Medical Surgical Notes
Medical Surgical Notes
Medical Surgical Notes
hemorrhoidectomy /
gastrointestinal bypass
Gastrostomy is the creation of an artificial external opening into the stomach for
nutritional support or gastric decompression. Typically this would include an incision in
the patient's epigastrium as part of a formal operation. It can be performed through
surgical approach, percutaneous approach by interventional radiology, percutaneous
endoscopic gastrostomy or percutaneous ultrasound gastrostomy.
1. Patient Education
Prior to the operation, the doctor will perform an endoscopy and take x rays of the
gastrointestinal tract. Blood and urine tests will also be performed, and the patient may
meet with the anesthesiologist to evaluate any special conditions that might affect the
administration of anesthesia.
Immediately after the operation, the patient is fed intravenously for at least 24 hours.
Once bowel sounds are heard, indicating that the gastrointestinal system is working, the
patient can begin clear liquid feedings through the tube. The size of the feedings is
gradually increased.
Patient education concerning use and care of the gastrostomy tube is very important.
Patients and their families are taught how to recognize and prevent infection around the
tube; how to insert food through the tube; how to handle tube blockage; what to do if the
tube pulls out; and what normal activities can be resumed.
Gastrectomy
A gastrectomy is the surgical removal of all or part of the stomach. The stomach is a J-
shaped organ in the upper abdomen. It is part of the digestive system, which processes
nutrients ( vitamins, minerals, carbohydrates, fats, proteins, and water) in foods that are
eaten and helps pass waste material out of the body. Food moves from the throat to the
stomach through a hollow, muscular tube called the esophagus. After leaving the
stomach, partly-digested food passes into the small intestine and then into the large
intestine.
Gastrectomy is performed for the following conditions:
Stomach Cancer
Bleeding Gastric Ulcers
Perforation (Hole) in the Stomach Wall
Benign Polyps
Pre-operative Care
1. In the preoperative period, the nurse per- forming the patient assessment
should verify the patient’s identity and the procedure. This should be done
verbally with the patient and by checking the patient’s name band
2. Aims to prepare the patient holistically, act as the patient’s advocate by
assessing their needs and identifying symptoms, risk factors and co-
morbidity that might impact the surgery and it’s recovery.
3. Education about the surgery. Having good pre-operative education decreases
anxiety and improves post-operative outcomes.
4. Try to tailor the information according to the patient’s needs. Use written
materials, pictures, videos
5. Help alleviate anxiety and fear (breathing techniques, music therapy, further
education)
6. Post-operative planning.
Post-operative Care
Complication
Early
1. Intragastric hemorrhage
2. Extragastric hemorrhage
3. Duodenal blow out/ stump leakage
4. Stomal obstruction
5. Afferent loop obstruction
6. Jejunal loop herniation
7. Gastric remnant necrosis
8. Post operative pancreatitis
9. Common bile duct injury
10. Omental Infarction
Late
1. Early dumping syndrome
2. Late dumping syndrome
3. Recurrent ulcers
4. Small gastric remnant syndrome
5. Gastrojejunocolic fistula
6. Internal hernia
7. Jejunogastric Intussusception
8. Chronic afferent loop obstruction
9. Chronic efferent loop obstruction
Post-operative Care
In the Surgical Ward:
Complication:
excessive bleeding
difficulty urinating
infection, which might cause a high temperature
loss of control of the rectal sphincter
narrowing or damage to the anal canal
Complication:
excessive bleeding
difficulty urinating
infection, which might cause a high temperature
loss of control of the rectal sphincter
narrowing or damage to the anal canal
Gastric bypass is a surgical procedure that can help people with obesity to lose weight
and improve their health. It decreases the size of the stomach and changes the way the
stomach and small intestine absorb food, making it easier to lose weight. This
procedure is also called a Roux-en-Y gastric bypass.
Gastric bypass, also called Roux-en-Y (roo-en-wy) gastric bypass, is a type of weight-
loss surgery that involves creating a small pouch from the stomach and connecting the
newly created pouch directly to the small intestine. After gastric bypass, swallowed food
will go into this small pouch of stomach and then directly into the small intestine, thereby
bypassing most of your stomach and the first section of your small intestine.
Gastric bypass is one of the most commonly performed types of bariatric surgery.
Gastric bypass is done when diet and exercise haven't worked or when you have
serious health problems because of your weight.
Pre-operative Nursing Care
1. Informed patient consent and motivation. Make sure that the consent is
signed.
2. Review NPO status
3. Bowel prep if indicated
4. Baseline Vital signs
5. Review or draw labs
6. Administer Medication (IVF and Antibiotics)
7. Insert IV and Foley catheter.
8. Remove jewelries , make up, nail polish, dentures, hearing aid, glasses and
contact lenses.
9. Advised Family to stay in the waiting room.
10. Interdisciplinary risk assessment
11. Optimized physical condition and medication
12. A detailed medical history and a thorough clinical assessment of the patient’s
physical and psychological condition are of utmost importance, as it may help
to identify patient risk factors for imminent morbidity or mortality.
13. Routine diagnostic tests
Laboratory tests
Standard blood count
International normalized ratio
Activated partial thromboplastin time (aPTT)
Concentrations of sodium, potassium, creatinine and glucose
Electrocardiography
Preoperative 12-channel electrocardiography (ECG) allows for screening of
as-yet undetected cardiac disorders.
Chest radiography
Echocardiography
Complication
Risks associated with the surgical procedure are similar to any abdominal surgery and
can include:
Excessive bleeding
Infection
Adverse reactions to anesthesia
Blood clots
Lung or breathing problems
Leaks in your gastrointestinal system
Bowel obstruction
Dumping syndrome, causing diarrhea, nausea or vomiting
Gallstones
Hernias
Low blood sugar (hypoglycemia)
Malnutrition
Stomach perforation
Ulcers
Vomiting
DEFINITION
Feeding a client through a nasogastric tube.
OBJECTIVE
To introduce liquid food and medications into the stomach through a tube when a patient is unable to take food into
a normal manner.
EQUIPMENT
Correct amount of feeding solution
20-50 ml syringe or Asepto syringe
Measuring glass
Water (60 ml, unless specified)
Kidney basin
Mouth wipes
Stethoscope
NG Tube
7. Explain procedure
8. Gain consent
9. Assist client to a fowler’s position in bed These positions promote gravitational flow
and sitting position on chair. If of solutions and prevent aspiration of fluids
contraindicated, slightly elevate head into the lungs
and place in right side lying position
10. Assess tube placement Ensure patency of the tube and prevent
aspiration
11. Assess residual feeding contents This is done to evaluate absorption of the
last feeding. If 50 ml or more of undigested
formula aspirated in adults and 10 ml or
more in infants, check the doctor’s order or
agency policy before giving the feeding.
12. Administer the feeding. To prevent excess air from entering the
stomach causing distention
When using a bulb syringe:
a) Remove the bulb from the syringe
and connect the syringe to a pinched or
clamped NGT
13. b) Add feeding to the syringe barrel and A quickly administered feeding can cause
permit the feeding to flow in slowly flatus, crampy pain and reflux vomiting.
14. Rinse the feeding tube by instilling 50- Water cleans the lumen of the tube and
60 ml of water prevents future blocking by sticky formula.
This should be done before the feeding
solution has drained from the neck of a bulb
syringe to prevent introduction of air.
15. Clamp and cover the feeding tube. To prevent leakage and air from entering
the tube.
16. Ensure client comfort and safety Ask client to remain sitting or in fowler’s
position for 30 minutes to facilitate digestion
and prevent potential aspiration
19. Document relevant information. Feeding, time given, duration and client’s
reaction
Rubrics
Satisfactory 2 points Performs the steps or task according to the standard procedure or guidelines
Unsatisfactory 1 point Performs the steps and task but unable to do it according to standard guidelines
Not Done 0 point Unable to perform the task
Diagnostic procedures GIT
Diagnostic Tests (Preparation,
Procedures and Care of Patient) in
GI Disturbances
Non-Invasive
1. Barium enema can be used to detect the presence of polyps, tumors, or other lesions
of the large intestine and demonstrate any anatomic abnormalities or malfunctioning of
the bowel. After proper preparation and evacuation of the entire colon, each portion of
the colon may be readily observed. The procedure usually takes about 15 to 30
minutes, during which time x-ray images are obtained.
2. Computed Tomography scan provides cross-sectional images of abdominal organs
and structures. Multiple x-ray images are taken from numerous angles, digitized in a
computer, reconstructed, and then viewed on a computer monitor.
3. Magnetic Resonance Imaging is used in gastroenterology to supplement
ultrasonography and CT. This noninvasive technique uses magnetic fields and radio
waves to produce images of the area being studied. The use of oral contrast agents to
enhance the image has increased the application of this technique for the diagnosis of
GI diseases. It is useful in evaluating abdominal soft tissues as well as blood vessels,
abscesses, fistulas, neoplasms, and other sources of bleeding.
4.Positron Emission Tomography scans produce images of the body by detecting the
radiation emitted from radioactive substances. The radioactive substances are injected
into the body IV and are usually tagged with radioactive isotopes of oxygen, nitrogen,
carbon, or fluorine (Bontrager & Lampignano, 2014).
5. Scintigraphy (radionuclide testing) relies on the use of radioactive isotopes (i.e.,
technetium, iodine, and indium) to reveal displaced anatomic structures, changes in
organ size, and the presence of neoplasms or other focal lesions such as cysts or
abscesses.
6. Abdominal Ultrasonography is a noninvasive diagnostic technique in which high-
frequency sound waves are passed into internal body structures, and the ultrasonic
echoes are recorded on an oscilloscope as they strike tissues of different densities. It is
particularly useful in the detection of an enlarged gallbladder or pancreas, the presence
of gallstones, an enlarged ovary, an ectopic pregnancy, or appendicitis.
Endoscopic Procedures
1. Fibroscopy/Esophagogastroduodenoscopy allows direct visualization of
the esophageal, gastric, and duodenal mucosa through a lighted endoscope
(gastroscope.
2. Fiberoptic Colonoscopy -Historically, direct visualization of the bowel was the only
means to evaluate the colon, but virtual colonoscopy (also known as CT colonography)
is now available. Virtual colonoscopy provides a computer-simulated view of the air-
filled distended colon using conventional CT scanning (ACS, 2015c).
3. Anoscopy, Proctoscopy, and Sigmoidoscopy. Endoscopic examination of the anus,
rectum, and sigmoid and descending colon is used to evaluate chronic diarrhea, fecal
incontinence, ischemic colitis, and lower GI hemorrhage and to observe for ulceration,
fissures, abscesses, tumors, polyps, or other pathologic processes.
Small Bowel Studies
Several methods are available for visualization of the small intestine, including
1. Capsule endoscopy allows the noninvasive visualization of the mucosa throughout
the entire small intestine.
2, Double-balloon enteroscopy has made it possible to visualize the mucosa of the
entire small bowel as well as carry out diagnostic and therapeutic interventions (ASGE,
2014).
Manometry and electrophysiologic studies are methods for evaluating patients with
GI motility disorders.
1. Manometry test measures changes in intraluminal pressures and the coordination of
muscle activity in the GI tract with the pressures transmitted to a computer analyzer.
2. Esophageal manometry is used to detect motility disorders of the esophagus and the
upper and lower esophageal sphincter
Gastric Analysis, Gastric Acid Stimulation Test, and pH Monitoring analysis of the
gastric juice yields information about the secretory activity of the gastric mucosa and the
presence or degree of gastric retention in patients thought to have pyloric or duodenal
obstruction. It is also useful for diagnosing Zollinger–Ellison syndrome or atrophic
gastritis
Laparoscopy (Peritoneoscopy) With the tremendous advances in minimally invasive
surgery, diagnostic laparoscopy is efficient, cost-effective, and useful in the diagnosis of
GI disease.
Additional tests:
1.Xray studies to include a -, flat plate of the abdomen, Ultrasound, MRI, CT scan, etc.,
laboratory tests such as T3, T4, TSH, FBS, CBG, PPBS, OGTT, IVGTT, Urine for sugar
and ketone, etc.