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.