case study main ot
TRANSCRIPT
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CARE AND MANAGEMENT OF
PATIENT WITH LIPOMA FOR
EXCISION OF LIPOMA ATRIGHT UPPER FLANK
Presenter : SN SANIAH BINTI SUHAILIMentor:SN PATRICIA ANAK LAGAN
Date:4th July 2014
Venue: Seminar Room Main OT
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OUTLINE OF PRESENTATION
1. OBJECTIVE
2. DEFINITION
3. ANATOMY AND PATOPHYSIOLOGY
4. SIGN AND SYMPTOM
5. RISK FACTOR
6. COMPLICATION
7. TREATMENTS
8. PROCEDURE
9. PREVISITING
10. RESPONSIBILITY OF RECEIPTION NURSE
IN PREOPERATIVE PHASE
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11. RESPONSIBILITY OF SCRUB ANDCIRCULATING NURSE IN PREOPERATIVE
PHASE12. RESPONSIBILITY OF SCRUB NURSE IN
INTRA OPERATIVE PHASE
13. RESPONSIBILITITIES IN HANDLING OF
THE SPECIMEN14. POST OP CARE IN RECOVERY BAY
15. NURSING CARE PLAN
16. DISCHARGE SUMMARY
17. HEALTH EDUCATION
18. CONCLUSION
19. REFERENCES
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OBJECTIVE
Understand the anatomy and physiology of thebody related to excision of lipoma.
Enable to understand and how ideal to handle
the instrument and principle of aseptic
technique. Prepare the OT before arrival of the patient.
Prepare the right equipment for the surgery.
Assist the surgeon more efficiently.
To learn and understand the nursing care
preoperatively, intra operatively and post
operatively
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ANATOMY
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DEFINITION OF LIPOMA
slow-growing, fatty lump that's mostoften situated between the skin and
the underlying muscle layer.
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PATHOPHYSIOLOGY
Tumor cells are cells that have grownautonomous transparmasi and last ofcontrol normal cell growth until the cell isdifferent from a normal cell in the formand structure.
Generally tumors began to grow from asingle cell somewhere (unisentrik) or
from some central (multilokuler) at thesame time.
During the growth of tumor is stillconfined to the organ remains essentially
the tumor is referred to in local phase.
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But if it happens infiltration into
surrounding organs, the tumor has
reached the local phase infasif or localinfiltratif.
These tumor cells continue to grow
indefinitely, until the tumor gets biggerand bigger and urgent surrounding
tissues until the body can clog vessels
and cause obstruction.
When the tumor is malignant can spread
other parts of the body and is generally
fatal if left for the concerned organ
damage and death.
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SIGNS AND SYMPTOMSSometimes painful.
painful if they growand press on nearby
nerves or containmany blood vessels.
Situatedunder theskin.
commonly occur in theneck, shoulders, back,abdomen, arms and
thighs.
Soft and doughy to thetouch.
move easily with slightfinger pressure.
Generally small. typically less than 2inches (5 centimeters)in diameter, but they
can grow larger.
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RISK FACTORS
Rare in children.Between 40 and
60 years old.
Adiposis dolorosa,Madelung disease,
Cowden syndrome and
Gardner's syndrome
Having certainother disorders.
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COMPLICATION
Lipomas under the skin(subcutaneous) rarely cause
complications, but large nodules may
interfere with muscle function or maycause nerve pain.
Lipomas occurring on a joint may limit
movement. If they develop in the bowel, lipomas
can cause potentially serious
obstruction.
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Anultrasound
or other
imagingtest, MRI or
CT scan
Physicalexam
INVESTIGATION
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TREATMENTS
1. SURGICAL REMOVAL
2. NON SURGICAL
Steroid injections.This treatment
shrinks the lipoma but usually doesn'tcompletely eliminate the tumor.
Liposuction.This treatment uses a
needle and a large syringe to removethe fatty lump.
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Surgical removal.
Most lipomas areremoved surgically by
cutting them out.
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PROCEDURE OF EXCISION
OF LIPOMA
Before the surgery,
the surgeon will draw
an outline of the
lipoma and a plannedskin excision with a
marker on the skin
surface.
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Skin cleansed with povidone iodine
(Betadine)solution,making sure to avoidwiping away the skin markings.
The area is draped with sterile towels.
Local anesthesia administered withchirocaine 5.0mg/ml,
Infiltrating the anesthetic in the
subcutaneous area surrounding theoperative field creates a field block.
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The skin insidethe incision
grasped with a
hemostat toprovide traction.
The lipoma is
dissected fromthe surrounding
tissue using
scissors or a
scalpel.
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Once freed,the lipoma is
delivered as
a whole, andhemostasis
is achieved.
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Interrupted 3-0
Vicryl sutures areused to partially
close the dead
space.
Skin closed with 4-0
nylon
Pressure dressing
placed to reduceincidence of
hematoma formation.
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PATIENT PARTICULAR
Patients name: Madam X
Age: 38 years old
IC No: 760204-13-XXXX
Reg. No : 2014/016520
Gender : Female
Patient electively admitted to the
female surgical ward on 26/05/2014
for excision of lipoma at the right
upper flank.
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Previsiting
Present historyRight upper flank swelling x 6 years.
Progressively increase in size
Pain around the swelling sometime atthe back
No skin changes over swelling
No pus dischargeFever accasionally whenever pain or
swelling.
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o Social historyNon smokingNon alchoholic
Married 20 years3 children with normal delivery.
o Menstrual historyMenarche at 14 years oldRegular no dysmenorheaLMP 11/5/2014
o Medical historyNil
o Surgical historyNil
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Responsibility of receiption nurse
in pre operative phasea) Reception bay
Prepare the trolley with the cleancanvas, blanket and pillow.
Greet patient, relatives and ward staff
that accompany her.
Transfer patient to the ot trolley andcover patient with blanket.
Transfer patient by lift the patient
gentlely, slowly and simulteously
Lock trolley during transfer
Pull out siderail after transfer.
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Check for the right patient.
Check patients wrist band.
Ask patients name and ic number withcorrect spelling.
Ask patient about the operation be done to
her and the side of operation. Make sure all consent correct and signed
by patient.
Ask patient to removed all jewellery,contacts lens,denture,
Ask patient time of last meal.
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Operation consent Blood transfusion consent Anaesthesia consent
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b) Holding bay
Check vital sign
and chart in the
SSSL form forbaseline data
Responsibilities of scrub and circulating
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Temperature insideoperation theatre must be
average of 18C to 22
C.
Humidity -50% to 60%Airconditioning is functioningwell with good HEPA filtersystem to reduce the
numbers of airborneorganism in operatingroom.
Air exchange - 15 to 25per an hour.
Close the OR door all thetime for positive pressure.
Temperature, humidity and air conditioning
Responsibilities of scrub and circulating
nurse in pre operative phase
Preparation in the theatre
Operation room
Induction room
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Prepare all theinstruments andequipments need forthe surgery.
Make sure it is cleanand functioning wellby checking theelectrical supplies,alarm system.Check thecompleteness of allitems needed forsurgery.
Preparation of all instruments and equipments
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Responsibility to position patient
left lateral position
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Before operation begins,scrub nurse have to wear a
proper operating room attire.
Prepare and check all the
instruments needed and
linen pack with circulator
together and the sub-sterile/utility area.
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After prepping, draping will beperform following the aseptictechnique.
The circulating nurse will preparethe suction machine andelectrosurgical unit.
After everything was ready, theoperation will start as order bysurgeon
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Responsibility of scrub nurse
intra operatively
a)INITIAL COUNT
Count sponge andinstrument beforecase start.
Count audibly &
clear withcirculating nurse.
b)SUBSEQUENT
COUNT(2ndcount)
count before closingcavity
Count all sponge,sharps and
instrument addedduring case.
C)FINAL COUNT
Count all sponge,sharps andinstrument beforeskin closing.
Inform surgeon
and document.
Surgical count
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Responsibilities in handling of thespecimen.
1. Receive the specimen with thereceiver ;kidney dish or gallipot.
Do not receive the specimen with
gauze because it can causespecimen desiccation and accidentlythrow away.
2. Enquiry type of specimen andexamination that will be done by thesurgeon
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3. Inform circulatingnurse the type of
specimen andexamination to bedone.
4. Hand over thespecimen in asepticmanner to avoid
contamination of theinstrument andsterile field.
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5.After surgery finish, check the
specimen and label with patient
particular together with circulator toensure it is correct before send to the
recovery nurse
6.Use fomaline 10%7.Put the specimen in 2 plastic bag
8.Make sure recovery nurse sign the
specimen and counter sign bysurgeon or MO.
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Check the
dressing/operativesite-sign ofbleeding.
Documentation.
If any problemoccur, or anyabnormalities onvital sign informdoctor immediately.
Discharged patientas ordered by
anesthetist.
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NURSING CARE PLAN
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Pre-operativeNursing
Diagnosis
Objectives Nursing intervention Evaluation
Knowledgedeficit
related to the
disease,
operation
and post
operativecomplication.
Patient willverbalize
feeling at
ease during
her stay.
1.Asess level of knowledge to thedisease and education.
2.Explain briefly about:
a. disease process
b. operation
c. post operative complications
3.Explain to patient the
importance of:
a. taking drugs according to
schedules.
b. type and well balanced diet.
c. exercise and healthy life style
to promote healing.
N i Obj ti N i I t ti E l ti
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Nursing
Diagnosis
Objective Nursing Interventions Evaluation
4.Teach patient to keep the surgical
wound clean such as do not put
other medication or touch the woundwithout doctor permission.
5.Ask patient inform doctor
immediately if there are signs of
infection- fever, redness of theoperation wound.
6.Refer patient to doctor if patient
still not understand about the
disease or lack of knowledge.
Patient understand
the process of the
disease afterfurther explanation
from the doctor.
Nursing Objective Nursing Intervention Evaluation
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diagnosis
Potential body
injury during
transfer and
transport.
Patient will b safe
from injury
Prepare OR trolley and
accessories device
-check for good functional
order.
Ensure enough man power
during transferring the
patient.
Lock the break before
transferring the patient.
During transferring patient,
make sure apply body
mechanic to prevent injury.
lift patient slowly, gentle
and simultaneously
Lift up the side rails to
prevent patient fall down.
Patient safe
from any
injury.
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Nursing
Di i
Objective Nursing Intervention Evaluation
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Diagnosis s
Potential of
electrical
burns
related tothe use of
the Electro
Surgical
Unit
Patient will
not sustain
electrical
burns
Check diathermy machine for the
functional before use.
Assess patients skin condition
before applying diathermy pad.
Place pad at the area of large
muscle mass,near the surgical site
and avoid area of scarred tissue, body
prominences and hairy surface area.
Protect patient from contact area
with metal surface by covering the
contact area with padding and folded
drapes.
Nursing
Di i
Objective Nursing Intervention Evaluation
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Diagnosis s
Ensure the active electode of the
diathermy does not touch other metal
parts when activated or in used.
Check patient;s skin at the pad site,
ECG electrode, bony prominences
area and the patients back sign and
symptoms of burn at the end of
surgery and document.
No sign and
symptoms of burn at
the patients body in
the end of surgery.
P t ti
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Post-operativeNursing
Diagnosis
Objectives Nursing Intervention Evaluation
Painrelated to
the
operation.
Patient willexperience
minimal
pain.
Asses and monitor the patientslevel of pains- pain score.
Do the vital signs observation.
Give patient analgesic-as ordered
by anesthetist.
Position patient on her back or lie
on the unaffected side.
Patients painfulreduce after taken
the analgesic as
ordered by
anesthetist
provider.
Pain score 01
/10
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Discharge summary
Patient discharge from ward at 11am No complaint of pain made while
discharge
Patient on PCM 1gm QID and TabletTramal 50mg TDS 5/7.
Wound inspection on D3,no need
STO. TCA 2 months with trace HPE.
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Health education
Advice patient to take care of wound Do not put any solution at the wound site
Do not lie at the operation site
Make sure the dressing not wet to prevent
infection and promote healing.
Teach patient to do dressing
Makes sure patient use correct solution toclean the wound area before applyingdressing.
If the wound still bleeding,ask pateint to seethe doctor immediately.
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Ask patient to take medication as
prescribed
Take medication with correct dose and
time
If patient still having pain,ask patient
to see the doctor immediately.
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CONCLUSION
Lipoma is a tumor (lump) which isunder the benign skin composed of fattytissue.
Clinical symptoms of lipoma is soft in
nature palpability, can be moved, and nopain.
Growth is very slow.
Lipoma majority is small, but can grow toreach more diameter 6 cm.
Basically lipoma not do any action,except evolved into pain and interfere
with the movement.
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references
Berry & Kohns, Phillips.N. (2007).Operating Room Technique (11th
edition): Specialized surgical
equipment, 20(6), 352-353.
http://www.mayoclinic.org/diseases-
conditions/lipoma/basics/definition/con-20024646
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