Post-Op Care and Complications - Exam 1 Flashcards by Johannah Crumpton

What are the 3 primary goals of the first 2 phases of postoperative care?

Homeostasis

Pain Control

Prevention & early detection of complications

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What are the 3 phases of postoperative care?

Immediate/Post Anesthesthetic Observation

intermediate phase: hospitalization period

convalescent phase: time from hospital discharge to full recovery

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Who is the main provider in the immediate postoperative period? What are their main focuses? How long does it take to be discharged from this period?

anesthesiologist

cardiopulmonary recovery, neurologic function, and pain control

Usually ready for d/c from recovery room within an hour or 2

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What 4 things are done from Immediate to Intermediate period?

Discharge from Recovery Room and transfer to hospital floor

Admit Orders

PostOp Note (Procedure Note)

Operative Report

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In the post-op note, what sentence super needs to be included?!

were the surgical counts correct??

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How long can you leave the sterile dressings on for after sx? What needs to happen when it gets changed?

48 hours

Must change under sterile technique within first 48 hrs

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**When does sutures or staples need to be removed based on the location? ______ are applied once sutures/staples are removed

Face
abdomen
extremities

Face : 3-5 days
Abdomen: 8-10 days
Extremities: 10-14 days

steri-strips are applied

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Epithelialization of the wound occurs in the ______. What is the recommendation with regards to keeping the wound dry?

first 48h

showering is okay but NOT submerging the wound for 2 weeks

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______ can be used if the wound cannot be closed

wound vac

they can be cut to fit

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If utilized, when are drains typically removed? What needs to be included in your order?

Typically removed in 3-5 days, once output diminishes

Orders include how often to check drains and record output, looking for signs of infection and the appearance of the drain output

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How long does pulmonary function decrease post-op? When does it return to baseline?

Remains markedly diminished for 12-14 hours postop, Slowly increases over next 5-7 days

Typically returns to baseline after 7 days

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**What is the MC pulmonary risk? What are 2 ways to minimize the risk?

Atelectasis

incentive spirometry and early mobilization

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What is the goal for incentive spirometry?

GOAL: ~500ml/cc
10 x per waking hr

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**What is the basic rule for maintenance fluids? What are your 2 fluid options?

Either LR or 0.9% NS

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When are fluid needs the highest?

over the first 24 hours postop, fluid needs are greater

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**What is the hemoglobin value cutoff before a pt REQUIRES a transfusion?

A Hemoglobin < 7 (in any patient) or < 8 in patients with cardiac, pulmonary, or cerebrovascular disease require blood transfusion.

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**What is used most commonly for blood transfusions? **How much does it increase the Hg?

packed RBCs

General rule: 1 unit of RBC’s increase Hg by 1g/dL and Hct by 3%

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For pain control, for the first 48 hours start with ____form then switch to ____ form

IV/patient controlled analgesia (PCA)

then switch to oral

If patient is tolerating PO intake post op they can have PO meds

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______ are used most commonly for postop pain control. _______ can be used in conjuction

opioids

NSAIDs, celecoxib, acetaminophen, gabapentin

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______ is used when a pt breaks more than 5 ribs

Spinal/Epidural/Caudal

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______ GI complaint is very common after abdominal surgery. What is the associated timing? What should you do next?

diminished peristalsis

first 24 hrs, slowly improves over 72 hrs

NG tube may be necessary - ileus

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What are the 3 ways to prevent DVT post-op?

Medications - most commonly Lovenox (LMWH) or SQ Heparin

Compression stockings/SCDs

Early ambulation

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If it okay to have a fever immediately post-op?

YES! it is okay if IMMEDIATELY post-op

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What are the “5 W’s” that are common complications a patient may experience post-op? When will a fever show up for each?

Wind: Atelectasis/Pneumonia
24-48hours post-op

Water: UTI
Fever 3-5 days post op

Wound: superficial or deep infection
Fever 5-7 days post op

Walking: DVT or PE
Fever 7-10 days post op

Wonder Drugs: medications or blood products
Fever at anytime post op

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What are the additional 2 "W"?

(W)Abscess fever (5-7d) Waterway "bloodstream": concerned for bacteremia within 24 hours

_____ is the MC postoperative pulm complication. Occurs in up to _____ of patients after abdominal surgery

atelectasis 25%

_____ is the most common cause of fever in the first 24-48h after surgery

atelectasis

What is atelectasis caused by?

Collapse of the bronchioles Caused by shallow breathing and failure to hyperinflate the lungs

What are risk factors for atelectasis?

smokers COPD increased secretions that can lead to obstructions elderly

Why is atelectasis a problem post-op? When will an infection develop?

decreased oxygenation of blood and it can lead to infection If atelectasis persist for >72h - pneumonia will develop

What is the tx for atelectasis? What are the 3 prevention strategies?

Deep breathing exercises/incentive spirometry/coughing Chest percussion, bronchodilators Bronchoscopy if severe Early mobilization Incentive Spirometry

When does pneumonia develop post-op?

tends to occur within 3 - 5 days postop

Fever, Tachypnea, Tachycardia Hypoxemia diminished breath sounds at bases

atelectasis

Fever, tachypnea, shortness of breath, increased respiratory secretions auscultatory crackles or diminished breath sounds

pneumonia

What will pneumonia sound like if you percuss?

dullness to percussion if consolidation is present

What is the tx for coverage of postoperative hospital acquired pneumonia with no other risk factors or known resistance:

Ceftriaxone (Rocephin), Ampicillin/Sulbactam (Unasyn), Levofloxacin (Levaquin), Ertapenem (Invanz)

What is the tx for pneumonia if concerns about resistant organisms or coverage for pseudomonas?

Piperacillin/Tazobactam (Zosyn), Cefepime (Maxipime), Imipenem

What is the MC cause of pulm related post-op death?

pneumonia

Cough SOB Chest pain Fever Dullness to percussion Decreased tactile fremitus Asymmetrical chest expansion What am I? What is the treatment?

pleural effusion small and causing no respiratory compromise: nothing!! causing respiratory compromise or also have pneumonia -> drain

What surgeries are associated with the highest risk of pneumothorax?

with subclavian central line placement or after surgery where diaphragm may be punctured (adrenalectomy, nephrectomy)

Sudden shortness of breath Chest pain/tightness Hypoxia Tachycardia Tachypnea Unequal breath sounds Hyperresonance with percussion Decreased wall expansio What am I? What is the tx?

pneumothorax thoracostomy (chest tube)

What is the MC organism for a UTI? What increases the risk post-op? What is the tx?

e coli Risk increases with prolonged catheterization (>2 days) cipro or Rocephin

_____ is a very common cause of post-op fever AFTER 48 hours

UTI

How do you dx urinary retention? What will you see? What is the tx?

Bladder scan with PVR of >400mL bladder cath (Foley)

What will the pt complain about with urinary retention? What context will you see it?

Abdominal/pelvic pain discomfort very painful!!! after spinal anesthesia

______ collection of blood caused by inadequate hemostasis. What are the risk factors?

hematoma anticoags coagulopathies marked-postop HTN vigorous coughing/straining after sx

What is the tx for a hematoma? Where are the 3 common sites?

Small hematomas may resorb on own Compression Dressing Evacuation of hematoma, ligation of bleeding vessels Breast, Joints, Thyroid

Where are the 2 most serious places on the body for a hematoma?

Neck: cut off air supply Spine: compress spinal cord

What are 2 ways to prevent hematomas?

Stop anticoagulants Drain placement intraoperatively

_____ is a collection of serous fluid. Where does it normally come from? What is it caused by?

seroma Typically from lymphatics Caused by transection of lymphatics

Where are 3 common places for a seroma?

Axilla Breast (post-mastectomy) Inguinal region

What is the tx for a seroma?

Needle aspiration, compression dressings If recurrent or severe = surgical wound exploration

_______ complete or partial disruption of any or all layers of incision. What is an evisceration?

wound dehiscence Rupture of all layers exposing internal organs

Where is the MC site for a wound dehiscence? What age range is a risk factor?

Abdominal Age > 60

What is the clinical presentation of wound dehiscence?

Most commonly occurs between POD 5-8 May start with increased drainage from incision, or sudden opening Absence of “healing ridge” by day 5

What is the tx for wound dehiscence? What is the area is small?

Moist towels and binder until surgical consult –return to OR Debridement and Reclosure of fascia - skin typically loosely approximated - heal by secondary intention (Retention Sutures/wound vac) small: Small areas of wound dehiscence that are not full thickness can be managed with meticulous wound care and not require operative intervention

What is the MC organism for a wound infection? What are the 3 types of surgical site infections?

staph aureaus superficial deep organ/open space

______ no hollow viscus entered, no inflammation/infection, no breaks in aseptic technique, primary wound closure, non-traumatic surgery

clean

_______ hollow viscus entered but controlled, no inflammation/infection, minor break in aseptic technique, primary wound closure

clean contaminated

_______ Uncontrolled spillage from viscus, inflammation/infection apparent, traumatic wounds, major break in aseptic technique

contaminated

_______ Untreated, uncontrolled spillage from viscus, pus in operative wound, open dirty traumatic wound

dirty

What are host risk factors for a surgical site infection?

DM Hypoxemia Immunosuppressive drugs Cigarette smoking Malnutrition Poor skin hygiene/contaminated or infected wounds

What is the management and treatment for a surgical site infection?

Culture Abx Surgical debridement

What are the abx prophylaxis treatment for surgical site infections? What is colorectal or appendix involvement? When should the pt receive it?

Cefazolin (Ancef) Ceftriaxone (Rocephin) Cefoxitin (Mefoxin) add Metronidazole (Flagyl) or Clindamycin Give one dose 30 minutes before incision and typically no longer than 24 hrs post op.

What is the timeframe for a normal functional postop ileus?

For first 24 - 72 hrs

What is an abdominal obstruction usually due to? When? How do you dx? What will it show?

Obstruction usually due to adhesions/blockage Usually occurs later in post op phase KUB XR- pronounced air fluid levels with distinct dilation above area of obstruction for bowel obstructions

If the obstruction occurs early post-op, what type of surgery is it MC with?

colorectal sx

Abdominal distention Abdominal Pain Absence of flatus Protuberant tense abdomen Tympanic abdomen to percussion What am I? What is the treatment?

ileus and obstruction NG tube decompression bowel rest/NPO

______ is the main risk associated with postoperative abx use

“Pseudomembranous Colitis”, “Antibiotic Associated Colitis”

malodorous diarrhea, abdominal distention, pain What am I? How do you dx? What is the tx?

C diff colitis stool culture abx

What is the complication of C diff colitis? How do you prevent it?

Toxic Megacolon contact precautions

_____ and ____ are the highest risk sx associated with CVA

Carotid Endarterectomy (CEA) open heart surgery

What are the 3 risks factors for CVA post-surgery?

Elderly Patients with severe known atherosclerosis severe hypotension during surgery (bleeding, sepsis, etc)

When are dysrhythmias common during sx?

Common during induction of anesthesia and during surgery - typically self limiting

What is the prevention of MI in the sx setting?

Stabilizing any underlying cardiovascular disorders prior to elective surgery

What is phlebitis caused by? What does it lead to? When will the fever show up?

Caused by needle or catheter introduced into the vein causing inflammation of the vein Can lead to infection and thrombosis common cause of fever after 72h

What is the tx for phlebitis?

removal of catheter/warm compresses/NSAIDS Abx and excision of affected area of vein with suppurative phlebitis

What is the prevention of phlebitis?

GOOD ASEPTIC TECHNIQUE rotation of insertion site

What is virchow's triad for thrombosis?

**fat embolism are MC associated with what type of surgeries? What is happening?

Orthopedic surgeries/long bone fractures Tiny fat globules entering bloodstream through bone marrow

Respiratory distress/hypoxemia, petechiae of axilla and chest, neurologic abnormalities mostly asymptomatic What am I? What is the onset after surgery?

fat embolism Onset - 12-72h after surgery

How do you dx fat embolism? What is the tx?

clinical, MRI can show emboli in the brain Symptomatic respiratory support

What are the criteria to discharge a pt?

______ phase begins once a pt is home and continues over the weeks/months post operatively

Convalescent Phase

When do you need to f/u with surgeon after sx? When do you f/u with PCP?

surgeon: Typically at 2 weeks, sooner with issues PCP: Recommend 2-4 weeks post discharge for continuity of care