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CARE AND MANAGEMENT OF

PATIENT WITH LIPOMA FOR


EXCISION OF LIPOMA AT
RIGHT UPPER FLANK
Presenter : SN SANIAH BINTI SUHAILI
Mentor:SN PATRICIA ANAK LAGAN
Date:4th July 2014
Venue: Seminar Room Main OT

OUTLINE OF PRESENTATION
1.

OBJECTIVE

2.

DEFINITION

3.

ANATOMY AND PATOPHYSIOLOGY


SIGN AND SYMPTOM
RISK FACTOR
COMPLICATION
TREATMENTS
PROCEDURE
PREVISITING
RESPONSIBILITY OF RECEIPTION NURSE
IN PREOPERATIVE PHASE

4.
5.
6.
7.
8.
9.
10.

11.

12.
13.
14.
15.
16.
17.
18.
19.

RESPONSIBILITY OF SCRUB AND


CIRCULATING NURSE IN PREOPERATIVE
PHASE
RESPONSIBILITY OF SCRUB NURSE IN
INTRA OPERATIVE PHASE
RESPONSIBILITITIES IN HANDLING OF
THE SPECIMEN
POST OP CARE IN RECOVERY BAY
NURSING CARE PLAN
DISCHARGE SUMMARY
HEALTH EDUCATION
CONCLUSION
REFERENCES

OBJECTIVE

Understand the anatomy and physiology of the


body 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

ANATOMY

DEFINITION OF LIPOMA

slow-growing, fatty lump that's most


often situated between the skin and
the underlying muscle layer.

PATHOPHYSIOLOGY
Tumor cells are cells that have grown
autonomous transparmasi and last of
control normal cell growth until the cell is
different from a normal cell in the form
and structure.
Generally tumors began to grow from a
single cell somewhere (unisentrik) or
from some central (multilokuler) at the
same time.
During the growth of tumor is still
confined to the organ remains essentially
the tumor is referred to in local phase.

But if it happens infiltration into


surrounding organs, the tumor has
reached the local phase infasif or local
infiltratif.
These tumor cells continue to grow
indefinitely, until the tumor gets bigger
and 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.

SIGNS AND SYMPTOMS


Sometimes painful.
painful if they grow
and press on nearby
nerves or contain
many blood vessels.
Generally small.
typically less than 2
inches (5 centimeters)
in diameter, but they
can grow larger.

Situated under the


skin.
commonly occur in the
neck, shoulders, back,
abdomen, arms and
thighs.
Soft and doughy to the
touch.
move easily with slight
finger pressure.

Inherited

Unknown

CAUSES

RISK FACTORS
Between 40 and
60 years old.

Having certain
other disorders.

Rare in children.

Adiposis dolorosa,
Madelung disease,
Cowden syndrome and
Gardner's syndrome

COMPLICATION
Lipomas under the skin
(subcutaneous) rarely cause
complications, but large nodules may
interfere with muscle function or may
cause nerve pain.
Lipomas occurring on a joint may limit
movement.
If they develop in the bowel, lipomas
can cause potentially serious
obstruction.

An
ultrasound
or other
imaging
test, MRI or
CT scan

INVESTIGATION

Physical
exam

TREATMENTS
SURGICAL REMOVAL
2. NON SURGICAL
Steroid injections. This treatment
shrinks the lipoma but usually doesn't
completely eliminate the tumor.
Liposuction. This treatment uses a
needle and a large syringe to remove
the fatty lump.
1.

Surgical removal.
Most lipomas are
removed surgically by
cutting them out.

PROCEDURE OF EXCISION
OF LIPOMA

Before the surgery,


the surgeon will draw
an outline of the
lipoma and a planned
skin excision with a
marker on the skin
surface.

Skin cleansed with povidone iodine


(Betadine)solution,making sure to avoid
wiping away the skin markings.
The area is draped with sterile towels.
Local anesthesia administered with
chirocaine 5.0mg/ml,
Infiltrating the anesthetic in the
subcutaneous area surrounding the
operative field creates a field block.

The skin inside


the incision
grasped with a
hemostat to
provide traction.
The lipoma is
dissected from
the surrounding
tissue using
scissors or a
scalpel.

Once freed,
the lipoma is
delivered as
a whole, and
hemostasis
is achieved.

Interrupted 3-0
Vicryl sutures are
used to partially
close the dead
space.
Skin closed with 4-0
nylon
Pressure dressing
placed to reduce
incidence of
hematoma formation.

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.

Previsiting
Present history
Right upper flank swelling x 6 years.
Progressively increase in size
Pain around the swelling sometime at
the back
No skin changes over swelling
No pus discharge
Fever accasionally whenever pain or
swelling.

o Social history
Non smoking
Non alchoholic
Married 20 years
3 children with normal

delivery.

o Menstrual history
Menarche at 14 years old
Regular no dysmenorhea
LMP 11/5/2014
o Medical
Nil
o Surgical
Nil

history

history

Responsibility of receiption nurse


in pre operative phase
a) Reception bay

Prepare the trolley with the clean


canvas, blanket and pillow.

Greet patient, relatives and ward staff


that accompany her.

Transfer patient to the ot trolley and


cover patient with blanket.

Transfer patient by lift the patient


gentlely, slowly and simulteously

Lock trolley during transfer

Pull out siderail after transfer.

Check for the right patient.


Check patients wrist band.
Ask patients name and ic number with
correct 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.

Operation consent

Blood transfusion consent

Anaesthesia consent

b) Holding bay
Check vital sign
and chart in the
SSSL form for
baseline data

Responsibilities of scrub and circulating


nurse in pre operative phase
Preparation in the theatre
Temperature, humidity and air conditioning

Temperature inside
operation theatre must be
average of 18C to 22C.
Humidity -50% to 60%Air
conditioning is functioning
well with good HEPA filter
system to reduce the
numbers of airborne
organism in operating
room.
Air exchange - 15 to 25
per an hour.
Close the OR door all the
time for positive pressure.

Operation room

Induction room

Preparation of all instruments and equipments

Prepare all the


instruments and
equipments need for
the surgery.
Make sure it is clean
and functioning well
by checking the
electrical supplies,
alarm system.
Check the
completeness of all
items needed for
surgery.

Responsibility to position patient


left lateral position

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.

After

scrubbing, perform gowning


and gloving following an aseptic
technique.

Layout the instruments needed by


surgeon after counting the gauze and
instruments together with the
circulator nurse as a baseline data.

After

prepping, draping will be


perform following the aseptic
technique.

The

circulating nurse will prepare


the suction machine and
electrosurgical unit.

After

everything was ready, the


operation will start as order by
surgeon

Responsibility of scrub nurse


intra operatively
Surgical count

a)INITIAL COUNT
Count sponge and
instrument before
case start.
Count audibly &
clear with
circulating nurse.

b)SUBSEQUENT
COUNT(2nd count)
count before closing
cavity
Count all sponge,
sharps and
instrument added
during case.

C)FINAL COUNT
Count all sponge,
sharps and
instrument before
skin closing.
Inform surgeon
and document.

Responsibilities in handling of the


specimen.
1. Receive the specimen with the
receiver ;kidney dish or gallipot.
Do not receive the specimen with
gauze because it can cause
specimen desiccation and accidently
throw away.
2. Enquiry type of specimen and
examination that will be done by the
surgeon

3. Inform circulating
nurse the type of
specimen and
examination to be
done.
4. Hand over the
specimen in aseptic
manner to avoid
contamination of the
instrument and
sterile field.

5.After surgery finish, check the


specimen and label with patient
particular together with circulator to
ensure 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 by
surgeon or MO.

Post op care in recovery bay


Receive patient from anaesthetist
and ask type of anaesthesia,type
of operation and blood lost.
Give O2 5L/min via face mask
Position patient to lateral position.
Covering patient with blanket and
bair hugger to avoid hypothermia.
Monitor vital sign every 10
minutes until discharge from the
recovery.

Check the
dressing/operative
site-sign of
bleeding.
Documentation.
If any problem
occur, or any
abnormalities on
vital sign inform
doctor immediately.
Discharged patient
as ordered by
anesthetist.

NURSING CARE PLAN

Pre-operative
Nursing
Diagnosis

Objectives

Nursing intervention

Knowledge
deficit
related to the
disease,
operation
and post
operative
complication.

Patient will
verbalize
feeling at
ease during
her stay.

1.Asess level of knowledge to the


disease 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.

Evaluation

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 wound
without doctor permission.

Patient understand
the process of the
disease after
further explanation
from the doctor.

5.Ask patient inform doctor


immediately if there are signs of
infection- fever, redness of the
operation wound.
6.Refer patient to doctor if patient
still not understand about the
disease or lack of knowledge.

Nursing
diagnosis

Objective

Nursing Intervention

Evaluation

Potential body
injury during
transfer and
transport.

Patient will b safe


from injury

Prepare OR trolley and


accessories device
-check for good functional
order.

Patient safe
from any
injury.

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.

Intra-operative
Nursing
Diagnosis

Objective

Nursing intervention

Evaluation

1.Potential
hypothermia
due to cold
environment
and expose of
body cavity
and blood
loss

Patients
body
temperature
will be
maintained
at 36 C 37
C

Patients body
Check patient baseline
temperature before surgery and temperature within
normal range.
hourly if indicated.
Avoid unnecessary exposure
of patient,keep patient covered
with blanket.
Provide warming blanket
Prevent pooling of preparation
solution under the patient
Use warm solution for
washing.
Clean and dry patient
throughly and provide dry
sheets, gown and blanket for the
patient.

Nursing
Diagnosis

Objective
s

Nursing Intervention

Potential of
electrical
burns
related to
the use of
the Electro
Surgical
Unit

Patient will Check diathermy machine for the


not sustain functional before use.
electrical
burns
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.

Evaluation

Nursing
Diagnosis

Objective
s

Nursing Intervention

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.

Evaluation

No sign and
symptoms of burn at
the patients body in
the end of surgery.

Post-operative
Nursing
Objectives
Diagnosis

Nursing Intervention

Evaluation

Pain
related to
the
operation.

Asses and monitor the patients


level of pains- pain score.

Patients painful
reduce after taken
the analgesic as
ordered by
anesthetist
provider.
Pain score 0 1
/10

Patient will
experience
minimal
pain.

Do the vital signs observation.


Give patient analgesic-as ordered
by anesthetist.
Position patient on her back or lie
on the unaffected side.

Discharge summary
Patient discharge from ward at 11am
No complaint of pain made while
discharge
Patient on PCM 1gm QID and Tablet
Tramal 50mg TDS 5/7.
Wound inspection on D3,no need
STO.
TCA 2 months with trace HPE.

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 to
clean the wound area before applying
dressing.
If the wound still bleeding,ask pateint to see
the doctor immediately.

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.

CONCLUSION

Lipoma is a tumor (lump) which is


under the benign skin composed of fatty
tissue.
Clinical symptoms of lipoma is soft in
nature palpability, can be moved, and no
pain.
Growth is very slow.
Lipoma majority is small, but can grow to
reach more diameter 6 cm.
Basically lipoma not do any action,
except evolved into pain and interfere
with the movement.

references

Berry & Kohns, Phillips.N. (2007).


Operating Room Technique (11th
edition): Specialized surgical
equipment, 20(6), 352-353.

http://www.mayoclinic.org/diseasesconditions/lipoma/basics/definition/con
-20024646