)‫ الثانية(العناية الجراحية‬2019 ‫دورة عام‬

.)thyroidectomy(‫إلى المستشفى إلجراء عملية استئصال للغدة الدرقية‬, ‫ سنة‬40 ‫عمرها‬,‫أدخلت اآلنسة ي‬

)10 mg PO daily(‫)منذ خمس سنوات وتتعالج بالكورتيزون‬Crohn’s Disease(‫وهي تعاني من مرض ال‬

:‫أسئلة إلزامية حول الحالة‬

‫استئصال‬,)Crohn’s Disease(‫مرض الكروهون‬,)Gastric sleeve(‫تكميم المعدة‬,)Liver Cirrhosis(‫ تشمع الكبد‬:‫عرف‬ -1
‫)؟‬thyroidectomy(‫الغدة الدرقية‬
‫)؟إشرح اآللية المرضية لفرط نشاط الغدة‬Hypothyroidism(‫ما هي العالمات السريرية لفرط نشاط الغدة الدرقية‬ -2
‫)؟‬hypothyroidism(‫الدرقية‬
‫وحدد العالمات‬, ‫عدد أربع دواعي لعملية استئصال الغدة الدرقية؟أعط المضاعفتين الرئيسيتين بعد عملية استئصال الغدة الدرقية‬ -3
‫والمراقبة التمريضية للكشف عنهما؟‬
‫عدد ثمانية تحضيرات تمريضية محددة قبل العملية لآلنسة ي؟‬ -4
‫ ساعة بعد العملية(أعط تشخيصين تمريضيين واقعين ووتشخيصين تمريضيين محتملين مع‬48 ‫ضع خطة تمريضية لآلنسة ي في أول‬ -5
)‫الهدف واإلجراءات التمريضية لكل تشخيص‬
‫أعط التعليمات المنزلية لآلنسة ي؟‬ -6

‫أسئلة إلزامية من خارج الحالة‬

‫ما هي وظيفة الكبد؟ما األسباب المحتملة لتشمع الكبد؟إشرح آثار تشمع الكبد في أنظمة الجسم؟‬ -7
‫)؟أذكر أربعة إجراءات تمريضية وقائية لكل مضاعفة؟‬Thoracotomy(‫سم أربعة مضاعفات مشتبهة بعد عملية بضع الصدر‬ -8
‫العناية التمريضية قبل اإلجراء وبعده؟‬,‫دواعي استعمالها‬,‫تعريفها‬:Positron Emission Tomography(PET)Scan -9
‫)؟‬reduce heart failure(‫كيف تعمل عائلة الدواء التالي لتخفف الفشل القلبي‬ -10
Angiotensin-converting-Enzyme(ACE)inhibitors:Enalapril(Vasotec) 

‫اإلجابة‬
1.liver Cirrhosis: Final pathway of many types of liver injury, Cirrhosis is a late stage of scarring (fibrosis)
of the liver caused by many forms of liver diseases and conditions, such as hepatitis and chronic alcoholism.
Defined by:
✓ Loss of hepatocyte mass → jaundice, coagulopathy, edema (low proteins)
✓ Fibrosis and distortion of vascular bed → portal hypertension
✓
Gastric sleeve: Sleeve gastrectomy is a surgical weight-loss procedure in which the stomach is reduced to
about 15% of its original size, by surgical removal of a large portion of the stomach along the greater
curvature.

Crohn’s Disease: is a type of inflammatory bowel disease (IBD). It causes inflammation of your digestive
tract, which can lead to abdominal pain, severe diarrhea, fatigue, weight loss and malnutrition.
It affects mouth to anus and has transmural involvement

Thyroidectomy: A thyroidectomy is an operation that involves the surgical removal of all or part of the
thyroid gland.
 2. clinical manifestations of hypothyroidism:

o Weakness
o Fatigue
o Forgetfulness
o Sensitivity to cold
o Unexplained weight gain
o Constipation
o Decreasing mental stability
o Puffy face, hands, and feet.
o Somnolence
o Increase sleeping hours
o Increase risk of cardiovascular disease
o Decrease body metabolism

Pathophysiology of hypothyroidism:

Hypothyroidism may reflect a malfunction of the hypothalamus, pituitary, or thyroid gland.

• Chronic autoimmune thyroiditis, also called chronic lymphocytic thyroiditis, occurs when autoantibodies
destroy thyroid gland tissue.
• Chronic autoimmune thyroiditis associated with goiter is called Hashimoto's thyroiditis. The cause of this
autoimmune process is unknown, although heredity has a role, and specific human leukocyte antigen
subtypes are associated with greater risk.

• Outside the thyroid, antibodies can reduce the effect of thyroid hormone in two ways.
• First, antibodies can block the thyroid-stimulating hormone (TSH) receptor and prevent the production of
TSH.
• Second, cytotoxic antithyroid antibodies may attack thyroid cells.

3) Indications of Thyroidectomy:

• Thyroid cancer. Cancer is the most common reason for thyroidectomy

• Noncancerous enlargement of the thyroid (goiter)
• Overactive thyroid (hyperthyroidism).
• Indeterminate or suspicious thyroid nodules.

Complications post thyroidectomy (possible complications of thyroidectomy)

1. Bleeding.

➢ Nursing interventions to monitor bleeding

- Monitor patient’s vital signs, especially BP and HR. Look for signs of orthostatic hypotension.
- Review laboratory results for coagulation status as appropriate: platelet count, prothrombin
time/international normalized ratio (PT/INR), activated partial thromboplastin time (aPTT),
fibrinogen, bleeding time, fibrin degradation products, vitamin K, activated coagulation time
(ACT).
- Monitor hematocrit (Hct) and hemoglobin (Hgb).
- Asses dressing frequently ( dry,intact,clean..) any oozing
- Educate patient for signs and symptoms of bleeding and how to properly report them.
2. Infection.
 3. Low parathyroid hormone levels (hypoparathyroidism) caused by surgical damage or removal of
the parathyroid glands. ...

➢ Nursing interventions to monitor hypocalcemia:

▪ Symptoms of low calcium levels are numbness or tingling of the fingers, toes, and/or around the
mouth; weakness; fatigue; emotional instability; anxiety; depression.
▪ Nursing will assess for hypocalcemia by the following:

o The above symptoms listed in A.

o Chvostek's sign: tapping the branches of the facial nerve in front of the ear and observing for
facial muscle twitching about the lips and eye.
o Trousseau's sign: applying and inflating blood pressure cuff on upper arm and observing for hand
spasms.
o Serum calcium levels; frequency will depend on the surgical procedure; usually daily if total
thyroidectomy is performed.

▪ Oral and/or IV calcium may be ordered if symptomatic or low serum calcium levels.

4. Airway obstruction caused by bleeding.

5. Permanent hoarse or weak voice due to nerve damage

4) pre op interventions pre thyroidectomy:

✓ Baseline evaluation: physical and emotional assessment, previous anesthetic history, known allergies
or genetic problems that may affect the surgical outcome)
✓ Preadmission testing: blood tests (CBCD, pt, ptt, ca level) Urine analysis
✓ Confirm and sign informed surgical consent.
✓ Iv line is inserted
✓ Pt instructed to keep NPO after midnight
✓ Pt instructed to remove dentures, hearing devices, eyeglasses.
✓ Vital signs are taken and properly documented.
✓ Pre-op education is given to the patient and his family about the surgery and its complications.

5) Nursing Plan:
Actual:
1) Acute pain related to surgical interruption/manipulation of tissues/muscles, Postoperative edema
evidenced by possible reports of pain.

➢ Desired Outcome/ goal: relief or control of pain.

➢ interventions
a) Assess verbal and nonverbal reports of pain, noting location, intensity (0–10 scale), and
duration

b) Place in semi-Fowler’s position and support head and neck with sandbags or small pillows.

c) Maintain head and neck in a neutral position and support during position changes. Instruct
patient to use hands to support the neck during movement and to avoid hyperextension of the
neck
 d) Keep call bell and frequently needed items within easy reach.

e) Give cool liquids or soft foods, such as ice cream or popsicles.

f) Encourage patient to use relaxation techniques: guided imagery, soft music, progressive
relaxation.

g) Administer analgesics and/or analgesic throat sprays and lozenges as necessary.

h) Provide ice collar if indicated.

2) Knowledge deficit related to Unfamiliarity with information resources

➢ Desired Outcomes:

• Client will verbalize understanding of surgical procedure and prognosis and potential
complications.
• Client will verbalize understanding of therapeutic needs.
• Client will participate in the treatment regimen.
• Client will initiate necessary lifestyle changes
➢ Interventions

a) Review surgical procedure and future expectations.

b) Discuss the need for a well-balanced, nutritious diet and, when appropriate, inclusion of iodized salt.
c) Recommend avoidance of goitrogenic foods, e.g., excessive ingestion of seafood, soybeans, and
turnips.
d) Identify foods high in calcium and vitamin D.
e) Encourage progressive general exercise program.
f) Review postoperative exercises to be instituted after incision heals: flexion, extension, rotation,
and lateral movement of head and neck
g) Instruct in incisional care: cleansing, dressing application.
h) Review importance of rest and relaxation, avoiding stressful situations and emotional outbursts.
i) Recommend the use of loose-fitting scarves to cover the scar, avoiding the use of jewelry.
j) Apply cold cream after sutures have been removed.
k) Discuss the possibility of a change in voice.
l) Review drug therapy and the necessity of continuing even when feeling well.
m) Identify signs and symptoms requiring medical evaluation. Watch out for fever, chills, continued or
purulent wound drainage, erythema, nausea and vomiting, insomnia, constipation, drowsiness,
intolerance to cold, fatigue.

Potential:

3) Risk for Ineffective Airway Clearance related to possible Tracheal obstruction; swelling,
bleeding, laryngeal spasms

➢ Desired Outcome/ goal: Client will maintain a patent airway, with aspiration prevented.
➢ Interventions:

a) Monitor respiratory rate, depth, and work of breathing.

b) Auscultate breath sounds, noting the presence of rhonchi.
c) Assess for dyspnea, stridor, “crowing,” and cyanosis. Note quality of voice
d) Caution patient to avoid bending neck; support head with pillows.
e) Assist with repositioning, deep breathing exercises, and/or coughing as indicated.
f) Suction mouth and trachea as indicated, noting color and characteristics of sputum.
 g) Check dressing frequently, especially the posterior portion.
h) Investigate reports of difficulty swallowing, drooling of oral secretions.
i) Keep tracheostomy tray at the bedside.
j) Provide steam inhalation; humidify room air.
k) Assist with procedures: Tracheostomy, return to surgery.

4) risk for Impaired Verbal Communication May be related to Vocal cord injury/laryngeal nerve
damage, Tissue edema; pain/discomfort.

➢ Desired Outcomes

• Client will establish a method of communication in which needs can be understood.

➢ Interventions:
a) Assess speech periodically. Encourage voice rest.
b) Keep communication simple. Ask yes or no questions.
c) Provide alternative methods of communication as appropriate: slate board, picture
board. Place IV line to minimize interference with written communication
d) Anticipate needs as possible. Visit patient frequently.
e) Post notice of the patient’s voice limitations at central station and answer call bell
promptly.
f) Maintain a quiet environment.

6) Home instructions:

At the completion of the home care instruction, the patient or caregiver will be able to:

• Medication compliance: State that compliance to medical regimen is life-long.

• Cold intolerance: State the need to avoid extreme cold temperature until condition is stable.
• Follow-up visits: State the importance of regular follow-up visits with health care provider.
• Weight reduction: Identify strategies for weight reduction and prevention of constipation such as
high-fiber, low-calorie intake and adequate fluid intake.

❖ In addition to education regarding crohn’s disease and cortisone in take

7- Role Of The Liver

1. liver is largest gland in body

2. overall function to “filter” and process nutrient-rich blood delivered to it
3. receives nutrient-rich blood from SI via the hepatic portal vein
4. many functions to liver besides aiding in digestion
5. regulates carbohydrate metabolism
a. glucose secretion into blood/absorption from blood into glycogen storage
b. regulated by insulin & glucagon (endocrine review)
6. regulates many aspects of lipid metabolism
a. chemical digestion of fatty acids (B-oxidation) for entry into Krebs cycle
i. release of ketones as metabolic waste product of fatty acid metabolism
b. cholesterol synthesis
 7. detoxifies blood
a. ETOH detoxification
b. other dietary toxins neutralized by liver
8. bile synthesis (approx 1L/day)
a. bile salts (cholesterol derivatives) function to emulsify fats to aid enzymatic digestion
i. bile salts are recycled (are not excreted) from colon back into liver for reuse
b. main bile pigment is bilirubin – derived from RBC heme
i. bilirubin and other neutral fats in bile do not aid in digestion; they are excreted
e. bile is synthesized in liver, stored in gall bladder
f. release of bile from gall bladder stimulated by CCK and vagus nerve
i. CCK also causes hepatopancreatic sphincter to relax – allows bile to enter duodenum
ii. secretin also stimulates bile synthesis
iii. bile salts also act as positive feedback activator to enhance more bile synthesis
g. “gallstones” are concentrated precipitates of cholesterol
i. gallstones form when bile is too rich in cholesterol or lacking bile salts

Possible causes:

• Alcoholic
• Cryptogenic
• NASH
• Post viral
• Biliary
• Cardiac
• Metabolic
• Drug related
Effect on body:
• Liver Enlargement
• Portal Obstruction And Ascites
• Infection And Peritonitis
• Gastrointestinal Varices
• Edema
• Vitamin Deficiency And Anemia
• Mental Deterioration

8)Possible risks from thoracotomy include:

• infection.
• bleeding.
• air leaking from your lungs.
• Nursing Diagnosis: Impaired gas exchange related to lung impairment and surgery
• Goal: Improvement of gas exchange and breathing
1. Monitor pulmonary status as directed and as needed:
a. Auscultate breath sounds. and assess for rate, rhythm, and depth.
b. Check rate, depth, and pattern of respirations.
c. Assess blood gases for signs of hypoxemia or CO2 retention, Monitor oxygenation with pulse oximetry
d. Evaluate patient’s color for cyanosis.
2. Monitor and record blood pressure, apical pulse, and temperature every 2–4 hours,
Central venous pressure (if indicated) every 2 hours.
3. Monitor continuous electrocardiogram for pattern and dysrhythmias.
4. Elevate head of bed 30–40 degrees when patient is oriented and hemodynamic status is stable.
 5. Encourage deep-breathing exercises and effective use of incentive spirometer
6. Encourage and promote an effective cough routine to be performed every 1–2 hours during first 24 hours.
7. Assess and monitor the chest drainage system:*
a. Assess for leaks and patency as needed.
b. Monitor amount and character of drainage and document every 2 hours.
-Notify physician if drainage is 150 mL/h or greater.
• Assess capillary refill, skin color, and status of the surgical dressing.

• Pneumonia.
• Nursing Diagnosis: Ineffective airway clearance related to lung impairment, anesthesia, and pain
• Goal: Improvement of airway clearance and achievement of a patent airway

1. Maintain an open airway.

2. Perform endotracheal suctioning until patient can raise secretions effectively.
3. Assess and medicate for pain. Encourage deep-breathing and coughing exercises.
Help splint incision during coughing.
4. Monitor amount, viscosity, color, and odor of sputum. Notify physician if sputum is excessive or contains
bright-red blood.
5. Administer humidification and mininebulizer therapy as prescribed.
6. Perform postural drainage, percussion, and vibration as prescribed. Do not percuss or vibrate directly over
operative site.
7. Auscultate both sides of chest to determine changes in breath sounds.

• blood clot in your leg (deep vein thrombosis) that can travel to a lung and cause a blockage (pulmonary
embolism)

9)Pet Scan Definition:

Positron emission tomography is a functional imaging technique that uses radioactive substances known as
radiotracers to visualize and measure changes in metabolic processes, and in other physiological activities
including blood flow, regional chemical composition, and absorption

Indications:
✓ Oncology: diagnosis of malignancy, staging, tumour characterisation, response assessment, restaging
and surveillance.
✓ Infection/inflammation: pyrexia of unknown origin, rheumatologic diseases, such as vasculitis.
✓ Neurology: epilepsy, dementia.
➢ Preparation pre pet scan:
- Check for any allergy.
- ask the patient if she is pregnant or could be pregnant

• You will be asked to follow the Limited Carbohydrate diet for the previous 24 hours before the
date of your appointment.
• Do not eat or drink anything, except water, for 6 hours before the exam. You may drink water, as
much water as you can would be helpful, until arrival.
• Routine medications may be taken, unless you have been instructed otherwise. If you are
diabetic, you may take your diabetes medication no less than 4 hours prior to the exam.
• Arrive 15-30 minutes before your PET scan.
• The technologist will verify your identification and exam requested.
• You will be given a contrast screening form to complete.
• In certain situations, the doctor may order lab tests prior to contrast being given.
 ‫‪Commonly, contrast is injected into a vein to better define the images throughout the body. If the‬‬
‫‪radiologist believes this is helpful, a small intravenous (IV) line is placed in an arm vein. Through this‬‬
‫‪line, the contrast and the isotope will be injected. The contrast will be excreted through your kidneys‬‬

‫‪➢ After the procedure:‬‬

‫‪• You should drink about 5 glasses of water.‬‬
‫‪• Nursing mothers should wait for 24 hours before resuming breast-feeding.‬‬
‫‪• If you feel any symptoms such as nasal congestion, itchy eyes, hives, rashes, sneezing,‬‬
‫‪restlessness, tremors, pain, nausea, vomiting, dizziness, please notify the staff immediately. The‬‬
‫‪staff is prepared to handle these situations. If you feel any of these symptoms after you have left‬‬
‫‪the department, please contact your doctor or go to the nearest emergency room.‬‬

‫قبل ‪ 24‬ساعة من اجراء التصوير ‪:‬‬

‫• على المريض أن ال يقوم بأي عمل أو مجهود ( الراحة التامة ) ‪.‬‬
‫• وضع مصل محلول فيزيولوجي ‪ N/S‬ال يحتوي على السكر ‪. Dextrose‬‬
‫• اعطاء طعام للمريض ال يحتوي على كاربوهيدرات أو سكريات ( بدون خبز ‪ ،‬معكرونة ‪ ،‬رز ‪ ،‬كاتو ‪ )...‬بالتنسيق مع أخصائية‬
‫التغذية ‪.‬‬
‫قبل ست ساعات من الموعد المحدد ‪:‬‬
‫• المريض على الريق بدون أكل او شرب ‪ ،‬يمنع حتى العلكة والقهوة ‪.‬‬
‫• التأكد من أن المريض ال يخاف من األماكن المغلقة ‪.‬‬
‫• التأكد من أن المريض ال يعاني من سلس بولي ‪ ، Incontinence‬ووضع ميل عند الضرورة ‪ ،‬مع ارسال كيس بول جديد مع‬
‫المريض عند ارساله الى قسم التصوير‪.‬‬
‫عند موعد الصورة ‪:‬‬
‫• أخذ معدل السكر في الدم وتسجيله ‪. HGT‬‬
‫• التأكد من أخذ الطول والوزن وتسجيلهما ‪.‬‬
‫• ملء ورقة ‪ Pre PET Scan Checklist‬بالشكل الكامل والمطلوب ‪.‬‬
‫• ارفاق المستندات الط بية السابقة للمريض معه من تحاليل وصور شعاعية ‪.‬‬
‫تحضير المريض المصاب بالسكري ‪:‬‬

‫اتباع ذات النقاط المحددة للمريض الذي ال يعاني من السكري باالضافة الى ‪:‬‬
‫• يجب اتباع حمية غذائية للسكري قبل يوم من الموعد ‪.‬‬
‫• فحص السكر بالدم ‪ HGT‬وابقاء معدل السكر بالدم أقل من ‪. 150mg‬‬
‫• اذا كان المريض يتناول دواء" للسكري عبر الفم عليه بأخذ الدواء كالمعتاد قبل ساعتين من الموعد ‪.‬‬
‫• اذا كان المريض يتعالج باألنسولين عليه أن يأخذ افطارا" خفيفا" قبل الساعة السابعة صباحا" وبعدها يأخذ كمية األنسولين المطلوبة‬
‫حسب األمر الطبي ‪.‬‬
‫العناية بالمريض وارشاده بعد اجراء التصوير ‪:‬‬
‫في قسم التصوير النووي‪:‬‬
‫• ابقاء المريض في قسم التصوير على األقل ساعتين بعد اعطاء الدواء ‪.‬‬
‫• يجب تسجيل وقت اعطاء الدواء على ورقة ‪ Demande Pet-CT‬وارسالها مع التقرير في ملف المريض ‪.‬‬
‫• تغيير كيس البول الم حتوي على كميات من البول ووضع كيس بول جديد قبل ارسال المريض الى غرفته من قبل تقني التصوير او‬
‫بطلب مساعدة من الفريق التمريضي في القسم ( في حال غياب تقني التصوير) ‪ ،‬يتم افراغ كيس البول في الحمام في قسم التصوير‬
‫مع رمي كميات وافرة من الماء فوقها ‪ ،‬ورمي كيس الب ول في سلة النفايات ذات الكيس األحمر ويغلق جيدا" ويتم التخلص منه من‬
‫قبل عمال التنظيفات في المكان المخصص ‪.‬‬

‫في القسم مكان اقامة المريض ‪:‬‬

‫• يمكن للمريض األكل والشرب مباشرة بعد التصوير ‪.‬‬
‫• نطلب من المريض االكثار من شرب الماء والسوائل في حال عدم وجود مانع طبي وبالتنسيق مع الطبيب المعالج ‪.‬‬
‫• نطلب من المريض سحب ‪ Siphon‬المرحاض مرتين بعد كل ّ‬
‫تبول ‪ ،‬وفي حال تواجد ميل يتم تغيير كيس البول بوضع كيس بول‬
‫جديد اول اربع ساعات كل ساعتين ( أي مرتين) ‪ ،‬ويتم افراغ كيس البول في الحمام في غرفة المريض مع رمي كميات وافرة من‬
‫الماء ف وقها‪ ،‬ورمي كيس البول في الكيس األحمر ويغلق جيدا" ويتم التخلص منه من قبل عمال التنظيفات في المكان المخصص ‪،‬‬
 ‫ومن بعد الساعات االربعة االولى بعد وصول المريض من قسم التصوير يتم مراقبة البول المراقبة الروتينية وافراغ كيس البول‬
.‫حسب الحاجة‬
.‫ ساعة بعد التصوير النووي‬24 ‫يجب وضع ورقة على الباب تقضي بعدم دخول األطفال والحوامل الى الغرفة لفترة اول‬ •

10)

Angiotensin Converting Enzyme(ACE):

₋CleavesangiotensinI potentvasoconstrictorangiotensinII&AngII↑Aldosterone ↑sodium&waterretention.
₋Breaksdownbradykinin.Bradykinin↑productionofpotentvasodilatorsnitricoxide&prostacyclinbythebloodv
essels.

•ACE Inhibitors inhibit the converting enzyme

₋↓AngiotensinII ↓vasoconstriction&↓Aldosterone(↓Na&H2Oretention)
₋↑Bradykininn(potent vasodilator) ↑vasodilation

ACEIs lower blood pressure by:

↓peripheral vascular resistance.