Surgical Nursing Flashcards
list benefits of performing a neurological exam
breaks down complex presentations
identify if neurological or other condition
localisation of condition
aid diagnosis and prognosis
continual assessment of patient condition
state aims of neuro exam
determine if condition is neurological
determine where the condition is
determine potential causes
what is the purpose of localisation of neuro conditions?
aids differential diagnoses
where can neurological conditions be localised to?
brain - forebrain, cerebellum, brain stem
spinal cord - C1-C5, C6-T2, T3-L3, L4-S2
peripheral nerves
neuromuscular
what is the 5 finger rule of localisation (neuro)?
signalment
onset - acute vs chronic
progression
symmetry
pain
what are the different parts to a neuro exam?
hands off observation
hands on exam
what is examined in hands off observation in neuro exam?
mentation
gait
posture
what is examined in hands on observation in neuro exam?
postural reactions
spinal reflexes
cranial nerves
sensory evaluation
palpation
what should be considered when assessing mentation?
state - alert, obtunded, stuporous or coma
are reactions to environment as normally expected for this patient
what should be considered when assessing gait in a neuro exam?
common presentation, not always neurological
can they generate coordinated movements and walk normally
breed differences
head turn or tilt, ventroflexion, curving of the spine
decerebrate rigidity or decerebellate rigidity
stance
how is a gait exam performed?
owner walks animal up and down at varying speeds as needed
can use sling or support if needed
what is decerebrate rigidity?
extension of all limbs, head and neck
non-ambulatory in lateral
what is decerebellate rigidity?
extension of thoracic limbs, head and neck
hind limbs flexed or flacid
what is the purpose of testing postural reactions?
test sensory nerves in ascending tract in spinal cord, brainstem and forebrain, descending tracts in brainstem and spinal cord, motor neurones and muscles
why cant postural reaction tests localise neuro lesions?
tests are affected by lesions in any area
list types of postural reaction tests
proprioception - replacing feet
hopping - lift each leg in turn and move from side to side
visual placing - should place feet when moved to table
tactile placing - same as visual but eyes covered
hemi-walking and wheelbarrowing
what does spinal reflexes test assess?
all limbs function
how are thoracic limbs tested in spinal reflexes?
withdrawal
extensor carpi radialis and biceps brachii reflexes
how are pelvic limbs tested in spinal reflexes?
withdrawal
patella and cranial tibial and gastrocnemius reflexes
list types of spinal reflex tests
thoracic limbs
pelvic limbs
perianal reflex
panniculus reflex
cutaneous trunchi reflex
how are withdrawal reflexes tested?
non-painful pinching of the toe inducing a reflex
how is a patella reflex test performed?
knocking patella hammer to cause kicking
how is perineal reflex tested?
pinching around perineum to cause contraction
how is paniculus reflex performed?
pinching thoracic skin causing flinching of the skin
how is cutaneous trunci reflex performed?
pinching along each side of the spine to observe skin twitches
what is the purpose of cutaneous trunci reflex test?
tests segmental nerve to aid localisation
list tests for cranial nerves
menace response
gag reflex
PLR
oculocephalic reflex
nystagmus
palpebral reflex
describe the menace response
reaction when hand moved to the face
describe the oculocephalic reflex
observing eye tracking when moving the head
how do you assess sensory function in neuro exams?
panniculus reflex
deep pain perception
where are deep pain tracts found and what is the impact of this?
in the spinal column
only affected by severe spinal damage
how do you assess deep pain?
pinching digits to induce pain, should see reaction not just reflex
why do you palpate to assess neuro function?
detect any abnormalities
why is pupillary assessment important in neuro patients?
can be miotic, mydriatic or anisocoria
rapid deterioration indicated when pupil goes from miotic to mydriatic, intense monitoring and treatment needed
midsized fixed pupils indicate very poor prognosis, brain herniation or brain death
monitor for any changes
define miotic pupils
constricted
define mydriatic pupils
dilated
define anisocoria
asymmetric pupils
which motor neurones can be effected by brain or spinal cord lesions?
upper and lower motor neurones
where are UMNs located?
between cerebral cortex and spinal cord
what do UMNs do?
send signals to LMNs
what is the effect of UMNs being damaged?
stronger reflexes than normal
increased muscle tone with chronic muscle atrophy
where are LMNs located?
connect CNS to effector organ
what do LMNs do?
cause effector organs to contract
what is the effect of LMNs being damaged?
weak or absent reflexes
reduced muscle tone and rapid muscle atrophy
flacid paresis and paralysis
what is the purpose of grading spinal cord injuries?
allows objective assessment
ongoing monitoring
aids prognosis
what is seen in grade 1 spinal injuries?
pain
no neurological deficits
normally walking
what is seen in grade 2 spinal injuries?
ambulatory paraparesis
walking with neurological defecits
weakness or incoordination of pelvic limbs
what is seen in grade 3 spinal injuries?
non-ambulatory paraparesis
unable to walk without assistance but good pelvic limb movement
what is seen in grade 4 spinal injuries?
paraplegia with intact nociception
no voluntary movement in pelvic limbs
can feel toes
deep pain positive
what is seen in grade 5 spinal injuries?
paraplegia without nociception
no voluntary movement in pelvic limbs
deep pain negative
what assessments should be done for nursing neuro patients?
consider previous and current conditions
normal activities to make care as normal as possible
owner desires and expectations
owners ability to care
what are patient considerations for neuro patients?
ambulation
surgery
continence
temperament
recumbency
normal routine
what are common nursing considerations for neuro patients?
decreased motor activity
bladder and bowel management
pressure sores
wound management
pain management
respiratory support in severe cases, may get aspiration pneumonia
state the purposes of physiotherapy
improve local and body circulation
reduce pain
bond with patient
prevent pressure sores
aid motor recovery
improve joint health
limit muscle wastage
prevent contracture
what are the goals of physiotherapy?
relearn motor movements
stimulate proprioceptive relearning and gait
when should you start physio?
as early as possible and increase intensity
list types of physiotherapy
massage
PROM
assisted exercise
active exercise
proprioceptive exercise
neuromuscular e-stim
hot/cold therapy
hydrotherapy
laser therapy
how is massage performed?
light pressure applied to patients limbs in strokes and circular movement
move towards heart if oedema
what are the benefits of massage?
calms patient
prepares for handling
aid circulation
mobilised dermal and subdermal tissue
warms muscle
how is PROM performed?
flex and extend joints through normal range of motion
what are the benefits of PROM?
improve joint health without active contraction
aid gait patterning
what are examples of assisted exercises?
standing
walking
sit to stand
stand to sit
3 legged standing
weight shifting
list examples of active exercise?
walking in different patterns
un assisted sit to stand
hydrotherapy
list examples of proprioceptive exercises
standing
wobble board
uneven surfaces
over poles
weaving
what are the benefits of neuro patients having physio on different surfaces?
aids sensory relearning
what are benefits of hot/cold therapy?
muscle relaxation
analgesia
what are the benefits of neuromuscular e-stim?
increased tissue perfusion
minimise muscle atrophy
how does e-stim work?
causes muscle contraction in patients who cant actively contract their muscles
what are considerations for physiotherapy on neuro patients?
previous injuries and surgery
patient temperament
client expectations and limits
disease processes
neurolocalisation
what is a common condition post-op in neurological patients?
urinary incontinence
list potential bladder issues
UTI
bladder atony - weakening bladder muscles
pyelonephritis
what makes UTI common in neuro patients?
urine is static in bladder as patient cant urinate continently
what can be a consequence of bladder distension?
pain
describe UMN bladder
distended
hard to express
describe LMN bladder
distended
easy to express
why does overflow incontinence happen?
patient is unaware bladder is full so urine leaks out
what are consequences of overflow incontinence?
urine scalding
risk of UTI
how do you manage neuro patients bladders?
manual expression 3-4x daily
intermittent catheterisation 2x daily
indwelling catheter
drug therapy to relax bladder to aid expression
why are neuro patients normally able to defecate without issues?
passing faeces is initiated by rectal wall stretching
what is a consideration for neuro patients who are continent?
may not be able to move away from excretions
what injury can make defecation reflex overactive?
UMN injury
how do you manage neuro patients bowel movements?
keep clean
check regularly
give opportunities to go on normal environment
why do pressure sores occur commonly in neuro patients?
likely recumbent
compression of local circulation causing ischemic necrosis
what is the progression of pressure sores?
mild erythema to full thickness ulcers and open wounds
how do you prevent pressure sores?
thick bedding
turn every 2-4 hours
donut bandages
porous bedding
inco pads
prop up with pillows
physio
close monitoring
keep skin dry
rapidly aggressively treat if start to form
how can you protect feet of neuro patients?
bandages or foot covers
how do you treat pressure sores?
keep clean and dry
debride if needed
antibiotics if needed
bandaging
how do you manage neuro patients surgical wounds?
cold therapy
analgesia
primapore initially
prevent patient interference
no neck leads for ventral slot
why do ventral slots have less issues than hemilaminectomy?
go through less tissue and muscle
less skin movement in recovery so hemi more prone to seromas
when can neuro patients self mutilate?
deep pain negative
paraesthesia
boredom
stress
define paraesthesia
feeling sensations that arent there
where does neuro surgery pain come from?
IVD
facets
nerve roots
muscles
meninges
tissue damage and compression causes pain
what are the benefits of preventing acute pain?
stop chronic pain
why is respiratory management important in neuro patients?
prone to hypoventilation
atelectasis due to recumbency
pneumonia
especially important in C spine patients
how does aspiration pneumonia occur and what are the consequences?
inhalation of GI contents causing pulmonary damage and inflammation
predisposes to bacterial infection
list signs of aspiration pneumonia
coughing
tachypnoea
harsh lung signs
crackles on auscultation
how do you care for aspiration pneumonia patients?
close monitoring
antibiotics
IVFT
oxygen
respiratory physio
may need ventilation
feed from height
regular turning
what are types of respiratory physiotherapy?
nebulisation - 10-15 minutes, in sternal if possible, breaks up secretions
vibration - shake patients chest walls on expiration for loosen aspirates
coupage - 10 minutes, loosens and allows patient to cough up secretions
define atelectasis
collapsed or underinflated lung
define borborygmi
stomach noises
define hyperpnoea
increased effort breathing
define ipsilateral
the same side
define modified transudate
fluid formed by leakage from normal/non-inflamed vessels
define orthopnoea
adaptation in posture to aid breathing
define TFAST
thoracic focused assessment with sonography for trauma patients
what should you consider when triaging thoracic patients?
signalment
onset
progression
what are signalment indications for different potential diagnoses for thoracic patients?
age - neoplasia more common if older, FeLV+ cats exception
species - mediastinal masses in cats
breed - tracheal collapse in yorkie, lung lobe torsion in pugs, chylothorax in afghans, FB in springer
lifestyle - indoor or outdoor cat, urban vas rural, fighting cats, gundogs
which speed of onset is more concerning in thoracic patients?
acute
list clinical signs commonly seen in thoracic surgical patients
tachypnoea
abnormal breathing - orthopnoea, hyperpnoea, dyspnoea, abdominal breathing
cough
pale mm
cyanosis
exercise intolerance
collapse
injuires
systemic illness
what is initial management of thoracic surgery patients?
minimise deterioration
monitoring
diagnostics
how can you minimise deterioration of thoracic surgery patients when first presenting?
oxygen
manage wounds if trauma and protect from further damage
what are you monitoring initially in thoracic surgery patients?
temperament
progression or deterioration
what diagnostics need to be done for thoracic surgery patients?
bloods
thoracocentesis for cytology and culture
imaging
tfast
why should you be careful radiographing dyspnoeic patients?
restraint needed may be fatal
what are the benefits of early imaging/TFAST?
determine potential causes and urgency of case
in cases of pleural effusion what should be determined?
bilateral or unilateral
volume of fluid
if need to do thoracocentesis
lab analysis
what should be determined in cases of pneumothorax?
is chest open or closed
unilateral or bilateral
volume of air
if thoracocentesis is needed
how do you assess thoracic FBs?
imaging
is it radiopaque or radiolucent
what needs to be determined as differentials in cases of soft tissue masses in the thorax?
normal structure with abnormal appearance, neoplasia or torsion
abnormal structure in thorax
diaphragmatic hernia
what are signs of trauma in thoracic patients?
skin damage
broken ribs
when can pneumothorax be seen?
with and without trauma
describe a closed pneumothorax
internal air leak from something in chest containing air (oesophagus, trachea, small airways)
very fast lung collapse
describe an open pneumothorax
external air leak
opening in the chest from trauma or iatrogenic causes such as surgery, diaphragmatic rupture, thoracocentesis complications
list signs of pneumothorax
dyspnoea
lethargy
cough
exercise intolerance
state diagnostic tests for pneumothorax
imaging
thoracocentesis
what should be determined in pneumothorax diagnosis?
if it is unilateral or bilateral
how are pneumothoraxs treated?
chest drain for conservative management of small air leaks that may heal
thoracotomy if big leak or not self sealing
list causes of thoracic trauma
accident - rta, fall, impaling
attack - dog, human, accident or not
list clinical signs of thoracic trauma
shock
dyspnoea
soft tissue damage - open wounds, bruising
orthopaedic damage to chest or body
how is thoracic trauma treated?
stabilised
surgery
list possible complications of thoracic trauma
infection
issues with healing
effusions
pneumothorax
etc
what affects prognosis of thoracic trauma?
injury severity
owners ability to fund treatment
define blebs
collection of air on the edge of lobes between lung and visceral pleura
define bullae
collection of air within lung lobes
list causes and signalment of pulmonary bullae and blebs
large breed deep chested dogs
concurrent disease
unknown cause
list clinical signs of pulmonary bullae and blebs
none unless ruptured
non-specific - lethargy, anorexia, exercise intolerance
respiratory - sudden onset dyspnoea, progressive tachypnoea, orthopnoea, coughing, pneumothorax
how are pulmonary bullae and blebs diagnosed?
radiography to diagnose pneumothorax, not lobe specific
CT for advanced assessment
how are pulmonary bullae and blebs treated?
50% respond to intermittent thoracocentesis or chest drain
thoracotomy/sternotomy for better localisation
lung lobectomy depending on number of effected lobes
what is the surgical approach to diaphragmatic ruptures?
abdominal
what are causes of diaphragmatic rupture?
blunt force trauma
increased intraabdominal pressure with closed glottis, diaphragm is weakest part
list clinical signs of diaphragmatic rupture
depends on severity, mild and vague to dyspnoea and shock
herniation of organs
torsion
dyspnoea
tachypnoea
orthopnoea
how is diaphragmatic rupture treated?
stabilise with oxygen
analgesia
IVFT
surgery - explore, reposition organs, removed badly torsed or unviable organs, repair diaphragm
place chest drains for iatrogenic pneumothorax
list causes of pleural effusion
CHF
FIP
pyothorax
tumours
haemorrhage
what are types of fluid that can be found in pleural effusions?
septic or non-septic exudates
modified transudate
transudate
blood
chlye
neoplastic effusion
etc
what is modified transudate?
fluid formed by leakage from normal/non-inflamed vessels
has high protien content
define transudate
passive fluid accumulation
list clinical signs of pleural effusion
dyspnoea
lethargy
cough
exercise intolerance
how is pleural effusion diagnosed?
imaging
bilateral or unilateral
thoracocentesis for SG of fluid, cytology, culture and sensitivity
how is pleural effusions treated?
CHF, cat pyothorax with medical management
pyothorax in dogs, diaphragmatic rupture with surgery
define pyothorax
pus in chest
list causes of pyothorax
bacterial infection - e coli in dogs, pasturella in cats
idiopathic - bites, extension from pulmonary abscess in cats
FB
oesophageal tears
pulmonary infection
list clinical signs of pyothorax
mild to severe
lethargy
inappetence
PUO
dyspnoea
how is pyothorax diagnosed?
cytology and culture of effusion
radiography
ultrasound
how is pyothorax treated?
systemic antibiotics
chest drain
lavage
sternotomy to explore, debride and flush
why do dogs typically undergo surgical treatment of pyothorax when cats is usually conservative treatment?
dogs have much higher incidences of FBs
define pericardial effusion
fluid around the heart
list causes of pericardial effusion
idiopathic
neoplastic
list signs of pericardial effusion
cardiac tamponade
depends on rate of fluid filling
why does severity of clinical signs of pericardial effusion depend on speed of development?
if it fills slowly the pericardium can stretch to accommodate larger fluid volumes
if rapidly fills pericardium cant compensate
how is pericardial effusion diagnosed?
radiography
echo
advanced imaging
cytology to see if neoplasia
how is pericardial effusion treated?
pericardiocentesis
pericardectomy
how does pericardectomy treat pericardial effusion?
stops tamponade and fluid becomes pleural effusion but unlikely large enough volume to cause any issues
list complications associated with pericardial effusion
recurrence
long term effusions cause adhesions
what determines prognosis for pericardial effusion?
underlying cause
what are the common types of pulmonary neoplasia seen?
malignant
secondary much more common than primary
list clinical signs of pulmonary neoplasia
vague
non-productive cough
haemoptysis (coughing blood)
dyspnoea
weight loss
exercise intolerance
anorexia
lameness/hypertrophic pulmonary osteopathy
describe hypertrophic pulmonary osteopathy
paraneoplastic syndrome caused by mets in legs leading to lameness
how is pulmonary neoplasia diagnosed?
bloods
urinalysis
cytology
advanced imaging
inflated imaging
how is pulmonary neoplasia treated?
palliative care
lung lobectomy if no mets
what determines prognosis of pulmonary neoplasia?
metastasis
histopathology
surgical margins
list surgical considerations for thoracic surgery patients
analgesia
manage hypothermia
IPPV
what needs to be monitored for thoracic surgery patients when not in surgery?
TRP
pain scoring
ventilation
how do you manage wounds following thoracic surgery?
prevent infection
general wound care
gels around drains to prevent air leaks
what are benefits of body bandages for thoracic surgery patients?
increase comfort
stop patient interference
reduce risk of infection
how do you care for thoracic surgery patients?
care for DUDE - IVFT, u cath if needed, feeding tubes
define thoracocentesis
puncture into pleural space for diagnostic and therapeutic purposes
what are important considerations for thoracocentesis?
prioritise patient safety
sterile prep
gloves and drape
what are the goals of thoracocentesis?
sample collection
drain fluid or air fully from pleural space
list equipment for thoracentesis
oxygen
LA
sterile prep
needle/butterfly cath/IV cath
3 way tap
syringes
extension set
kidney dish
sample tubes
refractometer
slides
what blood tubes are used for thoracocentesis and what are each for?
EDTA - EDTA
heparin - biochem
plain - culture
what are positives and negatives of using IV and butterfly catheter for thoracocentesis?
IV - can remove sharp, have to attach collection system so position may change, may kink or collapse
butterfly - have collection system attached so can do alone
describe the process of obtaining samples from thoracocentesis
use fist sample taken to avoid contamination
put in appropriate tubes
make fresh smear for cytology
check SG
what are the purposes of chest drains?
continuous or intermittent therapeutic drainage of the pleural space
why are intermittent chest drain placements not ideal long term?
risk increases with each placement
list reasons for indwelling chest drains
disease causing continued fluid or air production
large quantity of production
intermittent thoracicentesis not working
following thoracotomy
long term drainage needed
medication admin
what are considerations for indwelling chest drains?
patient temperament
patient tolerance
treatment plan
what can cause intermittent thoracocentesis not to work?
too high volumes being produced
too thick to come through butterfly cath
too high risk or causing lung trauma placing
what measures should be done following thoracotomy?
remove air/fluid from surgery
detect any air/fluid being produced from surgery complication or underlying condition
what conditions require long term drainage?
pneumothorax due to underlying disease
pleural effusion
what medications can be administered down chest drains?
LAs
saline to lavage pyo
antibiotics
chemotherapy
list types of chest drains
large bore
small bore
trocar placement
seldinger technique
what affects type of chest drains being used?
depends on type of medium being drained
what determines the size of chest drain used?
reasons for drainage
amount of fluid expected to drain
what are different methods of chest drain placement?
closed chest
open chest in surgery
where do you place chest drains?
uni or bilateral
if bilateral need on both sides if mediastinum intact
tip of drain cranioventrally to thoracic inlet
all fenestration in chest
what are the benefits of chest drain connectors?
allow efficient drainage without the risk of iatrogenic pneumothorax
how are chest drains secured in place?
sandal sutures - trocar drains
anchor flanges secures with simple sutures - seldinger
list nursing care for patients with chest drains
24 hour care
body bandage
buster collar
what are the advantages of trocar drains?
fenestrated
rigid so easy to position
lost of sizes available
good for air and fluid
large bore
dont collapse
clear so can check patency
what are disadvantages of trocar drains?
placed under GA
need SC tunnel to prevent air leaks
rigid so higher risk of lung damage and pneumothorax
needs careful training for placement and suturing
not comfortable
what are advantages of narrow bore/seldinger drains?
dont need SC tunnel
less invasive placement
air leak less likely
dont need to place under GA
easy to place and secure
versatile
more comfortable
what are disadvantages of narrow bore/seldinger drains?
more expensive
lots of parts to the drain
more likely to block
can be too long in small patients so kink or too much outside of chest
harder to place as flexible
list equipment needed for closed chest drain placement
sterile prep
anaesthetic equipment - LA or GA depending on drain
pre-measured drain
scalpel
forceps
needle holders
scissors
swabs
drape
3 way tap
syringes
extension set
kidney dish
suture material
what determines frequency of intermittent chest drainage?
RR and dyspnoea
usually done every 4-8 hours
when is continuous chest drainage normally used?
air leaks
what can be used to provide continuous chest drainage?
commercial drainage unit
heimlich valve - one way valve for air
list considerations for chest drainage
care suction wont collapse the tube or aspirate tissue
record volumes drained
how can you prevent infections with chest drains in place?
aseptic techniques
good bandage hygiene
culture before antibiotics
state analgesia that can be used for chest drains in hospital and at home
multi modal
hospital - LA, systemic opioids (care for respiratory effects), CRIs, paracetamol
home - NSAIDs, oral paracetamol
list some complications associated with chest drains
issues with placement
failure to drain
patient factors
iatrogenic issues
infection
what can cause issues with chest drain placement?
cant place
incorrect placement
ideally x-ray to check placement
list reasons for chest drains failing to drain
accidental removal
tube disconnection
obstruction
kinking
tube slipped out
how can patients interfere with chest drains?
removal of drain
damage to drain
list iatrogenic issues with chest drains
haemorrhage
haemothorax
heart or lung damage
premature removal so recurrence of issue
nerve damage
pneumothorax
pyothorax
seroma (due to high volume effusion, usually self resolves)
SC emphysema around skin incision
how do you manage infections associated with chest drains?
manage with aseptic techniques
antibiotics
may need to remove early
when should you remove a chest drain?
complications risk higher than benefit of drain
volume produced significantly reduced
recurrence unlikely
what should you do to prep for thoracotomy?
stabilise patient
surgical plan
how do you stabilise patients for thoracotomy?
oxygen
assess ASA
IVFT
bloods
what is included in surgical plan for thoracotomy patients?
drugs plan - analgesia, antibiotics
approach to surgery
kit
complications and management
what are benefits of intercostal thoracotomy?
less painful
can place chest drain with visual guidance
what should be considered when deciding to do intercostal thoracotomy?
which side and intercostal space
can it be treated with unilateral approach
describe how intercostal thoracotomy patient is prepped
clip from thoracic inlet to mid abdo
loosely tie front and back legs
keep sternum and spine level
what are the benefits of sternotomy for thoracotomy?
better for exploration and bilateral conditions
can place chest drain with visual guidance
when is sternotomy not useful to perform?
if dorsal thorax affected
do you prep patients for sternotomy?
clip from thoracic inlet to mid abdo
keep stable with cradle or sandbags
loosely tie legs out of way
what are considerations for thoracoscopy?
least painful
needs specialised equipment
limitations in procedures and visualisation
fully clip in case need to convert to open
can be in lateral or dorsal depending on procedure
list common thoracic surgery instruments
long handled forceps
scissors
needle holders
handheld or self retaining retractors
sternotomy instruments
what is a type of forceps for thoracic surgery and what are their features?
debakeys
atraumatic, fine dissection, clamping vessels
what are different types of clamps used for in thoracic surgery?
vascular/statinsky/soft palette clamps for vessels
right angle clamps for dissection
what retractors are used for thoracic surgery?
finchietto
gelpis
langenbeck
malleable
what sternotomy specific instruments are used?
chisel and hammer
oscillating saw
list other equipment for thoracic surgery
lap swabs
thick suture material
wire
suction
chest drain
tourniquet
pledget sutures
vessel loops
what are the types of electrosurgery?
monopolar
bipolar
what is needed with monopolar electrosurgery and why?
earthing plate to prevent burns
list examples of advanced electrosurgery
gen11
ligasure
harmonic
when is advanced electrosurgery used?
used instead of staples
can have various uses
expensive
define lung lobectomy
partial or total removal of one lung lobe
define pneumonectomy
removal of a lung
what makes patients manage well after a pneumonectomy?
remaining lung fills the rest of the chest
what are closure options for lung lobectomy?
sutures - slow, technical, higher risk of leakage
staples - quick, less risk of leaks, more expensive, technical
describe how to perform a leak test following lung lobectomy
fill chest with warm saline
IPPV and check for air bubbles, suction all fluid out once happy
describe the anatomy of the liver (location, lobes, attachment)
sits in cranial abdomen with 2/3 mass on midline
4 lobes - left (largest), right, caudate and quadrate, are divided into sublobes and processes
attached to diaphragm, right kidney, lesser curvature of the stomach and proximal duodenum
which main vessel runs through the liver?
vena cava
describe blood supply to the liver
recieves from hepatic portal vein and hepatic artery
blood leaves via short hepatic veins to the vena cava
highly vascular
what is the purpose of the hepatic portal vein?
carry blood from the digestive tract and spleen, rich in nutrients and 50% of oxygen supply
what proportions does the liver get blood flow from the vessels?
80% from hepatic portal vein
20% from hepatic artery
what is the purpose of the hepatic artery?
carry oxygen rich blood, providing 50% oxygen
describe how blood passes through the liver
portal and arterial blood mix in sinusoids in liver
drain into hepatic veins
leave via dorsal border into caudal vena cava
list functions of the liver
synthesis of albumin, globulin, clotting factors, glucose, cholesterol
clearance of ammonia, bilirubin, bile acids, drugs
metabolism of carbs, lipids, amino acids
production and activation of clotting factors
clearance of toxins (ammonia, drugs)
immunoregulation
GI function
storage of vitamins, fats, glycogen, copper
what can be the consequence of hepatic dysfunction on synthesis and clearance?
ascites
longer duration of albumin bound drugs
excess drug sensitivity
neurological signs
PUPD
anorexia
vomiting
what are the consequences of hepatic dysfunction on metabolism?
hypoglycaemia
lethargy
weight loss
what are the consequences of hepatic dysfunction on production and activation of clotting factors?
clotting issues
haemorrhage
what are the consequences of hepatic dysfunction on immunoregulation?
endotoxaemia
sepsis
what are the consequences of hepatic dysfunction on GI function?
weight loss
diarrhoea
list clinical signs of hepatic dysfunction
inappetence
lethargy
vomiting
diarrhoea
jaundice
ascites
hepatic synthetic failure - carbs, protein, fat, clotting factors
detox failure - encephalopathy, increased drug activity
what causes jaundice?
hyperbillirubinaemia and tissue deposition of bile pigment due to failure of routine clearance of bilirubin
what is pre-hepatic jaundice?
haemolysis causing too much bilirubin for liver to clear
what is hepatic jaundice?
failure of uptake, conjugation to water soluble form or transport of bilirubin by the liver
what is post-hepatic jaundice?
failure of excretion of bile due to cholestatic disease or biliary rupture
how does ascites occur?
fluid accumulation in abdomen due to hypoalbuminaemia and portal hypertension causing sodium and water retention
what causes detoxification failure in the liver?
hepatic dysfunction or PSS
what are the effects of detoxification failure in the liver?
failure of ammonia conversion to urea
failure of drug detoxification so longer effects
what is the effect of hepatic encephalopathy?
fore brain disfunction, is the behaviour mediator
list clinical signs of hepatic encephalopathy
lethargy
obtunded
pacing
circling
head pressing
seizure
coma
what worsens signs of hepatic encephalopathy?
high protein meal
GI haemorrhage
vomiting and diarrhoea
diuretics
what is the significance of the liver having large functional reserve?
clinical signs wont present until 70-80% functional hepatic tissue is lost
describe what happens to bile after it is synthesised in the liver
excreted into hepatic ducts which drain to common bile duct
if not digesting this goes via cystic duct to gall bladder for storage and concentration
in digestion bile leaves via cystic duct to common bile duct to duodenum
list functions of the biliary tract and bile acids
aid digestion and absorption of fats
neutralise gastric acid
inhibit gastric acid secretions to prevent intestinal ulceration
list diagnostic tests for liver disease
biochemistry
haematology
blood gas
blood glucose
electrolytes
dynamic bile acid testing
liver enzymes
bibirubin
blood clotting
urinalysis
US
CT, MRI, scintigrpahy
biopsies
list ways of managing liver disease
prescription diet
oral antibiotics
oral lactulose
describe a prescription diet for liver disease
contains levels of high BV proteins
restricted fat
copper restricted
antioxidant supplemented
why are oral antibiotics used for liver disease?
compensates for livers reduced immunoregulatory action of detoxification of pathogens in intestines
prevent endotoxemia
why is oral lactulose used in hepatic patients?
binds to ammonia so can be excreted in faeces
reduces risk of hepatic encephalopathy
list management that should be done for hepatic patients before taking to surgery
clotting times
IV antibiotics
planning GA drugs
IVFT
manage electrolyte imbalances
blood typing and cross match
general patient care
what tests should be done for clotting times before taking liver patients to surgery?
full coag panel
platelet count
APTT and PT
how often are liver patients effected with abnormal clotting times?
50%
how would you manage abnormal clotting times before taking liver patient to surgery?
treat with FFP or vitamin k to minimise risk of haemorrhage
why would you give IV antibiotics to liver patients before surgery?
bacteria is in the liver so prevents endotoxaemia and sepsis
how would you choose antibiotics for patients undergoing liver surgery?
culture liver, bile and gall bladder
give broad spectrum while waiting for results
what drugs should be avoided in hepatic patients?
any that undergo hepatic metabolism
how should you manage IVFT for liver patients?
account for additional losses and correct any electrolyte imbalances
why is blood typing important in liver patients?
significant haemorrhage a risk
may have clotting disorders
what are general patient considerations for liver patients?
water and toileting if PUPD
tempt to eat if anorexic
how can you take liver biopsies?
US guided percutaneous FNA
open or laparoscopic
what is the purpose of taking liver biopsies?
diagnosis
prognosis
what are advantages and disadvantages of US percutaneous FNA liver biopsy?
adv - least risky
disadv - poor diagnostic accuracy
what are advantages and disadvantages of surgical liver biopsy?
adv - more accurate and better samples, can grossly visualise
disadv - more risky and invasive
when is partial or complete liver lobectomy done?
mass removal
abscesses
liver lobe torsion
what are risks associated with liver lobectomy?
haemorrhage
liver failure
portal hypertension
define cholecystectomy
removal of gall bladder
define cholecystoenterostomy
rerouting gall bladder to duodenum
when are cholecystectomy and cholecystoenterostomy indicated?
biliary tract rupture
bile peritonitis
diseases causing extra hepatic biliary obstruction such as gall bladder mucocele, choleliths, pancreatitis, neoplasia
in gall bladder surgery, which part is better to try to preserve?
common bile duct better to keep than the gall bladder
what makes hepatic and biliary surgery challenging?
high risk surgery and GA
list peri-op considerations for hepatic surgery
hypotension, ideally monitor BP with art line
hypothermia
haemorrhage
IVFT
drug choices
ventilation
IV antibiotics
blood glucose
why are liver surgical patients prone to hypothermia?
liver is highly metabolic
open abdominal surgery
how should you prepare for haemorrhage during liver surgery?
haemostasis available
blood products
list post-op care for liver patients
intensive nursing for 24 hours, longer if biliary or PSS
analgesia
IVFT
antibiotics
diet management
parameter monitoring
BP
monitor for haemorrhage, hypotension
temperature monitoring
blood glucose
sepsis monitoring
check for bile leakage
mentation
PCV, TS, electrolytes, acid base
how many PSS are congenital?
80%
what are causes of congenital PSS?
65-75% extra hepatic, in small breed dogs (westie, yorkie, cairn)
25-35% intrahepatic, in large breed dogs (wolf hound, labs)
how many PSS are acquired?
20%
what causes acquired PSS?
secondary to other disease such as chronic portal hypertension
describe PSS
anomalous blood vessel connecting hepatic portal vein to vena cava/systemic venous circulation so portal blood bypasses the liver
list clinical signs of PSS
GI signs
LUTD
coagulopathies
slow growth
what causes PSS clinical signs?
reduced oxygen and nutrient supply to the liver
altered metabolism of fat and protein
low protein production
reduced detox
lower urea production and higher ammonia in urine
what is seen on labs in PSS patients?
low albumin
low cholesterol
high bile acids
high ammonia
describe how to do a bile acid stim test
12 hour fast to remove bile acids in the blood
take blood sample
feed
retake blood sample 2 hours later
use serum gel or plain tube
what causes acute liver disease?
toxins
infection
list nursing considerations for acute liver disease patients
manage encephalopathy
give lactulose
monitor electrolytes
anti-emetics
blood glucose
coagulopathies
antioxidants if needed
how is PSS treated?
hydrate and regulate blood potassium
restrict protein
lactulose
antibiotics to minimise ammonia by gut flora
surgical closure of the shunt
what are types of chronic inflammatory liver disease?
sterile or infectious
what causes sterile chronic inflammatory liver disease?
copper or idiopathic for dogs
lymphocytic cholangitis in cats
what causes infectious chronic inflammatory liver disease?
cholangitis/inflammation of bile duct system
cholangiohepatitis/inflammation of the bile ducts, gall bladder and surrounding liver tissue
leptospirosis
FIP
how is inflammatory liver disease treated?
de-coppering therapy
antibiotics
diet modification
anti-oxidants
anti-inflammatories
choleretics
treating encephalopathy
ascites management
what can you use for decoppering therapy?
chelating agent (bonds to heavy metal)
zinc therapy
prescription diet
manage water source
how do choleretics work?
synthetic bile salts to stimulate bile flow
modulates inflammatory response in liver
list metabolic liver diseases
gall bladder mucoceles
feline hepatic lipidosis
what is gall bladder mucocele?
gall bladder fills with inspissated bile and mucus
what are the consequences of gall bladder mucocele?
asymptomatic
obstruct bile flow
ruptured gall bladder
how can you manage gall bladder mucocele?
medical management
surgical removal
how does feline hepatic lipidosis occur?
hepatocyte triglyceride deposition when anorexic, fat stores mobilise for energy and accumulate in liver
list predispositions for feline hepatic lipidosis
obesity
high fat diet
high carb diet
systemic illness
diabetes mellitis
what are the effects of feline hepatic lipidosis?
intra cellular fat accumulation
liver failure - encephalopathy, coagulopathy
death
how is feline hepatic lipidosis treated?
treat underlying disease
nutritional support with tube feeding
list signs of hepatic neoplasia
asymptomatic
hepatic and obstructive symptoms
rupture and haemoabdomen
how can hepatic neoplasias be treated?
primary - surgery
infiltrative - chemotherapy
metastatic - no treatment
list primary boas problems
stenotic nares
elongated and thick soft pallete
hypoplastic trachea
excess tissue in skin and airways
everted laryngeal saccules
hyperplastic tonsils
describe how boas patients present
loud breathing
snoring
exercise and heat intolerance
gagging
regurg
list compensatory mechanisms for boas
harder inspiratory pull
what are the consequences of boas compensatory mechanism
negative pressure in the throat, neck and chest causing secondary respiratory and GI issues
list secondary boas problems as a result of compensatory mechanisms
hiatal hernia
laryngeal collapse
reduced quality of life
regurg and aspiration
how is boas diagnosed?
physical exam
history
sedated exam
fluroscopy
barium swallow
CT
rhinoscopy
chest x-rays
list management of BOAS long term
dont breed, especially if clinically affected
minimal stress
avoid heat
manage weight
harness not collar
surgery to correct abnormalities
list pre-op considerations for boas surgery
bloods
asa grade
oxygen
minimal handling and stress
eye lube
prepare for regurg
what can lead to shorter prognosis of boas patients?
if severe disease
list surgical options for boas patients
shorten and thinning of soft pallette
laryngoplasty
laryngeal tie back
wedge resection of nostrils
what is laryngeal paralysis?
dysfunction of the laryngeal nerves causing paralysis of the larynx.
what is the consequence of laryngeal paralysis?
fails to open on inspiration and close on swallowing
can cause partial obstruction of upper airways
describe typical laryngeal paralysis presentation
large older dogs
exercise intolerance
cough
inspiratory stridor
respiratory distress
list first aid care for laryngeal paralysis
keep cool and calm
oxygen
possibly give butorphanol to calm and as anti-tussive
monitor for aspiration pneumonia, dysphagia (discomfort swallowing), megaoesphagus
steroids for reducing laryngeal oedema
how is laryngeal paralysis diagnosed?
laryngeal exam under sedation/ga
how is laryngeal paralysis managed long term?
weight loss
harness not lead
keep calm
avoid heat
dont feed dry food - dust can be inhaled
laryngeal tie back
raised feeding
no swimming
why is aspiration pneumonia a risk in laryngeal paralysis?
larynx cant close appropriately during eating and swallowing so food may be aspirated
list risk factors for tracheal collapse
small and toy breeds
obesity
middle aged
breeds - chihuahua, pom, shih tzu, lhasa apsos, poodle, yorkie
how does tracheal collapse occur?
tracheal rings lose rigidity, usually at the thoracic inlet
membrane of trachea sags making it hard for air to pass through to lungs
describe presentation of tracheal collapse
goose honking cough, worse with excitement, pressure on neck or hot weather, after eating or drinking
how is tracheal collapse diagnosed?
physical exam
x-ray/fluroscopy
bronchoscopy
what is grade 1 tracheal collapse?
25% loss of lumen
what is grade 2 tracheal collapse?
50% loss of lumen
what is grade 3 tracheal collapse?
75% loss of lumen
what is grade 4 tracheal collapse?
total loss of lumen
how is tracheal collapse managed?
oxygen
airway management
surgery
anti-inflammatories
anti-tussives
butorphanol
steroids
bronchodilators
no collar
weight loss
exercise restriction
harness
what surgeries can be done for tracheal collapse?
extraluminal ring prosthesis
intraluminal stenting
what does a tracheostomy bypass?
nares
pharynx
larynx
proximal trachea
list reasons for permenant tracheostomy
physical or functional obstruction of upper airway
upper airway compromised
stabilise patients in acute respiratory distress
laryngeal paralysis
BOAS
FB
laryngeal trauma
severe chronic respiratory obstruction
list nursing considerations for tracheostomy tubes
high levels of nursing care
maintaining airway
keep clean
keep comfortable
remove secretions
humidification
tube care
list potential problems with tracheostomy tubes
blockage
infection
water getting into tube
overheating (less efficient cooling)
how do you care for trach tubes?
initially every 15 minutes then every 4-6 hours when stable
monitor respiration, dyspnoea, cyanosis
issues with stoma site
coughing
discharge
routine suctioning
describe how to suction trach tubes
pre-oxygenate
aseptic technqiue
use long soft catheter no longer than tip of trach, move in circular motions while suctioning and withdrawing for 15 seconds
light and intermittent suctioning
how do you manage blocked trach tubes?
change inner lumen if can be removed
full removal is aseptic, using stay sutures to keep site open and place new tube
why is humidification needed for patients with trach tubes?
trach bypasses URT humidification
drying can damage muscosa, cause inflammation, irritation, thick mucus and dehydration
how do you humidify air for patients with trach tubes?
humidification filter
nebulisation
can do small volumes of sterile saline down tube
list equipment needed for nasopharyngeal FB removal
rhinoscope (flexible)
crocodile forceps
flush
list risks of nasopharyngeal FB removal
damage to nasopharynx
bleeding
incomplete removal of FB
aspiration
what is peri-op care for nasopharyngeal FB removal?
oxygen
close monitoring
analgesia
anti-inflammatories
what is aspergillosis?
fungal infection - aspergillus fumigatus
commonly of the nose where fungus produces alfatoxins causing inflammatory response and destruction of bone and turbinates
what can cause secondary aspergillosis?
FB
how can aspergillosis become systemic?
if fungus enters the body via respiratory tract and travels in the blood
list risk factors for aspergillosis
dogs with immune compromise as is opportunistic
meso and dociocephalic dogs more prone
list clinical signs of aspergillosis
nasal discharge
epistaxis
sneezing
nasal pain
nasal depigmentation
less commonly facial deformity, stertor or CNS signs
how is aspergillosis diagnosed?
rhinoscopy
tissue biopsy as fungus not in nasal discharge
MRI, CT to see turbinate destruction
bloods are non specific
list risks of aspergillosis diagnosis and treatment
epistaxis
aspiration
less access to head for GA monitoring
how is aspergillosis treated?
topical antifungal into nostrils and sinuses sealed in
turned every 15 minutes for hour for full contact
suction out
debride
why is aspergillosis not treated with oral meds?
not effective
systemic effects
list post-op care for aspergillosis
cold pack on nose
analgesia
keep patient calm
monitor respiration
used to be standard post op care for ortho patients and how has it changed?
6-12 weeks cage rest, but now involves more rehab
how can understanding the healing process help the post-op recovery process?
means you can avoid excessive strain and stress while challenging tissues in recovery to encourage return to normal function
list the stages of surgical recovery
post operative
regeneration
remodelling
what is post operative phase of recovery?
24-72 hours
pain, oedema, healing tissues
what treatment is done during the post-operative phase of recovery?
analgesia
cryotherapy
rest
non-weight bearing movement
what is the regenerative phase of recovery?
day 5 to 3 weeks
new collagen fibres forming for soft tissues
bone calluses forming in ortho
important not to disrupt these processes
how is the regenerative phase of recovery managed?
controlled lead exercise
PROM and AROM
what is the remodelling phase of recovery?
6 weeks to 1 year
consolidation - cellular to fibrous tissue, strength and alignment for ST
maturation - vascularity and metabolic rate returns to normal at 10wks to a year for ST
remodelling - reunion of bone
when can active exercise start in recovery?
remodelling phase
what is the main risk for cruciate disease?
obesity
other cruciate gone
what management can be done pre cruciate disease surgery?
weight management
hydrotherapy
list treatment options for cruciate disease
small dogs can leave
TTA/tibial tuberosity advancement
TPLO/tibial plataeu leveling osteotomy
lateral suture
what is the disadvantage of not treating cruciate disease?
very prone to OA
how do you rehab after cruciate surgery?
active exercise
hydro
slow return to normal
what affects choice of treatment for cruciate disease?
patient size
client preference
clinician preference
what effects fracture treatment options?
degree of fracture
site
any disease affecting healing
soft tissue damage
open wounds
how do you rehab following fracture repair?
analgesia
restricted exercise until callus formed
cold compress
encourage use and ROM slowly
supportive dressing if needed to stabilise and reduce pain
what are considerations for ex-fix of fractures?
can be hard to apply treatment
can massage/PROM
need to extend distal limb as naturally flex in fixator
what are considerations for joint surgery?
very painful
manage with experienced staff and consequences can be severe if go wrong
list post op care for joint surgeries
analgesia
cryotherapy
pressure dressing for pain and swelling
PROM
massage
slow and controlled movement
keep calm
what are the benefits of PROM?
maintain ROM
maintain blood and lymphatic circulation
stimulate sensory awareness
how do you manage patients following tendon surgery?
rest
NSAIDs
PROM after 3 weeks
limited exercise for 6 weeks
list goals of recovery following ortho surgery
weight bearing
active ROM to be good
muscle building to support limb and function
what are the benefits or rehab?
assists return to function
minimise stress on surgical site
