Week 4: Care of the Surgical Patient Flashcards
Jennie's guest lecture
Pre-Op
Same day surgical admission (i.e. elective)
Emergency (i.e. appendectomy)
Intra-operative
Operating room
Ambulatory
Outpatient- wisdom teeth, vasectomy
Post-Op
PACU, ambulatory, admission to hospital
What are the 6 possible surgical indications?
Dx, cure/repair, palliation, prevention, exploration, cosmetic improvement
Does an endoscopy or colonoscopy count as a surgery?
Yes. It is under the Dx category
What are the 4 steps in a pre-op assessment?
Consults or diagnostic testing
Assess medical regime, emotional state, physical assessments if indicated
Review past medical diagnoses and surgical procedures
Review prescribed medications
What are some of the diagnostic tests of consults we would need to do in the pre-OP procedure?
Allergies, blood type, baseline vitals, blood work, psychosocial eval, mobility baseline, past medical Hx, Echo, ECG, substance-use?
Why is it important to learn whether a patient is on anti-coagulants or they smoke weed?
1st-pt is high vibes, but anticoagulants can lead to pt bleeding out, may need to stop up to 7 days before surgery. Pot can act on pain receptors may need more post-op narcotics.
Pre-Op checklist (day of surgery)
-Pre-OP checklist
-Baseline data
-Cultural considerations
-Confirm consultations are done
-Review pre-OP diagnostic tests
-Consent ability
-ID changes to pt physical assessment
-Review medications
Describe the process for pre-OP education, also called “pre-surgical screening”…
It is important to describe before/after for a patient.
-Protocol for routine meds
-Meds to stop pre-surgery
-NPO instructions
-Pain management options
-Infection prevention and wound care
-Post-op discharge and care
What are the main pre-OP considerations?
-Allergies
-Systems assessments
-Fluid and electrolyte status
-Nutritional status
-Labs and diagnostic tests
What is the highest possible ASA score? Who gives this score to a patient and what does it mean?
1-6. Anesthisiologist, this tells us how risky it is to give anesthia to a patient
What does an ASA 1 mean?
Healthy, non-smoking no-to minimal alcohol intake
What does ASA 2 mean?
Mild disease, minimal functional limitations, pregnant, obesity, controlled diabetes
Open surgery
Doesn’t tell you what the Dx is, tells you whether you cut them open/how you did
“-otomy”
Big incision of some kind
What does ASA 6 mean?
Brain dead. Organs are being removed for donation
What are the two surgical approaches?
Open, minimally invasive
Two types of minimally invasive surgery
-Less time in hospital
-Less pain
-Cosmetically
-Less risk of infection
Laparoscopic “-oscopy”
Little holes. Every instrument needs its own hole. Can begin with this and then can move to open if things get more SERIOUS
Robotic Minimally invasive surgery
With a robot, more ROM
Which RN’s are involved in the intraoperative team?
RN: circulating RN, scrub nurse,
RPN: Scrub nurse
RNFA: first assist, RN first assist-can suture, staple, harvest veins
Anaesthisologist
Surgeon
Describe the surgical safety checklist
-Go through checklist
-Roles
-Confirm the surgery
What are the risks of under inflating a patient?
Alveolar collapse, atelactisis, pneumonia
Do you fully inflate someone when you are ventilating them?
No
General Anesthia
IV or inhalation
e.g. opioids, benzos, antiemetics, paralytics
Used in long procedures, induce reversible loss of consciousness, analgesia, amnesia, muscles relax
Rapid onset, first fall asleep then placed on breathing tube
Risks: breathing difficulty, issue with sleep apnea, pneumonia
Local anesthia
Variety of routes
Nerve-Blocks: blocks initiation and transmission of nerve signals. used in pain control
Regional Anesthsia
Spinal, epidural, nerve
Local anaesthesia is injected into a nerve
Regional nerve block
What are the 3 most common clinical events in the operating room?
-Anaphylactic reactions
-Malignant hyperthermia
-Excessive blood loss
Anaphylactic reactions in the operating room
-Hypoxia, hypotension can mask this reaction
-Given many meds, hard to tell what pt is reacting to
Procedural Anesthesia
Sedatives with or without analgesia
Nitrous oxide (in labour, with IUD insertion)
Malignant hyperthermia in the operating room
-Metbolic disorder where you have hyperthermia with rigidity of muscle
-Genetic, family component
-Sustinylcholine
-Characterized by rise in body temp
What is the first sign of malignant hyperthermia?
Patient asleep, biting down on the tube
What is the main goal of post-op care?
Protect the patent who was placed at physiologic risk and prevent complications after surgery
Phase 1 in post-Op care
Focused on ABC, sustain life of a patient, 1:1 until artificial breathing removed, care in the immediate post-op period. Prepare patient for safe transfer to phase 2 or inpatient unit
Phase 2 of recovery in the pACU
Pt is ambulatory, the goal is to transfer to an extended care environment or home with discharge teaching
Phase 3 of recovery in PACU
Extended observation, more monitoring
What is the PACU nurse doing in her initial assessment following report from anesthesiologist and preoperative nurse reports?
Priority of care monitoring and management or ABC, pain, temperature, surgical site, and assessment of their response to the reversal of anaesthesia agents.
ABC, pulse oximetry, temp, skin colour, temp, LOC< incision, drains
What is the first sense that returns to patients?
Hearing
What aldrete score do patients need to be discharged from PACU?
9+ to leave. Depends on patient baseline of course.
What are the common post-OP respiratory complications?
Airway obstruction, atelectasis, aspiration, bronchospasm, hypoventilation, respiratory depression
What are the 3 most common post-OP CVS complications?
Hypotension, hypertension, dysrhythmias
What can cause changes in blood pressure
-Fluid loss
-NPO
-meds
-LOC, urine output; were worried about kidneys
-SNS from pain (HTN)
What can pain do to BP? How do we manage this?
-Increase
-Get pain under control because it makes the SNS go crazy and gives patient HTN
What can cause dysrhythmias following surgery?
K! Hypokalemia and hypoxia
When do you notify anesthesia ?
-SBP less than 90, more than 160
-HR less than 60, more than 120
-BP gradually decreases over consecutive readings
-Irregular rhythm develops
-Significant changes from pre-op readings
What are some immediate neurological complications to check for in the PACU?
-Emergence delirium
-Delayed awakening
Emergence delirium
-Common
-Hypoxia, anaesthesia agents, bladder distension, immobility, sensory and cognitive impairments, inadequate pain control, poly pharmacy, dehydration, malnutrition
Delayed awakening
-Often reversible
-Caused by meds
Is it common for patient sot have anxiety related to the procedure or the surgery itself?
Very common
Frequent pain assessments
Looking at pain scale, observations, and vitals. Also look into the efficacy of pain modulates. In the first hour, check every 15’
What are some temperature changes you might see in the PACU?
-Hypothermia
-Heat loss from surgery
-COld fluids in the OR
-Anaesthia agents
Can treat them with a bear hugger (yes, really )
What are some common complications in the GI in the PACU?
-INcrease in intercrnail pressure can dehires sutures
-N/V common
RF: 50+, women, non-smoker, long surgery, allowing up the abdomen
GU complications in the PACU ?
-Low urine output
-Acute urinary retention
What is the normal urine output in an adult?
-30mL/h
How can you address and patients acute urinary retention?
-Stand them up
-Private place, turn on the water
-May have to use in/out Cath or foley
-Nerve blockers can reduce need to pee
What should we look for in the patient surgical wound and dressings?
Monitor drainage amount/colour, look for fever, increasing erythema around site, purulent drainage, feeling unwell, swelling around wound
What is a common post-op complication that can be delayed and take place after some time?
-POst-op paretic ileum
-decreased peristalsis
-Persistent vomiting not helped by anti-emetics
Help by having them walk, NPO to NG to decompress
What is “general surgery”?
-Anything GI tract, not everything everywhere
Esophagectomy
TI: esophageal cancer
Approach: thoracotomy
Length: 8-10hr
Length of stay: 4-7 days, 1-2 in ICU
What are the post-OP considerations for an esophagectomy ?
-Jackons pratt drian
-Epidural or pain control
-Chest tubes
-Wound care
-J-tube for feeding, strict NPO
What is there a high risk of following an esophagectomy?
AFIB due to surgery’s proximity to the heart
Small bowel resection
TI: Bowel cancer, Crohn’s, Scar tissue/adhesions causing small bowel obstruction, bowel perforation
Approach: Laparoscopy, robotic or laparotomy
Surgery length: 2-4h
Stay: 1-2 days, open=3-5
What are some Post-OP considerations for a small bowel resection?
-Jackson pratt drain
-Epidural or pain control
-Ileostomy
-Wound care
Would you resect a bowel if a patient has UC?
NO. Only for crohns
what is the common name for a large bowel resection?
Colectomy
Is there a change in bowel function when a patient has a hemocolectomy?
No.
Large Bowel Resection
Indication: Bowel cancer, IBD (crohns, UC), diverticulitis, bowel perforation
Approach: laparoscopy, robotic or laparotomy
Surgical length: 2-4h
Length of stay: Minimally invasive-1-2 days, open=3-5 days
What are some common post-op considerations for the large bowel resection?
-Jackson pratt drain
-Epidural or pain control
-Ileostomy or colostomy
-Wound care
-Changes to output or BM
Appendectomy
Indications: Appendicitis, rarely cancer
Approach: laparoscopically
Length: 1-2h
Length of stay: Usually can go home post-OP, 1-2 days
What are some key Post-OP considerations following an appendectomy?
-Pain from laproscopy air
-Infection as connected to large bowel and tissue can become inflamed treated with a drain
Cholecystectomy
“Gallbladder”
Indication: Gall stones
Surgical Length: 1-2h
Length of stay: Go home post-OP, 1-2 days
What are some cholecystectomy considerations following the procedure?
-Pain from Lap air
-Retained gall stones leading to pancreatisits
Pancreaticoduodenectomy (Whipple)
Indication: Pancreatic or bile duct cancer
Approach: always laparoscopic
Surgical length: 6-8h
Length of stay: 4-7days
What are some common post-OP considerations when a patient has a whipple?
HIGH risk of complications
-Pain modalities
-Wound care
-Drains
-Nutrionional support
What are some of the best ways you can minimize complications following a surgery?
-Pain control
-Ambulation
-Nutrition
You can minimize this by getting the patient up for every meal
