Angeles University Foundation College of Nursing Angeles City

Perioperative nursing: Post-operative Phase

In Partial Fulfillment of the Requirements In Related Learning Experience 104

Submitted by: Bautista, Kimberly L. Gomez, Joanne S. Lim, Raymond Christopher P. Sicat, Kevin Angelo D.L. BSN III-4/ Group 13 Submitted to: Edwin Balatbat, RN Clinical Instructor November 23, 2011 A.Y. 2011-2012

Perioperative Nursing: Postoperative Phase I. Immediate post-anesthesia recovery extends from the time the client leaves the Operating Room to the time the client has established in the Recovery Room or the PACU and has been transferred to the Nursing unit. POSTANESTHESIA CARE UNIT (PACU, RR, PAR)

Provides maximal care for patients immediately following their operations. Evolved to meet a need for constant observation of patients by trained personnel within facilities equipped for specialized care until recovery from anesthesia is established sufficiently for safe transfer elsewhere.

It is usually adjacent to the OR suite.

Transporting patient from OR to RR prevent exposure, rough handling, hurried movement and rapid change in position. On stretcher: Cover patient with blanket. Secure patient with safety belts or restraints over the elbows and knees. Side rails of the stretcher should be up. Anesthesiologist, circulating nurse or sometimes the surgeon should accompany the patient to the RR. DATA TO BE OBTAINED WHEN PATIENT IS ADMITTED IN THE RR The time of admission to RR Current medical diagnosis Surgical procedure performed - what, why Agents administered

a. Anesthetic b. Narcotic c. Muscle relaxant d. Muscle relaxant reversal agent e. Antibiotic f. Others digitalis, diuretics Complications during surgery Fluids Pertinent Pre-op problems Contraptions Vital signs

EARLY POST-OP PATIENT ASSESSMENT AREA OF ASSESSMENT Respiratory OBSERVATIONS Patency of airways Respirations: rate, depth character Chest expansion Patient position: to facilitate ventilation Circulatory Status Ability to deep breathe and cough BP, Temperature Pulse: rate, strength (limb operation) Skin: color, temperature Neurologic Status Capillary refill LOC Ability to follow commands Sensation and ability to move extremities Urinary Status Comfort Safety following regional anesthesia Urine output Pain: presence, character, severity, N/V Patient position of comfort Necessity of side rails

Mobility Monitoring System IVF Dressing Drainage system urinary, T-tube)

Call cord within reach Ability to turn self Ability to do leg exercise Connected and functioning Rate, amount in bag, patency of tubing Drainage, frank bleeding chest, Type, patency of tube, connection to collecting container Character and amount of drainage

(Nasogastric,

POST-OPERATIVE DISCOMFORTS NAUSEA AND VOMITING Occurs in most post-op patients Causes: From accumulation of fluid or food in the stomach before peristalsis occur From abdominal distention Induced during anesthesia from inadequate ventilation Psychological induction Side effects of narcotics Vagal stimulation

Preventive measures: Insert NGT pre-op for GIT surgery Morphine and Meperidine, Digitalis and Dopamine may induce vomiting Be alert for any significant comments and notify anesthesiologist of this. Nursing Interventions:

 Avoid large intake of foods and fluids at one time especially after being on NPO. Maintain environment conducive to good appetite. Monitor tolerance to prescribed/ordered diet. Maintain bowel elimination Encourage deep breathing. Support wound during retching and vomiting. Turn head to side. Discard vomitus and refresh patient. Oral hygiene PRN Suspect idiosyncratic response to a drug if vomiting is worse when a medication is given. Assess allergic responses to analgesics/antibiotics. Administer antiemetic medication. Report excessive or prolonged vomiting. Detect presence of abdominal distention, hiccups. Suspect the possibility of paralytic ileus. RESTLESSNESS AND SLEEPLESSNESS Promoting Factors: 1. Discomfort such as back pain, headache and thirst a. Massage back b. Administer analgesic 2. Tight dressings or drainage-soaked dressings a. Change dressings and check for tightness 3. Urinary retention a. Measures to initiate voiding 4. Abdominal distention a. Ambulation

b. Insert rectal tube to relieve flatus 5. Noise and environmental stimuli a. Keep noise level to a minimum b. Limit visitors c. Provide privacy, darkness and quiet equipment d. Schedule treatments with rest periods in mind 6. Worry and anxiety a. Find cause of concern b. Allow for verbalization of feelings c. Seek advice for spiritual counselor if necessary d. Offer sedatives or hypnotics

THIRST Causes: Inhibition of secretions by pre-operative meds with atropine Fluid loss via perspiration, blood loss and dehydration due to preoperative fluid restriction Nursing Interventions: Assess for dehydration, weight loss Administer fluid by vein or by mouth if tolerated Sips of water or ice chips when on NPO Oral hygiene: Allow patient to rinse mouth with mouthwash Apply moistened gauze over lips occasionally Obtain hard candies or chewing gum

CONSTIPATION Causes:

Trauma and irritation to the bowel during surgery Local inflammation, peritonitis, abscess Long standing bowel problem

Preventive Measures: Early ambulation Adequate fluid intake Proper diet Query the patient to his usual remedy for constipation Nursing Interventions: Assess bowel sounds every 4 hours when client is awake Assess abdominal distention (paralytic ileus) Assess ability to pass flatus or stool Encourage movement in bed and ambulation (also relieves gas pain) Maintain privacy when using bedpan or urinal Administer suppositories or enemas as ordered Insert a gloved hand and break up the impaction manually URINARY RETENTION Cause: Side effect of anesthesia

Nursing Responsibilities: Monitor I and O Assess distention of urinary bladder (usually 6 to 8 hours after surgery) Maintain IVF regulation Provide privacy Carry out catheterization as ordered.

PAIN Incidence: One of the earliest symptoms that the patient expresses upon return to consciousness Occurs between 12 to 36 hours after surgery and usually disappears by 48 hours Soluble anesthetic agents are slow to leave the body then insoluble ones Older patients seem to have higher tolerance for pain than younger or middleaged persons There is no documented proof that one sex tolerates pain better than the other

Clinical Manifestations: 1. AUTONOMIC o Outpouring of epinephrine o Increased BP o Increased PR/HR o Increased and irregular RR o Diaphoresis 2. SKELETAL MUSCLE o Increase in muscle tension or activity 3. PSYCHOLOGICAL o Increase in irritability o Increase in apprehension o Increase in anxiety o Attention focused on pain

o Complains of pain Patients reaction depends on: a. Previous experience b. Anxiety or tension c. State of health d. Ability to concentrate away from the problem or be distracted e. Meaning that pain has for him/her

DISCHARGE FROM RR Criteria: 1. VS are stable and indicate adequate respiratory and circulatory function 2. The person is awake or easily aroused and can call for assistance if needed 3. Post-surgical complications have been thoroughly evaluated and are under control 4. The person who had regional anesthesia has motor as well as partial sensory return to all anesthetized areas

Convalescent Phase Extends from the time the client is discharged from the RR to the time the patient is discharged from the hospital. Surgeons Order: 1. Activity extent of activity allowed 2. Fluids, food IVF type, amount, rate

Per orem/ oral type and time these can be started

3. Meds exp. Pain meds 4. Other orders GOAL: 1. Prevent complications 2. Promote return to health

COMMON POST-OP COMPLICATIONS AND NURSING RESPONSIBILITIES I. CARDIOVASCULAR General Nursing Responsibilities: 1. Assess and document VS 2. Provide blankets to prevent chilling 3. Maintain fluid balance I and O; skin turgor and hydration of mucous membrane 4. Implement leg exercises and turning in bed every 2 hours 5. Assist with ambulation (usually begins the evening of surgery) 6. Give anticoagulant as ordered 7. Homans sign Complications:
a. Hemorrhage excessive blood loss

S/SX: Restlessness Anxiety Frank bleeding S/SX of shock

Goal: Stop bleeding and replace blood loss Nursing Responsibilities:

Apply pressure dressing to the operative/bleeding site.

Be prepared to return the patient to OR if bleeding cannot be stopped.

b. Shock bodys reaction to acute peripheral circulatory failure

Hypovolemic shock occur with a decreased blood volume

S/SX: Decreased BP Cold, clammy skin Decreased UO Apprehension Goal: Improve and maintain tissue perfusion by eliminating cause of shock Nursing Responsibilities: 1. Maintain airway 2. Place in a Trendelenburg position 3. Administer oxygen as ordered 4. Assist in fluid and blood administration 5. Maintain warmth 6. Administer meds as ordered 7. Monitor VS 8. Prevent potential complication- diaphragm may ascend decreasing lung volume and ventilation c. Thrombophlebitis Weak, thread, rapid pulse Deep, rapid respirations Thirst Restlessness

d. Embolism
Pulmonary embolism it lodges in the pulmonary vessel

II. RESPIRATORY Nursing Responsibilities: 1. Monitor VS 2. Implement deep breathing, coughing, incentive spirometry and turning every 2 hours 3. Ambulate as ordered 4. Maintain hydration 5. Monitor responses to narcotic analgesic Complications:
a. Pneumonia inflammation of alveoli as a result of infectious process or presence

of foreign material (emboli) S/SX: Increased temperature Dyspnea Chills Goal: Treat infection, maintain respiratory function and prevent spread of infection Nursing Responsibilities: 1. Administer oxygen Productive cough- rusty sputum Rales and ronchi chest pain

2. Semi/ Full Fowlers position 3. Maintain nutritional and fluid status 4. Oral hygiene and proper disposal 5. Deep breathing and coughing exercises b. Atelectasis

III. WOUND COMPLICATIONS Nursing Responsibilities: 1. Assess VS 2. Maintain hydration 3. Maintain nutritional status 4. Use medical asepsis protocol (hand washing) 5. Wound care 6. Maintain aseptic technique in dressing changes and care of tube or drains Complications:
a. Dehiscence separation of layers of a surgical ward b. Evisceration disruption of a wound with protrusion of body organs

Nursing Interventions: Return client to bed Dont attempt to replace organs

 Cover wound with sterile dressing moistened with NSS Monitor VS Notify surgeon immediately
c. Wound infection

Redness beyond the incision line Edema that remains after initial swelling Increased pain Increased drainage Fever, malaise, anorexia, leukocytosis

Nursing Interventions: Monitor VS Notify the surgeon Wound C&S ADMISSION TO THE POST-OPERATIVE CARE UNIT Adverse drug reaction occurring during anesthesia and operation are of increasing to both physicians and clients. These reactions are relatively frequent, often severe, and potentially fatal. Systemic reactions manifested by symptoms referable to the central nervous system and the respiratory and cardiovascular systems are caused by absorption into the circulation of a toxic amount of a local or general anesthesia drug. The main factors then in producing these reactions are vascular uptake and circulating blood level of the anesthetic. When the client is admitted to the post-anesthesia care unit (PACU), immediately assess for the following: 1. Patent airway and adequate gas exchange

An artificial airway, such as endotracheal (ET) tube, a nasal trumpet , or oral airway, may be in place. a. If the client is receiving oxygen, document the type of delivery device and the concentration or liter flow of the oxygen. b. Continuously monitor the pulse oximeter for oxygen saturation.

c. Assess the rate, pattern and depth of breathing to determine the adequacy of air exchange. d. Listen to the sounds over all the lungs. Also, check for the symmetry of breath sounds. 2. Assessing blood pressure, pulse and heart sound every 15 minutes until the clients condition is stable. Automated blood pressure cuffs and cardiac monitoring assist in continuous assessment. a. Monitor for decreased blood pressure, pulse pressure, and heart sounds. b. Bradycardia and hypothermia could indicate an anesthesia effect. 3. Assessing cerebral function and the level of consciousness or awareness for all clients who have received general anesthesia. a. Observe for lethargy, restlessness or irritability and test coherence. b. Determine awareness by observing responses to calling the clients name, touching the client and giving sample commands.

4. Monitor and sensory assessment

It is very important after epidural or spinal anesthesia. a. Evaluate motor function by asking the client to move each extremity. b. The client who had epidural or spinal anesthesia remains in PACU until sensory function and voluntary motor movement of the legs have returned.

5. Fluid, electrolyte and acid-base balance Fasting before and during surgery, loss of fluids during the procedure, and the type and amount of blood or fluid given affect the clients fluid and electrolyte balance after surgery. 6. Intake and output measurement It is part of operative record and part of circulating nurses report to the PACU nurse. a. Record any intake or output, including intravenous fluid (IV) intake , vomitus, urine and nasogastric (NG) tube drainage. b. The output from the both OR and PACU should be recorded differently.

7. Assessing the dressing and drains. Assess all dressings, including casts and elastic bandages, for bleeding or other drainage on admission to the PACU and then hourly thereafter. a. During dressing inspection, check for drainage and record the amount, color, consistency and odor. b. The surgeon inserts a drain into or close to the wound if more than a minimal amount of drainage is expected. A penrose drain(sing-le lumen , soft, open, latex tube) is a gravity type drain placed under the dressing.

c. Assess closed-suction drains such as Hemovac, Vacu-Drain and JacksonPratt drains, for maintenance of suction. d. A T-tube may be placed after abdominal cholecystectomy to drain the tube. e. Assess all drains for patency when the client is admitted to the PACU and every time vital signs are taken. Monitor the amount, color, and type of the drainage. f. Large amounts of sanguineous drainage may indicate internal bleeding. 8. Discomfort/pain assessment. The client almost always has pain or discomfort after surgery. Pain is a subjective experience. When possible, ask the client to rate the pain before and after drugs are given. POST-OPERATIVE REPORT The post-operative report provides information from the following: 1. Anesthesiologist 2. Surgeon 3. Circulating Nurse Anesthesiologists Report 1. Clients name, sex, age, surgical procedure and surgeon. 2. Type of anesthesia and the clients reaction(s). 3. Baseline vital signs and summary of vital signs. 4. Allergies and reaction to certain allergens; 5. Any physiologic changes or existing conditions and interventions to counteract them. 6. Medications administered pre, intra and post operatively.

7. Intravenous fluid administration and body fluid output. 8. Specific client care orders to be performed in the PACU or in the immediate postoperative period. Surgeons Report 1. Postoperative orders pertaining to immediate treatments or therapies to be performed in the PACU or the immediate postoperative period. 2. Specific diagnostic test that are to be initiated in the PACU and continued through the immediate postoperative period. 3. Specific interventions pertaining to the care of the surgical site. 4. Specific operative technique done during the surgery.

Circulating Nurses Report 1. Baseline assessment data. 2. Positioning and skin preparation. 3. Use of specialized surgical equipment, such as laser or endoscope. 4. Use of intraopertaive irrigation fluids. 5. Administration of medication or dyes in the surgical field. 6. Any implants, transplants, explants. 7. Type of dressings and presence of drains and or stents 8. Any pertinent information not reported by the anesthesiologist or surgeon.

INCISIONS

Kochers/Subcostal Incision the incision is started in the epigastrium and is

carried obliquely downward approximately 2 fingerbreadths below and parallel to the costal region.

 USES: Right and Left subcostal incision

Theodore Kocher originally described the subcostal incision; it affords excellent exposure to the gall bladder and biliary tract and can be made on the left side to afford access to the spleen (Kocher, 1903). It is of particular value in obese and muscular patients and has considerable merit if diagnosis is known and surgery planned in advance. The subcostal incision is started at the midline, 2 to 5 cm below the xiphoid and extends downwards, outwards and parallel to and about 2.5 cm below the costal margin (Hardy 1993; Dorfman et al, 1997). Extension across the midline and down the other costal margin may be used to provide generous exposure of the upper abdominal viscera. The rectus sheath is incised in the same direction as the skin incision, and the rectus muscle is divided with cautery; the internal oblique and transversus abdominis muscles are divided with cautery. Some authors have described the retraction of rectus muscle instead of dividing it (Brodie et al, 1976; Fink& Budd, 1984). Special attention is needed for control of the branches of the superior epigastric vessels, which lie posterior to and under the lateral portion of the rectus muscle. The small eighth thoracic nerve will almost invariably be divided; the large ninth nerve must be seen and preserved to prevent weakening of the abdominal musculature. The incision is deepened to open the peritoneum (Dorfman et al, 1997). In the recent years, many surgeons have advocated the use of a small 5-10 cm incision in the subcostal area for cholecystectomy - mini-lap

Midline Incision- Almost all operations in the abdomen and retroperitoneum can

be performed through this universally acceptable incision (Guillou et al, 1980). Advantages (a) It is almost bloodless, (b) no muscle fibres are divided, (c) no nerves are injured, (d) it affords goods access to the upper abdominal viscera, (e) It is very quick to make as well as to close; it is unsurpassed when speed is essential (Clarke, 1989) (f) a midline epigastric incision also can be extended the full length of the abdomen curving around the umbilical scar (Denehy et al, 1998). In the upper abdomen, the incision is made in the midline extending from the area of xiphoid and ending immediately above the umbilicus (Ellis, 1984). Skin, fat, linea alba and peritoneum are divided in that order. Division of the peritoneum is best performed at the lower end of the incision, just above the umbilicus so that falciform ligament can be seen and avoided. If necessary for exposure, the ligament can be divided between clamps and ligated. A few centimeters of upwards extension can be gained by extending the incision to either side of the xiphoid process, or actually excising the xiphoid (Didolkar & Vickers, 1995). The extraperitoneal fat is abundant and vascular in this area, and small vessels here need to be coagulated with diathermy. The infraumbilical midline incision also divides the linea alba. Because the linea alba is anatomically narrow at the inferior portion of the abdominal wall, the rectus sheath may be opened unintentionally, although this is of no consequence. In the lower abdomen, the peritoneum should be opened in the uppermost area to avoid possible injury to the bladder.

It is a good practice to place a bladder catheter before any surgery on the lower abdomen and to curve the properitoneal and peritoneal incisions laterally when approaching the pubic symphysis to avoid entry into the bladder (Nyhus & Baker, 1992). Special care is needed when operating on patients with intestinal obstruction or when reexploring following previous abdominal surgery (Fry& Osler, 1991). In intestinal obstruction, distended bowel loops may be there immediately below the incision and in re-exploration, the bowel may be adherent to the peritoneum. The way to avoid this is to open the peritoneum in a virgin area at the upper or lower part of the incision (Levrant et al, 1994).

Upper abdominal midline (vertical) the incision is started in the epigastrium and the level of the xiphoid process and is carried vertically downward to the level of the umbilicus.
SYNONYM: Epigastric incision, upper median or vertical incision. USES: Rapid entry to the abdomen to control bleeding ulcers, gastric

surgery, explor Lap, pancreatic surgery, transverse colostomy.

Lower abdominal midline incision incision is started opposite the umbilicus and is extended vertically downward in the midline to the suprapubic region.
USES:

pelvic

laparotomy,

TAHBSO,

suprapubic

prostatectomy,

cystectomy, cystolithotomy, CS, Sigmoid colon operation.

Paramedian incision the incision is extended in a vertical direction parallel to

and 2 fingerbreadths lateral to the midline. When the rectus muscle is reached, it may be splitted vertically or retracted laterally. USES: RUP: biliary tract, pancreas, duodenum RLP: Small bowel resection, AP LUP: Splenectomy, gastrectomy LLP: Sigmoid colon resection, hysterectomy The paramedian incision has two theoretical advantages. The first is that it offsets the vertical incision to the right or left, providing access to the lateral structures such as the spleen or the kidney. The second advantage is that closure is theoretically more secure because the rectus muscle can act as a buttress between the reapproximated posterior and anterior fascial planes (Cox et al, 1986). The skin incision is placed 2 to 5 cm lateral to the midline over the medial aspect of the bulging transverse convexity of the rectus muscle. Extra access can be obtained by sloping the upper extremity of the incision upwards to the xiphoid (Didolkar et al, 1995). Skin and subcutaneous fat are divided along the length of the wound. The anterior rectus sheath is exposed and incised, and its medial edge is grasped and lifted

up with haemostats. The medial portion of the rectus sheath then is dissected from the rectus muscle, to which the anterior sheath adheres. Segmental blood vessels encountered during the dissection should be coagulated. Once the rectus muscle is free of the anterior sheath it can be retracted laterally because the posterior sheath is not adherent to the rectus muscle. The posterior sheath and the peritoneum which are adherent to each other, are excised vertically in the same plane as the anterior fascial plane (Brennan et al, 1987). The deep inferior epigastric vessels are encountered below the umbilicus and require ligation and division if they course medially along the line of the incision (Chuter et al, 1992). A paramedian incision below the umbilicus is made in a similar manner. The only difference is that inferior epigastric vessels are exposed in the posterior compartment of the rectus sheath and the transversalis fascia is found in the anterior fascial layer below the semicircular line of Douglas. some surgeons still prefer to split the rectus muscle rather than dissect it free (Guillou et al, 1980). In this rectus-splitting technique, the muscle is split longitudinally near its medial border (medial 1/3rd or preferably onesixth), after which posterior layer of the rectus sheath and peritoneum are opened in the same line. This incision can be made and closed quickly and is particularly valuable in reopening the scar of a previous paramedian incision. In such circumstances, it is very difficult, or indeed impossible to dissect the rectus muscle away from the rectus sheath. Disadvantages : 1. It tends to weaken and strip off the muscles from its lateral vascular and nerve supply resulting in atrophy of the muscle medial to the incision. 2. The incision is laborius and difficult to extend superiorly as is limited by costal margin. 3. It doesnt give good access to contralateral structures. The Mayo-Robson extension of the paramedian incision is accomplished by curving the skin incision towards the xiphoid process. Incision of the fascial planes is continued in the same direction to obtain a larger fascial opening (Pollock, 1981).

Mcburneys incision the incision is extended obliquely from just below the

umbilicus through Mcburneys point upward.

USE: Appendectomy

The McBurney incision, first described in 1894 by

Charles McBurney is the

incision of choice for most appendicectomies (McBurney, 1894). The level and the length of the incision will vary according to the thickness of the abdominal wall and the suspected position of the appendix (Jelenko & Davis 1973; Watts & Perrone, 1997). Good healing and cosmetic appearance are virtually always achieved with a negligible risk of wound disruption or herniation. Classically, the McBurney incision is made at the junction of the middle third and outer thirds of a line running from the umbilicus to the anterior superior iliac spine, the McBurney point (Watts, 1991). However, if palpation reveals a mass, the incision can be placed directly over the mass. McBurney originally placed the incision obliquely, from above laterally to below medially. However, the skin incision can be placed in a skin crease transversely [Rockey-Davis Incision or Lanz Incision or Bikini Incision], which provides a better cosmetic result (Delany & Carnevale, 1976; Pleterski & Temple, 1990). Otherwise, the two incisions are similar. If it is anticipated that it may be necessary to extend the incision, then the incision should be placed obliquely, which enables it to be extended laterally as a muscle splitting incision (Losanoff & Kjossev, 1999).

After the skin and subcutaneous tissue are divided, the external oblique aponeurosis is divided in the direction of its fibres; exposing the underlying internal oblique muscle. A small incision is then made in this muscle adjacent to the outer border of the rectus sheath. The opening is enlarged to permit introduction of two index fingers between the muscle fibres so that internal oblique and transversus can be retracted with a minimal amount of damage. The peritoneum is then grasped with a thumb forceps, elevated and opened. If further access is required, the wound can be easily enlarged by dividing the anterior sheath of the rectus muscle in line with the incision, after which rectus muscle is retracted medially (Jelenko & Davis, 1973; Moneer, 1998). Wide lateral extension of the incision can be affected by combination of division and splitting of the oblique muscles along the line of their fibres in the lateral direction (Weir extension) (Askew, 1975). This incision also may be used in the left lower quadrant to deal with certain lesions of the sigmoid colon, such as drainage of a diverticular abscess.

Inguinal incision- skin incision 1 cm above and parallel to the inguinal ligament,

from the inner to the outer inguinal ring.

USES: Inguinal herniorrhaphy and hydrocelectomy of the spermatic cord. Preoperative Patient Preparation

 Patient positioning: supine position General, spinal or local anesthesia Perioperative antibiotic prophylaxis, if risk factors for wound infection are present Surgical Technique of an Inguinal Incision

Skin incision 1 cm above and parallel to the inguinal ligament, from the inner to the outer inguinal ring. Cut through the subcutaneous fat tissue and Camper's fascia to expose the aponeurosis of the external oblique muscle of the abdomen. Incision of the aponeurosis of the external oblique muscle, from the external inguinal ring to the level of the internal inguinal ring. Identification of the ileoinguinal nerve to facilitate preservation. Blunt mobilization of the spermatic cord Horizontal flank incision - incision is made at the lateral border of the rectus sheath at the level of the umbilicus and is extended out to the flank

USES: Nephrectomy, (GUT) , Lumbar symphthectomy, Ureterolithotomy, Inferior vena cava ligation Location: Mid-abdominal incisionthat extends out into the flank. Advantages: Rapidly excuted and closed Easily extended Provides a secure wound

Thoracotomy incision

USES: lung & Cardiac operation Purpose A physician gains access to the chest cavity (called the thorax) by cutting through the chest wall. Reasons for the entry are varied. Thoracotomy allows for study of the condition of the lungs; removal of a lung or part of a lung; removal of a rib; and examination, treatment, or removal of any organs in the chest cavity. Thoracotomy also provides access to the heart, esophagus, diaphragm, and the portion of the aorta that passes through the chest cavity. Lung cancer is the most common cancer requiring a thoracotomy. Tumors and metastatic growths can be removed through the incision (a procedure called resection). A biopsy, or tissue sample, can also be taken through the incision, and examined under a microscope for evidence of abnormal cells. A resuscitative or emergency thoracotomy may be performed to resuscitate a patient who is near death as a result of a chest injury. An emergency thoracotomy provides access to the chest cavity to control injury-related bleeding from the heart, cardiac compressions to restore a normal heart rhythm, or to relieve pressure on the heart caused by cardiac tamponade (accumulation of fluid in the space between the heart's muscle and outer lining).

Demographics Thoracotomy may be performed to diagnose or treat a variety of conditions; therefore, no data exist as to the overall incidence of the procedure. Lung cancer, a common reason for thoracotomy, is diagnosed in approximately 172,000 people each year and affects more men than women (91,800 diagnoses in men compared to 80,100 in women) Description The thoracotomy incision may be made on the side, under the arm (axillary thoracotomy); on the front, through the breastbone (median sternotomy); slanting from the back to the side (posterolateral thoracotomy); or under the breast (anterolateral thoracotomy). The exact location of the cut depends on the reason for the surgery. In some cases, the physician is able to make the incision between ribs (called an intercostal approach) to minimize cuts through bone, nerves, and muscle. The incision may range from just under 5 in (12.7 cm) to 10 in (25 cm). During the surgery, a tube is passed through the trachea. It usually has a branch to each lung. One lung is deflated for examination and surgery, while the other one is inflated with the assistance of a mechanical device (a ventilator). A number of different procedures may be commenced at this point. A lobectomy removes an entire lobe or section of a lung (the right lung has three lobes and the left

lung has two). It may be done to remove cancer that is contained by a lobe. A segmentectomy , or wedge resection, removes a wedge-shaped piece of lung smaller than a lobe. Alternatively, the entire lung may be removed during a pneumonectomy . In the case of an emergency thoracotomy, the procedure performed depends on the type and extent of injury. The heart may be exposed so that direct cardiac compressions can be performed; the physician may use one hand or both hands to manually pump blood through the heart. Internal paddles of a defibrillating machine may be applied directly to the heart to restore normal cardiac rhythms. Injuries to the heart causing excessive bleeding (hemorrhaging) may be closed with staples or stitches. Once the procedure that required the incision is completed, the chest wall is closed. The layers of skin, muscle, and other tissues are closed with stitches or staples. If the breastbone was cut (as in the case of a median sternotomy), it is stitched back together with wire. Diagnosis/Preparation Patients are told not to eat after midnight the night before surgery. The advice is important because vomiting during surgery can cause serious complications or death. For surgery in which a general anesthetic is used, the gag reflex is often lost for several hours or longer, making it much more likely that food will enter the lungs if vomiting occurs. Patients must tell their physicians about all known allergies so that the safest anesthetics can be selected. Older patients must be evaluated for heart ailments before surgery because of the additional strain on that organ. Aftercare Opening the chest cavity means cutting through skin, muscle, nerves, and sometimes bone. It is a major procedure that often involves a hospital stay of five to seven days.

The skin around the drainage tube to the thoracic cavity must be kept clean, and the tube must be kept unblocked. The pressure differences that are set up in the thoracic cavity by the movement of the diaphragm (the large muscle at the base of the thorax) make it possible for the lungs to expand and contract. If the pressure in the chest cavity changes abruptly, the lungs can collapse. Any fluid that collects in the cavity puts a patient at risk for infection and reduced lung function

Thoracoabdominal incision USE: Esophagastrectomy The thoracoabdominal incision, either right or left, converts the pleural and

peritoneal cavities into one common cavity and thereby gives excellent exposure. Laparotomy incisions, whether upper midline, upper paramedian or upper oblique can be easily extended into either the right or left chest for better exposure (Nyhus & Baker, 1992). The right incision may be particularly useful in elective and emergency hepatic resections (Kise et al, 1997). The left incision may be used effectively in resection of the lower end of the esophagus and proximal portion of the stomach (Molina et al, 1982; Ti, 2000).

When liver resection is anticipated, it is now more common to give a sternum splitting incision than to extending it into the right pleural space (Sato et al, 2000). The reasons for this are that the sternum heals with considerably less pain than does the costochondral junction; the exposure is as good, and the intrapericardial vena cava can be controlled through this incision if there is untoward venous bleeding (Miyazaki et al, 2001). The patient is placed in the cork-screw position. The abdomen is tilted about 45 from the horizontal by means of sand bags, and the thorax twisted into fully lateral position. This position allows maximal access to both abdomen and the thoracic cavity (Morrissey & Hollier, 2000). The abdomen is explored first through the abdominal incision to assess for the operative exposure and necessity for thoracic extension. The incision is extended along the line of the eighth interspace, the space immediately distal to the inferior pole of the scapula (Dudley, 1983). The thoracic incision is carried down through the subcutaneous fat and the lattismus dorsi, serratus anterior and external oblique muscles. The intercostals muscles are divided with cautery and pleural cavity is opened and lung allowed to collapse. The incision is continued across the costal margin, and the cartilage is divided in a V shape manner with a scalpel so that the two ends interdigitate and can be closed more securely. A chest retractor is inserted and opened to produce wide spreading of the intercostal space. After ligation of the phrenic vessels in the line of the incision, the diaphragm is divided radially (Zinner et al, 1997).

Pfannenstial/ Bikini incision transverse incision across the lower abdomen

within the hairline of the pubis. USES: Pelvic laparotomy, TAHBSO (Uterus, tubes, ovaries), CS, Prostate surgery, urinary bladder surgery

The Pfannenstiel incision is used frequently by gynaecologists and urologists for access to the pelvis organs, bladder, prostate and for caesarean section (Ayers & Morley, 1987; Mendez et al, 1999; Hendrix et al, 2000). The skin incision is usally 12 cm long and is made in a skin fold approximately 5 cm above symphysis pubis. The incision is deepened through fat and superficial fascia to expose both anterior rectus sheaths, which are divided along the entire length of the incision. The sheath is then separated widely, above and below from the underlying rectus muscle. It is necessary to separate the aponeurosis in an upward direction, almost to the umbilicus and downwards to the pubis. The rectus muscles are then retracted laterally and the peritoneum opened vertically in the midline, with care being taken not to injure the bladder at the lower end. The incision offers excellent cosmetic results because the scar is almost always hidden by the patients pubic hair postoperatively (Griffiths, 1976). Because the exposure is limited this incision should be used only when surgery is planned on the pelvic organs (Mendez et al, 1999).

References: NCM 103 Handout

Villacarlos, Pamela Pagunsan (2010) Operating Room Nursing: Perioperative Practice, C&E Publishing Inc. http://www.scribd.com/doc/38284130/Common-Incisions http://www.surgeryencyclopedia.com/St-Wr/Thoracotomy.html http://medind.nic.in/jae/t01/i2/jaet01i2p170.pdf http://www.urology-textbook.com/inguinal-incision.html