Intro to Surgery Flashcards
General Indications for Surgery (generally)
- worsening disease processes (medications no longer helping, etc.)
- pain
- loss of funtion
- masses/lesions
- trauma
- cosmetic
Types of Surgery
Diagnostic
Preventative
Curative
Pallative
Reconstructive
Approaches to surgery
openv endoscopic v robotic
Diagnostic
- obtaining the diagnosis
- example: biopsy to confirm cancer
Preventative
- prevent a disease process from occuring
- example: prophylatic mastectomy
Curative
- this will remove the problem
- example: gallbladder disease ==> remove the GB
Pallative
- to ease symptoms
- will NOT have any impact on the survival of teh pt
- example: breast reduction for back pain
- example: total knee replacement
___________________________________________
Open: entire cavity open
Endoscopic: instruments inserted through orifces
Robotic: completely done with instruments & robots
Special Considerations for History Taking
- H&P/Consultation
- Social History
H&P/Consult considerations
- current health conditions & how they may impact the surgery, outcome and recovery
Social History
- smoking = impact healing
- alcoholism = constirbute to the disease process
- alcohol withdrawal = imact recovery
- living conditions = impacting to disease process, support when post-op
- occupation: sense of mobility prior to surgery & expectations for afterwards (better, worse?)
- mental health considerations: sometimes surgeyr isnt the best thing
Pre-Op Lab Testing
- for most everyone
- for special populations
goal = to assess the surgical risk & predict/minimize complications
- screen for asymptomatic disease processes (anemia, DM, malnutrition)
- assess status of the pt. current medical conditions to see how that can/will impact healing, surgery, etc. (DM control, HF)
For Most Everyone
- CBC
- CMP
- type & screen
- pre-albumin (detects more acute changes in nutritional status)
Special Populations
- reanl dz. or diuretics? = BMP
- liver dx. = LFTs/PT/INR
- DM = A1c & FS day of surgery
- bleeding d/o or on anticoags = PT/INR, PTT, CBC, T&S
Any woman of Child bearing age = urine BHCG
EKG = for anyone with cardaic complcations, DM, vascualr or renal dz or liver dx.
individuals who may need clearance from the specialist
cardiac
primary care
Cardiac
- history of arrythmias/cardiomyopathy/CAD/valve diseases
- unstable or unworked up cardiopulmonary symptoms
- new changes on EKG
- abnormal EKG with no EKG to compare to
- someone with a KNOWN caridac disease who hasnt had a stress test in the past year
Primary Care
- untreated current illness
- not regularly seeing a PCP
Medications to Continue taking before surgery
HTN: Beta-Blockers & Calcium Channel Blockers
HLD: Statins
antidepressants/anxiolytics
anticoagulants (if they are low bleeding risk: this depends on type of surgery and the pt.)
Insulin
- take 20-50% of their long-acting dose the night before surgery
Medications to Discontinue the morning of surgery
HTN: ACE/ARBS or Diuretics
DM:
- Metformin
- Prandial Insulin (they’re not eating)
- SGLT-2 inhibitors : these need to be stopped FOUR days before (risk of UTI and ketoacidosis is high)
Management of Pre-Op Anti-Coag. Meds
when to stop the following meds
- asprin
- plavix (clopidogrel)
- heparin
- coumain (warfarin)
always talk to prescribing provider if questions or a high risk bleed surgery
Asprin: stop 5 -7 days before
Plavix: stop 7-10 days before
Heparain: stop 6 hours before
Coumadin (Warfarin): stop 5 days before & bridge with lovenox (LMWH)
what should be discussed with the pt. prior to surgery
- such as the pre-op oppointment/consulation
Things to be discussed
- risks
- common complications (like bleeding, pain, etc. & how to manage them)
- recovery process: no driving, etc.
- time from work off
- drains and management
- activity restrictions: exercise, showering, swimming
- how much additional help (should someone stay with them)
- expectations of surgery pain free? back to baseline?
- pre-op medication management should be a big discussion here
Explain the components of surgical consent
Surgical Consent: can be obtained from the PA
BY LAW: must discuss risks, alternatives to surgery and obtained an informed consent from the pt
- sometimes in emergency, this is bypassed
Components of Informed Consent
- indications for operation
- expected outcome
- alternatives
- expected process of disease if surgery is not persued
- details of the operation
- potential risks
- impact on health and QOL
- extent of recovery
- timing to normal activity
- residual effects (long term)
Orders to be obtained Pre-Op
(standing orders: things that should be waiting to be done on the day they arrive for the operation)
Individualized or other commonly obtained orders
Standing Orders
- Vitals
- IV access
- NPO
Individualized other others can include
Fingerstick (any DM pt.)
BHCG (any woman)
Antibiotics (if needing prophlayctic) : facility specific ones:
- Cefazloin (Clindamycin if PCN allergy)
VTE prophylaxis:
as deterined by the CAPRINI Score: determines what type of prophylaxis you need to do
- early ambulation, mechanial prophalyxis (compression leg) and chemcial prophylaxis are all the options
- always weigh the ris fo DVT/PE to the risk of bleeding
Day of Surgery: things to ensure you pt. has done
NPO after midnight
- clear liquids ok up to 2 hours before
- no meals within 8 hours
- okay to take appropriate meds with a sip of water
Pre-Op Holding Area: things to ASK and DOCUMENT
- vital signs
- mark the pt. side of surgery, etc. with initials, date and time
- review consent forms
- ensure anesthesia will meet them
always make them feel at ease!!!
Inside the OR: prepping the pt. for the operation
what are somethings that need to happen
indications for foley
prepping (shaving, draping)
Anesthesia
- will induce and intubate the pt.
- will administer abx.
Patient Positioning: PA
- putting the pt. in the proper position for the appropriate surgery: supine, prone, lateral decubitus
- always remeber your pressure points: elbows, knees, etc.
Foley?
- Indications: 3 hour+ surgery, epidural in place or limited mobility post-op
- always consider if it is necessary, risk of UTI is high
Prepping
- shave with clippers
- clean the surgical area (betadine, chlorhexadine)
then you would go get sterile
Draping
- towels (fold with fold underneath & place the part closest to the sit first)
- drapes (hold above the pt. first spread out then place
surgical time out!
Types of Prep Used for Surgery
Cholrhexadine
Betadine
Chlorhexadine
- NO OPEN WOUNDS
- leave it for 3 minutes before you drape
- do NOT wipe off: it will evaporate
- cannot be used on hair-bearing skin
- comes on a stick: 8x8 vigourous rub
Betadine
- can be used on a open wound and within
- no wait time needed
- wipe off the pt after: otehrwise they’ll be itchy
(always clean from cleaniest to dirtiest)
What goes into a Surgical Time Out
Right before first cut….
Anestheiologist
- reads off pt. name, MRN and what meds have been given
Surgeon
- procedure to be done
- postion of the pt.
- laterality of the operation (L or R)
Circulating Nurse
- consent signes, confirmed eqiptment in the room
- fire risk (prep site dried), eveyrone agree
Post Op
orders to get
what do you do as the PA
Post-Op
- pt is brought to the PACU by you and the anesthesiologist
Post-Op Orders
- vitals/monitoring
- pain meds
- diet instructions (NPO, clears?)
- discharge v. admit
Provdie Sign out
- fill the nurse in on all the above information
- also include everything in your post-op note including,..
- name, procedure, complciations, how they were closed, dressings, drains, labs/imaging neeeded from PACU, where the pt. will go
Post Op Pain Management
Non-opioid (try to maximie this therapy)
- Ketorolac: IV NSAID (good for the PACU)
- acetaminophen (max 3-4g/day): give 1,000 mg Q8H
- ibuprofen (600mg QID ?)
Opioids
- oxycodone
- morphine
- acetaminophen-codeine
want to try to get them on oral meds asap
Outpt. Surgery = going home with what instructions
Inpt. Surgery = getting admitted with what instructions
Outpt. = going home (write these down and make sure nurse tells them too)
- care instructions for surgical site
- care for drains
- diet
- weight bearing?
- warning signs/when to call & number to call
- where/when to follow up
- Rx. needed
- contanct # with questions
Inpt. = getting admitted
- pain control
- monitoring (EKG? FS? etc.)
- diet: tolerating? etc.
- bowel function
- urinary function
- consults neede d
- post-hosptial placement (rehab?)
then d/c from inpt. with the following as the outpt.
intra/post op changes of physiologic function that you can anticipate
anticipate = able to better treat afterwards
Volume Depletion
- bleeding, under-resuscitation of fluids = can lead to hypotension, AKI, tachycardia or low urine output
post-op Changes
- bleeding
- NG tube
- vomiting/diarrhea
these lead to volume loss and electrolye issues and vitals issues
Kelly Clamp
- forceps tool
- with ridges
- curved head
good for pinching tissue
Crile & Kocher
Crile
- forceps
- stright head
- ridges for pinching tissue
Kocher
- forceps
- stright head
- ridges for tissue
- TEETH on the ends to pinch
Right Angles
Right Angles
- long forceps
- for under the vessel/under tissue
- pull and tie the suture
Allis & Schnidt
Allis
- forceps
- very sharp end/teeth
- less integrey than the ones with ridges
Schnidt
- curved neck
- forceps (long)
Mayo Scissors
Curved Mayo
Mayo
- scissor
- for sutures
- slightly blunted edge
Curved Mayo
- scissor for sutures
- curved edge blade
Metz Scissor
Metz
- longer scissor
- smaller blade
- for cutting tissue
Adson’s Forceps
Rat’s Tooth Forceps
Adsons
- tweezer looking forcepts
- with teeth: to grab tissue and pick up needles
Rat’s Tooth
- bigger tweezer looking forceps
- same teeth, just larger
Debakey Forceps
Bonnie Forceps
Debakey
- long forceps: like tweezers
- very thin tip: for grabbing vessels
- NEVER grabbing skin
Bonnie
- bigger, heaveir, widers forceps
- for retracting deeper layers
Senn Retractor
Skin Hook Retractor
Senn Retractor
- has like a curved fork shape on one end
- other end is like a retractor flat
Skin Hook
- like a long fish hook with a sharp point
Army-Navy Retractor
Richardson Retractor
Deaver Retractor
Army-Navy Retractor
- the retractors curve the same way
- one bigger than the other
RIchardson
- big handle with larger retractor
- for abdominal surgery
Deaver Retractor
- wide, big retractor looks like a shoe horn tbh
- abdominal surgery
Sharp Rake Retractor
Malleable
Weitlander
Sharp Rake
- literally waht it sounds like
- sharp curved fork
Malleable
- a flat piece of metal
- used to protect body from sutureing puncture
Weitlander
- a self retracter
- two forks curved
needle driver: Webster
Webster
- needle driver: holds suture needle
- smallest kind
- not serrated so it ownt break small sutures
Electrocautery v Electrosurgery (Bovie)
Electrocautery
- current passes through a wired loop (closed circuit) with resistance within its own circuit causes electrical energy = heat is released
- the heat cautehrizes the tissue
- this is very very localized, small and microscopic precisions
Electrosurgery (the Bovie: but they called it cautery)
- high-frequency (radio) and electromag. waves (not heat) to send the waves which prodcue heat and destroy the tissue around it
- this sends electical current through the pt. so you need a grounding pad on the pt!!!
Bipolar Circuit: an electrosurgery current which doesnt need a ground as it circles back to itself
Electrosurgery
Cut v Burn
CUT (yellow button)
- the tip of the tool just ABOVE the tissue
- produces heat in a small area & cuts with minimal bleeding
COAG
- intermittent electical spikes
- producing less heat, but enough heat that it denatures the cells and coagulates them and controls local bleeding
Suture Types
Subcuticular (dissolvable)
- Vicryl (braided) = scarpa’s and deep dermal
- Monoderm (Biosyn) = deep dermal/running subcuti.
Skin (need to remove)
- Polene (blue)
- Nylon (black)
- simple inturrupted, running and vertical mattress
Indications for Drains
Types of Drains/Suctions
Drains
- drian out any fluid from the potential space created in the surgical site
- blood, serous fluid or purluent fluid can be drained (always document)
- prevents seroma, hematoma and infection
Types
Passive Drains
- Penrose
- Percut. drain
- Foley Cath.
Closed Suction
- Jackson-Pratt (JP) drain
- Blake
Wall Suction
- NG tube
what is a penrose drain
Penrose Drain
- a passive drain system
- thin, rubber tube that is a wick
- helps to prevent/drain and infection
JP and Blake Drain
what are they
removal criteria
how to remove
JP and Blake Drains = clsoed suction drains
- rubber tubes attached to a deflated bulb
- close suction: you squeeze the bulb and the vaccum pulls fluid out
removal criteria
- removed 1 at a time when the output is < 30 cc for two days in a row
JP drain = has the white piece inside, blake doesnt
Removal
-remove the suction
- remove the stich
- pull, fast
- place a dressing
NG Tube
indications for placement
confirm placement
NG tube
Indications
- post-op N/V
- feeding
- decompression (Bowel obstruction)
confirm placement with xray
Percutaneous Catheter
who places these
type
Foley Catheter
indications
Percutaneous Catheter
- placed into known collection of fluid via IR
Type
- most common = pigtail cath.
Foley Catheter
Indications
- procudeure > 3 hours lon
- those who need accurate urine long
- epidural placed
- lminited mobility after the surgery
careful with surgical technique, UTI risk is common
Complications of Drains
Clot/Clog
- strip(pinch and milk) or flush to help fix this
Accidental Removal
- restich under local or re-insert drain (IR)
Pt. Fails to record output
- educate on the importance!
Early Removal by Provider
- need to weigh the risk of fluid collection and complications aossciated with not having a drain
Acute v Chronic Wounds
Primary V Seondary Healing
Delayed Primary?
Acute
- occured in recently healthy, noncompromised tissue
- healing is reliable: 6-12 weeks
- surgical wounds are mostly this
Chronic
- tissue repair prolonged and pathologic
- the healing process is altered because of inflammatory processes
- infection, chronic irritation, tissue hypoxia is a cause
Primary Healing
- tissue is cleanly incised and anatomically reaprroximated
- this is surgical closure
Secondary Healing
- wound left open to heal through formulation of granulation tissue and epithelilization
- burns, infected wounds and bites are usually left to heal this way
Delayed Primary Closure
- a wound is left open for some time in a clean environement, then closed through primary agents
- this allows ideal environment for healing to be achieved (like infection gone)
Possible Complications of Wound Healing
Complications : why would it be delayed in healing?
- impaired perfusion to the location/ inadequate oxygenation to the area (think PVD, smokers, diabetics, paraplegics)
- dysregulated inflammatory process: anti-inflammatory corticosteroids, immunosupp. chemo
- malnutrition: healing needs protein synthesis! pt. weight loss and decrease albumin/prealbumin is a warning signs
- wound infection
- mechanial would failure: suture poorly
Manging Wounds
options for healing/fixing
Primary Healing
- sutures
- dressing for 2 days+
- keep it clean and protected
Secondary Healing (or delayed priamry)
- dressing: wet to dry is the most common: moist mechnial debridement
Negative Pressure Wound Therapy
- reduces edema, improves perfusion and promotes healing
