Test 1 Flashcards
informed consent
-basic info on the form -> nature, risks, benefits, alternatives
-1. explain dx
-2. proposed tx
-3. pro and cons
-4. alternatives
-5. confirming understanding- repeat back
operational vs procedural consent
-OPERATIONAL- in OR, general anesthesia, high complexity
-Scope- For major surgical interventions
-Setting- OR, inpt surgery centers
-Complexity- Higher, greater risk
-General Anesthesia or regional anesthesia is often required
-Ex. C-section, cholecystectomy, knee replacement
-PROCEDURAL
-Scope- For minor or non-surgical interventions
-Setting: Outpatient, clinic, emergency room, or bedside.
-Lower complexity or typically less invasive
-May involve local anesthesia or sedation
-Ex. Colonoscopy, wound suturing, IV catheter placement.
steps of the informed consent
-explain tx, procedure, test
-discuss purpose
-risk and benefits
-alternatives
-assess understand
-encourage questions
-document the consent
FHCDA- family health care decision act
-hierarchy of surrogate decision makers for pts who lack capacity and have NOT appointed a health care agent:
-1. court appointed guardian- guardian appointed under Article 81 of the Mental Hygiene Law
-2. spouse or domestic partner- legally recognized
-3. oldest adult child
-4. parent
-5. adulting sibling- 18+
-6. close friend or relative
-you can reject responsibility
-MOLST form once someone agrees
-if NO ONE - 2 attendings decide and document urgent procedure
-assault if not documented
during surgery consent
-wake the pt up and ask or ask the spouse, parent, child if non emergent
-if emergent and life saving -> just do it
goals of preoperative optimization
-1. reduce periop complications- infections, thromboembolism, organ dysfunction
-2. enhance recovery- improve outcomes and decrease stay
-3. address RF- control DM, nutritional status, smoking cessation
-4. optimize reserve- ensure pt can tolerate physical and metabolic stress of surgery by optimizing cardiorespiratory and functional capacity
-5. promote decision making- informed consent, expectation of PAIN
-6. reduce costs- decrease readmission, stay, resource use, by preventing complications
capacity
-proxy -> if no proxy
-FHCDA surrogate
focus on 4 modified areas: strong for surgery
-1. nutrition
-malnutrition
-testing albumin for risk stratification
-eval immunonutrition
-BEST DETERMINANT OF SURGICAL OUTCOME
-2. smoking
-SURGICAL SITE INFECTIONS ARE MORE PREVALENT
-decreases healing
-3. blood sugar
-screen for risk of DM
-screen blood sugar
-monitor periopeative glucose management
-4. medications
-identify drugs that can cause bleeding and cardiac risks
-reconciling herbal meds
ERAS (enhanced recovery after surgery) protocol: NSQIP
-perioperative care that optimizes pt recovery, improves outcomes, and reduced complications
-preventing Surgical site infection (SSI)
-evidence based protocols
-preop antibiotics
-normothermia during surgery
-glucose control in DM pts
-surgical risk calculator
-breakdown comorbidities and risks for surgery to make informed decision
optimization of periop care in older adults
-Colorectal, UGI, hernia, and hepatobiliary:
-encourage cessation of smoking and alc
-correct anemia
-colorectal only: prehabilitation - move and be active before surgery
-UGI, hernia, and HPB
-benefit of minimally invasive surgery (MIS) > open surgery
-benefit of enhanced recovery after surgery (ERAS) > conventional preop care
-evidence:
-supports MIS and ERAS in colorectal surgery for >65yo
-knowledge gaps in perioperative optimization
pre-op note
-dx code (ICD)
-procedure code (CPT)
-indication
-PMH
-prior surgery
-allergies/meds
-PE
-Anesthesiologist classification and route
-Labs
-Position
pre-op orders
-NPO
-IVF
-Meds
-Labs/imaging
-consults
-consent
post-op check
-SOAP note
-where is the incision
pain meds
-okay if taken correctly
-5 days of pain meds
-assess if pt needs more after
post op days
-same day- post op day 0
-24 hours later- post op day 1
hand hygeine
-MC mode of transmission of pathogens -> hands
-visibly dirty -> wash with non/antimicrobial soap and water for at least 15s
-if not -> alcohol based handrub for routine -> BEST
-Before:
-Patient contact
-Donning gloves when inserting a CVC
-Inserting urinary catheters, peripheral vascular
catheters, or other invasive devices that don’t require surgery
-After:
-Contact with a patient’s skin
-Contact with body fluids or excretions, nonintact skin, wound dressings
-Removing gloves
aseptic vs sterile
-clean- reduced germs -> boxed gloves, masks, scrubs
-aseptic- eliminates germs -> wearing sterile gloves
-sterile- the environment/setting -> use aseptic technique to create sterile environment
-skin prep- chlorohexidine (3 mins), betadine (until it dries)
OR scrubbing technique
-put on cap, mask, goggles
-antimicrobial soap
-scrub 2-6 mins with brush and water OR
-stroke counting technique (better) -> 30x nails, 10x surfaces
-AvaGard gel
OR gowning/gloving
-cuff are not sterile
-hands on blue drapes or folded across ribcage
-GLOVES:
-pick up glove on inside of cuff with opposite hand
-slip sterile glove hand under glove cuff and grasp opposite side of cuff with your thumb (pinch maneuver)
-fix the cuff of the first glove
gloving for sterile procedure
-foley insertion
-skin prep
-sutures
-I&D
Venipuncture
-15s hand wash before and after
-lab coat and gloves
-check order or draw and exp date
-order of draw avoids contamination of additives
-1. blood cultures -> 2. coagulation tube (light blue) -> 3. non-additive (red) -> 4. additive (mix these)
-NEVER use needle is shield is broken
-syringe needle vs vacutainer
-fill tubes -> release tourniquet (4-8inch above)
-5-30 degrees
selecting the site of a venipuncture
-antecubital MC
-use tip of index on nondominant to feel
-1. median cubital vein
-2. cephalic vein
-3. basilic
venipuncture gone wrong
-POOR SITES:
-veins that lack resiliency
-extensive scars
-hematoma
-edematous
-side of mastectomy
-IV line
-NO BLOOD:
-bad tube/vacuum
-collapsed vein
-REDRAW:
-use clean needle
-use fresh syringe if contaminated
-POOR COLLECTION TECHNIQUES:
-venous stasis
-hemodilution
-hemolysis
-clotted sample
-partially filled tubes
-specimen contamination
-specimen handling
-YOU STUCK URSELF:
-cleanse with alcohol
-wash wound
-notify someone
-follow site protocol
-complete incident report
-COMPLICATIONS:
-nerve and arterial injury
-abscesses (sterile or septic)
-bleeding
blood culture
-alcohol site for 5s
-dry for 30-60s
-chlorhexidine or tincture of iodine-center to periphery- dry for 45-60s
-gloves
-remove caps, clean with alc
-without palpating draw 20ml and put 10 in anaerobic and 10 in aerobic
ABG
-acid bases, partial pressures
-assess response to intervention- insulin in DKA, intubated pts
-measures abnormal hemoglobins (carboxyhemoglobin, methomoglobin), bicarbonate, pH, O2, CO2
-radial, brachial (bad collateral), femoral (90 degree), axillary, dorsalis pedis
-allen- <6s normal -> >10s abnormal
-pre-heparinized 3ml syringe
-30-45 degrees
-2-3ml
VBG
-venous CO2 tension (PvCO2)
-pH
-cant accurately assess O2 -> do pulse ox
-indications:
-serial ABG without arterial line
-daily assess for ventilator
-acute kidney injury
-ABG fail or refusal
PEE order
-gown, mask, goggles, gloves
-OR- mask, goggles, gown, gloves
-removal- gloves, goggles, gown, mask
intraosseous (IO) infusion and vascular access
-kids- prox or distal tibia
-adults- sternum or distal femur
-at least 2 unsuccessful IV attempts!!
-CI- fracture, burn, infection, missed IO attempt in that leg
-1-2 finger (1-2cm) below tibial tuberosity
injections
-Intradermal- TB, allergy
-SC- low volume -> insulin, heparin
-IM- vaccine, hormones
-Adults 5/8” vs. 1” vs. 1.5”
-Children 5/8” vs. 1”
-SC- 25-27g; 3/4-1in; 45 degree
-If less SQ fat, use shorter needle
-IM- 22g; 1.5in; 90 degree
-IM SITES:
-deltoid
-vastus lateralis
-gluteus medius: ventrogluteal and dorsogluteal
-CI- COAGULOPATHY
-SC SITES:
-abdomen- love handles
-thigh- anterior
-upper arm (outer back, tricep)
-ID SITES:
-inner forearm
-upper back
intradermal injections
