A. DEFINITION
Laparotomy
is the surgical removal of the colon due to intestinal adhesions and usually
occurs in the small intestine. (Arif
Mansjoer, 2000)
Laparotomy
surgery is a procedure to open the abdominal cavity for the purpose of
exploration.
Laparotomy
post treatment is a form of care given to patients who have undergone abdominal
surgery.
Range of Laparotomy
1. Midline incision
2.±2.5 cm), length (12.5 cm). Paramedian, ie,
slightly to the side of the center line (
3. Transverse
upper abdominal incision, namely an incision at the top, such as surgery and
splenektomy colesistotomy.
4. Transverse
lower abdominal incision, namely the transverse incision 4 cm above the operations.±anterior iliac spine, eg under appendictomy
B. Etiology
1. Abdominal trauma (blunt or sharp).
2. Peritonitis.
3. Bleeding in the gastrointestinal
tract.
4. Blockage of the small
intestine and colon.
5. The period of the abdomen
(Tumor, cyste etc.).
C. NURSING
MANAGEMENT
1. Reducing complications from
surgery.
2. Accelerate
healing.
3. Restoring
the function of patients as much as possible before surgery.
4. Maintaining
the patient's self concept.
5. Preparing
the patient goes home.
Care after surgery
1. Postoperative
nursing actions
a. Monitor
consciousness, vital signs, CVP, intake and output
b. Observation
and record drain darai properties (color, amount) drainage.
c. In
organizing and moving the position of the patient must be careful not to drain
uprooted.
d. Sterile wound care.
2. Food
In
the post-surgery patients are generally not allowed to swallow food after
surgery. foods
recommended in postoperative patients are foods high in protein and vitamin C. Protein
is needed in the process of wound healing, whereas the antioxidant vitamin C
helps increase body resistance to infection prevention.
diit
restriction does is NPO (nothing peroral)
Usually new foods
given if:
• Abdominal bloating not
• Peristaltic normal bowel
• Positive flatus
• Bowel positive movement
3. Mobilization
Usually
the patient is positioned to lie in bed so that the situation is stable. Usually
the initial position is supine, but must still be done in order to avoid
changes decubitus position. Patients
undergoing abdominal surgery are encouraged to perform early ambulation.
4. Meeting
the needs of elimination
Urinary system.
-
Voluntary control urinary function after 6-8 hours post inhalation anesthesia,
IV, spinal.
Anesthesia,
IV infusion, surgery manipulationàretained urine.
- Prevention: Inspection, Palpation, Percussionàlower abdomen (bladder distension).
- Dower catheteràexamine the color, the amount of urine, urine output < 30 ml / houràrenal complications.
Gastrointestinal System.
-
Nausea vomiting canà40% of clients with GA during the first 24 hours lead to stress and irritation of GI injury and
can improve ICT in head and neck surgery and IOP increases.
- Assess
the gastro intestinal function by auscultation of bowel sounds.
- Kaji paralitic ileusàbowel sound (-), abdominal distension, no flatus.
-
The amount, color, consistency stomach contents every 6-8 hours.
-
Insertion of intra-operative NG tube to prevent postoperative complications
with decompresi and gastric drainage.
• Increase the break.
•
Provide an opportunity to cure the GI trac.
• Monitor bleeding.
• Preventing bowel obstruction.
• Irrigation or drug
delivery.
D. COMPLICATIONS
1. Impaired
tissue perfusion with respect to tromboplebitis.
Tromboplebitis
postoperative usually occurs 7-14 days after surgery. Tromboplebitis
great danger arises when the blood is separated from the walls of veins and
join the bloodstream as emboli to the lungs, liver, and brain.
Prevention
tromboplebitis the postoperative leg exercises, ambulatif early.
2. Infection.
Wound
infections often appear in 36-46 hours after surgery. The
organisms that cause infections are most often stapilokokus aurens, organisms;
gram positive. Stapilokokus
resulted pernanahan.
To
avoid wound infection is the most important wound care with attention to
aseptic and antiseptic.
3. Damage
to skin integrity in relation to wound dehiscence or eviserasi.
Wound
dehiscence is an open wound edges.
Eviserasi
injury is the release of internal organs through an incision.
Factors
causing dehiscence or eviserasi are wound infection, surgical error closing
time, a heavy strain on the abdominal wall as a result of coughing and
vomiting.
The process of wound healing
• The first phase
Lasts up to 3 days. Trunk leucocytes much damaged
/ fragile. New
blood cells develop into healing where nodes fibers are used as a framework.
• The second phase
From day 3 to day 14. Charging
by collagen, the entire periphery of epithelial cells arising perfect in 1
week. The
new network is growing strongly and redness.
• The third phase
Approximately 2 to 10 weeks. Collagen
constantly dumped, new signage networks and muscles can be reused.
• The fourth phase
Last phase. Healing will shrink and
shrink.
Efforts to
accelerate wound healing
1. Increase
intake of foods high in protein and vitamin C.
2. Avoid
anti-inflammatory drugs such as steroids.
3. Prevention of
infection.
4. Returns
physical function.
Returns
physical function immediately after surgery with breathing and coughing
exercises effective, early mobilization exercises.
E. Evaluation
Criteria
Expected
results after postoperative patient care, include;
1. No there is pain during
wound healing.
2. Normal
incisional wounds without infection.
3. No
complications arise.
4. Elimination
pattern smoothly.
5. Patients remained in
the optimal level without disabilities.
6. Losing weight or at
least remain normal.
7. Before going home, patients
know about:
• Advanced Medicine.
• The type of drugs given.
• Diet.
• Limit
activity and plan activities at home.
F. Assessment
a. Primary Survey
1) Airway
-Check the airway obstruction of foreign matter (solid,
liquid) after the surgery due to administration of anesthesia.
- Potency airway, àput the hand over the mouth or nose.
- àkeadekwatan lung expansion, symmetry. Auscultasi lung
2) Breathing
- compression on the brainstem will cause disturbances in
heart rhythm, resulting in a change in breathing pattern, depth, frequency and
rhythm, can be Cheyne Stokes breathing or ataxia. Breath
sounds, stridor, ronkhi, wheezing (kemungkinana due to aspiration), there tends
to be an increase in sputum production in the airway.
Changes in breathing (on average, pattern, and
depth).- RR
<à depressive
disorder Narcotic, rapid respiration, shallow à10 X / cardiovasculair
minutes or an average increase metabolism.
- Inspection: The movement of the chest wall, muscle use a
respirator diaphragm, sternalàanathesi effects of excessive obstruction. retraction
3) circulating:
The effect of increased intracranial pressure
on blood pressure varies.- Pressure
on the vasomotor center will improve the transmission of parasympathetic
stimulation to the heart which would cause a slow pulse, a sign of increased
intracranial pressure. Changes
in heart rate (bradycardia, tachycardia interspersed with bradycardia,
dysrhythmias).
-Inspection mucous membrane: color and moisture, skin
turgor, bandage.
4)
Disability: focus on neurological status
-Assess the patient's level of consciousness, signs of eye
response, motor response, and vital signs.
- Inspection of response to stimuli, speech problems,
difficulty swallowing, limb weakness or paralysis, visual changes, and
restless.
5) Exposure
-Assess the patient's surgical bandage the bleeding
b. Secondary Survey: Physical
Examination
Patients
appear tense, facial pain, weakness. Awareness
compost mentis, GCS: 4-5-6, T 120/80 mmHg, N 98 x / min, S 374 0C, RR 20 X /
min.
1) Abdomen.
Inspection
no ascites, liver palpation palpable two fingers below the ribs, and the spleen
was not enlarged, faint percussion sounds, bowel sounds 14 X / min.
Abdominal
distension and intestinal peristaltic assessment is to be done on the
gastrointestinal tract.
2) Extremity
Able to lift up the
hands and feet. Upper
limb muscle strength and lower limb 4-4 4-4., Akral cold and pale.
3) Integumentary.
Skin wrinkles, pale. Turgor was
4) neurological examination
If
severe bleeding / wide and the brain stem will be interference with cranial
nerve, it can happen:
- Changes in mental status (orientation, alertness,
attention, concentration, problem solving, the influence of emotional /
behavioral and memory).
-Changes in vision, such as sharpness, diplopia, loss of
some field of view, photo phobia.
-Pupillary changes (response to light, symmetry),
deviation of the eyes.
-A decline in the power of hearing, balance the body.
-Often arise hiccup / hiccups due to the compression of
the vagus causes spasmodic diaphragm compression.
hipoglosus nerve disorders.- Disorders
that seemed tongue falling to one side, dysphagia, disatria, so hard to
swallow.
c. Tersiery Survey
1) Cardiovascular
Clients
appear weak, pale skin and kunjungtiva akral warm. Blood
pressure 120/70 mm Hg, pulse 120x/menit, capillary refill of 2 seconds. Laboratory
tests: HB = 9.9 g%, HCT and PLT = 32 = 235.
2) Brain
Clients
conscious, GCS: 4-5-6 (total = 15), the client seems weak, reflexes within
normal limits.
3) Blader
Client
installed doewer chateter urine deposited 200 cc, tawny color.
G. Nursing Diagnosis
1. Disruption
sense of comfort pain associated with the incision.
2. Damage to
skin integrity related to the incision.
3. High
risk of wound infection associated with poor hygiene.
4. Impaired
tissue perfusion related to bleeding.
5. Lack
of fluid volume associated with postoperative bleeding.
6. Ineffective
breathing pattern related to the effects of anesthesia.
7. Ineffective
airway clearance related to the buildup secret.
8. Changes
in the pattern of urinary elimination related to the effects of anesthesia.
9. Changes
in nutrition less than the needs associated with nausea and vomiting.
REFERENCES
Brunner and Suddart. (1988). Textbook of Medical Surgical
Nursing. Sixth Edition. J.B. Campany
Lippincott, Philadelphia.
Doenges, Marilynn E. (2000). Nursing
care plan. EGC, Jakarta.
www.CerminDuniaKedokteran.co.id
www.medicastore.com
And from a variety of sources.
