Chapter 3/4 Flashcards
The Surgical Patient and Special Populations
1
Q
What is the primary role of the CST in rendering care to the surgical pt?
A
Assisting the surgeon during the surgical procedure.
-establishment and protection of a sterile field
-care/handling of surgical instrumentation
-assistance with technical tasks throughout procedure.
2
Q
What is Maslow’s hierarchy of needs?
A
Model of human development. (lower levels must be met before the higher ones)
Physiological needs: Basic biological needs such as water, oxygen, food, and temperature regulation.
Safety needs: individual’s perception that his or her environment is safe.
Love and belonging needs: These are basic social needs: to be known and cared for as an individual and to care for others.
Esteem needs: positive evaluation of one’s self and others; a need to be respected and to respect others.
Self-actualization: individual’s need to fulfill what he or she believes is purposeful.
3
Q
What are some religious values to be aware of?
A
Roman Catholic: Bishop, priest; Bible; Holy day is Sunday; No meat on Friday and fast on lent; Medical treatment is encouraged; No birth control; infertility treatment allowed w some rules; no abortion; specific conditions before removal of life support; organ donation allowed
Mormon: Bishop; Bible, Book of Mormon, others; Sunday; No drugs, alcohol, coffee, tea, or tobacco; medical treatment is encouraged; BC is allowed; infertility tx is allowed; abortion w specific conditions; removal of life support is personal choice; organ donation allowed
American Indian: Medicine man/Elder; Oral Tradition; no holy day; diet varies; views of tx vary; BC is discouraged; Infertility tx allowed; no abortion; life support not necessary; organ donation discouraged
Protestant: Bishop, priest, minister, pastor; Bible; Sunday; Generally no diet; Yes medical tx; BC allowed; Infertility tx allowed; abortion under some circumstances allowed; removal of life support under specific conditions; yes organ donation
Jehovah’s Witness: Elders; New World Bible; No holy day; No blood containing food; Medical tx encouraged but no blood transfusion; BC allowed; Infertility tx allowed; No abortion; Removal of life support under specific conditions; yes organ donation
Islam: Imam; Koran; Friday is holy; No pork, alcohol, or drugs and fast on Ramadan; Medical tx is encouraged with emphasis on privacy; BC allowed; Infertility tx allowed w rules; Abortion under some circumstances; Removal of life support during certain circumstances; Yes organ donation
4
Q
What are the needs of the surgical patient?
A
Physical- Anything relating to genetics or anatomy/physiology (nutrition, sleep, regulation, fluid balance, o2/co2 exchange, elimination of waste)
Physiological- Anything related to identification and understanding of one’s self (shortened life, the unknown, anesthesia, death, pain, disfigurement, loss of self-control, financial, employment, individualism, self-image, left roles)
Social- Anything w identification of one’s self and interactions with others (relationships w peers and support system)
Spiritual- Anything with one’s identification and place within the universe (religion and right to refuse)
5
Q
What are the common factors that lead to surgical intervention
A
-Trauma
-Genetic Malformation
-Benign Neoplasm
-Condition
-Physiological State
6
Q
What are the two broad factors that apply to the majority of pt’s in reaction to hospitalization/health?
A
Adaption and Stress
7
Q
What is adaption?
A
both physiological and psychological changes that indicate the person’s attempt to adapt to and counter the stressors of illness or trauma. can be either rapid or slow, based on the nature and type of illness or trauma, family support, patient’s culture, level of the patient’s social development, level of the patient’s intelligence, patient’s personality, and learned responses.
8
Q
What are the two different types of stress?
A
Nonspecific response of the body to a demand. Emotional, physical, and chemical.
Distress- bad
Eustress- good
9
Q
What are the factors that contribute to stress?
A
-Type, nature, and severity of trauma/disease/condition
-previous experience
-age; peds pts feel vulnerable when taken away from parents, adolescents are conscious about privacy, and adults are concerned about death, family, finances, etc.
-family role
-economic factors
-religious beliefs
10
Q
What are the different coping mechanisms?
A
Denial- does not accept what is happening
Rationalization
Regression- pt regresses to an earlier stage of life (ex: fetal position, crying, pouting)
Repression: Avoids thoughts and feelings on the matter
11
Q
What are the three accepted stages of death?
A
Cardiac- Irreversible loss of cardiac and respiratory function
Higher-brain Death: Irreversible loss of higher brain function (breathing, BP, heartbeat)
Whole Brain Death: Loss of all functions of the brain (defined as death in courts). Examples are flat EEG, unresponsiveness etc.
12
Q
What are the five stages of grief?
A
-denial
-anger
-bargaining
-depression
-acceptance
stages may not occur in order and not everyone will go through all stages
13
Q
What are the general categories of death?
A
-accidental: natural disaster, gunshot, car accident, etc.
-terminal: cancer
-prolonged/chronic: high bp, asthma
-sudden: deaths without warning (SIDS)
14
Q
What are palliative procedures?
A
Procedures meant to provide pt w symptom relief and avoidance of pain. Does not alter the ultimate progression of original disease. Improves quality of life.
15
Q
What are therapeutic procedures?
A
Used to treat or manage a disease. For example, a pacemaker or live organ donation transplant.
16
Q
What is life support?
A
A set of therapies that preserve a patient’s life when body systems are not functioning sufficiently to sustain it.
(feeding tubes, IV drips, mechanical respiration, heart bypass, etc.)
17
Q
What are ordinary means of care?
A
Used to prolong life which physician is morally obligated to provide without imposing additional burden on the pt.
18
Q
What are extraordinary means of care?
A
Therapies that may impose an additional burden and may be costly. Pt has no obligation of accept treatment for second life threatening treatment when ding of first life threatening illness and surgeon is not morally obligated to provide it.
19
Q
What is the difference between active and passive euthanasia?
A
Passive: Physician does nothing to preserve life
Active: Actions that speed up the process of dying. PT initiates facilitation of death voluntarily or pt’s autonomous rights are violated.
20
Q
What does the AHA Patient Care Partnership do?
A
Allows patients the right to refuse care.
-medical facilities must inform pt of their right to choose the type and extent of medical care
-provide pt w info concerning living wills and powers of attorney
-STSR must refrain from imposing value system on pt and honor pts request.
21
Q
What does the Patient Self Determination Act do?
A
requires medical facilities to inform patients of their right to choose the type and extent of their medical care and to provide patients with information concerning advance directives
22
Q
What is an advanced directive?
A
general term that refers to one of two legal documents used to speak for patients in the event that they become incapacitated
23
Q
What is a living will?
A
allows patients to state in writing exactly what medical interventions they are willing to endure to sustain life
24
Q
What does a power of attorney do?
A
legal way to appoint a health care proxy who will make medical decisions for the patient in the event that he or she cannot
25
What does a DNR/DNI do?
states that resuscitation should not be attempted if a patient suffers a cardiac or respiratory arrest.
26
What is the common policy and procedure that must be followed by the surgical team when a death occurs in the OR?
-notify supervisor and implement postmortem care
-friends and family at hospital must be notified
-religious leader may be notified
-in certain cases evidence may be needed to be preserved
-postmortem care/preparation of viewing
27
What must happen for someone to be considered a candidate for donation after cardiac arrest (DCD)?
it is predicted that the heart will cease functioning within 90 minutes of removal from mechanical support.
28
What are the steps to organ donation after DCD
-family of pt is consulted
-assessments
-schedule procedure
29
What are the special terms for the pediatric patient?
neonate: <28 days
infant: 2-18 mo
toddler: 19-30 mo
preschooler: 31mo-5yr
school age: 6-12 yr
adolescent: 13-18 yr
30
What are some anatomical and physiological considerations for pediatric patients?
Temperature: kids under 6 mo can't shiver and are at risk for brachycardia, hypothermia, and acidosis
HR/resps: decline w age; adolescents are normal
BP: Child of 1 year and older: systolic pressure in mm Hg = 80 + (2 × age) and diastolic = systolic
Head: Suture ridges palpable until 6mo; posterior fontanelle closes at 3, anterior at 19
Vision: 2/200 at birth and no tears until 2-3 mo
Ears: more at risk for infection cuz of shape of auditory tube
sinuses: no sphenoid until puberty
breasts: develop at 9-13 and mature at 13-19
abd: liver proportionately larger
neurological: not fully developed
genatalia: testes descend at 1yr.
31
What are normal HR ranges for peds?
Infants: 80-130 (110)
2-6 years: 70-120 (100)
6-10 years: 70-110 (90)
10-16 years: 60-100 (85)
32
What are normal resp rates for peds?
1 yr: 10-40
3 yr: 20-30
6 yr: 16-22
10 yr: 16-20
17 yr: 12-20
33
What should be considered when it comes to language and peds patients?
Neonates and infants are startled easy so quiet environment is important. The preschool/school-aged child may use words to inform, persuade, distract, or manipulate but they will not use language the same way. Descriptions of pain, for instance, are likely to be imprecise in terms of both symptoms and location. Learning to understand the child takes considerable experience.
34
What is the main fear a child may have when it comes to surgery and how can the surgical team help?
Separation from parents/abandonment.
To help:
-Let child bring toy/stuffed animal
-Introduce all members of surgical team
-Show child department
-Let parents walk child to OR
-let parents come into PICU after first set of vitals
35
What is another primary fear of children?
Anesthesia. Preop visit is helpful where equipment should be shown and questions should be answered truthfully.
36
What are the critical parameters to monitor after surgery in pediatric patients?
temperature, urine output, cardiac function, and oxygenation.
37
How is temperature regulation in peds patients?
Neonates lack the ability to shiver, little subcutaneous fat, and lean body mass. They lose heat through radiation, conduction, convection, and evaporation. Incubators help.
Temperature is monitored through rectal, esophageal, skin, and axillary.
In OR, temp is often increased and overhead radiant heating is used for pt's under 2. Keep extremities wrapped. Warm water/air filled blankets may be used.
38
How is urine output different in peds patients?
Higher risk of infection and trauma to short urethra so no cauterization. Appropriate urine output is 1 to 2 mL/kg/hr.
39
How is cardiac function monitored in pediatric patients?
Intra arterial measurement (catheter inserted in artery)-ill children who require constant ECG monitoring. Cutdown to radial artery- Infants and children. Umbilical Artery- Neonates
Central Venous Catheter. Subclavian/internal jugular of older children w no cardiac abnormalities. Cutdown to External Jugular- Neonates and infants w no cardiac abnormalities. Saphenous vein can be accessed if necessary.
40
How is oxygenation measured for pediatric patients?
ABG is measured with pulse ox (same w all age groups)
41
How does shock present in pediatric patients?
Septic Shock- Most common in children. Caused by gram-negative bacteria usually be peritonsis from intestinal perforation. Other common causes are UTI, URI, and contaminated IV. Causes reduced circulating blood volume (tx is infusion of colloid solutions, broad spectrum antibiotics and sometimes dopamine)
Hypovolemic Shock- Brachycardia, Decreased venous return that leads to low cardiac output and tissue perfusion and then lactic acidosis. In infants dehydration is most common symptom (fixed w infusion of fluids and blood). Emergency tx is infusion of hypotonic sodium chloride.
42
How is the management of fluids and electrolytes different in pediatric patients?
Normal changes in body fluid are interrupted when neonate has to undergo surgery. To help, cover extremities with towels and humidify gases. An increased extracellular fluid (ECF) volume in a premature neonate stimulates the release of prostaglandin E2, which maintains ductus arteriosus patency.
43
Why are newborns at greater risk of infection?
Microbial barriers of skin and GI are underdeveloped and are the host defense mechanisms. (by day 10 they have the same flora as adults)
44
What are the most common sites of postoperative infection in neonates?
Lungs, surgical wound, urinary tract, and vascular sites. Tx includes incision, debridement, and packing of antibiotic impregnated packing or removal of catheter and administration of antibiotics. Fever is the first sign.
45
What are the three differences in side effects from antibiotics in children?
Sulfonamides (such as Bactrim or Septra) are associated with an increased incidence of kernicterus in neonates, which is an excess of bilirubin in the blood. Therefore, sulfonamides should not be administered to newborns.
Chloramphenicol (Chloromycetin) is the synthetic form of an antibiotic originally isolated from Streptomyces venezuelae and is associated with the cause of “gray syndrome” in which the infant’s skin turns gray from drug toxicity. Chloramphenicol should not be administered to newborns.
Tetracycline causes staining and hypoplasia of the enamel of the developing teeth; therefore, it should not be administered to children.
46
What does the administration of practically every antibiotic associated with?
pseudomembranous enterocolitis, from overgrowth of Clostridium difficile due to antibiotic suppression of the growth of normal bacteria in the colon. treatment consists of discontinuing the antibiotic that contributed to the cause of the enterocolitis (infection of the small and large bowel) and oral administration of vancomycin.
47
How are the metabolic/nutritional needs different in children?
Much higher than adults and surgery increases caloric needs (20-30%). Gastrotomy tubes are often used postop for procedures with the GI tract.
48
How is trauma unique in children?
Blunt trauma is the most common with MVAs being most common. Other causes are falls, bike accidents, drowning, burns, poisoning, and child abuse. Best tx is prevention.
49
What is a professional?
An individual who has specialized education and training in a given field and who meets certain competency-based and ethical criteria.
50
Why is it important to understand the cultural and religious influences?
Pt population in the United States is diverse and values can easily conflict w modern medicine. This can create both ethical and legal issues.
51
What is the Roy Adaption Model
Views the pt as a biopsychosocial individual that is interacting w environment w ability to adapt by using coping skills in dealing w internal and external stressors. Based on nature of illness/trauma, family support, culture, social development, intelligence, personality and learned responses.
52
What are some of the spiritual/religious rituals that play an important role in death and dying?
Roman Catholic: anointing the sick
Catholic/Protestant: offer last rights
Muslim: Turn east to face Mecca after death
Jewish: dying pt is not left alone. don't touch body until rabbi offers last right. relative closes eyes and washes and dresses body
Buddhist: reincarnation, last thoughts determine rebirth condition.
Hindus: Cremation- soul begins its journey
53
What are the changes in body fluid before and after birth?
First Trimester: 90% body weight is water
32 Weeks Gestation: 80% body weight; 60% extracellular fluid volume
Term: 78% body weight; 45% extracellular fluid volume
First Postnatal Week: 75% body weight
Next 1-2 Years: 60% body weight; 20% extracellular fluid volume
54
What is the general choice of antibiotics for children, infants, and neonates?
Usually same as adults. In clean contaminated procedures penicillin with aminoglycoside or third-generation cephalosporin. First dose is given just before skin incision is made and continued 24-48 hours.
55
What are the key differences in treatment for children?
-May experience communication barriers in indicating origin of pain.
-Display developmental regression
-Postop metabolic management is important
-Seemingly insignificant blood loss may result in hemodynamic changes
-Water and heat loss occur rapidly because children lack subcutaneous fat
-Hypothermia increases the effects of acidosis
-Vomiting bc of gastric dilation is common. Watch for aspiration
-Increase nutritional requirements
56
What are the general principles of emergency tx for peds?
-Make sure airway is clear. If difficulty breathing occurs immediately intubate w uncuffed ET tube
-Stabilize C-Spine is suspect injury
-If difficulty breathing is still there, pneumothorax may be present.
-Children hyperventilate which can cause gastric dilation. This can be fixed w a NG tube
-IV should the be placed which may require a cut down to the great saphenous vein or a central line
57
What are the common injuries seen during birth?
-Fx clavicle and upper brachial plexus palsy due to shoulder dystocia.
-Peripheral facial nerve damage may occur due to pressure on infant's place
-Injury to the spleen, liver, or adrenal glands from pressure on the abd
-Injury to the sternocleidomastoid which can result in contracture.
58
What is child abuse?
a tragic event where the patient often presents with multiple traumatic injuries, some of which may have already healed, especially in the case of fractures. Abuse can take the form of physical and/or mental injury, sexual abuse, nutritional neglect, verbal abuse, and/or delayed treatment of disease and injuries. Surgery is often required to treat soft tissue injuries, fractures, burns, and head trauma. Visceral injuries include internal liver and splenic lacerations, internal pancreatic damage, and duodenal hematomas.
59
What defines morbid obesity?
Pts whose body wt is 100lbs over ideal body wt. This leads to increases susceptibility to morbity and morality.
60
What are some physiological and disease conditions related to obesity?
-Myocardial hypertrophy which leads to CHF
-HTN
-CAD
-Vascular changes in kidneys affecting elimination of protein wastes and maintenance of normal fluid and electrolyte balance
-Varicose veins and edema in lower extremities due to poor venous return
-Pulmonary complications leading to hypoxia, SOB, SA, decreased lung expansion, and PE
-Liver and gallbladder disease
-Osteoarthritis
-DM
-Pituitary abnormalities
-Arteriosclerosis
-Dysfunctional uterine bleeding
61
What are some considerations to take when lifting and transferring an obese patient?
The pt may require a mechanical lifting device (Hoyer). Pt might be transported to OR on bed if the stretcher is not large enough. Extra individuals should be available to prevent injury to staff and falls. Since they are often self-conscious, minimum exposure is key. When on the table, a pillow should be placed under the pt's knees with a safety belt 2 inches above.
62
What are some considerations that anesthesia may have when providing care for an obese pt?
Venous cut-down might be required to gain IV access. There is an increased induction time bc decreased concentrations of anesthesia gas reach the lungs since there is decreased pulmonary function. Higher concentrations are needed since the adipose tissue absorbs this. This also leads to slower elimination and longer post op recovery time. Due to limited neck mobility, anesthesia may have a hard time intubating, help by hyperextending the neck and extending the jaw.
63
What considerations should the surgical team take when positioning an obese pt?
Two OR tables may be needed. Tissue must be protected from injury bc it can get caught in the crevices of the table. Skin wrinkles should be smoothed out to avoid cutting off circulation which can lead to necrosis. Areas of concern should be padded. Put in reverse Trendelenburg to increase ventilation. Use SCD's to prevent venous stasis
64
How should the ESU grounding pad be placed on an obese pt?
Avoid skin wrinkles to make sure the pad comes in full contact of the skin. One person can "stretch" the skin to provide a smooth surface. Pad should not be surrounded by other tissue to prevent burns.
65
What considerations should the CST take into consideration with instrumentation in bariatric cases?
Long and deep instruments will be required. The CST should prepare a longer surgery. CST should be prepared for various methods of closing such as Montgomery straps or suture bridges.
66
How is healing different in bariatric pts?
It is often delayed due to poor blood supply. There is an increased risk in infection.
67
What risks increase for obese patients in sx?
-postop infection
-dishinence
-PE
-anesthetic complications
-acute respiratory arrest
-thrombophlebitis
-ventricular failure
-postop asphyxia
-anastomotic leaks
-CAD and cardiac dysfunctions (postop EKG is imperative)
68
What should be done to prevent DVT in bariatric patients?
Risk of DVT increases when pt lays in supine. Heparin could be administered. SCD's should continue to be used during postop. Pt should try to walk as soon as possible after sx.
69
What are the most common complications after gastric bypass or a gastroplasty?
Abdominal catastrophes- s/s include pain indicated by pt, acute resp failure which leads to peritonitis, if perforation, perform ex lap
Internal Hernia- s/s include periumbilical pain if left untreated bowel necrosis will happen
Acute gastric distention- severe gaseous distention can lead to perforation. s/s include hiccups, bloat, severe left shoulder pain, and shock. Could cause damage to the jejunostomy.
70
How are gallstones a concern in bariatric patients?
Gallstones are common in obese pts. If in the abd, the gallbladder may be removed, the CST should have supplies available for a lap chole w a possible cholangiogram.
71
How could degenerative osteoarthritis impact bariatric patients?
Damage to joints is often extensive and may require TKA,THA,TSA, etc. Loosening of the prothesis is common and surgeon may require pt to lose a certain amount of wt.
72
What are the two types of DM?
Type 1- insulin-dependent diabetes mellitus (IDDM): The pancreas produces little or no insulin, and the individual must have daily, regular doses of insulin.
Type 2- non-insulin-dependent diabetes mellitus (NIDDM): The pancreas produces different amounts of insulin; the patient is not required to take insulin, and blood glucose levels are usually controlled by diet.
73
What conditions must be prevented when operating on diabetic patients?
Ketonuria.
Acetonuria.
Ketoacidosis.
Hyperglycemia.
Hypoglycemia and hypoglycemic shock.
74
What preop prep must be done for diabetic patients?
EKG.
Fasting.
Chest radiograph.
Blood urea nitrogen.
Complete blood count.
Serum electrolyte level.
Postprandial blood sugar level.
Urinalysis to determine presence of sugar and acetone.
75
What are some complications that are associated with diabetic patients in surgery?
affects normal caloric intake which affects insulin, and anesthesia affects metabolic processes. Blood glucose increases while blood serum insulin decreases. Type 2/nondependent typically have no complications. Type 1 can have many
-Tachycardia
-neuropathy
-dehydration
-coronary artery disease
-retinopathy resulting in blindness
-Delayed wound healing and infection
-thrombophlebitis and peripheral edema
-hypertension and myocardial infarction
-glucose levels postoperatively
-Neurogenic bladder resulting in frequent UTIs
-poor circular with vascular disease
-Neuropathic musculoskeletal disease resulting in severe bone deconstruction
-infection
Ulcers on the extremities like the foot can heal slowly resulting in infection and can be amputated if it doesn’t react to antibiotics.
76
What are some preop cares to do for a diabetic pt?
-blood sample to test fasting glucose level and provide data for case.
-The normal dosage of preoperative medication is decreased because narcotics can induce vomiting, predisposing the patient to fluid and electrolyte imbalance and causing a hypoglycemic reaction.
-insulin reduced to prevent hypoglycemia and insulin shock
-pad patient’s bony surfaces to prevent sores and ulcers
-Diabetes patients should be first case so they can go back to regular dietary schedule asap.
77
What are some intraop cares for a diabetic pt?
-anesthesia monitors, if electrolytes needed it is through IV and if insulin needed it can be inserted through IV or injection.
-To prevent crisis a glucometer is used to measure blood sugar levels and urine samples are used to detect presence of ketones
-patient wears antiembolic stockings to prevent thromboembolism
-sterile technique still applied
78
What are some postop cares for the diabetic pt?
Increased rate of infection due to diminished blood levels in affected area. Stress hormone levels can predispose patient to hyperglycemia as do meds intraoperatively. Glucose lowering agents should be determined during perioperative glucose management.
-provided with proper nutrients either orally or intravenously for healing and glucose control
-administer proper antihyperglycemic medication determined during perioperative management
-sequential compression devices/boots to prevent DVT
79
How many births in the US occur in a year and what percentage of those require surgery?
4.31 million live births a year with 1-2% needing surgery
80
When are surgeries performed on pregnant pts?
Emergent: Done ASAP (ectopic pregnancy, appendicitis, trauma injury, or incompetent cervix)
Urgent: delayed until after the second or third trimester or until the mother delivers.
Elective: delayed until after delivery and the mother has recovered from the ordeal of pregnancy and delivery.
81
What trimester has the safest to perform surgery on if the patient is pregnant?
2nd Tri bc fetus is stable and organs are well-differentiated.
First tri increases the risk of SA and third increases risk of premature labor by 40% and all organs are displaced
82
What are some considerations to take when caring for a pregnant pt?
-Since organs are displaced, anatomical landmarks are difficult to find. ie: the appendix may be displaced to the upper right quadrant (cholecystitis and appendicitis are most common non-OB problems)
-Lab tests are skewed bc of hormonal changes
-Pt should be observed postop for vaginal bleeding, ruptured membranes, or uterine irritability (could be caused by bladder distention so place Foley) for preterm labor
83
How does the pregnant patient's vital signs change?
-HR increases
-Arterial pressure is lower
-Does not show typical signs of shock making hypovolemic shock hard to diagnose (use an EFM)
84
How does anesthesia effect the pregnant pt?
-General anesthesia increases the risk of preterm labor, low birth wt, and fetal death
-Agent crosses the placenta barrier making tranquilizers and narcotics slowly metabolizing for the fetus
-sedatives, tranquilizers, halogenated agents, and nitrous oxide could cause respiratory arrest for the fetus
-Bupivacaine causes the fetus to be brachy
-Lidocaine causes CNS depression
-Halogenated agents cause decreased uterine definition
-Vasopressors and negostine cause preterm labor
85
What are some intraoperative considerations for the CST when operation on a pregnant pt?
-Move as quickly as possible to minimize time under general anesthesia
-Palpate uterus intraop to detect contractions
-Provide cricoid pressure during induction
-Accurately measure irrigation fluid so EBL can be accurately calculated
-Raise temp to reduce risk of maternal hypothermia w warm blankets
-Have emergency c-section supplies available
-Doppler ultrasound scanner has been placed on maternal abdominal wall away from operative site (sterile Doppler may be needed)
86
How should a pregnant patient be positioned?
Place a small pad underneath the right hip to shift the fetus to the left and take pressure off the aorta, tilt bed 30 degrees to the left and in slight Trendelenburg to aid in venous return
87
What is immunocompetence?
The degree or function of an immune system that is designed to keep a pt free from infection by pathogens
88
What factors can affect the immuncompromised status of a pt?
-Age (the old and young)
-Certain autoimmune and chronic disease (ie: MS, RA)
-Specific drugs (immunosuppressants)
-Chemo
89
What are some physical manifestations of an immunocompromised pt?
-Skin rashes/lesions
-Painful joints
-Generalized malaise
-Poor nutritional status
-Possible CV complications
90
What is important for the CST to remember in regards to a pt w a decreases ability to fight infection?
Adherence to sterile technique is imperative to prevent SSI's
91
What is Human Immunodeficiency Virus (HIV)
a retrovirus that may remain dormant and undetected within the body for a long period of time before causing disease. Once active, the virus disrupts the normal functions of the T-lymphocytes of the body impairing the immune system.
92
What is Acquired Immunodeficiency Syndrome (AIDS)
The most severe state of HIV where pts present w opportunistic infections such as Kaposi's sarcoma, severe psoriasis, pneumocystis carinii pneumonia, and fungal/parasitic infections.
93
What complications do lesions from Kaposi's sarcoma cause?
-Painful, open and infectious which must be treated carefully when transporting and positioning
-Lesions in esophagus can prevent swallowing
-Lesions in intestinal tract can halt absorption of nutrients which causes NVD and muscle deterioration.
94
how should the surgical team treat AIDS pts?
W compassion, empathy, and professionalism. Personal feelings and stigmas should not impact level of care
95
Why is it important to have additional personnel when transferring an AIDS pt?
Pt may have extreme muscle and tissue wasting. Pt may also not be able to move due to weakness, painful joints, and skin lesions
96
what are some complications that may occur when performing a procedure on an AIDs pt?
Anesthesia may not be able to intubate due to esophageal lesions, IV placement may be difficult, Placement of grounding pad may be difficult bc of lesions
97
What should the surgical team ensure when positioning an AIDS pt?
Bony prominences should be adequately padded and drapes should be carefully placed and not moved to avoid irritating external lesions
98
What are the four clinical symptoms in AIDS pts that require surgical intervention
1. Kaposi's sarcoma lesions on the Gi tract
2. Peritonitis secondary to cytomegalovirus
3. Mycobacterial infection of the retroperitoneum or spleen
4. Non-Hodgkin's lymphoma in Gi tract which result in obstruction or bleeding.
99
What are common surgical procedures that are performed on AIDS pts?
-Diagnostic Biopsies
-Emergent repair for cholecystitis and cholangitis bc of cryptosporidiosis and cytomegalovirus
-bowel resection, bypass, or colostomy for acute perforations
-Splenectomy for splenomegaly
-Placement of an indwelling catheter.
100
What are some considerations to take with hearing impaired patients?
-Could be partially or totally deaf and required to remove hearing aid.
-May need to communicate in sign language w an interpreter
-Nonverbal communication and a gentle touch go a long way
-Preop visit w hearing aid or family to translate might be helpful
101
What are some considerations to take with visually impaired pts?
-Glasses should be available upon return
-Contacts should be removed pre-op to avoid damage to the corneas
-Can hear verbal commands but may require extra personnel to carry out
-Explanation of surroundings is helpful
102
Why is treating a trauma pt difficult?
Multiple body structures could be injured and require several surgeons and teams. CST should be available to help on any procedure
103
What is the "golden hour"
Reaching the victim and providing treatment in the first hour after injury is critical in determining the patient's outcome. Best time for rapid and aggressive interventions to prevent mortality and morbidity
104
How are trauma centers ranked?
Trauma I: Meets all needs of trauma pt: Qualified personnel and equipment 24/7 w comprehensive care and highest level of surgical care
Trauma II: Can treat seriously injured or Ill but does not have all resources. Work in collaboration w Trauma I
Trauma III: Often a rural or community hospital which offers limited care. Have resources for immediate stabilization before pt is transferred
Trauma IV: Provide advanced life support before transport
105
What are some considerations to take with physically impaired pts (contractures, absence of an extremity, severe arthritis, paralysis, stiffness, deformities)
May require the surgical team to take extra precautions in positioning and padding the patient. Be aware of chronic diseases that could affect the respiratory system which need extra attention in positioning to protect the tissues the system serves. Paralyzed pts may need extra personnel to prevent falls.
106
What is a cognitive impairment and what are some complications which come with them?
A condition that limits an individual's ability to learn and reason.
-Communication may be a struggle. (communicate on their level and w the guardian)
-Pt may be anxious
-May be hard to obtain cooperation
107
What are some health concerns that Down Syndrome patients face?
-impairment of cognitive abilities
-excess joint laxity
-short neck
-GERD
-congenital heart defects
-recurring ear infections
-SA
-thyroid dysfunction
-microgenia
-muscle hypotonia
-flat nasal bridge
-macroglossia
108
What are some considerations the CST has to take when operating on a DS pt?
-time should be taken to establish rapport and comfort when transporting
-speech delay may cause noticeable understanding between what is being said and expressed
-parent should be allowed in preop and brought into PACU asap
-OR should have to be kept quiet. CST might have to stop setting up
-Returning physical contact can go a long way
109
What are the primary route of transmission of microorganisms?
-Droplet.
-Airborne.
-Contact: direct or indirect.
-Vector-borne (mosquitoes, flies, rats).
-Fomite-borne (medical devices, equipment, shelf and table tops, contaminated surgical instrument).
110
What are some challenges for an isolated pt?
-isolation can be psychologically challenging
-pt may also perceive care as cold and impersonal so team should put forth extra effort to communicate and reassure the pt
111
What are the fundamental cares of the isolated pt in a surgical environment?
-Frequent handwashing.
-Wearing masks (HEPA).
-Wearing eye protection or face shields.
-Wearing gloves. (Sterile surgical team members wear sterile gloves; nonsterile team members wear nonsterile exam gloves.)
-Wearing gowns. (Sterile surgical team members wear sterile gowns; nonsterile team members wear some type of nonsterile gown. Nonsterile gowns are worn by health care providers who work in the preoperative holding area and PACU.)
112
what is the minimum allowable respirator for isolation patients?
a filtering, nonpowered, air-purifying, half-facepiece respirator, such as the N95 disposable respirator model. Fit testing the respirator before exposure is critically important.
113
How are instruments and supplies handled for an isolation pt?
-dirty instruments should be transported to decontamination in an enclosed container and sterilized per usual
-sharps should be in a puncture proof container
-equipment should be wiped down w disinfectant
-linen should be in a leak-proof or double lined bag
-contaminated single-use should be handled and transported in a manner that reduces the risk of transmission
-EVS should be notified as possible to remove trash
114
What defines a geriatric pt?
individuals over 65 but this definition has grown meaningless bc some pts in this population are healthier than young adults
115
Why are geriatric pts a challenge to the surgical team?
80% of them come in w one or more comorbid conditions. Some form of chronic debilitation or decreased physiological status is often present which requires special planning which is why emergent cases have a higher morbidity rate
116
What are some considerations to take w geriatric pts?
-may come w hearing/vision impairments and items such as glasses should be returned asap
-restricted movements of extremities/ being arthritic/CV and resp problems take special consideration in positioning, lifting, and transporting
-elderly pts could easily become hypothermic so blankets should be available
-slow circulation and hypotension so have SCD's to prevent thrombi/DVT
117
What are some physiological changes in the geriatric pt?
Integumentary: loss of elasticity/subcutaneous fat. skin lesions, tags, and warts. skin prone to damage from pressure and shear forces
Musculoskeletal: loss of bone mass, skeletal instability, curvature of spine, osteopetrosis and arthritis, decreased ROM and balance
CV: increased BP, decreased coronary artery blood flow, decreased ability to repair damage
respiratory: decreased peristalsis and gastric mobility, decreased body water and plasma volume, decreased salivary and digestive gland secretion
GU: decreased bladder capacity, nephron function, tone in urinary system
Nervous: increased pain tolerance, decreased sense in extremities, decreased cerebral blood flow, sensory changes
118
What are some critical factors to maintain the best surgical outcome for geriatric pts?
-Careful surgical technique
-Optimization of functional level
-Recognition of alterations in clinical pharmacology
-Appropriate anesthesia and physiological monitoring
-Prevention of alterations in blood pressure and heart rate
-Avoidance of changes to fluid, electrolyte, and acid–base status
-Minimization of the postoperative stresses of hypothermia, hypoxemia, and pain
-Careful preoperative preparation of the patient to optimize medical and physiological status
119
What defines a substance abuse pt?
Someone who suffers with addiction from alcohol, illegal drugs, and prescription drugs. May have behavioral problems and comorbidities associated.
120
What are the two main difficulties with substance abuse pts in the OR?
-Pts behavior. Can range from calm to violent to catonic. Since they are often brought in as trauma pts, intensity is added to situation.
-Violent pts are hard to communicate w in the OR
121
What is something that is often associated with substance abuse pts?
Comorbid psychiatric disorders such and anxiety, depression, bipolar disorder, etc.
122
What could the surgical team benefit from when caring for a substance abuse pt?
The presence of a counselor or social worker. Family can also let team know of the pts "mood" for the day
123
What are kinematics/mechanism of injury (MOI)?
The action and effect of a particular type of force on the human body. Since there is little info on a trauma pt, MOI allows team to be more prepared
124
What are the three factors are important when considering the injury a trauma pt will sustain
-Flexibility of the tissue
-Shape of the injuring force
-Velocity of the injuring force
125
What can blunt trauma result from?
Forces such as deceleration, acceleration, compression, and shearing. Breaks in skin are not often present. Often sustained from MVA, sports injury, falls, and assaults.
126
What organ is most commonly injured in an MVA?
Spleen
127
What are the three types of collisions which could occur during an MVA?
-Car collides with another object.
-Person inside car collides with objects inside the car such as steering wheel or dashboard.
-Internal body structure collides with a rigid bony surface.
128
What injuries can be sustained from not wearing a seatbelt?
-Facial injuries
-Head and neck injuries
-Bruising of the heart muscle
-Liver and/or spleen lacerations
-Fractures of the sternum, clavicle, patella, and femur
129
What injuries could be sustained by wearing lap/shoulder belts or from an airbag?
-Facial fractures
-Pelvic fractures
-Rupture of the diaphragm
-Bruising of the heart muscle
-Liver and/or spleen lacerations
-Neck injuries, including cervical bone fractures
-Humeral, radial, and ulnar fractures (airbag related)
130
What is penetrating trauma?
When a foreign object passes through the tissue.
131
What does extent of injury in penetrating trauma depend on?
-Type of foreign object
-Body structures penetrated
-Distance the victim was from the foreign object
-Amount of energy (velocity) of the penetrating foreign object
-Size of foreign object, such as the caliber of the bullet, or width and depth of a knife blade (e.g., pocket knife versus a Bowie knife)
132
What are some components of bullet injuries?
-bullet is slow velocity if 2000 ft/s or slower; if faster it is high velocity (more damage)
-different bullets cause different types of injury
-bullet that travels through the body (through and through) has a bigger exit hole than entrance (M-16 bullet tumbles)
133
What are some components of stab wounds?
-low velocity wounds
-width of object influence the extent of injury
-penetrating object must not be removed bc it provides a tamponade effect
134
What is the Revised Trauma Score?
Scale to assess the injuries of a trauma. Assists in triage and standardized method of communication. Involves Glasgow Coma Scale
135
How should evidence be preserved for trauma pts if needed
All physical evidence, including the patient’s clothes, bullets and bullet fragments, knife fragments, trace evidence (hair), and biologic evidence (blood and body fluids), must be carefully handled, and facility policy must be followed for purposes of documentation.
-Remove clothing by cutting along the seams and around bullet holes or stab wounds. The shape of the hole can provide evidence as to the type of weapon that was used. The clothes should be placed in a paper bag and given to the law enforcement officials; avoid the use of plastic bags because they may trap the moisture and promote growth of mold that will destroy the evidence.
If there are multiple wounds keep the evidence from each wound separate.
After the patient is transferred from the stretcher to the OR bed, place the transfer sheet from the stretcher into a paper bag to capture evidence that may have fallen from the patient’s clothing onto the sheet.
Collect and preserve fabric or other debris that the surgeon removed from around the wound edges or from the wound itself.
Place tissue into a dry container; do not cover with a preservative fluid such as formaldehyde.
Hair, tissue, and gunpowder residue may be found on the hands of the victim. If the hand(s) does not require surgery, a plastic bag should be placed around the hand(s) and taped in place. However, in the OR, the plastic bags should be removed and cotton swabs used to collect gunpowder residue.
Bullets must be carefully handled because they can be easily scratched. They should not be handled with metal forceps or clamps so as to maintain the ballistic markings. After the bullet(s) are removed from the patient, the CST should place the bullet(s) on a clean gauze sponge and pass it from the sterile field to the circulator for placement in a dry plastic specimen container.
The chain of custody of evidence must be documented in writing accounting for the identification of all individuals on the surgical team who handled the evidence and the order of handling. The anatomical site from which the evidence is retrieved must be documented and the time it was removed from the patient. These documents are legal documents.
136
How should the CST prepare for a hypothermic truma pt?
patient should be kept as warm as possible by using warm blankets and by increasing the temperature in the OR. The surgical team should only use warm irrigating solutions, both externally when performing the skin prep and internally when the surgeon is irrigating the surgical wound.
137
Why is infection a high risk in trauma pts?
-wounds can be contaminated w debris, dirt, grass, and dirty penetrating object. perforated GI tract can cause contents to spill into abd cavity. if time, scrub skin w scrub brush or pulse lavage. if no time pour aesteptic solution over skin.
138
how can the CST prepare for a trauma case?
-there are preassembled emergency sets
-OR room has monitoring devices and crash carts
-some have fluoroscopic table for x ray
-positioning is a concern cuz there may be damage to the spine. positioning is determined by anesthesia.
-CST may have to organize several setups
-have adequate instrumentation and have more hemostats, hemostatic agents,
-may not have time for initial count. this should be charted and postop radiographs should be done.
139
What is PTSD caused from?
the result of prolonged exposure to traumatic situations characterized by the pt suffering long term emotional, psychological, and social problems. most associated w this are military personnel
140
What are some things that the surgical team should remember when treating a pt w PTSD?
-HCP should know abt the disorder
-level of PTSD varies from person to person. can be flashbacks, avoidance, sleep disorders. counselor should be consulted
-surgery team could be irritable and severely disassociated. have counselor in PACU and preop
-anesthesia should be informed of meds pt is taking
-pts can be startled easily bc they have hyperarousal. CST may have to stop setting up
-hypervigilant to visual threats. keeps sharps out of sight
-approach pt slowly
-pt may be suicidal
-don't fight the pt
