Peri-Op Care Flashcards
1
Q
Who needs special considerations when it comes to surgery?
A
- Pregnant ladies
- Diabetics
- Pts on steroids
- Pts with thyroid disease
- Pts with cardiorespiratory
- Pts with renal/hepatic disease
- Pts with neuro disease
Come back to this, its in the surgery oxford handbook
2
Q
What are some urinary complications of surgery?
A
AKI
Urinary retention
UTI
3
Q
How many criteria are there for diagnosing AKI?
A
3
4
Q
What are the criteria for diagnosing AKI?
A
- ≥50% rise in serum creatinine from baseline within last 7 days
- Increase in serum creatinine by ≥26.5mmol/l within 48 hours
- Urine output <0.5mls/kg/hour (oliguria) for more than 6hrs
5
Q
How many stages of AKI are there?
A
3
6
Q
What is stage 1 AKI?
A
Creatinine 1.5-2 times the baseline, and oliguric for 6-12 hours
7
Q
What is stage 2 AKI?
A
Creatinine 2-3 times the baseline , and oliguric for 12+ hours
8
Q
What is stage 3 AKI?
A
Creatinine >3 times the baseline plus either:
- <0.3ml/kg/h for 24hours + OR
- anuric for 12 hours +
9
Q
How can AKI be divided according to causes?
A
Pre-renal
Renal
Post-renal
10
Q
Which class of cause of AKI is the most common peri-op?
A
Pre-renal
11
Q
Give some examples of causes of pre-renal AKI
A
Sepsis Dehydration Haemorrhage HF Liver failure -> hepatorenal syndrome Intra-operative damage
12
Q
Give some examples of causes of renal AKI
A
Nephrotoxins
Parenchymal disease eg glomerulonephritis
13
Q
Give some examples of causes of post-renal AKI
A
Stones (at any level) Tumours Retroperitoneal fibrosis Acute urinary retention Blocked catheter Prostate enlargement
14
Q
What are the steps in assessing a pt with AKI?
A
Hx Examination Bedside tests Investigations Imaging
15
Q
On examination of a pt with AKI, what should we assess?
A
Fluid status
Bladder - palpable?
Catheter - is it draining?
Nephrotoxins on drug chart?
16
Q
What bedside tests can we do when assessing AKI?
A
Urine dip
Bladder scan
Use sepsis tool to check for possible sepsis
17
Q
What investigations can we do for AKI?
A
FBC U&Es ****Creatinine**** CRP LFTs Ca2+ Lactate (ABG)
18
Q
When is imaging used for AKI? What do we look at?
A
In severe cases to look at kidneys, ureters, and bladder
19
Q
Is AKI serious?
A
Yeah, its classified as an emergency situation
20
Q
If pre-renal AKI is suspected, what is a good first step?
A
Fluid challenge - 250-500ml over 15 minutes and reassess, repeat as necessary
21
Q
WRT fluids, in AKI what else should we monitor?
A
Urine output with a fluid balance chart. Escalate to catheter if necessary.
22
Q
Ultimately, how is AKI treated?
A
Treat the cause and monitor
23
Q
What are the 3 most common signs/symptoms of urinary retention?
A
- Little or no urine passed post-op
- Sensation of needing to void but being unable
- Suprapubic mass (dull to percussion)
24
Q
Alongside clinical assessment, what is the most important investigation for retention?
A
Pre- and post-void bladder scan for residual volume
25
What could unstable renal function suggest in retention?
High pressure retention
26
How should retention be managed?
Conservatively for most patients as post-op retention usually resolves itself
Catheterise if not resolving, then TWOC. If failed TWOC, recatheterise and TWOC again in 1-2 weeks
27
What organisms commonly cause UTIs?
E. coli ***
```
Klebsiella sp.
Enterobacteur sp.
Proteus sp.
Pseudomonas sp.
Staphylococcus sp.
```
28
What symptoms are common for UTIs?
Urinary frequency, urgency, and dysuria
29
O/E what is common for UTIs?
Suprapubic pain
| Pyrexia
30
Who should UTI be considered in?
Sepsis
Pts with delirium
Pts in acute retention
31
What shows up on a urine dipstick for a UTI?
Nitrites and leukocytes elevated +- blood
32
What is sterile pyruia?
Presence of elevated wbcs in urine without evidence of organisms
ie leukocytes without nitrites
33
What can cause sterile pyuria?
Inadequately treated UTI
STI
Renal stone
34
What are the basic steps in management of UTIs?
Ensure pt is well hydrated and has good urine output
35
What is the definitive management of a UTI?
Abx according to local guidlines
| eg LNR - uncomplicated -> trimethoprim or nitrofurantoin
36
What should be done with a UTI in a pt with a catheter?
Change any long-term catheter in-situ in the presence of a UTI
37
What is subcutaneous emphysema?
A known complication of laparoscopic surgery. Air/gas enters the subcut tissues of the chest.
38
How can subcutaneous emphysema be identified?
O/E - Pt short of breath, "rice krispie" feel over chest when pt breathes.
Radiograph - If anteroir chest wall affected -> able to see leaf like outline of pec major. Other muscles/overlying structures can be viewed in an unusual way.
39
What is the recommended cut off HbA1c for pre-op surgical pts?
48mmol/mol (6.5%)
40
What is the recommended range for pre-op cap glucose?
6-10mmol
41
Why are we worried about glycaemic control in the peri-op period?
Hyper and Hypo glycaemia can affect healing, prolong hospital stays, and cause complications
42
How is hyperglycaemia caused in the peri-op period?
Body is under stress -> more catabolic hormones released eg cortisol, GH, glucagon
43
What can peri-op hyperglycaemia cause?
DKA or HHS
Post-op sepsis, endotheial dysfunction, cerebral ischaemia
Impaired wound healing *****
44
Why is hypoglycaemia in a surgical patient important to avoid?
It is hard to recongise when a pt is anaesthetised so if hypoglycaemic for prolonged period of time -> neurological damage
Also leads to poor wound healing
45
What does the management of diabetic pts peri-op depend on?
How there diabetes is controlled - i.e. is it well controlled, is it oral meds, is it insulin etc?
46
How should diabetics be managed for minor operations?
Oral-controlled - give normal regimen
Insulin-controlled - omit insulin on the day before surgery, monitor blood glucose every 4 hours, restart insulin once back on food
47
How should diabetics be managed for major operations?
Oral-controlled - omit long acting drugs pre-op. Monitor BS every 4 ours, if over 15mmol/L -> IV insulin
Insulin-controlled - IV insulin sliding scale when NBM. Restart insulin once oral diet restarts.
48
What % of all healthcare infections are surgical site?
Up to 16%
49
What is the rate of infection for orthopaedic procedures?
Less than 1%
50
What is the rate of infection for large bowel procedures?
Over 10%
51
How many statements are there about how we can prevent surgical site infections?
7
52
In terms of skin prep, what are 2 of the statements to prevent surgical site infections?
Don't do hair removal unless required - if needed, use clippers.
Have a bath/shower day of or before surgery - some pts given antispetic wash
53
Other than skin prep, what do we do to prevent srgical infections?
Abx prophylaxis
Normothermia maintained pre-, during, and post-op
Give advice on wound dressing and care
54
What does abx prophylaxis choice depend on?
- Type of operation
- Mesh or prosthetic used
- Pt factors
- Length of procedure
- Organisms common to the site
- Local guidelines
55
What pt factors increase risk of infection?
ASA score more than 2
56
What is classed as a "clean" wound?
Ops where no inflammation is encountered, and resp, alimentary, and GU tracts aren't entered
57
What is classed as a "clean-contaminated" wound?
Ops where resp, alimentary, or GU tracts entered but with no significant spillage
58
What is classed as a "contaminated" wound?
Acute inflammation is encountered, visible wound contamination
59
What is classed as a "dirty" wound?
Pus is present during op, prev perforated hollow viscus, or open injury for more than 4 hours
60
In general terms, what qualities should abx prophylaxis have?
Narrow spectrum, less expensive
61
When should abx prophylaxis be given?
Iv abx within an hour before skin incised, as close to incision time as possible
Half life should cover the operation
62
How long should we give abx prophylaxis for for arthroplasry?
Up to 24 hours
63
What are the different types of pain?
```
Nociceptive
Somatic
Visceral
Chronic
Phantom
```
64
What are the 2 different types of nociceptor fibres?
Aẟ fibres
| C fibres
65
Which type of nociceptor fibres are the fast response ones?
Aẟ fibres
66
Why are Aẟ fibres faster than C fibres?
They are myelinated
67
Why do we give pain relief?
It's the human thing to do!
Also reduces stress response
Allows for early mobilisation
Allows for deep breathing and coughing
68
Why is a reduced stress response a good thing?
Reduced sympathetic response and lower BP -> lower O2 demand -> reduced risk of ischaemic events and faster healing
69
Why is early mobilisation good?
Prevent DVT
70
Why is deep breathing and coughing good?
Prevention of atelectasis and pneumonia
71
How do we give pain relief?
According to the WHO analgesic ladder
72
What is the first step of the WHO analgesic ladder?
Non-opiod +- adjuvants e.g. regular pracetamol or NSAID
73
What is the second step of the WHO analgesic ladder?
Weak opiod with non-opioid e.g. codeine PRN
74
What is the third step of the WHO analgesic ladder?
Strong opioid e.g. PRN oramorph
75
What is the top step of the WHO analgesic ladder?
Loading dose of opiate (IV/IM)
76
What regional anaesthesia is available?
Spinal, epidural, peripheral nerve blocks
77
What is an epidural?
Continuous infusion
78
What are the components of Virchow's triad?
Stasis, coagulation changes, vessel wall damage
79
How do we assess VTE risk?
Assess risk factors of VTE and risk factors for bleeding
80
What factors increase VTE risk?
It's a long list
- Active cancer or treatment for cancer
- Age over 60
- Dehydration
- Critical care admission
- Known thrombophilias
- Obesity
- PHx of VTE
- Significant co-morbidity
- HRT
- COCP
- Varicose veins with phlebitis
81
What increases risk of bleeding, and therefore is part of VTE assessment?
- Active bleeding
- Acquired bleeding disorder
- LP/epidrual/spinal within next 12 hours or past 4 hours
- Acute stroke
- Thrombocytopenia
- Uncontrolled HTN
- Inherited bleeding disorder
82
What does unfractionated heparin bind to?
Anti-thrombin III
83
How do we give heparins?
IV or S/C
84
How quickly can heprain wear off?
2-4 hours
85
What can be administered to reverse heparin?
Protamine
86
What is the best way to get oxygen into a critically ill patient?
High-flow oxygen
87
How can fluids be divided?
Into crystalloids and colloids
88
What do all crystalloids contain?
Water and salt/sugar
89
What do all colloids contain?
Water and protein
90
What crystalloid fluids are available?
```
NaCl
5% Dextrose
4% Dextrose + 0.18% saline
Hartmanns
NaHCO3
```
91
What colloid fluids are available?
Gelofusine/Volplex (gelatin)
Haemaccel
HAS 4.4% or 20%
92
What are the reasons for fluid prescription?
Resuscitation
Maintenance
Replacement
93
Other than reason for fluids, what do we need to take into account?
Weight and size of pt
Co-morbidities
Reason for admission
Current electrolyte balane
94
How much of total body fluid is intracellular?
2/3
95
Of the fluid left in the extracellular fluid, how much goes where?
1/5 in intravascular
| 4/5 in interstitium
96
What is the distribution aim of maintenance fluids?
Distribute fluid into every compartment
97
What is the distribution aim of resuscitation fluids?
Increase intravascular volume to increase tissue perfusion
98
Why do septic pts need loooooots of fluids?
Capillary endothelial junctions become very leaky & vascular permeability increases so lots of fluid needed to maintain intra-vascular volume.
99
How much fluid do we need in a day?
~2.5 Litres for a 70kg man
100
What is important for a pt NBM?
Fluid replacement via parenteral route
101
What do we look for in a ?fluid depleted pt?
- Dry mucous membranes
- Reduced skin turgor
- Decreased urine output
- Orthostatic hypotension
- Increased cap refill time
- Tachycardia
- Low BP
102
What signs will a fluid overloaded pt exhibit?
- Raised JVP
- Peripheral/sacral oedema
- Pulmonary oedema
103
How much water does a person need a day?
25mL/kg/day
104
How much Na+ does a person need per day?
1.0 mmol/kg/day
105
How much K+ does a person need per day?
1.0 mmol/kg/day
106
How much glucose does a person need per day?
50g/day
107
What is a surgeons favourite fluid?
Hartmann's solution
108
How should a reduced urine output be managed?
Aggressively, with fluid challenge, and monitor urine output
109
Why don't we use colloids much?
- Evidence suggests they aren't much better than crystalloids
- High cost
- Risk of hypersensitivity rxns
- Risk of coagulopathy
110
What can happen to a patient who is given fluids when they don't really need them?
Hyperchloraemic metabolic acidosis
111
How many classes of shock are there?
4
112
How much blood is lost in Class II shock?
Over 750mL
113
How much blood is lost in Class III shock?
1.5-2L
114
How much blood is lost in Class IV shock?
Over 2L
115
In terms of %s, whats a good way to remember the amount of blood volume lost in each class of shock?
Tennis scores!
Class I - 0-15%
Class II - 15-30%
Class III - 30-40%
Class IV - >40%
Geddit???
116
In terms of %s, whats a good way to remember the amount of blood volume lost in each class of shock?
Tennis scores!
Class I - 0-15%
Class II - 15-30%
Class III - 30-40%
Class IV - >40%
Geddit???
117
What are the important blood grouping systems?
ABO and Rhesus
118
Which Rhesus group is the most significant?
Rhesus D
119
Which ABO group is the universal donor?
O negative
120
Which ABO group is the universal acceptor?
AB positive
121
What is group and save?
Blood sample is sent to determine pts blood group and screens for atypical antibodies. No blood is issued
122
What is crossmatching?
Blood sample is sent and physically mixed with donor blood to see if any immune reactions take place. Blood can then be issued if no reaction occurs.
123
What kind of blood is it important to give to pregnant women and neonates, as well as for intra-uterine transfusions? Why?
CMV negative blood
CMV can lead to sensorineural deafness and cerebral palsy
124
Who do we give irradiated blood products to?
- Pts getting blodd from 1st or 2nd degree family
- Pts with Hodgkins lymphoma
- Pts having certain types of chemo
- Pts with recent HSC transplants
- Intra-uterine infusions
125
How should blood be prescribed?
Individually for each unit given
126
What size cannula should blood products be given through? Why?
18G (green) or 16G (grey). The cells with haemolyse in a narrow tube due to shearing forces.
127
When and how should patients recieving blood be assessed?
Before infusion, 15-20 minutes in, at 1 hour, and at completion.
Baseline obs looking for reaction to the blood product (antibodies, infection etc)
128
What does a blood giving set contain that a normal fluid giving set doesn't?
A filter in the chamber
129
What are the different blood products?
Packed red cells
Platelets
Fresh frozen plasma
Cryoprecipitate
130
Tell me about packed red cells...
RBCs given over 2-4 hours for acute blood loss, chronic anaemia Hb <70, or symptomatic anaemia.
131
How much should one unit of packed red cells improve a pts Hb by?
~10g/L
132
Why do we need a new group and save for subsequent transfusions?
The pt may develop autoantibodies to donor surface antigens, unless its within ~3 days
133
Tell me about platelet transfusions...
Platelets given over 30 minutes for haemorrhagic shock in trauma, profound thrombocytopenia, bleeding with thrombocytopenia, or a pre-op platelet level of less than 50x10^9/L
134
How much should one ATD of platelets increase platelet levels by?
20-40 x 10^9/L
135
Tell me about fresh frozen plasma...
FFP contains mainly clotting factors, and is given over 30 minutes for DIC, any haemorrhage secondary to liver disease, and all massive haemorrhages (alongside packed red cells).
136
Tell me about cryoprecipitate....
Contains fibrinogen, vWF, Factor VIII, and fibronectin, given stat for DIC with fibrinogen <1g/L, von Willebrands disease, or massive haemorrhage.
137
Why do we need to know if a surgical pt is pregnant?
There are changes is anatomy and physiology that we need to account for
138
In the first trimester of pregnancy, what do we need to account for surgically?
Teratogenic drugs could harm foetus
| Lower oesophageal sphincter tone reduced so increased risk of reflux andaspiration if supine
139
In the second trimester of pregnancy, what do we need to account for surgically?
Teratogenic drugs
| Increased risk of UTIs, VTE, and superficial infections
140
In the third trimester of pregnancy, what do we need to account for surgically?
Drugs that may induce labour
Displacement of abdominal visceral structures
Risk of hypotension if supine
141
What do we balance the risk of miscarriage by GA against?
Risk of sepsis from untreated surgical pathology
142
Why is diagnostic laparoscopy contraindicated in pregnancy?
Pneumoperitoneum can affect pregnancy
143
Why is the COCP important in surgery?
It increases the risk of thromboembolic disease
144
What should we do in a female pt on the COCP who needs elective surgery?
If surgery is medium or high risk, stop the pill at least 1 month prior to surgery
145
What should we do in a female pt on the COCP who needs urgent/emergency surgery?
If medium risk procedure, operate with full thromboprophylaxis
If high risk procedure, operate with extended prophylaxis
146
Pre-op, what should we do for pts on long term steroids?
Continue them to prevent Addisonian crisis. Switch to IV if can't take orally.
147
What are some important contraindications for LMWH?
Endocrine/neck surgery
Peptic ulcer disease
Previous cerebral haemorrhage
148
When should warfarin be stopped pre-op?
Usually 5 days prior to surgery
149
What is target INR for surgery?
<1.5
150
How should we reverse warfarinisation?
PO vitamin K
or
IV Vit K 5mg - works within 12 hours
If need to reverse ASAP, give Prothrombin complex concentrate or FFP
151
When should clopidogrel be stopped prior to surgery?
7 days beforehand - bridge with aspirin
152
How is LMWH given?
S/C
153
Why is LMWH better than unfractionated heparin?
Less protein binding to dose response is more predictable
154
How is LMWH cleared?
By the kidneys
155
Name some direct thrombin inhibitors...
Dabigatran
| Argatroban
156
What nerve can be damaged during a posterior triangle lymoh node biopsy?
Accessory nerve
157
What nerve can be damaged when surgery involves a posterior approach to the hip?
Sciatic
158
What nerve can be damaged when legs are in the Lloyd Davies position during surgery?
Common peroneal
159
When can the long thoracic nerve be damaged during surgery?
If an axillary lymph node clearance is done
160
Which nerves are at risk when operating on pelvic cancer?
Pelvic autonomic nerves
161
After thyroid surgery, what nerve damage should we look out for, and how should it be investigated?
Recurrent laryngeal nerve damage causing a hoarse voice.
Laryngoscopy
162
I break my arm and they repair it in surgery. Which nerves could they have damaged in the process?
Ulnar and median nerves
163
When can the hypoglossal nerve be damaged during surgery?
During a carotid endarterectomy
164
Give some examples of surgeries where only group and save is necessary as chance of transfusion is unlikely.
```
Hysterectomy (simple)
Appendicectomy
Thyroidectomy
Elective lower segment caesarean section
Laparoscopic cholecystectomy
```
165
Give some examples of surgeries where crossmatching of 2-6 units of blood is necessary as chance of transfusion is likely.
Salpingectomy for ruptured ectopic
| Total hip replacement
166
Give some examples of surgeries where crossmatching of 4-6 units of blood is necessary as chance of transfusion is definite.
```
Total gastrectomy
Oophrectomy
Oesophagectomy
Elective AAArepair
Cystectomy
Hepatectomy
```
167
What contraception is important to stop in the pre-op period?
Oestrogen containing contraceptives
168
Why do oestrogen containing contraceptives need to be stopped in the pre-op period?
They increase the risk of VTE
169
When should oestrogen containing contraception be stopped before surgery?
Ideally a full month before surgery. However if it is an emergency procedure, full/extended thromboprophylaxis should be used.
170
Why is a pt on steroids at a specific perioperative risk?
They reduce neutrophil and fibroblast function and immune response. This increases susceptibility to infection, inhibits wound healing, and can cause osteoporosis (important for orthopedic procedures)
171
If a pt on long term steroids suddenly has them stopped, what can happen?
Addisonian crisis
172
Why are surgical pts on long term steroids at risk of an addisonian crisis?
Surgery increases stress on the body so steroid use increases - if only source is exogenous steroids then supply can’t meet demand.
173
What are the features of an addisonian crisis?
- Lethargy/malaise
- Abdo pain (poorly localised)
- N+V
- Hypotension
- Hypoglycaemia
- Hyponatraemia
- Coma
- Death
174
How should an addisonian crisis be managed?
- IV dexamethasone 100mg QDS/400mg infusion over 24 hours
- Fluid resus
- IV dextrose (titrated against blood sugar)
175
How should a pt on steroids be managed pre-operatively?
- Wean dose of steroids if possible
- If not possible to wean, IV steroids should be prescribed on the morning of surgery, continuing until the pt can restart oral steorids
176
What dose of prednisolone is considered no significant and therefore need to peri-operative steroid cover?
5mg per day
This equates to:
1.6mg batamethasone and dexamethasone
40mg hydrocortisone
8mg methylprednisolone
177
What is the normal cortisol secretion from the adrenals?
About 30mg/day.
This is roughly equivalent to 7.5mg of prednisolone
178
How does cortisol secretion change post-operatively?
There is normally a rise for around 3 days post op.
179
What dose of hydrocortisone is given at induction for minor surgery to cover a pt on steroids?
25mg
180
What dose of hydrocortisone is given for moderate surgery to cover a pt on steroids?
25mg IV at induction
25mg IV every 8 hours for 24 hours
Then resume normal PO regime
181
What dose of hydrocortisone is given for major surgery to cover a pt on steroids?
50mg IV at induction
| 50mg IV every 8 hours for 48-72 hours until PO medication restarted.
182
What is the most important thing for a thyroid patient having surgery?
That they are euthyroid at the time of surgery. As such, all thyroid medication can be taken on the morning of surgery.
183
What are the principles of enhanced recovery after surgery?
Optimisation of patient before, during, and after surgery, to help them recover more quickly following surgery
184
Pre-operatively, what can be done according to the ERAS protocol?
- Pt education
- Optimisation of medical management
- Optimisation of fasting guidance
185
Intra-operatively, what can be done according to the ERAS protocol?
- Multimodal and opioid-sparing analgesia
- N&V prophylaxis
- Minimally invasive surgery
- Fluid therapy
186
Post-operatively, what can be done according to the ERAS protocol?
- Good pain control
- Early oral intake
- MDT follow-up
- Early mobilisation
187
What is the NICE guideline for water requirements for maintenance fluids?
25 mL/kg/day
188
What is the NICE guideline for Na requirements for maintenance fluids?
1.0 mmol/kg/day
189
What is the NICE guideline for K requirements for maintenance fluids?
1.0 mmol/kg/day
190
What is the NICE guideline for glucose requirements for maintenance fluids?
50g per day
191
What electrolyte imbalances are common in dehydration?
High urea:creatinine ration
| High PCV
192
What electrolyte imbalances are common in vomiting?
Low K+
Low Cl-
Alkalosis
193
What electrolyte imbalances are common in diarrhoea?
Low K+
| Acidosis
194
Why are malnourished patients poor surgical candidates?
Surgery causes physiological stress -> hyper-metabolic state and catabolic response.
195
How are patients screened for malnourishment?
Using MUST tool
196
How is malnourishment detected on MUST screening managed?
Expert input from dietician
197
What method of feeding is suggested if a pt is unable to eat sufficient calories?
Oral nutritional supplements
198
What method of feeding is suggested if a pt is unable to eat sufficient calories orally or has dysfunctional swallowing?
NG tube feeding
199
What method of feeding is suggested if a pt is has oesophageal blockage or dysfunction?
Gastrostomy feeding (PEG/RIG)
200
What method of feeding is suggested if a pt has inaccessible stomach or outflow obstruction?
Jejunal feeding
201
What method of feeding is suggested if a pt has intestinal failure or inaccessible jejunum?
Parenteral nutrition
202
What kinds of post-operative haemorrhages are there?
- Primary bleed
- Reactive bleed
- Secondary bleeding
203
What is a primary haemorrhage in a surgical patient?
Bleding that occurs within the intra-operative period.
204
What is a reactive haemorrhage in a surgical patient?
A bleed that occurs within 24 hours of the operation
205
What is a secondary haemorrhage in a surgical patient?
A bleed that occurs 7-10 days post-op, usually due o infection or vessel erosion
206
Why is haemorrhage following neck surgery so worrying?
Can cause airway obstruction as pretracheal fascia only extends so far.
207
How should airway compromise secondary to hameorrhage in neck surgery be managed?
- Remove skin clips and deep layer sutures
- Haematoma removal
All at bedside as no time to get patient to surgery!
208
How can pain be measured objectively?
According to clinical features such as tachycardia, tachypnoea, hypertension, and sweating/flushing.
209
Why is it important to assess pain at rest and during mobilisation?
Because if a pt is in pain on mobilisation, they will be reluctant to mobilise early.
210
What is it important to do with analgesia on discharge?
Wean the pt down the analgesia ladder
