Final study guide: Exam 1 content

Question 1

Differentiate primary, secondary, and tertiary intention

Answer 1

1) Primary intention (staples, sutures)
2) Secondary intention (wound purposely left open, which will heal on its own, may have wound vac but no sutures or anything else)
-Especially used if wounds are contaminated
3) Tertiary intention (aka, delayed primary closure/DPC)
-Wound left open x 5 days, then closed like primary intention

Question 2

Most important factor in determining whether to close a wound is?

Answer 2

Level of contamination

Question 3

Post op ileus: Clinical findings?

Answer 3

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 4

Post op ileus: Tx?

Answer 4

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

Question 5

Define postop fever

Answer 5

Temperature >100.4 F on two consecutive postoperative days or >102.2 F on any postoperative day.

Question 6

What are some causes of postop fever based on the day?

Answer 6

Wind: atelectasis (POD 1-2), pneumonia (POD 3)
Water: urinary; UTI, sepsis (POD 3-5)
Wound: integumentary; wound infection, abscess (POD 5-7)
Walk: vascular; DVT (POD 5-7)
Wonder (about) drug: multisystem; drug adverse reaction or drug-drug interaction, transfusion reaction (any POD)

Question 7

Malignant hyperthermia:
1) When does it occur?
2) Why?
3) Most reliable clinical sign?
4) Early sign and late sign?

Answer 7

1) Major risk w succinylcholine
2) Due to uncontrolled and abnormal shift in calcium in skeletal muscle
3) refractory hypercapnia with increased ETCO2 and tachypnea
4) Early sign is masseter muscle spasm, late sign is hyperthermia

Question 8

Malignant hyperthermia Tx?

Answer 8

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

Question 9

When should you give dialysis preop?

Answer 9

24-36 hrs before operation

Question 10

What meds can you take day of surgery w sips of water?

Answer 10

BBs, CCB, nitrates, HTN meds, alpha agonists or antagonists, statins, hormones (ex. levothyroxine), psychotropics, OCP

Question 11

What meds should you continue regardless of surgery?

Answer 11

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

Question 12

What meds should you d/c 1 wk prior to surgery?

Answer 12

Aspirin (taken for other reasons than primary or secondary prevention of MI or CVA), NSAIDs, herbals, & vitamin E

Question 13

What meds should you d/c 2-4 wks prior to surgery?

Answer 13

Estrogen receptor antagonists (ex. tamoxifen)

Question 14

When should you d/c warfarin prior to surgery?

Answer 14

warfarin usually discontinued 5 days prior (bridge therapy may be indicated)

Question 15

Who should get perioperative supplemental corticosteroids?

Answer 15

If primary or secondary adrenal insufficiency
If >3wks of >20 mg prednisone daily
If >2g/day topical steroid

Question 16

Who should get an EKG preop?

Answer 16

age >50 male; >60 female
Vascular operation
Pmhx HTN, MI/cardiac disease, significant respiratory disease, renal dysfunction, morbid obesity, & DM

Question 17

List the ASA classifications

Answer 17

ASA 1 = normal healthy pt
-not very young or old
ASA 2 = pts with mild systemic disease
-mild obesity, pregnancy, smoker
ASA 3 = pts with severe systemic disease
-controlled CHF, stable angina, morbid obesity, etc
ASA 4 = pts with 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 18

Descr PACU monitoring

Answer 18

Continual monitoring for ~ 1 hour or until meeting discharge criteria + Supplemental O2 to avoid hypoxemia
Use Postanesthetic Discharge Scoring System (measures vitals, activity, N/V, pain, bleeding)
≥9: okay to discharge
Adult must escort patient home after outpatient surgery
Policies governing discharge (usually anesthesiologist along with PACU nursing team)

Question 19

What are the 3 MC problems post-surgery?

Answer 19

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

Question 20

What are some common postop meds?

Answer 20

Morphine
hydrocodone/APAP (norco, vicodin)
Oxycodone
Hydromorphone (Dilaudid)
MOA→ inds to various opioid receptors, producing analgesia and sedation
Indications→ moderate to severe pain
CI→ many
AE→respiratory depression, hypotension, dizziness, somnolence, nausea

Question 21

What does LEMON stand for?

Answer 21

1) Look externally
2) Eval 3-2-1 rule
-Thyroid cartilage-to-mentum (chin) distance (ideal > 6 cm)
-Mouth opening (ideal > 3 cm)
3) Mallampati score
4) Obstruction
5) Neck Mobility (cervical spine ROM)

Question 22

Descr discharge planning/ summary

Answer 22

Required after any hospital stay >24 hours
Completed by hospitalist or primary service taking care of pt
Includes:
Patient info
Date of Admission
Date of Discharge
Admitting Diagnosis
Discharge Diagnoses
Attending Physician
Brief HPI, PMHx, PE, Labs/Imaging/Pathology
Hospital Course (brief summary of events)
Including procedure(s)
Date, Procedure Name, Surgeon Name
Discharge Instructions
Condition (at discharge)
Disposition
Discharge Instructions
Diet, wound care, fluid restriction, labs, follow-up
Call doctor when _____, Go to ER when ______
Confirm f/u appts