Week 1= periop care Flashcards
pre and intra operative
3 phases of surgical procedures
1- preop
2- intaop
3- post op
reasons for surgery
6
1- diagnosis (biopsy)
2. cure or repair ( fracture, pacemaker, appendix removal)
3. palliative (debulking, colostomy, shunt) prolong time not a cure
4. prevention (mole removal, breast removal)
5. exploratory (laparotomy)
6. cosmetic improvement (scar repair, breast reconstruction )
two types of surgeries
- elective (planned)
- emergency
most common surgery in canada
c section
other common surgeries in canada
4
knee replacement
fractures
coronary artery angioplasty (stent of intervention)
hip replacement
why more surgeries being completed
NDP says we need to
GCS less than 8 then
intubate
catagories of GCS
Eyes – spontaneous =4
verbal= 3
pain/touch= 2
nothing= 1
Verbal - orientated= 5
confused = 4
inappropriate words = 3
sounds = 2
none = 1
Motor obeys commands= 6
localizes to pain= 5
withdraw from pain (body away from
pain)= 4
flexion (go inwards, not as good as
withdraw) = 3
extension = 2 (can mean brainstem
injury)
none = 1
What preoperative diagnostic tests should be ordered?
for snowmobile accident with open tibial facture GCS of 7
4
- heat ct
- labs (lactate, CBC, ABGs, group and screen, electrolytes)
- x ray
- BGM
What preoperative diagnostic tests should be ordered?
penetrating chest wound
4
- CT
- US good for abdomen
- labs (g+s, CBC, lytes, lactate(how far in shock they are), ABG, HCG
- Heat CT
Who is responsible for obtaining consent?
The professional performing the procedure
Most often surgeon
Who is responsible for confirming consent
Nurse can
Confirming understanding and is there any questions
Teach back method ( have them tell you what’s going to happen)
If they don’t know call the surgeon
3 elements for consent
1-voluntary
2- mental capacity to consent
3- well informed
what if pt cant consent
is there an advanced directive
Advanced Directive
“… a capable adult may make an advance directive.
An advance directive is a written instruction that gives or refuses consent to health care in the event the adult later becomes incapable of giving the instruction at the time the health care is required
An advanced directive is typically done
ahead of time (ie. ADVANCED), usually when someone knows they are aging or a progressing mental illness (dementia, brain tumour, etc.)
Temporary Substitute Decision-Maker order
9
(a) the adult’s spouse;
(b) the adult’s child;
(c) the adult’s parent;
(d) the adult’s brother or sister;
(d.1) the adult’s grandparent;
(d.2) the adult’s grandchild;
(e) anyone else related by birth or adoption to the adult;
(f) a close friend of the adult;
(g) a person immediately related to the adult by marriage.
What to do if you cant get a hold of anyone
falls under Implied consent as long as they don’t have an advanced directive or DNR
waiting for a surgery depends on
- stability of patient and their availability
diagnostics for total knee arthroplasty
5
Labs (renal, liver, G+S, coagulation, CBC, Lytes, BG)
Chest X-ray (heart size, lungs clear?)
ECG (want to know before
MRI of knee
PMHx (maybe urine sample if they have a history)
What are some pre-surgical screening questions?
Allergies, previous surgery’s, anesthetic, dental work, medications or supplements, substance use
preparing for surgery
subjective (5)
objective (2)
Psychosocial (what is their frame of mind)
PMHx
Meds
Allergies
Alcohol/Drug use
Physical
Diagnostics
special consideration for older adult 65+
7
↑ sx site infection
Normothermia
Confusion, falls
Skin breakdown (poorer nutrition and thin skin)
VTE
↑ risk for pneumonia (more COPD or asthma)
Preexisting conditions
general surgery information
other info
What the surgery is + risks (consent)
DB&C ( prevent atelectasis, opioids and anesthetic can cause actelectesis)
Movement (restrictions) gets blood flowing, GI movement, urinary retention, resp
Splinting
Equipment (drains, monitoring)
Special prep closer to the surgery)
Shower
NPO
Pre-op meds (to give or to hold)
often hold these foods
No big leafy vegetables will impact clotting factors
Tell them when to stop eating
meds usually held
4
- Anticoagulants
- ACEI and ARBS (affect renal system) larger surgeries will also affect the kidneys
- Hypoglycemics (insulin oral hypoglycemics metformin, glyburide)
- Vitamins ( Es and Gs Garlic, ginseng, echinacea) these have clotting factors
Thyroid?
Preparing the patient: Day of surgery
Special prep
Shower
NPO
Pre-op meds (to give or to hold)
Assessment!!!
Confirm consent
Transport to OR
Personal items
Pre-Operative Steps
7
- What kind of surgery is it?
Emergency?
Planned? - Do we have all the diagnostics we need?
- Do we have informed consent?
Signed by who? - Has surgical education been done? (do they have all the info)
- Has surgical prep been done? (meds, post op prep)
- Assessed? (current, pmhx)
Is the patient safe for surgery? - Meds?
Given? Held? - Are post-op care needs addressed?
nurses…what is important for us to know about the OR…
- Aseptic Technique –sterile technique, surgical scrub
- Positioning – pressure injuries, clots, pain and help know why
- Surgical site prep – know that it was prepared properly
- Safety considerations –surgical count, operating on right limb
- Type of anesthetic -
types of anesthesia
4
1) General- opioids + neuroblocker
Fentanyl + propofol (decrease neurons and to stop pain)
2) Local
Ex: lidocaine
3) Regional
Spinal
Epidural ( more common)
4) Moderate sedation
- IV benzo
epidural vs spinal
epidural more common since more effective
can give less med more controlled
anaphylaxis is the
most common intraop emergency
allergies to latex, anesthetic, abx
anaphylaxis.
signs may be
signs
vigilante and rapid
masked by anesthesia
Increase HR, hypotension,
bronchospasm
pulmonary edema
angioedema *3 key to anaphylaxis
Vigilance and rapid intervention are essential
Malignant Hyperthermia*
what
triggered by
Rare metabolic disease
Rigid skeletal muscles with hyperthermia
Usually triggered with GA - succinylcholine
signs of malignant hyperthermia
Signs:
Hyperthermia, rigidity of skeletal muscles, ↑ HR, ↑RR, hypoxemia, lactic acidosis, ↑ temp
Can result in cardiac arrest and death
body hot muscles rigid
tx malignant hyperthermia
Dantrolene (slows metabolism down, & supports hemodynamic stability)
muscles really contracting get a
increase in lactic acid and lactate
signs of blood loss
: O2 sat, ↑HR, hypotension
tx blood loss
2
stop the bleeding, fluid replacement (ie. Colloids, cystalloids, blood products, volume expanders (Pentaspan, Voluven) – mass transfusion protocol
What is a common medication given by a nurse to a pre-operative patient right before surgery?
gravol
dimenhydrinate
A patient comes in to the Emergency Department with a gun shot wound to his abdomen. He has a GCS of 11, BP 73/42, HR 120, RR 26, O2 sat 87% RA. What would you anticipate the Most Responsible Provider (MRP) would order next?
- PRBC type 0 neg
- abdo US
- abdo CT
- CXR
A
Which medications are important for the patient to stop 3 days prior to his total hip arthroscopy?
- ginko
- st johns wort
- warfarin
- naproxen
- bisoprolol
- sertraline
ginko
st johns wort
warfarin
naproxen (risk of bleeding)
What are some common pre-op medications that you see
5
ativan
gravol
opioids
abx
eye drops
What is the prep for Day of Surgery
- special prep
- shower
- NPO
- assessment
- confirm consent
- give or hold meds
- transfer to OR
- store personal items
lactate shows us
how far along in shock we are
neuro questions pre op
hx of seizures
HA, migraines
confusion and delirium
resp questions pre op
3
smoking
cough or cold
COPD and asthma (at risk for atelectasis)
card questions pre op
dysrhythmias
HF
clotting/blood disorders
GI/GU questions post op
- crohns or UC
- constipation (common post op from meds)
- urinary retention/UTI
integ questions pot op
rashes
thin skin (older adult, skin tear, PI)
MSKL questions pre op
- impaired mobility
- any aids (crutched, scooters)
movement helps with
blood flowing
gi movement
urinary retention
resp
why a cold OR
decrease bacterial growth
why need to know about history of COPD and asthma
increase risk of atelectasis
