Surgery Postoperative Patient Care

Front 1

What is the normal heart rate and respiratory rate of a dog?

Back 1

HR: 60-130 beats per minute
RR: 10-40 / panting (can't count)

Front 2

What is the normal heart rate and respiratory rate of a cat?

Back 2

HR: 145-200
RR: 20-40, usually does not open mouth breathe

Front 3

Looking at the big picture, what are the 7 things you need to be checking to make sure your patient is stable?

Back 3

1) Cardiac/ respiratory/ vascular systems
2) Pain control
3) Skin/ incision care and protection
4) GI/ nutrition
5) Urinary care
6) Behavior (anxiety)
7) Skeletal/ neuromuscular (physical therapy, activity restriction)

Front 4

*What is the definition of shock?

Back 4

Decrease or loss of effective blood flow and oxygen delivery that does not meet the demand of tissues

Front 5

*What is the definition of pain?

Back 5

An unpleasant physical sensation and emotional experience associated w/ potential or actual tissue trauma

Front 6

Surgery often pushes patients to the limits and you will frequently encounter _____ and _____ postoperatively.

Back 6

Shock and pain

Front 7

Why is anesthesia the closest we can get to death?

Back 7

Pain is the last defense mechanism to go away, so anesthesia is the closest we get to death

Front 8

What are 8 clinical signs that indicate your patient is in trouble or isn't ready to leave the hospital?

Back 8

1) Syncope, collapse, unconscious, sedate or depressed
2) Difficulty breathing
3) Vomits/ can't keep food or water down
4) Painful (needs rescue IV pain meds)
5) can't (not won't) defecate/ urinate
6) Draining/ dehiscing wounds
7) Neurologic instability (progression of seizures, paralysis etc)
8) Orthopedic instability

Front 9

How often should you monitor oxygen/ventilation of a patient post-op?

Back 9

continuously or every 1-4 hours

Front 10

What are 3 clinical signs of inadequate oxygenation/ ventilation?

Back 10

1) Increased respiratory rate
2) Respiratory distress/dyspnea
3) Cyanosis (late sign)

Front 11

What are 2 causes of inspiratory distress?

Back 11

1) Upper airway obstdruction: nares, nasopharynx, pharynx, larynx, extrathoracic, trachea
2) Pleural space dysfunction: pneumothorax, hemothorax, pyothorax, chylothorax, diaphragmatic hernia

Front 12

What is a cause of expiratory distress?

Back 12

Obstruction at intrathoracic trachea, bronchi, bronchioles, alveoli

Front 13

What are 2 diagnostic tests you can perform to check ventilation/ oxygenation of your patient?

Back 13

1) Pulse oximetry: oxygen saturation should be 97-100%
2) Arterial blood gas analysis
-room air: PaO2 92-106 mmHg

Front 14

What are 2 ways to provide basic oxygenation?

Back 14

1) Oxygen supplementation
-oxygen E-collar: 1 L/min, nasal insufflation, oxygen cage
2) Ventilator

Front 15

What are 3 ways you can treat poor oxygenation due to upper airway problems?

Back 15

1) Anti-inflammatories (to reduce upper airway edema)
2) Sedatives
3) Bypass obstruction- endotracheal tube, tracheostomy tube

Front 16

What is a treatment for poor oxygenation due to lower airway issues?

Back 16

Bronchodilators

Front 17

What can you do to correct oxygenation due to pleural effusion?

Back 17

Thoracocentesis

Front 18

What are 3 upper airway diseases that are relevant to surgery?

Back 18

1) Brachycephalic syndrome
2) Laryngeal paralysis
3) Tracheal collapse

Front 19

What are 4 lower airway diseases relevant to surgery?

Back 19

1) Pulmonary cancer
2) Fungal infections
3) Lung torsion
4) Lung lobectomies

Front 20

What are 4 pleural diseases relevant to surgery?

Back 20

1) Vehicular trauma
2) Idiopathic pneumothorax
3) Chylothorax
4) Pyothorax

Front 21

What are the 20 components of Kirby's rule of 20 for critical care?

Back 21

1) Fluid balance
2) Blood pressure and perfusion
3) Cardiac function (rhythm, rate, contractility)
4) Albumin
5) Oncotic pull
6) Oxygenation/ ventilation
7) Glucose
8) Electrolyte and acid-base balance
9) Mentation/ intracranial pressure
10) Coagulation
11) RBC/ hemoglobin concentration
12) Renal function and urine output
13) Immune state, WBC and antibiotic coverage
14) GI motility and integrity
15) Drug metabolism and drug doses
16) Nutrition
17) Analgesia
18) Nursing care, patient mobility
19) Bandage and wound care
20) Tender loving care

Front 22

Perfusion of tissues depends on what 4 components?

Back 22

1) Heart rate
2) Heart contractility
3) Systemic vascular resistance
4) Blood volume

Front 23

What are 3 ways to monitor perfusion and blood pressure?

Back 23

1) Arterial catheterization
2) Dopplar
3) Oscillometric

Front 24

How often should you monitor blood pressure in a post-op patient?

Back 24

CONTINUOUSLY, HOURLY OR EVERY 4 HOURS

Front 25

What surgical disease can cause low blood pressure, poor tissue perfusion and therefore shock?

Back 25

Any surgical event or anesthetic

Front 26

What are 6 causes of low blood pressure?

Back 26

1) Dehydration
2) Hemorrhage
3) Sepsis
4) Trauma
5) Cancer
6) Infection

Front 27

What are 4 abnormalities that can occur with heart rate, rhythm and contractility post-op?

Back 27

1) Decreased contractility
-heart failure
2) Bradycardia
-opioids/sedatives
3) Tachycardia
4) Abnormal tachyarrhythmias

Front 28

What are 2 causes of tachycardia post-op?

Back 28

1) Pain: increased HR + increased BP
2) Shock: increased HR + low BP

Front 29

How often should you monitor heart rate, rhythm and contractility?

Back 29

MONITOR CONTINUOUSLY, HOURLY OR EVERY 4 HOURS

Front 30

What is the highest risk of premature ventricular contractions if left untreated?

Back 30

Can degenerate in to fatal rhythms such as ventricular fibrillation

Front 31

What are 5 causes/relevant surgical diseases that affect heart rate, contractility and rhythm?

Back 31

1) Splenic disease and surgery
2) Gastric dilatation and volvulus (bloat, GDV)
3) Vehicular trauma (traumatic myocarditis)
4) Pain/stress
5) Shock

Front 32

What are 3 clinical measure to check hydration

Back 32

1) Mucous membranes
2) Skin tent
3) Not detectable until 6% dehydrated

Front 33

How often should you perform the quantitative tests that measure the "ins" and "outs" of fluid balance?

Back 33

Every 4-6 hours

Front 34

What are 3 measurements that can be taken to quantitate fluid balance?

Back 34

1) PCV
2) Total solids (every 12-24 ours)
3) Central venous pressure (every 4-6 hours)

Front 35

How do you interpret fluid balance according to central venous pressure?

Back 35

Over-hydrated if above 10-30 cm H20
Dehydrated if below 1 or 0
-trends most important

Front 36

How much fluids should be given to a dog and cat for shock?

Back 36

Dog: 70-90mL/kg
Cat: 55-60 mL/kg

Front 37

How do you calculate the amount of fluids that need to be administered to a patient for fluid replacement?

Back 37

(% dehydration x gody weight (kg)) x 1000) + ongoing losses= replacement volume

Front 38

How much fluids should be given for maintenance?

Back 38

1 mL/ lb per hour

Front 39

What are the characteristics of replacement fluids?

Back 39

Resemble extracellular fluid composition and replace lost fluid

Front 40

What are 4 examples of replacement fluids?

Back 40

1) Lactated ringer's
2) Plasmalyte
3) Normosol-R
4) 0.9% normal saline

Front 41

What are the characteristics of maintenance fluids?

Back 41

Contain less sodium and more potassium

Front 42

When should you use maintenance fluids?

Back 42

Only if patient has normal (physiologic fluid loss)

Front 43

What are 2 types of fluid used for maintenance?

Back 43

1) Normosol-M
2) Plasmalyte-M

Front 44

You can discontinue fluid therapy when you see what 4 things?

Back 44

1) Stable blood pressure and other vitals
2) Eating on their own (usually drinking follows)
-cats may not eat well
3) Abnormal fluid loss has stopped (no bleeding, no excessive vomiting)
4) Able to urinate, maintain electrolytes and pH

Front 45

What are the relevant surgical diseases that can contribute to a loss of fluid balance?

Back 45

ANYTHING!!!!!!!

Front 46

What are 5 examples of relevant surgical diseases that can cause fluid imbalance?

Back 46

1) Evaporation (wounds!!!)
2) Excessive bleeding, salivation, vomiting, diarrhea
3) Loss of fluids/blood in to cavities (abdomen, chest, abscesses)
4) Loss of fluids due to 3rd spacing (edema, vasculitis)
5) Inadequate fluid intake

Front 47

Concentration of _____ and ______ in the cells, interstitium and plasma effects how much water is in each compartment.

Back 47

Na+ and protein

Front 48

What are 2 diagnostic tests that can be used to detect abnormalities in osmolarity or blood proteins/albumin?

Back 48

1) Blood colloid oncotic pressure
2) Can estimate from central venous pressure

Front 49

What are 2 treatments to correct abnormal osmolarity or blood proteins/albumin?

Back 49

1) Hetastarch
2) Plasma

Front 50

How much hetastarch do you administer to an animal that is in shock to correct the osmolarity and blood proteins/ albumin? How much for maintenance?

Back 50

Shock: 10-20 mL/kg over 20 min
Maintenance: 20 mL/kg/day

Front 51

How much plasma do you administer to raise the albumin levels?

Back 51

22.5mL/kg to raise albumin by 5 g/dL
-not always practical (big dose and expensive)
-also contains gamma globulins, macroglobulins, ATIII, coagulation proteins

Front 52

What is hetastarch?

Back 52

Special sugar that doesn't leave vessels for at least 24 hours, viscous- good oncotic pull

Front 53

The relevant surgical diseases that affect osmolarity and blood protein/ albumin levels is anything that causes what 3 things?

Back 53

1) Hypovolemia
2) Hyoalbuminemia
3) Reduce plasma oncotic pressure!!

Front 54

What are 2 causes of decreased albumin?

Back 54

1) Decreased production
2) Abnormal loss in the gut, urine, heorrhage, trauma, wounds, leaky vessels caused by vasculiits--> third spacing

Front 55

When you see spontaneous edema, you know that the albumin levels must be below _______.

Back 55

2.0 g/dL

Front 56

What are 2 diagnostic tests that can be ran to assess electrolytes and acid/base balance?

Back 56

1) Blood gas analysis
-every 6-24 hours
2) Serum chemistry (every 24 hours)

Front 57

What are the 4 abnormalities that may be detected on the serum chemistry of animals with electrolyte and/or acid base abnormalities?

Back 57

1) Metabolic acidosis
-Excess H+, low HCO3-
2) Respiratory acidosis
-Excess CO2
3) Metabolic alkalosis
-excess HCO3-
4) Respiratory alkalosis
-Low CO2

Front 58

What are 4 causes of metabolic acidosis?

Back 58

1) Shock
2) Poor perfusion
3) Diarrhea
4) Organic acids

Front 59

What should you do to treat metabolic acidosis?

Back 59

Provide hemodynamic and ventilatory support 1st before treating w/ bicarb!!!
-usually give fluids to increase perfusion

Front 60

What causes respiratory acidosis?

Back 60

Hypoventilation

Front 61

What causes metabolic alkalosis?

Back 61

Vomiting

Front 62

What causes respiratory alkalosis?

Back 62

Hyperventilation

Front 63

What are 5 relevant surgical diseases that a cause an increase in Na+ levels?

Back 63

1) Loss of free water
2) Water deprivation
3) Fever
4) Burns
5) Heatstroke

Front 64

What are 5 relevant surgical diseases that cause a decrease in sodium levels?

Back 64

1) Diarrhea
2) Vomiting
3) Anesthesia
4) Burns
5) ADH release secondary to anesthesia, stress & pain, and sepsis

Front 65

What are 5 surgically relevant diseases that can cause in increase in K+?

Back 65

1) Urinary obstruction
2) Ruptured bladder
3) Acute renal failure
4) Massive tissue necrosis
5) Hemolysis

Front 66

What are 3 clinically relevant diseases that cause decreased K+?

Back 66

1) Anorexia
2) Vomiting
3) Diarrhea

Front 67

What are 2 surgically relevant diseases that cause an increase in calcium?

Back 67

1) Paraneoplastic syndromes
2) Hyperparathyroidism

Front 68

What are 3 surgically relevant diseases that cause decreased calcium levels?

Back 68

1) Eclampsia
-little dog w/ giant puppies
2) Sepsis
3) Low magnesium

Front 69

What are 2 surgically relevant diseases that cause an increase in glucose?

Back 69

1) Diabetes
2) Stress

Front 70

What are 5 surgically relevant diseases that cause a decrease in glucose?

Back 70

1) Anorexic puppies
2) Sepsis
3) Neoplasia
4) Malnutrition
5) Liver failure

Front 71

When trying to diagnose coagulation or RBC/hemoglobin issues in a post-op patient what 2 components of hemostasis should you examine? What are some tests to check each parameter?

Back 71

1) Coagulation/clotting ability
-PT/PTT/FDPs
-ACT
-platelet count
-Buccal mucosal bleeding time
2) RBC and hemoglobin concentration
-PCV
-Hemoglobin concentration

Front 72

What are 4 types of solutions used for plasma transfusions?

Back 72

1) Fresh frozen plasma
2) Frozen plasma (older than 1 year)
3) Platelet rich (pRBCs?)
4) Cryoprecipitate

Front 73

What does frozen plasma lack?

Back 73

Poor in factors V and VII

Front 74

What are the advantages of cryoprecipitate for plasma transfusions?

Back 74

Higher in factors VIII and vWF

Front 75

When do you want to give a patient a plasma transfusion?

Back 75

Patients w/ hypoproteinemia or coagulopathies
-severe infectious/ inflammatory diseases (septic abdomen)

Front 76

What should you do PRE-OP in a patient that may need a blood transfusion?

Back 76

Cross match POST-OP

Front 77

How much blood can a healthy animal lose without problems?

Back 77

1% of BW in HEALTHY animal

Front 78

You should give an animal a blood transfusion if acute blood loss results in what 5 things?

Back 78

1) Loss of 20% of blood volume
2) PCV less than 20%
3) Signs of hypoxia
4) Hypoperfusion/shock
5) Anticipation of further bleeding

Front 79

What are 4 uses of blood transfusions w/ whole mblood?

Back 79

Anemia, acute bleeding, coagulopathy, shock

Front 80

What are 2 uses for a transfusion w/ packed RBCs?

Back 80

Anemia
Hemorrhage

Front 81

Surgerically relevant diseases that affect coagulation and RBC/hemoglobin is everything, but what are 6 cases that were given as examples?

Back 81

1) Dobies w/ von willebrands
2) Trauma or surgically induced hemorrhage
3) Splenic, adrenal, renal and hepatic surgery
4) Tumor resectios
5) Fractures/osteotomies
6) Cases in DIC

Front 82

What is the normal urine output of an animal?

Back 82

1 mL/kg/ hr
-check hourly to every 8 hours

Front 83

What are the 3 general causes of decreased urine output?

Back 83

Pre-renal
Renal
Post-renal

Front 84

Why do you need to monitor urine output of animals that are neuro patients or patients on IV opioids very closely?

Back 84

Because w/ opioids they can't relax the sphincter to pee so "urination" may be overflow incontinence, can cause atony or UTIs

Front 85

What are 2 ways to make sure that an animal urinates?

Back 85

Bladder expression
Urinary catheter

Front 86

What are 3 medications that can help an animal urinate?

Back 86

1) Phenoxybenzamine, prazosin
-relaxes internal bladder sphincter
2) Valium
-relaxes external bladder sphincter
3) Bethanecol
-causes bladder contraction

Front 87

What two diseases should you rule out first when an animal has decrease urine output?

Back 87

1) Dehydration
2) Opioid urine retention

Front 88

What are 6 types of patients/ surgical diseases that you should monitor closely for urine output?

Back 88

1) Critical patients
2) Any patient getting IV opioids, especially morphine
3) Ortho
4) Neuro
5) Genitourinary
6) Trauma

Front 89

How often should you check an incision post- op to reassure the immune status of the patient?

Back 89

Every 8-12 hours

Front 90

What are 6 signs that are evidence of infection?

Back 90

1) Fever
2) Anorexia
3) Edema
4) Swelling
5) Pain
6) Purulent drainage production

Front 91

What are two ways you can use laboratory data to detect infection?

Back 91

1) Differential WBC count
2) Culture and sensitivity

Front 92

What animals should receive antibiotics after surgery?

Back 92

Only use when treating an active infection

Front 93

What are 3 situations where you should give IV antibiotics post-op?

Back 93

1) Catastrophic infections
e.g. septic abdomen or joint, infected incision
2) Life threatening infections
3) aggressive treatment required

Front 94

When should you administer oral antibiotics post-op?

Back 94

For stable patient able to have oral intake

Front 95

When do you use perioperative prophylactic antibiotics?

Back 95

When there is no infection, only covering the patient for potential contamination during surgery

Front 96

What are 8 surgical diseases that are relevant to immune status/ antibiotics?

Back 96

1) Contaminated surgeries
2) Active infections
3) Pyometra
4) Prostatic abscesses
5) Septic cavities
-joint, abdomen, pyothorax
6) Skin/incisional infections
7) Abscesses
8) Contaminated wounds

Front 97

Nutrition is critical to _____ and _______ post-op.

Back 97

Wound healing and immune function

Front 98

**When should you intervene with nutrition in a post-op patient?

Back 98

If there is anorexia greater than 1 day

Front 99

What are 2 ways that anorexia negatively impacts the body?

Back 99

Contributes to ileus and bacterial translocation

Front 100

What are 3 situations in which you should expect anorexia?

Back 100

1) Abdominal surgery/ GI procedures
2) Palate defects
3) Exotics

Front 101

What are 2 different feeding techniques used on anorexic animals?

Back 101

1) Enteral
-per os, nasoesophageal tube, pharyngostomy tube, esophagostomy tube, gastrostomy tube, jejunostomy tube
2) Parenteral
-IV partial or complete nutrition

Front 102

What are 3 types of medications that can be used to ensure GI integrity?

Back 102

1) H2 blockers, proton pump inhibitors, coating agents
2) Prokinetics (metoclopramide)
3) Anti-emetic/ anti-nausea
-Cerenia

Front 103

How often should you check a post-op patient for adequate analgesia?

Back 103

continuously or every 4 hours

Front 104

What are 4 types of drugs used to provide analgesia post-op?

Back 104

1) Opioids
2) NSAIDs
3) Local blocks
-epidural injection
-catheters
4) Other drugs: ketamine, gabapentin

Front 105

What are 3 types of adjunctive therapies that can be used for analgesia post-op?

Back 105

1) Cold packing w/ pressure
2) Acupuncture
3) Massage

Front 106

What should you rule out before treating an animal for anxiety post operatively?

Back 106

Pain and full bladder!!!
-Opioids cause urinary retention
-Potty trained dogs become distressed if they need to go out

Front 107

To treat an anxious patient you can sedate then every _______ hours.

Back 107

6-12 hours

Front 108

Is the incision routinely cleaned and have salves applied?

Back 108

No, usually not necessary

Front 109

What are 3 ways to provide incision protection?

Back 109

1) Bandages
2) E-collar
3) Foot booties/ t-shirts

Front 110

How often should you check the incision for infection?

Back 110

2-3 times daily
-look for redness, swelling, pain, discharge

Front 111

When are skin staples or stitches usually removed?

Back 111

10-14 days (dogs)
14 days (cats)

Front 112

How often should you turn patients post-op to prevent sores and atelectasis?

Back 112

Every 4-6 hours

Front 113

How can you provide IV catheter care to patients?

Back 113

Swab the catheter site and change bandages daily

Front 114

What are 2 things to keep in mind when a urinary catheter is in place?

Back 114

1) Douche genitalia every 6 hours w/ 0.05% chlorehexidine solution
2) Prevent urine from running back into patient

Front 115

How should you treat fecal rash?

Back 115

Gentle cleaning and A&D diaper ointment

Front 116

What has the biggest impact on patient recovery?

Back 116

Nursing care and TLC

Front 117

What are 2 ways to check metabolic function before administering medications?

Back 117

1) Liver function tests
-Glucose
-BUN
-Albumin
-Cholesterol
-Bile acids
2) Renal function tests
-urine specific gravity
-BUN

Front 118

What are 2 classes of drugs used for pain control of post-op patients?

Back 118

1) Opioids
-fentanyl, hydromorphone, morphine, buprenorphine
2) NSAIDs

Front 119

**When should NSAIDs not be used for pain control post-op?

Back 119

in trauma cases, hypotension, post recent shock, G,I, renal or liver disease, coagulopathies
DO NOT GIVE W/ STEROIDS OR MIX NSAIDS

Front 120

How long should pain medication be administered post-op for orthopedic surgeries?

Back 120

10-14 days

Front 121

Why shouldn't NSAIDs be given long term post-op for orthopedic surgery?

Back 121

NSAIDs slow bone healing if given long term

Front 122

What is the postoperative strict rest requirement?

Back 122

-no off leash activity
-in a crate
-outside just to potty
-No running, leaping, playing
-sling walk
-sedation if necessary

Front 123

What is the average recovery time for bone? tendinous repairs? Joint replacements? Joint fusions?

Back 123

Bone: 2-3 months
Tendinous: 4-6 weeks
Joint replacement: 3 months
Joint fusions: 2-4 months

Front 124

When do you recheck films for orthopedic surgery?

Back 124

at 8 weeks

Front 125

What are 6 signs that your patient is ready to go home?

Back 125

1) All vital signs (BP, TPR) are normal and stable
2) Eating spontaneously and able to to keep food down
3) Able to urinate completely
-neuro patients
4) Comfortable on oral pain medications
5) Incision not bleeding or dripping fluid
6) Incisional swelling has plateaued or is improving

Front 126

Owners are often obsessed w/ a pet's defecation status, how important is this post-op?

Back 126

In dogs and cats defecation is not usually that critical