with pillows, water as possible, and wipe off moisture off toe end, and poke your thumb
make sure that the pillows have rubber that remains when youre done. through the hole you cut in the heel.
or plastic covers under the linen case. Trim the other end of the stocking to
Use a thin towel placed between the PROTECTING YOUR CAST about 11/2 (4 cm) longer than the cast,
cast and the pillows to absorb moisture. and tuck the ends of the stocking under
Avoid knocking your cast against a hard
Never place a wet cast directly onto the casts edges.
surface. To protect the foot of a leg cast
from breakage, scrapes, and dirt, place
a piece of used carpet (or a carpet
square) over the bottom of the cast.
To make sure that the cast dries evenly, Slash or cut a V shape at the back so
change its position on the pillows every the carpet fits around the heel when you
bring it up toward the ankle.

V-shaped carpet

5125C.qxd 8/15/08 10:51 AM Page 53

Caring for your cast (continued)

CARING FOR YOUR SKIN Heres a safe technique to relieve

itching. Set a handheld blow-dryer on
Wash the skin along the casts edges
cool, and aim it at the problem area.
every day, using a mild soap. Before
you begin, protect the casts edges
with plastic wrap. Then use a wash-
cloth wrung out in soapy water to If you have a plaster cast, youll need
clean the skin at the casts edges and to cover it with a plastic bag before
as far as you can reach inside the you shower, swim, or go out in wet
cast. Avoid getting the cast wet. weather. You can use a garbage bag or
Afterward, dry the skin thoroughly with a cast shower bag, which you can buy
a towel. Then massage the skin at and at a drugstore or medical supply store.
beneath the casts edges with a towel Above all, dont get a plaster cast wet.
or pad saturated with rubbing alcohol. Moisture will weaken or even destroy
This helps toughen the skin. To help it. If the cast gets a little wet, let it dry
prevent skin irritation, remove loose naturally, such as by sitting in the sun.
plaster particles you can reach inside Dont cover the cast until its dry. If
the cast. you have a Fiberglas or synthetic cast,
check with your health care provider to
RELIEVING ITCHING find out if you may bathe, shower, or
swim. If he does allow you to swim,
No matter how itchy the skin under
hell probably tell you to flush the cast
your cast may feel, never try to relieve
with cool tap water after swimming in
the itch by inserting a sharp or pointed
a chlorinated pool or a lake. Make sure
object into the cast. This could dam-
that no foreign material remains
age your skin and lead to infection.
trapped inside the cast. To dry a
Also, dont put powder or lotion in your
Fiberglas or synthetic cast, first wrap
cast or stuff cotton or toilet tissue un-
the cast in a towel. Then prop it on a
der the casts edges. This may reduce
pad of towels to absorb remaining wa-
your circulation.
ter. The cast will air-dry in 3 to 4
hours; to speed dry it, use a handheld


Family members and friends may want
to sign their names or draw pictures
on the cast. Thats okay, but dont let
them paint over large cast areas be-
cause this could make those areas
nonporous and damage the skin un-

This patient-teaching aid may be reproduced by office

copier for distribution to patients. 2007 Lippincott
Williams & Wilkins.

5125C.qxd 8/15/08 10:51 AM Page 54

Cataract extraction
dated and pain-free with local anes-
For a review of cataract removal pro-
Lens opacitiescataractsremoved The patient may receive a local or cedures, see Comparing methods of
by intracapsular cataract extraction general anesthetic. cataract removal.
(ICCE) or extracapsular cataract ex- AGE FACTOR Children are typi- After cataract removal, the surgeon
traction (ECCE) cally given general anesthesia to may insert a lens implant. After en-
ICCE: entire lens removed, most keep them in a deep sleep and pain- larging the incision, hell implant the
commonly with a cryoprobe free; adults usually are awake but se- lens into the capsular sac.
ECCE: anterior capsule, cortex, and
nucleus removed and posterior cap-
sule left intact; technique possibly Comparing methods of cataract removal
done by manual extraction, irrigation
and aspiration, or phacoemulsifica- Cataracts can be removed by intracapsular or extracapsular techniques.
mary treatment for congenital When performing intracapsular cataract Lens Cryoprobe
and traumatic cataracts. Its charac- extraction, the surgeon makes a partial Cornea
teristically used to treat children and incision at the superior limbus arc. He then
young adults because the posterior removes the lens using specially designed
capsule adheres to the vitreous until forceps or a cryoprobe, which freezes and
about age 20. By leaving the posterior adheres to the lens to facilitate its removal.
capsule undisturbed, ECCE avoids
disruption and loss of vitreous.
Immediately after removal of natural
lens, many patients implanted with
intraocular lens

Loss of vision or visual abnormalities
due to the presence of cataracts EXTRACAPSULAR CATARACT EXTRACTION below to express the lens. He then irrigates
When performing extracapsular cataract and suctions the remaining lens cortex.
extraction, the surgeon may use irrigation and During phacoemulsification, the surgeon
aspiration or phacoemulsification. If he uses uses an ultrasonic probe to break the lens into
irrigation and aspiration, he makes an incision minute particles, which are aspirated by the
at the limbus, opens the anterior lens capsule probe.
with a cystotome, and exerts pressure from


Cortical and nuclear cataract Nucleus and cortex

material aspirated through fragmented and
needle aspirated by probe

Lens Lens

5125C.qxd 8/15/08 10:51 AM Page 55

If he implants the lens without su-

tures, hell administer miotic agents, PRETREATMENT CARE PATIENT TEACHING
such as pilocarpine (Pilocar), to pre-
vent the iris from dilating too widely Explain the planned surgical tech- GENERAL
and causing the lens to slip. nique to the patient. Tell him that Instruct the patient to immediately
In ICCE and ECCE, the surgeon may hell receive mydriatics and cyclo- contact the surgeon if sudden eye
also perform a peripheral iridectomy plegics to dilate the eye and facilitate pain, red or watery eyes, photopho-
to reduce intraocular pressure (IOP) cataract removal, that hell receive bia, or sudden visual changes occur.
and may briefly instill alpha-chy- osmotics and antibiotics to reduce Tell the patient to avoid activities that
motrypsin, a proteolytic enzyme, in the risk of infection, and that he may raise IOP, including heavy lifting,
the anterior chamber to dissolve re- receive a sedative to help him relax. bending, straining during defecation,
sistant zonular fibers. Inform the patient that after surgery or vigorous coughing and sneezing.
After the procedure, the surgeon hell have to wear an eye patch tem- Tell him not to exercise strenuously
closes the sutures, instills antibiotic porarily to prevent traumatic injury for 6 to 10 weeks.
drops or ointment, and patches and and infection. Explain that follow-up appointments
shields the eye. Explain that hell temporarily experi- are needed to monitor the results of
ence loss of depth perception and the surgery and to detect any compli-
COMPLICATIONS decreased peripheral vision on the cations.
Papillary block operative side. Teach the patient or a family mem-
Corneal decompensation Perform an antiseptic facial scrub to ber how to instill eyedrops and oint-
Vitreous loss reduce the risk of infection, if or- ments and how to change the eye
Hemorrhage dered. patch. (See Eye care after cataract
Cystoid macular edema Verufy that the patient has signed a surgery, pages 56 and 57.)
Lens dislocation consent form. Suggest that the patient wear dark
Secondary membrane opacification glasses to relieve glare because pho-
Retinal detachment tophobia is common after eye sur-
Explain that changes in the patients
NURSING DIAGNOSES After the patient returns to his room, vision can present safety hazards if
notify the surgeon if severe pain, hell be wearing eyeglasses. To com-
Acute pain bleeding, increased drainage, or fever pensate for loss of depth perception,
Disturbed sensory perception occurs. show him how to use up-and-down
(visual) Because of the change in the pa- head movements to judge distances.
Risk for infection tients depth perception, keep the To overcome the loss of peripheral vi-
side rails of his bed raised, assist him sion on the operative side, teach him
with ambulation, and observe other to turn his head fully in that direction
safety precautions. to view objects to his side.
The patient will:
Maintain the eye patch, and have the Remind the patient that although his
express feelings of comfort
patient wear an eye shield, especially vision may not stabilize for several
demonstrate improved visual func-
when sleeping. Tell him to continue weeks following surgery, visual acuity
wearing the shield during sleep for will increase as the affected eye heals.
demonstrate intact tissue without
signs of infection. several weeks as ordered.
American Academy of Ophthalmology:
American Medical Association:

Selected references
Dunn, D. Preventing Perioperative Com-
plications in Special Populations,
Nursing2005 35(11):36-43, November


5125C.qxd 8/15/08 10:51 AM Page 56

Khng, C., and Snyder, M.E., Iris Recon-
struction with a Multipiece Endocap-
sular Prosthesis in Iridocorneal Endo- Eye care after cataract surgery
thelial Syndrome, Journal of Cataract
and Refractive Surgery 31(11):2051-54, Dear Patient,
November 2005.
Kuo, I.C., et al. Excimer Laser Surgery for Your eye surgeon wants you to remove the eye shield and eye patch from the
Correction of Ametropia after Cataract surgery 24 hours after the procedure. You have been given one or two eye med-
Surgery, Journal of Cataract and
Refractive Surgery 31(11):2104-10, ications to use, and a schedule for their administration. At bedtime for the next 4
November 2005. to 6 weeks, or anytime you lay down, you should reapply the eye shield. This will
Marsden, J. Cataract: The Role of Nurses prevent rubbing or bumping your eye during sleep.
in Diagnosis, Surgery and Aftercare,
Nursing Times 100(7):36-40, February
1. Wash your hands thoroughly with soap
and water.
2. Use a downward motion to peel the
tape off your forehead. Gently remove the
shield and patch from your eye and con-
tinue to peel the tape downward to your
cheek. Next, remove the tape from the
shield and discard the patch.
3. You may very gently soak away any
dried drainage with a warm moist clean
cloth, but dont rub or press on the eye.

1. Wash your hands thorough-
ly with soap and water.
2. Stand in front of a mirror.
3. Pull your lower lid down
gently with a finger or the
thumb of your nondominant
hand to make a pocket.

5125C.qxd 8/15/08 10:51 AM Page 57

Eye care after cataract surgery (continued)


4. Rest your dominant hand
with the bottle on your fore-
head to help steady it.
5. Look upward and slightly
away from the bottle tip.
6. Squeeze the appropriate
number of drops into the eye
7. Close your eye and press
gently where the nose meets
the inner eye for 2 or 3 min-
utes, without pinching.

8. With your eye closed, gently

wipe away any unabsorbed
drops and tears.
9. Wait 3 to 5 minutes before
instilling another medication.
10. Wash your hands with soap
and water when you are done.


1. Wash your hands thoroughly with soap
and water.
2. Place the shield over the affected eye.
3. Secure it with two parallel strips of hy-
poallergenic tape, taping from the middle
of your forehead to your cheekbone. Make
sure that you leave a space between the
strips of tape so that you can see through
the shield.
4. When you get up, carefully remove the
shield. Wash it with soap and water as
needed. Keep it in a convenient place
ready to apply again.

This patient-teaching aid may be reproduced by office copier for

distribution to patients. 2007 Lippincott Williams & Wilkins.

5125C.qxd 8/15/08 10:51 AM Page 58

Cerebral aneurysm repair

Willis (see Common sites of cerebral to dissect the aneurysm away from
OVERVIEW aneurysm) the vessels feeding the aneurysm and
AGE FACTOR The prognosis is al- expose the neck to receive the clip,
Surgical repair: clipping the aneu- ways guarded, but is affected by which is usually made of titanium.
rysm neck with at least one titanium the patients age and neurologic con- The clip is placed on the neck of the
clip dition, the presence of other diseases, aneurysm to stop the flow of blood
Endovascular repair: use of electri- and the extent and location of the into the aneurysm, causing it to de-
cally detachable platinum coils that aneurysm. flate or obliterate. (See Clipping a
promote electrothrombosis within cerebral aneurysm.)
the aneurysm INDICATIONS The brain tissue is carefully lowered
Decision of neurosurgeon and en- Cerebral aneurysm back into place, the various layers su-
dovascular radiologists whether to tured closed, and the bone flap is re-
obliterate an aneurysm surgically seated for healing.
through a craniotomy and clipping PROCEDURE The skin and other outer layers are
or to use endovascular methods also sutured closed.
based on the patient's condition
AGE FACTOR Treatment depends
General anesthesia is used and the COILING
on the patients age and the lo- A specially trained radiologist called
area of the skull where the cranioto-
cation of the aneurysm.Younger pa- a neurointerventionist performs the
my will occur is shaved. The exact
tients commonly undergo surgical procedure using fluoroscopic an-
position of the opening depends on
clipping because coiling has a high re- giography. A microcatheter is thread-
the approach that the neurosurgeon
currence rate. However, posterior fossa ed from the patient's femoral artery
will use to reach the aneurysm.
aneurysms (especially the basilar ar- to the aneurysm. The catheter is used
The bone flap is removed and the
tery tip) tend to be treated using the to place small platinum coils within
various layers of tissue are cut away
coil procedure. In most major aneur- the aneurysm using a delivery wire.
to expose the brain.
ysm centers, many cases are still oblit- Once the coil has been maneuvered
Brain tissue is gently retracted back
erated by surgical clipping, although into place, an electrical charge is sent
to expose the area containing the
coiling is being used more frequently. through the delivery wire that disin-
Cerebral aneurysms: usually arise at tegrates the stainless steel of the coil,
Surgical techniques performed
the arterial junction in the circle of separating it from the delivery wire,
through a microscope are then used
which is then removed from the
Several coils may be necessary to
Common sites of cerebral aneurysm block the neck of the aneurysm from
the normal circulation and obliterate
Cerebral aneurysms usually arise at the arterial bifurcation in the circle of Willis and its branches. it, as with the clip procedure.
This illustration shows the most common sites around this circle. The coils act as a thrombogenic
agent, causing blood to coagulate in
the aneurysm, decreasing the risk of
WARNING Coil treatment is con-
traindicated if the patient has a
cerebral hematoma (which precludes
anticoagulation during the proce-
Aneurysm in the dure) or an aneurysm with a wide
Left anterior anterior cerebral
artery opening.The coil mass could lapse
cerebral artery
into the parent artery, partially or
Aneurysm in the Internal carotid artery completely occluding it and causing a
left posterior
communicating artery

Basilar artery

5125C.qxd 8/15/08 10:51 AM Page 59

COMPLICATIONS Verify that the patient has signed a Monitor laboratory values and intake
Infection consent form. and output.
Rebleeding of cerebral aneurysm Monitor the femoral puncture site for
Vasospasm bleeding or hematoma and the leg
Neurologic damage POSTTREATMENT CARE for signs of ischemia.
Hypothermia WARNING Notify the surgeon im-
A postoperative magnetic resonance mediately if you notice pain, pal-
angiogram may be performed to lor, pulselessness, poikilothermia (cool
NURSING DIAGNOSES confirm good clip placement, total to touch), or paresthesia.
obliteration of the aneurysm, and Patients who received a coil are usu-
Ineffective tissue perfusion: Cerebral continued blood flow through the ally on a heparin infusion postopera-
Risk for infection neighboring vessels. tively and then on aspirin indefinite-
Risk for injury Treatments for vasospasm include ly.
medications to relax the smooth
EXPECTED OUTCOMES muscles in vessel walls or to increase
The patient will: blood pressure, or I.V. fluids to in- PATIENT TEACHING
demonstrate normal neurologic crease blood volume.
functioning Carefully monitor blood pressure GENERAL
remain free from infection and notify the surgeon of a signifi- Review signs of rebleeding to report,
remain free from injury. cant increase, especially in the sys- such as headache, nausea, vomiting,
tolic pressure. and changes in level of conscious-
Because aneurysms can re-form, pa- ness.
PRETREATMENT CARE tients are followed by angiography, Refer the patient to a home health
skull X-rays, or magnetic resonance care service or rehabilitation center
angiography. before hes discharged, as needed.
Check laboratory values, electrocar-
Administer oxygen as indicated; suc-
diogram, and chest X-rays as or-
tion and turn the patient. RESOURCES
dered; notify the surgeon or radiolo-
Apply elastic stockings or compres- Organizations
gist of any abnormalities.
sion boots to reduce the risk of deep American Academy of Neurology:
Explain the planned surgical tech-
vein thrombosis. www.aan.com
nique to the patient and his family,
Administer I.V. fluids as ordered. American Medical Association:
reinforcing the surgeons explana-
Assess the patients neurologic status www.ama-assn.org
tions as necessary.
and report changes in trends; moni-
Explain all tests, neurologic examina-
tor him for increased intracranial Selected references
tions, treatments, and procedures to
pressure. Dunn, D. Preventing Perioperative
the patient and his family.
Complications in Special Populations,
Perform a neurologic examination.
Nursing 35(11):36-43, November 2005.
Feng, L., et al. Healing of Intracranial
Aneurysms with Bioactive Coils, Neu-
Clipping a cerebral aneurysm rosurgical Clinics of North America
16(3):487-99, July 2005.
Wagner, M., and Stenger, K. Unruptured
The clip, which is made of Intracranial Aneurysms: Using Evi-
materials that wont affect dence and Outcomes to Guide Patient
metal detectors and that will Teaching, Critical Care Nursing Quar-
not rust, is placed at the terly 28(4):341-54, October-December
base of the aneurysm to stop 2005.
the blood supply. The clip re-
mains in place permanently.

5125C.qxd 8/15/08 10:51 AM Page 60

Cerebrospinal fluid drainage

cerebral dural healing after traumatic The practitioner will shave the hair
OVERVIEW injury or surgery from the area of the insertion site,
clean the insertion site, and adminis-
Aims to reduce cerebrospinal fluid ter a local anesthetic.
(CSF) pressure to desired level and PROCEDURE The practitioner will put on sterile
then to maintain it at that level gloves and drape the insertion site.
Fluid withdrawn from lateral ventri- Open all equipment using sterile To insert the drain, the practitioner
cle (ventriculostomy) or lumbar sub- technique. Check all packaging for will request a ventriculostomy tray
arachnoid space, depending on indi- breaks in seals and for expiration with a twist drill.
cation and desired outcome dates. After completing the ventriculosto-
To place the ventricular drain: practi- Label all medications, medication my, hell connect the drainage system
tioner inserts a ventricular catheter containers, and other solutions on and suture the ventriculostomy in
through a burr hole in the patients and off the sterile field. place.
skull; usually done in the operating The practitioner will then cover the
room, with the patient under general INSERTING A VENTRICULAR insertion site with a sterile dressing.
To place the lumbar subarachnoid
Place the patient in the supine posi- INSERTING A LUMBAR
drain: practitioner may administer a
local spinal anesthetic at the bedside Position the patient in a side-lying
Place the equipment tray on the
or in the operating room (see Using a position with his chin tucked to his
overbed table, and unwrap the tray.
cerebrospinal fluid drainage system) chest and knees drawn up to his ab-
Adjust the height of the bed so that
the practitioner can perform the pro- domen (as for a lumbar puncture).
INDICATIONS cedure comfortably. Urge the patient to remain still dur-
Ventricular drainage to reduce in- Illuminate the area of the catheter in- ing the procedure.
creased intracranial pressure (ICP); sertion site. An alternate position for the patient
lumbar drainage, to aid healing of would be sitting up at the bedside,
the dura mater leaning forward over a bedside table.
External CSF drainage, to manage in- To insert the drain, the practitioner
creased ICP and to facilitate spinal or attaches a Tuohy needle (or spinal
needle) to the whistle-tip catheter.
After the practitioner removes the
needle, he connects the drainage sys-
Using a cerebrospinal fluid drainage system tem, sutures or tapes the catheter se-
curely in place, and covers it with a
Cerebrospinal fluid drainage
sterile dressing.
aims to control intracranial CLOSED DRAINAGE SYSTEM After the practitioner places the
pressure (ICP) during treatment catheter, connect it to the external
Sample port
for traumatic injury or other drainage system tubing.
conditions that cause a rise in CSF is drained by a catheter or ven-
ICP. To catheter triculostomy tube in a sterile, closed
drainage collection system.
VENTRICULAR DRAIN Secure connection points with tape
For a ventricular drain, the or a connector.
practitioner makes a burr hole Place the collection system, includ-
in the patients skull and ing the drip chamber and collection
inserts the catheter into the Drip chamber
bag, on an I.V. pole.
ventricle. The distal end of the
catheter is connected to a
closed drainage system. COMPLICATIONS
Excessive CSF drainage
Acute overdrainage that may result in
collapsed ventricles, tonsillar hernia-
tion, and medullary compression
Drainage bag
Cessation of drainage due to clot for-

5125C.qxd 8/15/08 10:51 AM Page 61

The patient with a lumbar drain is

NURSING DIAGNOSES POSTTREATMENT CARE generally kept in a flat position, espe-
cially if the drain is placed for a
Disturbed sensory perception (all) Check the patients neurologic vital spinal dural tear.
Ineffective tissue perfusion: Cerebral signs regularly for signs of deteriorat- Be aware that the patient may experi-
Risk for infection ing level of consciousness from acute ence chronic headache during con-
overdrainage. tinuous CSF drainage.
EXPECTED OUTCOMES Assess for signs of excessive
The patient will: drainage, which may include
exhibit improved or normal sensory headache, tachycardia, diaphoresis, PATIENT TEACHING
functions and nausea. Reassure the patient
maintain normal neurologic status that this isnt unusual; administer GENERAL
exhibit no signs of infection. analgesics as appropriate. Instruct the patient and his family
Maintain a continuous hourly output not to change the head of the bed or
of CSF by raising or lowering the patient position without nursing as-
PRETREATMENT CARE drainage system drip chamber. sistance and approval as it may affect
Make sure the drip chamber is slight- the results of treatment.
Explain the procedure to the patient
ly lower than or at the level of the Tell the patient and his family to
and his family. lumbar drain insertion site. promptly report changes in vision,
For ventricular drains, make sure hearing, thinking, alertness, breath-
Verify that the patient has signed a
that the flow chamber of the ICP ing, extremity movement or sensa-
consent form.
Wash your hands thoroughly.
monitoring setup remains posi- tion, or discomfort levels.
Perform a baseline neurologic as-
tioned as ordered. Inform the patient and his family
Correlate changes in ICP readings to that the drainage system will be re-
sessment, including vital signs, to
the drainage. moved when ICP has stabilized, per
help detect alterations or signs of de-
Drain CSF as ordered, maintaining the practitioners assessment and
sterile technique. further diagnostic testing.
Document the time and the amount
of CSF obtained. RESOURCES
Check the dressing frequently for Organizations
drainage, which could indicate leak- American Academy of Neurology:
age of CSF. www.aan.com
Check the tubing for patency by American Medical Association:
watching the CSF drops in the drip www.ama-assn.org
Observe CSF for color, clarity, Selected references
amount, blood, and sediment. Matsumoto, J., et al. A Long-Term Ven-
Obtain CSF specimens for laboratory tricular Drainage for Patients With
analysis from the collection port at- Germ Cell Tumors or Medulloblasto-
tached to the tubing and not from ma, Surgical Neurology 65(1):74-80,
the collection bag. January 2006.
Norlela, S. Syndrome of Inappropriate
Change the collection bag when its
Antidiuretic Hormone Caused by Con-
full or every 24 hours, according to
tinuous Lumbar Spinal Fluid Drainage
your facilitys policy. after Transphenoidal Surgery, Singa-
WARNING Never empty the pore Medical Journal 47(1):75-76,
drainage bag. Instead, replace it January 2006.
when full using sterile technique. Overstreet, M. How Do I Manage a Lum-
Record and monitor hourly output of bar Drain? Nursing2003 33(3):74-75,
CSF. March 2003.
Check for kinked tubing, catheter Thiex, R., and Mull, M. Basilar Megado-
displacement, and drip chamber licho Trunk Causing Obstructive Hy-
placement. drocephalus at the Foramina of Mon-
Be aware that raising or lowering the ro, Surgical Neurology 65(2):199-201,
February 2006.
head of the bed can affect the CSF
flow rate.
When changing the patients posi-
tion, reposition the drip chamber.

5125C.qxd 8/15/08 10:51 AM Page 62

I.V. route (using peripheral or central Administration route dependent on
OVERVIEW veins) most commonly used, al- drugs pharmacodynamics and tu-
though also may be given orally, sub- mors characteristics; for example, if
Chemotherapeutic drugs: may be ad- cutaneously, intramuscularly, intra- malignant tumor is confined to one
ministered through several routes; arterially, into a body cavity, through area, drug may be administered
may be administered by specially a central venous (CV) catheter, or through localized, or regional,
trained nurses or practitioners through an Ommaya reservoir into method
Used to destroy or suppress the the spinal canal Regional administration: allows de-
growth of cancer cells Other routes: an artery, peritoneal livery of a high dose directly to the
May be used alone or as an adjunct cavity, or pleural space (see Intraperi- tumor, which is advantageous be-
to surgery or radiation therapy toneal chemotherapy: An alternative cause many solid tumors dont re-
approach) spond to drug levels that are safe for
systemic administration
Adjuvant chemotherapy: may be ad-
ministered to a patient whose cancer
Intraperitoneal chemotherapy: An alternative approach is believed to have been eradicated
through surgery or radiation therapy;
Administering chemotherapeutic drugs into the thats readily available on most units with on- helps to ensure that no undetectable
peritoneal cavity has several benefits for the cology patients. metastasis exists
patient with malignant ascites or ovarian can- In this method, the chemotherapy bag is Induction chemotherapy (or neoad-
cer that has spread to the peritoneum. connected directly to the Tenckhoff catheter juvant or synchronous chemothera-
Intraperitoneal chemotherapy passes drugs di- with a length of I.V. tubing, the solution is in- py): may be administered before sur-
rectly to the tumor in the peritoneal cavity, ex- fused, and the catheter and I.V. tubing are gery or radiation therapy; helps im-
posing malignant cells to high concentrations clamped. Then the patient is asked to change
prove survival rates by shrinking a
of chemotherapyup to 1,000 times the positions every 10 to 15 minutes for 1 hour to
amount that can be safely given systemically. move the solution around in the peritoneal cav-
tumor before surgical excision or ra-
Furthermore, the semipermeable peritoneal ity. diation therapy
membrane permits prolonged exposure of ma- After the prescribed dwell time, the Although proven to be more effective
lignant cells to the drug. chemotherapeutic drugs are drained into an I.V. when given in higher doses, adverse
Typically, this technique is performed using bag. The patient is encouraged to change posi- effects usually limit dosage; metho-
a peritoneal dialysis kit, but drugs can also be tions to facilitate drainage. Then the I.V. tubing trexate (MTX) being the exception,
administered directly to the peritoneal cavity by and catheter are clamped, the I.V. tubing is re- which is particularly effective against
using a Tenckhoff catheter (as shown here). moved, and a new intermittent infusion cap is rapidly growing tumors but toxic to
This method can be performed on an outpa- fitted to the catheter. Finally, the catheter is normal tissues that are growing and
tient basis, if necessary; it uses equipment flushed with a syringe of heparin flush solution. dividing rapidly (However, oncolo-
gists have learned that they can give
a large dose of methotrexate to de-
stroy cancer cells and then, before
the drug can permanently damage
vital organs, give a dose of folinic
acid antidote, which stops the effects
of methotrexate and, thus, preserves
normal tissue.)

5125C.qxd 8/15/08 10:51 AM Page 63

INDICATIONS Check your facilitys policy before ad-

Alkylating agents PROCEDURE ministering a vesicant. Because vein
Chronic and acute leukemias integrity decreases with time, some
Non-Hodgkins lymphoma Assess the patients physical condi- facilities require that vesicants be ad-
Multiple myeloma tion, and review his medical history. ministered before other drugs.
Myeloma Make sure that you understand what Conversely, because vesicants in-
Sarcoma needs to be given and by what route, crease vein fragility, other facilities
Breast, ovarian, and uterine cancers and provide the necessary teaching require that vesicants be given after
Testes, bladder, and prostate cancers and support to the patient and his other drugs.
Lung cancer family. Evaluate the patients condition, pay-
Brain cancer Determine the best site to administer ing attention to recent laboratory test
Stomach cancer the drug. When selecting the site, results, specifically the complete
consider drug compatibilities, fre- blood count, blood urea nitrogen lev-
Antimetabolites quency of administration, and the el, platelet count, urine creatinine
Acute leukemia vesicant potential of the drug. (See level, and liver function studies.
Breast cancer Classifying chemotherapeutic drugs.) Determine whether the patient has
GI tract adenocarcinomas For example, if the oncologist has or- received chemotherapy before, and
Non-Hodgkins lymphoma dered the intermittent administra- note the severity of any adverse reac-
Squamous cell carcinomas of the tion of a vesicant drug, give it by ei- tions.
head, neck, and cervix ther instilling the drug into the side Check the patients drug history for
port of an infusing I.V. line or by di- medications that might interact with
Antibiotic antineoplastic agents rect I.V. push. chemotherapy.
Sarcomas If the vesicant drug is to be infused WARNING As a rule, you shoul
Lymphomas continuously, administer it only not mix chemotherapeutic drugs
Acute nonlymphoblastic leukemia through a CV line or a vascular ac- with other medications. If you have
Nonlymphocytic leukemia cess device. questions or concerns about giving the
Breast cancer Nonvesicant agents (including irri- chemotherapeutic drug, talk with the
tants) may be given by direct I.V. oncologist or pharmacist before you
Hormonal antineoplastic agents push, through the side port of an in- give it.
fusing I.V. line, or as a continuous in- Double-check the patients chart for
Hormone-dependent tumors
Cancers of the prostate, breast, and fusion. the complete chemotherapy protocol
endometrium order, including the patients name,
drugs name and dosage, and the
route, rate, and frequency of admin-
Tubulin-interactive agents
Leukemias Classifying See if the drugs dosage depends on

Sarcomas chemotherapeutic drugs certain laboratory values.

Know that some facilities require two
Breast and ovarian cancers
Chemotherapeutic drugs may be classified
nurses to read the dosage order and
as irritants, vesicants, or nonvesicants. to check the drug and the amount
being administered.
IRRITANTS Vinblastine Check to see whether the oncologist
Carmustine Vincristine has ordered an antiemetic, fluids, a
Dacarbazine diuretic, or electrolyte supplements
Etoposide to be given before, during, or after
Ifosfamide Asparaginase chemotherapy administration.
Streptozocin Bleomycin
Verify the patients identity using two
Topotecan Carboplatin
patient identifiers according to facili-
Cisplatin (if > 20
ty policy.
VESICANTS ml of 0.5 mg/ml, it
Evaluate the patients and his familys
Dactinomycin is considered a
vesicant) understanding of chemotherapy, and
Doxorubicin Cyclophospha- make sure that the patient or a re-
Mechlorethamine mide sponsible family member has signed
Mitomycin-C Cytarabine the consent form.
Mitoxantrone Floxuridine Put on gloves. Keep them on through
Paclitaxel Fluorouracil all stages of handling the drug, in-

5125C.qxd 8/15/08 10:51 AM Page 64

cluding preparation, priming the I.V. Urticaria

tubing, and administration. Anorexia PRETREATMENT CARE
Before administering the drug, per- Esophagitis
form a new venipuncture proximal to Diarrhea Explain the treatment and prepara-
the old site. Constipation tion to the patient and his family.
To identify an administration site, ex- Psychological problems, including Verify that the patient has signed an
amine the patients veins, starting depression and altered body image appropriate consent form.
with his hand and proceeding to his Extravasation, causing inflammation, Provide emotional support to the pa-
forearm. ulceration, necrosis, and loss of vein tient and his family.
When an appropriate line is in place, patency Obtain the patients medical and
infuse 10 to 20 ml of normal saline drug history, and perform a physical
solution to test vein patency. assessment.
WARNING Never test vein patency NURSING DIAGNOSES Review laboratory test results.
with a chemotherapeutic drug. Assess the patients nutritional sta-
Next, administer the drug as appro- Fatigue tus, rehabilitation needs, and ability
priate: nonvesicants by I.V. push or Imbalanced nutrition: Less than to self-care.
admixed in a bag of I.V. fluid; vesi- body requirements Develop a care plan for managing
cants by I.V. push through a piggy- Risk for infection symptoms.
back set connected to a rapidly infus- Instruct the patient to report adverse
ing I.V. line. EXPECTED OUTCOMES reactions during chemotherapy.
During I.V. administration, closely If administering a vesicant agent,
The patient will:
monitor the patient for signs of a hy- maintain energy level to perform dai-
avoid sites in the wrist or dorsum of
persensitivity reaction or extravasa- ly activities the hand.
tion. Verify the drug, dosage, and adminis-
maintain normal body weight
During infusion, some drugs need tration route by checking the med-
exhibit no signs of infection.
protection from direct sunlight to ication record against the oncolo-
avoid possible drug breakdown. If gists order.
this is happens, cover the vial with a Make sure you know the immediate
brown paper bag or aluminum foil. and delayed adverse effects of the or-
If indicated, use an infusion pump or dered drug.
controller to ensure drug delivery Administer pretreatment medica-
within the prescribed time and rate. tions.
Check for adequate blood return af-
ter 5 ml of the drug has been infused
or according to your facilitys guide-
After infusion of the medication, in-
fuse 20 ml of normal saline solution.
Do this between administrations of
different chemotherapeutic drugs
and before discontinuing the I.V. line.

Nausea and vomiting
Bone marrow suppression
Intestinal irritation
Pulmonary fibrosis
Hearing loss
Alopecia (see Caring for your hair
and scalp during cancer treatment)

5125C.qxd 8/15/08 10:51 AM Page 65


Caring for your hair and scalp
Dispose of used needles and syringes during cancer treatment
To prevent aerosol dispersion of Dear Patient,
chemotherapeutic drugs, dont clip
needles. Place them intact in an im- Some hair loss is inevitable during chemotherapy or radiation therapy. But
pervious container for incineration. sometimes you can help minimize hair loss by keeping your hair and scalp clean
Dispose of I.V. bags, bottles, gloves, and treating them gently. Just follow these suggestions.
and tubing in a properly labeled and
covered trash container. IF YOURE HAVING CHEMOTHERAPY
Wash your hands thoroughly with
soap and warm water after giving any Shampoo regularlyevery 2 to 4
chemotherapeutic drug, even though days. (Shampooing every day may
you have worn gloves. be too harsh.)
Observe the I.V. site frequently for Use a mild protein-based sham-
signs of extravasation and allergic re- poofor example, Appearance, an
action (such as swelling, redness, and
apple pectin shampoo. (Baby sham-
WARNING If you suspect extrava-
poo isnt necessarily mild.) You may
sation, stop the infusion imme- want to talk with a hairdresser to
diately. Leave the I.V. catheter in place, determine which shampoo is best
and notify the oncologist. A conserva- for you.
tive method for treating extravasation
involves aspirating any residual drug
from the tubing and I.V. catheter, in- Avoid harsh chemicals, permanents,
stilling an I.V. antidote, and then re- and dyes. Also avoid tight curls or
moving the I.V. catheter. Afterward,
braids. Dont use a curling iron, hair
you may apply heat or cold to the site
and elevate the affected limb.
dryer, or hot rollers. And dont sleep
Observe the patient for adverse reac- with curlers in your hair.
tions. To minimize friction on your hair, try
Maintain a list of the types and sleeping on a satin pillowcase. And
amounts of drugs the patient has re- to keep your hair from shedding, try
ceived, especially if he has received using a hair net.
drugs that have a cumulative effect Wear a hat to protect your scalp
and that can be toxic to organs, such
from sunburn.
as the heart or kidneys.
For 48 hours after drug administra-
tion, wear latex gloves when han- Use a conditioner after shampooing. IF YOURE HAVING RADIATION
dling items contaminated with the Gently pat your hair dry. THERAPY
patients excreta. If your scalp is very dry and flaky,
Dont use anything on your scalp
try massaging it with mineral oil,
except Eucerin or Aquaphor cream.
castor oil, or vitamin A and D oint-
You can buy these products at your
ment after shampooing and rinsing
local pharmacy without a prescrip-
your hair.
Brush and comb your hair very gen-
When your hair starts to grow back,
tly, using a soft-bristled brush and a
follow the hair and scalp care in-
pliable, wide-toothed comb.
structions listed above.

This patient-teaching aid may be reproduced by office copier for distribution to patients. 2007 Lippincott Williams &


5125C.qxd 8/15/08 10:51 AM Page 66

Refer the patient to local resources or Interferon-alpha in Patients with

PATIENT TEACHING a home health care agency. Metastatic Melanoma, Melanoma
Research 16(1):59-64, February 2006.
Koppe, M.J., et al. Peritoneal Carcinoma-
GENERAL RESOURCES tosis of Colorectal Origin: Incidence
Review the medications and adverse Organizations and Current Treatment Strategies,
reactions with the patient. American College of Surgeons Oncology Annals of Surgery 243(2):
Discuss the management of adverse Group: www.acosog.org 212-22, February 2006.
reactions with the patient. (See American Medical Association: Sarela, A.I., et al. Clinical Outcomes with
Managing common adverse effects of www.ama-assn.org Laparoscopic Stage M1, Unresected
chemotherapy.) National Cancer Institute: Gastric Adenocarcinoma, Annals of
www.cancer.gov Surgery 243(2):189-95, February 2006.
Review the signs and symptoms of
abnormal bleeding, infection, or Slack, S.M., et al. Shared Decision
bone marrow suppression. Selected references Making: Empowering the Bedside
Advise the patient when to contact Cao, M.G., et al. Biochemotherapy with Nurse, Clinical Journal of Oncological
Temozolomide, Cisplatin, Vinblastine, Nursing 9(6):725-27, December 2005.
the practitioner.
Subcutaneous Interleukin-2 and
Emphasize follow-up care.

Managing common adverse effects of chemotherapy


Bone marrow Establish baseline white blood cell (WBC) and platelet counts, Instruct the patient to immediately report
depression hemoglobin level, and hematocrit before therapy begins. Monitor fever, chills, sore throat, lethargy, unusual fa-
(leukopenia, thrombocy- laboratory studies during therapy. tigue, or pallor.
topenia, anemia) If WBC count drops suddenly or falls to < 2,000/mm 3, stop the Warn the patient to avoid exposure to per-
drug and notify the practitioner. Initiate reverse isolation if absolute sons with infections during chemotherapy and
granulocyte count falls to < 1,000/mm3. Report a platelet count for several months after the treatments have
< 100,000/mm3. If necessary, assist with transfusion. ended.
Monitor temperature orally every 4 hours, and regularly inspect Explain that the patient shouldnt receive
the skin and body orifices for signs of infection. Observe for pe- immunizations during or shortly after
techiae, easy bruising, and bleeding. Check for hematuria and moni- chemotherapy because an exaggerated reaction
tor the patients blood pressure. Be alert for signs of anemia. may occur.
Limit subQ and I.M. injections. If these are necessary, apply Tell the patient to avoid activities that could
pressure for 3 to 5 minutes after injection to prevent leakage or cause traumatic injury and bleeding. Advise him
hematoma. Report unusual bleeding after injection. to report episodes of bleeding or bruising to the
Take precautions to prevent bleeding. Use extra care with ra- practitioner.
zors, nail trimmers, dental floss, toothbrushes, and other sharp or Tell the patient to eat high-iron foods, such
abrasive objects. as liver and spinach.
Give vitamin and iron supplements as ordered. Provide a diet Stress the importance of follow-up blood
high in iron. studies after completion of treatment.

Anorexia Assess the patients nutritional status before and during Encourage the patients family to supply fa-
chemotherapy. Weigh him weekly or as ordered. vorite foods to help him maintain adequate nu-
Explain the need for adequate nutrition despite the loss of ap- trition.
petite. Suggest that the patient eat small, frequent

Nausea and vomiting Before chemotherapy begins, administer antiemetics, as or- Teach the patient and his family how to in-
dered, to reduce the severity of these reactions. sert antiemetic suppositories.
Monitor and record the frequency, character, and amount of Tell the patient to take the drug on an empty
vomitus. stomach, with meals, or at bedtime. GI upset in-
Monitor serum electrolyte levels, and provide total parenteral dicates that the drug is working. Instruct him to
nutrition, if necessary. report vomiting to the practitioner.
Tell the patient to follow a high-protein diet.

5125C.qxd 8/15/08 10:51 AM Page 67

Managing common adverse effects of chemotherapy (continued)


Diarrhea and Assess the frequency, color, consistency, and amount of diar- Teach the patient how to use antidiarrheals,
abdominal cramps rhea. Give antidiarrheals as ordered. and instruct him to report diarrhea to the practi-
Assess the severity of cramps, and observe for signs of dehy- tioner.
dration and acidosis, which may indicate electrolyte imbalance. Encourage the patient to maintain adequate
Encourage fluids and, if ordered, give I.V. fluids and potassium fluid intake and to follow a bland, low-fiber diet.
supplements. Explain that good perianal hygiene can help
Provide good skin care, especially to the perianal area. prevent skin breakdown and infection.

Stomatitis Before drug administration, observe for dry mouth, erythema, Teach the patient good mouth care. Instruct
and white patchy areas on the oral mucosa. Stay alert for bleeding him to rinse his mouth with 1 tsp of salt dis-
gums or complaints of a burning sensation when drinking acidic liq- solved in 8 oz (237 ml) of warm water or hydro-
uids. gen peroxide diluted to half strength with water.
Emphasize the principles of good mouth care with the patient Advise the patient to avoid acidic, spicy, or
and his family. extremely hot or cold foods.
Provide mouth care every 4 to 6 hours with normal saline solu- Instruct the patient to report stomatitis to
tion or half-strength hydrogen peroxide. Coat the oral mucosa with the practitioner, who may order a change in
milk of magnesia. Avoid lemon-glycerin swabs because they tend to medication.
reduce saliva and change mouth pH.
To make eating more comfortable, apply a topical viscous anes-
thetic, such as lidocaine, before meals. Administer special mouth-
washes as ordered.
Consult the dietitian to provide bland foods at medium tempera-
Treat cracked or burning lips with petroleum jelly.

Alopecia Reassure the patient that alopecia is usually temporary. Suggest that the patient have his hair cut
Inform the patient that he may experience discomfort before short to make thinning hair less noticeable.
hair loss starts. Advise the patient to wash his hair with a
mild shampoo and avoid frequent brushing or
Suggest that the patient wear a hat, scarf,
toupee, or wig.

5125C.qxd 8/15/08 10:51 AM Page 68

Chemotherapy infusion and chemoembolization of liver

Primary liver cancer (also known as ARTERIAL CHEMOTHERAPY Deficient fluid volume
hepatoma or hepatocellular carcino- INFUSION Impaired nutrition: Less than body
ma): derives its blood exclusively An interventional radiologist works requirements
from the hepatic artery; very vascular closely with an oncologist, who de- Risk for infection
tumor termines the amount of chemothera-
Chemotherapy infusion: delivers py that the patient receives at each EXPECTED OUTCOMES
chemotherapeutic agents through session. Some patients may undergo The patient will:
hepatic artery directly to the tumor; repeat sessions at 6- to 12-week in- maintain adequate fluid volume
higher concentrations may be deliv- tervals. maintain normal weight
ered to tumors without systemic toxi- Under fluoroscopy imaging, a remain free from infection.
city catheter is inserted into the femoral
Arterial chemotherapy infusion of artery in the groin, threaded into the
the liver and chemoembolization of aorta, and advanced into the hepatic
the liver (transarterial chemoem- artery.
bolization or TACE): involve When the branches of the hepatic ar-
chemotherapy injected into the he- tery that feed the liver cancer are
patic artery supplying the liver tu- identified, the chemotherapy is in-
mor; however, with chemoemboliza- fused.
tion, additional injected material The procedure takes 1 to 2 hours,
blocks the small branches of the he- and then the catheter is removed and
patic artery a compression device is placed over
Provide relief or lessen the severity of the puncture site.
disease; however, not curative and
produces less than 50% decrease in CHEMOEMBOLIZATION
tumor size TACE is similar to intra-arterial infu-
Can be used only in patients with rel-
sion of chemotherapy; in TACE, how-
atively preserved liver function
ever, theres an additional step of em-
bolizing the small blood vessels with
INDICATIONS different types of compounds, such
Hepatoma or hepatocellular carcino- as gelfoam or small metal coils.
Systemic chemotherapeutic adverse
Inflammation of the gallbladder
Intestinal and stomach ulcers
Inflammation of the pancreas (pan-
Liver failure
Blocking of the feeding vessels to the
tumor with chemoembolization pos-
sibly making future attempts at intra-
arterial infusions impossible

5125C.qxd 8/15/08 10:51 AM Page 69


Review the procedure with the pa- ARTERIAL CHEMOTHERAPY GENERAL
tient and emphasize the importance INFUSION Refer the patient and his family to
of remaining still during the proce- Maintain sandbag or other compres- support services available in the
dure. Also review possible adverse re- sion device over the puncture site. community.
actions of the treatment with the pa- Monitor for signs of bleeding from Tell the patient that imaging studies
tient. the femoral artery puncture. of the liver are repeated in 6 to 12
Monitor laboratory results as or- Monitor pulses in the affected ex- weeks to assess the size of the tumor
dered, and notify the practitioner of tremity. in response to the treatment.
results. Monitor laboratory test results.
Monitor the patients vital signs and Generally, liver tests increase (get RESOURCES
intake and output. worse) during the 2 or 3 days after Organizations
Provide pretreatment medications as the procedure. This worsening of the American College of Surgeons Oncology
ordered. liver tests is actually due to death of Group: www.acosog.org
Check for patient allergies. the tumor (and some nontumor) American Medical Association:
Verify that the patient has signed an- cells. www.ama-assn.org
informed consent form. Monitor for postprocedure abdomi- National Cancer Institute:
nal pain and low-grade fever. Severe www.cancer.gov
abdominal pain and vomiting sug-
gests serious complications. Selected references
Monitor the patient for adverse ef- Fisher, R.A., et al. Non-resective Ablation
Therapy for Hepatocellular Carcinoma:
Effectiveness Measured by Intention-
Administer analgesics as ordered.
to-Treat and Dropout from Liver
Provide emotional support. Transplant Waiting List, Clinical
Transplant 18(5):502-12, October 2004.
Luo, B.M., et al. Percutaneous Ethanol
Injection, Radiofrequency and their
Combination in Treatment of
Hepatocellular Carcinoma, World
Journal of Gastroenterology
11(40):6277-80, October 2005.
Park, H.S., et al. Postbiopsy Arterioportal
Fistula in Patients with Hepatocellular
Carcinoma: Clinical Significance in
Transarterial Chemoembolization,
American Journal of Roentgenology
186(2):556-61, February 2006.
Slack, S.M., et al. Shared Decision
Making: Empowering the Bedside
Nurse, Clinical Journal of Oncological
Nursing 9(6):725-27, December 2005.

5125C.qxd 8/15/08 10:51 AM Page 70

Chest drainage
Uses gravity and suction to remove Open the packaged system, and Acute pain
material (air, blood, pus, chyle, other place it on the floor; after prepared, Impaired physical mobility
serous fluids, or blood clots) that col- hang it from the side of the bed. Ineffective breathing pattern
lects in the pleural cavity, thus restor- Remove the plastic connector from
ing negative pressure and reexpand- the short tube attached to the water- EXPECTED OUTCOMES
ing a partially or totally collapsed seal chamber, using a 50-ml, cathe- The patient will:
lung ter-tip syringe. Instill sterile distilled have adequate pain control
Underwater seal: allows air and fluid water into the water-seal chamber maintain physical mobility after
to escape from the pleural cavity but until it reaches the 2-cm mark or the analgesic administration
doesnt allow air to reenter mark specified by the manufacturer. display easy, unlabored respirations.
Water may need to be added to help
INDICATIONS detect air leaks with some systems.
Hemothorax Replace the plastic connector. PRETREATMENT CARE
Pneumothorax If suction is ordered, remove the cap
Pleural effusion (also called the muffler or atmos- Explain the procedure to the patient,
phere vent cover) on the suction- and wash your hands.
control chamber to open the vent. Maintain sterile technique through-
Next, instill sterile distilled water un-
out the procedure and when you
til it reaches the 20-cm mark or the
make changes in the system or alter
ordered level, and recap the suction-
control chamber.
Using the long tube, connect the
chest tube to the closed drainage col-
lection chamber and secure with
Connect the short tube to the suction
source, and turn on the suction.
Gentle bubbling should begin.

Tension pneumothorax

5125C.qxd 8/15/08 10:51 AM Page 71

Check chest tube dressing at least

POSTTREATMENT CARE every 8 hours according to facility PATIENT TEACHING
Note character, consistency, and Give ordered pain medication for GENERAL
amount of drainage; mark level in the comfort and to help with deep- Encourage the patient to cough fre-
drainage collection chamber; and breathing, coughing, and range- quently and breathe deeply.
note time and date at the drainage of-motion exercises. Instruct the patient to sit upright and
level on the chamber every 8 hours If excessive continuous bubbling oc- to splint the insertion site while
(more often if a large amount of curs, especially with suction, rule out coughing to minimize pain.
drainage). a leak in the system. Locate by WARNING Tell the patient to re-
Check water level in the water-seal clamping the tube momentarily at port breathing difficulty imme-
chamber every 8 hours. If necessary, various points along its length, be- diately. Notify the practitioner imme-
add sterile distilled water until the ginning at the proximal end and diately if cyanosis, rapid or shallow
level reaches the 2-cm mark. working down to the drainage sys- breathing, subcutaneous emphysema,
Check for fluctuation in the water- tem. If a connection is loose, push it chest pain, or excessive bleeding oc-
seal chamber as the patient breathes. together and tape securely. Bubbling curs.
To check for fluctuation with a suc- will stop when a clamp is placed be- Remind the ambulatory patient to
tion system, momentarily disconnect tween the air leak and the water seal. keep the drainage system below
the suction system so the air vent is If you clamp along the tubes entire chest level and to be careful not to
opened, and observe for fluctuation. length and bubbling doesnt stop, the disconnect the tubing to maintain
Check for intermittent bubbling in drainage unit may be cracked and the water seal.
the water-seal chamber. Absence of need replacement.
bubbling may indicate that the pleu- If the drainage collection chamber RESOURCES
ral space has sealed. fills, replace it. Double-clamp the Organizations
Check the water level in the suction- tube close to the insertion site (use American College of Emergency
control chamber. Detach the cham- two clamps facing in opposite direc- Physicians: www.acep.org
ber from the suction source; when tions), exchange the system, remove American Medical Association:
bubbling ceases, observe the water the clamps, and retape the connec- www.ama-assn.org
level. If needed, add sterile distilled tion.
water to bring the level to the 20-cm WARNING Never leave tubes Selected references
line or as ordered. clamped for more than 1 minute Allibone, L. Principles for Inserting and
WARNING Occlusion of the air to prevent tension pneumothorax. Managing Chest Drains, Nursing
vent results in buildup of pres- If the system cracks, clamp the chest Times 101(42):45-49, October 2005.
sure in the system that could cause a tube momentarily with the two rub- Carroll, P. Keeping Up with Mobile Chest
tension pneumothorax. ber-tipped clamps placed close to Drains, RN 68(10):26-31, October
Coil the systems tubing and secure it each other near the insertion site fac- 2005.
Clubley, L., and Harper, L. Using Nega-
to the edge of the bed. Make sure ing opposite directions. Observe for
tive Pressure Therapy for Healing
that tubing remains at the level of the altered respirations while the tube is
of a Sternal Wound, Nursing Times
patient. Avoid dependent loops, clamped. Replace the damaged 101(16):44-46, April 2005.
kinks, or pressure on the tubing. equipment. (Prepare the new unit Lehwaldt, D., and Timmins, F. Nurses
Avoid lifting the system above the pa- before clamping.) Knowledge of Chest Drain Care: An
tients chest; fluid may flow back into Instead of clamping the tube, sub- Exploratory Descriptive Survey,
the pleural space. merge the distal end of the tube in a Nursing Critical Care 10(4):192-200,
Keep two rubber-tipped clamps at container of normal saline solution July-August 2005.
the bedside to clamp the chest tube if to create a temporary water seal
the system cracks or to locate an air while you replace the drainage sys-
leak in the system. tem. Check your facilitys policy for
Check rate and quality of respira- the proper procedure.
tions; auscultate lungs to assess air
exchange. Diminished or absent
breath sounds indicates nonexpan-
When clots are visible, milk the tub-
ing depending on your facilitys poli-
cy. Milk in direction of the drainage
chamber as needed.

5125C.qxd 8/15/08 10:51 AM Page 72

Chest physiotherapy
WARNING Contraindications to
OVERVIEW chest physiotherapy include: PROCEDURE
active pulmonary bleeding with he-
Includes postural drainage, chest moptysis and the immediate pos- Explain the procedure to the patient,
percussion and vibration, and themorrhage stage provide privacy, and wash your
coughing and deep-breathing exer- fractured ribs hands.
cises; techniques mobilize and elimi- unstable chest wall Auscultate the patients lungs to de-
nate secretions, reexpand lung tissue, lung contusions termine baseline respiratory status.
and promote efficient use of respira- pulmonary tuberculosis Position the patient as ordered. In
tory muscles untreated pneumothorax generalized disease, drainage usually
Postural drainage: encourages pe- acute asthma begins with the lower lobes, contin-
ripheral pulmonary secretions to bronchospasm ues with the middle lobes, and ends
empty by gravity into the major lung abscess with the upper lobes.
bronchi or trachea; accomplished by tumor In localized disease, drainage begins
sequential repositioning of the pa- bony metastasis with the affected lobes and then pro-
tient head injury ceeds to the other lobes to avoid
Best drainage achieved with patient recent myocardial infarction. spreading the disease to uninvolved
positioned so that the bronchi are areas.
perpendicular to the floor Instruct the patient to remain in each
Lower and middle lobe bronchi: usu- position for 10 to 15 minutes.
ally empty best with patient in the During this time, perform percussion
head-down position; upper lobe and vibration as ordered. (See
bronchi, in the head-up position Performing percussion and vibra-
Percussing the chest with cupped tion.)
hands: mechanically dislodges thick,
tenacious secretions from the
bronchial walls Performing percussion and vibration
Can use vibration with percussion or
as an alternative in a patient whos Instruct the patient to breathe slowly and
frail, in pain, or recovering from tho- deeply, using the diaphragm, to promote
racic surgery or trauma relaxation. Percuss each segment with a
Hasnt proven effective in treating pa- cupped hand for 1 or 2 minutes. Listen for a
hollow sound on percussion to verify
tients with status asthmaticus, lobar
correct performance of technique.
pneumonia, or acute exacerbations
of chronic bronchitis when the pa-
tient has scant secretions and is be-
ing mechanically ventilated
Has little value for treating patients
with stable, chronic bronchitis

Bedridden patient to mobilize secre-
To perform vibration, ask him to inhale
deeply, and then exhale slowly. During
exhalation, firmly press your hands against
Pneumonia the chest wall. Tense the muscles of your
Patients who expectorate large arms and shoulders in an isometric
amounts of sputum, such as those contraction to send fine vibrations through
with bronchiectasis or cystic fibrosis the chest wall. Do this during five
exhalations over each chest segment.

5125C.qxd 8/15/08 10:51 AM Page 73

For optimal effectiveness and safety,

modify chest physiotherapy based on PRETREATMENT CARE PATIENT TEACHING
the patients condition: for example,
initiate or increase the flow of sup- Gather the equipment at the patients Teach the patient how to splint his
plemental oxygen, if indicated. bedside. incision to minimize pain during
Also, suction the patient who has an Set up suction equipment and test its coughing.
ineffective cough reflex. function.
If the patient tires quickly during Maintain adequate hydration in the RESOURCES
therapy, shorten the sessions be- patient to prevent mucus dehydra- Organizations
cause fatigue leads to shallow respi- tion and promote easier mobiliza- American College of Chest Surgeons:
rations and increased hypoxia. tion. www.chestnet.org
Refrain from percussing over the Avoid performing postural drainage American Medical Association:
spine, liver, kidneys, or spleen to immediately before or within 1 to 2 www.ama-assn.org
avoid injury to the spine or internal hours after meals to avoid nausea,
organs. Also avoid performing per- vomiting, and aspiration of food or Selected references
cussion on bare skin or the female vomitus. Bradley, J.M., et al. Evidence for Physical
patients breasts. Because chest percussion can induce Therapies (Airway Clearance and
Percuss over soft clothing (but not bronchospasm, adjunct treatment Physical Training) in Cystic Fibrosis:
over buttons, snaps, or zippers), or (for example, intermittent positive- An Overview of Five Cochrane
place a thin towel over the chest wall. Systematic Reviews, Respiratory
pressure breathing, aerosol, or nebu-
Medicine 100(2):191-201, February
lizer therapy) should precede chest
COMPLICATIONS physiotherapy. McCool, F.D., and Rosen, M.J. Nonphar-
Impaired excursion leading to hy- Explain deep-breathing and cough- macologic Airway Clearance Thera-
poxia or orthostatic hypertension ing exercises so that the patient can pies: ACCP Evidence-Based Clinical
that may occur during postural practice them preoperatively. Practice Guidelines, Chest 129(Suppl
drainage (in the head-down position Remove jewelry that might scratch or 1):250S-259S, January 2006.
due to abdominal contents placing bruise the patient. Rosen, M.J. Chronic Cough due to
pressure on the diaphragm) Bronchiectasis: ACCP Evidence-Based
Increased intracranial pressure (in Clinical Practice Guidelines, Chest
the head-down position, precluding POSTTREATMENT CARE 129(Suppl 1):122S-131S, January 2006.
Varela, G., et al. Cost-Effectiveness
the patient with acute neurologic im-
Analysis of Prophylactic Respiratory
pairment) After postural drainage, percussion, Physiotherapy in Pulmonary Lobec-
Rib fracture due to vigorous percus- or vibration, instruct the patient to tomy, European Journal of Cardio-
sion or vibration, especially in a pa- cough to remove loosened secre- thoracic Surgery 29(2):216-20, February
tient with osteoporosis tions. 2006.
Pneumothorax due to coughing in an First, tell him to inhale deeply
emphysematous patient with blebs through his nose and then exhale in
three short huffs.
Then have him inhale deeply again
NURSING DIAGNOSES and cough through a slightly open
Anxiety Three consecutive coughs are highly
Impaired gas exchange effective.
Ineffective airway clearance An effective cough sounds deep, low,
and hollow; an ineffective one, high-
Have the patient perform exercises
The patient will:
express feelings of comfort and
for about 1 minute and then rest for
demonstrate decreased anxiety 2 minutes; gradually progress to a
maintain adequate ventilation and
10-minute exercise period four times
oxygenation daily.
Provide oral hygiene because secre-
maintain airway patency.
tions may have a foul taste or a stale
Auscultate the patients lungs to eval-
uate the effectiveness of therapy.

5125C.qxd 8/15/08 10:51 AM Page 74

Using the laparoscope, the surgeon
OVERVIEW PROCEDURE passes instruments through the three
incisions to clamp and tie off the cys-
Surgical removal of the gallbladder The open abdominal and laparo- tic duct and excise the gallbladder.
May be performed as an open ab- scopic approaches require general The gallbladder is removed through
dominal surgical procedure or as a anesthesia. the umbilical opening.
laparoscopic procedure The surgeon sutures all four incisions
ABDOMINAL CHOLECYSTECTOMY and places a dressing over each.
INDICATIONS A right subcostal or paramedial inci-
Gallbladder or biliary duct disease sion is made. COMPLICATIONS
refractory to drug therapy, dietary The surgeon surveys the abdomen. Peritonitis
changes, and other supportive treat- Laparotomy packs are used to isolate Postcholecystectomy syndrome
ments the gallbladder from the surrounding Atelectasis
organs. Bile duct injury
After biliary tract structures are iden- Small bowel injury
tified, cholangiography or ultra- Wound infection
sonography may be used to identify Ileus
gallstones. Urine retention
The bile ducts are visualized using a Retained gallstones
The ducts are cleared of stones after
insertion of a Fogarty balloon-tipped
The surgeon ligates and divides the
cystic duct and artery and removes
the entire gallbladder.
A choledochotomy may be per-
formed, with a T tube inserted into
the common bile duct.
A Penrose drain may be placed into
the ducts.
The incision is closed and a dressing
is applied.

A small incision is made just above
the umbilicus.
A trocar, connected to an insufflator,
is inserted through the incision.
Carbon dioxide or nitrous oxide is in-
jected into the abdominal cavity.
A laparoscope is passed through the
trocar to view the intra-abdominal
The patient is placed in a 30-degree,
reverse Trendelenburgs position and
tilted slightly to the left.
With laparoscopic guidance, the sur-
geon makes three incisions in the
right upper quadrant: one below the
xiphoid process in the midline; one
below the right costal margin in the
midclavicular line; and one in the an-
terior axillary line at the umbilical

5125C.qxd 8/15/08 10:51 AM Page 75


Acute pain Administer medications as ordered. GENERAL
Ineffective breathing pattern Place the patient in low Fowlers posi- Review the medications and possible
Risk for infection tion. adverse reactions with the patient.
Attach the NG tube to low intermit- Instruct the patient about coughing
EXPECTED OUTCOMES tent suction as ordered. and deep-breathing exercises.
The patient will: Report drainage greater than 500 ml Teach the patient about T tube home
express feelings of comfort after 48 hours. care, if applicable. (See Caring for
maintain a normal breathing pattern Provide meticulous skin care, espe- your T tube, pages 76 and 77.)
remain free from infection. cially around drainage tube insertion Tell the patient about the signs and
sites. symptoms of biliary obstruction.
After the NG tube is removed, intro- Inform the patient about the signs
PRETREATMENT CARE duce foods as ordered. and symptoms of infection.
Clamp the T tube before and after Review the possible complications
Explain the treatment and prepara-
each meal as ordered. of the procedure with the patient.
After laparoscopic cholecystectomy, Emphasize follow-up care.
tion to the patient and his family.
Verify that the patient has signed an
start clear liquids as ordered when
appropriate consent form. the patient has fully recovered from RESOURCES
Withhold oral intake as ordered.
anesthesia. Organizations
Assist the patient with early ambula- American College of Gastroenterology:
Administer preoperative medications
as ordered. tion. www.acg.gi.org
Encourage coughing and deep- American Gastroenterological
breathing exercises. Association: www.gastro.org
ABDOMINAL APPROACH Encourage incentive spirometry use. American Medical Association:
Tell the patient that: www.ama-assn.org
Provide analgesics as ordered.
a nasogastric (NG) tube will be in Monitor the patients vital signs and
place for 1 or 2 days and an abdomi- intake and output. Selected references
nal drain will be in place for 3 to 5 Observe the patient for signs of com- Dalton, S.J., et al. Routine Magnetic
days after surgery plications and postcholecystectomy Resonance Cholangiopancreatography
a T tube may remain in place for up syndrome. and Intra-operative Cholangiogram in
to 2 weeks Monitor the patients respiratory sta- the Evaluation of Common Bile Duct
he may be discharged with the T tube Stones, Annals of the Royal College of
in place. Surgeons of England 87(6):469-70,
Record the amount and characteris- November 2005.
tics of drainage. Dunn, D. Preventing Perioperative
LAPAROSCOPIC APPROACH Monitor surgical dressings and pro- Complications in Special Populations,
Tell the patient that: vide wound care as ordered. Nursing2005 35(11):36-43, November
an indwelling urinary catheter will be Maintain the position and patency of 2005.
inserted into the bladder drainage tubes. Madsen, D., et al. Listening to Bowel
an NG tube will be placed in the Sounds: An Evidence-Based Practice
stomach Project, AJN 105(12):40-49, December
the tube is usually removed in the 2005.
postanesthesia room
three small incisions will be covered
with a small sterile dressing
discharge may occur on the day of
surgery or 1 day after.


5125C.qxd 8/15/08 10:51 AM Page 76


Caring for your T tube

Dear Patient,
Here are instructions for taking care of your T tube at home. Youll have this tube for 10 to 14 days. During that time, it will
drain excess bile so that your incision will heal faster. The tube will also allow passage of retained gallstones.
Caring for your T tube isnt difficult, but it takes time and planning. Set aside about 20 uninterrupted minutes per day to
empty your drainage bag and care for your incision. To help prevent infection and promote healing, carefully follow these direc-


First, assemble these supplies on a table or countertop: a Empty your drainage bag at about the same time each day or
large measuring container, toilet paper, soap, a clean towel, a when its two-thirds full. First, place the large measuring con-
paper bag, a sterile paper cloth, five sterile 4  4 gauze tainer within easy reach.
pads, alcohol, normal saline solution, hydrogen peroxide, 1. Sit on a chair, and remove the Velcro belt that secures the
povidone-iodine solution (Betadine), sterile gloves, povidone- drainage bag and connecting tubing to your abdomen. Uncoil
iodine ointment, scissors, and adhesive tape. the tubing and position the spout at the bottom of the
drainage bag over the measuring container. Dont pull on the
connecting tubing, and dont place too much tension on it
you may dislodge the T tube.
2. To empty the drainage bag, release the clamp on the
drainage spout so that the bile flows freely into the measuring
container. When the bag is empty, clean the drainage spout
with toilet paper. To reseal the drainage bag, close the clamp.
3. Gently coil the connecting tubing. Then position the
drainage bag and tubing below the incision site. Secure the
bag and tubing with the Velcro belt. Never place the drainage
bag and connecting tubing higher than your incision. This
could cause the draining bile to back up into the common bile
4. Finally, note the amount, color, and odor of drainage.
Contact your health care provider if you notice significant in-
creases or decreases in the drainage amount or changes in
the color or odor. These may signal complications, such as an
infection or a T-tube obstruction.


After you empty and resecure your drainage bag, youre ready
to clean and redress the incision site. Just follow these steps:
1. Wash your hands with soap and water, and dry them with a
fresh, clean towel. Carefully remove the soiled dressing and
discard it in the paper bag. Then wash and dry your hands
2. Open the package containing the sterile paper cloth. Unfold
the cloth and spread it on a table or countertop. Dont touch
the top surface of the cloth.

5125C.qxd 8/15/08 10:51 AM Page 77

Caring for your T tube (continued)

3. Open the five sterile gauze pads and drop them on the 10. Finally, tape a small segment of the T tube to your ab-
sterile cloth. domen so you wont accidentally dislodge the tube. Discard
4. Open the packets of alcohol, normal saline solution, hy- used supplies in a paper bag.
drogen peroxide, and povidone-iodine solution, and place
them on the table.
5. Put on the sterile gloves. Then pick up a sterile gauze pad
with your dominant hand (your sterile hand).
6. Pick up the saline solution with your other hand and thor-
oughly soak the gauze pad.
7. Clean the incision area with the soaked pad. Wipe outward
away from the tube in a 3 (7.5 cm) circular area.
Using a clean pad, repeat this with the hydrogen peroxide
and the povidone-iodine solution, again wiping outward.


Report the following signs of infection when youre caring for
your tubing and incision:
redness, swelling, or pain
puslike drainage.
Also contact your health care provider if you have:
clay-colored stools.
8. Soak a clean gauze pad with alcohol and use it to wipe
the first 6 (15 cm) of the tube. Start at the incision and wipe This patient-teaching aid may be reproduced by office copier for distribution to patients.
toward the drainage bag. 2007 Lippincott Williams & Wilkins.
9. Apply a nickel-size drop of povidone-iodine ointment over
the wound site. Cover the ointment with the remaining sterile
gauze pad. Be sure to apply the pad so that the slit end faces
up and slides under your tube. Next, tape the pad securely to
your abdomen.

5125C.qxd 8/15/08 10:51 AM Page 78

Removes about one-third of the pe- If performed on a child, Velcro straps Injury to the glans
nile skin (sensitive inner and outer are used to restrain the arms and Complications from anesthesia, if
preputial layers), including the legs. used
peripenic dartos muscle, the frenar The area is prepared with an antisep- Surgical error, including removal of
band, and part of the frenulum tic, such as iodine liquid, and a surgi- too much skin
cal drape is placed over the site. Meatal stenosis (narrowing of the
INDICATIONS Some practitioners will use local urethral opening due to infection
Primarily cultural, religious, or per- anesthesia, but injections will cause and subsequent scarring, that occurs
sonal reasons the penis to swell, causing pain and almost exclusively in circumcised
making the surgery more difficult. An boys)
anesthetic cream may be applied. Extensive scarring of the penile shaft
The foreskin is grasped with forceps Skin tags and skin bridges
and the opening widened. Curvature of the penis
AGE FACTOR The foreskin is nor- Tight, painful erections
mally attached to the glans by a Psychological and psychosexual
membrane called the synechia.The problems
glans and inner lining of the foreskin
are still developing in the young child.
During circumcision, the synechia
must be torn apart.
The foreskin is clamped and a slit is
made in the dorsal side of the fore-
The slit is separated and the foreskin
is laid back, exposing the glans.
A PlastiBell device of appropriate size
is slipped over the glans, and the
foreskin is laid over it. A ligature is
tied in the ridge of the bell, as tightly
as possible around the foreskin.
After 1 or 2 minutes, the foreskin is
sliced off at the distal edge of the lig-
ature using a knife or scissors. The
surgeon trims as much tissue as pos-
sible to reduce the amount of necrot-
ic tissue and the possibility of infec-
The handle of the bell is snapped off
at this time. The rim of tissue will be-
come necrotic and separate with the
bell in 5 to 10 days.
Occasionally, edema will trap the
plastic ring on the shaft of the penis
and the ring will need to be removed
using a guide and ring cutter.
Application of ice sometimes reduces
edema enough to remove the ring.
Impregnated gauze may be applied
to the site.

5125C.qxd 8/15/08 10:51 AM Page 79


Acute pain Verify that an informed consent has GENERAL
Impaired tissue integrity been signed by the patient or his par- Review the care of the circumcised
Risk for infection ents. penis.
Explain the procedure the patient Tell the patient or parents to notify
EXPECTED OUTCOMES and his parents, and answer any the practitioner if infection or exces-
The patient will: questions that they may have. sive bleeding occurs.
exhibit signs of comfort Note any patient allergies. Review follow-up care.
demonstrate skin thats intact and
show no signs of infection. POSTTREATMENT CARE Organizations
American Association of Clinical
Monitor the patients vital signs. Urologists: www.aacuweb.org
Monitor for excessive drainage and American College of Obstetrics and
for signs of infection. Gynecology: www.acog.org
Keep the wound area clean, and ap-
ply antibiotic ointment as ordered. Selected references
Atashili, J. Adult Male Circumcision to
Prevent HIV? International Journal of
Infectious Diseases 10(3):202-205, May
Tanne, J.H. Ultra-Orthodox Jews Criti-
cised over Circumcision Practice,
British Medical Journal 332(7534):137,
January 2006.
Van Howe, R.S. Incidence of Meatal Ste-
nosis Following Neonatal Circum-
cision in a Primary Care Setting, Clini-
cal Pediatrics 45(1):49-54, January-
February 2006.
Weise, K.L., and Nahata, M.C. EMLA for
Painful Procedures in Infants, Journal
of Pediatric Health Care 19(1):42-47,
January-February 2005.

5125C.qxd 8/15/08 10:51 AM Page 80

Clitoral therapy device

Promotes greater clitoral and genital The patient places the clitoral thera- Anxiety
engorgement, increased vaginal lu- py device over her clitoris. Deficient knowledge (disorder and
brication, enhanced ability to When the device is turned on, a gen- treatment)
achieve orgasm, and improved over- tle vacuum is created, increasing Sexual dysfunction
all sexual satisfaction blood flow to the genitalia, causing
Consists of a small, soft, plastic vacu- the clitoris to become engorged. EXPECTED OUTCOMES
um cup attached by a tube to a palm- Increased blood flow to the genitalia The patient will:
sized, battery-operated vacuum results in increased vaginal lubrica- express reduced anxiety
pump; cup placed over the clitoris tion, enhanced ability to achieve or- verbalize understanding of the disor-
before sex, with the pump drawing gasm, and increased clitoral and gen- der and treatment regimen
blood into the clitoris through gentle ital sensitivity. have improved sexual experience.
suction, thus causing engorgement
and sexual arousal COMPLICATIONS
None known
Diminished vaginal lubrication
Diminished clitoral sensation
Reduced ability to achieve orgasm
Lowered sexual satisfaction

5125C.qxd 8/15/08 10:51 AM Page 81


Review the patients medical history, Tell the patient that the device may GENERAL
especially previous sexual difficulty be used before having intercourse or Review instructions regarding the
(such as painful intercourse or vagi- without intercourse to condition and use of the device with the patient.
nal dryness), genital trauma (such as restore sexual responses. Inform the patient that it may take
genital body piercings), diabetes, Inform the patient that it should be up to several weeks of recommended
heart disease, hypertension, high used three to four times per week to use to see an improvement in overall
cholesterol, or spinal injuries. achieve the maximum benefits. sexual function.
Note any drug interactions that may Tell the patient that some women
influence the patients condition, may notice changes immediately,
such as hormone medication (estro- whereas others may take longer to
gen and progestin), phentolamine note results.
(Vasomax), prostaglandins, or vagi-
nal lubricants. Some drugs can cause RESOURCES
sexual problems in the female. Organizations
Prescription and nonprescription American Association of Clinical
medication, such as antidepressants Urologists: www.aacuweb.org
(amitriptyline [Elavil] or fluoxetine American College of Obstetrics and
[Prozac]) and beta-adrenergic block- Gynecology: www.acog.org
ers (metoprolol [Toprol] or propra- MedicineNet: www.medicinenet.com
nolol [Inderal]), can also affect sexual
response. Selected references
Review the device and manual that Archer, S.L., et al. Aetiology and Manage-
comes with the product. ment of Male Erectile Dysfunction and
Female Sexual Dysfunction in Patients
with Cardiovascular Disease, Drugs
and Aging 22(10):823-44, October
Hockel, M., and Dornhofer, N. Anatom-
ical Reconstruction after Vulvectomy,
Obstetrics and Gynecology 103(5 Pt
2):1125-28, May 2004.
Schroder, M., et al. Clitoral Therapy De-
vice for Treatment of Sexual Dysfunc-
tion in Irradiated Cervical Cancer
Patients, International Journal of
Radiation Oncology, Biology, Physics
61(4):1078-86, May 2005.

5125C.qxd 8/15/08 10:51 AM Page 82

Cochlear implantation
The device picks up sound through
OVERVIEW PROCEDURE the microphone and sends it to the
processor, where its broken down
Auditory prosthetic device that im- The surgeon implants the internal and stored.
proves auditory awareness; may im- component of the device complete The converted sound information is
prove hearing so that the patient can with one or more electrodes into the transferred to the external device,
understand conversation cochlea. further processed, and sent through
Works by directly stimulating the au- A receiver is implanted behind the any surviving nerve cells to the
ditory nerve that transmits impulses top of the auricle. brains hearing center, allowing the
to the brains hearing center (see On postoperative day 10 to 15, when patient to hear.
Cochlear implant: A closer look) wound healing is complete, the pa-
tient wears an external component COMPLICATIONS
INDICATIONS consisting of a small microphone Infection
Deafness secondary to sensorineural with an ear hook over the ear. Facial nerve paralysis
hearing loss The external component is connect- Facial numbness
ed to a speech processor and a trans- Tinnitus
mitter coil with a magnet that keeps
it in place over the receiver stimula-

Cochlear implant: A closer look

A cochlear implant has an internal coil with a stranded electrode lead thats surgically inserted into
the scala tympani of the cochlea (as shown). The external coil (the transmitter) aligns with the
internal coil (the receiver) by a magnet.
When the microphone receives sound, the stimulator wires receive the signal after its been
filtered. This filtering allows the sound to transmit comfortably for the patient. Sound is then passed
by the external transmitter to the inner coil receiver by magnetic conduction and is finally carried
by the electrode to the cochlea.

External transmitter
Internal receiver coil


External auditory canal

Internal electrodes
Stimulator wires to

5125C.qxd 8/15/08 10:51 AM Page 83


Acute pain Explain the treatment and prepara- GENERAL
Anxiety tion to the patient and his family. Share information about sensori-
Disturbed sensory perception Verify that the patient has signed a neural hearing loss with the patient.
(auditory) consent form. Inform the patient that hearing wont
When addressing the patient, speak return to preloss level.
EXPECTED OUTCOMES slowly in a clear, loud voice. Give the Stress the importance of learning
The patient will: patient time to process the informa- how to interpret sounds produced by
express feelings of comfort tion and respond. the device.
express his feelings and concerns Develop alternative communication Review possible complications with
regain hearing function. methods. the patient.
Emphasize follow-up care.


Report incisional redness, swelling, American Academy of Neurology:
or drainage. www.aan.com
Administer analgesics as ordered. American Medical Association:
Monitor the patients vital signs. www.ama-assn.org
Monitor the incision site for signs of
drainage or infection. Selected references
Ahmad, R.L., and Lokman, S. Cochlear
Implantation in Congenital Cochlear
Abnormalities, Medical Journal of
Malaysia 60(3):379-82, August 2005.
Dunn, D. Preventing Perioperative
Complications in Special Populations,
Nursing2005 35(11):36-43, November
Higgins, M.B., et al. Speech and Voice
Physiology of Children who are Hard of
Hearing, Ear and Hearing 26(6):546-
58, December 2005.
Jin, Y., et al. Vestibular-Evoked Myogenic
Potentials in Cochlear Implant
Children, Acta Oto-laryngologica
126(2):164-69, February 2006.

5125C.qxd 8/15/08 10:51 AM Page 84

Surgical repair of a defect in the vagi- Colporrhaphy may be performed on Acute pain
nal wall the anterior or posterior walls of the Impaired body image
AGE FACTOR Factors that are vagina. An anterior colporrhaphy Impaired urinary elimination
linked to pelvic organ prolapse treats a cystocele or urethrocele,
include age, repeated childbirth, hor- whereas a posterior colporrhaphy EXPECTED OUTCOMES
mone deficiency, ongoing physical ac- treats a rectocele. The patient will:
tivity, and prior hysterectomy. General, regional, or local anesthesia verbalize or demonstrate relief from
Reserved for more severe cases; mild is administered. pain
cases may be treated by Kegel exer- A speculum is inserted into the vagi- have a positive body image
cises (strengthens the pelvic floor na to hold it open during the proce- demonstrate normal elimination
and may help prevent urinary incon- dure. patterns.
tinence) or a pessary (device inserted An incision is made into the vaginal
into the vagina to help support the skin and the defect in the underlying
pelvic organs); hormone replace- fascia is identified.
ment therapy may be prescribed to a The vaginal skin is separated from
postmenopausal woman to improve the fascia and the defect is folded
quality of supporting pelvic tissues over and sutured. Excess vaginal skin
is removed and the incision is closed
INDICATIONS with stitches.
Urethrocele Anesthesia-associated complications
Injury to other pelvic structures
Dyspareunia (painful sexual inter-
Recurrent prolapse
Fistula between the vagina and blad-
der or the vagina and rectum

5125C.qxd 8/15/08 10:51 AM Page 85


Physical examination is most com- Monitor the patients vital signs and GENERAL
monly used to diagnose prolapse of amount and type of vaginal bleeding. Inform the patient of activities that
the pelvic organs; a cystogram may Administer analgesics and monitor cause strain on the surgical site are
also be used to determine the extent for effect. usually restricted for several weeks,
of a cystocele. Apply a sequential compression de- including lifting, coughing, long peri-
Review the procedure with the pa- vice. ods of standing, sneezing, straining
tient and verify that an informed Perform perineal care as ordered. with bowel movements, and sexual
consent form has been signed. Resume diet; usually a liquid diet is intercourse. She can resume normal
Instruct the patient to refrain from given until normal bowel function re- activities, including sexual inter-
eating or drinking after midnight on turns. course, about 4 weeks after the pro-
the day of the procedure. Assist with deep-breathing and cedure.
If posterior colporrhaphy is to be coughing exercises. Instruct the patient on the use of the
performed, inform the patient if an Encourage ambulation. incentive spirometer and coughing
enema will be administered the night Monitor for complications. and deep-breathing exercises.
before the procedure. Provide catheter care, informing the Tell the patient that after successful
A indwelling urinary catheter is in- patient that the indwelling catheter colporrhaphy, the symptoms associ-
serted before surgery. will be removed 1 to 2 days after sur- ated with cystocele or rectocele will
gery. recede.

American College of Obstetrics and
Gynecology: www.acog.org
American Medical Association:

Selected references
Jordaan, D.J. Posterior Intravaginal
Slingplasty for Vaginal Prolapse,
International Urogynecology Journal
and Pelvic Floor Dysfunction 27:1-4,
September 2005.
Lapitan, M.C., et al. Open Retropubic
Colposuspension for Urinary
Incontinence in Women, Cochrane
Database of Systematic Review
20(3):CD002912, July 2005.
Madsen, D., et al. Listening to Bowel
Sounds: An Evidence-Based Practice
Project, AJN 105(12):40-49, December
Tunuguntla, H.S., and Gousse, A.E.
Female Sexual Dysfunction Following
Vaginal Surgery: A Review, Journal of
Urology 175(2):439-46, February 2006.

5125C.qxd 8/15/08 10:51 AM Page 86

Tell the patient that her menses may
OVERVIEW PRETREATMENT CARE be heavier than normal for the first
two or three menstrual cycles after
Removal of a cone of tissue; most Explain the treatment and prepara- the procedure.
commonly refers to excision of the tion to the patient and her family. Emphasize follow-up care.
entire transformation zone and en- (See Understanding conization.)
docervical canal Verify that the patient has signed an RESOURCES
Uncommon procedure; has been re- appropriate consent form. Organizations
placed by colposcopy for diagnostic Provide emotional support. American College of Obstetrics and
purposes Obtain results of diagnostic studies, Gynecology: www.acog.org
medical history, and physical exami- American Medical Association:
INDICATIONS nation; notify the practitioner of any www.ama-assn.org
Microinvasive cervical cancer abnormalities.
Abnormal Papanicolaou test Make sure that the patient has fasted Selected references
and used an enema preoperatively. Robova, H., et al. Squamous Intraepi-
Administer I.V. fluids as ordered. thelial Lesion-Microinvasive Carcino-
PROCEDURE ma of the Cervix during Pregnancy,
European Journal of Gynaecology and
Oncology 26(6):611-14, 2005.
The patient receives a general or lo- POSTTREATMENT CARE Song, S.H., et al. Persistent HPV Infec-
cal anesthetic. tion after Conization in Patients with
The surgeon uses carbon dioxide, a Administer analgesics as ordered. Negative Margins, Gynecologic and
large hot loop, a scalpel, or a laser to Administer fluids as ordered. Oncology 101(3):418-22, June 2006.
cut a circular incision around the ex- Provide the ordered diet as tolerated. Ueda, M., et al. Diagnostic and Thera-
ternal os of the cervix. Institute safety precautions. peutic Laser Conization for Cervical
A cone-shaped piece of tissue is re- WARNING Be sure to report con- Intraepithelial Neoplasia, Gynecologic
tinuous, sharp abdominal pain Oncology 101(1):143-46, April 2006.
Biopsies are taken at the apex of the that doesnt respond to analgesics,
cone. which indicates a possible symptom of
The cervix is sutured. uterine perforation, a potentially life-
Dilatation and curettage may be per- threatening complication.
formed. Monitor the patients vital signs and
intake and output.
Monitor the type and amount of
Uterine perforation vaginal drainage, and observe for
Bleeding signs of infection.
Cervical stenosis
Decreased cervical mucus
Cervical incompetence GENERAL
Discuss the medications and possi-
ble adverse reactions with the pa-
Advise the patient about the possibil-
Anxiety ity of postoperative abdominal
Impaired tissue integrity cramping and pain in the pelvis and
Risk for infection lower back.
Inform the patient that postoperative
vaginal drainage may occur.
Inform the patient that abnormal
The patient will:
bleeding may occur and to report
express feelings of decreased anxiety
such signs to the practitioner.
remain free from discomfort
Review the signs and symptoms of
remain free from signs of infection.
Inform the patient about possible

5125C.qxd 8/15/08 10:51 AM Page 87


Understanding conization

Dear Patient,
Youre scheduled to undergo a conization. This procedure involves removing a small piece of tissue from your cervix for micro-
scopic study. Your health care provider may order a conization if previous tests show abnormal cells in your cervix.
The procedure takes less than 30 minutes. Its usually done in the hospital with either a local or spinal anesthetic. Make sure
that you follow any preoperative instructions.


If youre having a spinal anesthetic, youll receive it before the

procedure begins. Then youll lie on your back on an exami-
nation table with your feet in stirrups, just as you would for an
internal pelvic examination. The health care provider will in-
sert a speculum into your vagina. This instrument will widen
your vaginal canal to provide a clear view of your cervix.
If youre having a local anesthetic, youll receive it at the
time of the procedure. The health care provider will then re-
move a small, cone-shaped tissue sample from your cervix
for analysis in the hospital laboratory.
If cancer is suspected in your uterus, a dilatation and
curettage may be done to check for cancer cells. This will be
discussed with you beforehand. Cone-shaped tissue sample
After these procedures, the speculum will be removed.
Also expect your next two or three menstrual periods to be
heavier or longer than usual.
You can go home as soon as the anesthetic wears off, usually Immediately report these symptoms:
in about 30 to 60 minutes. Arrange to have someone trans- heavy bleeding
port you in case you feel unsteady. severe or persistent pain
Expect to feel some mild adverse effects from the coniza- foul-smelling vaginal discharge
tion. These may include abdominal cramping, some bleeding, fever.
and a feeling of fullness in your pelvisespecially if tempo-
rary vaginal packing has been inserted to control bleeding. This patient-teaching aid may be reproduced by office copier for distribution to patients.
2007 Lippincott Williams & Wilkins.

5125C.qxd 8/15/08 10:51 AM Page 88

Continuous passive motion

Anterior cruciate ligament recon-
Tendon repair
Postoperative treatment that moves Joint manipulation under anesthesia The device is applied to the joint
patients jointthrough full range of Arthroscopic debridement of adhe- needing continuous motion.
motion (ROM)without using mus- sions The machine moves a joint through a
cles, aiding in recovery after joint Open reduction and internal fixation defined ROM for an extended period.
surgery (stabilization) of intra-articular frac- The practitioner determines how the
Improves or maintains joint mobility tures CPM unit should be used by the pa-
and helps prevent contractures Rotator cuff repair tient (such as speed, duration of us-
Motorized device: gradually moves Articular cartilage microfracture age, amount of motion, and rate of
the joint resulting in accelerated re- Articular cartilage transplantation increase of motion); the calibrations
covery time by decreasing soft-tissue are set by the company or physical
stiffness, increasing ROM, promoting therapy department.
healing of joint surfaces and soft tis- Specialty CPM machines (hand, el-
sue, and preventing the development bow, shoulder, ankle, and great toe)
of motion-limiting adhesions (scar are available; these entail a more in-
tissue) volved setup, and a therapist is usu-
Continuous passive motion (CPM) ally needed for calibration and setup.
devices available for the knee, ankle,
shoulder, elbow, wrist, and hand (see COMPLICATIONS
Continuous passive motion machine) Increased pain
Intolerance of the procedure
Temporary or permanent loss of mo-
Total knee replacement

Continuous passive motion machine

Postoperatively, a continuous passive motion machine may be used to aid in exercising the
patients affected joint. This is an illustration of one such device used for the lower leg.

5125C.qxd 8/15/08 10:51 AM Page 89

American College of Surgeons:
Acute pain Review the procedure with the pa- www.facs.org
Impaired physical mobility tient. American Medical Association:
Ineffective tissue perfusion: Make sure the settings on the device www.ama-assn.org
Peripheral are as ordered by the practitioner
and physical therapy department Selected references
Friemert, B., et al. Benefits of Active
EXPECTED OUTCOMES and that its in working order.
Motion for Joint Position Sense, Knee
The patient will: Inform the patient about the purpose
Surgery, Sports Traumatology, and
express feelings of increased comfort of the device and that the joint can
Arthroscopy 23:1-7, November 2005.
attain the highest degree of mobility be moved through a ROM for an ex-
Lynch, D., et al. Continuous Passive
possible within the confines of the tended period. Tell him that CPM Motion Improves Shoulder Joint
injury machine use can significantly reduce Integrity Following Stroke, Clinical
exhibit adequate tissue perfusion the recovery time, promote healing, Rehabilitation 19(6):594-99,
and pulses distally. reduce the development of adhe- September 2005.
sions and scar tissue, and decrease Zeifang, F., et al. Continuous Passive
stiffness. Motion Versus Immobilisation in a
Cast after Surgical Treatment of
Idiopathic Club Foot in Infants: A
POSTTREATMENT CARE Prospective, Blinded, Randomised,
Clinical Study, The Journal of Bone
and Joint Surgery 87(12):1663-65,
Keep the patient as comfortable as December 2005.
Give analgesics as ordered and moni-
tor for adverse effects.
Maintain proper body alignment.
Use splints or braces as ordered.
Elevate the affected area and apply
ice as tolerated when the patients
joint isnt in motion.
Monitor the patients vital signs.
Monitor laboratory test results.
Assess mobility and ROM.
Monitor the patient for complica-

Stress the importance of follow-up
Advise the patient about activity re-
strictions and lifestyle changes.
Review the use of the device and
make sure that he can use it appro-
priately on discharge.
Refer the patient for follow-up care.
Refer the patient for physical and oc-
cupational therapy as indicated.

5125C.qxd 8/15/08 10:51 AM Page 90

Continuous renal replacement therapy

WARNING When calculating the
OVERVIEW PROCEDURE amount of replacement fluid, to-
tal the amount of fluid in the collec-
Given round the clock, providing pa- If necessary, assist with inserting the tion device from the previous hour
tients with continuous therapy and catheters into the femoral artery and with other fluid losses the patient may
sparing them the destabilizing he- vein, using strict sterile technique. have (such as blood loss, emesis, or na-
modynamic and electrolyte changes An internal arteriovenous fistula or sogastric tube drainage). From this to-
characteristic of intermittent he- external arteriovenous shunt may tal, subtract the patients fluid intake
modialysis (IHD) sometimes be used instead of the for the past hour and the net fluid loss
Slow continuous ultrafiltration: uses femoral route. If ordered, flush both prescribed by the practitioner.
arteriovenous access and the pa- catheters with the heparin flush solu- Assess hemodynamic parameters,
tients blood pressure to circulate tion to prevent clotting. including pulmonary artery pressure,
blood through a hemofilter; the pa- Apply occlusive dressings to the in- central venous pressure, pulmonary
tient doesnt receive any fluids sertion sites, and mark the dressings arter wedge pressure, and blood
Continuous arteriovenous hemofil- with the date and time. Secure the pressure hourly, or more frequently if
tration (CAVH): uses the patients tubing and connections with tape. indicated.
blood pressure and arteriovenous ac- Put on sterile gloves and mask. WARNING Stay alert for indica-
cess to circulate blood through a flow Prepare the connection sites by tions of hypovolemia, such as
resistance hemofilter; the patient re- cleaning them with gauze pads falling blood pressure and a decrease
ceives replacement fluids to main- soaked in povidone-iodine solution, in hemodynamic pressures, from too-
tain filter patency and systemic and then connect them to the exit rapid removal of ultrafiltrate, or of
blood pressure port of each catheter. hypervolemia due to excessive fluid re-
Continuous arteriovenous hemodial- Turn on the hemofilter and monitor placement with a decrease in ultrafil-
ysis (CAVH-D): combines hemodialy- the blood-flow rate through the cir- trate.
sis with hemofiltration; infusion cuit. The flow rate is typically 500 to Institute continuous cardiac moni-
pump moves dialysate solution con- 900 ml/hour. toring as indicated for arrhythmias
current to blood flow, adding the Inspect the ultrafiltrate during the (may indicate electrolyte imbalance).
ability to continuously remove solute procedure. It should remain clear If the patient is receiving CVVH and
while removing fluid; like CAVH, may yellow, with no gross blood. Pink- the pressure alarm sounds, check the
also be performed in patients with tinged or blood ultrafiltrate may sig- catheter for kinks, disconnections, or
hypotension and fluid overload nal a membrane leak in the hemofil- other problems. Determine whether
Continuous venovenous hemofiltra- ter, which permits bacterial contami- the arterial or venous pressure alarm
tion (CVVH): similar to CAVH except nation. If a leak occurs, notify the sounded; if its the arterial pressure
that a vein provides access thats practitioner so that the hemofilter alarm, check the arterial lumen and
channeled through the arterial lu- can be replaced. if its the venous pressure alarm,
men of a dual-lumen catheter and If the ultrafiltrate flow rate decreases, check the venous lumen. A sudden
then mechanically pumped to the raise the bed to increase the distance rise in pressure indicates blockage in
hemofilter between the collection device and the catheter or tubing, whereas a sig-
Continuous venovenous hemodialy- the hemofilter. Lower the bed to de- nificant drop in pressure suggests a
sis: similar to CAVH-D, except that a crease the flow rate. disconnection or opening of a port.
vein provides access while a pump is WARNING Clamping the ultrafil- Because blood flows through an ex-
used to move dialysate solution con- trate line is contraindicated with tracorporeal circuit during CAVH and
current with blood flow some types of hemofilters because CVVH, the blood in the hemofilter
pressure may build up in the filter, may need to be anticoagulated. To do
INDICATIONS clotting it and collapsing the blood this, infuse heparin in low doses
Acute renal failure compartment. (usually starting at 500 units/hour)
Patients unable to tolerate traditional Calculate the amount of filtration re- into an infusion port on the arterial
hemodialysis such as those with hy- placement fluid every hour, as or- side of the setup. Measure thrombin
potension dered, or according to your facilitys clotting time or the activated clotting
policy. Infuse the prescribed amount time. This ensures that the circuit,
and type of replacement fluid not the patient, is anticoagulated. A
through the infusion pump into the normal value for activated clotting
arterial side of the circuit. time is 100 seconds; during continu-

5125C.qxd 8/15/08 10:51 AM Page 91

ous renal replacement therapy

seconds, depending on the patients
clotting times. If the value is too high Deficient fluid volume Prime the hemofilter and tubing ac-
or low, the practitioner adjusts the Impaired gas exchange cording to the manufacturers in-
heparin dose accordingly. Risk for infection structions.
Wash your hands. Assemble the
COMPLICATIONS EXPECTED OUTCOMES equipment at the patients bedside
Bleeding The patient will: according to the manufacturers rec-
Hemorrhage maintain adequate fluid volume ommendations and your facilitys
Hemofilter occlusion maintain patent airway and ade- policy, and explain the procedure to
Infection quate oxygenation the patient. (See Setup for CAVH and
Hypotension remain free from infection. CVVH, page 92.)
Thrombosis (see Preventing compli- If a catheter will be inserted, have the
cations of CRRT) patient sign a consent form.
Hypothermia Weigh the patient, take baseline vital
Air embolism signs, and make sure that all neces-
sary laboratory studies have been
done (such as electrolyte levels, co-
agulation factors, complete blood
count, blood urea nitrogen, and crea-
tinine studies). Monitor the patients
weight and vital signs hourly or as in-

Assess the leg for signs of obstructed
blood flow, such as coolness, pallor,
and weak pulse. Check the groin area
Preventing complications of CRRT on the affected side for signs of
hematoma. Ask the patient whether
Measures to avoid complications of continuous renal replacement therapy (CRRT) are listed here. he has pain at the insertion sites.
If possible, infuse medications or
COMPLICATION NURSING INTERVENTIONS blood through another line rather
than the venous line to prevent clot-
Hypotension Monitor blood pressure.
Temporarily decrease the blood pumps speed for transient ting in the hemofilter.
hypotension. Assess all pulses (dorsalis pedis, pos-
Increase the vasopressor support. terior tibial, popliteal, and femoral)
in the affected leg every hour for the
Hypothermia Use an in-line fluid warmer placed on the blood return line to first 4 hours, then every 2 hours.
the patient or an external warming blanket. To help prevent clots in the hemofil-
ter, and also to prevent kinks in the
Fluid and electrolyte Monitor the patients fluid levels every 4 to 6 hours.
imbalances Monitor the patients sodium, lactate, potassium, and calcium catheter, make sure the patient
levels and replace as necessary. doesnt bend the affected leg more
than 30 degrees at the hip.
Acid-base imbalances Monitor the patients bicarbonate and arterial blood gas lev- Perform skin care at the catheter in-
els. sertion sites every 48 hours, using
sterile technique to prevent infec-
Air embolism Observe for air in the system.
Use luer-lock devices on catheter openings.
tion. Cover the site with an occlusive
Hemorrhage Check all connections and keep the dialysis lines visible.

Infection Perform sterile dressing changes.


5125C.qxd 8/15/08 10:51 AM Page 92

Setup for CAVH and CVVH

Continuous renal replacement therapy is frequently performed using one of the two systems described here.


In continuous arteriovenous hemofiltration (CAVH), Replacement Heparin
the physician inserts two large-bore, single-lumen solution
catheters (as shown at right). One catheter is
inserted into an arterymost commonly, the
femoral artery. The other catheter is inserted into a
vein, usually the femoral, subclavian, or internal
jugular vein. During CAVH, the patients arterial Heparin pump
blood pressure serves as a natural pump, driving Inflow pump
blood through the arterial line. A hemofilter removes
water and toxic solutes (ultrafiltrate) from the blood. From patient
Replacement fluid is infused into a port on the (arterial line)
arterial side. The same port can be used to infuse
heparin. The venous line carries the replacement
fluid and purified blood to the patient. Hemofilter

To patient
(venous line)
Outflow pump

Sampling port

collection device


In continuous venovenous hemofiltration (CVVH), the
Catheter (double lumen)
physician inserts a special double-lumen catheter
into a large vein, commonly the subclavian, femoral,
or internal jugular vein (as shown at right). Because
Arterial lumen Venous lumen
the catheter is in a vein, an external pump is used
to move blood through the system. The patients
venous blood moves through the arterial lumen to Heparin solution
the pump, which then pushes the blood through the
catheter to the hemofilter. Here, water and toxic
solutes (ultrafiltrate) are removed from the patients Hemofilter
blood and drain into a collection device. Blood cells
arent removed because theyre too large to pass
Infusion ports
through the filter. As the blood exits the hemofilter, Pressure monitors (I.V. solutions)
its then pumped through the venous lumen back
to the patient. Replacement
Several components of the pump provide safety fluid
mechanisms. Pressure monitors on the pump collection
maintain the flow of blood through the circuit at a Venous trap
constant rate. An air detector traps air bubbles Air detector
before the blood returns to the patient. A venous Venous clamp
trap collects blood clots that may be in the blood. A
blood leak detector signals when blood is found in
the ultrafiltrate; a venous clamp operates if air is
detected in the circuit or if theres a disconnection
in the blood line.

5125C.qxd 8/15/08 10:51 AM Page 93

Obtain serum electrolyte levels every

4 to 6 hours or as ordered; anticipate
adjustments in replacement fluid or
dialysate based on the results.
Inspect the site dressing every 4 to 8
hours for infection and bleeding. To
prevent infection, perform skin care
at the catheter insertion sites every
48 hours, using sterile technique.
Cover the sites with an occlusive

Remind the patient to keep his ex-
tremity still; procure an order for soft
restraints if needed to prevent injury
to the patient.

American Medical Association:
Continuous Renal Replacement
Therapies: www.crrtonline.com

Selected references
American Nephrology Nurses Asso-
ciation. Standards and Guidelines
of Practice for Continuous Renal
Replacement Therapy (Revised 2005
edition). Pitman, N.J.
Niu, S.F., and Li, I.C. Quality of Life of
Patients Having Renal Replacement
Therapy, Journal of Advanced Nursing
51(1):15-21, July 2005.
Schatell, D. Home Dialysis, Home
Dialysis Central, and What You Can Do
Today, Nephrology Nursing Journal
32(2):235-38, March-April 2005.

5125C.qxd 8/15/08 10:51 AM Page 94

Coronary artery bypass grafting

Grafting of a blood vessel segment The patient receives general anesthe- Decreased cardiac output
from another part of the body to cre- sia, and the surgeon makes a series of Hypothermia
ate an alternate circulatory route that incisions in the patients thigh or calf Ineffective tissue perfusion:
bypasses an occluded area of a coro- and removes a saphenous vein seg- Cardiopulmonary
nary artery, thus restoring normal ment for grafting; internal mammari-
blood flow to the myocardium an artery segments also may be re- EXPECTED OUTCOMES
Saphenous vein or internal mamma- moved. The patient will:
ry artery commonly used A medial sternotomy is done and the maintain adequate cardiac output
Can relieve anginal pain and improve heart is exposed. maintain a normal body temperature
cardiac function, enhancing quality Cardiopulmonary bypass is initiated; maintain hemodynamic stability.
of life cardiac hypothermia and standstill
Sometimes involves a minimally in- are induced.
vasive surgical procedure The surgeon sutures one end of the PRETREATMENT CARE
Commonly called CABG venous graft to the ascending aorta
and the other end to a patent coro- Explain the treatment and prepara-
INDICATIONS nary artery distal to the occlusion; tion and verify that an appropriate
Medically uncontrolled angina that this procedure is repeated for each consent form has been signed.
adversely affects quality of life artery that will be bypassed. Explain what to expect during the
Left main coronary artery disease After the grafts are in place, the sur-
immediate postoperative period, in-
(CAD) geon flushes the cardioplegic solu-
cluding endotracheal tube and me-
Severe proximal left anterior de- tion from the heart, and cardiopul-
chanical ventilator, cardiac monitor,
scending coronary artery stenosis monary bypass is discontinued.
nasogastric tube, chest tube, in-
Three-vessel CAD with proximal Epicardial pacing electrodes are im-
dwelling urinary catheter, arterial
stenoses or left ventricular dysfunc- planted and a chest tube is inserted.
line, epicardial pacing wires, and pul-
tion The incision is closed and a sterile
monary artery catheter.
Three-vessel CAD with normal left dressing is applied. Institute cardiac monitoring.
ventricular function at rest, but with The evening before surgery, have the
inducible ischemia and poor exercise COMPLICATIONS patient shower with antiseptic soap
capacity Cardiac arrhythmias as ordered, and restrict food and flu-
Hypertension or hypotension ids after midnight as ordered.
Cardiac tamponade Provide sedation as ordered and as-
Thromboembolism sist with pulmonary artery catheteri-
Hemorrhage zation and insertion of arterial lines.
Postpericardiotomy syndrome
Myocardial infarction
Postoperative depression or emo-
tional instability
Pulmonary embolism
Decreased renal function

5125C.qxd 8/15/08 10:51 AM Page 95

Kikura, M., et al. A Double-Blind,

POSTTREATMENT CARE PATIENT TEACHING Placebo-Controlled Trial of Epsilon-
aminocaproic Acid for Reducing Blood
Loss in Coronary Artery Bypass Graft-
Keep emergency resuscitative equip- GENERAL
ment immediately available. ing Surgery, Journal of the American
Review medications and possible ad-
College of Surgeons 202(2):216-22,
Maintain arterial pressure within the verse reactions with the patient. February 2006.
limits set by the practitioner. Review incentive spirometry therapy Reid, T., et al. Psychosocial Interventions
Adjust ordered I.V. medications ac- with the patient. for Panic Disorder After Coronary
cording to your facilitys protocol. Review ROM exercises with the pa- Artery Bypass Graft: A Case Study,
Maintain chest tube patency. tient. Dimensions of Critical Care Nursing
Assist with weaning the patient from Instruct the patient about how to 24(4):165-70, July-August 2005.
the ventilator as appropriate. care for the incision site. Shimamura, Y., et al. New Anastomosis
Promote chest physiotherapy; en- Tell the patient about the signs and Assist Devices for Coronary Artery
courage coughing, deep breathing, symptoms of infection, arterial reoc- Bypass Grafting, Asian Cardiovas-
and incentive spirometry use. clusion, and postpericardiotomy cular & Thoracic Annals 14(1):72-74,
Assist the patient with range-of- February 2006.
motion (ROM) exercises. Inform the patient about how to
Monitor the patients vital signs and identify and cope with postoperative
intake and output. depression.
Assess heart rate and rhythm, heart Review complications of the proce-
sounds, peripheral vascular status, dure with the patient.
electrocardiogram and hemodynam- Review dietary restrictions with the
ic values, and cardiovascular status. patient.
Monitor the patient for complica- Inform the patient about activity re-
tions. strictions, adequate rest periods, and
Assess nutritional status. prescribed exercise program.
Monitor arterial blood gas levels, and If the patient smokes, advise him to
assess respiratory status and breath stop.
sounds. Refer the patient to the Mended
Monitor the patients neurologic sta- Hearts Club and American Heart
tus. Association for information and sup-
Monitor the patient renal function. port.
Assess surgical wounds and dress-
Monitor for electrolyte imbalances. Organizations
American College of Cardiology:
American Medical Association:
HealthCenterOnline: www.heartcenteron-

Selected references
Akowuah, E., et al. Above-Knee Vein
Harvest for Coronary Revascu-
larization Increases ASEPSIS Score,
Asian Cardiovascular & Thoracic
Annals 14(1):57-59, February 2006.
Egerod, I., and Hansen, G.M. Evidence-
Based Practice among Danish Cardiac
Nurses: A National Survey, Journal of
Advanced Nursing 51(5):465-73,
September 2005.
Hartford, K. Telenursing and Patients
Recovery from Bypass Surgery,
Journal of Advanced Nursing 50(5):459-
68, June 2005.

5125C.qxd 8/15/08 10:51 AM Page 96

Corpus callosotomy
Surgical technique that divides the After the patient is given general Disturbed thought processes
corpus callosum, disconnecting the anesthesia, the surgeon makes an in- Ineffective tissue perfusion: Cerebral
cerebral hemispheres cision in the scalp, removes a piece of Risk for infection
Most effective in reducing atonic and bone, and pulls back a section of the
tonic-clonic seizures dura. This creates a window where he EXPECTED OUTCOMES
Seizure frequency reduced 70% to inserts instruments for disconnect- The patient will:
80% after partial callosotomy and ing the corpus callosum. exhibit normal thought processes
80% to 90% after complete callosoto- The surgeon gently separates the demonstrate normal neurologic
my hemispheres to access the corpus functioning
callosum and uses surgical micro- exhibit no signs of infection.
INDICATIONS scopes to magnify the brain struc-
Atonic seizures tures.
Tonic-clonic seizures He then dissects the corpus callo-
Tonic seizures sum. The front two-thirds are cut in a
partial callosotomy; this allows the
hemispheres to share visual informa-
tion. The other third is cut in a com-
plete callosotomy, which may be
done initially or in another proce-
After the corpus callosum is cut, the
dura and bone are fixed back into
place, and the scalp is closed using
stitches or staples.

Allergic reaction to anesthesia
Increased intracranial pressure (ICP)
Neurologic complications (such as
lack of awareness of one side of the
body, loss of coordination, problems
with speech, memory, or words)
Increase in partial seizures
Scalp numbness
Fatigue or depression

5125C.qxd 8/15/08 10:51 AM Page 97


Review the surgical procedure with Monitor the patients vital signs, in- GENERAL
the patient and his family, and verify take and output, and daily weight. Tell the patient that activities will re-
that a consent form has been signed. Monitor the patients level of con- turn gradually to normal within 2 or
Review laboratory study results and sciousness and respiratory status and 3 months.
the patients history and medica- for signs of increased ICP. AGE FACTOR Inform parents that
tions. Monitor the patients neurologic sta- their child should stay home
Have the patient take a bath and tus and immediately report any from school for about 6 weeks after
wash his hair the evening before or changes to the surgeon. the surgery.
the morning of the procedure. Monitor hemodynamic values and Review follow-up care and the need
Perform a neurologic examination to heart rate and rhythm. for continuing care.
obtain a baseline status. Monitor fluid and electrolyte bal- Tell the family its unlikely that the
Tell the patient and his family that ance. patients medications would be
the face may be bruised and swollen Monitor urine specific gravity. changed for at least 6 months.
after the surgery, but this will gradu- Maintain patency of any drains pres- Inform the patient that hair will grow
ally reduce. ent, monitor surgical wound and back over the incision site and cover
Candidates for corpus callosotomy dressings, and note drainage and the surgical scar.
undergo an extensive presurgical monitor for signs of complications. Review medications, dosage, and ad-
evaluationincluding seizure moni- Administer and assess effectiveness verse effects with the patient. Tell the
toring, electroencephalography, of analgesic. patient to continue taking antisei-
magnetic resonance imaging, and Maintain seizure precautions. zure medication as ordered.
positron emission tomography. Maintain oxygenation; encourage the
patient to take deep breaths and RESOURCES
cough; suction as indicated. Organizations
American Academy of Neurology:
American Medical Association:
Epilepsy.com: www.epilepsy.com

Selected references
Dunn, D. Preventing Perioperative
Complications in Special Populations,
Nursing2005 35(11):36-43, November
Schwartz, T.H., and Spencer, D.D.
Strategies for Reoperation after
Comprehensive Epilepsy Surgery,
Journal of Neurosurgery 95(4):615-23,
October 2001.

5125C.qxd 8/15/08 10:51 AM Page 98

Cortisone injection
Cortisone injected directly into an af- The area to be injected is cleaned Acute pain
fected joint to reduce severe, persist- with povidone-iodine. Impaired physical mobility
ent inflammation Topical anesthetics are used to numb Risk for infection
Usually done because other treat- the area around the injection site.
ment methods havent worked effec- If theres a large amount of fluid in EXPECTED OUTCOMES
tively or quickly; designed to act the joint, the practitioner will remove The patient will:
longer and more potently excess amounts. express feelings of increased comfort
The practitioner then injects the cor- attain the highest degree of mobility
INDICATIONS tisone into the joint. Lidocaine (or possible within the confines of injury
Shoulder bursitis Marcaine) may also be injected with remain free from infection.
Arthritis the cortisone.
Trigger finger
Carpal tunnel syndrome Crystallization of the cortisone at the
Any joint pain unresponsive to previ- injection site
ous therapies Whitening of the skin at the injection
Infection of the injection site
WARNING More than three to
four injections in 1 year in the
same area of the body arent recom-
mended due to adverse effects of glu-
cocorticoids. Research indicates that
as few as six injections per year can
permanently damage a joint or cause
an increased risk of tendon rupture.
Weight gain
High blood pressure
Puffiness around the face
Reduced immunity and increased
risk of infection
Long-term joint and tendon damage

5125C.qxd 8/15/08 10:51 AM Page 99


Review the procedure with the pa- Place ice over the affected area if the GENERAL
tient, and verify that an informed patient experiences cortisone flare Advise the dark-skinned patient that
consent form has been signed. the injected cortisone crystallizes whitening of the skin around the in-
and causes pain lasting for 1 or 2 jection site is a common, but an un-
days thats worse than before the harmful, adverse effect.
shot. Review activity restrictions with the
Observe for complications. patient depending on the injection
Promote rest of the extremity; elevate site: 3 days for knees, ankles, and
the joint and position for comfort. hips, and 2 days for wrists, elbows,
and shoulders. Tell the patient that
complete rest helps keep cortisone in
the joint, allowing the medication to
work effectively.
Tell the patient that the injected joint
usually recovers within 1 to 4 days,
whereas cortisone takes 2 to 3 weeks
to be eliminated.
Instruct the patient to report signs of
complications, such as infection or
sensitivity (increased pain and dis-
comfort within the first 24 to 48
Teach the patient the possible ad-
verse effects of glucocorticoids.
Inform the patient that theres a limit
on the number of cortisone injec-

American Academy of Orthopedic
Surgeons: www.aaos.org
American Medical Association:
MedicineNet: www.medicinenet.com

Selected references
Buccilli, T.A. Jr., et al. Sterile Abscess
Formation Following a Corticosteroid
Injection for the Treatment of Plantar
Fasciitis, Journal of Foot and Ankle
Surgery 44(6):466-68, November-
December 2005.
Hanypsiak, B.T., and Shaffer, B.S. Non-
operative Treatment of Unicompart-
mental Arthritis of the Knee, Ortho-
pedic Clinics of North America 36(4):
401-11, October 2005.
Nichols, A.W. Complications Associated
with the Use of Corticosteroids in the
Treatment of Athletic Injuries, Clinical
Journal of Sports Medicine 15(5):370-
75, September 2005.

5125C.qxd 8/15/08 10:51 AM Page 100

COMPLICATIONS Syndrome of inappropriate antidi-
OVERVIEW Infection uretic hormone
Vasospasm Seizures
Surgical opening into the skull, ex- Hemorrhage Cranial nerve damage
posing the brain for treatment Increased intracranial pressure (ICP)
Supratentorial craniotomy: involves Diabetes insipidus
such surgical approaches as frontal,
parietal, temporal, occipital, or a
Infratentorial craniotomy: involves
surgical approach in which the sur-
geon makes an incision above the
Craniotomy: A window to the brain
neck in the back of the skull
To perform a craniotomy, the surgeon incises drilling is complete, the surgeon uses a dural
the skin, clamps the aponeurotic layer, and elevator to separate the dura from the bone
INDICATIONS retracts the skin flap. He then incises and around the margin of each burr hole. He then
Placement of ventricular shunt retracts the muscle layer and scrapes the saws between the burr holes to create a bone
Tumor excision periosteum off the skull. flap. He either leaves this flap attached to the
Abscess drainage Next, using an air-driven or electric drill, he muscle and retracts it or detaches the flap
Hematoma aspiration drills a series of burr holes in the corners of the completely and removes it. In either case, the
Aneurysm clipping skull incision. During drilling, warm saline flap is wrapped to keep it moist and protected.
solution is dripped into the burr holes, and the Finally, the surgeon incises and retracts the
holes are suctioned to remove bone dust. When dura, exposing the brain.

The anesthetist starts a peripheral

I.V. line, a central venous pressure
line, and an arterial line; the patient
receives a general or local anesthetic.
The surgeon marks an incision line
and cuts through the scalp to the cra-
nium, forming a scalp flap thats fold-
ed to one side.
The surgeon then bores four or five
holes through the skull in the corners
of the cranial incision and cuts out a
bone flap.
After pulling aside or removing the
bone flap, the surgeon incises and re-
tracts the dura, exposing the brain;
the surgeon then proceeds with the BURR HOLES DRILLED BRAIN EXPOSED
required surgery.
The dura mater is closed, and a drain
may be used.
The bone flap may not be replaced. If
swelling is anticipated, it usually isnt
Periosteum and muscle are approxi-
mated. Skin closure is performed and
dressings are applied. (See Cranio-
tomy: A window to the brain.)

5125C.qxd 8/15/08 10:51 AM Page 101

Instruct the patient on the use of

NURSING DIAGNOSES POSTTREATMENT CARE antiembolism stockings or a pneu-
matic compression device.
Disturbed sensory perception (all) Maintain a patent airway. Review signs and symptoms of infec-
Ineffective tissue perfusion: Cerebral Administer prescribed oxygen. tion and complications, and when to
Risk for injury Take steps to protect the patients notify the practitioner.
safety. Discuss the use of a wig, hat, or scarf
EXPECTED OUTCOMES Administer medications as ordered. until hair grows back, as appropriate.
The patient will: Provide support to the patients fami- Advise the patient to avoid alcohol
exhibit improved or normal neuro- ly members. and smoking.
logic status Position the patient on his side with Emphasize follow-up care.
maintain ICP within normal limits the head of the bed elevated 15 to 30
remain free from injury. degrees; turn the patient carefully RESOURCES
every 2 hours. Organizations
Encourage careful deep breathing American Academy of Neurology:
and coughing; suction gently as www.aan.com
PRETREATMENT CARE needed. American Medical Association:
Ensure a quiet, calm environment.
Maintain seizure precautions. Epilepsy.com: www.epilepsy.com
Explain the treatment and prepara-
Monitor the patients vital signs, in-
tion and verify that an appropriate
take and output, level of conscious- Selected references
consent form has been signed. Dunn, D. Preventing Perioperative
Tell the patient that his head will be
ness, respiratory status, ICP, heart
rate and rhythm, and hemodynamic Complications in Special Populations,
shaved in the operating room. Nursing2005 35(11):36-43, November
Explain the intensive care unit and
WARNING Notify the surgeon im-
equipment the patient will see post- Horn, E.M., et al. Bedside Twist Drill
mediately if you detect a worsen-
operatively. Craniotomy for Chronic Subdural
Perform a complete neurologic as-
ing mental status, pupillary changes, Hematoma: A Comparative Study,
sessment. or focal signs such as increasing weak- Surgical Neurology 65(2):150-53,
ness in an arm or leg.These findings February 2006.
may indicate increased ICP. Movassaghi, K., et al. Cranioplasty with
Assess fluid and electrolyte balance, Subcutaneously Preserved Autologous
urine specific gravity, and daily Bone Grafts, Plastic and Reconstruc-
weight. tive Surgery 117(1):202-206, January
Monitor drain patency, surgical 2006.
wound and dressings, and drainage. Nolan, S. Traumatic Brain Injury: A Re-
Apply antiembolism stockings to view, Critical Care Nursing Quarterly
28(2):188-94, April-June 2005.
prevent deep vein thrombosis.
Tazbir, J., et al. Decompressive Hemi-
Monitor the patient for complica-
craniectomy with Duraplasty: A Treat-
tions. ment for Large-Volume Ischemic
Stroke, Journal of Neuroscience
Nursing 37(4):194-99, August 2005.
PATIENT TEACHING Tuncali, B., et al. Intraoperative Fetal
Heart Rate Monitoring During Eme-
GENERAL rgency Neurosurgery in a Parturient,
Journal of Anesthesia 20(1):40-43,
Review medications and possible ad-
January 2006.
verse reactions with the patient.
Review care of the surgical wound
with the patient.
Tell the patient that headache and fa-
cial swelling will probably occur for 2
to 3 days after surgery.
Instruct the patient on the impor-
tance of taking antiseizure medica-
tion postoperatively.
Review postoperative leg exercises
and deep breathing with the patient.

5125C.qxd 8/15/08 10:51 AM Page 102

complex cryosurgical unit to freeze though the speculum and placed
OVERVIEW the lesion. He may refreeze a tumor against the cervix. The tissue is
several times to ensure its destruc- frozen and later becomes necrotic
Destruction of tissue through appli- tion; for each cycle, monitor and and sloughs off.
cation of extreme cold record the number of seconds that
Success dependent on the type of le- elapse until the tissue reaches -4 F OPHTHALMIC CRYOSURGERY
sion, extent and depth of the freeze, (20 C) and the number of seconds After the eye dilates and becomes
and duration between freezing and that it takes the tissue to thaw. numb, the cryoprobe is positioned.
thawing; slow thaw destroys lesions After the surgery, the area is left un- Typically its placed on the conjuncti-
more effectively covered. va, directly over the anterior retinal
Liquid nitrogen and nitrous oxide break. However, if treating the poste-
most commonly used; carbon diox- GYNECOLOGIC CRYOSURGERY rior retinal area, an opening is first
ide and Freon less commonly used Anesthesia isnt usually given. The cut in the conjunctiva and the eye ro-
patient is placed in the lithotomy po- tated to expose a large portion of the
INDICATIONS sition and a speculum is inserted sclera.
Actinic and seborrheic keratoses into the vagina. After the procedure, a patch is ap-
Leukoplakia After locating and inspecting the plied to the affected eye.
Molluscum contagiosum cervix, the cryoprobe is inserted
Condyloma acuminatum
Basal cell epitheliomas Positioning thermocouple needles
Squamous cell carcinomas
Cervicitis During cryosurgery, you may be responsible for positioning thermocouple needles and then
Chronic cervical erosion operating them according to the surgeons direction. These needles measure the temperature of
Cervical polyps the tissue at its tip and help the surgeon gauge the depth of freezing a vitally important factor
Condyloma acuminate when destroying cancerous lesions. The needle may be placed in any of several positions.
Cataracts Precise temperature measurement can be difficult because a variation of only 1 mm in the
Retinal tears or holes needles position can translate into a difference of 50 to 59 F (10 to 15 C). For that reason,
youll usually place two or more needles in different areas to increase the accuracy of the reading.

PROCEDURE In this illustration, the nee-

dle is shown inserted at an Probe
angle so that its tip rests
The procedure varies with the area about 5 mm below the base
being treated. of the tumor to give a direct
reading of tissue tempera-
DERMATOLOGIC CRYOSURGERY ture. In this position, the Frozen tissue
A local anesthetic may be given temperature reading may
based on the type and extent of the be affected by chilling of
the shaft within the frozen Thermocouple
lesion. needle
tissue, but the error isnt
The correct temperature and depth
likely to be significant.
are determined for freezing. For su-
perficial lesions, this may be done by Here the probe is placed
palpating the lesion. For skin can- about 5 mm to one side of
cers, a thermocouple needle and py- the frozen tissue at a depth
rometer are used to make sure that of about 3 mm. In this posi- Probe
tissue at the deepest part of the le- tion, it registers the same
sion has been adequately frozen. temperature as the probe
The thermocoupler needles are in- above because both probe
serted and secured to the base of the tips are about the same
tumor. (See Positioning thermocou- distance from the frozen
ple needles.)
Frozen tissue
The operative site is cleaned with
povidone-iodine solution.
The surgeon then uses a cotton- Thermocouple
tipped applicator that has been
dipped into liquid nitrogen or the

5125C.qxd 8/15/08 10:51 AM Page 103

COMPLICATIONS For ophthalmic cryosurgery, mydri- to cover the wound with a loose
Hypopigmentation (from destruc- atic and anesthetic eyedrops are in- dressing when hes outdoors. After
tion of melanocytes) serted into the affected eye. the wound heals, he should apply a
Secondary infection sunscreen over the area.
Blood vessel, nerve, or tear duct Tell the gynecologic patient that
damage POSTTREATMENT CARE shell have a watery vaginal discharge
Cervical stenosis (if too large an area for several weeks. Advise her not to
of the cervix is frozen at one time) After gynecologic cryosurgery, tell use tampons and to avoid sexual in-
the patient to expect a heavy, watery tercourse while the discharge is pres-
discharge for the next several weeks. ent because the cervix is fragile dur-
NURSING DIAGNOSES Warn her that the discharge will be ing this time.
heavy enough to require a peripad. Emphasize the importance of notify-
Acute pain Monitor the amount and type of ing the practitioner promptly if the
Disturbed body image drainage. dermatologic patient experiences ex-
Risk for infection After dermatologic cryosurgery, clean treme pain, a widening area of ery-
the area gently with a cotton-tipped thema, oozing (of other than serous
material), or fever; if the gynecologic
EXPECTED OUTCOMES applicator soaked in hydrogen per-
oxide. Dont apply a bandage. patient experiences a vaginal dis-
The patient will:
After ophthalmic cryosurgery, re- charge other than a watery appear-
state relief from pain
move the eye patch when the anes- ance and fever; or if the ophthalmic
express positive feelings about his
thesia has worn off. patient experiences sudden changes
Apply an ice bag to relieve swelling, in vision or an increase in eye pain.
remain free from infection.
and give analgesics as ordered. If the patient had a cancerous lesion
destroyed, urge him to have regular
checkups because cancers may re-

Ask the patient if he has allergies or

hypersensitivities, especially to lido-
Tell the patient to expect pain but he Organizations
caine, iodine, or cold.
American College of Emergency
Briefly explain the procedure to the may take the prescribed analgesic as
Physicians: www.acep.org
patient and outline the basic steps. needed.
American Medical Association:
Tell him he will initially feel cold, fol- Tell the dermatologic patient to ex-
lowed by burning, during the proce- pect pain, redness, and swelling. Also
dure. tell him that a blister will form within
Selected references
Caution the patient to remain as still 6 hours of treatment, which will flat- Cryoablation Proves Effective, Safe,
as possible to prevent inadvertent ten within a few days and slough off Durable Treatment for Prostate
freezing of unaffected tissue. in 2 to 3 weeks. Serous exudate may Cancer, Oncology 19(9):1142, August
Gather equipment and make sure follow during the first week, accom- 2005.
that its working. Some surgeons use panied by the development of a Fikrle, T., and Pizinger, K. Cryosurgery in
gentian violet or a surgical marker to crust. Advise the patient to avoid the Treatment of Earlobe Keloids:
delineate the margins of the lesion. If breaking the blister. Report of Seven Cases, Dermatologic
necessary, obtain the appropriate Warn the dermatologic patient that Surgery 31(12):1728-31, December
marker. the blister may be large and may 2005.
bleed. Warn him not to touch it to Sinha, A., et al. An Update on Second-
Verify that the patient has signed an
promote healing and prevent infec- Generation Devices for Endometrial
appropriate consent form. Ablation, Expert Review of Medical
Position the patient comfortably. tion. Tell him that if the blister be-
Devices 2(5):635-41, September 2005.
The gynecologic cryosurgery patient comes uncomfortable or interferes
comes to the practitioners office 1 with daily activities, he should call
week after her menstrual cycle. the practitioner, who will decom-
Tell the patient undergoing gyneco- press it with a sterile blade or pin.
logic cryosurgery that she may expe- Tell the dermatologic patient to clean
rience headache, dizziness, flushing, the area gently with soap and water,
or cramping during the procedure. alcohol, or a cotton-tipped applica-
Reassure her that these adverse reac- tor soaked in hydrogen peroxide, as
tions are transient. instructed by the practitioner. To pre-
vent hypopigmentation, instruct him

5125C.qxd 8/15/08 10:51 AM Page 104

Partial or total removal of the urinary PARTIAL CYSTECTOMY Deficient fluid volume
bladder and surrounding structures The surgeon makes a midline low or Impaired urinary elimination
(see Types of cystectomy) transverse incision from the umbili- Risk for infection
Total cystectomy: necessitates per- cus to the symphysis pubis.
manent urinary diversion into an The bladder is opened and the tumor EXPECTED OUTCOMES
ileal or colonic conduit removed, along with a small portion The patient will:
of healthy tissue. maintain adequate fluid volume
INDICATIONS The wound is closed, leaving a Pen- maintain hemodynamic stability
Advanced bladder cancer rose drain and suprapubic catheter remain free from infection.
Bladder disorders such as interstitial in place.
Frequent recurrence of widespread SIMPLE CYSTECTOMY
papillary tumors not responding to The surgeon makes a midline ab-
endoscopic or chemotherapeutic dominal incision.
management The entire bladder is removed, leav-
ing only a portion of the urethra.

In addition to the bladder, the semi-
nal vesicles and prostate in male pa-
tients and the uterus, ovaries, fallopi-
an tubes, and anterior vagina in
female patients are removed.
Depending on the extent of the can-
cer, the urethra and surrounding
lymph nodes may also be removed.

Types of cystectomy TO COMPLETE A SIMPLE OR

In cystectomy, surgery may be partial, Urinary diversion is done by attach-
simple, or radical. ing the ureters to an external collec-
Partial cystectomy involves resection of tion device, such as a cutaneous
a portion of the bladder wall. Commonly ureterostomy, conduit of the large or
preserving bladder function, this surgery is small bowel, or continent urinary
typically indicated for a single, easily ac- neobladder.
cessible bladder tumor.
Simple or total cystectomy involves re-
section of the entire bladder. Its indicated COMPLICATIONS
for benign conditions limited to the bladder. Bleeding
It may also be performed as a palliative Hypotension
measure, such as to stop bleeding, when Nerve injury such as to the gen-
cancer isnt curable.
itofemoral or peroneal nerve
Radical cystectomy is generally indicat-
ed for muscle-invasive primary bladder Anuria
carcinoma. Besides removing the bladder, Stoma stenosis
this procedure removes several surround- Urinary tract infection
ing structures. This extensive surgery typi- Pouch leakage
cally causes impotence in men and sterility Electrolyte imbalances
in women. Ureteroileal junction stenosis
After removal of the entire bladder, the
Vascular compromise
patient requires a permanent urinary
Loss of sexual or reproductive func-
diversion, such as an ileal conduit or a
continent urinary pouch. tion
Psychological problems relating to
changes in body image

5125C.qxd 8/15/08 10:51 AM Page 105

Refer the patient to a support group,

tion, if appropriate.
Explain the treatment and prepara- Administer medications as ordered.
tion to the patient and his family. Report urine output of less than RESOURCES
Verify that the patient has signed an 30 ml/hour. Organizations
appropriate consent form. Maintain patency of the indwelling American Association of Clinical
Arrange for a visit by an enterostomal urinary catheter or stoma, as appro- Urologists: www.aacuweb.org
therapist. priate, and irrigate as ordered. American Medical Association:
Address the patients concerns about Test all drainage from the nasogastric www.ama-assn.org
inevitable loss of sexual or reproduc- tube, abdominal drains, indwelling eMedicine: www.emedicine.com
tive function. urinary catheter, and urine collection
Explain the equipment the patient appliance for blood; notify the prac- Selected references
will see immediately after surgery. titioner of positive findings. Dunn, D. Preventing Perioperative
If possible, arrange for the patient to Change abdominal dressings, main- Complications in Special Populations,
visit the intensive care unit. taining sterile technique. Nursing2005 35(11):36-43, November
Perform standard bowel preparation Encourage frequent position
Montie, J.E. Lymph Node Metastases in
as ordered. changes, coughing, deep breathing,
Non-muscle Invasive Bladder Cancer
Administer enemas or oral polyethyl- and early ambulation. Are Correlated with the Number of
ene glycol-electrolyte solution as or- Offer emotional support. Transurethral Resections and Tumour
dered. Monitor the patients vital signs, in- Upstaging at Radical Cystectomy,
Administer antibiotics as ordered. take and output, and drainage. Journal of Urology 175(1):95-96,
Observe surgical wound and dress- January 2006.
ings. Perimenis, P., and Koliopanou, E. Post-
Assess the patient for hypovolemic operative Management and Rehabil-
shock, frank hematuria, and clots. itation of Patients Receiving an Ileal
Provide stoma care. Orthotopic Bladder Substitution,
Assess the patients respiratory sta- Urologic Nursing 24(5):383-86, October
Ruggeri, E.M., et al. Adjuvant Chemo-
Monitor the patient for signs of infec-
therapy in Muscle-Invasive Bladder
tion. Carcinoma, Cancer 106(4):783-88,
February 2006.
Zaghloul, M.S., et al. Long-Term Results
PATIENT TEACHING of Primary Adenocarcinoma of the
Urinary Bladder: A Report on 192
GENERAL Patients, Urologic Oncology 24(1):
13-20, January-February 2006.
Review the signs and symptoms of
Warn the patient about abnormal
bleeding, including persistent hema-
turia, and that he should report it to
the practitioner immediately.
Review complications with the pa-
Instruct the patient about urinary di-
version care.
Tell the patient about the possibility
of cancer recurrence.
Emphasize follow-up care.
Refer the patient for home care nurs-
ing visits if appropriate.
Refer the patient for psychological
and sexual counseling as appropri-

5125C.qxd 8/15/08 10:51 AM Page 106

Urinary diversion techniques: ensure After the patient is anesthetized, the Acute pain
adequate drainage from kidneys or surgeon makes a midline or para- Anxiety
bladder and help prevent urinary medical abdominal incision. Risk for infection
tract infection or kidney failure An opening is made through the ab-
Tube usually placed percutaneously domen into the urinary bladder and EXPECTED OUTCOMES
(sometimes surgically inserted); a drainage tube inserted. The patient will:
drains urine from bladder, diverting Percutaneous large-bore suprapubic demonstrate or express feelings of
it from the urethra cystostomy catheters can be placed increased comfort
Tube inserted above the symphysis under fluoroscopic guidance as an demonstrate or express decreased
pubis; may be used alone or with an alternative to surgical cystostomy. anxiety
indwelling urinary catheter remain free from infection.
After certain gynecologic procedures Discomfort
Bladder surgery Pressure when urinating
Prostatectomy Bleeding
Severe urethral strictures
Traumatic injury

5125C.qxd 8/15/08 10:51 AM Page 107


Explain the procedure, reinforcing Irrigate a cystostomy tube as you GENERAL
the practitioners explanations as would an indwelling urinary cathe- Explain how to clean the site with
necessary. ter. soap and water, check for skin break-
Have an enterostomal therapist visit Perform irrigation to avoid damaging down, and change the dressing daily.
with the patient and review informa- suture lines. Teach the patient how to change the
tion. Curve a cystostomy tube to prevent leg bag or drainage bag.
Provide preoperative preparation as kinks; kinks are likely if the patient Explain how and when to wash the
ordered; the patient may receive a lies on the insertion site. drainage bag.
liquid or low-residue diet a few days Suspect an obstruction when the Encourage the patient to increase
before surgery and be kept on noth- amount of urine in the drainage bag fluid intake to 3 qt (3 L) daily, if no
ing-by-mouth status after midnight decreases or when the amount of contraindications.
the night before surgery. urine around the insertion site in- Discuss the signs of infection and tell
Verify that the patient has signed an creases. the patient to notify the practitioner
appropriate consent form. If a blood clot or mucus plug ob- if they occur.
structs a cystostomy tube, try milking Review activity restrictions.
the tube to restore patency.
Check cystostomy hourly for postop- RESOURCES
erative urologic patients. Organizations
To check tube patency, note the American Association of Clinical
amount of urine in the drainage bag Urologists: www.aacuweb.org
and check the patients bladder for American College of Obstetrics and
distention. Gynecology: www.acog.org
Keep the drainage bag below the lev-
el of the kidney at all times. Selected references
Notify the practitioner immediately if Burch, J. The Pre- and Postoperative
the tube becomes dislodged. Nursing Care for Patients with a
Cover the site with a sterile dressing; Stoma, British Journal of Nursing
provide wound care as ordered. 14(6):310-18, March-April 2005.
Monitor the patients vital signs, in- Faenza, A., et al. Urological Complica-
take and output, and urine quality. tions in Kidney Transplantation:
Ureterocystostomy Versus Uretero-
Monitor the patient for complica-
ureterostomy, Transplantation
tions. Proceedings 37(6):2518-20, July-August
Gomez, M. Promising New Suprapubic
Catheter, Urologic Nursing 25(4):288,
291-92, August 2005.
Modi, P., et al. Laparoscopic Ureteroneo-
cystostomy for Distal Ureteral Injur-
ies, Urology 66(4):751-53, October

5125D.qxd 8/15/08 10:56 AM Page 108

Remove the dressing after it com-
OVERVIEW PROCEDURE pletely dries and becomes adherent
to the necrotic tissue (4 to 6 hours).
Removes necrotic tissue by mechani- CONSERVATIVE SHARP
cal, chemical, or surgical means DEBRIDEMENT IRRIGATION
Includes wet-to-dry dressings, irriga- Expose only the area to be debrided Using sterile technique, instill a slow,
tion, hydrotherapy, and excision of to prevent chilling and fluid and elec- steady stream of solution into the
dead tissue with forceps and scissors trolyte loss. wound with an irrigating syringe or
May be performed at the bedside or a Wash your hands and put on a cap, catheter.
specially prepared area such as a hy- mask, gown or apron, and clean
drotherapy tub gloves. HYDROTHERAPY
Conservative sharp debridement: re- Remove the dressings and clean the Prepare the tub and check the pa-
moves necrotic tissue by using a wound. tients vital signs.
scalpel, scissors, or a laser Remove your dirty gloves, and put on Assist the patient into the tub.
Wet-to-dry dressings: used for sterile gloves. After the affected area has been in
wounds with extensive necrotic tis- Lift loosened edges of eschar with the water for the prescribed time, put
sue and minimal drainage forceps. on clean gloves, remove old dress-
Irrigation of a wound with a pressur- Use the blunt edge of scissors or for- ings, and discard items in a water-
ized antiseptic solution: cleans tissue ceps to probe the eschar. proof trash bag.
and removes wound debris and ex- Cut the dead tissue from the wound Spray rinse and pat dry the patient
cess tissue with scissors. before reapplying sterile dressings.
Hydrotherapy: involves immersing Leave a 14 (0.6-cm) edge on remain- WARNING Debride no more than
the patient in a tank of warm water, ing eschar to avoid cutting into vi- 4 (10 cm) square at one time
with intermittent agitation of the able tissue. with debridement procedures.
water Irrigate the wound to remove debris.
Other debridement techniques: Because debridement removes only
chemical debridement (with wound-
dead tissue, bleeding should be min- Infection
cleaning beads or topical agents that imal. If bleeding occurs, apply gentle Bleeding or hemorrhage
remove exudate and debris) or surgi- pressure on the wound with sterile Fluid and electrolyte imbalance
cal excision and skin grafting (usually gauze pads and apply a hemostatic
reserved for deep burns or ulcers) drug.
Daily debridement: prevents hemor- If bleeding persists, notify the practi-
rhage and the need for surgical inter- tioner; maintain pressure on the
ventions wound until he arrives.
May involve combination of debride- Excessive bleeding or spurting ves-
ment techniques sels may require ligation.
Local or general anesthesia: com- Perform additional procedures, such
monly used for surgical debridement as an applying topical drugs and re-
placing dressings as ordered.
Manage or prevent infection Put on clean gloves.
Promote healing Slowly remove the old dressings, us-
Prepare the wound surface to receive ing saline solution to moisten parts
a graft of the dressing that dont easily pull
WARNING Debridement is con- away. Discard old dressing and gloves
traindicated with closed blisters in a waterproof trash bag.
over partial-thickness burns. Put on sterile gloves.
Using sterile technique, moisten a
gauze pad with saline solution and
loosely pack it into the wound. Make
sure that the entire wound surface is
lightly covered.
Apply an outer dressing and secure it
with tape or an adhesive bandage.

5125D.qxd 8/15/08 10:56 AM Page 109


Acute pain Explain the procedure to the patient GENERAL
Impaired skin integrity to lessen anxiety and promote coop- Teach the patient distraction and re-
Risk for infection eration. laxation techniques to ease his pain.
Tell the patient that the procedure is
EXPECTED OUTCOMES painful but that hell be given pain RESOURCES
The patient will: medication. Organizations
express relief from pain Provide privacy. American Medical Association:
maintain or improve skin integrity Give an analgesic 20 minutes before www.ama-assn.org
remain free from infection. debridement begins, or give an I.V. Trauma Organization: www.trauma.org
analgesic immediately before the
procedure. Selected references
Make sure that the room is warm. Beitz, J.M. Wound Debridement: Ther-
apeutic Options and Care Consider-
ations, Nursing Clinics of North
POSTTREATMENT CARE America 40(2):233-49, June 2005.
Davies, C.E., et al. Exploring Debride-
ment Options for Chronic Venous Leg
Monitor the patients vital signs, pe-
Ulcers, British Journal of Nursing
ripheral pulses, and pulse oximetry. 14(7):393-97, April 2005.
Monitor the patient for signs of Ichioka, S., et al. Benefits of Surgical
bleeding. Reconstruction in Pressure Ulcers with
Assess the patient for complications. a Non-advancing Edge and Scar For-
Assess the patients pain level and re- mation, Journal of Wound Care
sponse to analgesics. 14(7):301-305, July 2005.
Assess the patient for signs and
symptoms of infection.
Monitor laboratory test results.

5125D.qxd 8/15/08 10:56 AM Page 110

Deep brain stimulation

OVERVIEW PROCEDURE The neurostimulator is generally
placed at a later time.
Suppresses tremors by delivering LEAD PLACEMENT This surgery is performed under gen-
mild electrical stimulation to block The patients scalp is anesthetized eral anesthesia.
signals from the thalamus, subthala- with local anesthetic. Occasional I.V. A small incision is made in the upper
mic nucleus, or globus pallidus that sedation is also used for patient com- chest near the collar bone. A subcu-
cause tremors without destroying fort but generally the patient is taneous pocket is formed and the
brain tissue awake during the lead placement. neurostimulator is implanted under
Target areas identified by a comput- An incision is made on the top of the the skin.
ed tomography scan or magnetic res- head behind the hairline and a small The lead is attached to an extension
onance imaging of the brain; many opening (burr hole) is made. cable which is passed under the skin
practitioners use microelectrode The neurologist and neurosurgeon of the scalp, neck, and shoulder and
recording technique to map the identify the target sites using micro- connected to the neurostimulator.
brain electrode mapping. (See Deep brain stimulation.)
Components of a deep brain stimu- Once the target site has been con- Programming of the neurostimulator
lator: implantable lead with four firmed a permanent DBS lead is in- usually takes place 3 to 4 weeks after
electrodes at the end; neurostimula- serted through the burr hole. implantation.
tor with an external programming The patient is asked to answer ques-
system to change stimulation set- tions and perform some tasks during COMPLICATIONS
tings; extension wire to connect the the procedure to test the stimulation Infection
lead to the neurostimulator and maximize symptom control. Paresthesia
Can be performed on one or both I.V. sedation is administered and the Paralysis
sides of the brain (Majority of pa- lead is anchored to the skull with a Ataxia
tients with Parkinsons disease re- plastic cap and the scalp incision is Intracerebral hemorrhage
quire stimulators placed on both sutured shut. Seizures
sides of the brain.) Stroke
Procedure usually staged with each Confusion
side of the brain done on separate
Stimulation adjustable and can be
changed as symptoms change

Essential tremor
Parkinsons disease
Deep brain stimulation
The deep brain stimula-
tion system consists of
the stimulating lead
(which is implanted to Lead
the desired target), the Electrode Targeted area
extension cable (which is of the brain
tunneled under the scalp
and soft tissues of the
neck to the anterior
chest wall), and the Extension cable
pulse generator (which
is the programmable
source of the electrical
impulses). This illustra-
tion shows the place-
ment of the stimulator
in the patients body.

5125D.qxd 8/15/08 10:56 AM Page 111


Deficient knowledge (deep brain Monitor vital signs and closely ob- GENERAL
stimulation) serve neurologic status. Review medications and possible ad-
Impaired physical mobility Ensure a quiet, calm environment. verse effects with the patient.
Risk for infection Monitor fluid and electrolyte bal- Review care of the surgical wound
ance. with the patient.
EXPECTED OUTCOMES Make sure dressings stay clean, dry Tell the patient that headache and
The patient will: and intact facial swelling may occur for 2 or 3
express an understanding of the WARNING Notify the surgeon days after surgery.
procedure immediately if you detect a Review postoperative leg and deep-
show improved mobility worsening of mental status, pupillary breathing exercises and the use of
remain free from infection. changes, or focal signs, such as in- antiembolism stockings or a pneu-
creasing weakness in an arm or leg. matic compression device.
Assist with activities of daily living as Discuss the signs and symptoms of
PRETREATMENT CARE appropriate. infection, complications, and when
Administer medications as ordered. to notify the practitioner.
Observe for signs of infection. Explain the importance of follow-up
Perform a complete neurologic as-
sessment. care.
Explain the treatment and prepara- Tell the patient not to engage in light
tion to the patient and his family. activities for 2 weeks after surgery
Verify that the patient has signed an and heavy activities for 4 to 6 weeks
appropriate consent form. after surgery.
Tell the patient that his head may be Explain to the patient that he will be
shaved in the operating room. provided with a magnet to activate
and deactivate the neurostimulator.

American Academy of Neurology:
National Institute of Neurological
Disorders and Stroke :
National Parkinson Foundation:

Selected references
Dunn, D. Preventing Perioperative
Complications in Special Populations,
Nursing2005 35(11):36-43, November
Miller, J.L. Parkinsons Disease Primer,
Geriatric Nursing 23(2):69-75, March-
April 2002.
Plaha, P., and Gill, S. Bilateral Deep Brain
Stimulation of the Pedunculopontine
Nucleus for Parkinsons Disease, Neu-
roreport 16(17):1883-87, November

5125D.qxd 8/15/08 10:56 AM Page 112

Dilatation and curettage or evacuation

D&E her colon before admission. Remind
OVERVIEW A suction curette is used to extract her that she wont be alert after the
the contents of the uterus. The uter- procedure and wont be able to drive.
Involves cervical expansion or dilata- ine cavity is explored to ensure com- Make sure that she has arranged
tion to allow access to the endocervix plete removal of the products of con- transportation.
and uterus ception. Ask the patient to void before admin-
Dilatation and curettage (D&C): istering preoperative medications,
curette used to scrape endometrial COMPLICATIONS such as meperidine (Demerol) or di-
tissue Uterine perforation azepam (Valium). Start I.V. fluids as
Dilatation and evacuation (D&E): Hemorrhage ordered to facilitate administration
suction applied to extract uterine Infection of the anesthetic. For the procedure,
contents WARNING If cervical trauma oc- tell the patient that she may receive a
curs during these procedures, general anesthetic, a regional parac-
INDICATIONS subsequent pregnancies may be affect- ervical block, or a local anesthetic.
Incomplete abortion ed. In fact, such trauma can lead to Offer emotional support and allow
Abnormal uterine bleeding spontaneous abortion, cervical in- the patient to verbalize her feelings.
Obtaining an endometrial or endo- competence, or premature birth. Make sure that the patient has signed
cervical tissue sample for cytologic an informed consent form for the
study procedure.
D&E for incomplete or a therapeutic NURSING DIAGNOSES
abortion (usually up to 12 weeks
gestation but occasionally as late as Acute pain
16 weeks) Anticipatory grieving
Risk for trauma Administer analgesics as ordered.
Expect the patient to have moderate
cramping and pelvic and lower back
pain, but report any continuous,
The patient will:
After receiving a local or general sharp abdominal pain that doesnt
express relief from pain
anesthetic, the patient is placed in respond to analgesics. This may indi-
use support systems to help with
the lithotomy position. cate perforation of the uterus.
A preliminary bimanual pelvic exam- Monitor the patient for hemorrhage
remain free from trauma during the
ination is done. and signs of infection (such as puru-
The cervix is exposed and the depth lent, foul-smelling vaginal dis-
and direction of the uterine cavity is charge). Also check the color and vol-
ume of urine; hematuria indicates
checked; in a D&E, this confirms ges- PRETREATMENT CARE infection. Report these signs imme-
tational size.
The cervical canal is dilated. diately.
Review the procedure with the pa- Administer fluids as tolerated, and
tient and answer her questions. Tell allow food if the patient requests it.
D&C her that she may have some uterine Keep the bed rails raised and help the
Metal dilators of increasing size are cramping during the procedure and patient to walk to the bathroom, if
used to dilate the cervix. that shell have some vaginal drain- appropriate.
The uterine cavity is explored and age and a perineal pad in place after-
polyps are removed. If cervical or ward. Explain that temporary ab-
uterine cancer is suspected, speci-
mens are obtained for biopsy from
dominal cramping and pelvic and
lower back pain normally occur after
the endocervical canal. the procedure.
Standard curettage is done to remove Make sure that preliminary studies
the superficial layer of the endome- Instruct the patient to report signs of
have been completed, including a
trium, taking tissue specimens from history, physical examination, urinal- infection. Tell her to use analgesics to
the four quadrants of the cervix. ysis, Papanicolaou test, and hemato- control pain but to report unrelent-
If done to treat an incomplete abor- crit and hemoglobin measurements. ing sharp pain. (See What to expect
tion, the remaining products of con- Alert the practitioner of abnormali- with a D&C.)
ception are also removed. Inform the patient that spotting and
Make sure that the patient has fol-
discharge may last for 1 week or
lowed preoperative directions for more. Tell her to notify the practi-
fasting and used an enema to empty tioner if bright red blood is observed.

5125D.qxd 8/15/08 10:56 AM Page 113

Instruct the patient to schedule an RESOURCES Takeda, A., et al. Management of Patients
appointment with the practitioner Organizations with Ectopic Pregnancy with Massive
for a routine checkup. American College of Obstetrics and Hemoperitoneum by Laparoscopic
Tell the patient to resume activity as Gynecology: www.acog.org Surgery with Intraoperative Autolog-
tolerated but to follow her practition- ous Blood Transfusion, Journal of
Minimally Invasive Gynecology
ers instructions for vigorous exercise Selected references
13(1):43-48, January 2006.
and sexual intercourse, which are Greenhouse, L. Justices Reaffirm Abor-
usually discouraged until after the tion Access for Emergencies, The New
follow-up visit. York Times, January 19, 2006, p. A1,
Advise the patient to seek birth con- A18.
trol counseling, if needed, and refer Kirby, T.O., et al. Surgical Staging in
Endometrial Cancer, Oncology
her to an appropriate center. Also ad-
20(1):45-50, January 2006.
vise her to seek psychological coun-
seling, if indicated.


What to expect with a D&C

Dear Patient,
Dilatation and curettage (D&C) is a surgical procedure designed to control abnormal uterine bleeding and to determine its

BEFORE THE PROCEDURE check your progress. If you have a local a menstrual period. You may also have
anesthetic, youll be awake during the lower back pain for 1 or 2 days. Here
Before you enter the hospital, youll
procedure. Heres what to expect: are tips for your recovery:
describe your health history, and your
The surgical team will help you lie on Ask your health care provider or
health care provider will give you a
your back on the operating table. Youll nurse to recommend a pain
physical and gynecological examination.
see stirrups for your legs. medicine.
Youll have a Papanicolaou test and
The health care provider will examine Use a sanitary napkin, not a tampon,
blood and urine tests to make sure that
you internally.Then hell do the D&C for mild spotting or staining that may
youre ready for surgery.
using surgical instruments to stretch last a few days or more.
You may be asked to shower with an
(dilate) your cervix and to gently scrape Resume your normal activities, but
antibacterial soap the night before the
the surface lining of the uterus ask your health care provider about
procedure; you may also be given an
(endometrium). He may remove polyps vigorous exercise.
enema to clean your bowel a
(growths that can cause bleeding) and Dont have sexual intercourse until
precaution against infection. Youll
take tissue samples from your cervix healing is complete (about 2 weeks).
probably be told not to eat or drink
and uterus. (The tissue will be studied to Report the following to your health
anything after midnight.
find out the reason for your bleeding.) care provider: vaginal bleeding that
In the hospital, youll be given a mild
If you feel temporary cramping, resembles a menstrual period; fever;
tranquilizer before surgery, and an I.V.
nausea, or light-headedness, breathe sharp, constant pelvic pain; increased
line will be started to give you fluids or
deeply and try to relax. Its unlikely pulse rate; or foul-smelling vaginal
medicine that you may need during the
youll feel discomfort. However, if you drainage.
do, tell your health care provider. He can Be sure to make and keep your
give you medicine. appointment for a checkup.
If you have a general anesthetic to let AFTER THE PROCEDURE This patient-teaching aid may be reproduced by office copier
for distribution to patients. 2007 Lippincott Williams &
you sleep through the procedure, youll Wilkins.
When your anesthetic wears off, youll
wake up in about 1 hour in the post-
feel mild to severe cramping, similar to
anesthesia care unit, where a nurse will

5125E.qxd 8/15/08 11:05 AM Page 114

Electroconvulsive therapy
time, treatment parameters, a brief If the patient is taking benzodi-
OVERVIEW ECG strip, and EEG monitors. azepines before the procedure, ob-
The CRNA or physician administers tain an order to begin tapering and
Electric current delivered to the pa- glycopyrrolate (Robinul) or atropine, discontinue the drugs 3 to 4 days
tients brain by electrodes placed followed by methohexital (Brevital). preprocedure. Benzodiazepines and
(bilaterally or unilaterally) on his Methohexital acts very rapidly. anticonvulsant drugs (such as lo-
temples Expect an abrupt loss of conscious- razepam [Ativan] and phenytoin
Produces seizure lasting from 30 sec- ness when the appropriate dose is in- [Dilantin]) negatively affect the pa-
onds to 1 minute fused. tients response to treatment.
Requires a multidisciplinary ap- After the patient is unconscious, suc- Make sure that all equipment, drugs,
proachphysician: obtains consent, cinylcholine (Anectine) is adminis- and emergency equipment are avail-
titrates drug dosages, and adminis- tered. A tremor or fasciculation of able.
ters the treatment; nurse: provides various muscle groups occurs due to Attach the ECG and EEG monitors.
care during the assessment, prepara- the depolarizing effect of this drug. Complete a preprocedure assess-
tion, treatment, and recovery; certi- Because succinylcholine also causes ment.
fied registered nurse anesthetist complete facial paralysis, mechanical The treatment parameters are set as
(CRNA): responsible for ensuring a ventilation is started at this time. A ordered for pulse width (ms), fre-
patent airway, administering positive rubber mouthpiece is inserted and quency (Hz), duration (sec), and cur-
pressure oxygen during the treat- positive-pressure oxygen is given. rent (amp).
ment and until the patient is breath- The physician initiates the stimulus, AGE FACTOR These parameters
ing well on his own, and administer- and mild seizurelike activity occurs represent the total volume of
ing specific drugs during the proce- for about 30 seconds. The patients electrical stimulus applied, which dif-
dure jaw and extremities must be support- fers depending on the patients age,
ed while avoiding contact with metal. medication use, seizure threshold, and
INDICATIONS Monitor the patients vital signs as other factors.
Affective disorders well as ECG and EEG rhythm strips. Plug in the electronic blood pressure
Selective schizophrenias Assess the skin for burns. monitor. Make sure that the crash
Severe depression when other thera- cart, with emergency drug kit, defib-
pies are ineffective COMPLICATIONS rillator, suction equipment, an endo-
Respiratory distress tracheal intubation tray, and oxygen
Malignant hyperthermia is readily available and that needed
PROCEDURE Persistent memory loss medications are properly prepared.
(See Preparing medications for ECT.)
Verify the orders and gather the ap-
Attach the patient to an electronic
blood pressure monitor and check NURSING DIAGNOSES propriate equipment.
After arrival in the electroconvulsive
his baseline vital signs. Attach a pulse
Disturbed sensory perception (all)
therapy (ECT) room, identify the pa-
oximeter, insert an I.V. catheter, and
Ineffective breathing pattern
tient and check his nothing-by-
attach him to the electrocardiogram
Ineffective tissue perfusion: Cerebral
mouth status.
(ECG) monitor.
Make sure that the patients history
Attach the EEG electrodes and stimu-
(including allergies to medications or
lus electrodes to the rubber head- EXPECTED OUTCOMES latex), physical examination, and
band. Coat the electrodes with con- The patient will: dental evaluation are documented in
duction gel and place the band return to baseline or improved neu-
his chart.
around the patients head. Place the rologic status WARNING Contraindications to
large, silver-colored stimulus elec- maintain adequate ventilation
ECT include brain tumors,
trodes on each temple at about eye exhibit improved or normal neuro-
space-occupying lesions, and other
level. Space the small, brown EEG logic status. brain diseases that cause increased in-
electrodes across the forehead.
tracranial pressure.The seriousness of
Connect the stimulus electrodes to
any physical illness, such as heart, liv-
the stimulus output receptacle on PRETREATMENT CARE er, or kidney disease as well as the psy-
the machine.
chiatric disorder, should be weighed
Run the EEG/ECG machine in the
Review the procedure with the pa- against each other before ECT is initi-
self-test mode. When the machine is tient and what to expect before, dur- ated.
ready, it displays the message Self ing, and after the procedure. Make sure that the following diag-
Test Passed and prints the date, Verify that the patient has signed an nostic tests have been completed
appropriate consent form. and assessed: complete blood count,

5125E.qxd 8/15/08 11:05 AM Page 115

thyroid profile, urinalysis, ECG, incontinence during the procedure. document his vital signs every 15
pseudocholinesterase activity deter- Assist the patient onto the stretcher. minutes until they stabilize.
mination (especially in patients with Discharge the patient from the recov-
severe liver disease, malnutrition, or ery area when hes able to move all
a history of sensitivity to muscle re- POSTTREATMENT CARE four extremities voluntarily, can
laxants or similar substances), chest breathe and cough adequately, is
X-ray, spine radiographs, EEG, and When spontaneous ventilation re- roused and oriented when called, has
cranial computed tomography scan. turns, usually in 3 to 5 minutes, dis- an Aldrete score of 7 or greater, has
Help the patient remove dentures, continue mechanical ventilation. stable vital signs and temperature
partial plates, or other foreign objects Continue to monitor the patients vi- within 1 F (0.6 C) of the pretreat-
from his mouth to prevent choking. tal signs. ment value, and has a normal swal-
Make sure that the patient removes As the patient becomes more alert, lowing reflex. A physicians order is
all jewelry, metal objects, and pros- speak quietly and explain whats hap- required to release the patient from
thetic devices before the procedure pening. Remove the rubber mouth- the recovery area.
to prevent injury. piece. Obtain and record the patients vital
Have the patient wear a hospital Place the patient on his side to main- signs 1 hour after treatment. Check
gown and ask him to void to prevent tain a patent airway. Measure and the patients temperature to assess
for malignant hyperthermia. Then
continue to check his vital signs
Preparing medications for ECT every hour as necessary until stable.

Even though the physician or certified registered nurse anesthetist administers medications during
electroconvulsive therapy (ECT), you should become familiar with the medications that can be used PATIENT TEACHING
so you can assess the patient for adverse effects. Brief descriptions of the most commonly used
drugs appear below. GENERAL
Review signs and symptoms to re-
port to the practitioner.
Dantrolene (Dantrium) Dantrolene is a direct-acting Seizures
skeletal muscle relaxant thats Muscle weakness
effective against malignant hy- Drowsiness
perthermia. Fatigue Organizations
Headache American Academy of Neurology:
Hepatitis www.aan.com
Nervousness American Psychiatric Association:
Insomnia www.healthyminds.org
National Mental Health Association:
Glycopyrrolate (Robinul) Glycopyrrolate has desirable Dilated pupils www.nmha.org
cholinergic blocking effects be- Tachycardia

cause it reduces secretions in Urine retention Selected references
the respiratory system as well Anaphylaxis
Gitlin, M. Treatment-Resistant Bipolar
as oral and gastric secretions. Confusion (in elderly pa-
Disorder, Molecular Psychiatry
It also prevents a drop in heart tients)
rate caused by vagal nerve Dry mouth
11(3):227-40, March 2006.
stimulation during anesthesia. Hanss, R., et al. Bispectral Index-
controlled Anaesthesia for Electrocon-
Methohexital (Brevital) Methohexital is a rapid, ultra- Hypotension vulsive Therapy, European Journal of
short-acting barbiturate anes- Tachycardia Anaesthesiology 23(3):202-207, March
thetic agent. Respiratory arrest 2006.
Bronchospasm Howland, R.H. Therapeutic Brain Stim-
Anxiety ulation for Mental Disorders, Journal
Hypersensitivity reaction of Psychosocial Nursing Mental Health
Emergent delirium Services 43(2):16-19, February 2005.
Sharma, A., et al. Electroconvulsive
Succinylcholine (Anectine) Succinylcholine is an ultra- Bradycardia Therapy after Repair of Cerebral Aneu-
short-acting depolarizing Arrhythmias rysm, The Journal of ECT 21(3):180-81,
skeletal muscle relaxant. Given Cardiac arrest September 2005.
I.V., it causes rapid, flaccid Prolonged respiratory
paralysis. depression
Malignant hyperthermia

5125E.qxd 8/15/08 11:05 AM Page 116

Endarterectomy, carotid
Surgical removal of atheromatous Cervical block anesthesia, sedatives, Ineffective tissue perfusion: Cerebral
plaque from inner lining of carotid or light general anesthesia may be Risk for impaired gas exchange
artery given to the patient. Risk for injury
Improves intracranial perfusion by A longitudinal incision is made over
increasing blood flow through the the area of the carotid bifurcation EXPECTED OUTCOMES
carotid artery and the soft tissue is dissected for ex- The patient will:
Often considered a prophylactic posure of the carotid artery and its maintain baseline neurologic status
treatment for stroke bifurcation. remain free from respiratory distress
The patient is systemically hepari- remain free from injury.
Reversible ischemic neurologic The external, common, and internal
deficit carotid arteries are clamped.
Completed stroke An arteriotomy is made over the
Transient ischemic attack stenotic area. The incision is length-
High-grade asymptomatic or ulcera- ened to expose the full extent of the
tive lesions occluding plaque.
The plaque or plaques are dissected
free from the arterial wall. The intima
is cleaned with heparin solution.
The arteriotomy is closed, and a syn-
thetic or autogenous patch may be
used to restore the arterial lumen if
its small.
The occluding clamps are removed
from the external and common
carotid arteries. The internal carotid
artery clamp is removed last to make
sure that minor debris missed is
flushed harmlessly into the external
rather than the internal carotid ar-
A drain is inserted through a separate
stab incision, the wound is closed,
and a dressing is applied.

Blood pressure lability
Perioperative stroke
Temporary or permanent loss of
carotid body function
Recurrent thrombosis
Respiratory distress
Wound infection
Ipsilateral vascular headache
Intracerebral hemorrhage
Vocal cord paralysis
Transient or permanent neurologic

5125E.qxd 8/15/08 11:05 AM Page 117


Explain the treatment and prepara- Perform a neurologic assessment GENERAL
tion to the patient, and verify that the every hour for the first 24 hours; Discuss care of the surgical wound.
patient has signed an appropriate check extremity strength, fine hand Review the signs and symptoms of
consent form. movements, speech, orientation, and infection.
Explain postoperative care and level of consciousness. Review potential complications of
equipment. Obtain an electrocardiogram if the the procedure.
Perform a complete neurologic as- patient experiences chest pain or ar- Discuss risk factor modification.
sessment. rhythmias. Discuss the management of neuro-
Assist with any invasive procedures Monitor the patients vital signs, in- logic, sensory, or motor deficits.
as appropriate. take and output, heart rate and Review medication administration,
Obtain a baseline EEG before the pa- rhythm, neurologic status, respirato- dosing, and potential adverse effects
tient is anesthetized as ordered. ry status, surgical wound and dress- with the patient and his family.
Tell the patient that hell have some ings, drainage, cervical edema, infec-
postoperative discomfort or pain, tion, seizures, and complications. RESOURCES
but that pain medication will be Asses for pain and administer med- Organizations
available. ications as ordered. American Heart Association:
American Medical Association:

Selected references
Hacke, W., et al. Carotid Endarterectomy
Versus Stenting: An International
Perspective Response, Stroke 37(2):
344, February 2006.
Madycki, G., et al., Carotid Plaque Tex-
ture Analysis Can Predict the Incidence
of Silent Brain Infarcts among Patients
Undergoing Carotid Endarterectomy,
European Journal of Vascular and
Endovascular Surgery 31(4):373-80,
April 2006.
Middleton, S., et al. Nursing Intervention
after Carotid Endarterectomy: A
Randomized Trial of Co-ordinated
Care Post-Discharge (CCPD), Journal
of Advanced Nursing 52(3):250-61,
November 2005.
Mitka, M. Carotid Artery Surgery
Guidelines Updated: New Data Also
Support Stents in High-Risk Cases,
JAMA 294(23):2955-56, December

5125E.qxd 8/15/08 11:05 AM Page 118

Endometrial ablation
Involves removal of the lining of the ELECTROCAUTERY Acute pain
uterus; considered an outpatient sur- After the patient is under anesthesia Anxiety
gical procedure in the operating room, a roller-ball Risk for infection
Offers an effective alternative to hys- or wire loop is used through a hys-
terectomy teroscope and the lining of the uterus EXPECTED OUTCOMES
Commonly chosen when other med- is cauterized. Alternately, freezing The patient will:
ical treatments have failed or are oth- may be done to destroy the uterine verbalize relief from pain
erwise undesirable lining. demonstrate decreased anxiety and
AGE FACTOR Most women cant The lining of the uterus is then va- increased comfort
have children after this proce- porized, using a heat-generating tool exhibit no signs of infection.
dure. Because theres still a slight inserted through the hysteroscope.
possibility of pregnancy, however, About 90% of women experience re-
the patient should continue to use lief of their symptoms within the first
contraception until menopause. few months, with many having brief
Laparoscopy: may be performed at or no menstrual periods after the
the same time to rule out other con- procedure.
ditions that could require further
INDICATIONS This technique is performed in an
Heavy or prolonged bleeding during outpatient surgical center or in a
menses physicians office.
The patient receives either a local or
general anesthetic.
A hysteroscope is inserted through
the vagina and cervix into the uterus.
A tiny camera is attached to allow the
uterine cavity to be shown on a TV
monitor during surgery. A triangular
balloon is placed into the uterus and
filled with fluid. The fluid is heated
for several minutes and most of the
uterine lining is destroyed.

Cardiac arrest
Respiratory arrest
Uterine perforation with resultant
bowel injury
Fluid overload

5125E.qxd 8/15/08 11:05 AM Page 119


Make sure that a medical history and Monitor the patients vital signs and GENERAL
physical examination have been cardiovascular and respiratory status Review activity restrictions with the
completed. Monitor for complications. patient: strenuous activity may be
Verify that the patient has signed an Monitor drainage and the patients avoided for a period, usually for 24
appropriate consent form. comfort level; perform perineal care hours after the procedure.
Make sure pretreatment testing has and apply peripads as indicated. Tell the patient to refrain from sexual
been completed, including complete If specimens are obtained, make sure intercourse, usually 2 weeks or until
blood count, uterine lining sampling that theyre labeled appropriately the discharge stops.
(biopsy), and hysteroscopy and ultra- and sent to the laboratory. Tell the patient to schedule a postop-
sonography. These procedures are Assess the effect of the analgesic. erative appointment about 1 week
usually done in the practitioners Women who have undergone en- after the procedure for follow-up.
office before the treatment. dometrial ablation may be treated Tell the patient that she may experi-
WARNING A biopsy of the uterine with progestogens to reduce the risk ence frequent urination during the
lining may be needed to exclude of developing uterine cancer when first 24 hours and that this is normal.
cancer because endometrial ablation postmenopausal estrogen replace- Tell the patient that she may experi-
isnt appropriate if cancer is suspect- ment therapy is prescribed. Women ence a small amount of bloody, wa-
ed. who have undergone hysterectomy, tery discharge for up to 6 weeks post-
For 1 or 2 months before the proce- in contrast, generally dont require operatively.
dure, the patient may be prescribed a progestogens. Warn the patient that its impossible
gonadotropin-releasing hormone to evaluate the effectiveness of sur-
analog medication or receive injec- gery until at least 3 months postoper-
tions to decrease the thickness of the atively.
endometrium. Thinning the uterine Tell the patient that heavy bleeding
lining exposes the basal layer of en- may recur several years after the ab-
dometrial cells, which are removed lation, requring additional surgery.
by electrosurgery. Review prescribed medications and
The day before surgery, the practi- their potential adverse effects with
tioner may choose to insert medica- the patient.
tion to gradually dilate the cervix be-
fore surgery. RESOURCES
American College of Obstetrics and
Gynecology: www.acog.org
American Medical Association:

Selected references
Bachmann, G. Expanding Treatment
Options for Women with Symptomatic
Uterine Leiomyomas: Timely Medical
Breakthroughs, Fertility and Sterility
85(1):46-67, January 2006.
League, D.D. Endometrial Ablation as an
Alternative to Hysterectomy, AORN
Journal 77(2):322-24, 327-38, February
Paddison, K. Menorrhagia: Endometrial
Ablation or Hysterectomy? Nursing
Standards 18(1):33-37, September

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Procedure in which skin between the Just before birth, the obstetrician Acute pain
vagina and anus (perineum) is cut numbs the vaginal area. Anxiety
Enlarges the vaginal opening so that The episiotomy is usually performed Deficient knowledge (condition and
the neonate can be easily delivered when the fetal head has stretched the treatment)
Usually heals without problems and vaginal opening to several centime-
may heal more quickly than a tear; ters during a contraction. EXPECTED OUTCOMES
also thought to help prevent vaginal One of two types of episiotomies The patient will:
stretching and to tighten the vagina may be done. A mediolateral cut is demonstrate or express feelings of
after delivery angled down away from the vagina increased comfort
and into the muscle. This type of epi- verbalize feelings of reduced anxiety
INDICATIONS siotomy doesnt tend to tear or ex- verbalize understanding of labor and
Infants head is too big for the moth- tend, but is associated with greater delivery process.
ers vaginal opening blood loss and may not heal as well.
Infant in a breech or shoulder posi- A midline cut is made straight down
tion between the vagina and anus. This
To prevent vaginal tearing type of episiotomy usually heals well
Preterm birth but may be more likely to tear and
Fetal distress necessitating rapid de- extend into the rectal area (a third- or
livery fourth-degree laceration).
The area is sutured closed after the
infant and placenta are delivered.

Intercourse-related pain after preg-
Formation of hematoma

5125E.qxd 8/15/08 11:05 AM Page 121

Jensen, K. Preventing Episiotomies,

PRETREATMENT CARE PATIENT TEACHING Midwifery Today International Midwife
(75):49, Autumn 2005.
Kearney, R., et al. Obstetric Factors
Check for allergies (especially latex) GENERAL
to iodine or medications before the Associated with Levator Ani Muscle
Inform the patient that the stitches
Injury after Vaginal Birth, Obstetrics
procedure. are absorbed by the body and dont and Gynecology 107(1):144-49, January
Verify that the patient has signed an need to be removed. 2006.
appropriate consent form. Review pain-relief measures with the Premkumar, G. Perineal Trauma: Reduc-
Explain the purpose of and intended patient: warm sitz baths and anal- ing Associated Postnatal Maternal
effect of the procedure. gesics and creams or local anesthetic Morbidity, RCM Midwives 8(1):30-32,
Place the patient in the lithotomy po- sprays may be used on the perineum January 2005.
sition just before childbirth. as directed by the practitioner.
WARNING Notify the practitioner Review perineal care and how to pre-
if theres a history of bleeding vent infection.
disorders or if the patient is taking an- If stool softeners are ordered, instruct
ticoagulants, aspirin, or other medica- the patient about their use.
tions that affect blood clotting. It may Tell the patient not to douche, use
be necessary to stop these medications tampons, or have intercourse until
before the procedure. approved by the practitioner.
Tell the patient to avoid strenuous
lifting until seen by the practitioner.
POSTTREATMENT CARE Tell the patient to notify the practi-
tioner if bleeding from the episioto-
Monitor the patients vital signs and my site occurs, there are signs of
intake and output. infection (such as foul-smelling
Monitor for vaginal discharge. drainage from the vagina, fever, or
Apply ice to the area. chills), or if shes experiencing severe
Perform perineal care. perineal pain.
Inspect the sutures and surgical site
for complications. RESOURCES
Perform routine postpartum care Organizations
and care of the neonate. American College of Obstetrics and
Monitor the incision site for infec- Gynecology: www.acog.org
tion. American Medical Association:

Selected references
Dencker, A., et al. Suturing after Child-
birth A Randomised Controlled
Study Testing a New Monofilament
Material, BJOG: An International
Journal of Obstetrics and Gynaecology
113(1):114-16, January 2006.
Eogan, M., et al. Does the Angle of Epis-
iotomy Affect the Incidence of Anal
Sphincter Injury? BJOG: An Inter-
national Journal of Obstetrics and
Gynaecology 113(2):190-94, February

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The second part of the procedure is
OVERVIEW PROCEDURE the thorascopic stage. Instruments
are inserted into the chest to remove
Surgical removal of the esophagus The patient receives general anesthe- the damaged parts of the esophagus.
Minimally invasive esophagectomy: sia and is positioned appropriately. After the fundus and lower esopha-
not performed as frequently as tradi- The transhiatal or transthoracic gus are free, both are removed. To
tional esophagectomy because it isnt esophagectomy (Ivor-Lewis proce- reestablish continuity of the digestive
suitable for all patients; advantages: dure) is performed. Transhiatal tract, the stomach is pulled upward
less trauma to the body, less blood esophagectomy is performed with- to join with the remaining portion of
loss, smaller surgical scars, less need out an incision in the chest cavity the esophagus.
for pain medication, shorter hospital and results in reduced pain and
stay, and faster return to normal ac- faster recovery for appropriate pa- COMPLICATIONS
tivities tients. The other approach involves a Infection
Minimally invasive (laparoscopic) thoracic approach. Bleeding
surgery: done through small inci- After the incision is made, the sur- Leakage from the area where the re-
sions (requiring only 1 or 2 stitches to geon will examine the peritoneal maining esophagus is reattached
close), using specialized techniques, cavity for metastatic disease. If Myocardial infarction
miniature cameras with micro- metastases are found, the operation Arrhythmias
scopes, tiny fiber-optic flashlights isnt continued.
and high-definition monitors; During an esophagectomy, the sur-
method not appropriate for all pa- geon removes a portion of the esoph- NURSING DIAGNOSES
tients agus and the top part of the stomach.
AGE FACTOR The type of surgery The esophagus is reconstructed us- Acute pain
performed depends on many ing one of several other organs, most Imbalanced nutrition: Less than
factors, such as the patients age; size commonly the stomach or large in- body requirements
and location of the cancer; whether testine. Risk for infection
the cancer has grown into other struc- A portion of the stomach is then
tures in the chest, such as the lungs or pulled up into the chest and con-
large blood vessels; overall health of nected to the remaining normal por-
The patient will:
the patient; and experience of the sur- tion of the esophagus. The patient
demonstrate or express feelings of
geon in performing the surgical tech- then has a new esophagus made
increased comfort
nique. up of the normal portion of the
maintain a normal weight
esophagus not removed at surgery,
remain free from infection.
INDICATIONS connected to a portion of the stom-
Esophageal cancer ach pulled up into the chest.
Achalasia (abnormal esophageal
nerve function, making swallowing MINIMALLY INVASIVE
The surgeon makes four to five small
incisions and inserts tubelike instru-
ments through them.
The abdomen is filled with gas to
help the surgeon view the abdominal
A camera inserted through one tube
displays images on a monitor located
in the operating room. Other instru-
ments are placed through additional
tubes, allowing the surgeon to work
inside the abdomen without using a
larger incision.
After the stomach is exposed, the
fundus is stapled off and cut from the
rest of the stomach.

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to eat several small meals each day.

PRETREATMENT CARE POSTTREATMENT CARE He can expect to lose about 20 lb
(9 kg) after surgery.
Required, presurgical diagnostic tests Maintain I.V. replacement therapy as Tell the patient to keep follow-up ap-
include blood tests, computed to- ordered. pointments.
mography scanning of the chest, Keep the NG tube patent, but dont Be sure to review medications and
endoscopy, and a chest X-ray. reposition it. their possible adverse reactions, care
An electrocardiogram and echocar- Provide wound care as indicated. for the incision site, signs and symp-
diogram may also be done to check Encourage regular coughing and toms of infection and complications,
for cardiovascular disease that could deep-breathing exercises. and prescribed activity restrictions.
complicate surgery. Encourage splinting of the incision
Make sure that the patient has noth- site as necessary. RESOURCES
ing to eat or drink from midnight be- Monitor the patients vital signs, in- Organizations
fore surgery. take and output, and daily weight. American College of Gastroenterology:
Tell the patient that he may also have Report signs of dehydration, peri- www.acg.gi.org
to undergo preparatory therapies, tonitis, sepsis, and infection. American Gastroenterological
such as bowel cleaning and antibiot- Monitor drainage from the wound. Association: www.gastro.org
ic therapy to help sterilize the bowel. WARNING Monitor for and im- American Medical Association:
Explain the treatment and prepara- mediately report signs and www.ama-assn.org
tion to the patient and his family. symptoms of anastomotic leakage, in-
Verify that the patient has signed an cluding low-grade fever, malaise, Selected references
appropriate consent form. slight leukocytosis, abdominal disten- DeMeester, S.R. Endoscopic Mucosal
Tell the patient that a nasogastric tion, tenderness, hemorrhage, hypov- Resection and Vagal-Sparing Esoph-
agectomy for High-Grade Dysplasia
(NG) tube will be in place after sur- olemic shock, and bloody stool or
and Adenocarcinoma of the Esopha-
gery and will be removed in a few wound drainage.
gus, Seminars in Thoracic and Cardio-
days. Administer medications as ordered. vascular Surgery 17(4):320-25, Winter
Prepare the patient for early postop- Assess for abdominal pain, abdomi- 2005.
erative ambulation. nal cramps, or shoulder pain. Explain Mackenzie, D.J., et al. Care of Patients
Tell the patient to expect to have an that bloating or abdominal fullness after Esophagectomy, Critical Care
I.V. line and abdominal drains after from laparoscopy will subside as gas Nurse 24(1):16-29, February 2004.
surgery. is absorbed, as appropriate. Pennathur, A., et al. Surgical Aspects of
Provide comfort measures. the Patient with High-Grade Dyspla-
sia, Seminars in Thoracic and Cardio-
vascular Surgery 17(4):326-32, Winter

Review with the patient coughing
and deep-breathing exercises and
splinting of the incision site.
Tell the patient to avoid abdominal
straining and heavy lifting until the
sutures are completely healed and
the practitioner approves.
Tell the patient to return to activities
as directed. Because a laparoscopic
procedure is less traumatic, he can
usually resume normal activities
soon after leaving the health care fa-
Tell the patient that after 1 month, he
can resume his normal diet, but
needs to eat smaller quantities. The
reduced size of the stomach limits its
capacity to hold food. Instead of eat-
ing three large meals, he may choose

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External enhanced coronary perfusion

Patients are treated with EECP 1 or 2
OVERVIEW PROCEDURE hours per day for a total of 35 hours.
The first week of treatment is limited
Noninvasive procedure that can re- The EECP device is placed on the pa- to 1 hour daily to facilitate familiar-
duce the symptoms of angina pec- tients legs and set to inflate and de- ization and monitor patient toler-
toris by increasing coronary blood flate a series of compression cuffs ance before increasing the daily
flow in ischemic areas of the heart wrapped around the patients calves, treatment time. Two hours of treat-
Involves the use of the external en- lower thighs, and upper thighs. (See ment on the same day is usually sep-
hanced coronary perfusion (EECP) External enhanced coronary perfu- arated by a rest period.
device to inflate and deflate a series sion device.)
of compressive cuffs wrapped At the start of treatment, external COMPLICATIONS
around the patients calves, lower compression is progressively in- Discomfort from the pulsatile move-
thighs, and upper thighs; inflation creased, as needed, to raise diastolic ment and pressure on legs and but-
and deflation of cuffs modulated by pressures gradually. Finger plethys- tocks
events in the cardiac cycle via com- mography is used to monitor correct
puter-interpreted electrocardiogram timings.
(ECG) signals Inflation and deflation of the cuffs NURSING DIAGNOSES
Concept of counterpulsation: based are modulated by events in the car-
on a favorable response of the left diac cycle via computer-interpreted Activity intolerance
ventricle to reduce arterial pressure ECG signals. Decreased cardiac output
during the systolic period; heart can During diastole, the cuffs inflate se-
Ineffective tissue perfusion: Cardio-
be rested and its demand for oxygen quentially from the calves proximally, pulmonary
reduced, if left ventricular pressure resulting in augmented diastolic cen-
can be reduced; increases stroke vol- tral aortic pressure and increased
ume per unit work and efficiency of coronary perfusion pressure. Rapid
The patient will:
the left ventricle; coronary flow and and simultaneous decompression of
carry out activities of daily living
collateral flow to ischemic regions of the cuffs at the onset of systole per-
without excess fatigue or decreased
myocardium increased mits systolic unloading and de-
creased cardiac workload.
maintain adequate cardiac output
INDICATIONS be free from signs of decreased car-
Stable or unstable angina pectoris
diopulmonary tissue perfusion.
Patients considered at high risk for
revascularization procedures or in
whom revascularization isnt techni-
cally possible
External enhanced coronary perfusion device
Heart failure
Cardiogenic shock The external enhanced
coronary perfusion SEQUENCE OF INFLATIONS
device is a series of
compression cuffs that
are placed on the
patients legs and set to
inflate and deflate. This
illustration shows the
sequence of inflations:
the calves are inflated
first, then the thighs,
then the buttocks.

5125E.qxd 8/15/08 11:05 AM Page 125

American College of Cardiology:
At each visit and before treatment Place the patient in a comfortable www.acc.org
begins, take and record the patients position and give supplemental oxy- American Medical Association:
resting blood pressure readings. Also gen as indicated. www.ama-assn.org
measure and record the sitting pulse Provide continuous cardiac monitor-
and respiratory rates. ing as indicated. Selected references
WARNING Patients with blood Administer medications and monitor Michaels, A.D., et al. The Effects of
pressure over 180/110 mm Hg or for effect as ordered. Enhanced External Counterpulsation
on Myocardial Perfusion in Patients
a heart rate of more than 120 beats/ Provide support for the patients fam-
with Stable Angina: A Multicenter
minute should have these conditions ily.
Radionuclide Study, American Heart
treated before beginning EECP. Monitor the patients vital signs and Journal 150(5):1066-73, November
The patients legs are examined for intake and output as ordered. 2005.
areas of redness, ecchymosis, and Shea, M.L., et al. An Update on
signs of other vascular problems. Enhanced External Counterpulsation,
Advise the patient to urinate imme- PATIENT TEACHING Clinical Cardiology 28(3):115-18,
diately before treatment. March 2005.
Ask the patient about symptoms of Soran, O., et al. Two-Year Clinical Out-
angina and review the patients comes after Enhanced External
Review the signs and symptoms of
record. Counterpulsation (EECP) Therapy
heart failure. in Patients with Refractory Angina
WARNING EECP shouldnt be Tell the patient that discomfort from Pectoris and Left Ventricular Dysfunc-
used to treat patients with un- the pulsatile movement and pressure tion (report from the International
controlled heart failure, severe valvu- on legs and buttocks may be elimi- EECP Patient Registry), American
lar disease, uncontrolled arrhythmias, nated or minimized by using suitable Journal of Cardiology 97(1):17-20,
hemorrhage, coagulopathy, throm- protective clothing during treatment, January 2006.
bophlebitis, and peripheral vascular such as tights or bicycle pants.
diseases involving iliofemoral arterial Advise the patient that if the pulsat-
obstruction. ing sensation becomes uncomfort-
able, he should notify the treatment
supervisor immediately to stop the
Instruct the patient to record each
anginal attack, its time of occurrence,
duration, severity, its relationship to
precipitating factors, and the num-
ber of nitroglycerin tablets used to
ease the attack. Check the patients
diaries for accuracy and complete-
ness at each treatment visit.
Emphasize the importance of follow-
up care.

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Extracorporeal membrane oxygenation

INDICATIONS The catheter is connected to the
OVERVIEW Severe acute respiratory failure in pa- ECMO circuit and therapy is initiat-
tients of all ages ed; a continuous heparin infusion is
Group of supportive therapies that Acute respiratory distress syndrome maintained throughout therapy. An
oxygenizes blood outside the body Perioperative cardiac failure ECMO specialist remains at the pa-
Exposes a patients lungs to low pres- Primary myocardial failure tients bedside. (See ECMO setup.)
sures, allowing them to rest and pro- Bridge to transplantation As blood leaves the patients body, its
viding a means for oxygen delivery pumped through a membrane oxy-
and carbon dioxide removal genator, which acts as an artificial
Lowers fraction of inspired oxygen PROCEDURE lung, supplying oxygen to the blood.
(FIO2) concentrations and volumes A roller pump regulates the blood
via mechanical ventilation, thereby The physician uses strict aseptic flow to the oxygenator, turning off
reducing the risk of oxygen toxicity technique to insert a cannula (adult whenever the pump flow is greater
and barotrauma size ranging from 16 French to 23 than blood return to the patient; ex-
Also called ECMO or extracorporeal French) percutaneously into the ap- cessive pressure on the right atrium
life support propriate vessel. or major vessels is averted. The
The patient receives a loading dose pump automatically restarts when
of heparin I.V. the flow rate balances.
AGE FACTOR Typical blood flow
rates for adults range from 70 to
90 ml/kg/minute; for children, 80 to
ECMO setup 100 ml/kg/minute; and for neonates,
120 to 170 ml/kg/minute.
Extracorporeal membrane oxygenation (ECMO) heater generates heat needed to keep An in-line fiber-optic catheter is used
is managed by either a critical care nurse or blood at a constant temperature
to monitor venous oxygen levels.
respiratory therapist with special training in its heat exchanger uses heat generated by a
Before returning to the patient, the
operation. Illustrated and described here is a heater to maintain the temperature of the blood
typical ECMO setup: as its oxygenated blood passes through a heat ex-
arterial filter removes air bubbles and hemochron monitors blood clotting changer where its warmed to pre-
clots from the blood as it travels through the I.V. pump allows injection of medications, vent hypothermia.
ECMO circuit such as antibiotics, into the cannula of the
cannula catheter through which blood ECMO circuit COMPLICATIONS
travels to and from the patient membrane oxygenator serves as the Numerous complications (see
control desk module continuously artificial lung supplying oxygen to the blood Complications of ECMO)
monitors pressure throughout the circuit and transonic blood flowmeter measures the
regulates blood flow rate as needed in amount of blood flowing through the cannula at
response to changing pressures in the system various places along the ECMO circuit.
Impaired gas exchange
Ineffective tissue perfusion: Cardio-
O2 blender pulmonary
Risk for infection

Warmed H2O input The patient will:
maintain adequate ventilation
maintain tissue perfusion
Postmembrane pressure monitor
Postmembrane remain free from infection.
pressure Fluids Heparin
reservoir Instruct the patient and his family
about the procedure and the ration-
ale for treatment. Reinforce the prac-
titioners explanation of the proce-
dure, equipment, and follow-up care,

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and verify that an appropriate con- Assess ET tube patency, position, and Expect to administer blood transfu-
sent form is signed. function, and mechanical ventila- sions, including packed red blood
As appropriate, inform the patient tion. Monitor oxygen saturation lev- cells to increase the oxygen carrying
that hell have an endotracheal (ET) els and arterial blood gas levels as or- capacity of the blood and help stabi-
tube in place and will be connected dered. Administer supplemental oxy- lize the patients intravascular vol-
to a mechanical ventilator. Review gen and suction as necessary. ume. Anticipate platelet transfusion
other equipment that may be used After ECMO is initiated and the pa- if the patients platelet count drops
and provide emotional support. tients gas exchange shows signs of below 100,000/mm3.
Administer sedation as ordered to re- improvement, expect to lower venti- Inspect catheter insertion sites for
duce pain and restrict movement lator settings. Stay alert for changes oozing or hematoma; change dress-
during catheter insertion and treat- in tidal volumes, which should in- ings as needed to keep the site clean
ment initiation. crease as the lungs improve. and dry. If necessary, weigh saturated
Perform chest physiotherapy and dressings to determine fluid volume
change the patients position fre- loss.
POSTTREATMENT CARE quently. Make sure that the ECMO If a hematoma develops, palpate and
circuit is unimpaired. mark the borders to monitor for an
Assess cardiopulmonary and hemo- Administer sedatives and analgesia increase in size.
dynamic status closely, including and apply soft restraints as ordered. Assess the affected extremity distal to
central venous pressure, pulmonary Monitor intake and output, daily the ECMO catheter insertion site for
artery pressure, and cardiac output, weight, blood urea nitrogen, and pulses, color, and temperature at
as indicated by the patients condi- serum creatinine levels closely for re- least every 2 hours.
tion or your facilitys policy. nal dysfunction. Administer diuretics WARNING A thready or absent
If the patient becomes hemodynami- as ordered to maintain fluid balance. pulse; a pale, cyanotic, or cool
cally unstable, expect to administer Assess for signs and symptoms of extremity; and a decrease in sensation
dopamine (Intropin)to raise blood acute renal failure; anticipate the indicate that the extremity isnt receiv-
pressure and dobutamine (Dobutrex) need for hemofiltration, which can ing adequate blood flow.This is an
to improve cardiac output; titrate be added to the ECMO circuit. emergency that must be reported to
dosages to desired response. Monitor activated clotting times as the practitioner immediately.
indicated and assist with adjust-
ments to heparin infusion.
Complications of ECMO GENERAL
Offer emotional support to the pa-
Extracorporeal membrane oxygenation (ECMO) is associated with numerous complications. tients family; encourage them to visit
and interact with the patient.
MECHANICAL COMPLICATIONS racic, intra-abdominal, or retroperitoneal hem-
Clots in the circuit (most common mechani- RESOURCES
cal complication) leading to oxygenator failure,
Myocardial stun (decrease in left ventricular
consumption coagulopathy, and pulmonary and American Medical Association:
systemic emboli shortening fraction on initiation with return to
Cannula placement leading to damage of in- normal after 48 hours of ECMO)
The Society of Thoracic Surgeons:
ternal jugular vein or dissection of the carotid Hypertension
arterial intima Pericardial tamponade
Air in the circuit Pneumothorax
Oxygenator failure Pulmonary hemorrhage Selected references
Oliguria Gay, S.E., et al. Critical Care Challenges
Cracks in connectors and tube rupture
Acute tubular necrosis in the Adult ECMO Patient, Dimen-
Pump malfunction
Hemorrhage from stress, ischemia, or bleed- sions of Critical Care Nursing 24(4):
Heat exchanger malfunction
ing tendencies 157-62, July-August 2005.
Failure of entire circuit
Hyperbilirubinemia Vlasselaers, D., et al. Ventricular
Failure of circuit monitoring equipment
Biliary calculi Unloading with a Miniature Axial Flow
PATIENT COMPLICATIONS Infection; sepsis Pump in Combination with Extracor-
Metabolic acidosis or alkalosis poreal Membrane Oxygenation, In-
Electrolyte imbalances (either high or low) tensive Care Medicine 32(2):329-33,
Intracranial bleeding
involving potassium, sodium, and calcium February 2006.
Hemorrhage at catheter site, surgical site, or
site of previous invasive procedures; intratho- Hyperglycemia or hypoglycemia

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Extratemporal cortical resection

Surgery to resect brain tissue that After the patient receives general Acute pain
contains a seizure focus anesthesia, the surgeon creates a Disturbed sensory perception (all)
May involve tissue removal from window to insert special instruments Risk for infection
more than one area or lobe of the to remove brain tissue by making an
brain incision in the scalp, and performs a EXPECTED OUTCOMES
Successful in eliminating or reducing craniotomy by removing a piece of The patient will:
seizures in 45% to 65% of cases; gen- bone and pulling back a section of verbalize relief from pain
erally more effective if only one area the dura. Surgical microscopes are exhibit improved or normal neuro-
of the brain is involved used to give the surgeon a magnified logic status
view of the area of the brain involved. exhibit no signs of infection.
INDICATIONS In some cases, a portion of the sur-
Disabling seizures uncontrolled by gery is performed while the patient is
medication awake, using medication to keep the
For patients who cant tolerate anti- person relaxed and pain-free. This is
seizure medication due to severe ef- done so that the patient can help the
fects on quality of life surgeon find and avoid areas in the
brain responsible for vital functions,
such as brain regions of language
and motor control.
After the brain tissue is removed, the
dura and bone are fixed back into
place, and the scalp is closed using
stitches or staples.

Allergic reaction to anesthesia
Swelling of the brain
Failure to relieve seizures
Changes in personality or behavior
Partial loss of vision, memory, or

5125E.qxd 8/15/08 11:05 AM Page 129

Selected references
PRETREATMENT CARE Seizure medications are continued Cascino, G.D. Surgical Treatment for
and unchanged to evaluate the initial Extratemporal Epilepsy, Current
An extensive presurgery evaluation is effects of surgery. Afterward, medica- Treatment Options in Neurology
usually done and includes such test- tions should be adjusted to maximal 6(3):257-62, May 2004.
effect. Cascino, G.D., et al. Ictal SPECT in
ing as video electroencephalographic
Nonlesional Extratemporal Epilepsy,
seizure monitoring, magnetic reso-
Epilepsia 45(Suppl 4):32-34, 2004.
nance imaging, and positron emis-
sion tomography. Other tests include PATIENT TEACHING Cho, D.Y., et al. Application of Neuro-
navigator Coupled with an Operative
neuropsychological memory testing, Microscope and Electrocorticography
Wada test (to lateralize the side of GENERAL in Epilepsy Surgery, Surgical Neurol-
language), ictal single-photon emis- Review care of the surgical wound ogy 64(5):411-17, discussion 417-18,
sion computed tomography, and with the patient. November 2005.
magnetic resonance spectroscopy. Inform the patient that headache
These tests help pinpoint the seizure and facial swelling will likely occur
focus and determine if surgery is for 2 or 3 days after surgery.
possible. Review postoperative leg exercises
Explain the treatment and prepara- and deep breathing and the use of
tion to the patient and his family. antiembolism stockings or a pneu-
Verify that the patient has signed an matic compression device.
appropriate consent form. Review signs and symptoms of infec-
Tell the patient that his head may be tion, complications, and when to no-
shaved in the operating room. tify the practitioner.
Perform a complete neurologic as- Explain the importance of follow-up
sessment. care.
Tell the patient that most people who
undergo this procedure can return to
POSTTREATMENT CARE their normal activities, including
work or school 4 to 6 weeks after sur-
Position the patient on his side with gery.
the head of the bed elevated 15 to 30 Inform the patient that hair will grow
degrees. over the incision site and hide the
Encourage careful deep breathing surgical scar.
and coughing; suction gently as Inform the patient that although he
needed. may need to continue taking anti-
Provide a quiet, calm environment. seizure medication for 2 or more
Maintain seizure precautions. years after surgery, when seizure
Monitor the patients vital signs, in- control is established, the medica-
take and output, level of conscious- tions may be reduced or eliminated.
ness, respiratory status, intracranial
pressure (ICP), heart rate and RESOURCES
rhythm, hemodynamic values, fluid Organizations
and electrolyte balance, urine specif- American Academy of Neurology:
ic gravity, daily weight, drain patency, www.aan.com
surgical wound and dressings, American Medical Association:
drainage, and complications. www.ama-assn.org
WARNING Notify the practitioner Epilepsy Therapy Development Project:
immediately if you detect a www.epilepsy.com
worsening mental status, pupillary
changes, or focal signs, such as in-
creasing weakness in an arm or leg.
These findings may indicate increased

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Femoral popliteal bypass

One end of the vein graft is attached
OVERVIEW above the blockage femorally, and NURSING DIAGNOSES
the free end of the graft is tunneled
Used to restore blood flow to the leg next to the artery to the popliteal site, Acute pain
with a femoral artery occlusion where its sutured in place. Impaired tissue integrity
Also called femoral-popliteal or fem- Blood flow is initiated through the Risk for infection
pop bypass graft and the connections are as-
sessed for leakage. EXPECTED OUTCOMES
INDICATIONS A repeat arteriogram is performed to The patient will:
Vessel damaged by an arteriosclerot- confirm that blood flow has been re- verbalize and demonstrate feelings of
ic or thromboembolic disorder stored. increased comfort
Arterial occlusive disease The incisions are closed and dress- demonstrate improvement in pe-
Limb-threatening acute arterial oc- ings are applied. ripheral pulsations and circulation in
clusion unresponsive to thrombolyt- the affected extremity
ic drug therapy COMPLICATIONS not show signs of incisional or deep
Vessel trauma, infection, or congeni- Vessel or nerve injury leg infection.
tal defect Thrombus or emboli formation
Vascular disease unresponsive to Myocardial infarction
drug therapy or nonsurgical revascu- Cardiac arrhythmias
larization Hemorrhage
PROCEDURE Pulmonary edema
Graft occlusion, narrowing, dilation,
The procedure may be done under or rupture
local or general anesthesia. (See
Femoropopliteal bypass.)
I.V. antibiotics may be administered
prophylactically during or just after
the procedure; blood pressure drugs
may be titrated to maintain the de-
sired range.
The surgical area is thoroughly
cleaned with an antiseptic solution.
Immediately before starting the pro-
cedure, the surgical team takes a
time out to verify the correct pa-
tient, procedure, and site. Femoropopliteal bypass
If the saphenous vein will be used, an
incision is made in the thigh and the A femoropopliteal bypass graft is used
other tissues are retracted until the to restore blood flow to the leg with a
vein can be seen. An appropriate femoral occlusion. The surgeon by-
length of the vein is excised for graft- passes the occluded part of the artery
ing and prepared (the vein is re- with an autogenous graft from the pa-
tients saphenous vein. If this vein
versed so that the end that was origi-
cant be used, a synthetic graft is
nally located in the groin is now con- placed.
nected to the popliteal artery to
eliminate hindrance of the valves).
If the saphenous vein is inadequate, Femoral
a synthetic vein graft is used.
The saphenous access incision is
Graft in place
closed and smaller incisions are
made in the groin area to access the
femoral artery, and behind the knee
for the popliteal artery.

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Explain the treatment and prepara- Monitor the patients vital signs, GENERAL
tion to the patient and his family. heart rate and rhythm, and neu- Review medications and possible ad-
Verify that the patient has signed an rovascular status per facility policy. verse reactions with the patient, in-
appropriate consent form. (Use Doppler ultrasonography if pe- cluding possible new antiplatelet
Explain postoperative care. ripheral pulses arent palpable.) drugs.
Perform a complete neurovascular Administer medications as ordered. Teach the patient to monitor his low-
assessment; mark the location of dis- Position the patient, as ordered, and er extremities for changes in temper-
tal peripheral pulses bilaterally (if encourage frequent turning, keeping ature, color, and sensation, and any
present) for ease of monitoring dur- pressure off the graft site. return of preoperative symptoms,
ing and after the procedure (may re- Provide comfort measures and anal- and to notify the surgeon of changes
quire Doppler ultrasound localiza- gesics as needed. noted.
tion in affected extremity). Assist with initial transfers and am- Teach the patient how to care for the
Obtain baseline vital signs and blood bulation when cleared by the practi- incision sites.
pressure. tioner, and explain recommended Review the signs and symptoms of
Obtain or verify the completion of activity levels to the patient. infection with the patient.
the baseline 12-lead electrocardio- Encourage frequent incentive Tell the patient about signs and
gram and laboratory studies. spirometer use, coughing, and deep symptoms of possible complications,
Restrict food and fluids as ordered. breathing. and to call the practitioner promptly.
Give the patient an aspirin before the Assist with and teach the patient Advise the patient to stop smoking, if
procedure, if ordered by the surgeon. range-of-motion exercises. appropriate, and encourage him to
Notify the surgeon if the patient is Assess incisions frequently for bleed- follow a low-cholesterol diet, exercise
sensitive to or is allergic to any med- ing and infection, and provide care regularly per the practitioners in-
ications, latex, iodine, tape, contrast and dressing changes as ordered. structions, and have regular moni-
dyes, or anesthetic agents (local or Record intake and output; remove toring of his blood pressure and cho-
general). urinary catheter as ordered. lesterol levels.
Notify the surgeon if theres a history Assess for complications, including
of bleeding disorders or if the patient abnormal bleeding, graft occlusion, RESOURCES
is taking anticoagulants, aspirin, or signs of infection, chest pain, and Organizations
other medications that affect blood breathing difficulty with embolism or American College of Surgeons:
clotting. It may be necessary to stop pulmonary edema. www.facs.org
these medications before the proce- American Heart Association:
dure. www.americanheart.org
Make sure the surgeon marks the site Vascular Disease Foundation:
where the procedure is to be per- www.vdf.org
Complete the preoperative verifica- Selected references
tion process. DAddio, V., et al. Femorofemoral Bypass
Shave the areas around the surgical with Femoral Popliteal Vein, Journal of
sites as ordered. Vascular Surgery 42(1):35-39, July 2005.
Initiate peripheral I.V. access; inform Galaria, I.I., et al. Popliteal-to-Distal
Bypass: Identifying Risk Factors Asso-
the patient that his heart rhythm will
ciated with Limb Loss and Graft Fail-
be monitored during the procedure. ure, Vascular and Endovascular
Insert a urinary catheter after prepar- Surgery 39(5):393-400, September-
ing the patient for the procedure. October 2005.
Administer sedation as ordered. Lee, T.L., and Bokovoy, J. Understanding
Discharge Instructions After Vascular
Surgery: An Observational Study,
Journal of Vascular Nursing 23(1):25-
29, March 2005.

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Gastric bypass
With laparoscopy, small incisions are express positive feelings about self
OVERVIEW made in the abdomen. Carbon diox- exhibit weight loss.
ide is insufflated to separate the or-
Malabsorption and restriction proce- gans from one another. The surgeon
dure in which a small stomach passes slender surgical instruments PRETREATMENT CARE
pouch is created using sutures and is through these incisions with a la-
attached to a portion of the jejunum; paroscope to perform the procedure A complete medical examination is
reduces the bodys intake of calories, and video monitoring during the sur- done to evaluate the patients overall
thus achieving potentially significant gery. health. A psychological evaluation is
weight loss also performed to determine if hell
Postoperatively, because stomach is COMPLICATIONS be adhering to the new lifestyle.
smaller, allows patient to feel fuller Bleeding Extensive nutritional counseling is
faster Infections done with the patient.
Also referred to as a Roux-en Y bypass Gallstones Explain the treatment and prepara-
Gastritis tion to the patient and his family.
INDICATIONS Vomiting Verify that the patient has signed an
Body mass index (BMI) of 40 or Iron or vitamin B12 deficiencies lead- appropriate consent form.
more; a patient with a BMI of 40 or ing to anemia Obtain blood samples for hemato-
more is at least 100 lb (45 kg) over his Calcium deficiency leading to osteo- logic and chemistry studies as or-
recommended weight (normal BMI, porosis dered.
18.5 to 25) Dumping syndrome (nausea, vomit- Withhold food and fluids as ordered.
BMI of 35 or more plus a life-threat- ing, diarrhea, dizziness, and sweat- Begin I.V. fluid replacement and total
ening illness that can be improved ing) parenteral nutrition (TPN) as or-
with weight loss, such as sleep apnea, dered.
type 2 diabetes, and heart disease Prepare the patient for abdominal
NURSING DIAGNOSES X-rays as ordered.
Explain postoperative care and
PROCEDURE Activity intolerance equipment.
Chronic low self-esteem Monitor the patients vital signs, in-
Immediately before starting the pro- Imbalanced nutrition: More than take and output, nutritional status,
cedure, the surgical team takes a body requirements and laboratory test results.
time out to verify the correct pa- Complete the preoperative verifica-
tient, procedure, and site. EXPECTED OUTCOMES tion process.
The surgery is performed under gen- The patient will:
eral anesthesia. perform activities of daily living
The surgeon divides the stomach
into a small upper section and a larg-
er bottom section using staples simi-
lar to stitches. Understanding gastric bypass
After the stomach has been divided,
the surgeon connects a section of the
In gastric bypass surgery, most
small intestine (commonly the je- of the stomach is bypassed as Esophagus
junum) to the pouch. shown. Staples
The surgeon then reconnects the
Stomach pouch
base of the Roux limb with the re-
maining portion of the small intes-
tines from the bottom of the stom- Stomach
ach, forming a Y-shape. (See Jejunum
Understanding gastric bypass.)
Gastric bypass can be performed us-
ing a laparoscope. Duodenum
WARNING If the patient weighs
more than 350 lb (159 kg) or if he
has had previous abdominal surgery,
he isnt a good candidate for la-

5125G.qxd 8/15/08 11:15 AM Page 133

Instruct that patient that after his

POSTTREATMENT CARE PATIENT TEACHING diet includes solid food, hell need to
chew slowly and thoroughly. Hell be
Maintain I.V. replacement therapy as GENERAL instructed on eating small meals fre-
ordered. Review medications and possible ad- quently during the day, rather than
Keep the nasogastric tube patent, but verse reactions with the patient. large meals.
dont reposition it. Instruct the patient to report exces- Advise the patient that he may need
Encourage regular turning, coughing sive bleeding from surgical sites. to separate fluid and food intake by
and deep-breathing exercises, and Review the signs and symptoms of at least 30 minutes and to sip fluids
use of incentive spirometry. infection with the patient. only.
Encourage splinting of the incision Teach the patient about the signs and Tell the patient he wont be able to
site with coughing and movement. symptoms of obstruction or perfora- tolerate large amounts of fat, alcohol,
Monitor vital signs, intake and out- tion. or sugar. Advise him to reduce his in-
put, and daily weight. Advise the patient to continue take of fat (especially fast-food
Report signs of dehydration, peri- coughing and performing deep- meals, deep-fried foods, and high-fat
tonitis, sepsis, infection, or postre- breathing exercises. foods) and sugar (such as cakes,
section obstruction. Teach the patient how to care for the cookies, and candy).
WARNING Monitor for and im- surgical wound.
mediately report signs and Inform the patient about dumping RESOURCES
symptoms of anastomotic leakage, in- syndrome (weakness, nausea, flatu- Organizations
cluding low-grade fever, malaise, lence, and palpitations occurring American College of Gastroenterology:
slight leukocytosis, abdominal disten- within 30 minutes after a meal) and www.acg.gi.org
tion, tenderness, hemorrhage, hypov- how to prevent it. American Gastroenterological
olemic shock, and bloody stool or Inform the patient that hell receive Association: www.gastro.org
wound drainage. extensive nutritional counseling. American Society of Bariatric Surgery:
Administer medications as ordered. www.asbs.org
Tell the patient that about 10 lb (4.5
Assess for abdominal pain, cramp- kg) per month is usually lost and that
ing, or shoulder pain. Explain that a stable weight occurs between 18 Selected references
bloating or abdominal fullness from and 24 months after surgery. Inform Blackwood, H.S. Help Your Patient
laparoscopy will subside as carbon Downsize with Bariatric Surgery,
him that most weight loss occurs at
Nursing (Suppl):4-9, Fall 2005.
dioxide is absorbed. the beginning. Cottam, D.R., et al. A Case-Controlled
Provide comfort measures. Inform the patient that during his Matched-Pair Cohort Study of
Administer medications as ordered. follow-up visits in the first year after Laparoscopic Roux-En-Y Gastric
Place the patient in low or semi- surgery, physical and mental health Bypass and Lap-Band Patients in a
Fowlers position. status, change in weight, and nutri- Single U.S. Center With Three-Year
Monitor bowel sounds. After bowel tional needs will be addressed. Follow-Up, Obesity Surgery
sounds return, begin oral intake, pro- Instruct the patient that to achieve 16(5):534-40, May 2006.
viding six small feedings per day. weight loss and avoid complications, Smith, B.L. Bariatric Surgery. Its No Easy
Monitor laboratory test results. he must exercise and eat as directed. Fix, RN 68(6):58-63, June 2005.
Provide wound care, and assess the Tell the patient hell remain on liquid
type and amount of drainage. or pureed food for several weeks after
Assess for signs of dehydration; en- the surgery. Even then, hell feel full
courage fluids to prevent dehydra- quickly because the new stomach
tion. pouch initially holds only 1 table-
Monitor for complications of morbid spoonful of food. Tell him that the
obesity, such as pneumonia, throm- pouch eventually expands.
boembolism, skin breakdown, and Advise the patient that he may need
delayed wound healing. replacement of iron, calcium, vita-
min B12, or other nutrients and that
supplements, such as a multivitamin
with minerals, may be prescribed.

5125G.qxd 8/15/08 11:15 AM Page 134

Gastric lavage
If using a syringe irrigation set, aspi-
OVERVIEW rate stomach contents with a 50-ml NURSING DIAGNOSES
bulb or catheter-tip syringe before
Irrigation of the stomach and aspira- instilling the irrigant. Disturbed sensory perception (all)
tion of stomach contents through a If using a syringe, after confirming Impaired gas exchange
large-bore gastric tube proper tube placement, instill about Ineffective tissue perfusion: Renal,
50 ml of solution at a time until 250 cerebral, cardiopulmonary, periph-
INDICATIONS to 500 ml has been instilled. Clamp eral
Preparation for endoscopic examina- the inflow tube and unclamp the
tion outflow tube to allow the irrigant to EXPECTED OUTCOMES
Life-threatening poisoning flow out. The patient will:
Life-threatening drug overdose WARNING Correct tube place- exhibit improved neurologic status
Upper GI bleeding ment is essential; accidental maintain patent airway and ade-
WARNING Gastric lavage is con- misplacement in the lungs followed by quate oxygenation
traindicated after ingestion of lavage can be fatal. demonstrate hemodynamic stability.
corrosive substances (such as lye, pe- If using the syringe irrigation kit, as-
troleum distillates, ammonia, alkalis, pirate the irrigant with the syringe
or mineral acids); the lavage tube may and empty it into a calibrated con- PRETREATMENT CARE
perforate the already compromised tainer. Measure inflow and outflow to
esophagus. make sure that outflow equals at
Explain the procedure to the patient
least the amount of irrigant instilled;
and his family.
this prevents stomach distention and
Remove the patients dentures if
PROCEDURE vomiting.
If the drainage amount is significant-
Maintain a patent airway.
ly less than the instilled amount,
If the patient has a decreased level of Gather equipment and set up per
reposition the tube until sufficient
consciousness (LOC), he may require facility protocol. A prepackaged,
solution flows out. Gently massage
endotracheal intubation before the syringe-type irrigation kit may be
the abdomen over the stomach to
procedure. used for intermittent lavage. For poi-
promote outflow.
After positioning the patient in a left soning or drug overdose, the contin-
Repeat the inflow-outflow cycle until
lateral position with his head in a de- uous lavage setup is faster and more
returned fluids appear clear, signal-
pendent position, the practitioner in- effective for diluting and removing
ing that the stomach no longer con-
serts the gastric tube nasally or orally the harmful substance.
tains harmful substances or that
and advances it slowly; forceful in- Make sure suction equipment is
bleeding has stopped.
sertion may injure tissues. Tube readily available.
After the practitioner completes the
placement is verified by aspiration of Monitor the patients vital signs.
lavage, an absorbent may be instilled
stomach contents. (See Using wide- Assess the patients LOC as well as
through the tube. After instillation,
bore gastric tubes.) respiratory, cardiac, and GI status.
the tube is clamped so that the ab-
WARNING The patient may vomit
sorbent can remain in the stomach
when the gastric tube reaches
and inactivate the toxic substance.
the posterior pharynx; be prepared to
suction the airway immediately.
After securing the tube with tape and COMPLICATIONS
making sure the irrigant inflow tube Vomiting
on the lavage setup is clamped, con- Aspiration
nect the unattached end of the irrig- Bradyarrhythmias
ant inflow tube to the lavage tube. After iced lavage, body temperature
Allow stomach contents to empty may fall, triggering cardiac arrhyth-
into the drainage container before mias
instilling the irrigant. This decreases
the risk of overfilling the stomach
with irrigant and inducing vomiting.
Save a sample of the aspirated stom-
ach contents in a labeled container
and send it for laboratory analysis to
identify the ingested substance.

5125G.qxd 8/15/08 11:15 AM Page 135


gastric tubes
Assess the patients vital signs, urine GENERAL
output, and LOC every 15 minutes. Provide follow up for the patient; ad-
To deliver a large volume of fluid rapidly
through a gastric tube (for such conditions
Notify the practitioner of changes. mit to facility as indicated, and in-
as profuse gastric bleeding or poisoning), a If ordered, remove the gastric tube. form authorities as appropriate.
wide-bore gastric tube works best. To control GI bleeding, the practi- Teach the patient how to prevent re-
Typically inserted orally, the tube remains tioner may order continuous stom- current overdose, and instruct him
in place long enough to complete the ach irrigation before withdrawing the about poison prevention.
lavage and evacuate stomach contents. gastric tube. Refer the patient for resource and
Never leave the patient alone during support services.
EWALD TUBE gastric lavage. Refer the patient for psychiatric
In an emergency, using the Ewald tubea Keep tracheal suctioning equipment treatment if poisoning was intention-
single-lumen tube with several openings at nearby; watch closely for airway ob- al.
the distal endallows you to aspirate struction caused by vomiting or ex-
large amounts of gastric contents quickly.
cess oral secretions. RESOURCES
Suction the oral cavity often to en- Organizations
sure an open airway and prevent as- American Academy of Neurology:
piration. www.aan.com
Obtain blood samples to check levels American Association of Poison Control
of the ingested substance, electro- Centers: www.aapcc.org
LEVACUATOR TUBE lytes, blood urea nitrogen, and creati- American College of Emergency
The Levacuator tube has two lumens. Use nine (if the substance was toxic). Physicians: www.acep.org
the larger lumen for evacuating gastric If gastric lavage was performed to
contents; the smaller, for instilling an irrig- control bleeding, obtain blood for Selected references
ant. hematology studies, and monitor for Bartlett, D. Acetaminophen Toxicity,
signs of increased bleeding. Journal of Emergency Nursing 30(3):
When lavage is done to stop bleed- 281-83, June 2004.
ing, keep precise intake and output Heard, K. Gastrointestinal Decontami-
nation, Medical Clinics of North
records to determine the amount of
America 89(6):1067-78, November
bleeding. When large volumes of flu- 2005.
EDLICH TUBE id are instilled and withdrawn, serum Littlejohn, C. Management of Intention-
The Edlich tube is a single-lumen tube that electrolyte and arterial blood gas lev- al Overdose in A&E Departments,
has four openings near the closed distal tip. els may be measured during or after Nursing Times 100(33):38-43, August
A funnel or syringe may be connected at lavage. 2005.
the proximal end. Like the Ewald tube, the Monitor intake and output and
Edlich tube lets you withdraw large quanti- record volume and type of irrigant
ties of gastric contents quickly. and amount of drained gastric con-
Note color and consistency of

5125G.qxd 8/15/08 11:15 AM Page 136

Immediately before starting the pro-
Creation of a channel that extends STANDARD FEEDING TUBE cedure, the surgical team takes a
from the gastric lumen to the skin for INSERTION time out to verify the correct pa-
insertion of a gastrostomy feeding Immediately before starting the pro- tient, procedure, and site and to
tube or button cedure, the surgical team takes a make sure that the gastrostomy feed-
Gastrostomy feeding tube: may be time out to verify the correct pa- ing button is readily available.
inserted through a midline abdomi- tient, procedure, and site and to After the patient receives general
nal incision or through percutaneous make sure that the gastrostomy feed- anesthesia, a small incision is made
endoscopy ing tube is readily available. and a laparoscope is inserted to visu-
Gastrostomy feeding button: may be After the patient receives a general alize the stomach and the area for in-
inserted laparoscopically anesthetic or moderate sedation, the sertion.
surgeon makes a vertical abdominal A small incision is made in the ab-
INDICATIONS incision directly over the stomach. dominal wall into the stomach and
Extensive oral or esophageal cancer, He then inserts a gastrostomy tube the feeding button is placed and then
obstruction, or trauma into the anterior gastric wall, inflates tested.
Prevention of starvation or malnutri- the balloon or tests the mushroom
tion disk to hold it in place, and aspirates COMPLICATIONS
WARNING Contraindications in- the gastric contents. Nausea and vomiting
clude intestinal obstruction that The tube is clamped and several Abdominal distention
prohibits the use of the bowel, diffuse purse-string sutures are inserted to Exit-site infection
peritonitis, intractable vomiting, par- hold it in place. Exit-site leakage
alytic ileus, and severe diarrhea that A sterile dressing is applied around Peritonitis
makes metabolic management diffi- the tube.
cult. Cautions include severe pancre-
atitis, enterocutaneous fistulae, and PERCUTANEOUS ENDOSCOPIC NURSING DIAGNOSES
Immediately before starting the pro- Acute pain
cedure, the surgical team takes a Imbalanced nutrition: Less than
time out to verify the correct pa- body requirements
tient, procedure, and site and to Risk for infection
make sure that the gastrostomy feed-
ing tube is readily available. EXPECTED OUTCOMES
After the patient receives moderate The patient will:
sedation, the patient receives a local verbalize and demonstrate increased
anesthetic to the throat and the ab- feelings of comfort
domen over the stomach. have stable weight and laboratory
The endoscopic tube is passed into values that return to within normal
the stomach and the area for tube in- parameters
sertion is visualized. experience no signs and symptoms
A small incision is made and the tube of skin or peritoneal cavity infection.
is pushed through the stomach and
abdominal walls, and the balloon in-
flated to hold it in position.

5125G.qxd 8/15/08 11:15 AM Page 137

pected to be permanent. Provide

If the patient is receiving nasogastric
Tell the patient that the surgeon will (NG) feedings, withhold them after Take the patients vital signs as or-
perform the initial insertion. midnight on the day of surgery. Dont dered postoperatively until hes fully
Make sure that a consent form has remove the NG tube unless the sur- recovered from the anesthesia.
been signed. geon orders its removalhe may Prepare the patient for the first fluid
Explain to the patient (if appropriate) want it to remain in place to decom- administration through the gastros-
and his family the purpose of a gas- press the stomach during surgery or tomy tube soon after surgery. Assess
trostomy tube, how and where its in- until gastrostomy tube feedings are for tube patency and leakage around
serted, and what it looks like. Answer started.P the tube. Ensure the patients privacy,
questions, and address concerns to Initiate I.V. therapy as indicated. and place him in semi-Fowlers posi-
allay their anxiety. Complete the preoperative verifica- tion before the instillation.
Tell the patient (if appropriate) and tion process. Prepare the patient for further gas-
his family if the gastrostomy is ex- trostomy instillations in the same
manner. Check tube patency by aspi-
rating gastric fluids with a syringe and
administering 30 to 60 ml of water at
How to reinsert a gastrostomy feeding button room temperature through the tube.
Expect to gradually increase the
If a gastrostomy feeding button pops out, follow these procedures to reinsert the device. amount given as the patient tolerates
PREPARE THE EQUIPMENT Remove the obturator by rotating it as you
it and if no leaking occurs. After instil-
withdraw it, to keep the antireflux valve from lation, clamp the tube, and follow the
Collect the feeding button (shown below);
wash it with soap and water; rinse thoroughly adhering to it. If the valve sticks, push the facilitys protocol for covering and se-
and dry. Also obtain an obturator and water- obturator back into the button until the valve curing the tube and dressing the site.
soluble lubricant. closes. Administer intermittent (bolus) tube
After removing the obturator, make sure the feedings as ordered. Check for resid-
Safety plug valve is closed. ual stomach contents before each
Close the flexible safety plug, which should feeding. Keep the patient in semi-
be relatively flush with the skin surface (as Fowlers position for at least 30 min-
Mushroom dome shown). utes after each feeding to facilitate
Antireflux valve
digestion and prevent aspiration.
Record the amount and contents of
INSERT THE BUTTON each feeding as well as the patients
Check the depth of the patients stoma to
If continuous feedings are ordered,
make sure you have a feeding button of the
correct size; clean around the stoma. periodically check for residual stom-
Lubricate the obturator with water-soluble ach contents and give feedings ac-
lubricant and distend the button several times cording to the surgeons guidelines.
to ensure the patency of the antireflux valve To maintain patency, flush the gas-
within the button. If you need to give a feeding right away, trostomy tube with water at least
Lubricate the mushroom dome and stoma. open the safety plug and attach the feeding once every 8 hours.
Push the button through the stoma into the adapter and feeding tube (as shown). Deliver Monitor the gastrostomy site for
stomach (as shown). feeding as ordered.
signs of skin irritation and infection.
Wash the area around the tube daily
Feeding catheter
Safety with soap and water or normal saline
plug Feeding adapter solution. A barrier ointment, such as
zinc oxide or petroleum jelly, may be
ordered to protect the skin from irri-
Obturator tation. Keep the gastrostomy site
Abdominal wall clean and dry.
If the button pops out while feeding,
reinsert it, estimate the formula al-
ready delivered, and resume feeding.
(See How to reinsert a gastrostomy
feeding button.)

5125G.qxd 8/15/08 11:15 AM Page 138

Once daily, clean the peristomal skin Provide skin care instructions, stress- RESOURCES
with mild soap and water or povi- ing the importance of keeping the Organizations
done-iodine, and let the skin air-dry skin around the tube clean and dry to American College of Gastroenterology:
for 20 minutes, to avoid skin irrita- prevent skin breakdown. www.acg.gi.org
tion. Explain that the patient should be American Gastroenterological
Clean the peristomal site whenever positioned with his head elevated at Association: www.gastro.org
spillage from the feeding bag occurs. least 30 degrees during the feeding The Society of American Gastrointestinal
and Endoscopic Surgeons:
and for 30 minutes afterward.
Teach the patient or caregiver how to
PATIENT TEACHING prepare and administer the type of
Selected references
gastrostomy tube feedings ordered.
Borkowski, S. G Tube Care: Managing
GENERAL Tell them to flush the tube or button
Hypergranulation Tissue, Nursing
Explain how the gastrostomy feeding with 30 ml of water after feedings. If 35(8):24, August 2005.
button is inserted and cared for. Tell continuous feedings are to be ad- Ditchburn, L., and Chapman, W. Joint
the patient how to use the button for ministered, make sure the patient or Primary-Secondary Care Design of
feedings. caregiver understands how to oper- PEG Care Pathways, Nursing Times
Advise the patient how to clean the ate the pump used for this proce- 101(18):34-36, May 2005.
equipment. dure. Owada, K. Use of a Hydrofiber Dressing
Teach the patient about peristomal Explain the importance of keeping to Manage PEG Sites, Advanced Skin
open cans of tube feeding formula and Wound Care 18(4):183-89, May
skin care.
refrigerated and to use them within 2 2005.
Tell the patient when and whom to
days of opening. However, explain Rimon, E., et al. Percutaneous Endo-
call with questions. scopic Gastrostomy: Evidence of
Tell the patient or caregiver to notify that the formula should be adminis-
Different Prognosis in Various Patient
the practitioner if signs of infection tered at room temperature.
Subgroups, Age and Ageing 34(4):353-
(such as redness, swelling, and puru- Provide instructions for clearing a 57, July 2005.
lent drainage), problems with ad- clogged tube.
ministering feedings, or leakage oc- Teach the patient or caregiver what
curs around the tube. they should do if the tube or button
Teach the patient or caregiver how to become dislodged.
care for the gastrostomy tube. If the Help arrange for visiting nurse
gastrostomy is permanent, show the follow-up after discharge.
patient or caregiver how to change
the tube every 2 to 3 days. Explain
that the tube may be removed after
several weeks and reinserted only for
feedings and that, between feedings,
the gastrostomy opening may be
protected by a small gauze pad held
in place by adhesive. (See Caring for
your gastrostomy tube.)

5125G.qxd 8/15/08 11:15 AM Page 139


Caring for your gastrostomy tube

Dear Patient:

Use these guidelines to review what the nurse taught you about caring for your gastrostomy tube.

Make sure the tube is in place. Look Change your dressing daily or whenever Keep the skin around your stomach
for a mark in indelible ink on the tube its wet or soiled, as follows. Dont use opening clean and dry to avoid skin irri-
where it should exit from your body. scissors to remove the old dressing; you tation and infection. Check it several
If you cant see the mark, the tube is might cut the tube accidentally. times per day.
slipping too far into your body. If you see 1. Carefully clean the skin around the If you see leakage of food or medi-
more tube below the mark than usual, tube with mild soap and warm water. cine around the tube, immediately apply
the tube is pulling out of your body. Then rinse and dry the skin thoroughly. a warm, moistened towel to soften en-
Either way, contact the home care 2. Position two 4  4 gauze pads crusted fluid, and wash, rinse, and dry
nurse or health care provider immedi- around the tube so that the slit sides the skin. Then call your health care
ately before trying to administer feed- overlap, to protect the skin from gastric provider.
ings or medicine through the tube. leakage. If the skin becomes irritated, dust it
When youre sure the tube is posi- with karaya gum powder.
tioned correctly, remove the cap or plug Notify your home care nurse or
and, if necessary, unclamp the tube. health care provider if the skin around
the tube feels sore, looks red, or seems<