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Clin Med - II (Surgery) > Overview > Flashcards

Overview Flashcards

1
Q

First Assistant

A

The person directly opposite the surgeon at the OR table who actively participates in the conduction the procedure

Historically, the roll was filled by experienced surgeons and nurses as well as certified sx techs or OR techs

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2
Q

Sx PA Tasks

A 
Inital pt eval
1st and 2nd assisting in sx
Independent procedures
Post-op care
Clinic
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3
Q

Non-sx tasks of a PA

A 
Thoracentesis
Chest tube insertion
LP
Paracentesis
ACLS
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4
Q

OR surgical team consists of the following rolls

A 
Attending surgeon
Fellow
Resident
Intern
RN first assistant
PA
Medical / PA student
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5
Q

OR anesthesia team consists of the following rolls

A

Anesthesiologist

CRNA

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6
Q

OR and recovery team consists of the following rolls

A

Recovery room nurse

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7
Q

Roll of the the recovery room nurse

A

Assesses post-op hemodynamic and cardiopulmonary stability

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8
Q

Rolls in the OR / Recovery (not including sx team, anesthesia, or recovery)

A 
OR Director
OR Supervisor
Control Room Supervisor
Head Nurse
Staff Nurse
Circulating nurse
Scrub nurse
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9
Q

Role of the OR director

A

Determines and enforces OR policy Usually an RN

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10
Q

Role of the OR supervisor

A

Oversees daily OR activities

Usually an RN

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11
Q

Role of the Control Room Supervisor

A

“traffic coordinator”

Schedules sx and personnel

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12
Q

Role of the Head Nurse

A

Manages the OR to ensure smooth and efficient operation

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13
Q

Role of the Circulating Nurse

A

Prepares pt and supplies for the operative procedure
Troubleshoots
Connects tubes and wires

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14
Q

Role of the Scrub Nurse

A

Assists surgeon by providing all instrument sutures and supplies required for smooth execution of procedure

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15
Q

Questions to review prior to procedure to be an effective assistant

A

What procedure is to be done?
What is the regional anatomy?
What is the normal physiology and pathophysiology or the organ?
What are the sx and non-sx options?
What is the effect of the procedure on the pathophysiology?

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16
Q

Pre-op responsibilities of a sx PA

A 
Admission H and P
Admission Orders
Pre-op orders
Pre-op note
Read about pt's specific dz processes and planned procedure prior to sx
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17
Q

Peri-op responsibilities of a sx PA

A 
Accompany pt to the OR 
Assist at procedure
Op note
Post-op orders
Post-op check
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18
Q

Post-op responsibilities of a sx PA

A

Daily pt care

  • Early morning eval, assessment, plan for the day
  • Morning round with pt progress reports
  • accompany pt to dx and therapeutic procedure with feasible
  • Write daily progress notes
  • Quick after assessment
  • Evening round with report of daily activities, lab results, dx studies, etc
  • Check final pathology results
  • Speak with pt’s family when indicated
  • Assist with the writing of d/c order, rx and other paperwork
  • Date/time on all notes and orders
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19
Q

Additional responsibilities of sx PA

A

Attend all rounds, conferences and lectures pertaining to sx service and sx rotation
Be the pt’s advocate - find answers to their questions

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20
Q

Acronym for Routine admission orders

A

ADCVANDIIMAL

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21
Q

ADCVANDIIMAL - Meaning of each letter

A 
Admit pt
Dx
Condition
Vital signs
Activity
Nursing
Diet
Intake and Output
IV Fluid
Meds
Allergies
Labs
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22
Q

ADCVANDIIMAL - Admit pt

A

Room number

Attending physician or service

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23
Q

ADCVANDIIMAL - Dx

A

Give pt’s admission dx

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24
Q

ADCVANDIIMAL - Condition

A 
Good
Stable
Fair
Guarded
Critical, etc
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25
Q

ADCVANDIIMAL- Vital signs

A

BP
Pulse
Respiration
Temperature

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26
Q

ADCVANDIIMAL - Activity

A 
Bed rest
Up as tolerated
Up in chair
PT
OT
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27
Q

ADCVANDIIMAL - Nursing

A

Dressing changes
Compression stockings
Neuro checks
Preventative measures

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28
Q

ADCVANDIIMAL - Diet

A 
Regular
ADA (diabetic)
NPO
Low Sodium
Clear liquids
29
Q

ADCVANDIIMAL - I and O’s

A

This has to be ordered

30
Q

ADCVANDIIMAL - IV Fluids

A

Type

Rate

31
Q

ADCVANDIIMAL - Meds

A

Pain
Home
Abx
Insulin, etc

32
Q

ADCVANDIIMAL - allergies

A

Specific meds

NKDA

33
Q

ADCVANDIIMAL - labs

A

CBC
X-rays
Urine
EKG, etc

34
Q

Emergency Admission orders

A

Diet - NPO
Meds - No meds for pain relief until dx established and operative decision determined
Fluid therapy - needed by most emergency admission to correct dehydration and electrolyte imbalance
Abx

35
Q

Components of OP Note

A 
Pre-op dx
Post-op dx
Procedure (s)
Surgeon(s)
Assistant (s)
Anesthesiologist / CRNA
Intra-op findings
Type of anesthesia
EBL
Urine output
IV fluids
Specimens
Drains
Tubes and lines
Implants
Complications
Disposition
36
Q

Post-Op orders - generally

A

Post-op orders must be revised at least daily on post-op rounds to reflect pts progress following the sx procedure

37
Q

Post-Op orders consists of

A 
Sx performed and type of anesthesia
Ambulation / Activity
Vital signs 
I and O
Body weight
Tubes and Drains
Meds
Tx vomiting
Lab testing
Wound care
Conditions for which a physician should be notified
38
Q

Post-Op orders - Ambulation / Activity

A

Pts should be out of bed and walking with assistance by post-op day 1 at the latest
Connection to IV tubes and drains may limit, but not prevent ambulation

39
Q

Post-Op orders - Vital signs

A

Taken often during the immediate post-op period and gradually less often

40
Q

Post-Op orders - I and Os and body weight

A

Should be measured daily to optimally plan and administer fluids

41
Q

Post-Op orders - Tubes and Drains

A

Should be maintained and output measured

42
Q

Post-Op orders - Meds

A

Orders should reflect the pt’s changing requirements

43
Q

Post-Op orders - Vomiting

A

Should be tx either with a NG tube and/or anti-emetic depending on etiology of the N/V

44
Q

Post-Op orders - Labs

A

Post-op tests can include

  • CBC
  • Electrolytes
  • CXR after throacotomy or placement of central line or endotracheal tubes
  • Daily UA when a urinary cath is present
45
Q

Post-Op orders - Wound Care

A

Orders for frequency of dressing changes and meds for use on wounds when indicated

46
Q

Post-Op orders - Conditions for which a physician should be notified

A

Parameters of changes in pt’s condition should be documented in order to provide for appropriate physician notification

47
Q

Contents of a Daily Progress Note - General

A 
SOAP
Subjective
Objective
Assessment
Plan
48
Q

Contents of a Daily Progress Note - Subjective

A

Pt comments (include all complaints)
Family and allied health observation
General observations - e.g. “looks better”

49
Q

Contents of a Daily Progress Note - Observation

A 
Vital signs
Daily weight
General
I and O's
Urine
Important meds
Labs
X-ray findings
Other (ventilation, pacemaker setting, etc)
Physical findings
50
Q

I and O’s include

A

Oral
Drains
IVF
NG Tube

51
Q

Urine measurement

A

Since sx if freshly post-op

Otherwise 24h

52
Q

Physical finding to include in SOAP note

A 
Mental status
Sx site
Heart
Lungs
Abdomen
Extremities
Other as needed
53
Q

Contents of a Daily Progress Note - Assessment

A

How is the pt progressing?

54
Q

Contents of a Daily Progress Note - Plan

A 
What should be done for the pt?
- Stop IV
- Increase dietary level
- Increase ambulation
- Dressing change, etc.
Address physical findings
55
Q

Components of a D/C note

A 
Admission / d/c dates
Admission / d/c dx
Service 
Referring physician 
Consults
Procedure
H and P
Course
D/c condition
Disposition
Meds
Instructions
F/u
56
Q

D/C note - Service

A

Service name

Attending

57
Q

D/C note - Consults

A

Physicians
Services
Dates

58
Q

D/C note - Procedures

A

Dates of sx

Angiograms, etc

59
Q

D/C note - H and P

A

Pertinent admission H and P

Lab test

60
Q

D/C note - Course

A

Summary of tx

Progress during hospital stay

61
Q

D/C note - D/c condition

A

Good
Stable
Fair
Guarded

62
Q

D/C note - Disposition

A

Home

Nursing Home

63
Q

D/C note - Meds

A

D/c meds with dosage and administration

64
Q

D/C note - Instructions

A

Activity restrictions
Diet
Dressing changes
Cast care

65
Q

D/C note - F/u

A

Clinic appt

66
Q

Role of a PA in sx - Initial pt eval

A

H and Ps
Admission orders
Pre-op prep)

67
Q

Role of a PA in sx - Independent procedures

A

Vein harvesting
Insertion of invasive monitoring lines
Incisions closure

68
Q

Role of a PA in sx - Post-op care

A

Daily rounds

D/c summaries

69
Q

Role of a PA in sx - Clinic

A

New pt eval and tx

Post-op visits

Clin Med - II (Surgery) (10 decks)

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