CASE PRESENTATION ON SPLENECTOMY

1. CASE PRESENTATION ON SPLENECTOMY PPREPARED BY ALPHONSA SEBASTIAN OR DEPARTMENT

2. DEMOGRAPHIC DATA NAME : MR.M. K. Z AGE/SEX : 24YRS/MALE DATE OF ADMISSION : 24/02/2013 DIAGNOSIS : HAEMOPERITONIUM SURGERY ON : 24/02/2013 SURGICAL INTERVENTION : EXPLORATORY LAPROTOMY WITH SPLEENECTOMY DISCHARGED ON : 02/03/2013

3. 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%

4. 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.

5. 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.

6. 7 . TEETH • Teeth is propely aligned with no dentures. • . • 8 . NECK • No tenderness of node. • 9. THORAX • The Thorax Is Symmetric On Inspection • 1O. GASTRO INTESTINAL • Tenderness Of Abdomen present on palpation.

7. . • 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

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

9. PATIENT HISTORY PAST MEDICAL HISTORY .No past medicalhistory. PAST SURGICAL HISTORY • No past surgicalhistory.

10. 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 epigatricpain.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 .

11. INVESTIGATIONS DONE FOR THE PATIENT • Ct abdomen with contrast • Ct abdomen with out contrast • Blood investigations • CBC • ABO RH • PT INR • ELECTROLYTES

12. LAB REPORTS

13. TREATMENT DONE FOR THE PATIENT • SURGICAL INTERVENTION • EXPLORATORY LAPAROTOMY • WITH SPLENECTOMY

14. MEDICATIONS

15. TOPIC PRESENTATION SPLENECTOMY

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

17. 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.

18. 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.

19. ANATOMY AND PHYSIOLOGY OF SPLEEN

20. 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.

21. 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.

22. 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

23. 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

24. 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 immunedefenses

25. 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

26. 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

27. VENOUSDRAINAGE

28. 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), • Polycythemiavera, • Thalassemia and sickle cell anemia. • Cancer. • Chronic lymphocytic leukemia, • hodgkin lymphoma and non-hodgkin lymphoma • Hairy cell leukemia.

29. 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

30. 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.

31. 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

32. 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.

33. 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.

34. 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 > 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

35. 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.

36. PRIORITIZATION OF NSG DIAGNOSIS

38. NURSING HEALTH TEACHING • Instruct The Patient • Take short walks on a level surface • Don’t 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 • Don’t lift anything heavier than 10 pounds or push a vacuum cleaner for 4 to 6 weeks after surgery. • Don’t drive until after first doctor’s 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 • .

39. Be sure to tell all your healthcare providers that he doesn’t have a spleen • Wash incision site with soap and water and pat dry. • Check incision every day for redness, drainage, swelling, orseparation of the skin. • Take the medications exactly as directed. Don’t skip doses. • Don’t 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.

40. 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.

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

42. THANK YOU