1 Periop & Wounds Exam Flashcards
Postop Complications - Respiratory
hypoventilation –> atelectasis –> PNE
Postop Complications - Respiratory
hypoventilation
- respiratory acidosis
Postop Complications - Respiratory
atelectasis
- dyspnea, tachypnea, reduced breath sounds, asymmetrical chest movement, increased restlessness, tachycardia
- Ix: DB&C, IS
Postop Complications - Respiratory
pne (infection)
- rapid & shallow respirations, fever, wet breath sounds, asymmetrical chest movement, productive cough, hypoxia (& cyanosis), tachycardia
- infection –> check CBC for increased WBC, CXR, ABG, sputum stain
Postop Complications - Respiratory
PE
- chest pain, dyspnea, pleuratic pain & cough, increased RR, tachycard, increased anxiety, diaphoresis, reduced orientation, reduced BP
- Ix: CXR
Postop Complications - Cardiac
hypovolemic shock
- too little circulating blood volume
- common problems: hemorrhage, dehydration
- FLUID LOSS, inadequate perfusion
- changes in mental status & behavior (early), increased HR (early), decreased urine resp alka + meta acidosis, increased BUN, sodium, alkaline, phosphate, and creatinine, decreased H&H
Assess: VS, pulse, heart & bowel sounds, cap refill, SpO2
Give: Lactate ringer or normal saline - primary, O2, blood
Postop Complications - Cardiac
Dysrhythmias
ensure K levels are therapeutic prior to surgery
Postop Complications - Cardiac
Sepsis
Infectious organisms have entered blood stream temp 100.4 RR >20 HR >90 WBC over 12,000 or >10% bands
Call RRT!
Postop Complications - Skin
- pressure ulcer
- wound infection: Acute: fever, warmth, edema, pain, purulence, erythema; Chronic: delayed healing, change in color of wound bed, absence or abnormal granulation tissue, increased odor, pain, drainage
- dehiscence - separation of incision
- evisceration - bowel thru incision, increased pain
Postop Complications - GI
- paralytic ileus: decreased bowel sounds, no stool or flatus, N/V, distension, tenderness of ab, Expected w/in first 24 hrs so don’t assess
- Ix: delay solid foods, increased activity, zofran for N/V, listen to bowel sounds after 24 hrs
Postop Complications - GU
- UTI
- RTN - unable to void for 8-10 hrs, palpable bladder, frequent small amt voiding, pain suprapubic area.
- Monitor I&O q4h, H&H, Bun & Creat, IV fluids, report UO <30 mL.
Risk factors for postop complications
age
certain meds - anticoags, nsaids
med history - diabetes, anemia, dehydration, HTN
prior surg experiences - previous complications
Health Hx: malnutrition, obesity, drugs, alcohol
Family Hx: malignant hyperthermia, cancers, bleeding DZ
Risk factors for elderly - CV
decreased CO, increased BP, decreased periph circulation → monitor and know baselines
Risk factors for elderly - Resp
reduced vital capacity, loss of lung elasticity, decreased oxygenation of blood → monitor and know baselines, pulmonary exercise
Risk factors for elderly - Renal
decreased blood flow to kidneys, reduced ability to excrete waste products, decline in glomerular filtration rate, nocturia → monitor IO & electrolytes, assess hydration, frequent toileting
Risk factors for elderly - Neuro
sensory deficit, slow rxn time, decreased ability to adjust to changes in surroundings → orient, allow time, ptn safety, baselines
Risk factors for elderly - MSK
increased incidence of deformities R/T osteoporosis and arthritis → assess mobility, teach turning & positioning, encourage ambulation, falls precaution
Risk factors for elderly - Skin
dry + less fat = greater risk for dmg; slow skin healing = risk for infection → assess before surgery for lesions, bruises, decreased circulation areas; pad bony prominences, avoid applying tape, turn q2h
greater incidence of chronic illness and malnutrition, more allergies, increased incidence of impaired self-care abilities, inadequate support systems, decreased ability to withstand the stress of surgery and anesthesia, increased risk for cardiopulmonary complications after surgery, risk of change in mental status when admitted (R/T unfamiliar settings, change in routine, drugs), increased risk of falls and resultant injury
Malignant hyperthermia
S/S
- Tachycardia – nonspecific early sign → of a lot of problems, in it of itself not specific
- Hypotension
- Muscle rigidity, especially jaw and chest
- Temp up to 111.2—late sign
Treatment—dantrolene (muscle relaxant)—if known pre-op, can be given prophylactically
When do you not give negative pressure wound therapy?
- inadequately debrided wound
- necrotic tissue w/ eschar
- osteomyelitis
- cancer in wound
- exposed vital organs
Ptns at risk for wound complications w/ wound vac
- those on anticoags
- those who have had vascular grafts or infected wounds
Why would a wound dehisce spontaneously
- infection
- hematoma
- mechanical stress
- poor blood supply (ischemia)
- edema
- malnutrition
Why would a wound be left open intentionally?
- edges cannot approximate
- wound is infected
Reasons for dehiscence (5)
- infection
- hematoma (ideal medium for bacteria to colonize)
- poor nutrition - lack of collagen - lack of strength in wound
- poor vasc supply (PVD, edema, anemia, smoking)
- mechanical stress (sutures inappropriately tight, obesity, edema, location)
Risks for dehiscence
- age
- comorbidities
- malnutrition (dehydration)
- meds (steroids, chemos, )
Types of documentation
- etiology (cause)
- anatomical location
- wound size
- tissue type
- pain
- exudate
- odor
- surrounding skin
Why is it important to document?
- to prove that wound was assess
- to inform colleagues of assessment
etiology
type of surgery undertake and reason wound is now open should be determined as it will influence type of care
ex: dehisced due to poor nutrition –> increase nutrition - proteins & vitamin C
Wound size
measure and record
sinuses (sacs or cavities)
fistulas, abnormal conditions
undermining
tissue type
tissue type measured in percentages
- epitheliazation, granulation, slough (subq fat and msk degen), eschar (full-thickness tissue loss)
pain
no sudden increase of pain
should be addressed before, during, and after
painfree
Exudate
too much or too little is bad
moist healing is best
excess high = infection, sinus or fistula, poor choice of dressing
excess Low = ischemia, dehydration
Surrounding skin
- maceration (white soggy wet tissue - too much exudate, change dressing more frequently)
- dry and scaly skin - need more moist
- excoriation
Edema
- fluid rtn
- encourage mobility, raise extremities, joint exercises
- do wound swabs only when there is an infection
5 classic symptoms of inflammation
- Redness (rubor )
- Edema (tumor )
- Heat (calor )
- Pain (dolor )
- Loss of function/immobility
shift to the L vs shift to the R
L: acute –> neutrophils –> VS are more affected
R: chronic –> monocytes
you have inflammation - how do you know it’s infected?
- are they at risk for infection? immunocompromised, elderly, steroid users, uncontrolled diabetes, type of surgery, transplant ptns, chemo ptns
- look for VS trends
- diagnostics - shift to L but also will need CBC (wbc), C&S
What do you assess when you assess a wound?
circulation distal to wound
Primary wound healing
incision closed
heals from outside in
advantages: less infection,
disadvantages: possible foreign material or bacteria in wound
dehiscence & evisceration
when does dehiscence and evisceration occur postop?
5th & 10th days
what is a partial thickness wound?
- can heal independently
- skin tear vs deep partial thickness
- damage to epidermis & partial loss of dermis
- painful due to exposed nerve endings; raw & red base or pale moist base
- requires regen of skin
- no slough or eschar
what is a full thickness wound?
- complete loss of dermis, extends to fascia, subq and or msk and bone
- requires connective tissue repair
- (stage 3 & 4 pressure ulcers)
- will not heal w/o interventions
granulation tissue
- beefy
- moist
- indication of healing
- starts 4 days after wounding and lasts 4 days in acute wounds
- proliferative phase
secondary wound healing
left open, heals from inside out
use it for tissue loss, infected wounds, or tissue can’t come together, chronic
disadvantage: longer time to heal, more scar tissue, increased rate of infection
4 stages of wound healing
- inflammatory - good blood supply & oxygenation
- destructive phase - phagocytic cells clean out tissue
- proliferative phase - fiberblasts and granulation
- remodeling phase
dehiscence and evisceration interventions
bedrest and least strain on wound
evisceration - cover w/ sterile shit
call DR for both- med emergency
safety features to prevent infection
coordinated care
strict surveillence for infection
Treat w/ antibiotics
sterile technique
7 principles of wound healing
- Remove/debride necrotic tissue. Except bony prominences like heels
- Maintain clean, moist wound surface.
- Identify and treat infection (culture & signs of infx)
- Fill dead space
- Absorb exudate.
- Insulate wound surface.
- Check healing wound for trauma & bacterial infection (transparent film)
Dressings from least to most absorbent
- gauze
- absorbent clear acrylic & hydrocolloids
- alginates & hydrofiber
- foams
- pouching
Wound assessment
- review ptn chart to see whether it’s open or closed
- type of wound healing - primary vs secondary
- indirect assessment if 1st dressing - detect pain or swelling, moisture, drainage, bleeding - if frank bleed, call dr ASAP
- remove outer dressing & inspect
- inspect suture line (clean, well-approximated, possible w/ crusts. inflamed swollen outer edges for first 2-3 days only. bruised-looking skin around suture line)
- look for necrotic tissue
- palpate wound. if there is drainage - know color, consistency, amount
- measure wound
- Redress
- document
Types of debridement (4)
- autolysis
- enzymatic debridement
- biological
- sharp/surgical debridement
