Very specific Flashcards
(34 cards)
1
Q
PPC S & S
A
- CXR evidence of atelectasis/consolidation
- Temp >38 after Day 1
- Raised WCC
- SpO2 <90% ORA
- New production of yellow/green sputum
- Dx of pneumonia/chest infection
- Prolonged stay >36hrs
2
Q
PPC Risk factors
A
- Surgical incision Upper abdominal incision
- Splinting/pain
- Supine/slumped
- Secretion
- Surfactant
- Shallow breathing
- Supplemental O2
- Smoking history
- Size
- Mech vent
3
Q
PPC Patient related risks
A
- Age>60
- Resp or cardiac disease
- Smoking history
- Impaired functional status
- ASA comorbidity score
- Malnutrition
4
Q
Explain a CABG
A
- Anaethesia, Artery or vein harvested and grafted to aorta and coronary arteries, cardiopulmonary bypass
- Saphenous vein:
5
Q
Precautions for Median Sternotomy
A
- Minimise pressure through UL
- Bilateral rather than unilateral UL activities
- Avoid reaching backwards when possible
- No weight for 1 month, limited weight elbows by side
- No heavy lifting or work for 3 months
- No driving 6 weeks
- Sternal support for cough
- Ladies wear bra esp bigger cup
6
Q
Explain Oesopagectomy
A
- Upper abdominal associated with high chance of PPC’s
- Removal of all of part of the oesophagus stomach is then pulled up and re-anastomosed to the end of the oesophagus
- Ivor Lewis upper abdominal + R) postural lateral thoracotomy
7
Q
Contraindications of Oesophagectomy
A
- Head down tilt avoided to prevent gastric reflux which may lead to aspiration or infection of wound site
- Care with nasopharyngeal suction, as the anastomosis may be damaged with insertion of the catheter
- Neck motion may be limited to prevent stress on the anastomosis
8
Q
Likely attachments
A
NGT ICC IDC Wound drainage Peripheral line Central line TED Oxygen device
9
Q
Implications of NGT
A
- Often pinned to pillow ensure NGT is not pulled out when sitting patient forward
- Ensure tube to well secured to patient’s nose with appropriate tape, and will not slip out when mobilising
- Switch off NG feeds when suctioning patient or when in HDT to avoid aspiration
- NG feeds can often be disconnected to mobilise patient. This should be done by nursing staff as flushing of line required prior to reconnection
10
Q
Implications of ICC
A
- Can use portable suction to mobilise patient
- Check with medical team if not sure about disconnecting
- Keep bottle below insertion level into patient’s chest wall so no danger of fluid entering pleural cavity
- If ICC dislodged from chest wall apply pressure,
- Do not pull out during the course of your management
- Check whether the fluid is swinging, draining or bubbling
- If the bottle breaks, if previously no bubbling double clamp, quickly change bottles; if previously bubbling do not clamp, quickly change the bottle
11
Q
Peripheral line
A
Don’t bend joint
Don’t dislodge
12
Q
Central line
A
- Care with line, do not dislodge
- Inaccurate in Hypoxaemia, Hypercarbia, Acidosis, A-a gradient of 50-150mmHg
- Don’t percuss over line
- Disconnection air embolus patient head down
- If CVP < 5cmH2O Hypovolaemic
o May not tolerate MHI or mobilisation - Atrial arrhythmias may occur with positioning if CVL slides into R atrium e.g. side lying
- Pneumothorax may occur after insertion wait for CXR to confirm before using positive pressure
13
Q
Wound drains
A
- Do not pull out during the course of your management
- Infection can be a problem, ensure safe, appropriate handling of this equipment
- Can mobilise patients with drainage bag keep below level of wound
14
Q
IDC
A
- Ensure bag is not too full prior to mobilising
- Do not pull catheter out when mobilising
- Keep bag below level of the catheter
15
Q
TED
A
- Remove to expose legs for assessment of DVT and circulation
- Do not leave rolled around the ankle as this can create a tourniquet and impair circulation
- Patient can ambulate in TEDs as long as shoes are worn
16
Q
Oxygen devices
A
- Check the device is worn correctly and that the correct concentration is being delivered to the patient
- Monitor SpO2 with pulse oximeter
- Mobilise post-op patients with portable oxygen (if appropriate), or if removed use portable pulse oximeter, and ensure oxygen device replaced when returned to bed/ chair
17
Q
Pre op interview questions
A
- Main concerns
- Respiratory (Cough, breathless, sputum, wheeze, chest pain)
- Info prior to surgery
- Social history
- Functional history
- Goals
18
Q
Pre op Physical Examination
A
-Bed mobility, functional, special assessment
19
Q
Post op Patient interview
A
Post op - Nausea - Drowsiness - Dizziness - Vomiting Epidural - Numbness - Weakness - P & N - Heaviness - Headache
20
Q
Post op Physical Examination
A
Top to Toe approach Observation Environment, Attachments, Medications Patient: incision, wound (location, dressing) Palpation Auscultation Cough (justify timing) Lower limbs DVT Circulation Special assessment Epidural (site, sensation, muscle strength) Readiness to mobilise
21
Q
Most op Mob assessment
A
- P/I: Nausea, vomiting, drowsiness, pain-incision, anxiety, epidural Qs (numbness, weakness, P&N, headache, heaviness)
- P/E: “Top to Toe”
o Observation; patient, environment, attachments
o Respiratory system (eg: obs, palp, ausc, cough)
o Circulation, DVT, Epidural, Muscle strength
o Vital: RR, BP, - Pre-mobility assessment (is it safe to walk?)
o Comprehend
o On-bed
o Off-bed
o Environment/Equipment
o Etiquette: shoes, Extras (attachments, comorbidities, medication, recent surgeries, pain level, BMI)
Equipment: Rollator, portable IV + oxygen, chair down hallway, attachments, shoe/socks
22
Q
GA Side effects
A
- Impairs airway clearance
o Drying of cilia ↓ mucociliary function
o Secretion retention
o Loss of cough reflex - Impairs ventilation
o ↓ FRC
o Respiratory inhibition
o Atelectasis
o ↓ Alveolar ventilation - Unavoidable changes in lung mechanics, lung defences and gas exchange
- Most profound effect is reduction in lung volumes especially FRC
23
Q
GA Implications
A
- GA has greater respiratory effects due to MV, intubation, and loss of cough
- GA > 20 mins increases the risk of post-op hypoxaemia
- GA > 30 mins increases the risk of DVTs
- Patients may report a sore throat or have a hoarse voice following intubation.
24
Q
Epidural anaesthesia Side effects
A
- Hypotension
- Urinary retention
- Motor block
- Blocks sensation (including pain) to the level below the epidural; but muscle power should remain intact
- The patient’s respiratory system is intact and thus no intubation or mechanical ventilation is needed (compared to GA)
25
Epidural anaesthesia Implications
- Will need to assess muscle power prior to walking the patient
- Reduced risk of respiratory complications as intubation and mechanical ventilation not required.
- The epidural catheter may be left in situ for post-operative pain management
- Assessment prior to mobilising (Strength)
26
Narcotic/ Morphine Side effects
- Respiratory depression
- Postural hypotension, syncope
- Nausea, vomiting
- Drowsiness
- Paralytic ileus
- Pruritis/ itchiness
- Urinary retention
27
Epidural analgesia side effects
* Hypotension (SBP <90 mmHg)
* Sedation
* Respiratory depression (RR<8bpm)
* Motor and sensory loss of upper and lower limbs
* Bowel and bladder disturbance (urinary retention)
* Infection, haemorrhage, inflammation, displacement of the epidural catheter
* Epidural haematoma
28
Mechanical ventilation positive effects
- Increase gas exchange
- Decrease WOB
- Decreased Preload & afterload
- Increase alveolar ventilation
- Improve thoracic stability
- Allows oxygen to be used by other organs
29
Mechanical ventilation Negatives
```
Pulmonary
- Maldistribution of ventilation
- Progressive atelectasis
- Hyperinflation
- V/Q mismatch
- Decreased surfactant
Ventilator induced lung injury
- Barotrauma, volumtrauma, atelectrauma, biotrauma
Ventilator associated pneumonia (HPP/V)
DVT
Haemodynamic effect decreased CO
Gastric ulcerations
Disuse atrophy respiratory muscles
Hypoxaemia
```
30
Precautions suctioning
```
Pulmonary Oedema
Haemoptysis
Respiratory burns
Head injuries
High level of PEEP, FiO2
Severe infection
```
3H’s PRFS
31
Side effects of suctioning
```
Hypoxaemia
Cardiac arrhythmias
Haemodynamic alterations
Gastric aspirations
Trauma
Distress
Pneumothorax
Atelectasis
Infection
```
32
Contraindications for NIV
* Cardiovascular instability
* Airway obstruction
* Respiratory or facial trauma/burns
* Severe Haemoptysis
* Undrained pneumothorax
* Severely depressed level of consciousness
33
Precautions for NIV
* Bullae/cystic disease
* GCS < 9, unprotected airway
* Inability to clear secretions
* Facial pressure areas
* GOR
* Persistent air leaks
34
NIV Complications
```
Pressure:
-SInus pain
-Gastric insufflaation
-pneumothorax
Airflow:
-dryness
-nasal congestion
-eye irritation
```
- Severe hypoxaemia
- Aspiration
- Hypotension
- Mucous plugging
- Pressure sores at nasal bridge
