general post operative care
TRANSCRIPT
General Post Operative care
Dr.VIMI JAINOral And Maxillofacial Surgery
ContentsIntroductionPost anesthesia care unitVitals monitoringFluid ,electrolyte & acid base balancePost operative medicationLocal wound examinationNutritionRenal/urinary assessmentGastrointestinal assessmentLaboratory assessmentBed careAdjunct careDischarge Follow up
INTRODUCTION
• Care in immediate postoperative period, including the operating room, postanesthesia care unit (PACU)& unit.
• Extent depends on the individual's pre-surgical health status, type of surgery,day-surgery setting or in the hospital.
• Goal - prevent complications such as infection
. - promote healing of the surgical wound - return the patient to a state of health.
Postanesthesia care unit (PACU) • Assessment in PACU. -patient's airway patency, -vital signs -level of consciousness • Discharged from the PACU -Aldrete scale
ALDRETE SCORE Post-Anesthesia Score A total discharge score of 8-10 is necessary Post-Anesthesia Score PRE-ANESTHESIA VITAL SIGNS/SOURCE TIME ADM 15" 30" 45" 1' 2' 3' 4' DISCHARGE SYSTOLIC BP 20% OF PRE-ANESTHETIC LEVEL
2
CIRCULATION 20-50% 1 > 50 0 FULLY AWAKE 2 CONCIOUSNESS
AROUSABLE ON CALLING 1
NOT RESPONDING 0 WARM, DRY SKIN W/ PREPROCEDURAL
COLORING 2
COLOR PALE, DUSKY, BLOTCHY, JAUNDICED, OTHER 1
CYANOTIC 0 ABLE TO DEEP BREATHE & COUGH FREELY
2
RESPIRATION DYSPNEA OR LIMITED BREATHING APKEIC 1
0 ABLE TO MOVE 4 EXTREMITIES 2 ACTIVITY ABLE TO MOVE 2 EXTREMITIES 1 ABLE TO MOVE 0 EXTREMITIES 0 COMMENTS TOTAL
Respiratory System Assessment
• Patient airway ,adequate gas exchange• Rate,pattern,dept of breathing• Breath sounds• Accesory muscle use • Snoring stridor• Respiratory depression or hypoxemia
• Respiratory care -Mechanical ventilation -Pain control -Simple breathing exercises -Correction of humidity deficit
• Prevention Respiratory Complications.
Pulse oximetry• Oxygen saturation should be above 95% on air• Oxygen canula-44% O2• Oxygen mask-60% O2 at 6 to 10L/MIN• Oxygen mask with reservoir-90-100% O2
CARDIOVASCULAR ASSESSMENT Heart Rate Tachycardia: hemorrhage &/or shock pain fluid overload anxious Blood Pressure
Hypotension-hemorrhage &/or shock
Hypertension -anesthetic , inadequate pain control.
Capillary refill time
Assess circulatory status
Colour & temperature of limbs
Identification reduced peripheral perfusion.
Body temperature
• Hypothermia : -Children & older adults are at risk. -Bacterial infection or sepsis. -Shivering :-anaesthesia• Use a bair hugger(forced-air blanket) and blankets• Hyperthermia -infection• Antipyretics , fanning ,tepid sponging.
Level of consciousness -should respond to verbal stimulation, -be able to answer questions and -aware of their surroundings• Assessment of consciousness - The AVPU scale
.
• Change in the level of consciousness -shock
Fluid,electrolyte &acid- base balance
• I & O• Hydration status• IV fluids • Vomitus• Urine• Wound drainage• NG tube drainage• Acid-base balance
• Three principles: 1.Correct any abnormalities 2.Provide the daily requirements 3.Replace any abnormal & ongoing losses. • Variation – age, gender, weight , body surface area.
ELECTROLYTE MONITORING
Hyponatremia- water excess-restrictrion of , electrolye free nutrition.
Hypernatremia- abnormal Na retention or abnormal Na reabsorption due to inceases ADH
Hyperkalemia-severe trauma, renal failure- causes arrythmias
Maintenance fluids calculation
For the first 0 to 10 kg - 100 mL/kg per dayFor the next 10 to 20 kg - 50 mL/kg per day
For remaining kgs - 20 mL/kg per day
(Schwartz's)4 ml/kg/hr – first 10 kg2 ml/kg/hr – second 10 kg1 ml/kg/hr – additional kg
(Fonseca)1000 ml RL1500ml D5
2000 ml of 5% dextrose(in water)500 ml of 5% dextrose (in saline)40 mEq of K, Cl
(G.O.Kruger)
(Schwartz's)30-100 mEq Na, K
Post operative medication
• To prevent infection.• Pain control• Anti-inflammatory• To promote wound healing• Supplementary
Local Wound Examination
Immediate post operative
Healing & healthy
infected unhealthy site
Hemorrhage
Localised
Generalised.
Reactionary
Secondary
Sutures
Intact & healthy suture
Infected Loss of continuity No approximation
Topical medicine
Povidone iodine ointment
Neosporine powderBetadine spray Antiseptic ointment
Clotrimazole powder
Drains
Corrugated rubber drain
Suction unit drain
Intraoral rubber drain
pressure dressing
gauze dressing
Dressing
Intact
Frequency of changeRemoval
Nutrition
•NPO (nothing by mouth) at least until their cough and gag reflexes have returned.
• Dry mouth following surgery- oral sponges dipped in ice water or lemon ginger mouth swabs.
•Oral- soft cold liquid
•Parentral-protein,carbohydrate & vitamin rich through feeding tubes
Renal /Urinary System •Assesments -Check for urine retention -Other sources of output(sweat,vomitus,diarrhoea stools) - Report urine output
• Micturition-After GA when this reflex acts the pressure in the
bladder rises sufficiently to cause the sphincter to relax and the detrusor muscle to contract.
-Encouraged by mobilisation
-Catheterisation
GASTROINTESTINAL SYSTEMAssessments -Post operative nausea/vomiting common -Peristalsis may be delayed up to 24 hrs -monitor bowel sounds
Constipation: organic or functional?Organic -partial obstruction of the lumen.Functional -defective movements of the colonic musculature, -deficiency in bulk of faeces due to feeding with
fluid diets.Rx-Feeding fruit, vegetables and whole meal
cereals ,laxatives.
Laboratory assessments
• Analysis of electrolyte• CBC• Specimen for C &S• ABGs• Urine & renal lab tests• Others( ECG, seum amylase,blood glucose)
Bed care• Bed making• Mouth care • Bed bath• Back care• Hair,fingernail,toe nail care• Perineal care• Position of patient
Mobilisation
• Aim To encourage good pulmonary ventilation
. To reduce venous stasis.• For those who cannot mobilise, - Physiotherapy - Pneumatic calf compression devices - Heparin
Physiotherapy
Respiratory exercises Pneumonia Blood clots Clear lungs circulation to the extremities pain control. Increases venous flow
Cold And Hot ApplicationCold application compression therapy pain control prevention of swelling
Warm application after 48 hrs increases circulation reduction of swelling
Communication
• Reassurance in the immediate post-operative period• Procedure• Any unexpected finding or complication encountered during the procedure• Presence of the patient's relatives.
Discharge• ensure that a patient is sufficiently recovered • a written policy establishing specific discharge criteria is a sound
basis for a legally sufficient discharge decision.
Discharge note On discharging the patient from the ward, record in the notes: • Diagnosis on admission and discharge • Summary of course in hospital • Instructions about further management, including drugs prescribed. Ensure that a copy of this information is given to the patient, together with details of any follow-up appointment . (WHO/EHT/CPR: WHO Surgical Care at the District Hospital 2003)
Followup
• To assume responsibility for the patient's after-care until all possibility of post-OP complications is past.
• Long-term follow-up
RECENTS
Additional wound management products/therapies that may be considered:
• Topical negative pressure (TNP) therapy• Growth factors (such as platelet-derived growth factor)• Antibacterial honey• Larva therapy (maggots)• Anti-scarring agents (such as transforming growth
factors)• Antiseptic-impregnated sutures (such as triclosan
coating).
NAME OF DRUGS DOSE INDICATIONS/ USES
Atropine Sulfate (anticholinergic )
0.6 mg IM/IV 1. Vasovagal shock2. Prevention of Bradycardia3. Preanesthetic medication4. To reduce salivary
secretions.
Adrenalin tartarate 1:1000 0.5-1mg IV/SC or intracardiac to be repeated every 5 min.
1. Cardiac arrest2. Anaphylactic shock3. Sever laryngobrancheal
spasm.
Dexamethasone 4-20mg of base IM/IV 5-50mg per day orally
1. Cereberal edema2. Allergic conditions3. Antiinflamatory 4. Shock 5. Immunosupperession
Sodium hydrocortisones sodium succinate/ hemisuccinate TN-Lycortin S
100mgIM/IV Stat; may be repeated once or twice
1. Shock 2. Status asthmaticus3. Acute adrenal
insufficiency4. Anaphylactic reaction5. Allergic reactions
NAME OF DRUGS DOSE INDICATIONS/USES
Pheniramine maleate. TN- Avil
Orally-25-50mg tabs. 25 mg tid50mg bidAmpule/vial 1-2ml IM 12 hrly
1. Allergic reaction2. Rigors3. Sedatives4. Anaphylactic shock5. Angioneurotic edema
Diazepam Orally 5-40mgInj. 2ml
1. Antianxiety2. Acute muscle spasm3. Spastic neurological disease4. Tetanus5. Orthopedic manipulation
Deriphyllin (bronchodialator)
2-4ml 2-3 times IV 1. Broncheal asthma 2. Cardiac insufficiency3. Central respiratory disorder4. Renal & cardiac edema
Frusemide. TN-lasix Orally 40 mg tabs.In edema 20-80 mg single dose daily.IV-10 to 20 mg over 1-2min
1. Edema in congestive heart failure2. Hepatic or renal disease3. Toxemia of pregnancy4. Mild & moderate hyertension5. Cerebral edema
Isosorbide dinitrate Sublingual 5-10 mg for immediate action, orally 5-10 mg 6 hrly
1. Angina pectoris
NAME OF DRUGS DOSE INDICATIONS/USES
Pheniramine maleate. TN- Avil
Orally-25-50mg tabs. 25 mg tid50mg bidAmpule/vial 1-2ml IM 12 hrly
1. Allergic reaction2. Rigors3. Sedatives4. Anaphylactic shock5. Angioneurotic edema
Diazepam Orally 5-40mgInj. 2ml
1. Antianxiety2. Acute muscle spasm3. Spastic neurological disease4. Tetanus5. Orthopedic manipulation
Deriphyllin (bronchodialator)
2-4ml 2-3 times IV 1. Broncheal asthma 2. Cardiac insufficiency3. Central respiratory disorder4. Renal & cardiac edema
Frusemide. TN-lasix Orally 40 mg tabs.In edema 20-80 mg single dose daily.IV-10 to 20 mg over 1-2min
1. Edema in congestive heart failure2. Hepatic or renal disease3. Toxemia of pregnancy4. Mild & moderate hyertension5. Cerebral edema
Isosorbide dinitrate Sublingual 5-10 mg for immediate action, orally 5-10 mg 6 hrly
1. Angina pectoris
NAME OF DRUGS DOSES INDICATIONS/USES
Oxygen 3-5 lit/min 1. Hypoxia
2. Shock
3. Cardiorespiratory failure
Pethidine 50mg IM 1. Severe pain
2. Preanesthetic medication
References
• Principles of monitoring postoperative patientsCathy Liddle ,school of professional practice, department of skills and simulation, Birmingham City University.31 May, 2013
• • Barone, C. P., M. L. Lightfoot, and G. W. Barone.
"The Postanesthesia Care of an Adult Renal Transplant Recipient." Journal of PeriAnesthesia Nursing 18, no.1 (February 2003): 32 41.
• Smykowski, L., and W. Rodriguez. "The Post Anesthesia Care Unit Experience: A Family-centered Approach." Journal of Nursing Care Quality 18, no. 1 (January-March 2003): 5-15.
• Wills, L. "Managing Change Through Audit: Post-operative Pain in Ambulatory Care." Paediatric Nursing 14, no.9 (November 2002): 35-8.