Lecture 4: care of surgical pt Flashcards
pre-op
- same day surgical admission (“elective”)
- emergency
intra-op
- operating rm
- ambulatory
post-op
- post anesthesia recovery (PACU)
- ambulatory
- admission to hospital
diagnostic surgical indication
just go to see what’s happening. Often written on their diagnosis, determining presence or non-presence of pathological abnormality. (endoscopy or colonoscopy). Can send a biopsy as well. Can be coupled up with exploration surgery.
cure or repair surgery
obviously to do this (appendicitis removal and whatnot, hip replacement), cleft pallet?
palliation procedure surgery
some cancers may be relieved with surgery, ostomy so you aren’t continuously vomiting is an example.
prevention surgery
Bilateral mastectomy if you are more high risk for breast cancer.
exploration surgery
going exploring to look at extent or presence of disease.
cosmetic improvement surgery
Rhinoplasty in the cosmetic sense, breast reduction also cosmetic sense, breast augmentation, liposuction, tummy tuck
pre-op assessments
- consults or diagnostic testing
- assess medical regime, emotional status & physical assessments if indicated
- review past medical diagnoses and surgical procedure
- review prescribed meds
Allergies
Call talking about what is going to happen - what the day will look like for the pt (what you can expect) and gather information regarding their medical conditions
Baseline vitals
Basic bloodwork
How they handle anesthesia
Diagnostic testing: MRI, ultrasound, x-ray, echo, ecg (baseline imaging so they can estimate what it’ll look like when u get in there)
Substances: caffeine, alcohol, etc.
Reviewing PMH and past surgeries
Knowing what medications they are on
- For ex: anticoagulants - may need to stop them up to 7 days in advance because we don’t want them to bleed out
pre-op education
- protocol for routine meds before surgery
- which meds to stop before surgery
- NPO instructions
- pain management options
- infection prevention and wound care
- post-op discharge and care
Use medical directives to figure out what the hell were doing
- Make the decisions on their own on what medications they are stopping, what they are taking, etc. the day of their surgery.
NPO before surgery -> to reduce the risk of aspiration during surgery
If stomach is full and people stick stuff down your throat you will vomit into you lungs and aspirate
People can have clear fluids up to 2 hrs before procedure -> but very surgeon dependent.
Give pt some pain reduction options, as well as infection prevention and wound care.
Give them realistic expectations for recovery. As well clear expectations of what life after their surgery will look like.
Using teach back methods.
pre-op day of surgery assessment
- pre-op checklist
- confirms consultations are completed
- identifies any changes in physical assessment
- establish baseline data
- review pre-op diagnostic tests
- review meds
- consider cultural considerations
- consent ability
pre-op considerations
- allergies
- sys assessment
- fluid and electrolyte status
- nutritional status
- labs and diagnostic tests
ASA 1 classification
healthy, non smoking no to minimal alcohol intake
ASA 2 classification
mild disease, minimal functional limitations (smoking, social alcohol intake, pregnancy, obesity, controlled diabetes)
ASA 3 classification
substantial functional limitations w one or more moderate to severe diseases (uncontrolled diabetes, MI, CVA)
ASA 4 classification
recent (<3 mo) MI, CVA, sepsis, acute resp disease
ASA 5 classification
ruptured abdominal aortic aneurysm, massive trauma, ischemic bowels
ASA 6 classification
brain-dead pt
organs being removed for donation
what is an open approaches
has incision, cutting them open (hips, knee surgeries)
- otomoy (big incision)
laparoscopy
I put little holes in you and instruments thru the holes
robotic approach
blue circle claws, almost looks like they are knitting and there’s foot peddles. Can use slicer, scope, etc. and can switch thru the robot.
less big incision perks
shorter stay, less risk of infection, less pain, better mobility (decrease risk of DVT, pneumonia, and a lot of post-op complications).
General anesthesia classifications
- IV or inhalation
- opioids, benzodiazepines, and antiemetics
General anesthesia: you have a breathing tube and are on a ventilator. Breathing on your own may be difficult afterwards Do they have respiratory issues?
Risk of underinflating his lung: alveolar collapse, atelectasis, post-op pneumonia
Overinflation: pneumothorax, lung burst
local anesthesia
- variety of routes
Local anesthesia into a nerve = regional anesthesia
regional anesthesia ex
spinal, epidural, nerve
procedural anesthesia
sedatives w or w/o analgesia
clinical events in the operating room (3)
- anaphylactic reactions
- malignant hyperthermia
- excess blood loss
anaphylactic reactions of anesthesia
- Your pt is asleep so hard to tell
- Hypotension, hypoxia (more normal things for being suppressed under sedation so difficult to tell)
Pts are given so many things so hard to tell what they are reacting too
- Hypotension, hypoxia (more normal things for being suppressed under sedation so difficult to tell)
malignant hyperthermia
- Metabolic disease
- Hyperthermia with rigidity of muscles
- Genetically receptible
- Usually triggered by sestible colleen (idk how to spell)
- Unnoticed causes cardiac death
Biting down on the tube is the first symptom - muscle rigidity
excess blood loss
Whether to resuscitate pt with fluids or blood is MD call
post op care
- protext pt who was placed at physiologic risk during surgery
- prevent complications after surgery
- PACU
- 3 recovery phases
phase 1 of recovery
Phase 1: care during immediate post-op period
- focused on life sustaining needs with constant monitoring
- goal: prepare pt for safe transfer to phase 2 or inpt unit
phase 2 of recovery
pt is ambulatory
goal: prepare pt for transfer to extended care environment or home with discharge teaching
phase 3 of recovery
extended observation
PACU initial assessment
- periop give report to PACU nurse
- management of airway and circulation, pain, temperature, surgical site, and assessment of their response to the reversal of anaesthesia agents
- ABCs
- pulse ox
- potential telemetry
- temp, skin colour, condition assessment
- LOC, orientation
- assess incision, drains, etc
aldrete scale
9 or greater u can go home
This is how they determine whether u can leave the PACU
This is why baseline vitals are important
what are 6 immediate post-op respiratory complications
- airway obstruction
- atelectasis
- aspiration
- bronchospasm
- hyperventilation
- resp depression
most common cause of airway obstruction
their tongue
(too much sedation or sleep apnea)
immediate post-operative CVS complications
- hypotension
- HTN
- dysrhythmias
in the immediate post-op period CVS complications when to notify anaesthesia if:
- SBP less than 90 or greater than 160
- HR less than 60 or greater than 120 bpm
- BP gradually decreases over consecutive readings
- irregular rhythm develops
- significant change from pre-op readings
what are we worried about with hypotension
- Fluid loss, blood loss
- Made patient NPO so haven’t been eating
- Some meds can cause hypotension
Ex are worried about: cerebral and renal injuries
What causes hypertension if pt just had surgery
- Pain
- If pt has to pee is a big one so scan their bladder cuz they can’t always tell
- Anxiety
- Resp compromise
- Hyperthermia
Pre-existing hypertension
emergence delirium
hypoxia, anaesthesia agents, bladder distension, immobilities, sensory and cognitive impairments, inadequate pain control, polypharmacy, dehydration, and malnutrition
exhibit bizarre behaviour can happen 24 hours after surgery. Post-op delirium
polypharmacy
meds interact w anesthesia
delayed awakening
often reversible (caused by medications)
when too much sedation is given. So usually we have to reverse this.
temperature alteration causes in the PACU
*hypothermia
- heat loss from surgery
- cold fluids in the OR
- anaesthesia agents
GI complications in the PACU
n/v
Risks:
- 50+
- History of motion sickness
- Being a non smoker
- Increased length of surgery
When you blow up their belly w air
GU complications PACU
- low urine output
- acute urinary retention
We didn’t let them eat or drink, they had diaphoresis, etc
Swelling, or inability for kidneys to function as well, and anesthesia, can cause urinary retention.
Epidurals: block sensation to pee
what’s a normal hr amount output for urine in an adult
30 mL/hour normal
skin alterations in PACU
- surgical wounds and/or dressing: monitoring drainage amount/colour
- drains: consider why your pt has this, what is the expected output
- surgical site infections (SSI)
- Fever
- Increased redness around wound
- Pus drainage
- Feeling generally unwell
Drain - is what is coming out expected from where it has been placed
what’s included in general surgery
anything to do w the GI tract
for esophagectomy what is the indication
esophageal cancer
for esophagectomy what is the surgical approach
thoracotomy or minimally invasive (thoracoscopy OR robotic)
for esophagectomy what is the surgical length
8-10 hrs
for esophagectomy what is the length of stay
4-7 days
- admitted to ICU for 1-2 days for closer monitoring
for esophagectomy what is the post op considerations
- jackson pratt drain
- epidural or pain control
- chest tubes
- wound care
- j-tube for feeding, strict
NPO
small bowel resection indication
bowel cancer, Crohn’s (NOT ulcerative colitis), scar tissue/adhesions causing small bowel obstruction, bowel perforation
small bowel resection surgical approach
laparoscopy, robotic, or laparotomy
small bowel resection surgical length
2-4 hrs
small bowel resection length of stay
if minimally invasive could be same day to 2 days, open = 3-5 days
small bowel resection post-op considerations
- jackson pratt drain
- epidural or pain control
- ileostomy (high output or no output)
- wound care
large bowel resection indication
bowel cancer, IBD (crohn’s ulcerative colitis), diverticulitis, bowel perforation
large bowel resection surgical approach
laparoscopy, robotic, or laparotomy
large bowel resection surgical length
2-4 hrs
large bowel resection LOS
if minimally invasive could be same day-2days, open =3-5 days
large bowel resection post-op care
- jackson pratt drain
- epidural or pain control
- ileostomy OR colostomy
- wound care
- changes to output or BMs?
appendectomy indication
appendicitis, very rarely appendiceal cancer
appendectomy surgical approach
laparoscopy (rarely open)
appendectomy surgical length
1-2 hours
appendectomy post-op considerations
- pain from laparoscopy air
- infection
cholecystectomy indication
gall stones
cholecystectomy surgical approach
laparoscopy (rarely open)
cholecystectomy surgical length
1-2 hrs
cholecystectomy LOS
usually can go home post-op or 1-2 days
cholecystectomy post-op considerations
- pain from laparoscopy air
- retained gall stones
pancreaticoduodenectomy (whipples) indication
pancreatic or bile duct cancer
pancreaticoduodenectomy (whipples) surgical length
6-8 hrs
pancreaticoduodenectomy (whipples) surgical approach
laparotomy
pancreaticoduodenectomy (whipples) post-op considerations
- pain modalities
- wound care
- drains
- nutritional support
pancreaticoduodenectomy (whipples) LOS
4-7 days
