In-patient Care Surgical Priorities Emergency — requires instant admission ex: acute infection, traumatic injury Urgent — can progress to emergency ex: subacute infection, neoplasm Routine — admitted the day before preparation: blood investigation, consultation, chest xray, EKG…
In-patient Care Pre-OP care n Visits the patient within a few hours of admission. n Review and revise the findings at the out-patient exam. n Record the pulse, temperature, blood pressure, haemoglobin estimation and urinalysis. n Check those teeth beyond conservation to be extracted. n Replace insecure dressings in case they are dislodged into a socket or wound.
In-patient Care Pre-OP care n Warn the anaesthetist about the loose teeth. n Extensive haemorrhage? n Explain to the patient about the nature of the operation and likely complications. n Informed consent obtained in writing for both the anaesthetic and the operation. n Not only to carry out the local treatment but also to supervise the day-to-day care.
In-patient Care Diet 1. Fluid intake and output Daily intake: 2500 ml; Daily output: 1000~1500ml Water is excreted as exhaled air (400 ml), sweat (500~1000 ml), urine (1200 ml), and faeces (200 ml) Insufficient fluid intake urine output↓ (minimum: 600 ml) If difficulty in feeding fluid balance chart Fluid given by mouth or intravenously
In-patient Care Diet 1. Solid food Balanced diet: carbohydrates + fats + proteins + vitamins + mineral salts Fats are not easily digested. Carbohydrate to prevent ketosis. Protein for the repair of tissue. Discussed with the dietitian. NG tube: brought out and cleaned every 2 or 3 days. Replaced through the other nostril. Weighed weekly
In-patient Care Diet 1. Pre-operative diet LA: normal meal If the patient has missed a meal he should be given a glucose drink before the injection is given. GA: light meal Chiefly of protein and carbohydrate, is advised the night before. No food taken for 4 hours nor clear fluids for 2 hours before operation!
In-patient Care Diet 1. Post-operative diet Feeding should be started as soon as possible to avoid nausea. Tenderness/tismus specially prepared food
In-patient Care Excretion 1. Micturition This reflex act occurs when the pressure in the bladder rises sufflciently to cause the sphincter to relax and the detrusor muscle to contract. It may occur after GA. Micturition can be encouraged by getting the patient up but if this fails catheterisation may be necessary.
In-patient Care Excretion 1. Sweat Sweat contains 0.5 percent of solids (NaCl). In fever or in hot weather sweating 10 g of NaCl can be lost in an hour
In-patient Care Excretion 1. Defaecation Constipation: organic or functional? Organic is due to partial obstruction of the lumen. Functional is due to defective movements of the colonic musculature, or a deficiency in bulk of faeces due to feeding with fluid diets. Feeding fruit, vegetables and wholemeal cereals or by giving laxatives.
In-patient Care Sleep Pain: analgesics/hypnotics External stimuli: keep the wards dark and quiet at night Worry or change of habit: dozing by day lead to insomnia, hypnotic drugs, but only if really necessary for they are habit-forming.
In-patient Care Hygiene Oral hygiene instruction Mouth rinse with 0.2% CHX after every meal Intraoral sutures: debris removed each day Arch bars: brush with toothpaste, rinse Gutta-percha moulds: after the first 10 days, a syringe between the graft and the mould to clean the dead space
In-patient Care Post-OP care n Put into bed with a pillow behind shoulders to enable drainage from mouth. n Arms kept folded over chest. n Nurse sits by to watch the airway, suck out the mouth and oro- pharynx n Watch for vomiting and haemorrhage, and records the vital signs and level of consciousness.
In-patient Care Post-OP complications 2. Fever Natural reaction to infection, common for 2~3 days Chest complaint sputum culture Symptomatic treatment: confinement to bed, more fluid intake and a high carbohydrate diet to prevent the breakdown of body proteins. > 39.4°C: sponged down with tepid water at 27°C
In-patient Care Post-OP complications 1. Vomiting due to the anaesthetic or swallowed blood > 8 hours upset of the acid base equilibrium TX: give milk or alkaline drinks with glucose. sipped very slowly but frequently or antiemetic 2. Conjunctivitis Gently irrigated with normal saline. Chloramphenicol eye-drops
In-patient Care Post-OP complications 1. Sore throat or pharyngitis Trauma from the endotracheal tube, excoriation from a dry pack TX: gargles and inhalations 2. Pulmonary conditions Routine post-OP breathing exercises will reduce the incidence. TX: antibiotics, physiotherapy, humidified oxygen, sedatives and mucolytic drugs, frequent hot drinks
In-patient Care Routine monitoring n Vital signs: temperature, pulse, blood pressure n Fluid balance chart n Bloods: full blood count, haemoglobin, electrolytes n Bowel habit n Dietary intake n Drug requirements: analgesics, antibiotics, normal medications
Out-patient Care Day cases Minor operations under endotracheal anaesthesia Morning Suitable transport must be available
Out-patient Care Pre-OP instructions for out-patients n The nature of the operation must be explained. n Permission obtained in writing for both general anaesthetic and surgery. n Told to come accompanied n Light and easily digested diet n Wear no restrictive clothing n Fast from food or drink for at least 4 hours before OP n Before entering the surgery, remove their dentures, contact lenses and earrings, and to empty bowel and bladder.
Out-patient Care Post-OP care n Adequate instructions: diet, oral hygiene, analgesics and the rest period required before return to work. n The operator must be easily available to the patient to deal with any surgical complications.
Follow Up To assume responsibility for the patients after-care until all possibility of post-OP complications is past. Long-term follow-up will benefit both the surgeon and his patients.
ReferrencePrinciples of Oral and Maxillofacial Surgery, 5th edition, UJ Moore