summarizing whole topic briefly.

1. General Post Operative care
Dr.VIMI JAIN
Oral And Maxillofacial Surgery

2. Contents
Introduction
Post anesthesia care unit
Vitals monitoring
Fluid ,electrolyte & acid base balance
Post operative medication
Local wound examination
Nutrition
Renal/urinary assessment
Gastrointestinal assessment
Laboratory assessment
Bed care
Adjunct care
Discharge
Follow up

3. 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.

5. Postanesthesia care unit (PACU)
• Assessment in PACU.
-patient's airway patency,
-vital signs
-level of consciousness
• Discharged from the PACU
-Aldrete scale

6. 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
CONCIOUSNES
S
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

8. Respiratory System Assessment
• Patient airway ,adequate gas exchange
• Rate,pattern,dept of breathing
• Breath sounds
• Accesory muscle use
• Snoring stridor
• Respiratory depression or hypoxemia

9. • Respiratory care
-Mechanical ventilation
-Pain control
-Simple breathing exercises
-Correction of humidity deficit
• Prevention Respiratory Complications.

10. 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

11. CARDIOVASCULAR ASSESSMENT
Heart Rate
Tachycardia:
hemorrhage &/or shock
pain
fluid overload
anxious
Blood Pressure
Hypotension-hemorrhage &/or shock
Hypertension -anesthetic , inadequate pain control.

12. Capillary refill time
Assess circulatory status
Colour & temperature of limbs
Identification reduced peripheral perfusion.

13. 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.

14. 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

15. Fluid,electrolyte &acid- base balance
• I & O
• Hydration status
• IV fluids
• Vomitus
• Urine
• Wound drainage
• NG tube drainage
• Acid-base balance

16. • Three principles:
1.Correct any abnormalities
2.Provide the daily requirements
3.Replace any abnormal &
ongoing losses.
• Variation –
age, gender, weight ,
body surface area.

17. 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

18. Maintenance fluids calculation
For the first 0 to 10 kg - 100 mL/kg per day
For 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 kg
2 ml/kg/hr – second 10 kg
1 ml/kg/hr – additional kg
(Fonseca)
1000 ml RL
1500ml 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

19. Post operative medication
• To prevent infection.
• Pain control
• Anti-inflammatory
• To promote wound healing
• Supplementary

20. Local Wound Examination
Immediate post operative
Healing & healthy
infected unhealthy site

21. Hemorrhage
Localised
Generalised.
Reactionary
Secondary

22. Sutures
Intact & healthy suture
Infected
Loss of continuity
No approximation

23. Topical medicine
Povidone iodine ointment
Neosporine powder
Betadine spray Antiseptic ointment
Clotrimazole powder

24. Drains
Corrugated rubber drain
Suction unit drain
Intraoral rubber drain

25. pressure dressing
gauze dressing
Dressing
Intact
Frequency of change
Removal

27. 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

29. 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

30. GASTROINTESTINAL SYSTEM
Assessments
-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.

31. Laboratory assessments
• Analysis of electrolyte
• CBC
• Specimen for C &S
• ABGs
• Urine & renal lab tests
• Others( ECG, seum amylase,blood glucose)

32. Bed care
• Bed making
• Mouth care
• Bed bath
• Back care
• Hair,fingernail,toe nail care
• Perineal care
• Position of patient

33. Mobilisation
• Aim
To encourage good pulmonary ventilation
. To reduce venous stasis.
• For those who cannot mobilise,
- Physiotherapy
- Pneumatic calf compression devices
- Heparin

34. Physiotherapy
Respiratory exercises
Pneumonia
Blood clots
Clear lungs
circulation to the extremities
pain control.
Increases venous flow

35. Cold And Hot Application
Cold application
compression therapy
pain control
prevention of swelling
Warm application
after 48 hrs
increases circulation
reduction of swelling

36. Communication
• Reassurance in the immediate
post-operative period
• Procedure
• Any unexpected finding or
complication encountered during the procedure
• Presence of the patient's relatives.

37. 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)

38. Followup
• To assume responsibility for the patient's after-
care until all possibility of post-OP complications
is past.
• Long-term follow-up

40. 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).

41. NAME OF DRUGS DOSE INDICATIONS/ USES
Atropine Sulfate
(anticholinergic )
0.6 mg IM/IV 1. Vasovagal shock
2. Prevention of Bradycardia
3. Preanesthetic medication
4. To reduce salivary
secretions.
Adrenalin tartarate 1:1000 0.5-1mg IV/SC or intracardiac
to be repeated every 5 min.
1. Cardiac arrest
2. Anaphylactic shock
3. Sever laryngobrancheal
spasm.
Dexamethasone 4-20mg of base IM/IV 5-
50mg per day orally
1. Cereberal edema
2. Allergic conditions
3. 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 asthmaticus
3. Acute adrenal
insufficiency
4. Anaphylactic reaction
5. Allergic reactions

42. NAME OF DRUGS DOSE INDICATIONS/USES
Pheniramine
maleate. TN- Avil
Orally-25-50mg tabs.
25 mg tid
50mg bid
Ampule/vial 1-2ml IM 12
hrly
1. Allergic reaction
2. Rigors
3. Sedatives
4. Anaphylactic shock
5. Angioneurotic edema
Diazepam Orally 5-40mg
Inj. 2ml
1. Antianxiety
2. Acute muscle spasm
3. Spastic neurological disease
4. Tetanus
5. Orthopedic manipulation
Deriphyllin
bronchodialator)
2-4ml 2-3 times IV 1. Broncheal asthma
2. Cardiac insufficiency
3. Central respiratory disorder
4. 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 failure
2. Hepatic or renal disease
3. Toxemia of pregnancy
4. Mild & moderate hyertension
5. Cerebral edema
sosorbide dinitrate Sublingual 5-10 mg for
immediate action, orally 5-
1. Angina pectoris

43. Pheniramine
maleate. TN- Avil
Orally-25-50mg tabs.
25 mg tid
50mg bid
Ampule/vial 1-2ml IM 12
hrly
1. Allergic reaction
2. Rigors
3. Sedatives
4. Anaphylactic shock
5. Angioneurotic edema
Diazepam Orally 5-40mg
Inj. 2ml
1. Antianxiety
2. Acute muscle spasm
3. Spastic neurological disease
4. Tetanus
5. Orthopedic manipulation
Deriphyllin
(bronchodialator)
2-4ml 2-3 times IV 1. Broncheal asthma
2. Cardiac insufficiency
3. Central respiratory disorder
4. 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 failure
2. Hepatic or renal disease
3. Toxemia of pregnancy
4. Mild & moderate hyertension
5. Cerebral edema
Isosorbide dinitrate Sublingual 5-10 mg for
immediate action, orally 5-
10 mg 6 hrly
1. Angina pectoris

44. Oxygen 3-5 lit/min 1. Hypoxia
2. Shock
3. Cardiorespiratory failure
Pethidine 50mg IM 1. Severe pain
2. Preanesthetic medication

45. 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.

46. • 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.