수술 후 진단명: ONFH, hip, Lt. (Osteo-Necrosis of the Femoral Head)
의식수준: Alert
수술서약서 확인: 예
수술 전 투약여부 확인: 예
소지품, 장신구 제거확인: 예
피부준비 확인: 예
금식여부 확인: 예
배뇨, 배변 확인: 예
정맥확보여부 확인: 예
감염여부 확인: HBsAg(-), AIDS(-), MRSA(-), VDRL(-)
수술 전 검사: CBC, ESR, CRP, ECG, Hip X-ray, TTE
(2) 신체사정
(3) 심리사회적 사정
-수술에 대한 불안
-낯선 환경에 대한 두려움
(4) 대상자의 교육계획 작성
날짜
교육내용
11/30
수술 전 수술종류, 목적, 절차 및 소요 시간 수술 전 검사 종류와 목적과 방법 수술실 내부의 환경에 대한 정보 제공 수술 후 기침과 심호흡의 중요성 수술 후 재활의 중요성 수술 후 PCA 사용 방법 수술 후 inspirometer 사용방법 수혈 후 부작용에 관한 정보제공 Line 연결부위 감염 증상에 대한 교육 (발열, 발적, 부종)
12/1
통증 관리에 대한 교육 (PCA 사용법) 수술 후 재활에 대한 교육 수술 후 기침과 심호흡 격려 및 inspirometer 사용법 감염에 대한 교육
2. 간호계획 및 수행
II. 수술 중 간호
(1) 대상자의 수술명
THRA, Lt (Total Hip Replacement Arthroplasty)
(2) 대상자의 수술 중 간호활동
진단명: ONFH, hip, Lt. (Osteo-Necrosis of the Femoral Head)
예정 수술명: THRA, Lt (Total Hip Replacement Arthroplasty)
Under general anesthesia, the patient was placed in the supine position on the
operation table. Foley catheter was inserted. After the anesthesia was obtained, the
patient's position was changed from supine to true lateral position with the left hip
uppermost and right hip downward on the operation table. True lateral postion was maintained with two antetior and posterior lateral bars and one pubic bar. An axillary bar was placed underneath the left axilla. Entire lower extremity including the flank area was prepared and draped in usual fashion. Surgi bi-drape was attatched on the hip to block the incision site off.
The skin incision line was mapped along with posterolateral incisional line with a
marking pen, which was consistent with a minimally invasive posterolateral approach. We began the skin incision proximally at the point level with the ASIS along a line parallel to the posterior edge of the greater trochanter. Incision was exteneded down to the tip of greater trochanter and passed through the midway between anterior and posterior border of greater trochanter and extedned down to the proximal thigh at the level of 5cm distal to the base of greater trochanter.
The skin incision was made with #10 blade knife and the incision was deepened
down to the level of subcutaneous tissue and exposed the fascia lata distally and
proximally. Hemostasis was completed with electrical cauterization and the fascia lata was incised along the skin incisional line with the cutting Bovie. Trochanteric bursa was opened up and the gluteus maximus muscle was splitted along the muscle fiber line. By internally rotating the hip joint, the gluteus maximus muscle insertion to the linea aspera of the femur and vastus lateralis muscle were exposed.
After doing sharp dissection of the arelor tissue overlying the short external rotators and posterior border of the glutues muscle, short external rotators were exposed. Posterior border of the gluteus medius muscle was retracted anteriorly and exposed the piriformis tendon beneath the gluteus minimus muscle. The interval between piriformis tendon and gluteus minimus muscle was developed and the tendinous portion was detetched from the greater trochanteric fossa with a cutting Bovie. And then the short external rotators were detatched from the greater trochanter.
External rotators were peeled off from the posterior hip joint capsule and the Cobra retractor was placed to the inferior portion of the femoral head and neck,
Homann and right angle retractor were placed to expose the proximal portion of the femur.
T-flap was made on the hip joint capsule and posterior hip joint capsulectomy was done followed by cultural study with cotton swab and syringe. Then one awl was inserted to themonitor the leg length before and after the total hip replacement.
Actetabulum was exposed using by cobra retractor, hohmann retractor, and
double2cm from the lesser trochanter and femur head was extracted. Remaining
ligamentum teres, labrum and soft tissue were removed using rongeur and mass.
Acetabular reaming was done.
Porous coated acetabular cup was inserted and impacted. Before then, we added broad-spectrum antibiotics powder underneath the cup component. Cobra retractor
was used posteriorly at lesser trochanter and gluteus medius muscle was retracted
anteriorly by hohmann retractor and femur osteotomy site was exposed by double
hohmann retractor. The medullary canal of femur was enlarged with reaming and
broaching. Calcar and neck portion was reamed with sleeve reamer. Neck trial head was assembled. We checked the ROM and stability after reduction.
After dislocation, trial and broach were removed. After irrigation of femoral canal, femoral stem was inserted. Liner, neck and head were assembled and hip was reduced gently.
Previously assembled intraoperative leg-length measurement device was applied
마취 기록>
The anesthesia machine and medication were checked.
Patient was identified and time-out was performed.
ECG, NIBP, SPO2 and BIS or entropy monitoring were applied and functioned.
Pre-oxygenation with O2 8L/min via facial mask.
IV line function test was done.
Mask ventilation with O2 8L/min for 3min
Intubation & Both lung sound OK, fixed at 19cm.
Teeth: OK, eye protection
Esophageal stethoscope insertion.
일반 후두경으로 기관내 삽관 어려움 (개구제한, 치아손상위험) 예상되어 video laryngoscope (McGrath) 사용하여 intubation 시행함.
08:25 Lidocaine 2% 20ml 2ML
Freefol-MCT 120mg 100MG
Esmeron 50mg 40MG
08:30 Ultiva 1mg 0.2MG
+NS 50ml IV drip
08:35 NS 500mL/bag 500ML 시술용
A-line with 20G at Lt. radial artery by Dr. 원영주 with M.A.T (+)
08:37 Plasma-lyte 1L 1L
C-line with 7Fr. 3 lumen at Rt. IJV by Dr. 원영주
(Film dressing 건조, 부종/삼출/발적 없음)
Hot line apply (장시간 수술로 인한 저체온 방지 & 다량 수혈 위하여 적용함.)
08:40 항생제: Jetiam 1g(삼진) 1G, AST: (-)
NS 50mL/BTL(중외), AST: (-)
08:44 Foley cath insertion
08:47 Position change supine -> Rt. lateral decubitus position
신경손상 예방위해 팔에 Pillow apply 다리에 방석 & Cotton 대어줌 by surgeon 시
행함.
08:48 PhenylEphrine 10mg 0.1MG
08:52 Perdipine 10mg/10mL 0.3MG
09:00 장시간 수술로 저체온 방지 위하여 Air-blanket 적용함.
09:48 PhenylEphrine long(하나) 5MG + NS 50ml IV drip
