Lecture 3

Question 1

First two phases of postop care deal primarily with what?

Answer 1

Maintenance of homeostasis
Control of pain
Prevention and detection of complications

Question 2

Early complications and death postop are usually from what?

Answer 2

Airway issues
Acute pulmonary insufficiency
Acute cardiac insufficiency
Fluid derangements
Acid-base derangements

Question 3

If the patient goes to PACU, who are responsible for any problem directly related to the surgery?

Answer 3

The surgery team (surgical PA) and anesthesia

Question 4

Detailed treatment orders direct postoperative care, such as?

Answer 4

Monitoring
Respiratory care
Position in bed
Diet
Fluids & electrolytes
Drainage tubes (Is and Os)
Medications (scheduled and PRN)
Lab exams & imaging

Question 5

What monitoring instructions should be included for the nurses to know abt postop pts?

Answer 5

-Vital signs
-EKG
-I’s & O’s
>Recorded by anesthesia in the OR
>Post Op recorded by nursing
-If needed, special monitors: ICP (intracranial pressure monitor), CVP (such as an IJ catheter), Swan-Ganz
-Fluid orders
-Position in Bed and Activity
-Turning of patient

Question 6

Hypothermia:
1) Is it common?
2) Descr how to prevent it

Answer 6

1) Hypothermic pt in PACU requires rewarming to prevent shivering
2) -Forced-air warming devices (Bair Hugger)
-Small doses of meperidine for shivering
>Anesthesia often prophylactically gives meperidine and ondansetron

Question 7

What are some elements of postop respiratory care?

Answer 7

Pulse oximetry
Incentive Spirometry
Cough and deep breathing
Adequate pain management (allows for full inhalation/exhalation)
Out of bed orders/ambulation
Oxygen, if appropriate

Question 8

Descr postop mechanical ventilation

Answer 8

Mode
Rate (12-20 good start)
Tidal Volume (5-7cc/kg)
FIO2
PEEP
Check an ABG in 30 minutes

Question 9

Descr postop dietary care

Answer 9

1) NPO: Until risk for aspiration or emesis has decreased
Tube feedings: 25kcal/kg initially
2) Clear liquids: Next step after surgery when able to function and tolerate PO
3) Full liquids: Usually seen in oral surgery
4) Soft/Regular diet
5) Specialty diet: Diabetes, renal and hepatic failure (ex. low sodium)

May require Speech and Swallow test if concern for neuro deficits

Question 10

How often do you monitor Foley catheter postp?

Answer 10

Monitored hourly for high-risk patients
Monitored q shift if acuity is not high

Question 11

Descr monitoring of urine postop

Answer 11

If the patient does not have a Foley, nursing will still have to measure
Be on the lookout for urinary retention esp elderly male
Remove foley as soon as possible

Question 12

Nasogastric (NG) tube postop:
1) What does it do? Explain
2) When is it okay to pull the tube?

Answer 12

1) Collects saliva and gastric secretions
-Saliva: 500 cc/day
-Stomach secretions: 1500 cc/day
2) When <500mL in 24hrs + at least 2 other signs of return to bowel function

Question 13

What should you know abt Chest tube (thoracostomy tube) postop?

Answer 13

1) Why was it placed?
2) When can I take it out? If <200-200cc/24hrs output and no air leak (no bubbles during exhalation or cough)
3) CXR 4hrs after removal

Question 14

Descr chest tubes for PTX

Answer 14

Tube is placed to collect air on suction.
May want a trial of water seal prior to removal.
When the air stops leaking, you can remove the tube

Question 15

Descr chest tubes for pleural effusions

Answer 15

Often removed by thoracentesis
Suction initially, then water seal

Question 16

1) Which diagnoses are known to be transudative?
2) Exudative?

Answer 16

1) Hypoalbuminemia, HF
2) Cancer, infection, pneumonia, TB, PE

Question 17

Descr chest tube for hemothorax

Answer 17

1) Usually placed on suction
2) Initial placement: >20cc/hr [200/day] needs operative intervention

Question 18

Descr chest tubes for empyema

Answer 18

Infected material in the pleural cavity usually secondary to pneumonia
When noted, early thoracic surgery consult, chest tube+ prompt abx

Question 19

Descr the use of Closed suction drains

Answer 19

1) Why is the drain present? Can be used to drain blood, bile, purulent material, pancreatic secretions, etc.
2) Prevent hematoma, seromas, aids in wound healing.
3) Nursing measures at least once q shift
4) Hemovac can vacuum out blood/ fluid/ etc

Question 20

Who uses drains most?

Answer 20

Plastic Surgery
Orthopedic Surgery
Trauma Surgery

Question 21

Descr the quantity drains can hold

Answer 21

Hemovac: holds up to 500mL
JP drain: holds up to 25-200 mL

Question 22

Descr the ordering of drains

Answer 22

1) Every drain must have an order that specifies instructions.
*Order sets in EMRs have these shortcuts
How often to measure it
When to report the output to the medical providers
2) As a PA, you need to understand why it is there and when to remove it.
Review the chart. Ask if you don’t know.
*Some drains should not be removed by nursing.

Question 23

Descr postop pain mgmt

Answer 23

Most patients will experience some degree of postoperative pain
Perception of pain is unique to each patient

Opioid epidemic complicates pain control

Question 24

Postop pain mgmt; describe the use of:
1) Opioids
2) NSAIDs

Answer 24

1) Can be administered oral, IV, IM, PCA; Highly effective
Warning: can be addictive
2) Highly effective; Oral, IV
Caution/May not be used in pts with CAD, stroke, renal insufficiency and fractures.
Caution: may mask fever

Question 25

Postop pain mgmt; describe the use of: 1) Acetaminophen 2) Gabapentin/Lyrica

Answer 25

1) Highly effective; Oral, IV and rectal -Can cause liver toxicity -Caution: may mask fever 2) Initially for seizures; Rx for nerve pain -Can be given preop -Caution: may cause agitation in the elderly

Question 26

List and descr 3 local pain mgmt agents in the OR (nerve block or locally given)

Answer 26

1) Lidocaine: up to 1 hour 2) Marcaine: 4-6 hrs, longer if mixed with steroids 3) Bupivacaine: 3 days

Question 27

Common postoperative medications include?

Answer 27

Morphine Hydrocodone/APAP (Norco, Vicodin) Oxycodone Hydromorphone (Dilaudid)

Question 28

Descr Hydromorphone (Dilaudid) postop

Answer 28

MOA: binds to various opioid receptors, producing analgesia and sedation Indications: moderate to severe pain CI: multiple Adverse reactions: Respiratory depression, hypotension, dizziness, somnolence, nausea

Question 29

Acetaminophen: 1) MOA? 2) Indication? 3) CI? 4) Adverse effects?

Answer 29

1) Analgesic unknown. Antipyretic effect via direct action on the hypothalamic heat-regulating center 2) Mild pain 3) Hypersensitivity. Caution in hepatic & renal impairment, severe hypovolemia, chronic alcohol use 4) anaphylaxis, hepatotoxicity, acute ATN

Question 30

NSAIDs (ex. ibuprofen) 1) MOA? 2) Indication? 3) CI? 4) Adverse effects?

Answer 30

MOA: Inhibits COX, reducing prostaglandin & thromboxane synthesis Indications: mild to moderate pain CI: CABG surgery periop use, advanced renal disease, multiple cautions Adverse reactions: GI bleeding/perforation/ulcer, MI, stroke, thromboembolism, HTN, CHF, multiple others

Question 31

Pantoprazole (Protonix) 1) MOA? 2) Indication? 3) CI? 4) Adverse effects?

Answer 31

MOA: inhibits gastric parietal cell hydrogen-potassium ATPase (PPI) Indications: hypersecretory conditions, ulcer prophylaxis CI: hypersensitivity, caution if hypomagnesemia Adverse reactions: interstitial nephritis, renal impairment, pancreatitis

Question 32

Promethazine (Phenergan) 1) MOA? 2) Indication? 3) CI? 4) Adverse effects?

Answer 32

MOA: H1 receptor antagonist, anticholinergic Indications: nausea & vomiting CI: respiratory depression, SC injection, arterial/periarterial injection Adverse reactions: tissue damage (IV use), apnea, respiratory depression

Question 33

Ondansetron (Zofran) 1) MOA? 2) Indication? 3) CI? 4) Adverse effects?

Answer 33

MOA: selectively antagonizes serotonin 5-HT3 receptors Indications: GI-related nausea & vomiting CI: congenital long QT syndrome, multiple cautions Adverse reactions: bronchospasm, QT prolongation, serotonin syndrome

Question 34

Polyethylene glycol (Miralax) 1) MOA? 2) Indication? 3) CI? 4) Adverse effects?

Answer 34

MOA: causes water retention in stool Indications: constipation CI: known or suspected GI obstruction Adverse reactions: electrolyte disorders (prolonged use), abdominal distension, diarrhea

Question 35

Postop fever: 1) Etiology? 2) Epidemiology?

Answer 35

1) Physiologic (self-limited) -DDx includes infectious & non-infectious causes -More likely due to infection as time increases -Possibly multiple causes 2) Very common (~40% after major surgery) -Usually POD#1 or POD#2 -Highest incidence in abdominal & chest procedures

Question 36

What are the 5 W’s of postoperative fever? Explain each

Answer 36

1) Wind: atelectasis (POD 1-2), pneumonia (POD 3) 2) Water: urinary; UTI, sepsis (POD 3-5) 3) Wound: integumentary; wound infection, abscess (POD 5-7) 4) Walk: vascular; DVT (POD 5-7) 5) Wonder (about) drug: multisystem; drug adverse reaction or drug-drug interaction, transfusion reaction (any POD)

Question 37

Descr Measures to provide protection from postoperative atelectasis

Answer 37

Lung expansion: Deep breathing exercises or incentive spirometry Early mobilization Maybe epidural analgesia in place of parenteral opioids *Avoid NSAIDs for analgesia in pts with asthma or AERD Consider CPAP for high-risk pts (may reduce incidence of hypoxemia, pneumonia, reintubation, ICU admission)

Question 38

Sutures, skin staples, and other closures are usually left in place ___ days or longer depending on the site and the patient.

Answer 38

7

Question 39

How long are sutures/ staples/ etc left on on the: 1) Face 2) Neck 3) Scalp 4) Trunk and UE 5) LE

Answer 39

1) 5-7days 2) 7 days 3) 10 days (staples most common) 4) 10-14 days 5) 14-21 days

Question 40

Surgical Site Infection (SSI): What are the criteria to diagnose?

Answer 40

At least one of the following: 1) Purulent drainage is present 2) Organisms are isolated from fluid/tissue of the superficial incision 3) At least one sign of inflammation (eg, pain or tenderness, induration, erythema, local warmth of the wound) is present 4) The surgeon or clinician declares the wound infected

Question 41

Seroma: 1) What is it? When do they usually occur? 2) Why are they bad?

Answer 41

1) Abnormal accumulation of serous fluid in a dead space -Usually occurs within 7-10 days after wound closure or drain removal 2) Delay healing, increase risk of infection -May lead to pain, infection, abscess formation, wound dehiscence, or necrosis

Question 42

Hematoma: 1) What causes them? 2) Sxs? 3) Are they common?

Answer 42

1) Result from unrecognized inadequate hemostasis 2) Patients may have pain, pressure, and swelling within the wound 3) Nonexpanding hematomas are common within first 48hrs

Question 43

Wound Dehiscence: 1) What is it? 2) When does it occur? 3) What should you do if it begins to occur?

Answer 43

1) Partial or total separation of previously approximated wound edge 2) Usually occurs 5-8 days post op 3) Investigate it

Question 44

Measures to prevent wound infections include what?

Answer 44

1) Maintain normothermia 2) Maintain oxygenation 3) Control glucose: *Glucose >180 48hrs postop associated with >100% increase in SSIs 4) Limit traffic through OR 5) Timing of antibiotics 6) Operative wound barriers 7) Sterile field

Question 45

Stress Ulcer Prophylaxis in ICU: 1) What causes these ulcers? 2) Who do they occur in?

Answer 45

1) Ulcerations of the upper GI tract due to hospitalization in critically ill patients 2) Asymptomatic patients not receiving prophylaxis (>75%) -Occult bleeding 15-50% -Overt bleeding 1.5-8.5%

Question 46

Postop care: 1) What should you look for if a pt has concerning GI sxs? 2) What are some Tx options?

Answer 46

1) Impaction, constipation 2) Minimize narcotics Bowel Stimulants: bisacodyl Suppositories/enemas: colace Chew gum Water/ IV fluids Move

Question 47

What are the clinical findings of Postoperative Ileus?

Answer 47

1) Abd pain 2) +/- N/V 3) Abd distention 4) Decreased or absent B 5) On abd XR: generalized dilatation and gaseous distention of small and large bowl

Question 48

What is the main Tx for postp ileus?

Answer 48

NG tube

Question 49

As a PA, what are your documentation responsibilities for?: 1) Preop 2) Postop 3) Discharge planning

Answer 49

1) Orders Consent (usually surgeon… but not always) 2) Brief op note, orders 3) Discharge summary, Rx, Discharge instructions to patient/ family, Confirm f/u appts

Question 50

When are H&P done?

Answer 50

Differences: CC, HPI Elective: done at pre-op visit Sample surgical admission H&P (pg 149-150) Same-day H&P example (pg 147)

Question 51

Brief operative note should include waht details?

Answer 51

Date Preop Dx: Postop Dx: Procedure: Surgeon(s): Assistant: Anesthesia: EBL: Fluids: Findings (if relevant): Tubes/Wires: Specimens: Complications: Signature:

Question 52

Step by step procedure documented by surgeon includes what details?

Answer 52

Procedure Name: Indication: Consent: Anesthesia: Procedure: (explained in detail) Findings:

Question 53

Discharge summary: What details does it include?

Answer 53

-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 ______