surgery 3 Flashcards
instruments that pick up tissue and for closure (graspers)
adson rongeur
pituitary rongeur
pick-ups
what are hemostats used for
stop bleeding
kelly clamp
used for clamping large amount of tissue in bowl resection- messentery
kocher clamp
can grab bone and other firm tissue
enteral feeding
NG tube (most common)- short period of time (these put pts at aspiration risk) NJ tube (nasaljejunal)- reduce reflux, use if impaired gastric motility, short period of time PEG tube (percutaneus endoscopic gastrostomy) long period of time, indications- stroke, parkinsons, esophageal cancer Percutaneous jejunostomy tube- early postoperative feedings, used in pts w/ risk of reflux
benefits of enteral of parenteral
Enteral feedings lead to more rapid advancement of PO feedings
Fewer infections
Lower costs
Shorter hospital stays
More physiologic way to provide nutrition
dumping syndrome
when food leaves the stomach too fast and enters bowel too early
sxs- faintness, palpitations, diaphoresis, pallor, tachycardia and hypoglycemia
tx- slow down infusion of nutrition or change to one w/ more complex carbs
parenteral nutrition
used when oral route can not be used
central locations are SVC, IVC, or RA
estimating fluid loss
Hourly urine output
Daily weights
Skin turgor, mucus membrane moisture
Orthostatics
normal daily maintenance requirements
Water-2500 ml (35 ml/kg) Sodium-100 mEq Potassium-60mEq Chloride-100 mEq Calories-2000 (25 cal/kg) (if pt has ng tube these change)
colloids
5% and 25% Albumin
Fresh-frozen plasma (FFP)
6% hydroxyethyl starch (Hetastarch)
Dextran-40 10%; Dextran-70 6%
isotonic
.9% NaCl
Lactated ringer
hypotonic
.45% NaCl
D5 .45% NaCl
fluid compartments
intracellular 2/3 (interstitial, intravascular, thirdspace)
extracellular 1/3
when determining fluid status
Urine output
Serum Sodium
Urine osmolality (easiest as urine Na)
(bp and edema are also important)
ideal fluid for maintenance
0.45% NaCl + 20 mEq KCl
estimate fluid requirements for pts w/out fever
obligate fluid loss 1500
for daily- 1500+ 20 mL/kg for each Kg >20 to max of 3900 mL/ day
for hourly- 60 + 1mL/kg for each Kg >20 to max of 3900 mL/day
how much do water requirements increase w/ fever
100-150ml/day for each degree fever > 37C
hypovolemia due to decreased intake or excess excretion
.45% NaCl until labs back
if Na>145 then switch to .25% NaCl
if Na<138 then switch to .9% NaCl
run at 125 mL/hr unless hemodynamically unstable
renal perfusion should be 30cc/hr (minimum)
hypovolemia due to vomitting or diarrhea
0.9% NaCl (NS) until labs are back
If serum Na > 145 change to 0.45% NaCl
hypovolemia due to hemorrhage
Bolus 1-2 LITERS 0.9% NaCl (NS) or LR through large bore IVs until labs are back
Continue fluid resuscitation based on vital signs and urine output
Packed Red Blood Cells (PRBC) as soon as available
Monitor electrolytes, ABGs and vitals
Gross estimate of renal perfusion is to make 30cc/hr (minimum) urine
rules of 9
head 9 anterior chest 9 anterior abdomen 9 posterior same for total of 18 each arm-9 (anterior 4.5 post 4.5) each leg 18 (ant 9 post 9) groin 1
fluid calc for burn
4 x weight in kg x % TBSA burn
Give ½ of that volume in first 8 hours
Give other ½ in next 16 hours
isotonic fluids are fluids of choice
great way to watch fluid status
keep weighing the pt
history for water depletion
if water depletion- thirst and hypernatremia
intravascular depletion-bp,hr, jvp, cool extremities, dry mucous membranes
ecf depletion- skin turgor, sunken eyeballs, weight
fluid maintenance for kids
Maintenance fluid volume 24 hour period
Weight 10kg to 20kg – 1000mL for first 10kg of body weight plus 50mL/kg for any increment of weight over 10kg
Weight from 20 to 80kg – 1500mL for first 20kg of body weight plus 20 mL/kg for any increment of weight over 20 kg up to a maximum of 2400mL daily
Maintenance fluid needed on an hourly basis:
Weight < 10kg – 4mL/kg per hour
Weight >10kg to 20kg – 40mL/hour for first 10kg of body weight plus 2 mL/kg per hour for any increment of weight over 20kg
Weight >20kg to 80kg – 60mL/hour for first 20kg of body weight plus 1 mL/kg per hour for any increment of weight over 20kg to a maximum of 100 mL/hour, up to maximum of 2400mL daily
signs of volume depletion
lack of jvp at 45 tacycardia oliguria postural hypotension orthostatics decrease skin turgor dry mucous membrane organ failure
signs of volume overload
HTN increased jvp gallop rhythm edema pleural effusion pulmonary edema organ failure
