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Gen Med: Surgery > Perioperative Care > Flashcards

Perioperative Care Flashcards

1
Q

What is included in the ADC VAAN DIML acronym?

A

A- Admitting (i.e. Admit to Dr. Lee, Floor/Telemetry/ICU)
D- Diagnosis
C- Condition (i.e Stable/Guarded/Critical)
V- Vitals (How often, special considerations i.e. pulse ox, neuro)
A- Allergies
A- Activity (OOB/Up Ad Lib/Ambulate TID/Bedrest)
N- Nursing orders (Foley catheters/ Drains/ Dressings/ Miscellaneous Therapies/ Communication w/ nursing)
D- Diet (NPO/ Sips/ Clears/ Fulls/ Reg/ Restrictions)
I- Input/Output
M- Medications (Home meds/ Fluids/The four P’s)
Pain, Puke, Pus (Analgesic/Infection/Abx), Prophylaxis (DVT)
L- Labs (Bloodwork/Cultures/Imaging)

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2
Q

What is included in the ABC DAVIDS?

A 
A = Admit to…( floor/unit) & Attending
B = Because (admitting Dx)
C = Condition & Code status & Consults
D = Diet  & DVT prophylaxis
A = Allergies & Activity
V = Vital signs
I = IV fluids
D = Diagnostic tests & Drugs
S = Special nursing (catheter, NG, I & O, dressings, drains, therapy, etc)
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3
Q

When is pre-admission testing done? What is included?

A
  1. Done before scheduled surgical procedures
  2. Full H&P & medication review
  3. Pre-op Clearances (EKG, CXR, CBC, BMP/CMP, PT/INR, PTT, Beta-HCG)
  4. Patient education about procedure, how to prepare, & what to expect
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4
Q

How is a pt admitted to the hospital?

A

Admission through the ER or directly from office

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5
Q

What is included in hospital admission?

A
  1. Full H&P
  2. Med Record
  3. Orders
  4. Patient Ed.
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6
Q

What is included in the surgery-focused H&P?

A 
1. PMH: Look for conditions that could affect your orders or the general treatment of your pt
A. DM
B. Cardiac Hx
C. Renal Pt
D. Bleeding disorders
E. Pulmonary Dz
F. Hx of CA
G. Autoimmune Dz/ Immunosuppressed 
H. Anything requiring chronic med
I. Cognitive impairment
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7
Q

What is included in the surgery focused PSH?

A
  1. Virgin belly vs prior surgery, could affect approach
  2. Pre-existing mesh
  3. Ortho hardware- consider electrocautery
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8
Q

What meds need to be asked about in the surgery focused med list?

A 
1. Medications- Be thorough or get pharmacy assistance
A. Anticoagulants
B. Chronic/Recent steroid use
C. Home/Prior narcotic use
D. Diabetes medications/insulin
E. Diuretics/Antihypertensives
F. Meds for chronic conditions
G. Always ask about supplements and vitamins!
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9
Q

What is included in the family hx in a surgery focused hx?

A
  • Often less helpful in acute situations

Hx of CA, Heart disease, familial/genetic disorders

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10
Q

What is included in the social hx in a surgery focused hx?

A
  1. Always ask, NEVER assume
  2. Smokers hate being intubated
  3. ETOH/Illicits
    A. Look out for withdrawal- symptoms 1-3 days after admit
    B. CIWA protocol - Frequent vitals, neuro checks, Ativan on call
    C. (Clinical Institute Withdrawal Assessment for Alcohol)
  4. Work/ Home considerations
    A. May require discharge planning or STR (short term rehab)
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11
Q

What are the four P’s of orders?

A
  1. Pain
  2. Puke
  3. Pus
  4. Prophylaxis
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12
Q

What are the options of pain med delivery?

A

PO/SQ/IV/PCA/Epidural/ON-Q

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13
Q

What are the common po pain meds?

A
  1. Lortab/Percocet 5/325 mg q4h

2. Ultram 50 mg tid

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14
Q

What are the common iv pain meds?

A
  1. IV (mini bag)-
    A. Morphine (4mg q4h)
    B. Dilauded (.5mg q3h)
    C. Demerol/ Toradol (15/30mg q6h)
  2. Check Renal function/ comorbidities with Toradol
  3. Also for ICU pt- Fentanyl 25mg IV q1h
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15
Q

What are the common PCA pain meds?

A
  1. PCA (Pt. controlled anesthesia)-

2. Morphine/Dilauded/Demerol

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16
Q

How do you write an order for PCA?

A

Continuous Rate/Loading dose/Pt controlled dose/ Lockout Interval/ Max Hourly Dose

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17
Q

What needs to be watched for epidural pain meds?

A

Beware of hypotension

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18
Q

How is nausea/vomiting (Puke) controlled?

A
  1. Antiemetics
    A. Zofran 4mg IV q6h prn nausea
    B. Reglan 5-10mg IV q6h prn nausea if Zofran fails
    -Can give 20mg one time dose if desperate
    C. Phenergan, Compazine, possibly Ativan
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19
Q

What is used to control ‘pus’?

A
  1. Antibiotics
  2. Always on call to OR for prophylaxis
  3. Continue if infection/contamination/sepsis
    A. Kefzol 1gm (80kg) IV on call to OR
    B. If PCN allergic: Cleocin 600mg or Cipro 400mg + Flagyl 500m
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20
Q

What are the mc used abx?

A

Kefzol 1- 2gm IV q8h
Unasyn 3gm IV q6-8h
Zosyn 3.375gm IV q6-8h
Cipro 400mg IV q8-12h + Flagyl 500mg IV q8-12h
Cleocin 600mg IV q6-8h
Vanco for MRSA  pharmacy doses
If stomach involvement think fluconazole 200mg IV
If Pseudomonas  Carbapenem family or 4th gen cephalosporin

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21
Q

What are the UTI prophylaxis measures?

A

Remove Foley cath POD#1 unless indicated to keep

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22
Q

What are the atelectasis/pneumonia prophylaxis measures?

A
  1. Incentive spirometry (IS) q1h x 10 while awake

2. EARLY AMBULATION

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23
Q

What are the DVT prophylaxis measures?

A
  1. Think Virchow’s Triad & Hypercoagulable states
  2. PCD’s (pneumatic compression device) on call to OR
    A. PCD’s to pt on 8h off 1h
  3. LMW Heparin 5000 units SQ q8 - 12h
  4. EARLY AMBULATION
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24
Q

What types of dressings are available?

A
  1. Dry dressings
  2. Wet-to-dry dressings
  3. Chemical-impregnated dressings
  4. Foam dressings
  5. Alginate dressings
  6. Hydrofiber dressings
  7. Transparent film dressings
  8. Hydrogel dressings
  9. Hydrocolloid dressings
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25
Q

Describe dry dressing

A
  1. Simple, inexpensive, & widely available
  2. Used on wounds w/small amounts of exudate
  3. Can stick to the wound bed of heavily exudative wounds
  4. Soak off
  5. Can expose the wound to the outside environment
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26
Q

What chemical can be infused into the chemical impregnated dressings?

A 
Povidone-iodine (Betadine) 
Silver
Petroleum
Collagen
Antibiotics
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27
Q

What needs to be considered with chemical impregnated dressings?

A
  1. Cost
  2. Availability
  3. Potential for allergic reactio n
28
Q

Describe a foam dressing

A

1, Additional foam padding to protect wound fields
2 .Self-adherent
3. Absorptive & provide a moist healing environment
4. Protect wounds that resulted from pressure, friction, or shear
A. Early-stage pressure ulcers

29
Q

What are wet to dry dressings used for?

A

Used for wounds requiring debridement

30
Q

Describe a wet to dry dressings

A
  1. Saline-soaked gauze placed w/in wound w/exudate or drainage → as dressing dries, it pulls exudate out of the wound. A. Now negative-pressure wound therapy (NPWT), aka Vacuum Assisted Closure (V.A.C) “Wound-VAC”
31
Q

What are the disadvantages of wet to dry dressings?

A
  1. Nonselective w/ debridement (removes healthy & necrotic tissue)
  2. Wet-to-dry dressings may appear inexpensive, but labor & frequency of dressing changes makes them fairly costly
  3. Time-consuming to apply & generally painful to remove
32
Q

What is alginate dressing made of?

A

Composed of calcium, calcium or sodium salts, or seaweed w/in a gel dressing

33
Q

How does a alginate dressings function?

A
  1. Contact w/ wound bed activates the gel; apply a secondary dry dressing
  2. Provides moist environment for healing & good absorption of exudate
34
Q

What is alginate dressing used for?

A
  1. Treats wounds w/large amounts of exudate

2. Ulcers, donor sites, tunneling wounds, bleeding wounds

35
Q

What are the advantages to alginate dressings?

A
  1. Good for hemostasis

2. Does not adhere to the wound

36
Q

What is a hydrofiber dressing made of?

A
  1. Composed of the polymer, carboxymethylcellulose (absorbs exudate)
  2. Manufactured in sheets to place in wounds that have considerable exudate
  3. The sheet materials swell on contact w/exudate, absorbing it
  4. Cut dressing to a size just larger than wound cavity & use a secondary dressing
37
Q

Does hydrofiber dressing affect hemostasis?

A

Does not affect hemostasis

38
Q

What is transparent film dressing?

A
  1. Thin layer of plastic that covers the wound area
  2. Provides no absorption
  3. Create a barrier to the environment
  4. Allow some oxygen exchange to reduce anaerobic bacteria growth & wet environment to promote healing
39
Q

What is transparent film dressing used for?

A
  1. Used for wounds w/dry eschar or superficial skin tears

2. NOT recommended for infected wounds

40
Q

What is hydrogel dressing used for?

A
  1. Used for autolytic debridement
    A. Promotes the body’s own natural functions of removing necrotic tissue
  2. Maintains moist wound environment
  3. Used for wounds w/ necrosis, infection, moderate amounts of exudate, & a need for a moist healing environment
  4. DO NOT use on dry gangrene or dry ischemic wounds
41
Q

How often should hydrogel be changed?

A

Change dressing qd or qod

42
Q

What is the disadvantage to hydrogel?

A

Expensive

43
Q

What is hydrocolloid dressing used for?

A
  1. Used for autolytic debridement
  2. NOT recommended for infected wounds but helpful for wounds that are vulnerable to infection
  3. DO NOT use to treat dry gangrene or dry ischemic wounds
44
Q

How does a hydrocolloid dressing work?

A
  1. Do not allow oxygen to enter the wound, which can lead to anaerobic bacteria growth
  2. Not transparent, so difficult to assess wound between changes
45
Q

How often is a hydrocolloid dressing changed?

A

Stay in place up to 7 days but may be changed more often if they become saturated

46
Q

What are the goals of surgical drains?

A
  1. To decompress/drain fluid or air from the surgical area
  2. To prevent the accumulation of fluid (blood, pus & infected fluids)
  3. To prevent accumulation of air (dead space)
  4. To characterize fluid (i.e. early identification of anastomotic leakage)
47
Q

What are the characteristics of an open drain?

A
  1. Open → drains fluid on to a gauze pad or into a stoma bag

2. ↑ the risk of infection

48
Q

What are the characteristics of an closed drain?

A
  1. Closed → formed by tubes draining into a bag or bottle
  2. Chest, abdominal & orthopedic drains
  3. Risk of infection is reduced
49
Q

What are the characteristics of active drains?

A

Active drains are maintained under suction (low or high pressure)

50
Q

What are the characteristics of passive drains?

A

Passive drains have no suction & work according to the differential pressure between body cavities & the exterior

51
Q

What are the characteristics of silastic drains?

A

relatively inert & induce minimal tissue reaction

52
Q

What are the characteristics of red rubber drains?

A

can induce intense tissue reaction, sometimes allowing a tract to form

53
Q

What are the general drain rules?

A
  1. Ensure drain is secured
    A. Dislodgement can occur when transferring patients
    B. Dislodgement can ↑ risk of infection & irritation to surrounding skin
  2. Accurately measure and record drainage output
  3. Monitor changes in character or volume of fluid
  4. Identify any complications resulting in leaking fluid
    A. Bile, pancreatic secretions, blood
  5. Use measurements of fluid loss to assist IVF replacement
54
Q

When should a drain be removed?

A
  1. Should be removed once the drainage has stopped or
55
Q

How can drains be shortened?

A

Drains can be ‘shortened’ by withdrawing them gradually (typically by 2 cm per day)

56
Q

How is a drain removed?

A
  1. Warn the patient that there may be some discomfort when the drain is pulled out
  2. Consider the need for pain relief prior to removal
  3. Place a dry dressing over the site where the drain was removed
  4. Some drainage from the site commonly occurs until the wound heals
57
Q

What are the indications for a Foley catheter?

A
  1. Acute retention
  2. Urinary obstruction
  3. Need for strict I+O’s
  4. Intra-op placement
  5. Post-op urological procedures
  6. Need to keep pt dry due to non-healing ulcers
58
Q

When should a foley be removed?

A

Foley should be pulled POD #1 unless indicated

59
Q

What are common causes of hematuria?

A

Common causes include bladder CA, trauma, UTI, radiation/chemo cystitis, stones, kidney lesions

60
Q

What is the work up for hematuria?

A

Work up includes UA, Urine C+S, Cystoscopy

61
Q

What is included in CBI: continuous bladder irrigation?

A
  1. Must place a 3-way catheter. Saline only
  2. ALWAYS IRRIGATE NO CLOTS!
  3. Constantly flushes the bladder to avoid obstruction
  4. Strict I+O’s
62
Q

What are post-op surgical duties?

A
  1. Daily rounding & routine management

2. Management of acute issues/ post-op complications

63
Q

What is included in daily rounding?

A
  1. Differs case to case, but surgical discharge criteria more or less are the same
    A. Pain controlled on PO meds
    B. Tolerating a diet
    C. Back to baseline functionality (usually)
    D. Voiding
  2. How’s is pain? OOB & walking? Passing gas? Having BM? Urinating? CP, SOB, N/V/D, fever,cills? Any other problems or concerns?
64
Q

What are progress notes?

A
  1. POD #
  2. Short subjective of previously mentioned criteria
  3. Review Vitals, Labs, I/O’s
  4. Surgically focused exam- General, Heart, Lungs, Abdomen, Extremities. Anything else as needed
  5. Make note of incision/dressings, any drains, ports, IV access
65
Q

What is included in the assessment/plan regarding post-op?

A
  1. Address any chronic medical comorbidities being managed

2. Be thorough, med changes,procedures, therapy, consults, diagnostics, social

66
Q

What are potential post-op complications?

A
  1. Fever
  2. Abscess/ anastomotic leak
  3. Chest pain
  4. Respiratory distress
  5. Bleeding
  6. Low urine output
  7. Electrolyte abnormalities
  8. Ileus
  9. Hypotension/ Sepsis
  10. Arrhythmias

Gen Med: Surgery (6 decks)

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