Surgery tools

Question 1

Answer 1

Question 2

Answer 2

Question 3

staples

Answer 3

Question 4

Question 5

tissue flap

Answer 5

tram flap

Question 6

FREE FLAP

Answer 6

Question 7

Question 8

SKIN GRAFTING

harvest site

Answer 8

Harvest site:
Hair/hairless
Color
Elasticity
Size requirements

Question 9

Answer 9

Question 10

Answer 10

Question 11

POST-ANESTHESIA CARE UNIT (PACU)

Answer 11

“PACU, Recovery room, RR”
Monitor patients following surgery
One nurse to one patient
Frequent assessment
Monitor vital signs

Anesthesia has primary responsibility for cardiopulmonary function
Any items related to anesthesia
Surgery team oversees surgical site and other non-anesthesia issues

15-30 minutes up to 3-4 hours

Question 12

PACU

Monitoring

Answer 12

Blood pressure – frequently (5 -15 minutes) to continuously (Arterial line)
Pulse – frequently to continuous
Pulse oximeter – continuous
EKG – continuous
Temp – initial and prior to discharge

Acute changes communicated immediately

Question 13

PACU

Dressing/wound and IVF/urine output

Answer 13

Assess for drainage
Bleeding
Dehiscence
Cast/brace – ’fit’

IVF and urine output
Foley or “void prior to discharge” or collect in urinal

Question 14

POST-OPERATIVE CHECK

Answer 14

PACU (if going home)
Prior to D/C
Communicate with patient/Family

Floor/Unit
Check 4-6 hours after discharge
Communicate with patient/family
Check wound, fluids, vitals since surgery, PULSE
Assess pain control, diet, activity, drainage

Question 15

OPERATIVE NOTE

Answer 15

Communicates essential information

Acute change in recovery room
For ‘on-call’ coverage
For billing/coding
Legal defense
Surgery, surgeon, assistant, anesthesia
Fluids, blood loss, implants, complications, prep, dressing
Disposition

THINK: 4 weeks, 6 months, 3 years later??
Anyone should be able decipher what was done and why with all details

Question 16

OPERATIVE NOTE

Written/EHR

Answer 16

Done immediately – prior to leaving OR
Essential communication for PACU/On-call/Anesthesia

Question 17

OPERATIVE NOTE

Dictation

Answer 17

Complete operative report
Billing/Legal/Informative

Question 18

OPERATIVE NOTE

what needs to be included

Answer 18

Patient, DOB, ID number/MR#
Operation performed +/- indication
Preoperative diagnosis
Post-operative diagnosis
Anesthesia
Surgeon
Assisting surgeon/Assistant

Surgical findings
Basic prep, position, findings
Unusual issues, findings or outcomes
Specifics of approach, drains, dressing, closures

Estimated Blood Loss (EBL)
Intravenous fluids (IVF)
Drains
Specimen

Complications

Disposition
Awake
Intubated
To RR, PACU, ICU
Continued under anesthesia for next portion
Discharged home

(Follow-up)

Question 19

OPERATIVE NOTE

Don’t forget:

Answer 19

Who is dictating/writing
Why done
Specific Surgery
Complications (major)
Be appropriate
Mention what matters and could have an effect
No one cares that a knot had to be redone- as long as it is fine now

Question 20

Question 21

POST-OPERATIVE ORDERS

general

Answer 21

Order sets versus written orders
Determine status
Inpatient
Recovery room or Extended recovery
Observation
Medications, pain control, antibiotics
Nursing and ancillary instructions and orders
Discharge instructions, diet, activity, dressing, follow-up

Question 22

Answer 22

Question 23

Answer 23

Question 24

ADMIT

Where is the patient going to end up that day?

Answer 24

Most go to PACU – but then where
Extended recovery – up to 24 hours
Observation – Medicare status up to 24-72 hours
Floor - which floor
ICU/Step-down
Home – discharge
Same day surgery unit – planning to discharge

Question 25

# DIAGNOSIS Admitting diagnosis

Answer 25

Used for billing, bundling Generally don’t use “status-post” as primary diagnosis S/P Lap chole Use: ‘Cholelethiasis’ or ‘cholecystitis’ S/P left knee replacement – ‘Osteoarthritis with knee pain and disability” Must justify level of admission and location

Question 26

CONDITION

Answer 26

One-word description of status Good, fair, poor, guarded, grave “stable” – not a good descriptor

Question 27

VITALS

Answer 27

Frequency of vitals Note any special vitals Understand what are “routine vitals” at your institution BP, Pulse, Temp, Resp, Pain Daily weights? Arterial line? CVP/Swan Continuous pulse ox EKG/Telemetry

Question 28

ALLERGIES

Answer 28

All medication allergies Relevant allergies Latex Peanut – if significant and life threatening Seasonal allergies? – NO!

Question 29

NURSING

Answer 29

Specific orders for nursing Dressing changes, wound check Drains to handle, record, remove Foley, urinal, strain urine Ins/Outs (I/O’s) Monitoring Positioning in bed

Question 30

DIET

Answer 30

Dietary orders Not just oral intake TPN, tube feeds, supplements Remember co-morbid conditions Diabetes – ADA +/- cal CAD Gluten, lactose, soft mechanical, NPO ‘Regular’

Question 31

ACTIVITY

Answer 31

Stay in bed/out of bed Up to chair Ambulation? Be aware of number of tubes/drains/poles required to ambulate

Question 32

LABS

Answer 32

Which labs to draw and when Call with results? Alert levels outside of normal range? Frequency (if applicable) Only order if needed – avoid routine daily labs unless truly indicated

Question 33

IV

Answer 33

List which IVF Rate Indications to stop? Number of total fluids Hours When taking PO ‘SLIV’ = saline lock IV

Question 34

SPECIAL STUDIES

Answer 34

X-ray, CT, MRI Swallowing studies, stress test, Echo Telemetry could go here, EKG on arrival or in AM

Question 35

MEDICATIONS

Answer 35

Home meds Only what is needed or harmful to stop Be conscious of intake and route Does it matter if they skip a dose of a vitamin or supplement? Specific for surgery Antibiotics Pain medications Regional blocks Nausea/vomiting Prophylaxis Gastric acid suppression DVT Comfort/Hospital specific Sedatives Sleep Laxatives/Softeners

Question 36

POST-OPERATIVE PAIN

Answer 36

Each patient is different Each surgery is different – EVEN IF IT IS THE SAME SURGERY Patient perception Severity of surgery Complications, length, involvement

Question 37

POST-OPERATIVE PAIN MEDICATION

Answer 37

Intravenous Morphine Dilaudid (hydromorphone) Demerol (meperidine) – not used much due to risk Patient Controlled Analgesia Type of drug Frequency Dose Basal Rate (continuous infusion) Oral Narcotic based (Lortab, Percocet, Tylox, Vicodin, Darvocet, Percodan) Codeine, Oxycodone, hydrocodone Tramadol Non-narcotic (NSAID – Ketorolac, Ibuprofen, Tylenol) ASA – bleeding properties Be aware of all components of medications Tylenol in Lortab/Percocet NSAIDs, ASA

Question 38

POST-OPERATIVE PAIN MEDICATION

Answer 38

Scheduled PRN IV or Oral or PCA Regional pain control Block, epidural, spinal Antispasmodics Muscle spasms Neuropathic Sedation “Reasonable control” “Tolerable” Surgical patients will have pain Addiction worries are over-inflated acutely Longer term pain control Switch to non-narcotic when feasible Expect pain, just control it

Question 39

ACUTE RETURN TO OR

Answer 39

Bleeding – internal or external Wound dehiscence Abnormal drainage/output Vascular, lymphatic, CSF Possible collateral injury Ureter, bowel, bladder, esophagus perforation Nerve injury, compartment syndrome Pneumothorax Retained objects – instruments, sponge, sharps