Surgery tools Flashcards
SKIN GRAFTING
harvest site
Harvest site:
Hair/hairless
Color
Elasticity
Size requirements
POST-ANESTHESIA CARE UNIT (PACU)
“PACU, Recovery room, RR”
Monitor patients following surgery
One nurse to one patient
Frequent assessment
Monitor vital signs
Anesthesia has primary responsibility for cardiopulmonary function
Any items related to anesthesia
Surgery team oversees surgical site and other non-anesthesia issues
15-30 minutes up to 3-4 hours
PACU
Monitoring
Blood pressure – frequently (5 -15 minutes) to continuously (Arterial line)
Pulse – frequently to continuous
Pulse oximeter – continuous
EKG – continuous
Temp – initial and prior to discharge
Acute changes communicated immediately
PACU
Dressing/wound and IVF/urine output
Assess for drainage
Bleeding
Dehiscence
Cast/brace – ’fit’
IVF and urine output
Foley or “void prior to discharge” or collect in urinal
POST-OPERATIVE CHECK
PACU (if going home)
Prior to D/C
Communicate with patient/Family
Floor/Unit
Check 4-6 hours after discharge
Communicate with patient/family
Check wound, fluids, vitals since surgery, PULSE
Assess pain control, diet, activity, drainage
OPERATIVE NOTE
Communicates essential information
Acute change in recovery room
For ‘on-call’ coverage
For billing/coding
Legal defense
Surgery, surgeon, assistant, anesthesia
Fluids, blood loss, implants, complications, prep, dressing
Disposition
THINK: 4 weeks, 6 months, 3 years later??
Anyone should be able decipher what was done and why with all details
OPERATIVE NOTE
Written/EHR
Done immediately – prior to leaving OR
Essential communication for PACU/On-call/Anesthesia
OPERATIVE NOTE
Dictation
Complete operative report
Billing/Legal/Informative
OPERATIVE NOTE
what needs to be included
Patient, DOB, ID number/MR#
Operation performed +/- indication
Preoperative diagnosis
Post-operative diagnosis
Anesthesia
Surgeon
Assisting surgeon/Assistant
Surgical findings
Basic prep, position, findings
Unusual issues, findings or outcomes
Specifics of approach, drains, dressing, closures
Estimated Blood Loss (EBL)
Intravenous fluids (IVF)
Drains
Specimen
Complications
Disposition
Awake
Intubated
To RR, PACU, ICU
Continued under anesthesia for next portion
Discharged home
(Follow-up)
OPERATIVE NOTE
Don’t forget:
Who is dictating/writing
Why done
Specific Surgery
Complications (major)
Be appropriate
Mention what matters and could have an effect
No one cares that a knot had to be redone- as long as it is fine now
POST-OPERATIVE ORDERS
general
Order sets versus written orders
Determine status
Inpatient
Recovery room or Extended recovery
Observation
Medications, pain control, antibiotics
Nursing and ancillary instructions and orders
Discharge instructions, diet, activity, dressing, follow-up
ADMIT
Where is the patient going to end up that day?
Most go to PACU – but then where
Extended recovery – up to 24 hours
Observation – Medicare status up to 24-72 hours
Floor - which floor
ICU/Step-down
Home – discharge
Same day surgery unit – planning to discharge
DIAGNOSIS
Admitting diagnosis
Used for billing, bundling
Generally don’t use “status-post” as primary diagnosis
S/P Lap chole
Use: ‘Cholelethiasis’ or ‘cholecystitis’
S/P left knee replacement – ‘Osteoarthritis with knee pain and disability”
Must justify level of admission and location
CONDITION
One-word description of status
Good, fair, poor, guarded, grave
“stable” – not a good descriptor
VITALS
Frequency of vitals
Note any special vitals
Understand what are “routine vitals” at your institution
BP, Pulse, Temp, Resp, Pain
Daily weights?
Arterial line?
CVP/Swan
Continuous pulse ox
EKG/Telemetry
ALLERGIES
All medication allergies
Relevant allergies
Latex
Peanut – if significant and life threatening
Seasonal allergies? – NO!
NURSING
Specific orders for nursing
Dressing changes, wound check
Drains to handle, record, remove
Foley, urinal, strain urine
Ins/Outs (I/O’s)
Monitoring
Positioning in bed
DIET
Dietary orders
Not just oral intake
TPN, tube feeds, supplements
Remember co-morbid conditions
Diabetes – ADA +/- cal
CAD
Gluten, lactose, soft mechanical,
NPO
‘Regular’
ACTIVITY
Stay in bed/out of bed
Up to chair
Ambulation?
Be aware of number of tubes/drains/poles required to ambulate
LABS
Which labs to draw and when
Call with results?
Alert levels outside of normal range?
Frequency (if applicable)
Only order if needed – avoid routine daily labs unless truly indicated
IV
List which IVF
Rate
Indications to stop?
Number of total fluids
Hours
When taking PO
‘SLIV’ = saline lock IV
SPECIAL STUDIES
X-ray, CT, MRI
Swallowing studies, stress test, Echo
Telemetry could go here, EKG on arrival or in AM
MEDICATIONS
Home meds
Only what is needed or harmful to stop
Be conscious of intake and route
Does it matter if they skip a dose of a vitamin or supplement?
Specific for surgery
Antibiotics
Pain medications
Regional blocks
Nausea/vomiting
Prophylaxis
Gastric acid suppression
DVT
Comfort/Hospital specific
Sedatives
Sleep
Laxatives/Softeners
POST-OPERATIVE PAIN
Each patient is different
Each surgery is different – EVEN IF IT IS THE SAME SURGERY
Patient perception
Severity of surgery
Complications, length, involvement
POST-OPERATIVE PAIN MEDICATION
Intravenous
Morphine
Dilaudid (hydromorphone)
Demerol (meperidine) – not used much due to risk
Patient Controlled Analgesia
Type of drug
Frequency
Dose
Basal Rate (continuous infusion)
Oral
Narcotic based (Lortab, Percocet, Tylox, Vicodin, Darvocet, Percodan)
Codeine, Oxycodone, hydrocodone
Tramadol
Non-narcotic (NSAID – Ketorolac, Ibuprofen, Tylenol)
ASA – bleeding properties
Be aware of all components of medications
Tylenol in Lortab/Percocet
NSAIDs, ASA
POST-OPERATIVE PAIN MEDICATION
Scheduled
PRN
IV or Oral or PCA
Regional pain control
Block, epidural, spinal
Antispasmodics
Muscle spasms
Neuropathic
Sedation
“Reasonable control”
“Tolerable”
Surgical patients will have pain
Addiction worries are over-inflated acutely
Longer term pain control
Switch to non-narcotic when feasible
Expect pain, just control it
ACUTE RETURN TO OR
Bleeding – internal or external
Wound dehiscence
Abnormal drainage/output
Vascular, lymphatic, CSF
Possible collateral injury
Ureter, bowel, bladder, esophagus perforation
Nerve injury, compartment syndrome
Pneumothorax
Retained objects – instruments, sponge, sharps
