Case Study Main Ot

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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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