Intro to Surgery Flashcards

1
Q

General Indications for Surgery (generally)

A
  • worsening disease processes (medications no longer helping, etc.)
  • pain
  • loss of funtion
  • masses/lesions
  • trauma
  • cosmetic
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2
Q

Types of Surgery
Diagnostic
Preventative
Curative
Pallative
Reconstructive

Approaches to surgery
openv endoscopic v robotic

A

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

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3
Q

Special Considerations for History Taking
- H&P/Consultation
- Social History

A

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

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4
Q

Pre-Op Lab Testing
- for most everyone
- for special populations

A

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.

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5
Q

individuals who may need clearance from the specialist

cardiac

primary care

A

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

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6
Q

Medications to Continue taking before surgery

A

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

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7
Q

Medications to Discontinue the morning of surgery

A

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)

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8
Q

Management of Pre-Op Anti-Coag. Meds

when to stop the following meds
- asprin
- plavix (clopidogrel)
- heparin
- coumain (warfarin)

A

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)

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9
Q

what should be discussed with the pt. prior to surgery
- such as the pre-op oppointment/consulation

A

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

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10
Q

Explain the components of surgical consent

A

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)

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11
Q

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

A

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

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12
Q

Day of Surgery: things to ensure you pt. has done

A

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!!!

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13
Q

Inside the OR: prepping the pt. for the operation

what are somethings that need to happen

indications for foley
prepping (shaving, draping)

A

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!

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14
Q

Types of Prep Used for Surgery
Cholrhexadine
Betadine

A

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)

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15
Q

What goes into a Surgical Time Out

A

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

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16
Q

Post Op
orders to get
what do you do as the PA

A

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

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17
Q

Post Op Pain Management

A

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

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18
Q

Outpt. Surgery = going home with what instructions

Inpt. Surgery = getting admitted with what instructions

A

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.

19
Q

intra/post op changes of physiologic function that you can anticipate

A

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

20
Q

Kelly Clamp

A
  • forceps tool
  • with ridges
  • curved head

good for pinching tissue

21
Q

Crile & Kocher

A

Crile
- forceps
- stright head
- ridges for pinching tissue

Kocher
- forceps
- stright head
- ridges for tissue
- TEETH on the ends to pinch

22
Q

Right Angles

A

Right Angles
- long forceps
- for under the vessel/under tissue
- pull and tie the suture

23
Q

Allis & Schnidt

A

Allis
- forceps
- very sharp end/teeth
- less integrey than the ones with ridges

Schnidt
- curved neck
- forceps (long)

24
Q

Mayo Scissors
Curved Mayo

A

Mayo
- scissor
- for sutures
- slightly blunted edge

Curved Mayo
- scissor for sutures
- curved edge blade

25
Q

Metz Scissor

A

Metz
- longer scissor
- smaller blade
- for cutting tissue

26
Q

Adson’s Forceps
Rat’s Tooth Forceps

A

Adsons
- tweezer looking forcepts
- with teeth: to grab tissue and pick up needles

Rat’s Tooth
- bigger tweezer looking forceps
- same teeth, just larger

27
Q

Debakey Forceps

Bonnie Forceps

A

Debakey
- long forceps: like tweezers
- very thin tip: for grabbing vessels
- NEVER grabbing skin

Bonnie
- bigger, heaveir, widers forceps
- for retracting deeper layers

28
Q

Senn Retractor

Skin Hook Retractor

A

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

29
Q

Army-Navy Retractor

Richardson Retractor

Deaver Retractor

A

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

30
Q

Sharp Rake Retractor

Malleable

Weitlander

A

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

31
Q

needle driver: Webster

A

Webster
- needle driver: holds suture needle
- smallest kind
- not serrated so it ownt break small sutures

32
Q

Electrocautery v Electrosurgery (Bovie)

A

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

33
Q

Electrosurgery
Cut v Burn

A

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

34
Q

Suture Types

A

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

35
Q

Indications for Drains

Types of Drains/Suctions

A

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

36
Q

what is a penrose drain

A

Penrose Drain
- a passive drain system
- thin, rubber tube that is a wick
- helps to prevent/drain and infection

37
Q

JP and Blake Drain
what are they
removal criteria
how to remove

A

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

38
Q

NG Tube
indications for placement
confirm placement

A

NG tube

Indications
- post-op N/V
- feeding
- decompression (Bowel obstruction)

confirm placement with xray

39
Q

Percutaneous Catheter
who places these
type

Foley Catheter
indications

A

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

40
Q

Complications of Drains

A

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

41
Q

Acute v Chronic Wounds
Primary V Seondary Healing
Delayed Primary?

A

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)

42
Q

Possible Complications of Wound Healing

A

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
43
Q

Manging Wounds
options for healing/fixing

A

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