Preop Flashcards
Health Care Proxy Vs. Living Will
Health Care Proxy
Statement by the patient appointing someone to manage health care
treatment decisions in the event that the patient is unable to do so
nA copy of these must be put in the chart treatment decisions in the event that the patient is unable to do so
nA copy of these must be put in the chart
n
Living Will
Document prepared by the patient & Lawyer providing specific
instructions about what medical treatment the patient chooses to
accept or refuse in the event that the patient is unable to make such
decisions.
Restorative/ reconstruction
restores function or appearance to traumatized tissue
pallative
reduce pain/symptoms, does not produce a cure
comestic/plastic
performed to improve personal appearance ( plasty)
laparoscopic cholecystectomy
surgical removal of gallbladder through open incision
Emergent
immediate need
urgent
within 24 hrs-48 hrs ( find a tumor…)
required
scheduled surgery
elective
recommended - not required ( cataracts) (tonsils ) (back surgery)
optional
patients’ desire or choice ( breast augmentation) (face lift)
Preoperative Risk Factors
A potential or actual problem or condition that could cause an
adverse reaction, complication, or fatality to the patient during the
peri-operative period
Pre-Operative Risk Factors:
nDrugs
nSteroids
nNSAIDS
nChemotherapy
nImmunosuppressive
nAnticoagulants
nChronic Disease
nLifestyle
Time Out Sheet
Patient safety:
Universal Protocol/Surgery Procedure Record:
nEnsures that patient is prepared for surgery
nVerification of surgery/procedure
nLocation of surgery (part of body)
nConfirm patient identity
nReduces chance for potential error
- Malignant Hyperthermia
first sign is
vSusceptible pts exposed to certain general anesthetic agents-
succinylcholine (Anectine) and inhalation agents)
Life threatening
vInitial s/s: increased expired CO2, muscle and jaw rigidity,
tachycardia, tachypnea, dysrhthmias, hypoxemia, metabolic acidosis
( blood PH d/t hypoxemia), unstable blood pressure, high fever-
Malignant Hyperthermia
TREATMENT: ( medications stated 2)
nOxygen (hyper-oxygenate) * 100% oxygen*
nOR Nurse- Initiate active cooling (chilled IV fluids, cooling
blanket)
nDantrium (dantrolene sodium) IV
nSodium Bicarbonate IV (for met. acidosis-low PH)
nProtocol displayed in ALL Surgical suites
Malignant Hyperthermia (cont.)
PREVENTION:
v during preop assessment obtain a thorough patient history of
previous reactions to anesthesia
vas well as any family history of reactions to anesthesia (including hx
of MH)
vnotify anesthesia provider immediately
Latex Allergy
nHigh Risk Groups- add healthcare workers to list
nSigns and Symptoms (S&S):
nLocalized
nSystemic
nTreatment: epinephrine, antihistamines (Benadryl), latex-free
environment
nThorough pre-op questioning
nIdentify all patients with actual or suspected latex allergies with
wristband
risk: tropical fruits/spinal Bifida/ alot of surgeries in life
General Anesthesia:
vUse of inhalation and skeletal muscle relaxation
vGiven IV and/or inhalation
vPatient has loss of sensation/pain, consciousness, and reflexes
vRequires advanced airway
management
vUsed for “major surgeries”
Anesthetic given IV and inhalation:
Sedative Hypnotics- IV
( BAM)
Nonbarbiturate hypnotic: Propofol (Diprivan)
a.Barbiturates: pentothal, brevital
b.Benzodiazepines:
-midazolam (Versed)
-diazepam (Valium)
-lorazepam (Ativan)
Narcotics:
Anticholinergics:
Muscle relaxants:
Narcotics: (opioids -provide analgesia, induce and maintain
anesthesia) morphine, fentanyl, dilaudid
Anticholinergics: (depress gastric secretions and motility) robinul,
atropine
ADD: Antiemetics (prevents nausea/vomiting): zofran, reglan
Muscle relaxants: (cause skeletal muscle relaxation, allowing for
easier intubation) succinylcholine
IV Induction Agents
Induction- administration of anesthetic agent for placement of
endotracheal tube (ET) or laryngeal masked airway (LMA)
vGiven IV- smooth and rapid induction with short duration of action.
Barbiturates: sodium pentothal
Others: propofol, succinylcholine, etomidate, ketamine
Inhalation Agents:
Administered through mask or ET tube while on mechanical
ventilation
ET tube permits control of ventilation,
from aspiration
protects the airway
n
nExamples:
nVolatile liquid: isoflurane, desflurane, sevoflurane, (halothane)
nGaseous agent: nitrous oxide
(relax)
(paralyze)
nSuccinlcholine, anectine- depolarizing agent (relax)
nPavulon, curare- non-depolarizing agent (paralyze)
Undesirable Effects
of General Anesthesia
Decr ciliary-HRF infection (pneumonia)/ HRF ineffective airway
clearance RT increased secretions
Loss of gag reflex- HRF aspiration
Snoring- HRF ineffective airway clearance
Atelectasis- HRF ineffective gas exchange
Hypotension- HRF ¯ cardiac output, increased HR
Decr peristalsis- HRF constipation/altered bowel
Diagnostic surgery
going in the patient looking
Palliative Surgery
providing relief
ablative surgery think “ ectomy”
the removal or destruction of a body part or tissue or its function.
reconstructive
one to correct facial and body abnormalities caused by birth defects, injury, disease, or aging
Pre Induction-
Induction-
Maintenance –
Emergence –
pre-anesthesia evaluation
and sedation to reduce pt anxiety
administration of anesthetic with
endotracheal intubation
positioning pt, prepping skin,
surgical procedure, anesthesia maintained
surgery complete, anesthetics
are decreased, pt begins to waken, airway
removed
Post Op Pulmonary Complications: Atelectasis (cont.)
Assessment:
I- poor chest expansion; poor cough
P- uneven expansion; decreased excursion; absent or decreased
“99” where no air is moving
P- consolidation=dullness on percussion
A- crackles, decreased breath sounds,
Hypostatic pneumonia –
.
due to ̄ mobilization of secretions/stasis –
RT poor C&DB, secretions, lying in bed, poor resp effort
Aspiration pneumonia –
mechanical / chemical reaction in the lungs
Pleurisy
symptomatic unless pneumonia
Hemorrhage
Internal –
Refer to Shock Content for assessment and treatment guidelines
External-
Wound – must assess the dressing frequently postoperatively.
nPhlebitis:
nVenous Thrombosis:
n SVT (Superficial Vein Thrombus):
n DVT (Deep Vein Thrombosis):
nVenous Thromboembolism (VTE): includes DVT and PE (pulmonary
emboli)
SVT and/or DVT caused by:
- Venous stasis
- Injury to vessel wall
- Increased blood coagulability
Patients at highest risk for DVT or SVT:
nDehydrated, fluid volume deficit
nStroke pts – 75% in affected side
nSpecific surgeries – Gyn – esp vaginal / abdominal hysterectomy,
prostate, bladder, orthopedic
nDrugs – hormonal replacements, birth control
nFamily history of DVT
nBedrest, occupations with prolonged sitting/standing
nVaricosities, obesity, elderly, smokers
SVT:
s/s and treatment
Symptoms: palpable, cordlike vein. Surrounding area may be itchy,
tender, reddened and warm.
Treatment: arm/leg exercises, TEDS, ambulation, ASA, NO
massage/rubbing to area, (anticoagulant therapy is not usuallyneeded for superficial vein thrombus)
Deep Vein Thrombus
S/S:
nTenderness on palpation
nPain, severe cramping, or heaviness
nEdema; discoloration
nPositive Homan’s sign (if leg vein)
nMalaise, fever
Location: axillary or subclavian veins of arms; femoral or iliac veins of legs
DVT
Diagnosis:
nBloodwork: H & H; aPTT; INR; bleeding time; platelet level; D-
dimers
nDoppler ultrasound
nVenogram : CT and/or MRI
DVT PREVENTION
nPrimary Goal for all surgical patients = Prevention of DVT formation
nEarly ambulation or T & P Q2hr minimum if on bedrest
nHip and knee flexion exercises if not contraindicated
nPneumatic Compression Devices: Flowtrons, Foot Pumps; DVT
cuffs, etc.
nCompression stockings - TEDS, JOBST, ace bandages
nProphylactic anticoagulants:
nUH: Heparin
n Vitamin K Antagonists: warfarin (Coumadin)
nLMWH: Lovenox, Fragmin
nDirect Thrombin Inhibitors: Arixtra
DVT TREATMENT
nSurgical :
nUH, LMWH, or Factor Xa Inhibitor and warfarin
nMonitor appropriate labwork
- watch out for shaving
nUH, LMWH, or Factor Xa Inhibitor and warfarin
nMonitor appropriate labwork
nBleeding precautions
nThrombolytic agent
nMonitor for & prevent PE
nSurgical :
nVenous thrombectomy
nGreenfield Filter
Pulmonary Embolism-
PE: Blood clot/ mass of cells lodged in pulmonary artery
Diagnosis: ______scan;
PE: Blood clot/ mass of cells lodged in pulmonary artery
nPartial or total occlusion resulting in loss of blood flow to 1 or more
lobes of lung
nEmbolism may be bone, fat, air, blood, foreign object, amniotic fluid
Life threatening!!!
Diagnosis: V/Q scan; ABG; Chest x-ray; CT
Pulmonary Embolus
Pulmonary Embolus
S/S: Vary on size of embolus
n Chest Pain ( head of the bed with oxygen)
n Tachycardia,
n tachypnea,
n Dyspnea,
n Skin changes-
n LOC changes- hypoxia
n Hemoptysis- blood in sputum
n Cough, crackles, wheezes, cyanosis
Anticoagulation Therapy
For DVT prophylaxis: (subcutaneous)
nUH (Heparin SC) and LMWH (Low molecular weight heparin)
nWhen given as prophylaxis – given in low doses that and routes that do not change lab values significantly or need monitoring
nIV Heparin –
given according to WEIGHT BASED at first then adjusted to aPTT
time q6h ® qd to prevent further thrombus
naPTT values:
n Normal also referred to as control; varies according to type of
reagent/test used by lab
nControl/Normal aPTT value = 30 – 40 seconds
nFor treatment of DVT need anti-coagulated values which is an aPTT
nFor treatment of DVT need anti-coagulated values which is an aPTT
at 1.5 – 2.5 times control (also called therapeutic level)
nAntidote for heparin = NEED TO KNOW!
protamine sulfate***
Warfarin (Coumadin) Therapy:
nNormal/Control/ value PT -
n PT Therapeutic levels -
nINR therapeutic levels-
(normal = )
nAntidote for Coumadin =
Warfarin (Coumadin) Therapy:
nUsually started within 24 hrs of heparin initiation
nOral dosage
nAdjusted daily according to Prothrombin time (PT) and International
Normalized Ratio (INR)
nPT normal
nNormal also referred to as control; varies according to type of
reagent/test used by lab
nNormal/Control/ value PT - 11 – 12.5 seconds
n PT Therapeutic levels - 1.5 – 2 X control value
nINR therapeutic levels- 2 – 3
(normal = 0.75-1.25)
nAntidote for Coumadin = Vitamin K
Adjusted daily according to Prothrombin time (PT) and International
Normalized Ratio (INR)
Tells you how long it takes for your blood to clot
NEED TO KNOW*
DVT prophylaxis
Orthopedic surgery
DVT Treatment
Pulmonary embolism
Preferred INR
1.5-2.0
2.0-3.0
2.0-3.0
3.0-4.0
BLEEDING PRECAUTIONS:
nNo razor (electric ok)
nIM very cautiously with pressure after
n pressure on bleeding areas
nSoft toothbrush
nAvoid trauma- risk of internal bleeding
nOn coumadin – Health teaching patients to keep Vit. K foods
consistent (Dark green veggies) Don’t change amount daily.
nAntidotes on unit AAT –
nHeparin –protamine sulfate (aPTT)
nCoumadin –Vitamin K (PT/INR)
nDo not give anticoagulants if :
nAny existing bleeding – vaginal, rectal, urinary, open wounds,
aneurysm
nAlcoholism
Heparin-
Coumadin-
Heparin- aPTT
Coumadin- PT/INR
Post Op GI Complications-
Causes-
1. Anesthesia
- Pain
- Manipulation of internal organs
- Pain
- Manipulation of internal organs
Treatment-GI
v NPO, progressing to clear to full liq to regular diet
nOften order written as “Advance as tolerated”
v Antiemetic meds
v Pain meds
v N/G tube prn
v Prevent injury to suture line
FUNCTIONAL BOWEL
(s/s)/ upper vs lower
A.Paralytic Ileus –
define : Peristalsis does not return to parts of the bowel within 3-5 days post op
Signs and symptoms –
ØUpper intestine- discomfort, mild distention, nausea / vomiting
ØLower intestine –Colicky pain, distention evident, tympany on
percussion, vomiting- may look like fecal matter (but usually pt has
been NPO and bowel emptied before OR)
GI Complication: Paralytic Ileus
Diagnosis
Diagnosis:
nX-ray - Flat plate abdomen
nEndoscopy
nGI series
nIAPP
Paralytic Ileus-
Treatment
(lay on WHAT SIDE)
ØOOB and AMBULATE!!!
ØNPO until + bowel sounds – listen carefully
ØNG tube in or unclamped
ØGive metoclopramide (Reglan) if ordered –GI stimulant
ØAvoid meperidine (Demerol) – slows smooth muscle.
Ø Pt should lie on RIGHT side when in bed
Post op GI Complication: Bowel Obstruction mechanical
Causes:
vIntussusception
vTumors
vStrictures / hernias
vAdhesions from previous surgeries (scar tissue that grows in
peritoneum between and around organs)
vAbscesses
Bowel Obstruction – mechanical
(Signs and symptoms:)
v Pain – crampy, wavelike, colicky
vAbdominal distention
vLeakage or passing blood or mucus rectally
vNo stool, No flatus
vVomiting intestinal contents
vS/S dehydration-?? 3rd spacing
“Third Spacing” =
fluid shifts to an area not contributing to
equilibrium
3rd spacing
causes/s/s / rx
nSurgical trauma- esp. bowel surgery of bowel obstruction, burns,
peritonitis, bleed into joints causes inflammatory process.
nS/S - imbalance of fluid – more in than out
nOliguria, look of dehydration, poor VS but lots of IV fluid in.
nBowel can sequester (hold) up to 12 Liters
nWeight gain – each Liter of fluid retained =1kg = 2.2 lbs.
nRx – hypertonic IV to draw fluid from cells to intravascular spaces
Bowel Obstruction – mechanical
Diagnosis –
Abdominal x-ray, CBC, Chemistries
Treatment – NPO, monitor VS esp Temp., minimal pain meds until Dx
made.
vNG tube (Salem sump), Miller-Abbott tube
vEndoscopy
vExploratory laparoscopy/laparotomy
Nasogastric (NG) Tube
Used to decompress stomach & upper GI tract, rest GI system,
decompression for obstruction
Levin- single lumen
Salem Sump- double lumen with air vent
Pt NPO
Assess-
nPlacement, drainage, patency, tape/pin
nSuction (intermittent or low continuous)
nI/O, Fluid &Electrolyte balance, Labs
nOral care, nasal care, HOB , T&P q2h
nAssess bowel sounds (turn off suction first)
NG Complications
nDehydration
nFluid &Electrolyte imbalance
nHyponatremia – low sodium (Na+)
nHypokalemia –low potassium (K+)
nMetabolic alkalosis
nHunger-irritable- assess depression
nGood oral care
Electrolyte imbalances
nSodium (Na+) imbalance – fluid & electrolyte shifts. ̄ Na+ = less
water retained
Na+ = fluid volume excess
nPotassium (K+) imbalance – muscle contractility affected – esp
heart muscle
̄K+ OR K+ -both need attention and medical collaboration -
meds
RULES for KCl use IV
(potassium chloride)
nCheck lab values of K+ and Na+ often
nEKG done if ordered
nMust have urine output >30cc/hr- KCL is excreted by kidneys
nEKG done if ordered
nMust have urine output >30cc/hr- KCL is excreted by kidneys
nNever more than 80 mEq / liter of IV flds -40 mEq/L preferred amt
nIVPB – NEVER IV PUSH
nRate of infusion
Post Op Wound Care
Wound Drains:
1.
2.
3.
Wound Drains: Reduce edema, drainage
1. Penrose
- Jackson Pratt drain- works by suction, must be compressed
.
3. Hemovac- must be compressed
Must empty drains every shift and prn
Responsibilities with drains
nAssess q time of vitals and more often prn
nMaintain compression of JP drains and Hemovac
nExpect large amount of drainage on drsg. with penrose drains
nDon’t expect much drainage on drsg with JP & Hemovac drains if
working.
nBe careful when moving pt.- drains are not always sutured in!!
Wound Separations
nDehiscence –
S/S –
nEvisceration –
S/S –
pt.
TREATMENT –
Wound Separations
nDehiscence – wound edges open and disintegration of underlying
layers
S/S – open incision. Serous oozing. Wound pain
nEvisceration – contents of body cavity protrude through dehiscence
S/S – organs through skin, gush of fluid
nEvisceration – contents of body cavity protrude through dehiscence
S/S – organs through skin, gush of fluid
pt. Feels something pop! Or let go!
TREATMENT –
NS soaked STERILE Drsg- must keep moist
CALL surgeon STAT
Wound Healing
primary
secondary
tertiary
refers to when doctors close a wound using staples, stitches, glues, or other forms of wound-closing processes.
Secondary wound healing, or secondary intention wound healing, occurs when a wound that cannot be stitched causes a large amount of tissue los
delayed primary closure, occurs when there is a need to delay the wound-closing process.
VQ scan
measures the airflow (ventilation) and blood flow (perfusion) in your lungs. You breathe in and are injected with radioactive material while a provider takes pictures of your lungs
