the surgical patient & special patient populations concorde career college st210

The Surgical Patient & Special Patient

Populations

Concorde Career CollegeST210

List and differentiate between the preoperative duties of the circulator and the surgical technologist in the scrub role

Identify the biological needs of the patient and identify fundamental patient care elements used to meet these needs in the surgical environment

Objectives

Identify the psychological needs of the patient and identify fundamental patient care elements used to meet these needs in the surgical environment

Identify the social needs of the patient and identify fundamental patient care elements used to meet these needs in the surgical environment

Objectives

Identify the spiritual needs of the patient and identify fundamental patient care elements used to meet these needs in the surgical environment

Identify the cultural needs of the patient and identify fundamental patient care elements used to meet these needs in the surgical environment

Objectives

Objectives

Identify the needs of special patient populations (e.g., pediatric, geriatric, immunocompromised) and identify fundamental patient care elements used to meet those needs in the surgical environment

Team Members

Surgical Team Members

Team Members

Who are the surgical team members and what are their roles?

Needs of the Patient



Maslow’s Hierarchy of Needs


Biological Needs (also called physical, physiologic)

Necessary for LifeOxygenNutrition (water, food)Regulation of body processes (sleep,

fluid balance, O2/CO2 exchange, temperature regulation, elimination of waste)


Safety Needs

Perception that one’s environment is safe


Love and Belonging Needs

Basic social needsTo be known and cared for as an

individualTo care for another (others)


Prestige & Esteem Needs

Need to have a positive evaluation of oneself and others

Need to be respected and respect others


Self Actualization

Need to fulfill what is believed to be one’s purpose


Psychological Needs

Any need or activity related to the identification and understanding of oneself Fear Loss of security Family issues


Social Needs

Any need or activity related to one’s identification or interaction with another individual or group


Spiritual Needs

Any need or activity related to the identification and understanding of one’s place in an organized universe


Cultural Needs

Every culture has different beliefs and value orientations

Cultural values will specify the way the patient thinks and feels about these values

Special Patient Populations

© 2004 by Delmar Learning, a division of Thomson Learning, Inc. All Rights Reserved.

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Patients with Special Needs

Surgical patients with special needs present various challenges

Unique physical and psychological needs

Surgical technologists must be aware of those needs


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Special Needs Patients Unique physical & psychological needs

PediatricsImmunocompromisedPregnantDiabeticDisabledObeseGeriatric

Pediatrics

Developmental levels and Biological differences Neonate - birth to 28

days Infant – 1–18 months Toddler – 18-30

months Preschooler – 30 months to 5 years School age – 6-12

years Adolescent – 13-18 years


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Monitoring the Pediatric Patient

Temperature Urine output

(collection bag/no catheter)

Cardiac function Intra-arterial

measurement Central Venous

Catheter Oxygenation

(ABG’s)


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Shock in the Pediatric Patient

Septic Shock• Caused by gram-negative bacteria• Intestinal perforation, UTI, URI

Hypovolemic Shock• Common cause: Dehydration• Treated by quick fluid and blood

replacement


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Fluids & Electrolytes/Infection

Monitoring fluids & electrolytes

Infection• Monitoring• Antibiotics


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Metabolic & Nutritional Metabolic & Nutritional ResponsesResponses

A gastrostomy feeding tube is usually placed after GI surgery


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Pediatric Trauma Concerns

Emotional reactions differ from those of an adult

Hypothermia Torticollis Blunt trauma Motor vehicle

accidents Falls

Pediatrics

Accidents are the number one cause of death in children ages 1-15.

Approximately 20 million childhood injuries result in death or permanent disability annually

Obesity

Obesity – defined by BMI

•An adult who has a BMI between 25 and 29.9 is considered overweight.

•An adult who has a BMI of 30 or higher is considered obese.

Obesity Scale

Height Weight Range BMI Considered

5' 9"

124 lbs or less Below 18.5 Underweight

125 lbs to 168 lbs

18.5 to 24.9 Healthy weight

169 lbs to 202 lbs

25.0 to 29.9 Overweight

203 lbs or more 30 or higher Obese


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Care of Obese PatientsCare of Obese Patients

Patient whose body weight is 100 pounds greater than ideal weight

Physiological disease conditions related to obesity• Myocardial hypertrophy• Coronary artery disease• Hypertension & vascular changes of the kidneys• Varicose veins and edema• Pulmonary Functions• Liver & Gallbladder Disease• Diabetes• Osteoarthritis• Pituitary abnormalities

Gastric Bypass Gastric Bypass (Bariatric Surgery)(Bariatric Surgery)


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What is Morbid Obesity?

Morbid Obesity is a serious disease process, in which the accumulation of fatty tissue on the body becomes excessive, and interferes with, or injures the other bodily organs, causing serious and life-threatening health problems, which are called co-morbidities.


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Indications

Gastric bypass surgery is recommended only for patients who are morbidly obese. Usually more than 100 pounds overweight, these individuals have major health problems related to their weight.

The Body Mass Index BMI is typically used to identify surgery candidates with a cut-off of 40 being used by most surgeons. BMI’s down to 35 are typically permitted if the individual has other serious health issues.

Gastric bypass is overwhelmingly successful, with many patients losing over 100 pounds within the first 18 months following surgery. Gastric bypass surgery should always be accompanied by an exercise regimen.


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Today, there are several surgical Today, there are several surgical procedures used for achieving procedures used for achieving weight loss. The most common are:weight loss. The most common are:

: Roux-en-Y gastric bypass Lap-Band

Gastric Bypass Surgery


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Comparison between the Lap-Band

& Gastric Bypass procedures Lap-Band

Less invasive Outpatient surgery Reversible Adjustable No rearrangement of

anatomy Slower weight loss Not endorsed by NIH Less well studied in US More follow-up required More dietary

compliance required

Gastric Bypass

More invasive Inpatient surgery Not easily reversible Not adjustable Anatomy rearranged Faster weight loss Endorsed by NIH Well studied in US Less follow-up required Less dietary compliance

required


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Gastric Bypass Surgery

Laparoscopic Banding

Roux-en-Y Anastamosis


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The Procedure…

The patient is placed in the supineposition and trocars are placed appropriately.


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The stomach is sized to a small pouch by first identifying the esophago -gastric junction and then passing a Baker tube filled with 15 cc of saline solution. The Endo GIA stapler (US Surgical), 60 mm long with 4.8 mm staples is then fired three times as shown in this figure.


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The stomach is sized to a small pouch by first identifying the esophago-gastric junction and then passing a Baker tube filled with 15 cc of saline solution. The Endo GIA stapler (US Surgical), 60 mm long with 4.8 mm staples is then fired three times as shown in this figure.


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In order to create the Roux-limb, the jejunum is divided 15 cm beyond the ligament of Treitz by using an Endo GIA II stapler (US Surgical), 45 mm long with 3.5 mm staples. In addition the mesentery is also divided with a Endo GIA II stapler, but this time using the vascular load (45 mm length, 2.0 mm staples). This maneuver will facilitate mobilization of the small intestine through the mesocolon. A rubber drain is sutured to the jejunum to help with the pulling.


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The Roux-limb is measured according to the patient BMI (Body Mass Index) and can range from 75 to 200 cm in length. Notice that the laparoscopic grasper is used as a ruler.


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An end-to-side anastomosis between the proximal jejunum and the roux limb is created by firing two Endo GIA II staplers. The enterotomy is closed using another load of staples. The mesentery

is also closed to prevent bowel entrapment (internal hernias).


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Close up view of the enteroenterostomy


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The Roux-limb is now advanced trough the mesocolic window (retrocolic and retrogastric) near the transected stomach.


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Using the rubber drain, the Roux-limb is pulled to a

retrogastric position


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Following an enterotomy an anastomosis between the gastric pouch and the Roux-limb is created by firing a Endo GIA II.


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The enterotomy is stapled shut with another load of Endo GIA II. The anastomosis is secured by placing an extra row of stitches. The gastrojejunostomy and the enterotomy site are tested for leakage by applying insufflation through an nasogastric tube (or endoscope) and submerging the area

in irrigation solution.


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Lifetime Commitment

Undergoing a gastric bypass requires patients to commit to a new lifestyle. They will no longer be able to eat large portions of food at one sitting, nor will they be able to eat foods high in sugar or fat, which often result in dumping syndrome, an unpleasant feeling of faintness caused by the sudden absorption of these foods in the shortened digestive tract. Due to the limited amount patients can take in at any one time, they must constantly drink small amounts of water or risk dehydration.

The operation while highly successful does have a morbidity rate of approximately 2% overall. 1% having immediate complications and death another 1% will commonly have post operative complications that lead to death within one month of surgery. This can be mitigated by compliance with the surgeon's post operative plan and using a Doctor who has performed more then 200 procedures.

However it should be noted that a full 25% of people undergoing this operation will have some form of post operative complication either requiring a further procedure or change in habits.


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Diabetes Mellitus

Type I (IDDM)Insulin dependent: The pancreas

produces little or no insulin

Type II (NIDDM)Non insulin dependent: The pancreas

produces different amounts of insulin


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Care of Diabetic Patients

Insulin and glucose must be monitored

IV access Avoid metabolic crisis Antiembolic stockings required Postoperative compression boots


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Complications Associated with Diabetes

Infection Dehydration Poor circulation Myocardial Infarction Delayed wound healing Control of blood sugar Neuropathic skeletal disease Neurogenic bladder Retinopathy Coronary Artery Disease Thrombophlebitis Tachycardia

Pregancy


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The Pregnant Surgical Patient

Surgical procedures in first trimester avoided

Anesthesia Abdominal organs displaced from

normal position Physiological assessment is difficult


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Fetal SurgeryFetal Surgery

ImmunocompromisedPatients

HIV+ Multiple sclerosis Lupus erythematosus Rheumatoid arthritis Transplant recipients Steroid use

(Cushing’s syndrome) Patient undergoing

radiation or chemotherapy


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Care of Care of Immunocompromised Immunocompromised

PatientsPatients

Additional personnel to move patient Possible difficult intubation IV placement is difficult Grounding pad placement could be

difficult


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Surgical Intervention Surgical Intervention RequiredRequired

Peritonitis secondary to cytomegaloviris

Non-Hodgkin’s lymphoma of GI tract Kaposi’s sarcoma of the GI tract Mycobacterial infection of

retroperitoneum or spleen HIV/AIDS (splenomegaly,

diagnostic biopsies)

Disabled Patients

Geriatrics

Biological differences


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Geriatric PatientsGeriatric Patients

Usually over the age of 65 Chronic debilitation Decreased physiologic status Visual impairments Hearing impairments


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Other Special Needs Other Special Needs PatientsPatients

Hearing impaired Visually impaired Physically disabled


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Trauma PatientsTrauma Patients

“Golden Hour” Trauma Centers

• Level I• Level II• Level III• Level IV

Blunt Trauma Penetrating Trauma


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Trauma Scoring Trauma Scoring

Eye Opening Response Spontaneous--open with

blinking at baseline 4 points To verbal stimuli, command,

speech 3 points To pain only (not applied to

face) 2 points No response 1 point

Verbal Response Oriented 5 points Confused conversation, but

able to answer questions 4 points

Inappropriate words 3 points Incomprehensible speech 2

points No response 1 point

Motor Response Obeys commands for movement 6

points Purposeful movement to painful

stimulus 5 points Withdraws in response to pain 4

points Flexion in response to pain

(decorticate posturing) 3 points Extension response in response to

pain (decerebrate posturing) 2 points

No response 1 point Categorization:

Coma: No eye opening, no ability to follow commands, no word verbalizations (3-8)

Head Injury Classification:Severe Head Injury----GCS score of 8 or lessModerate Head Injury----GCS score of 9 to 12Mild Head Injury----GCS score of 13 to 15


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Preservation of EvidencePreservation of Evidence

Violent crime items must be preserved for law enforcement

Physical evidence must be handled carefully

Facility policy must be strictly followed


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Other Considerations for the Trauma Patient

Hypothermia Infection Preparation of the case

The EndThe End

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