Southwestern University-Medical Center

OR/DR

Intensive Nursing Practicum

Mondoy, Reignna Azucena T.

Nyamuttah, Joy
Palulay, Janerose V.
Ponio, Janeth French D.
Quirong, Jimlhea Mae U.
Rago, Maria Antonette D.
Resano, Ma. Zandra Gerardine O.
Restauro, Lesty Jane B.
Roces, Meriette L.
Sesaldo, Louise Camille M.
Tagab, Mae P.
 HEMORRHOIDECTOMY
Indication
• Very large internal hemorrhoids
• Internal hemorrhoids that still cause symptoms after nonsurgical
treatment
• Large external hemorrhoids that cause significant and make it
difficult to keep the anal area clean
• Both internal and external hemorrhoids
• Had other treatments for hemorrhoids (suck as rubber band
ligation) that have failed.
Type
• Open hemorrhoidectomy (Milligan-Morgan hemorrhoidectomy) - is
excised in the same manner as in a closed procedure, but here the
incision is left open. Surgeons may opt for open hemorrhoidectomy
when the location or amount of disease makes wound closure
difficult or the likelihood of postoperative infection high.
• Closed hemorrhoidectomy - is the surgical procedure most
commonly used to treat internal hemorrhoids. Typically, all three
hemorrhoidal columns are treated at one time.
• Stapled hemorrhoidectomy - is mostly used in patients with grade
III and IV hemorrhoids and those who fail prior minimally invasive
treatments. During stapled hemorrhoidectomy, a circular stapling
device is used to excise a circumferential ring of excess hemorrhoid
tissue, thereby lifting hemorrhoids back to their normal position
within the anal canal.
• Rubber band ligation - A rubber band is placed around the base of
the hemorrhoid inside the rectum. The band cuts off circulation, and
the hemorrhoid withers away within a few days.
• Lateral Internal Sphincterotomy - opening of the inner anal
sphincter muscle is sometimes performed during hemorrhoidectomy
in patients with high resting sphincter pressures. It is hypothesized
to reduce postoperative pain. It is not used in most cases.
Post-operative preparation
• Patients should ideally be put on a high fiber diet and stool
softeners for several days prior to the procedure, this is to reduce
post-operative pain and to reduce the chances for post-operative
fecal impaction
• Lactulose taken for 4 days prior to Hemorrhoidectomy
• Antibiotic prophylaxis is advisable for all clean- contaminated
operations such as hemorrhoidectomy
• Enema on the day of the operation
• Prophylactic antibiotic (at induction)
• Anesthesia
• Position the patient properly
• Do skin preparation
• Surgeon sits facing the procedure
Procedure
• Insert Parkes anal speculum to display the hemorrhoid to be
operated upon
• Grasp the hemorrhoid at the mucocutaneous junction with
hemostatic forceps and retract towards the surgeon
• Incise the skin at the base of the hemorrhoid with a scissors as a V-
shape incision with the base of the V towards the hemorrhoid.
• Extend this incision into the mucosa to the either side of the
hemorrhoid raising it off the muscles of the internal sphincter
• The dissection is continued just beyond the dentate line
• Transfix and ligate the pedicle of the hemorrhoid with a 2-0 vicryl
suture leaving a long length of suture material attached
• Excise the hemorrhoid 0.5cm distal to the ligature
• Repeat the procedure with the other hemorrhoids.
• Leave a mucocutaneous bridge between each hemorrhoid to reduce
any subsequent anal structure
• At the end place of a small paraffin-soaked pack to reduce bleeding
within the anal canal, supported by a T-shaped bandage
Going Home After Surgery
• Right after the surgery, when the patient is still under anesthesia,
the patient will be given a long-acting local anesthetic. It should
last 6-12 hours to provide pain relief after surgery. If the patient
will not be going to stay overnight in the hospital after the surgery,
leave the anesthesia until it wears off and if the patient urinated.
• Someone should drive home
Care After the Surgery
• Advise patient to take prescribed medication for pain
• Educate patient that some bleeding is normal, especially the first
bowel movement
• For few days after surgery, teach patient to drink liquids and eat
bland diet, then he/she can return to regular foods and gradually
increase the amount of fiber in the diet
• Teach patient to apply numbing medicines before and after bowel
movements to relieve pain
• Apply ice packs to anal area to reduce swelling and pain
• Frequent soaks in warm water (sitz baths)
• Some doctors may recommend patient to take antibiotic (such as
metronidazole) after surgery
• Doctors recommend that patient should take stool softeners that
contain fibers
• Educate patient about the follow-up exams with the surgeon usually
done 2-3 weeks after surgery
Complication
Early problems
• Bleeding from anal area
• Collection of blood in the surgical area
• Inability to control the bowel and bladder
• Infection of the surgical area
• Stool trapped in anal canal (fecal impaction
Late problems
• Narrowing of the anal canal
• Recurrence of hemorrhoids
• An abnormal passage that forms between the anal and fecal canal
and another area
• Rectal prolapse, which happens when the rectal lining slips out of
the anal opening
 APPENDECTOMY
What is appendicitis?
● Appendicitis is a condition in which the appendix becomes inflamed.
● The appendix is a finger or worm-shaped pouch that projects out
from the cecum (the beginning of the colon).
● The infection may occur when the opening of the appendix becomes
clogged with bacteria and stool. This causes your appendix to
become swollen and inflamed.
● Deep tenderness at the McBurney's point (the location of
McBurney's point is about 2/3 the distance starting from the
umbilicus to the right anterior superior iliac spine); however, young
children and pregnant females may experience pain elsewhere in
the abdomen.

Types of Appendicitis
Chronic appendicitis vs. acute appendicitis
● Chronic appendicitis and acute appendicitis are sometimes
confused. In some cases, chronic appendicitis isn’t diagnosed until
it becomes acute appendicitis.
● Chronic appendicitis can have milder symptoms that last for a long
time, and that disappear and reappear. It can go undiagnosed for
several weeks, months, or years.
● Acute appendicitis has more severe symptoms that appear suddenly
within 24 to 48 hours. Acute appendicitis requires immediate
treatment.
Risk Factors
● Age: Appendicitis most often affects people between the ages of 15
and 30 years old.
● Sex: Appendicitis is more common in males than females.
● Family history: People who have a family history of appendicitis are
at heightened risk of developing it.
 Etiology

Signs and Symptoms

If you have appendicitis, you may experience one or more of the
following symptoms:
● pain in your upper abdomen or around your bellybutton
● pain in the lower right side of your abdomen
● loss of appetite
● indigestion
● nausea
● vomiting
● diarrhea
● constipation
● abdominal swelling
● inability to pass gas
● low-grade fever
Diagnostic Test
Tests and procedures used to diagnose appendicitis include:
● Physical exam to assess your pain. Your doctor may apply gentle
pressure on the painful area. When the pressure is suddenly
released, appendicitis pain will often feel worse, signaling that the
adjacent peritoneum is inflamed.
● Your doctor may use a lubricated, gloved finger to examine your
lower rectum (digital rectal exam). Women of childbearing age may
be given a pelvic exam to check for possible gynecological problems
that could be causing the pain.
● Blood test. This allows your doctor to check for a high white blood
cell count, which may indicate an infection.
● Urine test. Your doctor may want you to have a urinalysis to make
sure that a urinary tract infection or a kidney stone isn't causing
your pain.
● Imaging tests. Your doctor may also recommend an abdominal X-
ray, an abdominal ultrasound, computerized tomography (CT) scan
or magnetic resonance imaging (MRI) to help confirm appendicitis
or find other causes for your pain.
 Treatment options for appendicitis
Depending on your condition, your doctor’s recommended
treatment plan for appendicitis may include one or more of the
following:
● surgery to remove your appendix
● needle drainage or surgery to drain an abscess
● antibiotics
● pain relievers
● IV fluids
● liquid diet
In rare cases, appendicitis may get better without surgery. But in
most cases, you will need surgery to remove your appendix. This is
known as an appendectomy.
What is Appendectomy?
Removal by surgery of the appendix, the small worm-like
appendage of the colon (the large bowel). An appendectomy is
performed because of probable appendicitis, inflammation of the
wall of the appendix generally associated with infection.
And the easiest and quickest way to treat appendicitis is to remove
the appendix. Your appendix could burst if appendicitis isn’t treated
immediately and effectively. If the appendix ruptures, the bacteria
and fecal particles within the organ can spread into your abdomen.
This may lead to a serious infection called peritonitis. You can also
develop an abscess if your appendix ruptures. Both are life-
threatening situations that require immediate surgery.
Types of Appendectomy
● Open appendectomy. A cut or incision about 2 to 4 inches long is
made in the lower right-hand side of your belly or abdomen. The
appendix is taken out through the incision.
● Laparoscopic appendectomy. This method is less invasive. That
means it's done without a large incision. Instead, from 1 to 3 tiny
cuts are made
How Is an Appendectomy Performed?
Open Appendectomy
During an open appendectomy, a surgeon makes one incision in the
lower right side of your abdomen. Your appendix is removed and
the wound is closed with stiches. This procedure allows your doctor
to clean the abdominal cavity if your appendix has burst.
 Your doctor may choose an open appendectomy if your appendix
has ruptured and the infection has spread to other organs. It’s also
the preferred option for people who have had abdominal surgery in
the past.

Laparoscopic Appendectomy
During a laparoscopic appendectomy, a surgeon accesses the
appendix through a few small incisions in your abdomen. A small,
narrow tube called a cannula will then be inserted. The cannula is
used to inflate your abdomen with carbon dioxide gas. This gas
allows the surgeon to see your appendix more clearly.
Once the abdomen is inflated, an instrument called a laparoscope
will be inserted through the incision. The laparoscope is a long, thin
tube with a high-intensity light and a high-resolution camera at the
front. The camera will display the images on a screen, allowing the
surgeon to see inside your abdomen and guide the instruments.
When the appendix is found, it will be tied off with stiches and
removed. The small incisions are then cleaned, closed, and dressed.
Laparoscopic surgery is usually the best option for older adults and
people who are overweight. It has fewer risks than an open
appendectomy procedure, and generally has a shorter recovery
time.

● In general, laparoscopic surgery allows you to recover faster and

heal with less pain and scarring. It may be better for older adults
and people with obesity.
● But laparoscopic surgery isn't appropriate for everyone. If your
appendix has ruptured and infection has spread beyond the
appendix or you have an abscess, you may need an open
appendectomy, which allows your surgeon to clean the abdominal
cavity.
● Expect to spend one or two days in the hospital after your
appendectomy
What Are the Risks of an Appendectomy?
• Bleeding
• Infection
• injury to nearby organs
• blocked bowels
It’s important to note that the risks of an appendectomy are much
less severe than the risks associated with untreated appendicitis.
An appendectomy needs to be done immediately to prevent
abscesses and peritonitis from developing.
Preoperative Care
● It is important to prepare a patient several hours pre-surgery. The
patient may be dehydrated due to symptoms such as vomiting. It
may be necessary to administer IV fluids. The patient’s vital signs
should be recorded every 2-4 hours. The nurse should not apply
any heat over the area of pain while the patient is awaiting
diagnosis as this could cause the appendix to rupture.
● Analgesia should not be administered before examination because
this can lead to an inaccurate diagnosis as the pain may subside
and the examination will be ineffective. Aperients should also be
avoided as induced peristalsis may cause perforation. If appendicitis
has been diagnosed regular analgesia, usually an opioid depending
on pain severity, should be given to make the patient comfortable
before treatment. They may feel anxious so the nurse or surgical
team should fully explain the procedure to them and answer any
questions. The operation site will be washed and shaved before
surgery, depending on local procedures.
Postoperative Care
● The severity of the patient’s pain needs to be assessed with the use
of a pain scale. Appropriate pain relief can then be administered.
Vital signs should be regularly monitored at 15mins intervals for
two hours postoperatively, hourly for two hours and, if stable, every
four hours while the patient is recovering in hospital.
● If the patient has had a straightforward appendectomy the surgical
team should review the patient on recovery and decide when they
may eat and drink.
● A drain may have been inserted during surgery. If so, the output of
the drain should be recorded every 24 hours. The drain can be
removed when there is minimal drainage - usually 50ml or less.
● The wound should be managed aseptically. If the wound is covered
with a dry dressing then it should be changed every 1-2 days.
Clips/stitches should be removed 10 days postoperatively. The
patient can go home with these in place and the district or practice
nurse can remove them. If dissolvable stitches have been used this
is unnecessary, although a visit to check the wound will reduce
anxiety. Before discharge, the patient must be confident in how to
manage their wound and have details of who they should contact in
case of concern.
● The patient should be encouraged to get up and out of bed as soon
as possible to prevent the formation of emboli. Anticoagulants are
usually administered in the form of subcutaneous injections before
surgery and postoperatively. Antiembolism stockings should be
worn. If peritonitis has developed, the patient’s postoperative
management will be over a longer period but will follow the same
principles.
● The patient will not be able to commence food and fluids for a few
days, this is to enable the bowel to regain normal function. The
convalescence period is almost invariably smooth and the patient
recovers rapidly. The hospital stays for patients who have
undergone an uncomplicated appendectomy is usually 2-3 days. In
most cases the patient will be discharged when their temperature is
normal and their bowels have started to function again.
● People can live a full life without their appendix. Changes in diet,
exercise or other lifestyle factors are not necessary.
 CHOLECYSTECTOMY
Definition
Cholecystectomy is a surgical procedure to remove your
gallbladder. The gallbladder a pear-shaped organ that sits just
below your liver on the upper right side of your abdomen. It collects
and stores bile, a digestive fluid produced in your liver that
functions to emulsify fats.
Gallstones can block the flow of bile in your digestive system. This
blockage can cause bloating, nausea, vomiting, and pain in your
abdomen, shoulder, back, or chest. Gallstones can also block the
ducts that channel the bile from the liver or gallbladder to the
intestine. Gallstones can cause the gallbladder to become infected.
A blockage in the common bile duct can cause jaundice or irritate
the pancreas.
There are two types of performing cholecystectomy which are open
cholecystectomy and laparoscopic cholecystectomy. Open
cholecystectomy is performed by making a large incision in the
abdomen to remove the gallbladder. Laparoscopic cholecystectomy
is the most commonly performed type of surgery. It is done by
inserting a tiny video camera and a special surgical tool though four
small incisions to be able to remove the gallbladder.
Causes
 Gallstones in the gallbladder (cholelithiasis)
 Gallstones in the bile duct (choledocholithiasis)
 Gallbladder inflammation (cholecystitis)
 Large gallbladder polyps
 Pancreas inflammation (pancreatitis) due to gallstones
Risks
 Bile leak
 Bleeding
 Infection
 Injury to nearby structures, such as the bile duct, liver and small
intestine
 Risks of general anesthesia, such as blood clots and pneumonia
Pre-op procedures
 History and physical examination
 Name of procedure on surgical consent
 Signed surgical consent
 Laboratory results
 Client is wearing identification bracelet
 Allergies have been identified
 NPO status
 Skin preparation completed
 Vital signs assessed
 Jewelry, dentures and nail polish removed
 Client is wearing a hospital gown and hair net
 Client has urinated
 Location of iv site, type of iv fluid, and rate of infusion identified.
Intra- op procedures
1. Open Cholecystectomy
 A general anesthetic is given to relax your muscles, prevent pain,
and help you fall asleep.
 A single cut is made below the right side of your rib cage or in the
center of the abdomen.
 Your doctor can see the gallbladder and surrounding anatomy
through the cut.
 The gallbladder is cut away from surrounding tissue.
 The blood supply is tied off and divided. Sometimes a
cholangiogram (a special X-ray) is done to check for stones in the
common bile duct.
 If there are stones in the common bile duct, they are removed at
this time.
 The skin is closed using surgical clips and stitches.

2. Laparoscopic Cholecystectomy
 A general anesthetic is given to relax your muscles, prevent pain,
and help you fall asleep.
 Your abdomen is inflated with carbon dioxide, a harmless gas.
 The laparoscope is then inserted through a cut in your navel, so
your doctor can look inside.
 A cholangiogram (a special X-ray) may be done while the surgery is
going on to check for stones in your common bile duct.
 Other instruments are then inserted through additional small
incisions. Your gallbladder is removed through one of these
incisions.
 Benefits:
Less discomfort than regular surgery.
 Shorter hospital stays, with a quicker recovery time compared to
regular (open) surgery.
Smaller scars than regular surgery.
Post op procedure
You'll be taken to a recovery area as the anesthesia drugs wear off.
Then you'll be taken to a hospital room to continue recovery.
Recovery varies depending on your procedure:
 Laparoscopic cholecystectomy. People are often able to go home
the same day as their surgery, though sometimes a one-night stay
in the hospital is needed. In general, you can expect to go home
once you're able to eat and drink without pain and are able to walk
unaided. It takes about a week to fully recover.
 Open cholecystectomy. Expect to spend two or three days in the
hospital recovering. Once at home, it may take four to six weeks to
fully recover.
 PROCTOSIGMOIDOSCOPY
Definition
 Proctosigmoidoscopy is a combined proctoscopy and sigmoidoscopy
 Proctoscopy is a procedure to examine the inside of the rectum and
the anus.
 Sigmoidoscopy is a test used to check the sigmoid colon.
 Proctosigmoidoscopy is an endoscopic visualization
of the anal canal, rectum and the sigmoid colon.

Anatomy of The Colon

When Is It Performed?
 changes in your bowel habits
 rectal bleeding
 abdominal pain
 unexplained weight loss
Indication
 Biopsy of lesions
Diagnosis
• Inflammatory Bowel Disease (IBD)
• Bowel Obstruction
• Colon Polyps
• Colon Cancer
• Diverticulosis
Inflammatory Bowel Disease
An umbrella term used to describe disorders that involve
chronic inflammation of the digestive tract.
 Ulcertaive Colitis - a condition that causes long-lasting inflammation
and ulcers in the colon and rectum.
 Crohn's Disease - a type of IBD that is characterized by
inflammation of the lining of your digestive tract, which often
spreads deep into affected tissues.
Signs & Symptoms
 abdominal pain
 diarrhea that may be bloody
 severe urgency to have a bowel movement
 fever
 weight loss

Bowel Obstruction
 Bowel Obstruction, also known as Intestinal Obstruction, is a
blockage that keeps food or liquid from passing through your small
intestine or large intestine (colon).
Signs & Symptoms
 vomiting
 diarrhea
 constipation
 bloating
 severe abdominal pain
 inability to pass stool or gas

Colon Polyps
 a small growth of tissue that projects from the colon.
Signs & Symptoms
 bleeding from the rectum
 abdominal pain
 a change in the color of stools
 iron deficiency anemia
 a change in bowel habits that lasts longer than a week, including
constipation or diarrhea
Diverticulosis
A condition that develops when pouches form in the wall of the
colon.
Signs & Symptoms
 abdominal pain
 bloating
 constipation
 diarrhea

Client Preparation
 Ensure the presence of a signed informed consent form.
 Generally, clear liquid diet is ordered for the evening before the
procedure.
 Instruct to take a laxative; administer enema the evening before
the procedure as ordered.
 Administer enema before the procedure as ordered.
Client Teaching Before Procedure
 The procedure takes approximately 15 minutes.
 A mild sedative may be given during the procedure.
 You may be positioned on your left side or in the knee-chest
position.
 The scope will be inserted through the anus into the sigmoid colon.
 Feces may be suctioned.
 A biopsy may be taken. Polyps may be removed.
 taking deep breaths when you feel discomfort may help you relax.
Procedure
 The patient will be asked to lie on your left side with your knees
pulled up or Left Lateral (Sim's) Position, or the patient may be
asked to kneel on the table with the buttocks raised in the air or the
Knee Chest Position.
 Before the sigmoidoscopy, the doctor checks if anything is blocking
the rectum by inserting a gloved finger into the anus and rectum.
 The doctor inserts the sigmoidoscope through the anus and into the
rectum and sigmoid colon. Air is pumped into the colon to stretch
the lining so that the entire surface can be seen.

 Small tools may be passed through the sigmoidoscope to collect

biopsy samples, remove polyps, and stops bleeding.
Nursing Responsibilities After Procedure
 Observe the patient closely for signs of bowel perforation.
 Obtain and record the patient's vital signs.
 Instruct patient to resume a normal diet, fluids, and activity as
advised by the health care provider.
 Provide privacy while the patient rest after the procedure.
 Monitor for any rectal bleeding.
Contraindication
 Bowel perforation
 Acute diverticulitis
 Active peritonitis
 Fulminant colitis
 Cardiopulmonary instability
Interpretation of Results
Normal Results
Normal findings show that the lining of the sigmoid colon, rectal
mucosa, rectum and anus appear normal in color, texture and size.
Abnormal Result can indicate
 Hemorrhoids
 Anal fissures
 Anorectal abscess
 Cancer
 Colorectal polyps
 Inflammation or infection (proctitis)
 Bowel obstruction
 Inflammatory bowel disease
 Diverticulosis
Complications
 Perforation
 Bleeding
 Cardiac Arrhythmias
Nursing Diagnosis
 Anxiety related to change in health status
 Deficient Knowledge related to lack of information about the
procedure
 THYROIDECTOMY
• The removal of all or part of your thyroid gland.
• The thyroid gland is a butterfly-shaped gland located at the base of
your neck.
• It produces hormones that regulate every aspect of your
metabolism, from the heart rate to how quickly you burn calories.
Potential complications include
• Bleeding.
• Infection.
• Low parathyroid hormone levels (hypoparathyroidism)
– caused by surgical damage or removal of the parathyroid glands.
These glands are located behind your thyroid and regulate blood
calcium. Hypoparathyroidism can cause numbness, tingling or
cramping due to low blood-calcium levels.
• Airway obstruction caused by bleeding.
• Permanent hoarse or weak voice due to nerve damage.
This procedure may be advised for
1. Thyroid cancer --is the most common reason for
thyroidectomy.
2. Noncancerous enlargement of the thyroid (goiter)
3. Overactive thyroid (hyperthyroidism)
4. Indeterminate or suspicious thyroid nodules
5. Thyroid cancer --is the most common reason for
thyroidectomy.
Several approaches include
Conventional thyroidectomy --involves making an incision in the
center of your neck to directly access your thyroid gland.
Transoral thyroidectomy --avoids a neck incision by using an
incision inside the mouth.
Endoscopic thyroidectomy --uses smaller incisions in the neck.
Surgical instruments and a small video camera are inserted through
the incisions.
After the procedure
Patient may experience neck pain and a hoarse or weak voice, but
are often temporary and may be due to irritation from the breathing
tube (endotracheal tube) that's inserted into the windpipe (trachea)
during surgery, or as a result of nerve irritation caused by the
surgery.
 Long term effects
• Partial thyroidectomy--may not need thyroid replacement hormones
• Complete thyroidectomy--need to take a pill every day that
contains the synthetic thyroid hormone levothyroxine (Levoxyl,
Synthroid, Unith roid). This hormone replacement is identical to the
hormone normally made by your thyroid gland and performs all of
the same functions.
Nursing Diagnoses
1. Acute pain r/t surgical manipulation of tissues, possibly
evidenced by reports of pain, guarding behavior, and restlessness.
* maintain the head and neck in neutral position and support during
position changes, to avoid hyperextension.
2. Risk for ineffective airway clearance r/t tracheal obstruction;
swelling, bleeding, laryngeal spasms.
* support head with pillows; suctioning; keep tracheostomy set at
bedside
* check dressing frequently, especially the posterior portion where
the blood pools
* investigate reports of difficulty swallowing, which may indicate
edema or bleeding
3. Impaired verbal communication r/t tissue edema; pain or
discomfort; laryngeal nerve damage
* provide alternative methods of communication: slate board,
picture board, to facilitate expression of needs
* keep communication simple; ask yes or no questions.
What is Salpingectomy?
● A salpingectomy is the surgical removal of one (unilateral) or both
(bilateral) fallopian tubes. Fallopian tubes allow eggs to travel from
the ovaries to the uterus.
Types of Salpingectomy
● Partial Salpingectomy, where only a part of the fallopian tube is
removed
● Complete or Total Salpingectomy, where the entire fallopian tube is
removed
● Bilateral Salpingectomy, where both the fallopian tubes are
removed
● Unilateral Salpingectomy, where only one fallopian tube is removed
● Salpingo-oophorectomy, where the ovaries are removed along with
the fallopian tubes
 Indications for Salpingectomy
● an ectopic pregnancy
● a blocked fallopian tube
● a ruptured fallopian tube
● an infection
● fallopian tube cancer
Diagnostic Tests
● Abdominal and Pelvic Ultrasound:
● Hysterosalpingogram: During this test, contrast medium is
introduced into the uterus via the vaginal passage through a
syringe. The contrast passes through the uterus and the fallopian
tube into the abdomen, which can be visualized with imaging tests.
● Diagnostic Laparoscopy: Laparoscopy is sometimes used to directly
visualize the fallopian tubes and other structures of the abdomen
and diagnose the problem
Salpingectomy Procedure
● Once you are anesthetized, an incision is made in the lower
abdomen. If you have to undergo laparoscopy, small incisions will
be made to pass the laparoscope and instruments for the surgery.
● During laparoscopy, the abdomen is insufflated with carbon dioxide
for better visualization.
● Once the fallopian tube is identified, it is separated from
surrounding tissues while controlling the bleeding. The tube is tied
at its uterine end and it is cut out. In some cases, instead of
ligatures, endoscopic staples, endocoagulation, cautery, or laser
may be used. The ovary may also be removed along with the
fallopian tube.
● In younger women who would like to maintain their ovarian
function and fertility, the ovaries are retained. The procedure will be
repeated on the other side in patients undergoing bilateral
salpingectomy. The incision is then closed.
 Complications
● Complications due to anaesthesia
● Bleeding
● Injury to surrounding structures
● Infection
● Chronic pain
Preoperative Care
● Assess the woman’s understanding of the procedure. Provide
explanation, clarification, and emotional support as needed.
● Reassure that the anaesthesia will eliminate any pain during
surgery and that medication will be administered postoperatively to
minimize discomfort.
● Cleanse the abdominal and perineal area, and, if ordered, shave
the perineal area
● If ordered, administer a small cleansing enema and ask the woman
to empty her bladder. This precaution helps prevent contamination
from the bowel or bladder during surgery.
● Administer preoperative medications as ordered.
● Check the chart to ensure that the consent form has been signed.
Post-operative Care
● Assess for signs of haemorrhage. Haemorrhage is more common
after this surgery.
● Monitor vital signs every 4 hours, auscultate lungs every shift and
measure intake and output.
● Once the catheter has been removed, measure the amount of urine
voided.
● Assess for complications, including infection, ileus, shock
haemorrhage, thrombophlebitis, and pulmonary embolus
● Assess vaginal discharge; instruct the woman in perineal care.
● Assess incision and bowel sounds every shift.
● Encourage turning, coughing, deep breathing, and early
ambulation.
● Encourage fluid intake
● Instruct to restrict physical activity for 4 to 6 weeks. Heavy lifting,
stair climbing, douching, tampons, and sexual intercourse should be
avoided.
● Explain to the woman that she may feel tired for several days after
surgery and needs to rest periodically.
● Teach the woman to recognize signs of complications that should be
reported to the physician or nurse:
a. Temperature greater than 100°F (37.7°C)
b. Vaginal bleeding that is greater than a typical
menstrual period or is bright red
c. Urinary incontinence, urgency, burning, or frequency
d. Severe pain
● Reinforce the need to obtain gyneacologic examinations regularly
even after the procedure.
 CASE STUDY
General Objective
The Level IV students will be able to demonstrate knowledge
regarding the health and disease condition of the patient with
diagnosis, its disease process, possible complications, treatment
plan, medical and nursing interventions.

Specific Objectives
 Understand the pathophysiology and etiology of the diseases being
presented.
 Recognize the contributing factors associated in the development of
the diagnosis.
 Systematically present the data pertinent to the case being
gathered.
 Efficiently provide appropriate and proper nursing diagnosis in line
with the client’s medical condition and skillfully formulate nursing
care plans for the problems identified.
 Comprehend the relevance of the laboratory results in the diagnosis
and its presenting signs and symptoms.
 Understand the role of drug therapy in managing the client related
to the patient’s diagnosis.
 Exhibit mastery and proper understanding in answering relevant
questions with positive attitude towards criticisms and suggestions.
 PATIENT’S DEMOGRAPHIC DATA

Patient’s Initials: R. M. T.
Sex: Female
Age: 59
Date of Birth: 06/19/1960
Marital Status: Married
Address: 8-19 A Borres St., Brgy. Suba, Cebu City
Religion: Roman Catholic
Date and Time of Admission: 11/6/2019 7:20 PM
Chief Complaint: dyspnea; increasing abdominal girth
Admitting Diagnosis: Ascites secondary to ovarian new growth,
probably malignant
Admitting Physician: Virnil Revelo, MD.
PATIENT’S MEDICAL HISTORY
A. History of Present Illness
A case of Mrs. R.M.T., 59 years old, married, from Brgy. Suba,
Cebu City, was admitted at Southwestern University-Medical Center
due to dyspnea and increasing abdominal girth.
Three months prior to admission, patient noted round mass
palpated at hypogastric area with pain on palpation. Condition was
tolerated, and no consult was done.
One month prior to admission, patient’s daughter noticed her
mother had unintentional weight loss, with occasional numbness at
lower extremities. No change in urinary and bowel habits. Condition
was tolerated, and no consult was done.
Two weeks prior to admission, patient had episodes of dyspnea,
aggravated by doing physical task such as laundry, and can only
talk up to two sentences. It was relieved by rest. Patient also had
body malaise and increasing abdominal girth, sought consult at
Cebu Doctor’s University Hospital, labs were done. Complete blood
count revealed Hgb 9.8, Hct 31%. Ultrasound whole abdomen
revealed moderate to massive ascites, and revealed bilateral
ovarian new growth, and so patient was advised for paracentesis
and admission, but refused.
One day prior to admission, condition worsened, so patient went
to VSMMC for admission but was advised for transfer to another
hospital because their Gynecology ward was full, thus decided to
seek consult and was admitted to this institution.
B. PAST HEALTH HISTORY
Menstrual History: Menarche at 12 years old, with regular
interval 28-33 days, lasting 3-4
days, using 4 pads moderately soaked. No
dysmenorrhea. Menopause at 55 years old.
Sexual History: Coitus at 20 years old, with 1 sexual partner. No
contraceptive use. No post-coital bleeding
noted.
Obstetrics History: G1, Female (born in 1989) via NSVD at
Sacred Heart Hospital. No complications.
Allergies: Shrimps
No previous hospitalizations.
C. FAMILY HEALTH HISTORY
(maternal side)
(+) hypertension
(+) diabetes mellitus
(+) cardiac disease
(+) sister operated at ovary due to cyst as claimed
D. PSYCHOSOCIAL HISTORY
Patient attained high school level education. She had been
working at the parlor for 20 years. She does not consume alcoholic
beverages, but smokes for the past 20 years, consuming 2-3 sticks
a day. No illicit drug use.

PHYSICAL ASSESSMENT/EXAMINATION
General Survey
Awake, Coherent, Weak-looking, In respiratory distress
Vital Signs
Temperature: 36.7
Pulse Rate: 105 beats per minute
Respiratory Rate: 29 cycles per minute
Blood Pressure: 110/70 mmHg
Oxygen Saturation: 95%
Review of Systems
Constitutional: (+) Weight loss
Respiratory:(+) Shortness of breath, (+) decreased lung sounds
at lower lung field
Gastrointestinal:(+) Abdominal pain, (+) Nausea, (+)
Protuberant, distended
 AG=113cm (+) Fluid wave (+) Tenderness on deep
palpation at hypogastric area (+) Dullness on
percussion
Neurological: (+) Alert Orientation (+) time (+) place (+)
person
HEENT: (+) pale palpebral conjunctiva (+) dry lips and oral
mucosa
Problem List
1. Ovarian New Growth, probably Malignant
2. Massive Ascites secondary to #1
3. AKI secondary to Abdominal Compartment Syndrome
secondary to #2
Anatomy and Physiology
Ovarian cancer is a type of cancer that begins in the ovaries.
The female reproductive system contains two ovaries, one on each
side of the uterus. The ovaries — each about the size of an almond
— produce eggs (ova) as well as the hormones estrogen and
progesterone.
Malignant ovarian lesions include primary lesions arising from
normal structures within the ovary (epithelial ovarian carcinoma)
and secondary lesions from cancers arising elsewhere in the body.
Ovarian cancer is the most common cause of cancer death from
gynecologic tumors in the United States.
Metastases to the ovaries are relatively frequent; common
sources are tumors in the endometrium, breast, colon, stomach,
and cervix.
Ovarian cancer often goes undetected until it has spread within
the pelvis and abdomen. At this late stage, ovarian cancer is more
difficult to treat.
End stage ovarian cancer leads to both ovaries, the fallopian
tubes and the uterus would remove. This is called a total
hysterectomy with bilateral salpingo-oophorectomy (TAH/BSO).
Many ovarian cancer patients have cancer deposits in other
parts of the pelvis or abdomen. This may necessitate the removal of
the omentum (omentectomy), appendix (appendectomy), or even a
possible resection of the bowel (intestine), sampling of the lymph
nodes and removal of any nodules in the diaphragm or other
organs, in addition to the hysterectomy.
 (an enlarged ovary with a papillary serous
carcinoma on the surface)

Causes:
 when a cell develops errors (mutations) in its DNA.
 The abnormal cells continue living when healthy cells would die.
 They can invade nearby tissues and break off from an initial tumor
to spread elsewhere in the body (metastasize).
Risk Factors:

• Older age. Ovarian cancer can occur at any age but is most
common in women ages 50 to 60 years.
• Inherited gene mutations. A small percentage of ovarian cancers
are caused by gene mutations you inherit from your parents. The
genes known to increase the risk of ovarian cancer are called breast
cancer gene 1 (BRCA1) and breast cancer gene 2 (BRCA2). These
genes also increase the risk of breast cancer.
• Other gene mutations, including those associated with Lynch
syndrome, are known to increase the risk of ovarian cancer.
• Family history of ovarian cancer. People with two or more close
relatives with ovarian cancer have an increased risk of the disease.
• Estrogen hormone replacement therapy, especially with long-
term use and in large doses.
• Age when menstruation started and ended. Beginning
menstruation at an early age or starting menopause at a later age,
or both, may increase the risk of ovarian cancer.
Signs and Symptoms
 Abdominal bloating or swelling
 Quickly feeling full when eating
 Weight loss
 Discomfort in the pelvis area
 Changes in bowel habits, such as constipation
 A frequent need to urinate
Ascites is an abnormal accumulation of serous fluid (>50 mL) in
the peritoneal cavity between the membrane lining the abdominal
wall and the membrane covering the abdominal organs.
Although ascites is most commonly observed in patients with
cirrhosis, 7–10% of patients with ascites develop it secondary to
malignancy. The commonest primary tumour associated with the
development of ascites is ovarian cancer (OC).
Causes:
- when cancer cells spread to the lining of the abdomen
(peritoneum), they can irritate it and cause fluid to build up.
- cancer can block part of the lymphatic system so fluid can't
drain out of the abdomen as usual.
Risk Factors:
- The most common cause of ascites is cirrhosis of the liver.
- The most common risk factors include hepatitis B, hepatitis C,
and long-standing alcohol abuse.
- Other potential risk factors are related to the other underlying
conditions, such as congestive heart failure, malignancy, and kidney
disease
Symptoms may include increased abdominal size, increased
weight, abdominal discomfort, and shortness of breath.

Abdominal compartment syndrome (ACS) occurs when

the abdomen becomes subject to increased pressure reaching past
the point of intra-abdominal hypertension (IAH).
ACS is present when intra-abdominal pressure rises and is
sustained at > 20 mmHg and there is new organ dysfunction or
failure because of the compromised perfusion to the organs. This
includes decreased cardiac output and hypotension decreased
pulmonary compliance and increased airway pressures leading to
impaired ventilation decreased visceral perfusion, which in turn may
lead to intestinal ischemia, and infarction and oliguric AKI.
Normal intraabdominal pressure in adults is about 5 mmHg.
To Consider Acute Kidney Injury secondary to abdominal
compartment syndrome and Compartment Syndrome secondary to
massive ascites: It is thought that increased renal venous pressure
is the primary cause of AKI in the abdominal compartment
syndrome.
Causes:
• trauma with intra-abdominal hemorrhage
• abdominal surgery
• peritonitis
•pancreatitis
•massive fluid resuscitations
Signs and symptoms
• Increase in abdominal girth.
• Difficulty breathing.
• Decreased urine output.
• A feeling of tightness and swelling.
• Pain with certain movements, particularly passive stretching of
the muscles
Pathophysiology
Laboratory
Tumor Marker Test
Date: November 7, 2019

HEMATOLOGY
Date: November 17, 2019
 Medical Management
Surgeries performed to the patient
Exploratory laparotomy is a method of abdominal exploration, a
diagnostic tool that allows physicians to examine the abdominal
organs. The procedure may be recommended for a patient who has
abdominal pain of unknown origin or who has sustained an injury to
the abdomen.
Some other conditions that may be discovered or investigated
during exploratory laparotomy include:
 cancer of the abdominal organs
 peritonitis (inflammation of the peritoneum, the lining of the
abdominal cavity)
 appendicitis (inflammation of the appendix)
 pancreatitis (inflammation of the pancreas)
 abscesses (a localized area of infection)
 adhesions (bands of scar tissue that form after trauma or surgery)
 diverticulitis (inflammation of sac-like structures in the walls of the
intestines)
 intestinal perforation
 ectopic pregnancy (pregnancy occurring outside of the uterus)
 foreign bodies (e.g., a bullet in a gunshot victim)
 internal bleeding
 The patient is usually placed under general anesthesia for the
duration of surgery. The advantages to general anesthesia are that
the patient remains unconscious during the procedure, no pain will
be experienced nor will the patient have any memory of the
procedure, and the patient's muscles remain completely relaxed,
allowing safer surgery.
Diagnosis/Preparation
Various diagnostic tests may be performed to determine if
exploratory laparotomy is necessary. Blood tests or imaging
techniques such as x ray, computed tomography (CT) scan,
and magnetic resonance imaging (MRI) are examples. The presence
of intraperitoneal fluid (IF) may be an indication that exploratory
laparotomy is necessary; one study indicated that IF was present in
nearly three-quarters of patients with intra-abdominal injuries.
Directly preceding the surgical procedure, an intravenous (IV)
line will be placed so that fluids and/or medications may be
administered to the patient during and after surgery. A Foley
catheter will be inserted into the bladder to drain urine. The patient
will also meet with the anesthesiologist to go over details of the
method of anesthesia to be used.
Risks inherent to the use of general anesthesia include:
 nausea
 vomiting
 sore throat
 fatigue
 headache
 muscle soreness
 more rarely: blood pressure problems, allergic reaction, heart
attack, or stroke may occur
Additional risks include:
 bleeding
 infection
 injury to the abdominal organs or structures, or formation of
adhesions (bands of scar tissue between organs)

Hysterectomy
A surgery to remove the uterus and cervix. “Abdominal” is the
surgical technique that will be used. This means the surgery will be
 done through an incision in your abdomen. A bilateral salpingo-
oophorectomy is surgery to remove both of your ovaries and
fallopian tubes. The hysterectomy and bilateral salpingo-
oophorectomy will both be done during one procedure. This surgery
will remove the uterus, cervix, ovaries, and fallopian tubes. After a
hysterectomy you will no longer have periods or be able to become
pregnant.
Multiple reasons why doctors may suggest a hysterectomy and
salpingectomy:
 Heavy periods
 Endometriosis
 Uterine fibroids
 Cancer
Patient may also need to have a bilateral salpingo-
oophorectomy if they are high risk for ovarian cancer, have certain
types of breast cancer, or have ovarian masses or cysts.
This procedure has a small risk of:
 Bleeding during surgery, which may require a blood transfusion
 Infection of the bladder or surgical site
 Damage to surrounding organs (bladder, bowel, and ureters)
 Possible need for further surgery
Peritoneal Fluid Analysis
Also known as paracentesis or an abdominal tap. It’s a
procedure that tests the fluid collected from the peritoneal space.
Doctors recommend this analysis when an abnormal amount of fluid
collects in the peritoneal space. The peritoneal space is part of the
abdomen that contains the gastrointestinal organs.
The most common reason for performing peritoneal fluid
analysis is to determine why an unusual amount of fluid is building
up in the abdomen.
Peritoneal fluid analysis is also the test doctors use to
diagnose peritonitis, a potentially fatal bacterial or fungal infection
of the lining of the inner abdominal wall. Trauma teams may use
this procedure to quickly check for internal bleeding in patients with
abdominal trauma.
Finally, peritoneal fluid analysis can be a comfort measure to
remove large amounts of fluid from the abdomens of people who
have liver failure or advanced cancer.
There are a few results that doctors are quick to notice:
 bile-stained fluid, which indicates gallbladder or liver disease
 pink or red fluid, which implies internal bleeding
 a large difference between amount of albumin in peritoneal fluid
and amount of albumin in blood, which suggests failure of the
heart, liver, or kidneys
 increased white cell count, which indicates an inflammation or
infection (peritonitis)
 increased protein in the sample, which could indicate liver disease
or cancer
Risk:
 Hypotension
Other potential risk: damage to the surrounding organs, and
infection or prolonged bleeding at puncture site
Random peritoneal biopsies are routinely performed as part of
surgical staging for epithelial ovarian cancer and some endometrial
cancers such as clear cell and serous adenocarcinomas.
Omentectomy
A surgical procedure designed to remove the omentum, which is a
thin fold of abdominal tissue that encases the stomach, large
intestine and other abdominal organs. This fatty lining contains
lymph nodes, lymph vessels, nerves and blood vessels. During
ovarian cancer treatment, an omentectomy may be performed
along with a hysterectomy to remove the uterus, an oophorectomy
to remove one or both ovaries and/or a salpingectomy to remove
one or both fallopian tubes. While ovarian cancer is often treated
with surgery, the optimal approach will depend on the stage and
extent of the cancer, the patient’s general health and other factors.
The procedure may also be performed as a preventive measure
to reduce the risk of cancer spreading from the ovaries to the
stomach and other abdominal organs.
There are two main types of omentectomy:
 A total or supracolic omentectomy – a surgeon completely removes
the omentum
 A partial omentectomy – a surgeon removes a portion of the
omentum
An omentectomy is often completed during an operation to
remove the primary tumor. The procedure may be performed
traditionally, through a single incision in the abdomen, or
laparoscopically, through several small incisions.
 Bilateral Lymph Nodes Dissection
A surgery to remove an area of lymph node bilaterally. It is done to
remove lymph nodes that have cancer and other lymph nodes when
there is a very high chance that the cancer may spread there. It is
also called a lymphadenectomy. The lymph nodes are part of
the lymphatic system.
Appendectomy
A surgical removal of the appendix. It’s a common emergency
surgery that’s performed to treat appendicitis, an inflammatory
condition of the appendix.
An appendectomy is often done to remove the appendix when an
infection has made it inflamed and swollen. This condition is known
as appendicitis. The infection may occur when the opening of the
appendix becomes clogged with bacteria and stool. This causes your
appendix to become swollen and inflamed.
Some risks associated with the surgery, including:
 bleeding
 infection
 injury to nearby organs blocked bowels

Nursing Management:
Before:
 Secure consent
 Give the prescribed pre-op medications
 Prepare the materials needed
 Prepare the incision site by cleaning it aseptically
During:
 Assist the doctor during the surgery
Nursing Interventions for Ovarian Cancer
 Administer anxiolytic and analgesic medications as prescribed and
provide support throughout the diagnostic process.
 Administer or teach the patient or caregiver to administer
antiemetics as needed for nausea and vomiting due to
chemotherapy.
 Encourage small, frequent, bland meals or liquid nutritional
supplements as able. Assess the need for I.V. fluids if patient is
vomiting.
 Prepare the patient for body image changes resulting from
chemotherapy.
 Encourage the patient to prepare ahead of time with turbans, wig,
hats, and so forth.
 Stress the positive effects of the patient’s treatment plan.
 Prepare the patient for surgery as indicated.
 Postoperatively, reposition frequently and encourage early
ambulation to promote comfort and prevent adverse effects.
 Explain to the patient that ovary removal will cause menopausal
symptoms.
 Tell the patient that disease progression will be monitored closely
by laboratory tests and that a second-look laparoscopy may be
necessary.

Nursing Interventions for Massive Ascites

 Assess for crackles and increased respiration
 Placed the client in semi fowler's position with arms supported with
pillows
 Maintained calm attitude while dealing with client and to significant
of others
 Encouraged to adequate rest periods between activities
 Instructed patient to avoid overeating/ gas-forming foods
Nursing Interventions for Acute Kidney Injury (Aki)
 Monitor fluid and electrolyte balance. The nurse monitors the
patient’s fluid and electrolyte levels and physical indicators of
potential complications during all phases of the disorder.
 Reducing metabolic rate. Bed rest is encouraged and fever and
infection are prevented or treated promptly.
 Promoting pulmonary function. The patient is assisted to turn,
cough, and take deep breaths frequently to prevent atelectasis and
respiratory tract infection.
 Preventing infection. Asepsis is essential with invasive lines and
catheters to minimize the risk of infection and increased
metabolism.
 Providing skin care. Bathing the patient with cool water, frequent
turning, and keeping the skin clean and well moisturized and
keeping the fingernails trimmed to avoid excoriation are often
comforting and prevent skin breakdown.

 Provide safety measures. Patient with CNS involvement may be

dizzy or confused.
Pathophysiology

Etiology RISK FACTORS

 Gene mutation  Older age
 Genetics
 Family history
 Reproductive health

OVARIES

Gene mutation causing abnormal

cell growth

Rapid cell multiplication

Tumor formation  weight loss

Spread of cancer cells outside the

pelvis into the abdominal cavity

Irritation to the lining of the abdomen

& fluid build up

Ascites

Increase abdominal pressure

 dyspnea
Abdominal Compartment  increased
Syndrome abdominal girth

Decrease renal perfusion

Acute Kidney Injury