Surgical Procedures in the ICU

Submitted by:

Sheryl Anne F. Atienza

BSN IV - B

Submitted to:

Ms. Lilibeth Nucum C.I

GROUP 5
 LUMBAR PUNCTURE

Definition

In medicine, a lumbar puncture (colloquially known as a spinal tap) is a diagnostic

and at times therapeutic procedure that is performed in order to collect a sample of
cerebrospinal fluid (CSF) for biochemical, microbiological, and cytological analysis,
or very rarely as a treatment ("therapeutic lumbar puncture") to relieve increased
intracranial pressure.

Indications

The most common purpose for a lumbar puncture is to collect cerebrospinal fluid in a
case of suspected meningitis, since there is no other reliable tool with which
meningitis, a life-threatening but highly treatable condition, can be excluded. Young
infants commonly require lumbar puncture as a part of the routine workup for fever
without a source, as they have a much higher risk of meningitis than older persons and
do not reliably show signs of meningeal irritation (meningismus). In any age group,
subarachnoid hemorrhage, hydrocephalus, benign intracranial hypertension and many
other diagnoses may be supported or excluded with this test. Lumbar punctures may
also be done to inject medications into the cerebrospinal fluid ("intrathecally"),
particularly for spinal anesthesia or chemotherapy.It may also be used to detect the
presence of malignant cells in the CSF,as in carcinomatous meningitis or
medulloblastoma. Lumbar punctures can be unpleasant for some people, due to
increased sensitivity when the needle is inserted to collect the cerebrospinal fluid.

Materials Needed

1. Lumbar puncture tray (to include 20 or 22 gauge Quinke needle with stylet, prep
solution, manometer, drapes, tubes, and local anesthetic)

2. Universal precautions materials.

Procedure

In performing a lumbar puncture, first the patient is usually placed in a left (or right)
lateral position with his/her neck bent in full flexion and knees bent in full flexion up
to his/her chest, approximating a fetal position as much as possible. It is also possible
to have the patient sit on a stool and bend his/her head and shoulders forward. The
area around the lower back is prepared using aseptic technique. Once the appropriate
location is palpated, local anaesthetic is infiltrated under the skin and then injected
along the intended path of the spinal needle. A spinal needle is inserted between the
lumbar vertebrae L3/L4 or L4/L5 and pushed in until there is a "give" that indicates
the needle is past the dura mater. The needle is again pushed until there is a second
'give' that indicates the needle is now past the arachnoid mater, and in the
subarachnoid space. The stylet from the spinal needle is then withdrawn and drops of
cerebrospinal fluid are collected. The opening pressure of the cerebrospinal fluid may
be taken during this collection by using a simple column manometer. The procedure is
ended by withdrawing the needle while placing pressure on the puncture site. In the
past, the patient would often be asked to lie on his/her back for at least six hours and
be monitored for signs of neurological problems, though there is no scientific
evidence that this provides any benefit. The technique described is almost identical to
that used in spinal anesthesia, except that spinal anesthesia is more often done with
the patient in a sitting position. The upright seated position is advantageous in that
there is less distortion of spinal anatomy which allows for easier withdrawal of fluid.
It is preferred by some practitioners when a lumbar puncture is performed on an obese
patient where having them lie on their side would cause a scoliosis and unreliable
anatomical landmarks.

Nursing Responsibilities

> A lumbar puncture, or spinal tap, is a procedure to collect cerebrospinal fluid to

check for the presence of disease or injury.

> A spinal needle is inserted, usually between the 3rd and 4th lumbar vertebrae in the
lower spine.

> Once the needle is properly positioned in the subarachnoid space (the space
between the spinal cord and its covering, the meninges), pressures can be measured
and fluid can be collected for testing.

HEMODIALYSIS

Definition

A hemodialysis shunt, graft, or fistula provides vascular access for hemodialysis, a

treatment that cleans the blood by removing wastes and excess water from the body.

Indication
 • Pericarditis or pleuritis (urgent indication)
• Progressive uremic encephalopathy or neuropathy, with signs such as
confusion, asterixis, myoclonus, wrist or foot drop, or, in severe cases,
seizures (urgent indication)
• A clinically significant bleeding diathesis attributable to uremia (urgent
indication)
• Fluid overload refractory to diuretics
• Hypertension poorly responsive to antihypertensive medications
• Persistent metabolic disturbances that are refractory to medical therapy; these
include hyperkalemia, metabolic acidosis, hypercalcemia, hypocalcemia, and
hyperphosphatemia
• Persistent nausea and vomiting
• Weight loss or signs of malnutrition

Materials Needed

> Vascular access

> Primary AV fistula

> Synthetic bridge graft

> Central venous catheter

> Dietary changes

Procedure

Kidneys remove wastes from the blood through the urine, regulate the amount of
water and minerals needed by the body, and produce hormones. When the kidneys
lose their ability to filter wastes and excess water from the blood, hemodialysis is
required. During hemodialysis, the blood is circulated through a hemodialysis
(artificial kidney) machine. Hemodialysis cleans blood similar to the way kidneys do.
A vascular site, such as an arteriovenous (AV) fistula or graft, provides access for the
removal and return of blood during hemodialysis. The patient's blood is removed and
circulated through a machine that contains a dialyzer. The wastes and excess water
from the patient's blood pass through the dialysis machine's membrane into the
dialysate, and are then discarded. The dialyzed (cleaned) blood is returned to the
patient'sbloodstream.

Nursing Responsibilities

> To administer medications to oversee and coordinate care.

> Ensuring treatment and access of sites is done correctly with safety checks done.
> Charting is correct and completed.
> Physician orders carried out.
> Labwork drawn as needed or per protocols or orders.
> That social work or dietitian or other ancillary services are involved in patient care.
 CT-SCAN

Definition

Computerized tomography scan. Pictures of structures within the body created by a

computer that takes the data from multiple X-ray images and turns them into pictures
on a screen. CT stands for computerized tomography. The CT scan can reveal some
soft-tissue and other structures that cannot even be seen in conventional X-rays. Using
the same dosage of radiation as that of an ordinary X-ray machine, an entire slice of
the body can be made visible with about 100 times more clarity with the CT scan.

Indication

CT scans provide more detail than plain x-rays and have largely replaced them for the
imaging of certain structures. Indications may include the following:

• Kidney stones
• Hematuria
• Renal cyst or mass
• Recurrent infection (urinary)
• Operative planning
• Staging of cancer

Materials Needed

CT scanning has the unique ability to image a combination of soft tissue, bone, and
blood vessels. Among all available imaging techniques, it is one of the best tools for
studying the lungs and abdomen. It is also invaluable in cancer diagnosis, and is the
preferred method for diagnosing lung, liver, and pancreatic cancer.

Procedure

The patient lies still on a special table, which is part of the CT scanner, and while the
table moves, numerous x-rays are taken in rapid sequence. Depending on the
indications for the study, IV and /or oral contrast may be given. During the scan the
patient may be given instructions to hold their breath for a few seconds if possible.
The entire process takes only a few minutes.
Nursing Responsibilities

> Nursing care for patients with ICH is as critical as medical and surgical treatments.
> Collaboration with the healthcare team is necessary.
> Despite advances in technology, frequent and careful neurological examination of
the patient remains critical.
> In patients with elevated ICP, therapies to reduce ICP would be instituted, as
previously discussed.

MRI

Definition

The MRI, an abbreviation for magnetic resonance imaging, uses magnetic signals to
create image "slices" of the human body. Like all imaging techniques, an MRI scan
creates images based on differences between types of tissues. The MRI shows us the
different tissues, and thus creates an image inside the body.

Indication

> After 4 to 6 weeks of leg pain, if the pain is severe enough to warrant surgery

> After 3 to 6 months of low back pain, if the pain is severe enough to warrant
surgery

> If the back pain is accompanied by constitutional symptoms (such as loss of

appetite, weight loss, fever, chills, shakes, or severe pain when at rest) that may
indicate that the pain is due to a tumor or an infection

> For patients who may have lumbar spinal stenosis and are considering an epidural
injection to alleviate painful symptoms

> For patients who have not done well after having back surgery, specifically if their
pain symptoms do not get better after 4 to 6 weeks.

Materials Needed

> MRI scanner

Procedure

No special preparation is needed for an MRI. You may eat normally and take your
seizure medicine or any other medicines as usual, unless you will be having sedation
or anesthesia during the procedure. You should wear loose, comfortable clothing
without metal fastenings such as zippers or clasps because metal will interfere with
the test. Do not wear jewelry, hairspray, makeup, a hearing aid, or any removable
dental work. If you are being treated with a vagus nerve stimulator (VNS), it will need
to be turned off before your MRI. Many centers will refuse to perform an MRI scan
on anyone with a stimulator in place.

Nursing Responsibilities

> Double check ALL charts to make sure all orders are signed/carried out.
> Decubitus checks/skin assesments for High risk patients.
> Keep peace between the staff in the unit(sometimes the hardest thing to
do).
> Last hour round again and make sure the staff doesn't need help with
anymore baths or turning.
> Figure out to staff your own unit by calling agencies/other staff for OT
if someone calls in. All the while making sure the OT is spread equally.

CATHETER INSERTION

Definition

A hollow flexible tube for insertion into a body cavity, duct, or vessel to allow the
passage of fluids or distend a passageway. Its uses include the drainage of urine from
the bladder through the urethra or insertion through a blood vessel into the heart for
diagnostic purposes.

Indication

By inserting a Foley catheter, you are gaining access to the bladder and its contents.
Thus enabling you to drain bladder contents, decompress the bladder, obtain a
specimen, and introduce a passage into the GU tract. This will allow you to treat
urinary retention, and bladder outlet obstruction.

Materials Needed
> Sterile gloves - consider Universal Precautions
> Sterile drapes
> Cleansing solution e.g. Savlon
> Cotton swabs
> Forceps
> Sterile water (usually 10 cc)
> Foley catheter (usually 16-18 French)
> Syringe (usually 10 cc)
> Lubricant (water based jelly or xylocaine jelly)
> Collection bag and tubing

Procedure

 Gather equipment.

 Explain procedure to the patient

 Assist patient into supine position with legs spread and feet together

 Open catheterization kit and catheter

 Prepare sterile field, apply sterile gloves

 Check balloon for patency.

 Generously coat the distal portion (2-5 cm) of the catheter with lubricant

 Apply sterile drape

 If female, separate labia using non-dominant hand. If male, hold the penis with the
non-dominant hand. Maintain hand position until preparing to inflate balloon.

 Using dominant hand to handle forceps, cleanse peri-urethral mucosa with

cleansing solution. Cleanse anterior to posterior, inner to outer, one swipe per swab,
discard swab away from sterile field.

Nursing Responsibilities

> Occluded ports

> Balloon rupture caused by overinflating the balloon or frequent use of the balloon. >
> Pneumothorax - may occur during initial placement.
> Dysrhythmias - caused by catheter migration
> Air embolism - caused by balloon rupture or air in the infusion line.
> Pulmonary thromboembolism - improper flushing technique, non-heparinized flush
solution.
> Pulmonary artery rupture - perforation during placement, overinflation of the
balloon, overuse of the balloon.
> Pulmonary infarction - caused by the catheter migrating into the wedge position, the
balloon left inflated, or thrombus formation around the catheter which causes an
occlusion.
CARDIAC ARREST
Definition

Cardiac: pertaining to the heart. Arrest: stop. Cardiac arrest: previously equated with
death, but since the advent of modern resuscitation methods, an emergency well
known to viewers of hospital soaps. When the heart stops, and the circulating blood
therefore comes to a standstill, that part of the brain which allows conscious function
has only a few minutes to survive. The heart stops beating if the pacemaker-generated
rhythm is halted, or if conduction of the electrical impulses is disrupted, sending the
muscle of the ventricles — the heart's pumps — into the irregular and useless
twitching state of fibrillation. If the instrument and the expertise are available, electric
shocks are administered with a defibrillator, which may or may not restore a normal
electrical rhythm and hence a regular beat. When this amenity is not at hand, or access
to it is delayed, the first aid measure is external cardiac massage, consisting of
rhythmic pressure on the chest, at the lower end of the sternum. By squeezing the
heart against the spinal column, this can temporarily restore circulation of the blood.
Since breathing is likely to have stopped at the same time, or very soon after, the heart
beat, attention must be divided between cardiac massage and mouth-to-mouth
respiration.

Indication

The ICDs were previously approved for patients who had survived cardiac arrests and
for patients who had undergone invasive electrical testing (done through a catheter
from the groin to the heart) to determine if they were suitable candidates for an ICD.
With the approval of this new indication, some patients may not be required to
undergo this electrical testing prior to the implantation of the ICD.

Materials Needed

Equipment size, drug dosage, and CPR parameters vary with patient age and weight
(see Table 3: Respiratory and Cardiac Arrest: Abdominal thrusts with victim standing
or sitting (conscious). and Table 4: Respiratory and Cardiac Arrest: Expired air
ventilation—child. ). Size-variable equipment includes defibrillator paddles or
electrode pads, masks, ventilation bags, airways, laryngoscope blades, endotracheal
tubes, suction catheters. Weight should be measured rather than guessed;
alternatively, commercially available measuring tapes that are calibrated to read
standard patient weight based on body length can be used. Some tapes are printed
with the recommended drug dose and equipment size for each weight. Dosages should
be rounded down; eg, a 2 1⁄2 yr old should receive the dose for a 2 yr old.
Procedure

Personnel who encounter a person in a cardiac/respiratory arrest state should initiate a

cardiac arrest call. For cardiac/respiratory arrest occurring in a building contiguous*
with the Hospital, dial the cardiac arrest team at (212)305-3333 and Columbia
Security at (212)305-7979. For cardiac/respiratory arrest occurring in a building non-
contiguous with the Hospital, dial NYPH EMS at (212)305-9999 and Columbia
Security at (212)305-7979. Persons with a medical emergency are to dial Columbia
Security at (212)305-7979. Telephone stickers** with the emergency contact numbers
will be distributed to University personnel at the Health Sciences Campus. Telephone
stickers placed in buildings contiguous with Hospital, will have a “C” in the lower
right hand corner of the sticker.

Nursing Responsibilities

> Environmental Health & Safety

SUNCTIONING

Definition

Removal of material through the use of negative pressure, as in suctioning an

operative wound during and after surgery to remove exudates.

Indication

> Coarse breath sounds by auscultation or 'noisy' breathing

> Increased peak inspiratory pressures during volume-controlled mechanical
ventilation or decreased tidal volume during pressure-controlled ventilation.
> Patient's inability to generate an effective spontaneous cough.
> Visible secretions in the airway
> Changes in monitored flow and pressure graphics
> Suspected aspiration of gastric or upper airway secretions
> Clinically apparent increased work of breathing
> Deterioration of arterial blood gas values
> Radiologic changes consistent with retention of pulmonary secretions

Materials Needed
> Vacuum source
> Calibrated, adjustable regulator
> Collection bottle and connecting tubing
> Sterile disposable gloves
> Sterile water and cup
> Sterile normal saline, if instillation is desirable
> Goggles, mask, and other appropriate equipment for Universal Precautions(33)
> Oxygen source with a calibrated metering device
> Manual resuscitation bag equip-ped with an oxygen enrichment device
> Stethoscope

Procedure

This procedure covers the suctioning of the patient (with or without an artificial
airway) when cared for in the home. This includes nasal, oropharyngeal, and
endotracheal suctioning.

Nursing Responsibilities

> Remove client's oxygen delivery device, if applicable. Gently but quickly insert catheter into
client's naris during inhalation. Insert .........it at a slight downward slant or through mouth,
without applying suction. Do not force catheter through naris. Position client's .........head to
right or left. Pull catheter back 1 cm if resistance is felt.
> Apply intermittent suction for up to 10 to 15 seconds, withdrawing catheter while rotating it
back and forth between dominant .........thumb and forefinger. Encourage client to cough.
Replace oxygen device, if applicable.
> Rinse catheter and connecting tubing with normal saline or water until cleared.
> Assess for need to repeat suctioning procedure. Allow adequate time between suction
passes. Ask client to breathe deeply and .........cough.
> Perform oropharyngeal suctioning when secretions have been cleared. Do not suction nose
again after suctioning mouth.

RENAL CUT DOWN

Definition

A renal biopsy is the removal of a small piece of kidney tissue for laboratory
examination.

Indication

Renal failure can be divided into two categories: acute kidney injury or chronic
kidney disease. The type of renal failure is determined by the trend in the serum
creatinine. Other factors which may help differentiate acute kidney injury from
chronic kidney disease include anemia and the kidney size on ultrasound. Chronic
kidney disease generally leads to anemia and small kidney size.

Materials Needed

> Molecular Techniques

> DNA Sequence Determination

> mRNA Expression Analyses

> Fluorescent in Situ Hybridization

Procedure

Patients are typically able to walk within two to six hours following the procedure and
return to their normal routine by the following week.

Nursing Responsibilities

> Avoid strenuous activities and lifting heavy objects for 2 weeks after the test.
> Sometimes a repeat biopsy is needed.

ECG

Definition

A recording of the electrical activity of the heart. An electrocardiogram is a simple,

non-invasive procedure. Electrodes are placed on the skin of the chest and connected
in a specific order to a machine that, when turned on, measures electrical activity all
overaround the heart. Output is usually in the form of a long scroll of paper displaying
a printed graph of activity. Newer models output the data directly to a computer and
screen, although a print-out may still be made.

Indication

• Cardiac murmurs
• Syncope or collapse
• Seizures
• Perceived dysrhythmias
• Symptoms of myocardial infarction.
Materials Needed

> ECG graph paper

> Electrodes

> Leads

> Augmented limb leads

> Limb leads

Procedure

A transthoracic interpretation of the electrical activity of the heart over time captured
and externally recorded by skin electrodes.[1] It is a noninvasive recording produced
by an electrocardiographic device. The etymology of the word is derived from the
Greek electro, because it is related to electrical activity, cardio, Greek for heart, and
graph, a Greek root meaning "to write". In English speaking countries, medical
professionals often write EKG (the German abbreviation) in order to avoid confusion
with EEG.

Nursing Responsibilities

> To administer medications to oversee and coordinate care.

> Ensuring treatment and access of sites is done correctly with safety checks done.
> Charting is correct and completed.
> Physician orders carried out.
> Labwork drawn as needed or per protocols or orders.
> That social work or dietitian or other ancillary services are involved in patient care.