CHAPTER 49. Special Procedures
Theresa L. Clifford
OBJECTIVES
At the conclusion of this chapter, the reader will be able to:
1. List common ambulatory nonsurgical diagnostic or interventional procedures.
2. Describe assessment parameters pertinent to the patient undergoing special procedures.
3. Identify nursing interventions appropriate to the care of the patient undergoing select nonsurgical diagnostic or interventional procedures.
4. Describe six types of reactions that can occur as a result of a blood transfusion.
5. Identify three potential complications for the patient undergoing electroconvulsive therapy (ECT).
I. OVERVIEW
A. Definition
1. Variety of procedures performed throughout facility may be termed “special procedures.”
a. Endoscopic procedures
b. Diagnostic procedures
c. Interventional procedures
d. Electroconvulsive therapy
e. Infusion therapies
2. May be performed in:
a. Endoscopy
b. Radiology
c. Vascular or catheterization lab
d. Operating room/minor surgery suite
e. Nursing unit
f. Post anesthesia care unit (PACU)
g. Ambulatory care unit
B. Responsibilities of perianesthesia staff
1. May or may not include:
a. Preprocedure preparation of patient
b. Intraprocedure assessment and monitoring
c. Postprocedure recovery and discharge
2. Varies according to facility protocols
3. Varies according to patient workflow processes
II. ANATOMY AND PHYSIOLOGY
A. Gastrointestinal (GI) procedures (see Chapter 35)
1. Anatomy of GI tract
a. Mouth (oral or buccal cavity)
(1) Teeth, tongue, hard and soft palates, cheeks, lips, pharynx
(2) Salivary glands
(a) Parotid
(b) Sublingual
(c) Submandibular
b. Esophagus
(1) Hollow muscular tube
(2) Approximately 23 to 25 cm (10 inches) long
(3) Approximately 2 to 3 cm (1 inch) in diameter
(4) Extends from pharynx to stomach
(a) Passes through diaphragm into the abdomen opening called diaphragmatic hiatus
(5) Positioned posterior to trachea and anterior to vertebral column
(6) Wall made up of three layers
(a) Mucosa
(b) Submucosa
(c) Muscularis
(7) Sphincters
(a) Upper pharyngoesophageal
(b) Lower esophagogastric (cardiac)
(8) Disorders
(a) Gastroesophageal reflux disease
(b) Esophageal varices
(c) Tumors
(d) Diverticula
(e) Motility disorders
(f) Foreign bodies
(g) Strictures, rings, and webs
(h) Infectious disease
c. Stomach
(1) J-shaped distensible organ
(2) Located in left upper quadrant of abdomen (just below diaphragm, between esophagus and duodenum)
(3) Approximately 25 to 30 cm (l0-12 inches) long
(4) Approximately 10 to 15 cm (4-6 inches) wide at widest point
(5) Function
(a) Digests food and prepares nutrients for absorption
(b) Serves as reservoir for swallowed food, drink, and digested secretions
(c) Mixes and delivers chyme to the small intestine for further digestion and absorption
(d) Originates signals for hunger and satiety
(6) Consists of:
(a) Fundus
(b) Body
(c) Pylorus (antrum)
(d) Cardiac region
(7) Sphincters
(a) Esophagogastric (cardiac)
(i) Prevents backward reflux of stomach contents
(b) Pyloric
(i) Works with duodenum to create pressure gradient, which allows emptying of stomach
(8) Disorders
(a) Acid-peptic disorders
(b) Helicobacter pylori
(c) Polyps
(d) Gastritis
(e) Gastric cancer
(f) Gastric varices
(g) Hiatal hernia
(h) Gastric outlet obstruction
(i) Stress ulcers
(j) Motor dysfunction—swallowing disorders
(k) Bezoars (concretions of foreign material found in stomach)
d. Small intestine
(1) Tube-shaped structure
(2) Approximately 18 feet long, 1 inch in diameter
(3) Three sections
(a) Duodenum
(i) C shaped
(ii) First section
(iii) Begins at pyloric sphincter
(iv) Ends at ligament of Treitz
(b) Jejunum
(i) Middle section (proximal two fifths)
(c) Ileum
(i) Last section
(ii) Distal three fifths of small bowel
(4) Properties
(a) Circular folds increase absorptive surfaces of small intestine.
(5) Disorders
(a) Duodenal ulcer
(b) Bacterial and viral infections
(c) Parasitic disease
(d) Crohn’s disease
(e) Meckel’s diverticulum
(f) Malabsorption syndromes
(g) Celiac spruce (poor food absorption and gluten intolerance)
(h) Tropical sprue (chronic disorder acquired in endemic tropical areas)
(i) Whipple disease
(i) Rare disorder characterized by chronic diarrhea and progressive wasting
(j) Short bowel syndrome
(k) Lactase deficiency
(l) Small bowel tumors
(m) Motility disorders
e. Large intestine
(1) Tube-shaped structure
(a) Approximately 4 to 6 cm (2 inches) in diameter
(b) Approximately 90 to 150 cm (4-5 feet) long
(c) Extends from ileocecal value to the anus
(2) Consists of:
(a) Cecum
(i) Positioned at junction of ileum and colon
(ii) Contains ileocecal valve and appendix
(b) Ascending colon
(i) Portion from cecum to hepatic flexure
(c) Transverse colon
(i) Segment from hepatic flexure to splenic flexure
(ii) Transverses abdominal cavity
(d) Descending colon
(i) Segment from splenic flexure to iliac crest
(ii) Located on left side of abdomen
(e) Sigmoid colon
(i) S-shaped segment
(ii) Ends at rectum
(f) Rectum
(i) Last portion of large intestine
(ii) Approximately 5 inches long
(iii) Segment after sigmoid colon
(iv) Connects to anal canal
(3) Disorders
(a) Polyps
(b) Angiodysplasia (vascular dilations in the submucosa)
(c) Colitis
(d) Necrotizing enterocolitis
(e) Ulcerative colitis
(f) Pseudomembranous colitis
(g) Crohn’s colitis
(h) Irritable bowel syndrome
(i) Diverticular disease
(j) Diverticulosis
(k) Colorectal cancer
(l) Hemorrhoids
(m) Anorectal disorders
(n) Encopresis (chronic constipation that results in involuntary leaking of feces)
(o) Anal fissure
(p) Rectal prolapse
(q) Anorectal abscess
(r) Anorectal fistula
(s) Anorectal fissure
2. Nerve supply—occurs two ways
a. Neural transmission to smooth muscle
(1) Stimulates movement of food through GI tract
(2) Occurs as a result of distention of myenteric plexus or submucosal plexus
b. Autonomic nervous system
(1) Sympathetic
(a) Thoracic and lumbar splenic nerves
(b) Inhibit secretions and movement
(c) Cause contraction of sphincters
(2) Parasympathetic
(a) Vagus nerve: causes increase in motor activity
(b) Causes increase in secretions
(c) Causes sphincters to relax
(d) Results in peristalsis
3. Function of GI system
a. Ingestion
b. Transport
c. Digestion
d. Absorption
e. Elimination
B. Pulmonary procedures
1. Pulmonary anatomy (see Chapter 31)
a. Nose and sinuses
(1) Upper airway cleans, humidifies, and warms air.
(2) Sinuses lighten the skull, assist in speech, and produce mucus.
b. Pharynx
(1) Divided into three regions
(a) Nasopharynx
(i) Area where tonsils and adenoids (masses of lymphoid tissue in the back wall of nasopharynx) trap and destroy infectious agents
(b) Oropharynx
(i) Carries both air and food
(ii) During swallowing, the soft palate rises to prevent food from entering the nasopharynx.
(iii) The lining of the oropharynx protects it from damage by friction and from chemicals in food and fluids.
(c) Laryngopharynx
[i] Passageway for both food and air; connects oropharynx to larynx
c. Larynx
(1) Contains vocal cords to produce speech
(2) Protected by cartilages to keep it open
d. Lungs
(1) Soft and spongy, composed of elastic connective tissue
(2) Apex of each lung just below the clavicle
(3) Base of each lung rests on the diaphragm.
(4) Right lung has three lobes.
(5) Left lung is smaller, with only two lobes.
e. Bronchi and alveoli
(1) Trachea divides into right and left mainstem bronchi .
(2) Mainstem bronchi enter lungs at the hilus .
(3) Bronchi branch into smaller bronchi.
(4) Smaller bronchi branch into smaller bronchioles.
(5) Bronchioles end in the tiny alveoli.
(a) Where gas exchange occurs
(b) Extremely thin walls, made of a single layer of cells over a very thin connective tissue (basement) membrane
(c) Oxygen and carbon dioxide easily diffuse across the walls of the alveoli and capillaries.
(d) Alveoli contain cells that secrete surfactant, a detergent-like substance that helps keep them open.
C. Vascular procedures
1. Vascular anatomy (see Chapter 44)
a. Peripheral vascular system
(1) Network of blood vessels that carries blood to peripheral tissues and then returns it to the heart; network includes arteries, veins, and capillaries.
b. Arteries
(1) Arteries carry blood away from the heart.
(2) Oxygenated blood leaves the left ventricle via the aorta.
(3) Major arteries branch off the aorta and into successively smaller arteries. These eventually divide into arterioles.
(4) Arterioles feed into beds of hairlike capillaries within the organs and tissues.
(a) In capillary beds, oxygen and nutrients are exchanged for metabolic wastes, and deoxygenated blood begins its journey back to the heart through venules.
(5) Venules join onto veins, which in turn join larger veins.
c. Veins
(1) Carry blood toward the heart
(2) Peripheral veins empty into the superior and inferior vena cava, and then into the right atrium.
d. Three layers of blood vessel walls
(1) Tunica intima
(a) Endothelium; has a slick surface to assist blood flow
(2) Tunica media
(a) Contains smooth muscle
(b) Layer is thicker and more elastic in arteries than it is in veins.
(c) Allows arteries to expand and contract, maintaining blood flow to the capillaries between heartbeats
(3) Tunica adventitia
(a) Outermost layer
(b) Connective tissue that protects and anchors the vessel
III. GENERAL CARE
A. Preprocedure education
1. General
a. Nothing-by-mouth (NPO) instructions as appropriate
b. Hygiene
c. Environment
d. Facility protocols
e. Aftercare arrangements
f. Amnesic effects of sedation and analgesia
g. Medication—discontinue or dose as usual
B. Perianesthesia priorities
1. Preprocedure
a. Objectives
(1) Assess and prepare patient for procedure.
(2) Obtain baseline data.
(3) Allow for development and implementation of nursing care.
(4) Initiate educational process.
(a) Continues throughout continuum of care
b. Nursing process
(1) Assessment parameters
(a) Physical assessment as noted previously
(b) Assess for educational needs.
(c) Assess for psychosocial needs related to developmental age including:
(i) Availability of family member or responsible adult companion
(ii) Community resources needed
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