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general post operative care
- 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
- 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.