Term
| removal, excision, resection |
|
Definition
|
|
Term
| surgical repair, surgical correction |
|
Definition
|
|
Term
| process of visual examination |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
| an agent such a heat, radiation, or a chemical that disinfects by destroying, neutralizing, or inhibiting the growth of disease-carrying microorganisms |
|
Definition
|
|
Term
| destruction of pathogenic organisms to prevent infection. Processes, procedures, or chemical treatments that kill or inhibit microorganisms to prevent infection |
|
Definition
|
|
Term
| the state of being without contamination or other microorganisms. Not producing microorganisms or free from microorganisms. |
|
Definition
|
|
Term
| preventing bacteria from growing and multiplying but possibly not killing them |
|
Definition
|
|
Term
| an agent that destroys bacteria |
|
Definition
|
|
Term
|
Definition
front of gown from collarbone to waist
gloved hands
arms to the shoulders
draped part of the pt down to the tabletop
covered part of the Mayo stand
top of the back table (instruments are kept here) |
|
|
Term
| anything that falls __________ is considered contaminated |
|
Definition
| below the level of the tabletop |
|
|
Term
| purpose of the surgical hand scrub |
|
Definition
| to decrease bacterial skin flora via mechanical cleansing of the arms and hands prior to the surgical procedure |
|
|
Term
| what is the needed contact time of the scrub solution in order to be effective. |
|
Definition
|
|
Term
| procedure to reduce medical errors while preparing the pt |
|
Definition
read the surgical permit aloud
clearly identify the patient
clearly identify the operation
clearly identify the site of operation |
|
|
Term
| your job as a student in the OR |
|
Definition
| wait patiently, out of the way, with hands held above your waist. Do not cross your arms. Remember the sterile areas on your body. |
|
|
Term
| this set of guidelines was established by the CDC to decrease the risk of blood-borne infections. Underlying principle is to treat all pts as if they are infected. |
|
Definition
|
|
Term
| surgeon who has completed their general surgical training and have elected to obtain more specialized training to become a surgical specialist. |
|
Definition
|
|
Term
| physician who has completed at least one year of residency, can last for 3-7 years |
|
Definition
|
|
Term
| physician who has completed medical school and is in the first year of residency. Has a medical degree but not license |
|
Definition
|
|
Term
| this person is responsible for all legal documentation in the OR, what degree must they have? |
|
Definition
| circulating nurse, must be an RN |
|
|
Term
| who is responsible for the collection and counting of all needles, sponges, etc, at the end of the procedure |
|
Definition
|
|
Term
| what is the order of nerve blockage in anesthesia |
|
Definition
first = autonomic
second = sensory
last = motor |
|
|
Term
| pts are deeply sedated, likely amnestic but can still respond to vocal and noxious stimuli |
|
Definition
MAC - monitored anesthesia care
most common agent = propofol |
|
|
Term
| inhaled agent suitable for outpt surgery |
|
Definition
|
|
Term
| why are opioids used in anesthesia? |
|
Definition
produce profund analgesia and minimal cardiac depression.
to reduce the MAC of potent inhaled agents. |
|
|
Term
| only depolarizing agent in use today |
|
Definition
|
|
Term
|
Definition
| hyperkalemia, malignant hyperthermia |
|
|
Term
| SE of local anesthesia that is concerning |
|
Definition
| oral numbeness (often first sign of systemic absorption) |
|
|
Term
| what can be added to a local anesthetic to increase the percent of nonionized anesthetic --> accelerated penetration of the drug |
|
Definition
|
|
Term
| this can be added to local anesthetics to aid in vasoconstriction --> decreased systemic absorption, increased duration of action |
|
Definition
|
|
Term
| when should epi not be added to a local anesthetic? |
|
Definition
| fingers, toes, penis, nose |
|
|
Term
| reversal agent for benzos |
|
Definition
|
|
Term
| reversal agent for narcotics |
|
Definition
|
|
Term
|
Definition
| sudden return of severe pain --> HTN, stroke, tachycardia, arrhythmia, CHF, cardiac arrest |
|
|
Term
| pneumonic for admission orders |
|
Definition
ADVAANDIMSLC
Admit to
Dx
VS
Allergies
Activity
Nursing Orders - wound care, weights, I&O, etc
Diet
IV fluids - type, rate, time
Medications - med, route, dose
Studies - CXR, EKG, PFT, etc
Labs
Call MD |
|
|
Term
| surgical history pneumonic |
|
Definition
AMPLE
Allergies
Medications
PM/surgical Hx (relavent)
Last oral intake
Events leading up to problem |
|
|
Term
| pneumonic for daily progress note |
|
Definition
SOAP
Subjective
Objective
Assessment
Plan |
|
|
Term
| decision to proceed with an operative procedure is based on |
|
Definition
| analysis of the risk-benefit ratio |
|
|
Term
|
Definition
determine the dz and if surgery is needed.
recognize co-morbidities
develop a relationship with the pt. |
|
|
Term
| surgery cannot proceed without this in a patient's chart |
|
Definition
|
|
Term
| persons who make decisions when a patient cannot speak for themselves |
|
Definition
| surrogate decision makers |
|
|
Term
| legal document to inform health care providers about the pt's wishes regarding the level of care to be delivered when the pt is unable to do so |
|
Definition
|
|
Term
| elements of the "surgical" social hx |
|
Definition
| tobacco, ETOH (prevent DT's), drug use |
|
|
Term
| how long should coumadin be stopped before surgery? |
|
Definition
|
|
Term
| how long should ASA be stopped prior to surgery? |
|
Definition
|
|
Term
| what may lessen the risk of surgery |
|
Definition
| pre-operative intervention |
|
|
Term
|
Definition
smoking (8 pack/yr increases risk 2-6 fold)
asthma
obesity
COPD
malnutrition |
|
|
Term
| pulmonary changes usually return to baseline within ________ of surgery |
|
Definition
|
|
Term
| minimal fasting period for clear liquids |
|
Definition
|
|
Term
| minimum fasting period for solids and nonclear liquids (milk or OJ) |
|
Definition
|
|
Term
| most common cause of post-op morbidity |
|
Definition
|
|
Term
| 2 physiologic changes that create stress on the myocardium |
|
Definition
catecholamine surge resulting from anxiety about procedure or pain from procedure.
Vasoconstriction from receptor stimulation --> suppression of the fibrinolytic system --> thrombosis. |
|
|
Term
| how long should you wait after an MI for elective procedures? |
|
Definition
|
|
Term
| what impact does a + H/O unstable angina have on surgery? |
|
Definition
| should avoid surgery except CABG |
|
|
Term
| diabetes risks with surgery |
|
Definition
derangements in blood sugar (maintain BS between 150-200 mg/dL to avoid hypoglycemia).
CV complications (increase with age and duration of DM).
Increased risk of infection (decreased immune function and vascular disease). |
|
|
Term
| hyperthyroidism risks with surgery |
|
Definition
| increased risk of thyroid storm, arrhythmias (A-Fib) |
|
|
Term
| what criteria is used to classify hepatic risks with surgery? |
|
Definition
Child Pugh Criteria
Class A: mortality < 10%
Class B: mortality = 40%
Class C: mortality > 80% |
|
|
Term
| when do alcohol withdraws occur? when do they peak? |
|
Definition
occur in 1-5 days.
peak in 3 days. |
|
|
Term
| what is the "cocktail" for alcoholic pts? |
|
Definition
| vitamins, thiamine, folate |
|
|
Term
|
Definition
|
|
Term
| when can acute adrenal insufficiency be seen? how is it treated? |
|
Definition
pts on steroids > 5 days
tx = supplemental steroids so the pt can stand the stress of surgery |
|
|
Term
| malnutrition complications with surgery |
|
Definition
| decreased healing, infection, increased pulmonary complications |
|
|
Term
| surgery precautions with renal disease |
|
Definition
ESRD = consult nephrology first!
DO NOT access dialysis catheters
fluid balance is critical
avoid K+ in IV fluids
use "renal dose" with abx |
|
|
Term
| when is prophylactic abx therapy initiated? |
|
Definition
|
|
Term
| when should bacterial prophylaxis be used for surgery? |
|
Definition
| only when there is a high likelihood of bacterial contamination |
|
|
Term
| indications for abx prophylaxis |
|
Definition
| high risk GI procedures (biliary procedures, colon/small intestine resection), cardiac surg via median sternotomy, vascular surgery (lower extremity or aorta), amputation for ischemia, hysterectomy, c-section, head/neck procedures, craniotomies, prosthetic implants, trauma, gross contamination |
|
|
Term
| abx used for prophylaxis when anaerobic flora is NOT suspected |
|
Definition
|
|
Term
| abx used for prophylaxis with suspected colonic anaerobes or bacteroides |
|
Definition
|
|
Term
| abx used for prophylaxis with colonic surgery |
|
Definition
| nichols prep: neomycin, erythromycin |
|
|
Term
| rules for abx prophylaxis |
|
Definition
| must be given in tme to reach adequate tissue levels before contamination, adequate levels must be maintained throughout surgery |
|
|
Term
| antibiotics are not effective with continuing contamination such as: (3) |
|
Definition
| tracheostomy, indwelling catheters, burns |
|
|
Term
|
Definition
| elimination of dead space, even distribution of tension along suture lines, maintain tensile strength along the wound until tissue tensile strength is adequate, approximate and evert the epithelial area of the closure |
|
|
Term
|
Definition
| easy to handle, minimal reaction in tussie, inhibits bacterial growth, hold securely when knotted, resist shrinking in tissue, non-capillary, non-allergenic, non-carcinogenic, non-ferromagnetic, absorbs with minimal reaction after tissue has healed |
|
|
Term
|
Definition
| chromic catgut, vicryl, dexon simlar, PDA, monocryl |
|
|
Term
|
Definition
| silk-braided, nylon monofilament, prolene monofilament, polypropylene, braided synthetic polyesters (mersilene, ethibond), steel wire |
|
|
Term
suture size used in different places:
face
scalp
trunk & extremities
deep tissues |
|
Definition
face = 5-0, 6-0 nylon or polypropylene
scalp = 3-0 nylon or polypropylene, or staples
trunk & extremities: 4-0, 5-0 nylon or polypropylene
deep tissues: 3-0, 4-0 absorbable sutures (dexon, vicryl) |
|
|
Term
| advantages of monofilament sutures |
|
Definition
| less tissue drag, don't have interstices that may harbor bacteria |
|
|
Term
| advantages of multifilament sutures |
|
Definition
more pliable and flexible than monofilament sutures.
results in considerably better knot holding security. |
|
|
Term
| why are multifilament sutures coated? |
|
Definition
|
|
Term
|
Definition
| process by which fluid and bacteria are carried into the interstices of multifilament fibers |
|
|
Term
| where should capillary sutures not be used? |
|
Definition
| contaminated or infected sites. |
|
|
Term
| what can help decrease suture stract epitheliazation? |
|
Definition
| using a topical antibiotic (polysporin) |
|
|
Term
| what is the relationship between time a suture is in place and scarring? |
|
Definition
| the longer a suture is in place, the more it scars |
|
|
Term
| when are face/neck sutures removed? |
|
Definition
|
|
Term
| when are scalp/body sutures removed? |
|
Definition
|
|
Term
| when are extremity sutures removed? |
|
Definition
|
|
Term
| how is total body water distributed? |
|
Definition
2/3 = intracellular
1/3 = extracellular
85% venous, 15% arterial |
|
|
Term
| what is the average amount of Total Body Volume for an adult? |
|
Definition
|
|
Term
| what is hydrostatic pressure? |
|
Definition
| "out" pressure, maintained by systemic BP |
|
|
Term
| what is oncotic pressure? |
|
Definition
| "in" pressure, maintained due to impermeability of capillary walls to protein. |
|
|
Term
| major determinant of capillary oncotic pressure |
|
Definition
|
|
Term
| receptors that help to maintain homeostasis by triggering fluid shifts |
|
Definition
arterial/renal baroreceptors, atrial stretch receptors (sense change in circulating volume).
Macula densa in kidney (sense change in Na+ concentration).
osmoreceptors in brain/liver (sense shifts in plasma osmolality) |
|
|
Term
|
Definition
atrial natriuretic factor
adrenotrophic hormone
growth hormone
vasopressin
renin/angiotensin
epinephrine
beta-endorphins |
|
|
Term
|
Definition
| decrease in total body water, loss>intake |
|
|
Term
| what is the average insensible loss/day? via what? |
|
Definition
750-1000ml
vapor from lungs, skin, etc. |
|
|
Term
| what is included in sensible losses? |
|
Definition
| stool (diarrhea), urine (diuretics), sweat (heat, fever, exercise), bodily fluids (drains) |
|
|
Term
| is a pathologic space, fluid "hides" in tissues & cavities due to increased capillary permeablity (capillary leak) |
|
Definition
|
|
Term
| what is third spacing stimulated by? |
|
Definition
| injury/inflammatory response (trauma, major sugery, intra-abd infections) |
|
|
Term
| preferred fluid replacement in "third spacing" |
|
Definition
crystalloid solutions (NS, LR).
fluids must be replaced even with increasing interstitial fluid (IF) & TBW |
|
|
Term
| failure to replace and maintain adequate fluid volume leads to what? |
|
Definition
| tissue ischemia and necrosis from decreased volume and decreased oxygen delivery |
|
|
Term
| fluid used as a volume expander for short term use |
|
Definition
|
|
Term
| fluid used to provide sustained volume expansion for acute, severe hemorrhage and large volume loss |
|
Definition
|
|
Term
| only fluid choice during resuscitation |
|
Definition
|
|
Term
| why should dextrose be avoided in aggressive resuscitation? |
|
Definition
| body doesn't utilize dextrose during times of severe stress. Hyperglycemia will result which can lead to an osmotic diuresis. |
|
|
Term
| used for maintenance fluid in a 70kg man |
|
Definition
| D5 1/4NS with 20mEq KCl @125cc/hr |
|
|
Term
| used for maintenance fluids in a peds pt |
|
Definition
|
|
Term
| extracellular cations and anions |
|
Definition
cations = Na, K, Ca, Mg
anions = Cl, HCO3, proteins, sulfates, organic acids |
|
|
Term
| intracellular cations and anions |
|
Definition
cations = K, Mg
anions = phosphates (PO4), Sulfates (SO4), proteins |
|
|
Term
|
Definition
<136mEq/L Hypo-osmotic
hypovolemic = GI loss, burns, renal dz, diuretics.
euvolemic = polydipsia, SIADH, decreased renal function, adrenal insufficiency, isotonic replacement of fluid losses.
Hyperostmotic: hypertonic infusion, hyperglycemia, mannitol infusion.
Isosmotic: pseudohyponatremia (increased lipids, increased protein) |
|
|
Term
| symptoms of hyponatremia at 120-130mEq/L |
|
Definition
| apathy, confusion, lethary, anorexia, nausea, muscle twitching, hyperactive DTR's |
|
|
Term
| sxs of hyponatremia <120mEq/L |
|
Definition
| convulsions, loss of reflexes, coma, death |
|
|
Term
| treatment of hyponatremia |
|
Definition
| ID cause, calculate defecit, correct slowly |
|
|
Term
|
Definition
> 146mEq/L
hypovolemia: GI loss, diaphoresis, burns, diuretics, glycosuria, mannitol, ARF, CRF.
isovolemia: DI, hypodipsia
hypervolemia: iatrogenic, Cushing dz |
|
|
Term
|
Definition
| dry mucous membranes, lethargy, restless, twitching, ataxia, seizure, delirium, stroke |
|
|
Term
|
Definition
>5.0mEq/L
impaired excretion (renal failure, mineralocorticoid insufficiency), drugs (NSAIDs, K+ sparing diuretics, ACEIs), pseudohyperkalemia (hemolysis), acidosis (DKA), hypocalcemia, insulin deficiency, massive tissue destruction (compartment syndrome), rhabdomyolysis (crush injury) |
|
|
Term
|
Definition
>5.5mEq/L
N/V/D, ECG changes, heart block, arrest |
|
|
Term
| treatment of hyperkalemia |
|
Definition
ECG changes = IV calcium
glucose/insulin infusion
kayexalate
loop diuretics
dialysis |
|
|
Term
|
Definition
<3.0mEq/L
excessive loss from kidneys, GI losses (V/D), trancellular shifts (alkalosis) |
|
|
Term
|
Definition
| vomiting, constipation, ileus, ECG changes, weakness, hyporeflexia, confusion |
|
|
Term
|
Definition
| ID underlying cause, PO replacement has rapid onset (preferred), slow IV replacement, reverse hypomagnesemia |
|
|
Term
| preferred route of replacement in hypokalemia |
|
Definition
| PO - it has a more rapid onset |
|
|
Term
|
Definition
>10.4mEq/dL
primary hyperparathyroidism, malignancy, vitamin D excess, thiazides |
|
|
Term
|
Definition
| fatigue, N/V, constipaton, lethargy, arrhythmias |
|
|
Term
| treatment of hypercalcemia |
|
Definition
| aggressive hydration, bisphosphonates, calcitonin, dialysis |
|
|
Term
|
Definition
<8.4 mg/dL
hypoparathyroidism, CRF, vit D deficiency, liver disease, drugs |
|
|
Term
|
Definition
| Chvostek sign, Trousseau sign, mental status changes, convulsions, arrhythmias |
|
|
Term
|
Definition
| parenteral supplementation |
|
|
Term
|
Definition
|
|
Term
|
Definition
| some asx. In conjucntion with hypocalcemia --> tetany |
|
|
Term
| treatment of hyperphosphatemia |
|
Definition
| aggressive hydration, calcium carbonate, aluminum based antacids, dialysis |
|
|
Term
|
Definition
<2.5 mg/dL
inadequate intake, excess loss (burns), hyperparathyroidism |
|
|
Term
|
Definition
| weak, fatigue, rhabdo, cardiomyopathy, obtunded, seizures |
|
|
Term
| treatment of hypophosphatemia |
|
Definition
| IV sodium or PO4, dairy products |
|
|
Term
|
Definition
>2.9 mg/dL
RF, acidosis, adrenal insufficiency, antacids |
|
|
Term
|
Definition
| N/V, weak, fatgue, loss of DTRs, bradycardia, hypotension |
|
|
Term
| treatment of hypermagnesemia |
|
Definition
| calcium gluconate, IV saline, loop diuretics |
|
|
Term
|
Definition
<1.8 mg/dL
inadequate intake, malabsorption, diuretics, SIADH, DKA |
|
|
Term
|
Definition
| anorexia, N/V, weak, confused, tetany, seizurse, psychosis, delirium |
|
|
Term
| treatment of hypomagnesemia |
|
Definition
| MgSO4 parenterally, Milk of Magnesia (MOM), mag hydroxide |
|
|
Term
| caused by an underlyng anatomic or mechanical problem which must be addressed to be cured. Not cured by antibiotics alone |
|
Definition
|
|
Term
| what is of utmost important with post-op infections? |
|
Definition
|
|
Term
| treatment for gram + post-op infections (5) |
|
Definition
| cefotazime, ceftizoxime, ceftriaxone, ceftrazadime, aztreonam |
|
|
Term
| treatment of gram - post-op infections |
|
Definition
| gentamycin, tobramycin, amikacin, flouroquinalones |
|
|
Term
| SE of gentamycin and tobramycin |
|
Definition
|
|
Term
|
Definition
| achilles tendon rupture, don't give < 18 yo |
|
|
Term
| treatment of anaerobic post-op infections (3) |
|
Definition
| clindamycin, metronidazole, chloramphenicol (lots of SE) |
|
|
Term
| post op infection days 1-3 |
|
Definition
|
|
Term
| dx and tx of necrotizing soft tissue |
|
Definition
dx: STAT gram stain and wound culture
tx = PCN G + clindamycin ( clostridia)
1st generation cephalosporin (non-clostridia) |
|
|
Term
| post op infection 5 days post op |
|
Definition
| superficial wound with purulent drainage, erythema, fever |
|
|
Term
| MC organisms for superficial wound infection above the waist? axillae? below the waist? |
|
Definition
above the waist = staph aureus, strep
axillae = prominant gram - bacteria
below the waist = mixed aerobic/ anaerobic gram - flora |
|
|
Term
| tx of intraabdominal wounds |
|
Definition
| braod spectrum systemic abx: ampicilln, gentamycin, clindamycin, unasyn, piperacillni, etc. and FIX the problem |
|
|
Term
| when can you d/c abx after post-op infection? |
|
Definition
| if pt is afebrile x 48 hrs d/c therapy or cahnge to PO rx for 7-10d |
|
|
Term
| risks inherent to surgery |
|
Definition
| bleeding, infection, pulmonary complications, DVT's, etc |
|
|
Term
| significant co-morbid illness for surgery |
|
Definition
| DM, heart failure, COPD, etc |
|
|
Term
| cause of post-op fever in first 24 hrs |
|
Definition
| may be normal response to surgical trauma |
|
|
Term
common superficial wound infection:
early
late |
|
Definition
early = necrotizing soft tissue
late (5-10d) = superficial abscess |
|
|
Term
| 5 W's of post-op wound care |
|
Definition
Wound infection
Wind - atelectasis, aspiration
Water - UTI
Walk - DVT
Weird drugs/What did we do? (if fever think transfusion related or drug related esp PCN and derivatives) |
|
|
Term
| return of normal GI propulsion post-op |
|
Definition
small bowel = first
stomach = 24-48 hrs
colon activity = 48 hrs |
|
|
Term
| how long is a pt NPO after surgery? |
|
Definition
| until bowel sounds are auscultated and pt passes flatus |
|
|
Term
|
Definition
| usually resolves spontaneously, may need to pass an NG tube |
|
|
Term
| partial or total disruption of any/all layers of post-op wound: early, late |
|
Definition
early = wound dehiscence
late = incisional hernia |
|
|
Term
| collection of liquified fat, serum, and lymphatic fluid, often opened or aspirated |
|
Definition
|
|
Term
| a collection of blood, usually in the subcutaneous layer of recent incision |
|
Definition
|
|
Term
| type of closure when wound edges are opposed and closed by either sutures, clips, tapes, or dermal adhesives immediately |
|
Definition
|
|
Term
| 2 possible methods used for permanent closure |
|
Definition
| running or interrupted sutures |
|
|
Term
| type of closure typically used for GI reapir and closure and external skin/scalp repair |
|
Definition
|
|
Term
| used for closure of non-tension wounds or as an adjunt to reinforce and provide a watertight seal |
|
Definition
|
|
Term
| method of closure when wound edges are left unopposed |
|
Definition
|
|
Term
| method of closure used for contaminated wounds, may initially be treated by repeated debridement or antibiotics for several days to prevent infection, closure is completed after several days |
|
Definition
| tertiary intention (delayed primary closure) |
|
|
Term
| causes of abnormal wound healing pneumonic |
|
Definition
DIDNTHEAL
Diabetes
Infection
Drugs
Nutritional problems
Tissue necrosis
Hypoxia
Excessive tension on wound edges
Another concurrent wound
Low temperature |
|
|
Term
|
Definition
staphylococcus aureus
staphylococcus coagulase negative
enterococcus
escherichia coli |
|
|
Term
| malnutrition impact on wound healing: specific parts |
|
Definition
protein catabolism delays wound healing
Vit C deficiency decreases wound healing
Vit A deficiency impedes monocyte activation.
Vit K metabolism impeded antibiotics.
Zinc deficiency results in early wound healing delay. |
|
|
Term
|
Definition
| Wind - atelectasis, Tx = spirometry |
|
|
Term
|
Definition
| water - UTI. tx = D/C foley, abx |
|
|
Term
|
Definition
| wound infection. tx = abx and I&D |
|
|
Term
|
Definition
| wonder drugs, d/c offending agent |
|
|
Term
| S&S of malignant hyperthermia |
|
Definition
rapid rise in body temp (up to 105F or higher), core temp can rise 2-4 degrees every 5 minutes.
muscle rigidity or stiffness
dark brown urine
muscle ache |
|
|
Term
| triggers of malignant hyperthermia |
|
Definition
inhaled halothane anesthetic agents
succinylcholine |
|
|
Term
| gold standard for the dx of malignant hyperthermia |
|
Definition
IVCT - in vitro contracture test
+ occurs with contracture of muscle fibers to halothane or caffeine |
|
|
Term
| treatment of malignant hyperthermia |
|
Definition
| danrolene via rapid IVP, d/c tiggering anesthetic |
|
|
Term
| complications of malignant hyperthermia |
|
Definition
| rhabdomyolysis, renal failure, myopathy, death |
|
|
Term
| causes of subacute post-op fever |
|
Definition
usually infection
#1 = wound
#2 = UTI
#3 = pneumonias (if on vent or COPD)
C Diff, line sepsis & bacteremia, intra-abd abscess |
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Term
| post op fever, weeks later |
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Definition
| endocarditis, infected prostheses |
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Term
| important portion of post op follow up |
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Definition
| patients should be given strict post-op instructions. |
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