CASE PRESENTATION ON SPLENECTOMY

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CASE PRESENTATION ON SPLENECTOMY

• PPREPARED BY
• ALPHONSA SEBASTIAN
• OR DEPARTMENT

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DEMOGRAPHIC DATA NAME
MR.M. K. Z AGE/SEX
24YRS/MALE DATE
OF ADMISSION 24/02/2013 DIAGNOSIS
HAEMOPERITONIUM SURGER
Y ON
24/02/2013 SURGICAL INTERVENTION
EXPLORATORY LAPROTOMY WITH
SPLEENECTOMY DISCHARGED ON
02/03/2013
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• PHYSICAL ASSESMENT
• 1. GENERAL APPEARANCE
• Patient is conscious.
• Looks weak and fatigue
• His vital signs are
• 120/67mmof hg
• P/R 82/mt
• RR 22/mt
• SPO2 98

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• 2. SKIN
• Skin is warm .
• Light complexion.
• Warm to touch.

• 3. HEAD
• Absence Of Dandruff.
• 4. EYES
• Able to move both eyes
• No redness.
• Hair Is Equally Disrtibuted.
• .

• Pupils reactive to light.

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• 5. EARS
• Patients pinna is same colour as fascial.
• Skin,aligned with eye level .
• Able to hear sounds clearly .
• No discharges.

• 6 .MOUTH
• No ulcers present in the mouth.
• Oral cavity is pale in colour.
• Lips pale and dry.

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• 7 . TEETH
• Teeth is propely aligned with no dentures.

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• 8 . NECK
• No tenderness of node.

• 9. THORAX
• The Thorax Is Symmetric On Inspection

• 1O. GASTRO INTESTINAL
  
  
• Tenderness Of Abdomen present on palpation.

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• .

• 11 . MUSCULOSKELETAL
• No deformities of upper and lower limbs.

• 12 . CARDIO VASCULAR
• Absence Of Chest Pain .
  
  
• Heart sounds are clear.
• Upon auscultation his Bp is 132/78mmofhg

• 13. GENITO URINARY
• With foley catheter fr.16

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.

• 14. NEUROLOGIC
• 
  
  Patient Is Mentally Alert And Oriented With
  Circumstances.
• Able To Follow Commands.
• No neurovascular deficit.

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PATIENT HISTORY PAST MEDICAL
HISTORY . No past medical history.
PAST SURGICAL HISTORY

• No past surgical history.

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PRESENT MEDICAL HISTORY Patient was brought
to emergency department on 23/02/2013 after
being involved in RTA . After the observation in
ER he was refered to general surgery.But the
patient refused for further treatment and went
LAMA. The next day he was again brought to ER
with c/o dizziness,body weakness and epigatric
pain.Patient was conscious and oriented but with
body weakness. After general surgery consultation
he was sent for CTabdomen, which revealed free
fluid in abdomen .And they suggested emergency
laparotomy. The patient underwent Exploratory
Laparotomy With Splenectomy On 24/02/2013, the
same day of admission .
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• INVESTIGATIONS DONE FOR THE PATIENT
• Ct abdomen with contrast
• Ct abdomen with out contrast
• Blood investigations

• CBC
• ABO RH
• PT INR
• ELECTROLYTES

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LAB REPORTS
INVESTIGATIONS RESULTS NORMAL VALUE
CBC WBC NEUT RBC HB PLT 20.63 76.6 2.68 8.2 236 4.23-9.07 34-67.9 4.63-6.08 13.7-17.5G/DL 163-337
PT 16.3 10.9-16.3secs
APTT 30 27-39secs
Urea 23.2 3.2-7.1mmol/L
Creatinine 121 46-110mmol/L
Sodium 140 137-145mmol/L
Pottassium 5.1 3.5-5.1mmol/L
Chloride 114 98-107mmol/L
ABO RH O ve
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• TREATMENT DONE FOR THE PATIENT
• SURGICAL INTERVENTION
• EXPLORATORY LAPAROTOMY
  
• WITH SPLENECTOMY

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MEDICATIONS
NAME OF THE MEDICINE DOSE ROUTE FREEQENCY ACTION
INJ.PREMOSAN 10mg IV /BID Antiemetic
INJ.RISEK 40mg IV/OD H2receptor antagonist
INJ.CIPROXIN 200mg IV/BID Antibiotic
INJ.FLAGYL 500mg IV/BID Antibiotic
INJ.TRAMADOL 50mg IM/TID Analgesic
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TOPIC PRESENTATION

• SPLENECTOMY

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Splenectomy is a surgical procedure to Remove
spleen an organ that sits under rib cage on
the left side of abdomen.


TYPES OF SPLENECTOMY

1. Minimally invasive (laparoscopic) splenectomy

During laparoscopic splenectomy, the surgeon
makes four small incisions in abdomen. A tube
with a tiny video camera is inserted into abdomen
through one of the incisions. Surgeon watches the
video images on a monitor in the operating room
as special surgical tools are inserted through
the other incisions in abdomen and spleen is
removed. The incisions are then closed.
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2 . Traditional (open) splenectomy. During
open splenectomy surgeon makes an incision in the
middle of abdomen. Muscle and other tissue are
moved aside to reveal spleen. surgeon then
removes the spleen, and closes the incision.
Laparoscopic splenectomy isn't
appropriate for everyone. A ruptured spleen
usually requires open splenectomy. In some cases
surgeon may begin with a laparoscopic approach
and find it necessary to make a larger incision
because of scar tissue from previous operations
or other complications.
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Preparation of patient for surgery

• Receive blood transfusions before surgery to
  ensure have enough blood cells following removal
  of spleen.
• Receive a pneumococcal vaccine to help prevent
  infection after spleen is removed.
• Temporarily stop taking certain medications and
  supplements.
• Avoid eating or drinking for a certain amount of
  time before the surgery.

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ANATOMY AND PHYSIOLOGY OF SPLEEN
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The spleen is an organ shaped like a shoe that
lies relative to the 9th and 11th ribs and is
located in the left hypochondrium and partly in
the epigastrium. Thus, the spleen is situated
between the fundus of the stomach and the
diaphragm. The spleen is very vascular and
reddish purple in color its size and weight
vary. A healthy spleen is not palpable.
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The spleen is a lymphatic organ interposed in the
blood stream. The surface projection of the
longitudinal axis of the spleen is the tenth rib.
It is concealed anteriorly by the greater
curvature of the stomach and the left colic
(splenic) flexure. Its weight varies from 50 to
250g.
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HILUM The hilum can be found on the inferomedial
part of the gastric impression (see the image
above). The hilum transmits the splenic vessels
and nerves and provides attachment to the
gastrosplenic and splenorenal (lienorenal)
ligaments
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PERITONEAL RELATIONS The spleen is surrounded by
peritoneum and is suspended by multiple
ligaments, as follows

• The gastrosplenic ligament

• The splenorenal ligament

• The phrenicocolic ligament

• VISCERAL RELATIONS
• The visceral surface of the spleen contacts
  the following organs
• Anterior surface of the left kidney .
• Splenic flexure of the colon
• The fundus of the stomach
• Tail of pancreas

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• 
  FUNCTIONS OF SPLEEN
• There are three major functions of the spleen and
  these are handled by three different tissues
  within the spleen.
• Concerned with phagocytosis of erythrocytes
  and cell debris from the blood stream. This same
  tissue may produce foci of haemopoiesis when
  rbc's are needed.
• Along with the power of the spleen to
  contract, provides a method for expelling the
  contained blood to meet increased circulatory
  demands in certain animals.
• Provides lymphocytes and a source of
  plasma cells and hence antibodies for the
  cellular and humoral specific immune defenses

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Vascular supply The splenic artery
supplies blood to the spleen.This artery is the
of the celiac trunk and reaches the spleen's
hilum by passing through the splenorenal
ligament. It divides into multiple branches at
the hilum.It divides into straight vessels
called penicillin ellipsoids, and arterial
capillaries in the spleen.
largest branch
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NERVE SUPPLY Sympathetic fibers are
derived from the celiac plexus. LYMPHATIC
DRAINAGE Proper splenic tissue has no
lymphatics however,some arise from the capsule
and trabeculae and drain to the
pancreaticosplenic lymph nodes.
VENOUS DRAINAGE The splenic vein provides the
principal venous drainage of the spleen. It runs
behind the pancreas (after forming at the hilum)
before joining the superior mesenteric vein
behind the neck of the pancreas to form the
portal vein. The short gastric, left
gastro-omental, pancreatic, and inferior
mesenteric veins are its tributaries
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VENOUS DRAINAGE
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ETIOLOGY

• Ruptured spleen.
• If spleen ruptures due to a
  severe abdominal injury or because of enlargement
  of spleen (splenomegaly), the result may be
  life-threatening, internal bleeding.
• Blood disorder.
• Idiopathic thrombocytopenic purpura (ITP),
• Polycythemia vera,
• Thalassemia and sickle cell anemia.

• Cancer.
• Chronic lymphocytic leukemia,
• hodgkin lymphoma and non-hodgkin lymphoma
• Hairy cell leukemia.

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• Infection.
• A severe infection or a large collection of pus
  surrounded by inflammation (abscess) within your
  spleen that doesn't respond to other treatment
  may require splenectomy

• Cyst or tumor.
• Noncancerous cysts or tumors inside the spleen
  may require splenectomy if they become large or
  are difficult to remove completely.
• Blood vessel problems
• Aneurysm in the spleen's artery
• Blood clot in the spleen's blood vessels

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COMPLICATIONS

• Infections

• Streptococcus pneumonia
• Neisseria meningitides
• Haemophilus influenzae

These bacteria cause severe pneumonia,
meningitis, and other serious infections.
Vaccinations to cover these bacteria should be
given in patients without a spleen.
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• Other complications related to splenectomy
  include
• Blood clot in the vein that carries blood to
  the liver
• Hernia at the incision site
• Infection at the incision site
• Inflammation of the pancreas (pancreatitis)
• Lung collapse
• Injury to the pancreas, stomach, and colon

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• Call the doctor right away if you have any of
  the following after a splenectomy
• Bleeding.
• Chills.
• Cough or shortness of breath.
• Difficulty eating or drinking.
• Increased swelling of the abdomen.
• Pain that doesn't go away with prescribed
  medications.
• Increasing redness, pain, or discharge (pus) at
  the incision site.
• Nausea or vomiting that persists.
• Fever over 101 degree.

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• TREATMENT AFTER SPLENECTOMY
• Hospitalization for 2 days .
• Iv fluids .
• Antibiotics .
• To guard against infections, doctor may
  recommend a pneumonia vaccine, as well as yearly
  flu vaccines.
• Immunizations against pneumococcus species as a
  routine of postoperative management. Immunization
  should be administered anywhere from 24 hours
  after injury to 2 weeks.

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NURSING INTERVENTIONS POST OP

• Report even minor signs or symptoms of
  infection immediately to the physician.

• Monitor carefully for hemorrhage

• Monitor post-op temperature elevation

• Observe for abdominal distension and discomfort

• Ambulate early and provide chest physical
  therapy

Assess for

• Temperature elevation above 101 degrees Celsius,
  chills, increased pulse above 100

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• Tachypnea, ronchi, crackles, cloudy foul
  smelling urine, urgency frequency, irritation
  ulcers of oral, vaginal or other mucosa redness
  or drainage from wound or invasive sites.

• Hypotension, shock-like state. Indicates
  potential for meningeal infection .

Monitor, Describe, Record

• White blood cells increases, urine, blood and
  wound cultures and sensitivities. WBC of gt 10,000
  cu/mm positive cultures for infectious organisms.
  
• Immunoglobulins. IgM decreases, IgG ad IgA within
  normal ranges indicating deficiencies.
• Vital signs and temperature every four hours.
  Indicates presence of infection

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Administer

• Antibiotics specific to identified infectious
  agent.

• Antipyretic (acetaminophen.

Perform or provide

• Handwash techniques before giving care.

• Aseptic technique for any invasive procedures.

• Adequate fluids, nutritional and activity
  support.

• Meticulous mouth and perineal care.

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PRIORITIZATION OF NSG DIAGNOSIS
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ASSESSMENT NSG DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE I have fever and chilling as verbalized by the patient OBJECTIVE Elevated temperature P/R-126/mt TEMP-38.6C RR-24/mt Chills Tachypnea Cloudy foul smelling urine Redness or drainage from wound or invasive sites. High risk for infection related to inadequate secondary defenses by immunosuppresion resulting from decreased immunoglobulins. After series of nursing interventions the client should manifest no signs of infection . 1.Asses for Temperature elevation above 101 fh,chills 2. Assess for tachypnea, crackles, cloudy foul smelling urine, urgency frequency. 3.Asses for hypotension, shock-like state. Monitor urine, blood and wound cultures and sensitivities. 5.Administer specific antibiotics INJCIPROXIN 200MG IV ,BID. INJFLAGIL 500MG IV,BID 6.Administered antipyretics INJPERFALGAN 1GM STAT 1.High grade fever indicates infection 2. Indicates pneumococcal infection or overwhelming infection. 3.Indicates potential for meningeal infection. 4.To identify the presence of infectious organisms. 5.Acts to destroy microorganisms by inhibiting cell wall synthesis. 6.Reduces fever by inhibiting heat-regulating center. After 12 hrs of nursing interventions the goals were fully met as evidenced by.. Absence of infection evidenced by 1 .Temperature, white blood cell, urinalysis, cultures within normal ranges Temp-36.6c Pr/82bpm,rr-20/mt 2.Breath sounds, urinary pattern, mucous membranes within baseline levels.
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• NURSING HEALTH TEACHING
• Instruct The Patient
• Take short walks on a level surface
• Dont overexert to the point of fatigue.
• Limit stair climbing to no more than once or
  twice a day. Climb steps slowly and stop to rest
  every few steps
• Dont lift anything heavier than 10 pounds or
  push a vacuum cleaner for 4 to 6 weeks after
  surgery.

• Dont drive until after first doctors
  appointment after surgery.

• Get medical attention even for mild illnesses
  such as sinus problems or colds.
• Take antibiotic medication after surgery as
  directed by doctor

• .

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• Be sure to tell all your healthcare providers
  that he doesnt have a spleen

• Wash incision site with soap and water and pat
  dry.
• Check incision every day for redness, drainage,
  swelling, or separation of the skin.

• Take the medications exactly as directed. Dont
  skip doses.
• Dont take any over-the-counter medication unless
  the doctor tells to do so.
• Check temperature each day for 1 week after
  surgery.
• Make a follow-up appointment as directed.

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• CONCLUSION
• A case of RTA patient who underwent splenectomy
  as an emergency procedure on 24/02/13.
• Splenectomy is a surgical procedure to remove
  spleen an organ that sits under rib cage on the
  left side of abdomen.

• The two types of splenectomy are open splenectomy
  and laproscopic splenectomy . A ruptured spleen
  usually requires open splenectomy.
• Patient was discharged on 02/03/13 .
• He was instructed about the follow up care and
  has been explained he is prone to infection as he
  does not have a spleen.

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Bibliography

• Lippincott manual of nursing practice 9th edition
  
• www.mayoclinic .com
• Wikipedia
• Grays anatomy and physiology

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THANK YOU