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General Care of the Surgical Patient

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General Care of the Surgical Patient General Care of the Surgical Patient Presentation Transcript

  • General Careof the Surgical Patient Presenter: R1 鄭瑋之 Instructor: VS 陳靜容醫師 Date: 2012/3/9
  • Outlines Surgical patients  In-patient  Out-patient
  • 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… View slide
  • 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. View slide
  • 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
  • Thank youfor your attention!