Surgical Oncology SubI – Discharge

Surgical Oncology SubI – Discharge

Click on the link or image below to read student reviews.

As I prepare for my surgery subI experience, I will keep a list of wonderful resources and things I learn along the way.

I came across AccessSurgery today. I didn’t even know it existed. It seems like a good resource. I came across it while looking for some free online atlases for surgery. They even have a board review/questions section.

http://www.accesssurgery.com/index.aspx

http://medicalpblukm.blogspot.com/2008/08/ethicon-suture-manuals.html This website has the link to downloadable suture manuals and knot tying document.

Below are links to SDN sites

http://forums.studentdoctor.net/archive/index.php/t-189749.html

http://forums.studentdoctor.net/archive/index.php/t-302514.html

http://forums.studentdoctor.net/showthread.php?t=534606

Ethicon Knot Tying Manual

http://www.mcg-2008.com/knot_tying_manual.pdf

You can call  1-80… (Ethicon) and ask for the following:Ethicon Knot Tying Board
Ethicon Knot Tying Manual
Ethicon Knot Tying Rope
They will ship these to you for free. This is the board that is shown in the above manual.

 

Other surgical skills sites:

http://www.edu.rcsed.ac.uk/video_album_clips_menu_basicskills.htm

If you have any advice for me, leave it below. Thanks!

 

Admit Orders

– Admit to level of care: Acute care (if after regular operation)

– Service: obvious

– Attending: attending on the operation

– First call provider/pager:  service pager, usually held by the intern

– Diagnosis/Operation performed: obvious

– Condition: Good, fair, or poor

– Code status: Most all of the patients are full code

– Allergies: Check their preop notes, or recently filled out forms for any listed allergies. This is very important.

– Check vital signs:  For acute or transitional care, you can check the vitals Q4H

– Call house officer for: 

HR >110, <55

BP > 180, <95

RR > 26, <10

T > 38.5, <36

O2 sat < 93%

UO < 30 ml/hour

Continuous cardiac monitoring: Do you need it?

Activity: Usually Walk TID is a good option.

Special precautions: Are there any? (seizure, neutropenic, aspiration, fall risk, respiratory, organism)

Smoking cessation counseling: Do they smoke?

Bedside care: Usually AM weights on admit, and daily if clinically indicated

Intake and Output: usually Q8H to start off

Bedside Care:  foley (if the patient is using an epidural, you need to keep the foley in; otherwise you can D/C the foley at midnight after the operation, and have the nurses call HO if patient has not urinated within 6 hours after the foley is removed), NGT, JP drains, chest tubes, compression stockings, blood glucose checks, wound care/dressing orders, other.

Oxygen: 0-6L adjust oxygen to keep > 92%

ICS

Does the patient need continous pulse oximetry? CPAP? BIPAP (IPAP, EPAP?), Other respiratory orders?

Intravenous fluids:

– Can start with D5 NS @ 125 ml/hr or D5LR @ 175ml/hr; but there are many different ways people start the fluids

Diet: Can the patient start off with a regular diet? Or do they need a special type of diet?

List of diet types:  regular, diabetic carb control  (1800,2000,2400 calories/day); renal, CRI/neutropenic, ice chips/sips for comfort not to exceed 100ml/8hrs; enteral tube feeding form, advance diet as tolerated, begin with…., patient may have food from home/outside; full liquid, soft, pureed, dysphagia, NPO except medications, TPN forms, clear liquid, low fiber, 2g sodium (cardiac), post-surgical, strict NPO.  (wow, what a long list!)

More to come…

—————————

Pre-rounding

– the morning after surgery, you should know what the patient’s urine output has been within the past 3-6 hours. Talk to the nurse to get the information on how they are doing fluid wise.

– know how much the patient’s drain has put out. Look at the drains yourself and add the volume you see to the volume that has already been recorded by the nurses. Is the JP drain to bulb suction or continuous suction?

– know what your patient is getting for prophylasis: ICS, SQH, TEDS, etcs.

– Know what your patient is getting for pain management: epidural, PCA, pain meds, etc.

– Know why the patient is having pain. Is it due to the incision or due to something else?

– know what antibiotic and abx day and the reason for the abx and the length of time you plan to give it to the patient

– Know if labs are pending, if they were ordered for this am, if you have to recheck them this afternoon, and if you have to write for labs for tomorrow am

– Know the patient’s labs and cultures

 

Rounds/Presentations/Orders

– Know the post operative date, and importantly, know what operation the patient had done

– replete electrolytes

– decrease their IVF if you’re advancing their diet and increasing their PO intake

– Is the patient hyponatremic? Consider fluid restriction (for example, to 1.5L/day) if clinically indicated

Progress Notes

– Only write the pertinent labs and abnormal labs; Other labs can be looked up by anyone

– Know what part of the body the drain is coming out of, why you have the drain there, and under what conditions you will pull the drain

– know when you should get a tube check for the drain

– check the patient’s wound, check to see if it’s infected, send it for culture if you have to, start abx if you suspect infection

– change dressings

– Are you doing wet to dry dressings? removing staples? etc. etc.

– Ins and outs

– does the patient have nausea? emesis? do they need NGT?

– IVF TKO or SLIV, etc. i.e. when to stop the IVF?

– follow up with any consult notes

– Do you need to do a 24 hour urine collection to determine the nitrogen balance of your patient?

– Have you calculated the total caloric needs of your patient and whether or not you are supplying them with that?

– Talk to the nurses and ask for their opinion, advice

– Who needs to be discharged today? You’ll have to fill out the discharge orders and medications; You’ll need a script for controlled medications.

– When should you take out the wound bag? When you do though, make sure to put guaze over it and tape around the circumference of the guaze

 

Random Notes

– always check the patient chart for admission forms

– If the patient has an abdominal infection after an abdominal surgery, the primary goal is to control the infection

– Most fistulas that develop after abdominal surgery will resolved on their own if they can’t see it.

– Enteral nutrition is preferable

– You should replete lytes on all patients.

 

Discharge

– Don’t D/C a patient’s PCA the day you plan to send them home. You should d/c it the day before so that you can they’re pain is managed well with oral medications.

Topics to review

– wide local excision

– right axillary sentinel node dissection

– inguinal lymph node dissection

– Abdominal partial gastrectomy

– calculation of caloric needs; Harris-Bennedict equation, using usual body weight

– abdominal liver wedge biopsy

 

What I learned from different folks

– The personality of surgeons is: They like to get things done; they like to cut.

Common Medications

Norco 10/325 1-2 po q6h prn pain #40

Colace 250mg #30 BID X 2 weeks

Vicodin 1-2 tabs po Q4h prn pain #50

 

How to help in the operating room

– Write the orders

– What exactly are you doing to include in your op note? You’re going to include the patient’s diagnosis, type of surgery, and specimens collected. You’re going to also need to know the names of the people who helped with the surgery.  You should also include whether the patient is being sent to the PACU, Ward, discharge from hospital, ICU, NICU, or other.

– You should know all of the patients home meds, including prn meds

 

Books I used for this rotation:

Hospitalist handbook by Shah

The Mont Reid Surgical Handbook 5th ed by Fisher and Kelly

The MD Anderson Surgical Oncology Handbook by Feig, Berger, Fuhrman  You should get the newest edition b/c recommendations change

Essentials of Surgical Oncology by Kaiser, Sabel, Sondak, Sussman. Very helpful.  ISBN 0-8151-4385-0

An Atlas of Surgical Oncology; Fundamental Procedures, volume 1 and 2. by Sugarbaker.  Very old book, but also helpful in helping you visualize what will happen in the OR

Color Atlas of Anatomy: A photographic study of the human body: 5th edition. By Rohen, Yokochi, Lutjen-Drecoll.  ISBN 0-7817-3194-1   (priceless book. It pretty much used this to review anatomy before each case. One of the best anatomy books I’ve come across.

Surgical Recall 4th edition by Blackbourne. This was a great quick read before each operation. It’s definitely wort it.

Surgery. 6th edition. Current Clinical Strateries; By Wilson. Also very good, short read.

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