General Surgery—Intro, Pre and Post Op Care with Geriatric ...



General Surgery—Intro, Pre and Post Op Care with Geriatric Considerations

Elective Surgical History – not an emergency

1) Identify location of pain and consider organs in that area (explore PQRST factors) – relate location of pain to associated underlying structures or organs. Consider possibility of referred pain from other locations. Utilize more sources for history in geriatric patients.

2) Explore associated symptoms – anemia, n/v, anorexia, change in bowel habits and/or appetite

3) Detection of comorbid disease – DM, HTN, seizure disorders, underlying coagulopathies

4) Document previous surgical procedures and explore past surgical history

5) Identify medications and allergy triggers – assess anesthesia risk, previous anesthesia reactions

6) Relate patient position at time of injury to trajectory path with penetrating injuries – may help anticipate underlying organ problems

Emergent Surgical History

A – Allergies

M – Medications, especially cardiovascular

P – Past medical history

L – Last meal/last BM

E – Events preceding the emergency (see above), such as LOC

Physical Exam of the Surgical Patient

Elective Physical Exam

1) Comprehensive physical exam from hair down to toes

Emergent Physical Exam

1) Stabilize vitals (BCLS/ACLS protocol)

2) Spinal cord assessment/protection – do not remove collar unless screening exams have been performed

3) “Survey exam” – consider not only area of trauma but the entire patient. Search for other exit and entry wounds (i.e. gunshot wound)

4) Life-threatening vs. limb threatening injury – patient may have both. Any life-threatening injury should be considered primary. Look for pulseless extremities

Risk Factors Associated with Surgical Procedures

Surgical Factors

1) Type of surgical procedure AND if elective or emergent – procedures directly involving the lung, heart, brain, kidney, and CNS are associated with a higher risk.

2) Consider complications peri and post-op – most common post-op complications are pulmonary. The procedure does not have to include the lungs. Patients with mid-line incisions (sternum to pelvis) and thoracotomy have a great amount of post-op pain. Longer operations cause greater derangements in pulmonary function, fluid and electrolyte disturbances

Anesthesia Factors

1) Local vs. general anesthesia – less risk with local anesthesia. General anesthesia is associated with intubation and mechanical ventilation, poising a greater risk.

2) Pulmonary complications (peri and post-op) – patients under anesthesia cannot cough or clear mucus. Sedation also suppresses respiratory drive, reduces tidal volume. Respiratory rate is controlled by the anesthesiologist and the ventilator.

3) Cardiac complications (peri and post-op)

Patient Factors

1) Age - >60 is associated with progressive decline in static lung volume

2) Underlying cardiac and/or pulmonary disease – previous MI ................
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