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Clin Med - II (Surgery) > Overview > Flashcards

Overview Flashcards

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1
Q

First Assistant

A

The person directly opposite the surgeon at the OR table who actively participates in the conduction the procedure

Historically, the roll was filled by experienced surgeons and nurses as well as certified sx techs or OR techs

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2
Q

Sx PA Tasks

A 
Inital pt eval
1st and 2nd assisting in sx
Independent procedures
Post-op care
Clinic
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3
Q

Non-sx tasks of a PA

A 
Thoracentesis
Chest tube insertion
LP
Paracentesis
ACLS
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4
Q

OR surgical team consists of the following rolls

A 
Attending surgeon
Fellow
Resident
Intern
RN first assistant
PA
Medical / PA student
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5
Q

OR anesthesia team consists of the following rolls

A

Anesthesiologist

CRNA

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6
Q

OR and recovery team consists of the following rolls

A

Recovery room nurse

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7
Q

Roll of the the recovery room nurse

A

Assesses post-op hemodynamic and cardiopulmonary stability

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8
Q

Rolls in the OR / Recovery (not including sx team, anesthesia, or recovery)

A 
OR Director
OR Supervisor
Control Room Supervisor
Head Nurse
Staff Nurse
Circulating nurse
Scrub nurse
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9
Q

Role of the OR director

A

Determines and enforces OR policy Usually an RN

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10
Q

Role of the OR supervisor

A

Oversees daily OR activities

Usually an RN

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11
Q

Role of the Control Room Supervisor

A

“traffic coordinator”

Schedules sx and personnel

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12
Q

Role of the Head Nurse

A

Manages the OR to ensure smooth and efficient operation

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13
Q

Role of the Circulating Nurse

A

Prepares pt and supplies for the operative procedure
Troubleshoots
Connects tubes and wires

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14
Q

Role of the Scrub Nurse

A

Assists surgeon by providing all instrument sutures and supplies required for smooth execution of procedure

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15
Q

Questions to review prior to procedure to be an effective assistant

A

What procedure is to be done?
What is the regional anatomy?
What is the normal physiology and pathophysiology or the organ?
What are the sx and non-sx options?
What is the effect of the procedure on the pathophysiology?

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16
Q

Pre-op responsibilities of a sx PA

A 
Admission H and P
Admission Orders
Pre-op orders
Pre-op note
Read about pt's specific dz processes and planned procedure prior to sx
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17
Q

Peri-op responsibilities of a sx PA

A 
Accompany pt to the OR 
Assist at procedure
Op note
Post-op orders
Post-op check
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18
Q

Post-op responsibilities of a sx PA

A

Daily pt care

  • Early morning eval, assessment, plan for the day
  • Morning round with pt progress reports
  • accompany pt to dx and therapeutic procedure with feasible
  • Write daily progress notes
  • Quick after assessment
  • Evening round with report of daily activities, lab results, dx studies, etc
  • Check final pathology results
  • Speak with pt’s family when indicated
  • Assist with the writing of d/c order, rx and other paperwork
  • Date/time on all notes and orders
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19
Q

Additional responsibilities of sx PA

A

Attend all rounds, conferences and lectures pertaining to sx service and sx rotation
Be the pt’s advocate - find answers to their questions

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20
Q

Acronym for Routine admission orders

A

ADCVANDIIMAL

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21
Q

ADCVANDIIMAL - Meaning of each letter

A 
Admit pt
Dx
Condition
Vital signs
Activity
Nursing
Diet
Intake and Output
IV Fluid
Meds
Allergies
Labs
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22
Q

ADCVANDIIMAL - Admit pt

A

Room number

Attending physician or service

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23
Q

ADCVANDIIMAL - Dx

A

Give pt’s admission dx

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24
Q

ADCVANDIIMAL - Condition

A 
Good
Stable
Fair
Guarded
Critical, etc
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25
ADCVANDIIMAL- Vital signs
BP Pulse Respiration Temperature
26
ADCVANDIIMAL - Activity
``` Bed rest Up as tolerated Up in chair PT OT ```
27
ADCVANDIIMAL - Nursing
Dressing changes Compression stockings Neuro checks Preventative measures
28
ADCVANDIIMAL - Diet
``` Regular ADA (diabetic) NPO Low Sodium Clear liquids ```
29
ADCVANDIIMAL - I and O's
This has to be ordered
30
ADCVANDIIMAL - IV Fluids
Type | Rate
31
ADCVANDIIMAL - Meds
Pain Home Abx Insulin, etc
32
ADCVANDIIMAL - allergies
Specific meds | NKDA
33
ADCVANDIIMAL - labs
CBC X-rays Urine EKG, etc
34
Emergency Admission orders
Diet - NPO Meds - No meds for pain relief until dx established and operative decision determined Fluid therapy - needed by most emergency admission to correct dehydration and electrolyte imbalance Abx
35
Components of OP Note
``` Pre-op dx Post-op dx Procedure (s) Surgeon(s) Assistant (s) Anesthesiologist / CRNA Intra-op findings Type of anesthesia EBL Urine output IV fluids Specimens Drains Tubes and lines Implants Complications Disposition ```
36
Post-Op orders - generally
Post-op orders must be revised at least daily on post-op rounds to reflect pts progress following the sx procedure
37
Post-Op orders consists of
``` Sx performed and type of anesthesia Ambulation / Activity Vital signs I and O Body weight Tubes and Drains Meds Tx vomiting Lab testing Wound care Conditions for which a physician should be notified ```
38
Post-Op orders - Ambulation / Activity
Pts should be out of bed and walking with assistance by post-op day 1 at the latest Connection to IV tubes and drains may limit, but not prevent ambulation
39
Post-Op orders - Vital signs
Taken often during the immediate post-op period and gradually less often
40
Post-Op orders - I and Os and body weight
Should be measured daily to optimally plan and administer fluids
41
Post-Op orders - Tubes and Drains
Should be maintained and output measured
42
Post-Op orders - Meds
Orders should reflect the pt's changing requirements
43
Post-Op orders - Vomiting
Should be tx either with a NG tube and/or anti-emetic depending on etiology of the N/V
44
Post-Op orders - Labs
Post-op tests can include - CBC - Electrolytes - CXR after throacotomy or placement of central line or endotracheal tubes - Daily UA when a urinary cath is present
45
Post-Op orders - Wound Care
Orders for frequency of dressing changes and meds for use on wounds when indicated
46
Post-Op orders - Conditions for which a physician should be notified
Parameters of changes in pt's condition should be documented in order to provide for appropriate physician notification
47
Contents of a Daily Progress Note - General
``` SOAP Subjective Objective Assessment Plan ```
48
Contents of a Daily Progress Note - Subjective
Pt comments (include all complaints) Family and allied health observation General observations - e.g. "looks better"
49
Contents of a Daily Progress Note - Observation
``` Vital signs Daily weight General I and O's Urine Important meds Labs X-ray findings Other (ventilation, pacemaker setting, etc) Physical findings ```
50
I and O's include
Oral Drains IVF NG Tube
51
Urine measurement
Since sx if freshly post-op | Otherwise 24h
52
Physical finding to include in SOAP note
``` Mental status Sx site Heart Lungs Abdomen Extremities Other as needed ```
53
Contents of a Daily Progress Note - Assessment
How is the pt progressing?
54
Contents of a Daily Progress Note - Plan
``` What should be done for the pt? - Stop IV - Increase dietary level - Increase ambulation - Dressing change, etc. Address physical findings ```
55
Components of a D/C note
``` Admission / d/c dates Admission / d/c dx Service Referring physician Consults Procedure H and P Course D/c condition Disposition Meds Instructions F/u ```
56
D/C note - Service
Service name | Attending
57
D/C note - Consults
Physicians Services Dates
58
D/C note - Procedures
Dates of sx | Angiograms, etc
59
D/C note - H and P
Pertinent admission H and P | Lab test
60
D/C note - Course
Summary of tx | Progress during hospital stay
61
D/C note - D/c condition
Good Stable Fair Guarded
62
D/C note - Disposition
Home | Nursing Home
63
D/C note - Meds
D/c meds with dosage and administration
64
D/C note - Instructions
Activity restrictions Diet Dressing changes Cast care
65
D/C note - F/u
Clinic appt
66
Role of a PA in sx - Initial pt eval
H and Ps Admission orders Pre-op prep)
67
Role of a PA in sx - Independent procedures
Vein harvesting Insertion of invasive monitoring lines Incisions closure
68
Role of a PA in sx - Post-op care
Daily rounds | D/c summaries
69
Role of a PA in sx - Clinic
New pt eval and tx | Post-op visits

Clin Med - II (Surgery) (10 decks)

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