Lecture 3 highlights

Question 1

What are the 3 phases of postop care?

Answer 1

Immediate (postanesthesiaphase)
Intermediate (hospitalization)
Convalescent (after hospital)

Question 2

Differentiate the postop timelines of same-day surgery patients (outpatient) vs surgical inpatient

Answer 2

1) Outpatient: Post-anesthesia Care Unit (PACU) with subsequent discharge
2) Surgicalinpatient: PACU for 1-3 hours then to hospital room or to ICU directly postoperatively

Question 3

Hypothermia:
1) What is a key thing to know abt this?
2) What are 2 ways to prevent this?

Answer 3

1) Prevention is key
2) Bair hugger and small doses of meperidine

Question 4

1) What do you need to give every pt postop regarding respiratory care?
2) What are some potential diet orders postop?
3) What are the preferred postop fluids?

Answer 4

1) Incentive spirometry [and pulse ox]
2) NPO, clear liquids, full liquids, soft/regular diet, or specialty diet
3) Lactated ringers or Normal saline preferred

Question 5

1) When should you remove a foley postop?
2) What is the most common reason why CT [chest tube] is placed?
3) What is the second most common reason for CT?
4) What is another reason for a CT?

Answer 5

1) ASAP
2) Pneumothorax
3) Pleural effusion
4) Hemothorax

Question 6

1) What is a less common reason for a chest tube?
2) What is the least common reason for CT placement? What is it characterized by?

Answer 6

1) Empyema
2) Chylothorax; high triglycerides

Question 7

Descr chest tube for Chylothorax

Answer 7

Usually caused by trauma or result of cardiothoracic procedure
Characterized by high triglyceride level
Chest tube can be removed when there is NO CHYLE in the chamber after a fatty meal.
If it doesn’t resolve, pt may need to go to OR for thoracic duct ligation

Question 8

In the context of drains, define:
1) Serous
2) Sanguineous
3) Serosanguinous
4) Purulent

Answer 8

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

Question 9

Postop pain mgmt:
1) Who cannot use NSAIDs?
2) What can liver toxicity?
3) What should you Rx for nerve pain?

Answer 9

1) Pts with CAD, stroke, renal insufficiency and fractures.
2) Tylenol
3) Gabapentin/Lyrica

Question 10

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

Answer 10

Lidocaine, Marcaine, Bupivacaine

Question 11

What are some potential adverse effects of Hydromorphone (Dilaudid)?

Answer 11

Respiratory depression, hypotension, dizziness, somnolence, nausea

Question 12

Define postop fever

Answer 12

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

Question 13

What are the 5 W’s of postoperative fever?

Answer 13

Wind, water, wound, walk, wonder [about drug]

Question 14

List 3 Measures to provide protection from postoperative atelectasis

Answer 14

Lung expansion, early mobilization, and epidural analgesia

Question 15

How should you care for a wound in the operating room?

Answer 15

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

Question 16

Surgical Site Infection (SSI):
1) When do they occur?
2) What do they affect?

Answer 16

1) Within 30 days postop
2) Skin and subcutaneous tissue only

Question 17

Seromas:
1) What should you do if a large seroma (>75-100mL)?
2) What if minimal in volume?
2) What if chronic or if infection present?

Answer 17

1) Usually repeat aspiration.
2) Likely can be treated conservatively with observation.
3) Open surgical drainage and debridement

Question 18

What can you do for hematomas if concernedfor infection or a lack of improvement?

Answer 18

May remove a few sutures to let hematoma drain (+culture)

Question 19

Wound Dehiscence:
1) What causes it?
2) What is a concern when on the abdomen?
3) What is essential?

Answer 19

1) inadequate closure or issues such as malnutrition, steroid use, or DM
2) Concern for evisceration
3) Prompt identification

Question 20

What should you use for Stress Ulcer Prophylaxis in ICU?

Answer 20

PO PPI preferred (Pantoprazole most common)

Question 21

1) What should you ask abt every day? Why?
2) What is the main Sx of Postoperative Ileus?
3) What do you see on XR of postop ileus?

Answer 21

1) About N/V/D, gas, BMs.
-GI peristalsis returns within 24hrs after non-abd surgery (~48hrs after laparotomy)
2) Abd distention
3) Generalized dilatation and gaseous distention of small and large bowl

Question 22

What are the 3 types of hospital orders?

Answer 22

1) Admitting Orders: Use the mnemonic AD CAVA DIMPLS
2) Perioperative Orders
3) Transfer Orders

Question 23

What is the Admitting Orders mnemonic?

Answer 23

AD CAVA DIMPLS

Question 24

List the first half of the admitting orders mnemonic

Answer 24

A: admit (name of admitting physician, name of unit or floor)
D: diagnosis, procedure (if postop orders)
C: condition (stable, unstable, guarded, critical, morbid, comatose)
A: activity level (ie, OOB= out of bed, NWB, TTWB)
V: vital sign frequency
A: allergies (meds, food, others; response if exposed)

Question 25

List the second half of the admitting orders mnemonic

Answer 25

D: diet (ie, NPO; pg 157) I: I&Os (fluids, drains, NGT, foley, arterial lines, etc) M: medications (home vs inpatient, scheduled vs prn) P: procedures (wound care, ostomy care, etc) L: labs (shorthand on pg 176) S: special instructions

Question 26

Hospital notes; who writes the?: 1) Admission Note 2) Consult Note 3) Brief Operative Note (completed immediately after surgery) 4) Procedure Note (full, detailed report) 5) Progress Note

Answer 26

1) PA/MD/DO/NP 2) PA/MD/DO/NP 3) Usually PA 4) Usually surgeon 5) Surgeon or surgical PA/NP

Question 27

Step by step of a procedure is documented by who?

Answer 27

surgeon

Question 28

Discharge summary: 1) When is it required? 2) Who completes it?

Answer 28

1) Required after any hospital stay >24 hours (pg 194) 2) Completed by hospitalist or primary service taking care of patient