SURGERY + HOSPITAL Flashcards
PreOp conditions that might make you cancel or defer a scheduled surgery
Focus on CV, Pulmonary, Neuro and CoMorbidities
AGE is itself a big risk
CARDIAC: looking for MI risk, JVD, 3rd or 4th
heart sounds, sufficient ejection fraction
CAROTID BRUITS (new ones) - you should order a doppler. If over 50% occluded no surgery. Pt could stroke on the table. If under 50% advise pt of risks, note it to surgeon but you can go forward.
PNEUMONIA just don’t do surgery until its over
DM - ensure BG is controlled and EKG is clear
HTN - End organ damage is the issue, review
cardiomegaly/ej fraction kidney, retina,
possibly ejection fraction assessment d/t
cardiomegaly
Tests you WILL do if asked to clear your Pt for elective Surgery:
EKG and CXR if over 40
EKG in ALL diabetics d/t silent MI silent d/t nerve damage so they don’t feel it.
CXR on ANY smoker regardless of age
Main causes of Morbidity in Pts undergoing Surgery:
MI + Heart Failure
Stroke (DON’T MISS a Carotid Bruit!!!)
You could use the Goldman, Lee or the American Association of Cardiologists PreOp Risk Assessment - that might be a good place to start
Mneumonic for Hospital Admission Note
Deb’s fav
ABC DAVIDS
A- Admit to (Dr. & Floor)
B- Because… Dx requiring Admission + others
C- Condition (stable, not stable + why not)
D- Diet + DVT prophylaxis orders
A - Allergies (any) + Activity level orders
V- Vitals (how often taken)
I - IV Fluids + Drugs (Medicines are usually IV)
D- Diagnostic Testing
S- Special Nursing Orders
Floors in a Hospital
MED-SURG (is general) SURGERY (OR Suites + pre/post op rooms) OB ICU ER PAC-U/ RECOVERY TELEMETRY ONCOLOGY ORTHO Mother/Baby/Nursery LABOR + DELIVERY
Even OTC Vitamin E can cause problems in a hospitalized patient, what does it do?
Slows Clotting
Nice for avoiding embolus but not so good if you’re having surgery…
How long is Pre-Op blood work good?
10-14 days depending on the doc
Personally, I would repeat the pregnancy test before surgery and the CBC…
How long is a Pre-Op CXR good?
6 Months
Is a pelvic necessary for a Pre-Admission H+P?
A DRE?
Pelvic is optional
DRE + Guiac are not optional. A (+) Guiac is cause to delay a surgery until the cause is found and neutralized.
Maintenance D5W NS for NPO patients
100-150 cc/hr
You might start high for an hour or two then lower it to maintenance if the pt has been N/V/D for more than 1 day to make up the fluid deficit
Specialty Nursing Directives include?
Anything out of the ordinary that you want the nurses to do/arrange:
PT q day Respiratory Therapy orders Restraints Assist to Toilet Bed by window, shades up during day... Notify if daily CBC shows changes to BUN/CR...
OOB means
Out of Bed
If a pt gets admitted from the ER, how long does the hospitalist MD/PA have to get the Admission H+P done + into the notes
24 hrs
but better in the first shift after admission, so the nurses and other providers know what’s going on.
What is the focus of the SURGICAL H+P, done to the extent possible on an 911 admission to surgery ?
Focus on conditions that will impact surgical outcome:
Comorbidities:
Cardiac
Renal
Bleeding Disorders
Pulmonary Disease
-Asthma/COPD/Smoking
CANCER OF ANY KIND - they will look for
mets whereas they wouldn’t if they didn’t
know of a prior/cured cancer
Past Surgeries: No Tonsils, No Appendix..
-Were there complications
- Is there Mesh inside?
- How about metal joints/replacements…
-Any problems with the anesthesia
SOCIAL HX:
-Who can we speak with after the surgery?
-End of life planning/ CPR Intubation
Heroic Measures Refusal
- Will you be able to recover at home
-Supervision
-Stairs
-Toilet on 1st Floor…
ADDICTIONS
ETOH/DRUGS get CIWA protocol
Why does COPD send up red flags for Surgery
They don’t come off vents well, neither do smokers. Some surgeons won’t operate on COPD or even on active Smokers until they’ve quit.
CIWA Protocol?
Frequent Vitals, Neuro Checks and Ativan for Addicts to prevent the DTs
The Four Ps for:
MEDICATION
Pain
Puke
Pus
Prophylaxis
Pain: Oral? Oxycodone/Tramadol/Percocet
IV - usually for break thru or if NPO
Toradol IV/IM is nice but watch the kidney
PCA - your doc will have a protocol
Epidural still in? you can use that
Puke: Don’t rip out those stitches heaving!
Put in an order of Zofran PRN for most
surgical patients. Try 4mg IV, may need
to increase for over 170 lbs
Pus: Avoid Infection!!!
PreOp, IntraOp and PostOp ABX!
Prophylaxis: Think DVT and Atelectasis
Use Heparin for DVT (and get them up and
walking ASAP
Order Spirometry q 4 hrs to prevent lung
collapse
Toradol Protocol
15-30 mg q 6 Hrs
Not more than 120 mg/day
Not more than 5 Days
Daily BUN/CR (daily CBC really)
As Toradol does a number on the kidneys
PCA
Patient Controlled IV Anesthesia
What is the concern with epidurals?
HypOtension
What’s the trouble with surgery pts on beta blockers?
They slow the heart and reduce contractility and that might not be desirable in a surgery patient but you can’t just stop them as you’ll likely get rebound tachycardia
Consider holding them the morning of surgery and then monitoring HR often, hourly and adding them back in if HR climbs out of your target range.
Zofran aka?
Odansetron
4mg IV or IM to start, may need to increase for pts over 175 lbs.
Its a serotonin (5HT3) blocker that works in about 30 minutes (orally) ASAP via IV/IM
Hepatically conjugated then renal cleared. Take care with Liver Dz as it will keep circulating in active form until the diseased liver gets around to deactivating it.
DON’T use with other serotonin blockers like SSRI, SNRI or MAO Inhibitors. May cause Serotonin Syndrome, watch out for:
gitation, ataxia, diaphoresis, diarrhea, hyperreflexia, mental status changes, myoclonus, shivering, tremor, or hyperthermia
Don’t Forget QT prolongation. If you’re giving it to your cardiac pts or someone on erythromycin or Amitriptyline or other QT lengtheners, keep them on an EKG or better yet, don’t give it. A little nausea is better than Torsades.
Serotonin Syndrome
Symptoms coincide temporally with the addition of a serotonergic agent to a patient’s regimen or with an increase in the dose of a previously prescribed serotonergic agent
At least 3 of the following physical findings are present:
agitation, ataxia, diaphoresis, diarrhea, hyperreflexia, mental status changes, myoclonus, shivering, tremor, or hyperthermia
A neuroleptic agent has not been recently added to the patient’s regimen or increased in dose, if previously prescribed
Other etiologies, such as infection, intoxication, metabolic derangements, substance abuse, and withdrawal, have been ruled out
Kefzol (Cephazolin)
1st Gen Cepahlosporin
often used before, during + after surgery
1-2 grams IV q 8 hrs
Clindamycin (Cleocin)
Lincosamide Abx
Good for G(-) Anaerobes + Protozoa which is why its often used in the gut.
THIS is the antibiotic most associated with promoting c. Dif (gram (+) gut bacilli)
Clostridium Dificile
Gram + Gut Bacillus
Causes severe diarrhea, painful + perhaps bloody when it displaces the normal flora of the colon, usually after a course of broad spectrum ABX aimed at Gram (-) anaerobes i the gut.
Best to use an antibiotic that also kills cdif too! That’s why we always add Flagyl to a gut regimen, specifically to kill the c Dif - though it has many other wonderful qualities. For severe C Dif infection, only oral Vanco will do. This is the only oral use for Vanco.
These guys are HIGHLY contagious and form spores in bad conditions and they do it when exposed to many “disinfectants” as well, thus surviving even a good cleaning. KILL C Dif with BLEACH, use bleach wipes, strong ones. You can disinfect a hospital room with a hydrogen peroxide vapor systems or ultraviolet light.
how to kill MRSA?
VANCO IV
Vanco orally for c Dif
Describe the presentation of a peritonitis patient
Patient should have diffuse abdominal pain, ascites, likely a fever, possibly chills and bloating. You may see air under the diaphragm on CXR and abdomen should be hyper resonant to percussion.
This pt is SICK SICK SICK and looks it
Peritonitis pts are not wiggly or in the fetal position, they just lie very very still and don’t want anyone to touch them.
Suspected peritonitis pts must have PARACENTESIS in the ER. You’re looking for Neutrophils over 500/microliter. This takes time right now but there is a leukocyte esterase dip-stick in the works that appears likely to replace the physical cell count and speed diagnosis.
Medscape says Cefoxatime is as good as the classic ampicillin/gentamycin regimen for empiric Rx of peritonitis (bacterial, of course)
Manipulation of the bowel is a set up for…
ILIUS!
Opening of the peritoneal cavity and handling of the intestines both precipitate a local inflammatory rxn which immediately induces smooth muscle relaxation and ilius. In Fact, the degree of bowel manipulation during surgery DIRECTLY CORRELATES to the duration of post op Ilius.
Post Op Ilius (POI) usually lasts 3-5 days
It appears to be lessened/shortened by epidural during the procedure and by post op NSAID therapy (controls local inflammation). The COX-2 Inhibitor CELECOXIB is favored for this d/t reduced peptic damage but carries the risk of increased vascular events by blocking COX-2 on blood vessel walls, preventing secretion of prostacyclin which both dilates vessels and prevents platelet aggregation - thus long term use of celecoxib increases risk of “vascular events” aka MI - not so welcome after surgery. But a single dose post op is not uncommon.
Opiates post op will also delay resumption of normal intestinal peristalsis.
TO REDUCE POST OP ILIUS
1) Consider Laproscopy vs Laparotomy access
2) Consider Epidural anesthesia, at the Thoracic level
3) Give a dose of Celecoxib post op
4) Initiate post op oral food as soon as possible, Gum chewing before hand if actual eating is not yet possible.
5) Up and out of bed - just for good measure
WHO changes surgical dressings in the 24-48 hrs immediately following surgery?
MD or PA… Nurses don’t. Don’t know why. They do seem to monitor them though.
Post Op failure to urinate plan
Always leave a plan for monitoring of urination post op in patients who do not get a foley in the or.
If no pee within 6-8 hrs post op, insert FOLEY. If you get over 500 ml out, leave the foley inserted. If you don’t get 500, you can assume there was no pee to urinate out and remove the foley. Always order a foley post op, cause you cannot leave a robin in if it turns out pt has urinary retention from surgery.
DON’T Strait Cath after surgery - if a lot of urine is evacuated because you have retention, you’ll just have to RECATH with a foley. It’s OK to treat a foley like a strait cath and NOT leave it in if you don’t evac much urine.
What is CIWA protocol?
Frequent Vitals + Neuro Checks for Addicts with standing orders for Ativan to prevent DTs
Laproscopy vs Laprarotomy
Laproscopy: Through small incisions with instruments. Reduces post op ilius when compared with laparotomy
Laparotomy: Open Air Abdominal incision
What are chemically impregnated dressings and when do you use them?
Bandages impregnated, usually with Vaseline but also with Silver.
Come in a foil packed, nice for:
-Skin Avulsions (bandaid has a product)
-Sometimes the vaseline occludes minimal
bleeding
Perfect dressing for early pressure sores
Foam Dressing : DUODERM
They’re self adherent and waterproof
They protect the wound and pad the ulcer and prevent further damage from sliding over sheets
REVIEW DEB’S DRESSINGS PWR PT
AND make slides - notes are not good on this
Tegaderm?
DRY wounds
Burns- AFTER they stop weeping
Dry Eschar on Elbows/Heels
NOT for Infected Wounds
Why use a drain post op?
When can you take out the drain?
Difference between Active + Passive Drains
How to remove drains?
To ensure neither fluid nor air build up beneath the suture site.
You can take it out when there is less than 25ml of fluid in a day.
Active drains are hooked to Low Wall Suction or they are end in a bulb from which the air is expressed creating a vacuum (Jackson Pratt Drain for mastectomy + Tummy tucks).
Passive Drains are just rubber or silicone tubes - DO inquire about latex allergy of every surgical patient!!!
Premedicate Pt before removing - it HURTS!!
- Remove 2cm/day so track heals from the inside out
- At the very end, cover remaining tubing with vaseline impregnated bandage SNIP THE STITCH - DON’T FORGET THIS!!! then yank the tube out in one swift motion + press down on the bandage - secure with tape.
Jackson Pratt Drains
Closed system drain that ends in a bulb from which air is removed, creating a low pressure vacuum. Mastectomies and Tummy Tucks typically use these.
What is Continuous Bladder Irrigation
Its a 2-Way Foley through which sterile saline is run INTO the bladder to prevent build up of clots or sediments typically after genitourinary surgeries (prostate, bladder, ureter)
A 3-way Stop Cock is attached to the special Foley: Urine comes out one tube, One tube is for inflating the balloon and sterine NS goes into the bladder through the third tube.
Post Op instructions need to state how often the catheter must be drained and irrigated and how often (at minimum) Nursing is to check the catheter to ensure it isn’t blocked. They will check frequently but an order for checking every 20 minutes for the first few hours post op is not out of line.
Pulmonary Wege
Balloon inserted thru SWAAN GANZ catheter to measure pulmonary pressures
This is not such a popular technique these days and is mainly seen in ICU
Normal Wedge Pressure is 2-15 mm Hg
PWP is the GOLD STANDARD for diagnosing the CAUSE OF PE, not really whether or not there IS a PE.
High PWP indicates impaired left ventricular function and may indicate Mitral Valve Stenois.
PE Diagnostic Tests
Thoracic Ultra Sonography (TUS) and Spiral CT or CT angiogram.
Sonogram is faster and very effective but a Negative soon doesn’t rule OUT PE. However a positive SONO can point you toward clot dissolution ages before you can get a CT Angiogram done and read.
CT Angiogram (aka Spiral CT) is the GOLD STD but sono is faster, reliable and worth the extra step if you can’t get your CT done and read right away.
Pulmonary Wedge Pressure (PWP) is the GOLD STANDARD for diagnosing the CAUSE OF PE, not really whether or not there IS a PE. High PWP indicates impaired left ventricular function and may indicate Mitral Valve Stenois.
Anasarca
Extreme
Generalized EDEMA
Usaually caused by liver or kidney failure but can be induced by Fluid Volume Excess caused by IV therapy.
Ex: Swollen face of child with Malaria caused Nephrosis and PEDIATRIC NEPHROTIC SYNDROME associated swelling is called Anascarca.
Fluid Volume Excess
Usually over hydration caused by IV Therapy
It means so much fluid onboard has deranged the electrolytes - namely SODIUM
If not caused by IV Therapy, it can be induced by release of BNP in response to right atrial distention. This will cause the kidneys to stop conserving sodium so as to decrease overall blood volume, but sometimes it backfires.
911 Rx for FVE is:
Loops Limit Fluids and GIVE SODIUM!! Dialysis if that doesn't work Continuously monitor paO2, EKG, Lytes Monitor Is + Os
How does morphine reduce pulmonary edema?
It seems MORPHINE causes VASODILATION and this increases drainage of fluid from the lungs into the venous system.
It also decreases after load in the cardiac patient, which is why it’s not a bad idea in the MI pt with High Blood Pressure.
It also reduces tachypnea, which may help with PE.
presurgical medication changes
Aspirin - stop 7 days prior
Coumadin - stop 3 days prior
Diabetic Meds - stop orals
- give 1/2 dose am INSULIN
the morning of surgery
HTN meds - try holding them. Anesthesia
BP. Monitor and add back in if
warranted by rising BP.
Where can you use IV Regional Anesthesia?
aka BIER METHOD
On arms/legs distal to elbow/knee
Blood is driven proximally by a pressure bandage then a double pneumatic cuff is applied to keep it out during the nerve block - the prevents the meds from going systemic in a huge bolus and causing trouble outside the extremity.
Then Lidocaine, the block agent, is suffused into the limb from as far distal as possible, usually the dorsal hand or foot. A 20- minute wait ensues then the pneumatic devices can be partially reduced.
Obviously surgery has to be quick (less than 1 hr) d/t the reduced blood flow.
Benzos and Fentanyl help prevent seizures though why this is a risk with this method I’m not sure.
AMPLE 911 Hx Pneumonic
A- Allergies !!! M- Medicines P- Past Medical Hx L- Last oral intake E- Events leading up to surgery
Life threat side effect to succynl choline?
Hyper Thermia - use cooling blankets!
Fluid Shift caused by:
Isotonic/ Hypotonic/ Hypertonic
Iso - no shift
Hypotonic in the ECF Shifts fluid INTO the cell
