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Nursing Interventions
Implements aseptic technique (Im.300)
Protects from cross-contamination
(Im300.1)
Nursing Interventions
Nursing Interventions
General Considerations
Anesthesia
• Local anesthesia is often used in
conjunction with sedation, regional and
general anesthesia
• Epinephrine may be added to prolong
anesthetic action & provide hemostasis
• Epinephrine generally not used in local on
digits (fingers/toes)
Positioning
• Position patient so that all operative sites
appropriately exposed and airway easily
observed & accessed
• OR bed may be turned for ease of access
• Provide comfort measures, such as pillow
under knees, as some procedures are long in
duration
• Always check patient after position changes
Skin Preparation
• Most skin marking is done prior to patient
going to sleep-don’t wash off when
prepping
• Colorless solution is preferred to observe
true skin color
• Avoid pooling of prep around or in eyes or
ears
Draping
• Blue towels and medium sheets are used
when large amounts of skin must be
exposed
• Head drape used when working on face,
ears & neck
• Both sides of body may be exposed for
comparison purposes
Supplies/Equipment
• Marker/Methylene Blue
• Undyed suture often used, clear may be
used on face
• Bipolar
• Silastic and Teflon Implants
– Available in several sizes and shapes
– Contraindicated for use in an infected area
Tissue Expanders
Breast Implants
Facial Implants
Dermatome
Skin Mesher
Skin Mesher
Head Light & Light Source
Lighted Retractors
Jackson Pratt Drain
Microscope
Suction Assisted Lipectomy
Instrumentation
Gillies needle holder
Stevens scissors
Castroviejo Forceps
Hartman Mosquito
Skin Hook
Liposuction Cannulas
Medications
• Local Injections
– Lidocaine (Xylocaine)
– Bupivicaine (marcaine)
• Topical
– Cocaine 4%
• Tumescent Anesthesia
– 1 liter NS with 500-1000mg lidocaine & 1mg
epinephrine
Pressure Infuser
Dressings
• Apply even pressure over wound to prevent
dead spacing, seromas & hematomas
• Collect drainage
• Provide comfort for the patient
• Protect wound
Brow lift
• Minimizes forehead creases, drooping eyebrows,
hooding over eyes, furrowed forehead and frown
lines by removing excess tissue, altering muscles
& tightening forehead skin
• Length: 1-3 hours
• Risks: facial nerve injury, muscle weakness,
asymmetrical look, infection, scarring
Open Brow Lift
• Hair is tied with
rubber bands on either
side of incision
• Coronal incision is
made running ear to
ear
• Skin of forehead is
lifted, excess skin is
removed & muscles
altered
Endoscopic Brow Lift
• 3-5 short (1 inch) incisions
made
• Endoscope inserted to
view muscle & tissue
• Elevator inserted through
different incision to lift
skin
• Underlying tissue &
muscle removed or altered
Brow Lift Before & After
Rhytidectomy (Face Lift)
• Improves sagging facial skin, jowls &
loose neck skin by removing excess fat,
tightening muscles, & redraping skin.
• Length: several hours
• Risks: Facial nerve injury, infection,
bleeding, poor healing, scarring, asymmetry
or change in hairline
Rhytidectomy
• Incision is made close
to or in the hairline
• Skin and subcutaneous
tissue are mobilized by
undermining
(separation from their
attachments)
• Avoid injury to facial
& greater auricular
nerves
Rhytidectomy
• After deep tissues are
tighten with sutures,
the excess skin is
pulled up and back,
trimmed and sutured
into place
• Drains may be placed
Post-Op Dressing
Rhytidectomy Before & After
Facial Implants
• Improve & enhance facial contours using
shaped implants to build up the chin, cheeks
& jaw line
• Length: Chin 30 min – 1 hr, Cheek 30-45
min, lower jaw 1-2 hr
• Risks : shifting or imprecise positioning of
implant, infection, scar tissue around
implant causing unnatural shape
Chin Implant
• Incision is made inside
mouth or under the
chin
• A pocket is created in
front of the jawbone
• Implant is inserted &
wound closed
Chin implant Before & After
Cheek Implant
• Incision is made either
inside the upper lip or
lower eyelid
• Implant is placed
either directly on or
below cheek bone
Cheek Implant Before & After
Lower Jaw Implant
• Internal incisions are
made on either side of
the lower lip
• A pocket is created
and the implant is
inserted
Jaw Implant Before & After
Rhinoplasty
• Reshape nose by reducing or increasing
size, removing hump, changing shape of tip,
narrowing span of nostrils, changing angle
between nose and upper lip
• Length: 1-2 hours
• Risks: infection, temporary swelling &
bruising around eyes & nose, headaches,
bleeding, stiffness
Rhinoplasty
• Incisions are made
inside the nose or at
the base of the nose,
providing access to the
cartilage and bone
which can then be
sculpted into shape
Rhinoplasty
• Hump is removed with
a chisel or rasp, then
the nasal bones are
brought together to
form a narrower
bridge
• Cartilage is trimmed to
reshape the tip of the
nose
Rhinoplasty
• Trimming the septum
improves the angle
between the nose and
upper lip
Rhinoplasty
• If the nostrils are too
wide, small wedges of
skin are removed from
the base to bring them
closer together
Post-Op Splint
Rhinoplasty Before & After
Otoplasty
• Sets prominent ears back closer to the head,
or reduce the size of large ears
• Length: 2-3 hours
• Risks: infection, scarring, blood clot
formation on the ear, recurrence of
protrusion
Otoplasty
• Incision is made in the
back of the ear so
cartilage can be
sculpted or folded
• Stitches are used to
close the incision and
help maintain the new
shape
Ear Dressing
Otoplasty Before & After
Cleft Lip Repair
• Correction of a congenital split in the upper
lip. Incidence 1 in 800 babies
• Length: 30 min-1 hour
• Risks: Pain, Restlessness, difficulty with
feeding
Cleft Lip Repair
• Incision is made along
each side of cleft
• Outer portion of cleft
will be turned down &
muscle and skin of lip
is pulled together and
sutured
Cleft Lip Before & After
Cleft Palate Repair
• Correction of a congenital deformity that
results in a cleft in the hard palate, soft
palate or both
• Length: 1-1.5 hours
• Risk: Pain, decrease in appetite requiring an
IV for 1-2 days
Cleft Palate Repair
• Incision is made on
both sides of the
separation, tissue from
each side is moved to
the center of the roof
of the mouth and
sutured
Cleft Palate Before & After
Augmentation Mammoplasty
• Use of implants to enhance breast size,
correct breast asymmetry, or recreate the
breast after mastectomy
• Length: 1-2 hours
• Risks: deflation, scar tissue around implant
(capsular contracture), infection, change in
nipple sensation, difficult mammograms
Augmentation Mammoplasty
• Incisions are made to •
keep scar as
inconspicuous as
possible, in the breast
crease, around the
nipple, or in the
armpit. Breast tissue &
skin is lifted to make a
pocket for the implant
Augmentation Mammoplasty
• Implants may be
placed in front or
behind the muscle
Post Op Dressing
Augmentation Before & After
Mastopexy (Breast Lift)
• Raise and reshape sagging breasts by
removing excess skin & repositioning
remaining tissue and nipples
• Length: 1-3 hours
• Risks: infection, skin loss, scarring,
unevenly positioned nipples, loss of
sensation in nipples or breast
Mastopexy
• The skin outlined by
the incision is
removed
• The nipple & areola
are moved up and the
skin surrounding the
areola is brought down
and together to
reshape the breast
Mastopexy Before & After
Reduction Mammoplasty
Reduction Before & After
Breast Reconstruction
• Performed either immediately after
mastectomy or can be delayed
• Accomplished via tissue flap or with tissue
expander & implant
• Length: expanders – 1 hr; latissimus flap –
3-4 hr; TRAM flap – 5-7 hr; DIEP flap – 6-
8 hr
• Risks: bleeding, infection, scarring, loss of
circulation to flap
Tissue Expanders
• Tissue expander is
placed below the
pectoralis muscle,
wound is closed &
expander inflated until
skin blanches
Tissue Expanders
• Additional inflation
occurs 2-3 weeks post-
op and every 7 days
thereafter
• When maximum
expansion is achieved
the expander is
exchanged for
permanent implant
Tissue Expanders After
TRAM Flap
• Transverse Rectus
Abdominis
Myocutaneous
• Skin, fat & muscle are
dissected and
tunneled to the midline
of the abdomen
• Blood vessels remain
intact
TRAM Flap
• Flap is brought to the
chest wall with the
thinnest part of the
flap superior &
medial, thickest part
inferior & lateral
TRAM Flap Before & After
Diep Flap
• Deep inferior epigastric perforator flap
• Muscle sparing, free Tram flap
• Deep inferior epigastric artery and vein are
anastomosed to recipient vessels in the
chest, usually the internal mammary or the
thoracodorsal vessels.
Diep Flap
• Decrease in abdominal wall morbitiy
• Longer surgery time
• Risk – flap failure due to microvascular
thrombosis
Diep Flap
• Tissue expander
Abdominalplasty
• Flattens abdomen by removing excess fat &
skin and tightening abdominal muscles
• Length : 2-5 hours
• Risks: blood clots, infection bleeding under
skin flap
Abdominoplasty
• Incision is made from
hip bone to hip bone
just above pubic area
• Umbilicus is freed
from surrounding
tissue
Abdominoplasty
• Abdominal skin flap is
elevated up to the ribs
• Abdominal muscles
are tightened by
pulling them together
and suturing
Abdominoplasty
• The skin flap is
stretched down and
extra skin removed
• A new hole for the
umbilicus is made
• Umbilicus & skin are
sutured into place
Abdominal Binder
Abdominoplasty Before & After
Botox Injection
• Used to temporarily reduce wrinkles
• Botox is a purified form of botulism type A
• Works by blocking release of acetylcholine
so the muscle does not receive the message
to contract
• Usually lasts 3 months
• Risks: headache, drooping eyelid, paralysis
of neighboring muscles
Botox Injection
Collagen Injection
Skin Resurfacing
• Used to minimized wrinkles and treat scars
& areas of uneven pigmentation
• Length: 1 hour
• Risks: burning sensation, crust formation
for several days, redness for several weeks
• 3 methods: laser, chemical peel,
dermabrasion
Laser
• CO2 laser used
• Best for fine lines
around eyes & mouth
Chemical peel
• Chemical solution
applied to skin to treat
wrinkles, acne scars,
sun damaged skin
• Alphahydroxy-weak
• Trichloroacetic-
medium
• Phenol-strong
Dermabrasion
• Refinish skin’s top
layer through scraping
• Best for coarse
wrinkles and scars
Skin Grafts
• Split thickness (STSG)
contains epidermis &
part of dermis from
donor site
• Full thickness (FTSG)
contains both
epidermis & dermis
from donor site
Split Thickness Skin Graft
• Graft is taken from
large flat body
surfaces (thigh,
abdomen, back) using
a dermatome
• Donor site may be left
open to air or covered
with a non-adherent
dressing
Split Thickness Skin Graft
• Graft may be meshed
to increase area of
coverage
• Graft secured with
suture or staples
Split Thickness Skin graft
Full Thickness Skin Graft
• Graft is taken from
area where scar will
least visible and
provide best skin
match
• Areas include behind
ears, volar elbow
crease, groin area
Full Thickness Skin Graft
• Graft is excised with a
scalpel and underlying
subcutaneous tissue is
removed
• Graft is sutured in
placed
• Donor site is closed
with sutures
Full Thickness Skin Graft
Skin Flaps
• Flaps are detached from one area of the
body and transferred to the recipient area
with original blood supply intact or
reestablished
• Useful for covering exposed bone & tendon
• Used in reconstruction and wound closure
Skin Flap
Mohs Surgery
• Performed to treat basal cell & squamous cell
carcinoma of the skin, performed in clinic or
office
• Specimen is examined microscopically; small
amounts of tissue continues to be removed until
free from cancer
• Differs from frozen section in that the entire
specimen is examined rather than random sections
• Skin defect closed later in the OR
Operation Mend
• Wounded U.S. soldiers receive
reconstructive surgeries thanks to
"Operation Mend" partnership between
UCLA and Brooke Army Medical Center
• http://operationmend.ucla.edu/
• http://youtu.be/HMoX-y6wXNE
Operating Mend
• http://operationmen
d.ucla.edu/