Surgical Skills Flashcards
What is the correct order for assessment of the posterior chest?
inspection, palpation, percussion, auscultation
What is the purpose of posterior chest auscultation?
to detect airflow within the resp. tract.
When is posterior chest auscultation performed?
every 4 hours and PRN on a stable post-op pt. and may be performed frequently with abnormal resp. findings
Where can bronchial sounds be heard?
over the trachea
Describe bronchial sounds
high pitched loud sounds like air blowing through a follow pipe. short I and long E
Describe bronchovesicular sounds
medium pitch and intensity. blowing sound. = I and E
Where can bronchovesicular sounds be heard?
main bronchi
Describe vesicular sounds
soft low pitched gentle rustling sound. best heard on inspiration. I longer than E
Where can vesicular sounds be heard?
Best heard at best of lungs. can be heard in all lung areas except major bronchi.
Describe crackles
crackling sound like hair near ear. best heard on inspiration but can be heard on both I and E
Cause of crackles
air passing through fluid which may indicate fluid or mucous in air passage
Rhonchi (gurgles)
continuous low pitched rumbling, snoring, gurgling or rattling sounds. best heard on E but can be heard both I and E
Cause of rhonchi (gurgles)
air passing through a narrowed passage. may be a result of secretions, tumors. Ex. pneumonia, chronic obstructive pulmonary disease
Wheezes
continuous high pitched musical sounds. best heard on E but can be heard on I as condition worsens
Cause of wheezes
air passing through a constricted bronchus as a result of secretions, swelling, tumors. Ex. asthma, airway obstruction
Emphysema
chronic pulmonary condition in which the air sacs (alveoli) are dilated and distended
Adventitious breath sounds
air passes through narrowed airways or airways filled with fluid or mucous when pleural linings are inflamed
Pleural Space
The potential space between the visceral and parietal layers of the pleurae. The space contains a small amount of fluids that acts as a lubricant, allowing the pleurae to slide smoothly over each other as the lungs expand and contract with respiration
Pleural Effusion
An abnormal accumulation of fluid in the intrapleural spaces of the lungs. The fluid is an exudate or a transudate from inflamed pleural surfaces and may be aspirated or surgically drained. May result from pulmonary infarction, trauma, tumor, or infection (TB).
Assessment data pleural effusion
dyspnea, chest pain, adventitious lung sounds (crackles), non-productive cough.
TNI pleural effusion
administer ordered medications (corticosteroids, diuretcs, vasodilators), oxygen therapy, intermittent positive-pressure breathing, or use of a pleurx catheter
Subcutaneous emphysema
The presence of air or gas in the subcutaneous tissues. The air or gas may originate in the rupture of an airway or alveolus and migrate though the subpleural spaces to the mediastinum and neck.
Assessment data subcutaneous emphysema
swollen face, chest, neck. painful skin tissues and may produce a crackling/popping sound as air moves under them. dyspnea, cyanosis is air leak is severe.
Treatment for subcutaneous emphysema
an incision to release the trapped air (aerodermectasia)
Thoractomy
a surgical opening into the thoracic cavity
Mediastinal shift
The mediastinum is the part of the thoracic cavity that is in the middle of the thorax, between the pleural sacs containing the two lung. Extends from the sternum to the vertebral column and contains all of the thoracic viscera except the lungs. A shift is when the contents in the mediastinum shift to where they are not supposed to be(like in the case of lung removal they will shift to the side of the remaining lung)
Waterseal drainage
three compartments that collect and drain the fluid or air without allowing air to backflow into the tube
Purpose of turn, cough, deep breath exercises
prevents atelectasis, improves lung expansion, helps expel anesthetic gases and respiratory secretions, facilitates oxygenation of tissues, improves venous return, allows full respiratory expansion and promotes GI peristalsis
Atelectasis
characterized by the collapse of alveoli, preventing the respiratory exchange of carbon dioxide and oxygen in a part of the lungs. symptoms may include diminished breath sounds or aspiratory crackles, a mediastinal shift toward the side of the collapse, fever, and increasing dyspnea. may be caused by obstruction of the major airways and bronchioles, by compression of the lung as a result of fluid or air in the pleural space or by pressure from a tumor outside the lung
How often should TCDB exercises be done?
10 times every 1-2 hours during waking hours for first few post-op days
When are coughing exercises contraindicated?
head and/or neck injuries
TNIs for TCDB
explain rationale of TCDB to patient/family, teach how to perform activity with return demonstration pre-op, reinforce activity post-op beginning in PACU, medicate before doing exercises prn
Purpose of incentive spirometer
to promote a series of voluntary sustained maximal inspirations which improve ventilation and prevent atelectasis
How often should an incentive spirometer be used?
every 1-2 hours while awake for the first few days post-op
Define mist therapy
provides moisture to inspired air, decreases the viscosity of secretions and makes secretions easier to remove. If the mist is heated it increases the capacity of air to hold moisture. heated mist provides 100% humidy, cool mist provides 40% humidity
Define nubulization
The process of adding particulate water mist or fine particles of medication to inspired air. This may be done by rapidly passing air through a liquid at a high frequency. The goal is to improve the clearance of resp. secretions. it is often used to the administration of bronchodilators or mucolytic agents.
Assessments with nubulizers
lung sounds, RR, and o2 sat before and after each treatment
Purpose of mist therapy and nebulizer treatments
provides moisture to inspired air (mist), decreases viscosity of secretions and makes secretions easier to remove (mist), delivers medications VIA fine spray (fog or mist) (nebulizer)
State the difference between heated mist and cool mist therapy
heated = 100% humidity. cool= 40% humidity
Purpose of pulse oximetry
noninvasive and continous monitoring of a patient’s arterial blood oxygen saturation. potentially serious problems can be detected early. can alert RN of hypoxemia before signs and symptoms develop.
Normal SpaO2
= or greater than 92%. if it falls below 85%, the tissue will receive inadequate oxygenation because less oxygen will be released by the hemoglobin. Below 70% is life threatening
How often should SpaO2 be assessed?
every four hours in a post-op patient or when there has been a change in a patient condition or oxygen setting
Correct order for assessment of the abdomen
inspection, auscultation, percussion, palpation
What are we looking for during the process of auscultation of the abdomen?
bowel sounds, bruit (no aortic bruit should be heard)
Terms to use to describe bowel sounds
absent, gurgling, hypoactive, hyperactive
Hypoactive
soft, fewer than 3 per minute
Hyperactive
loud, every 3 seconds
When should abdomen assessment be performed?
every 8 hours and PRN
Purpose of an abdominal binder
provides protection and support for the operative incision, the surrounding muscles and viscera during the postoperative period. It protects the wound, holds the dressing in place and offer the patient comfort and security
Purpose of postoperative leg exercises
to facilitate venous return from the lower extremities to help prevent venous stasis
When are leg exercises contraindicated?
on the affected side with vascular surgery in legs, groin, joint surgery of hip or knee or presence of venous thrombosis. exercises of the unaffected side are encouraged
What types of leg exercises should be done?
calf pumping, quad setting, foot circles, hip and knee movements to facilitate venous return from lower extremities
When should leg exercises be performed?
10-12 times every 1-2 hours while awake for first few preoperative days
Definition/Purpose of a sequential compression device?
provide rhythmic intermittent external compression through inflatable stocking or leg wraps. Intermittent pneumatic compression devices have proven effective in reducing deep vein thrombosis in general surgical, high risk oncology, orthopedic patients, bariatric patients, as well as those on extended bedrest. May be contraindicated for patients with dermatitis, gangrene, recent skin grafts, pressure sores, massive edema of legs, pulmonary embolism, or acute inflammatory phlebitis. They should be removed for assessment, skin care and ambulation and then reapplied
Purpose of skin closure strips
plastic bandaid-type material in strips that are applied across a wound to keep edges approximated or across a healing wound after the wound closure materials have been removed. The strips give support and approximate the skin edges until the wound is fully healed
Purpose of staples
bring together severed tissue. less irritating than sutures and produce good skin approximation with less scarring than sutures. they are applied with a stapler and removed with a stapler remover
Define suture
a thread used to sew body tissues together
Absorbable sutures
used in an area that cannot be reached for suture removal like tissue beneath the skin. they are temporary because tissue enzymes attack and breakdown the suture strands which are eventually absorbed by the body
Natural gut absorbable sutures
derived from the intestine of sheep and cattle. plain are absorbed in 10 days, chromic are absorbed in 20 days
Synthetic gut absorbable sutures
used more because there is less tissue reaction to this product, breaks down at a predictable rate, absorbed in 90 days by hydrolysis
Nonabsorbable sutures
permanent. tissue enzymes encapsulate the suture which remains embedded except for skin closure stitches which are removed several days after surgery depending on the type of suture used. silk, stainless steel wire, polypropylene, polyester, nylon, retention sutures
Definition/Purpose of Retention Sutures
Nonabsorbable suture which provides a secondary suture line and reinforces/supports the primary suture line. Usually large, wide, and deep sutures which provide extra strength when unusual stress on the suture line is anticipated (obesity, abdominal distention) or when slow healing is expected. Retention sutures are used in some abdominal wounds. They are stitched deep enough to encompass all the abdominal wall layers. They may appear as gauze sponges or bumpers on each side of the primary suture line, or as a piece of rubber tubing or plastic strip which is threaded over the retention suture material in each side of the primary suture line.
TNI retention sutures
assess incision site for drainage, inflammation, infection, wound disruption, report any increasing wound drainage, pain, redness or gaping of wound edges, preserve integrity of wound closure materials by not pulling on the material and ensuring that gauze or clothing does not get caught in sutures, assist with removal as prescribed
Penrose Drain
Flat, follow, rubber drain which is placed in a wound to facilitate drainage and promote healing of underlying tissues
TNI penrose drain
check operating room report in chart of caremap to determine if a drain is present to reduce risk of accidental removal while changing dressing, if dressing change is ordered a sterile safety pin is usually attached to the drain and is critical that the old dressing be removed very carefully (the pin prevents drain from retreating into the wound and can be located on xray, careful removal of old dressing prevents accidental dislodgement of the drain), inspect and cleanse drain site and surrounding skin to protect skin surface from irritating drainage, apply pre-cut sterile gauze around the drain and stagger sterile 4X4s over and below the drain so that loose threads are not introduced into the wound where they may cause inflammation and infection, assess amount and characteristics of drainage and collection bag if secretions are copious
T-Tube Definition/Purpose
a thin catheter with a stem and crossbar which looks like a T. The crossbar is inserted into the common bile duct and the stem leads to a drainage collection device. The t-tube maintains the patency of the common bile duct. it is inserted to ensure drainage of the bile out of the body until the edema at the surgical site has subsided enough for bile to drain normally into the duodenum
TNIs t-tube
pin device to patient’s gown at or slightly below the level of the drain’s exit from the skin, empty drainage device every shift, when 2/3 full or as prescribed, use aseptic technique when emptying device, check tuving that connects the drain to the drainage bag for kinks and ensure that it is not pulled too tightly, keep site free of bile drainage and notify MD of excessive bile leakage around wound, anticipate a decrease of drainage over time as bile begins to flow into the duodenum, before removal a clamping regime is usually ordered and the patency of the duct may be assessed by xrayi
Definition/Purpose of a nephrostomy drainage tube
inserted temporarily to preserve renal function when an obstruction of the uterer exists. expected drainage from the nephrostomy is amber urine
TNIs nephrostomy
the catheter is inserted into the pelvis of the kidney and attached to connecting tubing for closed drainage. as with most ureteral catheters, care must be taken to ensure that the catheter is never kinked, compressed, or clamped. assess patient for complaints of excessive renal pain or excessive drainage around the tube, check patency of tube, if irrigation is ordered, strict aseptic technique must be used, no more than 5 mL of sterile saline solution is instilled into the nephrostomy tube at one time
What is the difference between a colostomy and a urstomy?
ostomy is an opening created surgically in the body for discharge of body wastes. a colostomy is a surgically created opening of the large intestine where a part of the colon or rectum is removed and the remaining colon is brought to the abdominal wall resulting in a stoma. A urostomy is a surgical procedure that allow for diversion of urine away from a diseased bladder. A section of the ileum or cecum is surgically removed and relocated as a passageway for urine to pass from the kidneys to the outside of the body through a stoma
Ileostomy
opening between the ileum and the abdominal wall. liquid. up fluid requirement.
Cecostomy
opening between cecum and abdominal wall.
Colostomy
opening between the colon and abdominal wall
Reasons for Ascending colostomy
perforating diverticulities in lower colon, trauma, inoperable tumors of colon, rectum, pelvis, retrovaginal fistulas
Reasons for ilestomy
ulcerative colitis, crohn’s disease, diseased or injured colon, birth defect, familial polyposis, trauma, and cancer
Reasons for transverse colostomy
birth defect, perforating diverticulitis in lower colon, trauma, inoperable tumors of colon, rectum, pelvis, retrovaginal fistulas
Reasons for sigmoid colostomy
cancer of the rectum or retro sigmoid area, perforating diverticulum, trauma
Assessment data for patient with an intestinal ostomy
color of stoma, edema, excessive bleeding.
TNIs ostomy care
empty the ostomy bag before removal unless using a closed ostomy appliance, assess stool for consistency, color, and amount, remove ostomy bag per agency policy and type of appliance used, clean stoma with warm water and a washcloth, apply peristomal skin barrier, teach pt and family how to care for stoma,
When should an ostomy bag be emptied?
1/3 to 1/2 full
Mixing compatiable meds from two vials
- draw up volume of air equal to volume of medication to be withdrawn from both vials A and B into syringe
- inject a volume of air equal to the volume of medications to be withdrawn into vial A. Ensure that the needle does not touch medication
- withdraw needle from vial A and inject the remaining air into vial B
- Withdraw required amount of medication from vial B
- change the needle then withdraw the required amount of medication from vial A. avoid pushing the plunger as it will introduce medication B into vial A
TNIs for mixing meds in one ampule and one vial
- Withdraw the med from the vial
- change needle to a filter needle
- withdraw the required amount of medication from the ampule
Definition/Purpose of portable wound suction device
closed, self-contained portable drain system that relies on presence of a vacuum to withdraw accumulated drainage from the wound. The device consists of a drain with multiple perforations that lies inside the surgical wound. The drain is attached to tubing that leads to a closed reservoir. The closed system prevents drainage from coming in contact with the skin and provides a gentle suction for evacuation of wound drainage. The device only operates if the tubing is patent/clear and a gentle vacuum exists.
TNIs portable wound suction
visibly pinned to the patient’s gown and receptacle at or below the level of the drain exit from the skin. remember to release and reapply the pin when changing the patient’s gown, empty suction device when approximately 1/3 full using soft pulses, recreate negative pressure on hemovac by compressing device on a flat, hard surface with palm and on JP drain by gently compressing bulb in your hand and replace plug while compressed
Definition/Purpose of a nasogastric tube
vented nasogastric tube (salem sump tube) is a double lumen sump tube is a tube within a tube. one lumen empties the stomach while the second lumen provides a continuous flow of air. the air flow lumen controls suction by preventing the drainage lumen from pulling stomach mucosa into the tube’s eyes and irritating the stomach lining. gastric drainage is normally pale yellow-green and watery consistency. the primary purpose of this gastric tube from a post-op patient is to decompress the stomach to prevent N/V and ileus due to GI paralysis and manipulation during surgery
What is the purpose of a NG tube?
to relieve abdominal distention, to maintain gastric decompression, to remove blood and secretions from the GI tract
Conditions requiring chest drainage
pneumothorax, hemothorax, tension pneumothorax, pleural effusion
Pneumothorax
air between the pleurae
Open pneumothorax
opening in the chest wall (gunshot, surgery)
Closed pneumothorax
chest wall intact (blunt trauma, ruptured bleb)
Hemothorax
blood in the pleural space
Tension pneumothorax
causes pressure on heart and great vessels, blood flow is compromised, emergency medical intervention
Goals of chest tube therapy
remove fluid and air as promptly as possible, present evacuated air from returning to chest cavity, expand lungs and restore negative pressure
Compartments of the chest tube drainage system
collection chamber, water seal chamber, suction control chamber, air leak monitor
Purpose suction control chamber
maintains negative pressure throughout the entire closed drainage system. negative pressure is what keeps the lung fully expanded. chamber functions as a safety device protecting against excess suction pressure in the pleural cavity
Purpose of the water-seal chamber
allows air to drain from pleural space, prevents air from reentering pleural space
Purpose of the collection chamber
received fluid and air from the chest cavity
Expected drainage from pediatric client
greater than 5mL/Kg/hr. REPORT IF ABOVE
