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Clin Med- P > Surgery: Post-op > Flashcards

Surgery: Post-op Flashcards

1
Q

what is included in “early mobilization” to prevent complications of post-op? (5)

A
  1. Deep breathing and coughing
  2. Active daily exercise
  3. Joint range of motion
  4. Muscular strengthening
  5. Make walking aids such as canes, crutches and walkers available
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2
Q

infection is usually confined to what?

A

SubQ tissues

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3
Q

surgical wound classification 1-4

KNOW

A

(1) Clean : no gross contamination from exogenous or endogenous sources
1. 5%

(2) Lightly contaminated: clean-contaminated
2–5%

(3) Heavily contaminated: 5–30%
(4) Infected: in which obvious infection has been encountered during operation

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4
Q

two types of surgical site infections (SSIs)? There are two types of the 1st SSI

A

Incisional SSIs
Superficial: Incisional (skin and subcutaneous tissues)
Deep: Incisional (deeper soft deep fascia, muscles, and tissues beneath subcutaneous tissue of the incision)

Organ/space SSIs
Any part of the anatomy other than body wall layers that was manipulated during the procedure

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5
Q

Host factors that contribute to surgical infections (9) KNOW

A 
Diabetes mellitus 
Hypoxemia
Hypothermia
Leukopenia
Nicotine (tobacco smoking)
Long-term use of steroid or immunosuppressive agents
Malnutrition
Nares colonization with S aureus 
Poor skin hygiene
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6
Q

prophylactic abx are indicated for what two types of “surgical classification”s ? when are they discontinued?
(kinda weeds)

A

clean contaminated or contaminated cases

  • use for just about for any big surgery (b/c most will be clean-contam.)
  • discontinue usually within 24 hours of operation
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7
Q

Abx resistance risk factors in post-op patient (6)

A

1) . Immunodeficient / compromised
2) . Implants/invasive devices
3) . Elderly patients
4) . Illness severity
5) . Extended LOS (length of surgery)
6) . Exposure to broad spectrum antibiotics

*but wont really change how we prophylax

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8
Q

one of the most common wound complications that is almost always caused by imperfect hemostasis? (KNOW)

A

hematoma (collection of blood and clot in the wound)

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9
Q

why are hematomas bad for post-op? how to prevent them? (KNOW)

A

Increased chance of dehiscence (opening up of the wound) and infection (due to poor circulation).
-give anti-coags and make sure wound is DRY

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10
Q

what is a seroma? why are they bad? how to prevent them? (KNOW)

A

Fluid collection in the wound other than pus or blood. Seromas delay healing and increase the risk of wound infection; prevent them by placing drains

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11
Q

what is wound dehiscence? when is it most commonly seen? (KNOW)

A

Wound dehiscence is partial or total disruption of any or all layers of the operative wound. (ABD)

most commonly observed between 5th-8th postoperative days, when the strength of the wound is at a minimum

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12
Q

MOST important factor in preventing wound dehiscence ? (KNOW

A

adequacy of closure: performing a neat incision, avoiding devitalization of the fascial edges by careful handling of tissues during the operation, placing and tying sutures correctly, and selecting the proper suture material.

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13
Q

what gives “strength “ to a closure?

A

The fascial layers give strength to a closure, and when fascia disrupts, the wound separates.

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14
Q

the most common single cause of morbidity after major surgical procedures? (KNOW)

A

pulmonary complication

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15
Q

what type of operations are pulmonary complications most common? (KNOW)

A

emergency operations (also chest and upper abd operations)

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16
Q

most common pulmonary complication? affects 25% of patients who have _______ surgery. how is it fixed? (KNOW)

A

atelectasis (lung collapse); abdominal surgery

-self- limited

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17
Q

fever within 48 hours post-op MOST likely means what? (KNOW)

A

atelectasis (over 90% of febrile episodes)

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18
Q

most common pulmonary complication among pts who die post-operatively? (KNOW)

A

Pneumonia

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19
Q

fat particles are found in 90% of patients with these two types of injuries? fat embolism can also be caused by (3)?

A
  • fractures of long bones or joint replacements.

- exogenous sources of fat, such as blood transfusions, intravenous fat emulsion, or bone marrow transplantation.

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20
Q

fat embolism syndrome (KNOW)

A

consists of neurologic dysfunction, respiratory insufficiency, and petechiae of the axillae, chest, and proximal arms.

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21
Q

to dec cardiac complications, how do we want the blood to be during surgery and then after? when do we stop oral anticoags? (KNOW)

A

sticky/thicker during surgery, Thin after

-Oral anticoagulant drugs should be stopped 3–5 days before surgery, put back on after

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22
Q

what is bridging anti-coag? who might need this?

A

use of a short-acting parenteral agent to reduce the interval without anticoagulation
-patients on warfarin with an especially high thromboembolic risk

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23
Q

cardiac complications: General anesthesia depresses the _______, and some anesthetic agents predispose to what?
what do you do about this? (KNOW)

A

myocardium; predispose to dysrhythmias by sensitizing the myocardium to catecholamines.

-Monitoring of cardiac activity and blood pressure during the operation detects dysrhythmias and hypotension early.

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24
Q

cardiac complications: In patients with a high cardiac risk, _______may be safer than _________for procedures below the umbilicus. (KNOW)

A

regional anesthesia (e.g. nerve block) may be safer than general anesthesia

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25
Q

how does post-op ileus occur?

A

Anesthesia and surgical manipulation result in a decrease of the normal propulsive activity of the gut

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26
Q

GI peristalsis returns when after post-op ileus?

A

within 24 hours after most operations that do not involve the abdominal cavity

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27
Q

what is gastric dilation? how does it present?

A

a rare life-threatening complication, consists of massive distention of the stomach by gas and fluid
-patient appears ill, with abdominal distention and hiccup

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28
Q

diagnosis and txt of gastric dilation? (KNOW)

A

XRay (to see gas) and gastric decompression with a nasogastric tube.
In the late stage, gastric necrosis may require gastrectomy.

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29
Q

how to differentiate between ileus and obstruction? (KNOW)

A 
plain film (xray) 
- obstruction will show lots of gas stuck in there
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30
Q

bowel obstruction is most often caused by what?

how does it present?

A

Mechanical obstruction is most often caused by postoperative adhesions or an internal (mesenteric) hernia

-patients experience a short period of apparently normal intestinal function before manifestations of obstruction supervene.

31
Q

post-op fecal impaction presentation

A

Early manifestations are anorexia and obstipation or diarrhea. In advanced cases, marked distention may cause colonic perforation.
- results from ileus and impaired perception of rectal fullness

32
Q

how common is post-op fever? how bad is it?

A

Fever occurs in about 40% of patients after major surgery.
In most patients the temperature elevation resolves without specific treatment.
BUT important, if there are other symptoms as well, evaluate clinically cause could be significant

33
Q

Features often associated with an infectious origin of the fever include (6)… how many of these must be present for the chance of a bact. infection to be near 100%

KNOW

A
  • preoperative trauma,
  • ASA class above 2
  • fever onset after the second postoperative day
  • initial temperature elevation above 38.6 °C
  • postoperative white blood cell count greater than 10,000/L
  • postoperative serum urea nitrogen of 15 mg/dL or greater.

If three or more of the above are present, the likelihood of associated bacterial infection is nearly 100%.

34
Q

fever after 5th post-op day may indicate what? (KNOW)

A

wound infection or less often, anastomotic breakdown and intra-abdominal abscesses.

35
Q

Dx test for wound infections/ intra abd abscess? (KNOW)

A

CT scan of the abdomen and pelvis is the test of choice and should be performed early, before overt organ failure occurs.

36
Q

The 5 W’s: commonly cause post-op fever

KNOW

A

1) . Wind: pneumonia, aspiration, PE
2) . Water: UTI (foley)
3) . Walking: DVT PE
4) . Wound: SSI (surgical site infection)
5) . Wonder drugs /What did we do? drug reaction, infection from vascular access, blood product reactions

37
Q

post-op fluid replacement is based on what 4 things

A

(1) maintenance requirements
(2) extra needs resulting from systemic factors (eg, fever, burns)
(3) losses from drains
(4) requirements resulting from tissue edema and ileus (third space losses).

38
Q

best test for renal fxn

A

how much urine is produced

39
Q

how much fluid do you replace?

A

multiplying the patient’s weight in kilograms times 30

eg, 1800 mL/24 h in a 60-kg patient

40
Q

fluid maintenance requirements are increased by what 3 factors?

A

Maintenance requirements are increased by fever, hyperventilation, and conditions that increase the catabolic rate.

41
Q

Assessment of the status of fluid balance requires accurate records of what? how do you record this?

A

fluid intake and output; by weighing the patient daily.

42
Q

patient’s post-op progress should be monitored and those observations include? (4)

A
  • comment on medical and nursing observations
  • specific comment on wound/op site
  • any complications
  • any changes made in tx
43
Q

what is the focus of post-op aftercare?

A

prevention of complications

44
Q

when does prevention of post-op complications start?

A

PRE-OP: ex quitting smoking and losing weight

45
Q

and the second most common cause of postoperative deaths in patients older than 60 years? (KNOW)

A

pulmonary complication

46
Q

two surgical locations that are prone to pulmonary complications?

A

chest and upper abdominal

47
Q

course of atelectasis?

A

most cases, the course is self limited and uneventful recovery

48
Q

pts at high risk of thromboembolic dz should receive what until 6 hrs prior to surgery? (KNOW)

A

heparin

49
Q

when can heparin be restarted after surgery? (KNOW)

A

36-48 hrs

50
Q

postop dysrhythmias may be the first sign of what? (KNOW)

A

MI

51
Q

supraventricular dysrhythmias usually have ____ consequences but may decrease what? (KNOW)

A

few; cardiac output and coronary blood flow

52
Q

treatment for pts with atrial flutter or afib with rapid ventricular response? (KNOW)

A

cardioversion

53
Q

ventricular premature beats are often precipitated by what? (4) KNOW

A

hypercapnia, hypoxemia, pain or fluid overload

54
Q

which type of dysrhythmia has a more profound effect on cardiac function? KNOW

A

ventricular- bc can lead to fatal ventricular fibrillation

55
Q

over ___% of post op MI are asymptomatic

A

50%

56
Q

cessation of smoking for ___ weeks before surgery decreases the incidence of postoperative pulmonary complications from ___% to __%

A

6 weeks; 50% to 10%

57
Q

Correction of _______ ________ decreases intra-abdominal pressure and the risk of wound and respiratory complications and improves ventilation postoperatively

A

gross obesity

58
Q

Perioperative factors (things healthcare workers do) to surgical infection (8) KNOW

A

operative shaving
breaks in sterility
inadequate dosing of ABX, delayed ABX
poor wound care
Infected or colonized surgical personnel (skin or surgical attire)
Prolonged hypotension
Poor operating room air quality (contaminated ventilation)
Contaminated operating room instruments or environment

59
Q

predisposing factors/risk factors for post-op pneumonia? (5) KNOW

A 
peritoneal infection
those requiring prolonged ventilatory support
Atelectasis
aspiration
copious secretions
60
Q

risk factors for atelectasis? (4) KNOW

A

elderly
overweight
smoke
have symptoms of respiratory disease.

61
Q

risk factors for pulm aspiration? KNOW (6)

A 
NG or ET tubes
drugs that suppress NS
reflux
food in stomach
patient position
trauma pt
62
Q

to decrease cardiac complications what do you do for the first 3-4 days post-op? KNOW

A

continuous electrocardiographic monitoring to detect episodes of ischemia or dysrhythmias

63
Q

people with high risk of thromboembolic dz should receive heparin until what point pre-op? when should it be restarted? (KNOW)

A

up until 6 hrs before surgery; restarted 36-48 hrs after (debated)

64
Q

when to start and stop warfarin for surgery?

A

stop 5 days before and restart within 24 hrs

65
Q

some non-cardiac complications that can cause cardiac probs? (3) KNOW

A

fluid overload
sepsis
hypoxemia

66
Q

what type of procedures increases risk of post-op MI? KNOW

A

operations for manifestations of atherosclerosis

67
Q

clinical manifestations of post-op MI (3)

A

hypotension, chest pain and cardiac dysrhythmias

68
Q

what is the most common cause of post-op heart failure? KNOW

A

fluid overload (in pts with limited myocardial reserve)

69
Q

risk factors for GI motility complications (5) KNOW

A 
general anesthesia
surgical manipulation
meds- opioids
electrolyte abnormalities
inflammatory conditions- pancreatitis, peritonitis
70
Q

complications of GI immobility post-op (3) KNOW

A

gastric dilation
bowel obstruction
post-op fecal impaction

71
Q

predisposing risk factors for gastric dilation (6) KNOW?

A

asthma
recent surgery
gastric outlet obstruction
absence of the spleen
infants and children in whom oxygen masks are used in the immediate postoperative period
adults subjected to forceful assisted respiration during resuscitation

72
Q

risk factors for post-op fecal impaction? (4) KNOW

A

ELDERLY
post-op ileus
opioids
anticholnergic drugs

73
Q

how to diagnose and tx post-op fecal impaction (KNOW)

A

rectal exam

tx: manually removed, enemas given, and digital exam repeated

Clin Med- P (124 decks)

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