Exam 1 study guide

Question 1

1) Differentiate sterile and aseptic
2) Define Surgical conscience

Answer 1

1) Sterile → absence of life
Aseptic → techniques that keep and environment in its sterile state
2) An individual inner awareness of aseptic principles and adherence to aseptic technique in all situations; professional honesty

Question 2

1) What part(s) of the sterile drape are sterile?
2) What part(s) of a sterile package are sterile?

Answer 2

1) Only the top surface of a sterile drape is sterile
-Any item that extends beyond the sterile boundary is contaminated/cannot be re-introduced onto the sterile field.
2) After a sterile package is opened, the edges (1 inch margin) are unsterile.
-On peel pack sterile packages, the inner edge of the heat seal is the line of demarcation.

Question 3

1) What part(s) of a sterile bottle are sterile?
2) How close can you get to sterile fields?
3) When should sterile fields be prepared?

Answer 3

1) The edge of a bottle cap is contaminated once cap has been removed from bottle
-Do not replace cap → sterility cannot be ensured if cap is replaced
2) Maintain at least a 1-foot distance from sterile fields to help prevent accidental contamination; whenever a sterile barrier is permeated, it must be considered contaminated.
3) As close as possible to the scheduled time of use

Question 4

What part(s) of a surgical gown are sterile? Explain

Answer 4

1) Gowns are considered sterile at the front from chest to the level of the sterile field
2) Sleeves are sterile from 2 inches above the elbow to the stockinet cuff
-Cuff is not sterile and should always be covered w gloves
-Cuff tends to collect moisture → not effective bacterial barrier
3) Back of gown is not sterile

Question 5

Surgical site infections (SSI):
1) What causes them?
2) When do they occur?
3) How do they differ from medical infections?

Answer 5

1) Most caused by host resident microflora or break in sterile technique
2) Within 30 days from procedure or up to 1-yr after implantation of prosthetic device)
3) Result from impaired host defenses & are typically polymicrobial (host’s native flora)

Question 6

Surgical site infections (SSI):
1) Most common surgical infection in surgical ICUs is?
2) Most serious skin infection is what?

Answer 6

1) Postop pneumonia
2) Necrotizing soft tissue infections

Question 7

How can you limit post op infections?

Answer 7

Tetanus prophylaxis
Hair removal
Site preparation (iodine or chlorhexidine)
Perioperative antibiotic choice/administration
Ensure sterility in the OR
Maintaining normoglycemia (<180)

Question 8

How can you limit post op infections during incision closure?

Answer 8

Obliterate dead space
Remove devitalized tissue
Close wounds without tension
Use closed drains

Question 9

Define ASA classification categories 1, 2, and 3

(important)

Answer 9

ASA 1 = normal healthy pt
-Excludes very young or old
ASA 2 = pts with mild systemic disease (well controlled disease of one body system)
-Mild obesity, pregnancy, smoker
ASA 3 = pts with severe systemic disease (controlled disease of more than one body system)
-Controlled CHF, stable angina, morbid obesity, etc

Question 10

Define ASA classification categories 4, 5, and 6

(important)

Answer 10

ASA 4 = pts w severe systemic disease that is a constant threat to life
-Symptomatic COPD, unstable angina
ASA 5 = moribund pts not expected to survive >24hr w/o operation
-Sepsis, hypothermia, etc
ASA 6 = clinically brain dead & removing organs for donation

Question 11

How can you manage preoperative conditions such as:
1) HTN
2) DM

Answer 11

1) Keep taking meds, even on day of operation
-Get CMP and ECG for preop testing
2) Elevated perioperative blood glucose correlates to higher risk of SSIs, greater likelihood of post op infections & prolonged hospital stays after non cardiac surgeries
-Goal → <180 periop and postop
-IV insulin best for peri-operative glucose control

Question 12

What should you do for dialysis pts before surgery?

Answer 12

ESRD → dialysis 24 - 36 hrs before operation

Question 13

Who should you give supplemental perioperative corticosteroids to?

Answer 13

Those with:
1) Primary or secondary adrenal insufficiency
2) Use > 3 wks of > 20 mg prednisone daily
3) Use > 2g/day topical steroid

Question 14

How do you maintain IV fluids?

Answer 14

4:2:1 rule
4mL/kg for first 10kg
2mL/kg for second 10kg
1mL/kg for every kg over 20

Question 15

What IV fluids should you use for surgery?

Answer 15

Use balanced salt solution without dextrose
Lactated ringers
Normal saline

Question 16

What are some critical medications pts should still take the day of an operation with sips of water?

Answer 16

BB
CCB
Nitrates
HTN meds
Alpha agonists/antagonists
Statins
Hormones (levothyroxine)
Psychotropics
OCP

Question 17

List 5 meds a pt should still take preoperatively (but not start unless already on)

Answer 17

BB
A2 agonists
CCB
Digoxin
Statins

Question 18

What med(s) should you withhold on morning of procedure for most patients?

Answer 18

ACEi/ARB

Question 19

What meds should be continued preop?

Answer 19

Chronic narcotics (methadone)
MAOIs (without confounding meds)
Bronchodilator inhalers
Eye drops (beta blockers)

Question 20

Preop testing:
1) When should you get CBC?
2) When should you get CMP?

Answer 20

1) Hx of infection
-Anemia
-Expected blood loss during surgery
-Female greater than 12 y/o
2) h/o of renal, cardiopulmonology, liver, hypertensive, dz or DM
-Taking diuretics, steroids, or potassium

Question 21

Preop testing:
1) When should you get coag factors?
2) What are some other specific tests?

Answer 21

1) Taking anticoagulants, low threshold for bleeding, or liver dz
2) Serum drug levels (lithium, seizure meds) and tumor markers

Question 22

Preop testing:
1) When should you get a blood bank specimen?
2) When should you pregnancy test?

Answer 22

1) Current/possible significant hemorrhage or Anemia
2) Any female with uterus over age of 9, unless hysterectomy or menopausal

Question 23

1) When should you get a blood glucose preop?
2) What are some bacterial tests you can get?

Answer 23

1) Routine for DM
2) Staph aureus (MRSA) screening/nasal swab; Wound & abscess cultures

Question 24

1) Who should you get an ECG for preop?
2) When should you get a CXR?

Answer 24

1) Age > 50 male or >60 female; Vascular operation; Pmhx HTN, MI/cardiac dz, significant resp distress, renal dysfunction, morbid obesity & DM
2) Reserved for malignancy & significant pulm dz or smoking > 20 yrs

Question 25

What are some other preop tests to consider?

Answer 25

Echo Cardiac stress test Baseline ABG Pulm functions testing (PFTs) Carotid US Non-invasive venous studies

Question 26

Epidural anesthesia: 1) What are 3 locations to do it? 2) What is a common complication? 3) Where should you do it for a thoracotomy? What abt for abdominal or lower extremity procedures?

Answer 26

1) Thoracic, spine, intra-abdominal 2) Prolonged blockade of parasympathetic fibers innervating bladder (leads to urinary retention → urinary bladder catheter) 3) Midthoracic region for thoracotomy -Lower thoracic or lumbar region placement for abdominal or lower extremity procedures

Question 27

1) What are some pros of epidurals compared to spinals? 2) What are some cons?

Answer 27

1) Subdural space not entered: No CSF leak → no spinal headache -Insertion of small catheter allows for continued use 2) Much slower onset compared to spinal & requires high volumes of local anesthetics

Question 28

What are two reasons to give small initial doses of epidural anesthesia?

Answer 28

1) Potential IV injection (CV compromise or high block) 2) Potential catheter misplacement into subarachnoid (CV collapse)

Question 29

What can be used for Postoperative atelectasis prevention?

Answer 29

Epidural anesthesia in place of parenteral opioids

Question 30

Spinal anesthesia: 1) What is it used for? 2) What type of medication/ anesthetic is used? How long do they last? 3) Where is it inserted?

Answer 30

1) For surgery below waist, below umbilicus, perineum 2) Subdural lidocaine or bupivacaine: 5-10 min onset, 2-5 hours duration 3) Below L2-L3 interspace (spinal cord ends L1-L2 vertebral interspace)

Question 31

Describe the most common complication of spinal anesthesia and how to treat it

Answer 31

Post-spinal headache: 1) MC in young women; 1-2 days following procedure 2) Tx: hydration, recumbency, & analgesics (Tylenol) -Severe HA may require “blood patch” (stop CSF leak)

Question 32

Malignant hyperthermia: 1) What is it? What causes it? 2) What does it result in? 3) What medication is it common with?

Answer 32

1) True anesthesia emergency; a rare, life-threatening, genetically inherited disease with intense muscle contraction -Due to uncontrolled and abnormal shift in calcium in skeletal muscle 2) Results in hypermetabolic state: Hyperthermia, hypercapnia, tachycardia, metabolic acidosis 3) Common with succinylcholine

Question 33

Malignant hyperthermia: 1) What is the most reliable sign? 2) What may cause it if a pt has a personal or family Hx?

Answer 33

1) Most reliable clinical sign → refractory hypercapnia with increased ETCO2 and tachypnea 2) Succinylcholine or volatile inhalation agent used

Question 34

How do you Tx malignant hyperthermia?

Answer 34

Discontinuation of volatile anesthetics Hyperventilation with 100% O2 Conclusion of surgery asap Maintenance of urine output Active cooling measures Dantrolene

Question 35

1) How do you use absorbable sutures? 2) How do you use non-absorbable sutures?

Answer 35

1) Absorbable = Square knot, 3-4 ties (throws) 2) Non-absorbable = Surgeon’s knot, 4-5 ties

Question 36

How do you decide what size suture to use?

Answer 36

Question 37

The timing of nonabsorbable suture removal varies with the anatomic site, according to the expected rate of healing; when should you remove sutures in the: 1) Face 2) Eyelids 3) Neck

Answer 37

1) 5 days 2) 5 days (3 days for low-tension and up to 7 days for high-tension wounds) 3) 5 days

Question 38

The timing of nonabsorbable suture removal varies with the anatomic site, according to the expected rate of healing; when should you remove sutures in the: 1) Scalp 2) Trunk and UE 3) LE 4) Digits, palms, and soles

Answer 38

1) 7-10 days 2) 7 days 3) 8-10 days 4) 10-14 days

Question 39

1) What allows for the best outcome/ cosmesis with sutures? 2) How must the skin be positioned? How is this accomplished?

Answer 39

1) Wounds that parallel Langer's lines and are under minimal tension 2) Edges of the wound must be everted -Needle should penetrate the skin at 90 degrees

Question 40

PACU: 1) What must be reversed in intubated pts? What must be increased? 2) When do pts go to PACU?

Answer 40

1) Muscle relaxant reversed & anesthetic depth decreased 2) Pt extubated, transferred to stretcher, & transported to PACU -Some critically ill patients transported directly to ICU (still intubated, sedated, & ventilated)

Question 41

What is done in the PACU?

Answer 41

1) Post-anesthesia vital signs & initial post-op nursing care 2) Supplemental O2 to avoid hypoxemia 3) Equipped same as operating room (specialized, short-stay ICU) -Continual monitoring for ~ 1 hour or until meeting discharge criteria

Question 42

Descr the continual monitoring for ~ 1 hour or until meeting discharge criteria in the PACU

Answer 42

1) Use Postanesthetic Discharge Scoring System (measures vitals, activity, N/V, pain, bleeding) ≥9: okay to discharge 2) Adult must escort patient home after outpatient surgery 3) Policies governing discharge (usually anesthesiologist along with PACU nursing team)

Question 43

What are the 3 most common problems in pts after surgery?

Answer 43

1) Post-operative nausea & vomiting (PONV) 2) Hypothermia (forced air warming devices help, small doses of meperidine and ondansetron for shivering) 3) Pain control (may need extra doses of opioids)

Question 44

What are some other immediate postop problems?

Answer 44

Hypotension, hypertension Hypercapnia/hypoventilation Agitation Inability to void

Question 45

Postop fever: 1) Define it 2) Descr the etiology 3) Descr the epidemiology

Answer 45

1) Temperature >100.4 °F on 2 consecutive postop days OR >102.2 °F on any postop day 2) Self-limited; Ddx includes infectious and non-infectious causes -More likely due to infection as time increases -Possibly multiple causes 3) Very common ( ~40% after major surgery) Usually postop day 1 or 2 Highest incidence in abdominal and chest procedures

Question 46

Postop fever: Descr the most common causes based on the timing

Answer 46

1) Day 1-2: atelectasis 2) Day 3-5: urinary tract infection, pneumonia, phlebitis 3) Day 5-7: wound infection, anastomotic breakdown, intra-abdominal infection, DVT Anytime: drug reaction, transfusion reaction, bacteremia

Question 47

What are the 5 Ws of postop fever? What are the causes of each?

Answer 47

Wind: atelectasis Water: urinary; UTI, sepsis Wound: integumentary; wound infection, abscess Walk: vascular; DVT Wonder (about) drug: multisystem; drug adverse reaction or drug-drug interaction, transfusion reaction

Question 48

NG tube: 1) What is its use based on? 2) What does it do? Explain

Answer 48

1) Based on maintenance needs + any losses not replaced in surgery + any losses from drains, NG tube + any surgery specific needs 2) Collects saliva and gastric secretions Saliva: 500 cc/day Stomach secretions: 1500 cc/day

Question 49

When can you pull an NG tube?

Answer 49

<500mL in 24hrs AND at least 2 other signs of return to bowel function Flatulence, passing stool, return of appetite, tolerating PO

Question 50

Descr closed suction drains

Answer 50

Vacuum fluid into reservoir container or pouch used to drain blood, bile, purulent material, pancreatic secretions, etc. Prevent hematoma, seromas, aids in wound healing Nursing measures at least once q shift Who uses drains the most: plastics, ortho, trauma

Question 51

Drains; define: 1) Serous 2) Sanguinous 3) Serosanguinous 4) Purulent

Answer 51

1) Clear, watery plasma 2) Fresh bleeding 3) Pale & watery with some traces of blood 4) Thick, yellow, green or brown drainage

Question 52

1) How much do the 2 main types of drains hold? 2) Every drain must have an order w/ specific instructions, such as what?

Answer 52

1) Hemovac: holds up to 500mL Jackson-pratt (JP): holds up to 25-200 mL 2) How often to measure it When to report the output to the medical providers Note that some drains should not be removed by nursing

Question 53

Descr Stress ulcer prophylaxis

Answer 53

PO PPI preferred (Pantoprazole most common) for prophylaxis Stress ulcers can be asymptomatic Give to pts who are in the ICU or: have severe head trauma, hepatic failure, SCI, >35% burns, gastric ulcers or bleeding w/in past year, etc

Question 54

What are some clinical findings with postop ileus?

Answer 54

Abd pain +/- N/V Abd distention Decreased or absent bowel sounds On abd XR → generalized dilation and gaseous distention of small and large bowel

Question 55

How is postop ileus treated?

Answer 55

NG tube Early postop feeding Laparoscopic procedures Local epidural anesthetic/analgesic Chewing gum Laxatives NSAIDs

Question 56

Hemostasis: 1) ___________ cells serve as anticoagulant barrier 2) Define primary hemostasis 3) Explain how primary hemostasis occurs

Answer 56

1) Endothelial 2) Formation of platelet plug 3) Vasoconstriction -Platelet adhesion, activation, and plug formation stimulates coagulation cascade -Process allows localized and rapid hemostatic control and limits ongoing blood loss

Question 57

Secondary hemostasis 1) Define it 2) Explain how it works

Answer 57

1) Coagulation 2) Circulating coagulation factors activate and interact with one another -Factors from extrinsic/intrinsic pathways interact to form large amounts of thrombin -Activation of fibrin (factor 1a activated to form factor 1) -Fibrin formed from fibrinogen -Fibrin weaves through platelet plug forming stable fibrin clot

Question 58

Descr normal platelet count and what happens when it's low

Answer 58

Normal = 150-400K -<50K easy bruising and bleeding -<20K spontaneous bleeding

Question 59

Warfarin therapy prolongs ______ Heparin prolongs ________

Answer 59

1) PT/INR 2) aPTT

Question 60

Define: 1) Normal PT 2) Normal INR 3) Normal aPTT

Answer 60

1) 11-13.5 sec 2) 0.8-1.1 sec 3)21-35 sec

Question 61

1) Give examples of antiplatelets 2) Give examples of anticoagulants

Answer 61

1) Aspirin, clopidogrel, cilostazol; abciximab, eptifibatide, tirofiban 2) Antithrombin III agents: unfractionated heparin, LMWH Vitamin K antagonists: warfarin Direct thrombin inhibitors: dabigiatran Factor Xa inhibitors: xarelto,eliquis Thrombolytics: tPA

Question 62

What is the admission orders mnemonic?

Answer 62

AD CAVA DIMPLS Admit (name of admitting physician, name of unit or floor) Diagnosis, procedure (if postop orders) Condition (stable, unstable, guarded, critical, morbid, comatose) Activity level (ie, OOB, NWB, TTWB) Vital sign frequency Allergies (meds, foods, others; response if exposed) Diet (ie, are they NPO) I&Os (fluids, drains, NGT, foley, arterial lines, etc) Medications (home vs inpatient, scheduled vs prn) Procedures (wound care, ostomy care, etc) Labs Special instructions

Question 63

Descr postop dressing

Answer 63

Sterile dressing placed in the operating room Generally left intact for 24-48 hrs unless signs of infection

Question 64

1) When should you use a controlled airway? 2) What should you look for externally before intubating? (3 things) 3) What is the 3-3-2 rule?

Answer 64

1) General anesthetic = Drug-induced loss of consciousness. Not arousable even by noxious stimulus; often requires a controlled airway 2) Dentition (dentures, missing teeth, poor conservation) -Jaw protrusion (lower incisors past upper incisors) -Presence of a beard 2) Thyroid cartilage-to-mentum (chin) distance (ideal > 6 cm) -Mouth opening (ideal > 3 cm)

Question 65

Descr Mallampati score

Answer 65

Oral opening based on: a) Size of tongue b) Size of pharyngeal structures Done w/ pt sitting upright& looking forward

Question 66

Define the following types of procedures and give examples: 1) Emergent 2) Urgent 3) Time sensitive 4) Elective

Answer 66

1) Emergency: life/limb-threatening situation requiring surgery immediately/as soon as possible, typically within < 6 hours -Ex. trauma, ruptured aneurysm 2) Urgent: usually life/limb-threatening condition requiring intervention, typically within 6-24 hours -Ex. intestinal obstruction, appendicitis, wounds 3) Time-sensitive: a delay of > 1-6 weeks will negatively affect outcome -Ex. oncologic 4) Elective: non-life/limb-threatening condition for which surgery can be planned in advance; delayed up to 1 year -Ex. hernia, varicose veins, knee joint replacement

Question 67

Perioperative medications; what should you do for: 1) Beta blockers 2) ASA 3) Thyrotoxicosis

Answer 67

1) Continue if already taking 2) Continue of mod-high risk for CAD (unless risk of hemorrhage outweighs likelihood of atherothrombotic event) 3) Antithyroid meds, BB, possibly corticosteroids

Question 68

Perioperative medications; what should you do for?: 1) Hypothyroidism 2) Illicit drug and alcohol use

Answer 68

1) Daily levothyroxine, possible IV thyroid hormone 2) Postop acute withdrawal: Monitor, benzodiazepines -Advise patients to refrain from alcohol for at least 1-week preop

Question 69

What are the 4 requirements for interpreters?

Answer 69

Knows target language Skilled in medical terminology Physically present, telephone, or virtual Can NOT be a family member