Nancy Lowrey, RN, Barbara L Taylor, RN

Nursing care of the acoustic neurorna patient The operating room nurse’s care of the patient with a n acoustic tumor is most challenging. The patient i s in t h e nurse’s care the majority of the day of operation-8 to 12 hours-and his apprehensions are understandable. The OR nurse must insure a sense of belonging for the patient in the secluded world of the operating room. During the preoperative assessment interview with the patient and his family, the OR nurse can discover and assimilate the personal, emotional, and

Barbara L Taylor, RN

Nancy Lowrey, RN, is staff nurse in the operating room, Trinity Lutheran Hospital in Kansas City, Mo. She is a diploma graduate of Methodist Medical Center School of Nursing in St Joseph, Mo. Barbara Taylor, RN, is staff nurse in the operating room, Trinity Lutheran Hospital in Kansas City, Mo. She received her BS in nursing from Northwestern State University in Natchitoches, La.

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nursing needs of his or her patient. Adequate time should be allotted for the interview because it is important to achieve the patient’s full trust in the competency of the surgical team. The nurse discusses the major points of the operation with the patient and his family. The patient is told the purpose for thromboembolitic deterrent hose, which a r e fitted preoperatively and kept in place throughout the procedure. Because of the length of the operation, anesthesia, and postoperative bedrest, the hose will aid in achieving adequate lower extremity circulation. The nurse explains that an indwelling urinary catheter will be inserted for monitoring and assuring normal output and that it will be removed as soon as possible after the procedure. He or she also discusses the need for the shave preparation. The patient is told that his head and abdomen will be prepared in the operating suite before entering the operating room because of the need to minimize excess and undue contamination from loose hair. At Trinity Lutheran Hospital in Kansas City, Mo, we use a photograph of the operating room setup to explain the equipment the patient will see on entering the OR: the operating table, microscope, anesthesia machine, electrocardiogram monitor, cautery machine, nitrogen tank, and irrigating solutions. Our institution also uses a videotape system for instruction and further edu-

AORN Journal, May 1978, Vol27, No 6

cation, and the presence of this console is also explained t o the patient. Anesthesia should be discussed briefly by the OR nurse, who explains the intravenous mode of medication and the fact that the patient may be asked t o demonstrate signs of facial nerve competence such as blinking, moving his cheeks, or showing his teeth. The patient may also expect a visit from a n anesthesiologist, who will explain in greater detail the preoperative medication, the type of anesthesia planned, and the method for induction. During the preoperative interview, we also encourage the patient to remove all jewelry, dentures, and personal belongings and give them to a family member before the operation. On occasion, due t o religious preference, a patient may want t o take a rosary or bible to the operating room. While we discourage this, its importance to the patient may supersede operating room regulations. In any instance, immediately following induction, we remove the article from the operating room, label it, and give it directly to the patient’s family. The patient’s apprehensions understood and many alleviated, the nurse should leave his or her patient after the preoperative interview with an air of reassurance and trust in his team. At this time, the nurse checks the patient’s hospitalization record for results of all preoperative diagnostic tests and laboratory work as well as allergies to medication. On the day prior to surgery, the nurse again visits the patient to reassure him that he or she will be with him in the operating room and remain with him throughout the entire procedure. We encourage the patient to ask any questions he may have, no matter how unimportant or trivial they may seem to him. Patients often ask, How much hair will be shaved off! Where will I wake up? What will all the wires mean? On

the morning of surgery, while the unit nurse is preparing the patient for transport to the surgical suite, the operating room nurse relays his or her knowledge of the patient to the operating team assigned to his care. In our institution, an orderly transports the patient from his room to the OR suite holding area. The circulating nurse greets the patient and remains constantly with him throughout the surgery and entrance into the intensive care unit. The patient’s record is thoroughly checked and reaffirmation is made of the affected side. Assembled on a small table are items needed for skin and shave preparation of the area; razor, scrub brush, lubricant, tincture of benzoin, cotton-tipped applicators, and two surgical adhesive plastic incise drapes (cut in half). The shaved area should include an area about three fingerbreadths around the affected ear. The scrub brush coated with lubricant is used to comb the remaining hair away from the operative area. Tincture of benzoin is then swabbed on the peripheral edges of the prepared site. After an appropriate drying time, the surgical adhesive plastic incise drapes are placed with overlapping corners to square off the surgical area. By this time, the anesthesiologist has readied all supplies needed and awaits the patient’s entrance into the operating room. The patient moves to the operating table with some assistance and all possible efforts are made to insure his comfort and confidence. The anesthesiologist begins the intravenous fluids with a large bore catheter to enable blood transfusions and a lasting patent pathway for all medications. The nurse secures pads and leads for electrocardiogram monitoring, which is of utmost importance. An accurate check for pressure points and good body alignment is necessary prior to and again following

AORN Journal, M a y 1978, V o l 2 7 , No 6

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icrofibrillar collagen should be available for prompt hemostasis.

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induction of anesthesia. This should include a supine position with a r m s tucked in at the patient’s side and the head placed in a foam donut with the affected e a r up a f t e r i n t u b a t i o n . Ophthalmic ointment is applied to the cornea, after which the lids are taped shut. A cautery pad is secured to the anterior aspect of the thigh and a n indwelling catheter with urimeter is inserted, readily visible to the circulating nurse and anesthesiologist. If a local anesthetic for hemostasis is t o be used, it is injected prior t o the skin preparation. The surgical site is scrubbed for ten minutes with a povidone-iodine scrub, followed with povidone-iodine solution and alcohol paint. The lower left quadrant of the abdomen is shaved and scrubbed in a similar manner to be used for adipose tissue removal. Two circulating nurses a r e necessary to accomplish the nursing care and reduce anesthesia time. Following the draping procedure, the scrub nurse will hand off the following to be connected: the suction tubings, the irrigating solution lines, the drill hose, and the cautery cord. With the operation in progress, the circulating nurses must be aware of the importance of continued surveillance of the patient and the surgical team. They must anticipate and have available ample supplies of nitrogen for the drill and fluid for irrigation. It is not uncommon to use four 2,000 psi tanks of nitrogen and 8,000 cc

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of irrigant. The surgeon may request slight l a t e r a l repositioning of t h e operating table during the procedure. Microfibrillar collagen should be readily available since it has proven quite effective i n accomplishing prompt hemostasis. Throughout the procedure, the family is kept notified and informed of the patient’s progress. They should be aware t h a t a great deal of operating time, sometimes as many as six hours, will be needed in approaching the acoustic tumor. The surgeon’s choice of dressings applied to both the head and abdomen, emergence from anesthesia, awareness of facial nerve competence, and transport to the intensive care unit should be accomplished with gentle ease and care. After many hours, the patient wakes to a strange, cold environment. Warm blankets and a soothing, reassuring voice many times makes this emergence less traumatic. A variety of nursing care plans are necessary for the postoperative care of the patient with acoustic tumor. A s in all postoperative patients, vital signs must be strictly monitored. An elevation in temperature could be alleviated by cooling measures, such as alcohol and ice packs in conjunction with the use of antipyretics. A rectal temperature above 101 F should be reported t o the surgeon as increased temperature could indicate brainstem irritation. While respiratory complications are

AORN Joirrrinl. Mnv 1978, \701 27, No 6

not specific to the recovery of the patient w i t h acoustic t u m o r , n u r s i n g care should include equipment for intubation and possible tracheotomy. Codeine may be successfully used for pain due t o its nondepressive respiratory effects. Postoperative hemorrhage should be closely observed, dressings reinforced, and the physician notified of excess drainage. Since restlessness could also indicate hemorrhage, the nurse should not depend solely on overt symptoms. The otological tray is kept at the bedside in the event the surgical incision needs reopening. The severity of all neurologwal cases necessitates close observance of signs of increased c r a n i a l pressure. Strict neurological checks include level of consciousness, pupil reaction, hand grasps, and movement of extremities. Any variance should be immediately reported. While conducting the neurological check, the nurse might observe facial nerve competence. To inspect the potential loss of function, the patient is requested to wrinkle his nose, pucker his lips, close his eyes tightly, smile, and stick out his tongue. A dripping in the back of the throat may be indicative of postoperative cerebrospinal fluid leak. Since cerebrospinal fluid has a high glucose level, tape to test this level may be used initially to identify the drainage. In this strange environment and surrounded by multiple monitoring equipment, the patient must be considered a s a n individual with specific needs. Competent nursing care, constant reassurance, and explanation will provide the patient with the best qual0 ity care.

Radiation acne treatment and thyroid cancer Improperly administered radiation treatment for acne may cause thyroid cancer years later, according to a report in Archives of Dermatology. Two Chicago physicians report that of their patients who had been treated with radiation for acne, 60% later developed thyroid cancers. The interval between the radiation treatment and development of the cancer ranged from 9 to 41 years. Edward Paloyan, MD, and A M Lawrence, MD, of Loyola University Stritch School of Medicine and the Veterans Administration Hospital at Hines, Ill, stress that radiation therapy for acne, properly handled, is safe. Radiation therapy is usually administered in small, carefully controlled doses and has been regarded as an effective, safe, and justifiable treatment in selected cases, such as potentially disfiguring and emotionally disabling severe cases among adolescents and young adults. The patients are selected carefully for treatment, which is administered by qualified dermatologists. Unofficial estimates are that more than a million adolescents have been exposed to radiation for the treatment of acne, they say. ' Unfortunately, many patients were treated in 'institutes' and not under the supervision of a qualified dermatologist. As a result, there is no information in many instances regarding the administered dose, the energy and penetrance of the x-rays, the calibration of the equipment, and the shielding of other parts of the body," say Drs Paloyan and Lawrence. Fortunately, thyroid cancer is highly treatable and is seldom fatal. The thyroid gland, when cancerous, is removed by surgery. The patient then takes a regular thyroid supplement. It is possible that the association of thyroid cancer with previous radiation treatment for acne is purely coincidental, the physicians point out. But the 60% incidence of cancer in this group is commensurate with the incidence in patients who received radiation for the treatment of tonsillitis.

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Nursing care of the acoustic neuroma patient.

Nancy Lowrey, RN, Barbara L Taylor, RN Nursing care of the acoustic neurorna patient The operating room nurse’s care of the patient with a n acoustic...
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