Surgery: Post-op Flashcards
what is included in “early mobilization” to prevent complications of post-op? (5)
- Deep breathing and coughing
- Active daily exercise
- Joint range of motion
- Muscular strengthening
- Make walking aids such as canes, crutches and walkers available
infection is usually confined to what?
SubQ tissues
surgical wound classification 1-4
KNOW
(1) Clean : no gross contamination from exogenous or endogenous sources
1. 5%
(2) Lightly contaminated: clean-contaminated
2–5%
(3) Heavily contaminated: 5–30%
(4) Infected: in which obvious infection has been encountered during operation
two types of surgical site infections (SSIs)? There are two types of the 1st SSI
Incisional SSIs
Superficial: Incisional (skin and subcutaneous tissues)
Deep: Incisional (deeper soft deep fascia, muscles, and tissues beneath subcutaneous tissue of the incision)
Organ/space SSIs
Any part of the anatomy other than body wall layers that was manipulated during the procedure
Host factors that contribute to surgical infections (9) KNOW
Diabetes mellitus Hypoxemia Hypothermia Leukopenia Nicotine (tobacco smoking) Long-term use of steroid or immunosuppressive agents Malnutrition Nares colonization with S aureus Poor skin hygiene
prophylactic abx are indicated for what two types of “surgical classification”s ? when are they discontinued?
(kinda weeds)
clean contaminated or contaminated cases
- use for just about for any big surgery (b/c most will be clean-contam.)
- discontinue usually within 24 hours of operation
Abx resistance risk factors in post-op patient (6)
1) . Immunodeficient / compromised
2) . Implants/invasive devices
3) . Elderly patients
4) . Illness severity
5) . Extended LOS (length of surgery)
6) . Exposure to broad spectrum antibiotics
*but wont really change how we prophylax
one of the most common wound complications that is almost always caused by imperfect hemostasis? (KNOW)
hematoma (collection of blood and clot in the wound)
why are hematomas bad for post-op? how to prevent them? (KNOW)
Increased chance of dehiscence (opening up of the wound) and infection (due to poor circulation).
-give anti-coags and make sure wound is DRY
what is a seroma? why are they bad? how to prevent them? (KNOW)
Fluid collection in the wound other than pus or blood. Seromas delay healing and increase the risk of wound infection; prevent them by placing drains
what is wound dehiscence? when is it most commonly seen? (KNOW)
Wound dehiscence is partial or total disruption of any or all layers of the operative wound. (ABD)
most commonly observed between 5th-8th postoperative days, when the strength of the wound is at a minimum
MOST important factor in preventing wound dehiscence ? (KNOW
adequacy of closure: performing a neat incision, avoiding devitalization of the fascial edges by careful handling of tissues during the operation, placing and tying sutures correctly, and selecting the proper suture material.
what gives “strength “ to a closure?
The fascial layers give strength to a closure, and when fascia disrupts, the wound separates.
the most common single cause of morbidity after major surgical procedures? (KNOW)
pulmonary complication
what type of operations are pulmonary complications most common? (KNOW)
emergency operations (also chest and upper abd operations)
most common pulmonary complication? affects 25% of patients who have _______ surgery. how is it fixed? (KNOW)
atelectasis (lung collapse); abdominal surgery
-self- limited
fever within 48 hours post-op MOST likely means what? (KNOW)
atelectasis (over 90% of febrile episodes)
most common pulmonary complication among pts who die post-operatively? (KNOW)
Pneumonia
fat particles are found in 90% of patients with these two types of injuries? fat embolism can also be caused by (3)?
- fractures of long bones or joint replacements.
- exogenous sources of fat, such as blood transfusions, intravenous fat emulsion, or bone marrow transplantation.
fat embolism syndrome (KNOW)
consists of neurologic dysfunction, respiratory insufficiency, and petechiae of the axillae, chest, and proximal arms.
to dec cardiac complications, how do we want the blood to be during surgery and then after? when do we stop oral anticoags? (KNOW)
sticky/thicker during surgery, Thin after
-Oral anticoagulant drugs should be stopped 3–5 days before surgery, put back on after
what is bridging anti-coag? who might need this?
use of a short-acting parenteral agent to reduce the interval without anticoagulation
-patients on warfarin with an especially high thromboembolic risk
cardiac complications: General anesthesia depresses the _______, and some anesthetic agents predispose to what?
what do you do about this? (KNOW)
myocardium; predispose to dysrhythmias by sensitizing the myocardium to catecholamines.
-Monitoring of cardiac activity and blood pressure during the operation detects dysrhythmias and hypotension early.
cardiac complications: In patients with a high cardiac risk, _______may be safer than _________for procedures below the umbilicus. (KNOW)
regional anesthesia (e.g. nerve block) may be safer than general anesthesia
how does post-op ileus occur?
Anesthesia and surgical manipulation result in a decrease of the normal propulsive activity of the gut
GI peristalsis returns when after post-op ileus?
within 24 hours after most operations that do not involve the abdominal cavity
what is gastric dilation? how does it present?
a rare life-threatening complication, consists of massive distention of the stomach by gas and fluid
-patient appears ill, with abdominal distention and hiccup
diagnosis and txt of gastric dilation? (KNOW)
XRay (to see gas) and gastric decompression with a nasogastric tube.
In the late stage, gastric necrosis may require gastrectomy.
how to differentiate between ileus and obstruction? (KNOW)
plain film (xray) - obstruction will show lots of gas stuck in there
bowel obstruction is most often caused by what?
how does it present?
Mechanical obstruction is most often caused by postoperative adhesions or an internal (mesenteric) hernia
-patients experience a short period of apparently normal intestinal function before manifestations of obstruction supervene.
post-op fecal impaction presentation
Early manifestations are anorexia and obstipation or diarrhea. In advanced cases, marked distention may cause colonic perforation.
- results from ileus and impaired perception of rectal fullness
how common is post-op fever? how bad is it?
Fever occurs in about 40% of patients after major surgery.
In most patients the temperature elevation resolves without specific treatment.
BUT important, if there are other symptoms as well, evaluate clinically cause could be significant
Features often associated with an infectious origin of the fever include (6)… how many of these must be present for the chance of a bact. infection to be near 100%
KNOW
- preoperative trauma,
- ASA class above 2
- fever onset after the second postoperative day
- initial temperature elevation above 38.6 °C
- postoperative white blood cell count greater than 10,000/L
- postoperative serum urea nitrogen of 15 mg/dL or greater.
If three or more of the above are present, the likelihood of associated bacterial infection is nearly 100%.
fever after 5th post-op day may indicate what? (KNOW)
wound infection or less often, anastomotic breakdown and intra-abdominal abscesses.
Dx test for wound infections/ intra abd abscess? (KNOW)
CT scan of the abdomen and pelvis is the test of choice and should be performed early, before overt organ failure occurs.
The 5 W’s: commonly cause post-op fever
KNOW
1) . Wind: pneumonia, aspiration, PE
2) . Water: UTI (foley)
3) . Walking: DVT PE
4) . Wound: SSI (surgical site infection)
5) . Wonder drugs /What did we do? drug reaction, infection from vascular access, blood product reactions
post-op fluid replacement is based on what 4 things
(1) maintenance requirements
(2) extra needs resulting from systemic factors (eg, fever, burns)
(3) losses from drains
(4) requirements resulting from tissue edema and ileus (third space losses).
best test for renal fxn
how much urine is produced
how much fluid do you replace?
multiplying the patient’s weight in kilograms times 30
eg, 1800 mL/24 h in a 60-kg patient
fluid maintenance requirements are increased by what 3 factors?
Maintenance requirements are increased by fever, hyperventilation, and conditions that increase the catabolic rate.
Assessment of the status of fluid balance requires accurate records of what? how do you record this?
fluid intake and output; by weighing the patient daily.
patient’s post-op progress should be monitored and those observations include? (4)
- comment on medical and nursing observations
- specific comment on wound/op site
- any complications
- any changes made in tx
what is the focus of post-op aftercare?
prevention of complications
when does prevention of post-op complications start?
PRE-OP: ex quitting smoking and losing weight
and the second most common cause of postoperative deaths in patients older than 60 years? (KNOW)
pulmonary complication
two surgical locations that are prone to pulmonary complications?
chest and upper abdominal
course of atelectasis?
most cases, the course is self limited and uneventful recovery
pts at high risk of thromboembolic dz should receive what until 6 hrs prior to surgery? (KNOW)
heparin
when can heparin be restarted after surgery? (KNOW)
36-48 hrs
postop dysrhythmias may be the first sign of what? (KNOW)
MI
supraventricular dysrhythmias usually have ____ consequences but may decrease what? (KNOW)
few; cardiac output and coronary blood flow
treatment for pts with atrial flutter or afib with rapid ventricular response? (KNOW)
cardioversion
ventricular premature beats are often precipitated by what? (4) KNOW
hypercapnia, hypoxemia, pain or fluid overload
which type of dysrhythmia has a more profound effect on cardiac function? KNOW
ventricular- bc can lead to fatal ventricular fibrillation
over ___% of post op MI are asymptomatic
50%
cessation of smoking for ___ weeks before surgery decreases the incidence of postoperative pulmonary complications from ___% to __%
6 weeks; 50% to 10%
Correction of _______ ________ decreases intra-abdominal pressure and the risk of wound and respiratory complications and improves ventilation postoperatively
gross obesity
Perioperative factors (things healthcare workers do) to surgical infection (8) KNOW
operative shaving
breaks in sterility
inadequate dosing of ABX, delayed ABX
poor wound care
Infected or colonized surgical personnel (skin or surgical attire)
Prolonged hypotension
Poor operating room air quality (contaminated ventilation)
Contaminated operating room instruments or environment
predisposing factors/risk factors for post-op pneumonia? (5) KNOW
peritoneal infection those requiring prolonged ventilatory support Atelectasis aspiration copious secretions
risk factors for atelectasis? (4) KNOW
elderly
overweight
smoke
have symptoms of respiratory disease.
risk factors for pulm aspiration? KNOW (6)
NG or ET tubes drugs that suppress NS reflux food in stomach patient position trauma pt
to decrease cardiac complications what do you do for the first 3-4 days post-op? KNOW
continuous electrocardiographic monitoring to detect episodes of ischemia or dysrhythmias
people with high risk of thromboembolic dz should receive heparin until what point pre-op? when should it be restarted? (KNOW)
up until 6 hrs before surgery; restarted 36-48 hrs after (debated)
when to start and stop warfarin for surgery?
stop 5 days before and restart within 24 hrs
some non-cardiac complications that can cause cardiac probs? (3) KNOW
fluid overload
sepsis
hypoxemia
what type of procedures increases risk of post-op MI? KNOW
operations for manifestations of atherosclerosis
clinical manifestations of post-op MI (3)
hypotension, chest pain and cardiac dysrhythmias
what is the most common cause of post-op heart failure? KNOW
fluid overload (in pts with limited myocardial reserve)
risk factors for GI motility complications (5) KNOW
general anesthesia surgical manipulation meds- opioids electrolyte abnormalities inflammatory conditions- pancreatitis, peritonitis
complications of GI immobility post-op (3) KNOW
gastric dilation
bowel obstruction
post-op fecal impaction
predisposing risk factors for gastric dilation (6) KNOW?
asthma
recent surgery
gastric outlet obstruction
absence of the spleen
infants and children in whom oxygen masks are used in the immediate postoperative period
adults subjected to forceful assisted respiration during resuscitation
risk factors for post-op fecal impaction? (4) KNOW
ELDERLY
post-op ileus
opioids
anticholnergic drugs
how to diagnose and tx post-op fecal impaction (KNOW)
rectal exam
tx: manually removed, enemas given, and digital exam repeated
