Week 4: Care of Surgical Patient Flashcards
what is pre-operative care
- same day surgery
- elective or emergency
what is intra-operative care
- in operating room or ambulatory
- begins when we enter procedure room and ends when they enter recovery area
what is post-operative care
- post-anesthesia recovery (PACU)
- ambulatory (in and out)
- admission to hospital
what are the 6 surgical indications and examples
- diagnosis: determine absence/presence of abnormality - ex. biopsy
- cure or repair: ex. hip replacement
- palliation: increase quality of life and comfort - ex. jejunostomy
- prevention: ex. mastectomy
- exploration: exploring what is going on - ex. colonoscopy
- cosmetic improvement: ex. rhinoplasty
what are the 4 pre-operative assessments
- consult / diagnostic testing
- assess medical regime, emotional status, physical assessments if indicated
- review past medical diagnoses and surgical procedures - helps decrease post-op complications
- review prescribed meds
all of this is extremely individualized
what are the 6 education pre-operative topics?
- protocol for routine meds before surgery
- which medications to stop before surgery
- NPO instructions
- pain management options
- infection prevention and wound care
- post-operative discharge and care
majority of education begins in pre-op stage!
what is the typical pre-operative day surgery assessment? (8 things)
- pre-operative checklist (standardized)
- establish baseline data (vital signs, violence risk)
- consider cultural considerations
- confirm consultations are completed
- review preoperative diagnostic tests
- consent ability
- identify any changes in physical assessment
- review medications
what are the 5 important preoperative considerations
- allergies
- systems assessment
- fluid and electrolyte status
- nutritional status
- labs and diagnostic tests
what is the ASA physical status classification system?
standardized score anesthesiologists use to determine risks of the person
what are the 6 ASA physical status levels?
ASA 1: healthy individual
ASA 2: patient with mild systemic disease (ex. smoking, pregnancy, obesity)
ASA 3: patient with severe systemic disease (uncontrolled diabetes, MI)
ASA 4: patient with severe systemic disease (recent <3 months, MI, sepsis, resp disease)
ASA 5: moribund patient not expected to survive without surgery (ex. ruptured abdominal aortic aneurysm, massive trauma, ischemic bowels)
ASA 6: brain-dead patient (organ removal)
what are the 2 surgical approaches
- open (-otomy)
- minimally invasive (laparoscopic -oscopy, robotic)
what are the benefits of laproscopic and robotic surgeries
- less invasive
- shorter recovery time
- less pain and cosmetically beneficial
- decrease infection risks
what is the intraoperative team
RN: circulating nurse, scrub nurse
RPN: scrub nurse
RNFA (first assist) - cardiac and orthopedic
Anaesthesiologist
Surgeon
how do we give general anesthesia and provide example. what are some complications?
- IV or inhalation
- opioids, benzodiazepines, and antiemetics, paralytics
complications
- risk of not fully ventilating leading to pneumothorax (collapse), alveolar collapse (atelectasis), and pneumonia
how do we give local anesthesia
variety of routes
- nerve block that blocks initiation and nerve transmission/impulse
how we do give regional anesthesia
- spinal, epidural nerve
- local injection INTO a nerve
how do we give procedural anesthesia
sedatives with or without analgesia
- ex. nitrous oxide
what are the 3 critical events in the operating room
- anaphylactic reactions
- no subjective indications, no way of us really knowing - malignant hyperthermia
- metabolic disease with rigidity of muscles
- genetically susceptible
- triggered by succinylcholine that relaxes muscles
- can result in cardiac death - excess blood loss
what are the aspects of postoperative care
protect patient placed at physiologic risk during surgery
prevent complications
PACU - recovery room
3 phases of recovery
what are the 3 phases of recovery
phase 1: care during immediate post-operative period
- focused on life sustaining needs with constant monitoring
- goal: prepare patient for safe transfer to phase 2/inpatient unit
phase 2: patient is ambulatory
- goal: prep patient for transfer to extended-care environment or home with discharge teaching
phase 3: extended observation
Explain the PACU initial assessment
- anaesthesiologist and perioperative nurse gives report to PCU nurse
- priority of care is monitoring and managing airway and circulation, pain, temp, surgical site, and response to anaesthesia reversal
assessment includes:
- ABCs
- pulse oximetry
- telemetry or arterial BP monitoring
- temp, skin colour, condition assessment
- LOC, orientation, sensory and motor assessment, pupillary response
- assessing incision, drains, etc.
what is the Aldrete Scale
determines if patient is stable enough to leave the PACU
- need a score of 9+ to leave
what are the immediate postoperative respiratory complications? (6) what is it influenced by?
- airway obstruction (most common by tongue)
- atelectasis
- aspiration
- bronchospasm
- hypoventilation
- respiratory depression (opioids and sedation)
influenced by past medical history
what are the immediate post-operative CVS complications? (3) what are they caused by?
- hypotension: fluid loss, worried about cerebral and renal perfusion
- hypertension: overstimulation of CNS
- dysrhythmias: hypokalemia, hypoxia, acid base changes
when would we notify anaesthesia regarding CVS complications?
- SBP <90 or >160
- heart rate <60 or >120bpm
- BP gradually decreases over consecutive readings
- irregular rhythm develops
- significant change from pre-operative readings
what are the immediate neuro complications in PACU? (2) what are they caused by?
- emergence delirium: hypoxia, anaesthesia agents, bladder distension, immobility, sensory and cognitive impairments, inadequate pain control, polypharmacy, dehydration, malnutrition
- delayed awakening: over administration of anaesthesia - biggest cause of delirium
what do we assess regarding pain and discomfort?
- assess for anxiety related to pain
- assess via pain scale, observations, vitals
- assess effectiveness of pain modalities
what is a temperature alteration in the PACU? what causes it?
hypothermia
- heat loss from surgery
- cold fluids in OR
- anaesthesia agents
what are the GI complications in PACU? (2) what are the risk factors for these?
- nausea
- vomiting
risk factors: over 50 y/o female, history of motion sickness, being non-smoker
what are the GU complications in the PACU?
- low urine output (looking for 30mL/h)
- acute urinary retention (swelling causing issues passing urine from kidneys down)
what are the 3 common skin alterations we assess
- surgical wounds and/or dressings: monitor drainage amount/colour
- drains: consider why patient has this, what is the expected output
- surgical site infections
what are the emotional considerations in PACU? what are potential causes?
anxiety and depression
- radial surgery
- poor diagnosis post-op
- grief, loss
- changes to independence
what is the most common delayed post-op complication? what is it? what are the symptoms? how do we treat?
paralytic ileus
- delayed gastric emptying, decreased peristalsis
- symptoms: no bowel movement, bloating, and distended abdomen, persistence nausea/vomiting
- treatment: walking around, antiemetics, conservative management (NPA and then NG to see if we can have slow return of bowel function)
what is general surgery
anything to do with GI tract
- esophagus
- small and large bowel
- rectum
- stomach (gastric)
- liver
- pancreas
- gallbladder
Esophagectomy:
- indication
- surgical approach
- surgical length
- length of stay
- post-operative considerations
- indication: esophageal cancer
- surgical approach: thoracotomy or minimally invasive (thoracoscopy or robotic)
- surgical length: 8-10h
- length of stay: 4-7 days, ICU for 1-2 days for close monitoring
- post operative considerations: jackson pratt drain, epidural/pain control, chest tubes, wound care, J-tube feeding, strict NPO
Small bowel resection:
- indication
- surgical approach
- surgical length
- length of stay
- post-operative considerations
- indication: bowel cancer, Crohn’s, scar tissue/adhesions causing small bowel obstruction, bowel perforation
- surgical approach: laparoscopy, robotic, or laparotomy
- surgical length: 2-4h
- length of stay: if minimally invasive could be same day to 2 days, open 3-5 days
- post-operative considerations: jackson pratt drain, epidural/pain control, ileostomy (high output), wound care
Colectomy (large bowel resection)
- indication
- surgical approach
- surgical length
- length of stay
- post-operative considerations
- indication: bowel cancer, IBD (crohn’s), diverticulitis, bowel perforation
- surgical approach: laparoscopy, robotic, or laparotomy
- surgical length: 2-4h
- length of stay: if minimally invasive same day or 2 days, if open 3-5 days
- post-operative considerations: jackson pratt drain, epidural or pain control, ileostomy OR colostomy, wound care, changes to output or bowel movements?
appendectomy
- indication
- surgical approach
- surgical length
- length of stay
- post-operative considerations
- indication: appendicitis, very rarely appendiceal cancer
- surgical approach: laparoscopy, rarely open
- surgical length: 1-2h
- length of stay: can go home post-op, or 1-2 days
- post-operative considerations: pain from laparoscopy air, infection
cholecystectomy
- indication
- surgical approach
- surgical length
- length of stay
- post-operative considerations
removal of gallbladder
- indication: gall stones
- surgical approach: laparoscopy, rarely open
- surgical length 1-2h
- length of stay: usually go home post-op, or 1-2 days
- post-operative considerations: pain from laparoscopy air, retained gall stones
Pancreaticoduodenectomy (whipples)
- indication
- surgical approach
- surgical length
- length of stay
- post-operative considerations
- indication: pancreatic or bile duct cancer
- surgical approach: laparotomy
- surgical length: 6-8h
- length of stay: 4-7 days
- post-operative considerations: pain modalities, wound care, drains, nutritional support
key considerations of caring for a surgical patient (post med history, discharge info, minimizing complications)
post med history
- How does this influence length of stay?
What considerations for post-operative management?
discharge info
- Education on new appliances, drains or ostomies
- Education on potential complications & when to seek medical attention (Teach-back method)
- Follow up information
minimizing complications
- pain control
- ambulation
- nutrition
