P0st operative care
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P0ST-OPERATIVE CARE. PHASES. IMMEDIATE ( POST-ANAESTHETIC ) PHASE (1) INTERMEDIATE ( HOSPITAL STAY ) PHASE (2) CONVALESCENT ( AFTER DISCHARGE TO FULL RECOVERY ). AIM OF PHASES 1 & 2. HOMEOSTASIS TREATMENT OF PAIN PREVENTION & EARLY DETECTION OF COMPLICATIONS.

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P0ST-OPERATIVE CARE

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P0st operative care

P0ST-OPERATIVE CARE


Phases

PHASES

  • IMMEDIATE ( POST-ANAESTHETIC ) PHASE (1)

  • INTERMEDIATE ( HOSPITAL STAY ) PHASE (2)

  • CONVALESCENT ( AFTER DISCHARGE TO FULL RECOVERY )


Aim of phases 1 2

AIM OF PHASES 1 & 2

  • HOMEOSTASIS

  • TREATMENT OF PAIN

  • PREVENTION & EARLY DETECTION OF COMPLICATIONS


Immediate post operative period

IMMEDIATE POST-OPERATIVE PERIOD


Causes of complications death

CAUSES OF COMPLICATIONS & DEATH

  • ACUTE PULMONARY PROBLEMS

  • CARDIO-VASCULAR PROBLEMS

  • FLUID DERANGEMENTS


Prevention

PREVENTION

  • RECOVERY ROOM :

    ANAESTHETIST RESPONSIBILITIES TOWARDS CARDIO-PULMONARY FUNCTIONS.

    SURGEON’S RESPONSIBILITIES TOWARDS THE OPERATION SITE.

  • TRAINED NURSING STAFF :

    T0 HANDLE INSTRUCTIONS.

  • CONTINUOUS MONITORING OF PATIENT (VITAL SIGNS etc.)


P0st operative care

DISCHARGE FROM RECOVERY SHOULD BE AFTER COMPLETE STABILIZATION OF CARDIO-VASCULAR, PULMONARY AND NEUROLOGICAL FUNCTIONS WHICH USUALLY TAKES 2-4 HOURS.

IF NOT SPECIAL CARE IN ICU.


Post operative orders

Post-Operative Orders

A)Monitoring

  • Vital sign (pulse, BP, R.R, Temp) every 15-30 min.

  • C.V.P (? Swan – gins for pulmonary artery wedge pressure) and arterial line for continuous BP measurement.

  • ECG

  • Fluid balance ( intake and output) ? Needs urinary catheter.

  • Other types of monitoring :

    • Arterial pulses after vascular surgery.

    • Level of consciousness after neurosurgery.


Post operative orders1

Post-Operative Orders

B) Respiratory Care:

  • O2 mask.

  • Ventilator.

  • Tracheal suction.

  • Chest physiotherapy.

    C) Position in bed and mobilization:

  • Turning in bed usually every 30 min. until full mobilization.

  • Special position required sometimes.

  • DVT prevention mechanically ( intermittent calf compression).


P0st operative care

D) Diet:

  • NPO

  • Liquids.

  • Soft diet.

  • Normal or special diet.

    E) Administration of I.V. fluids:

  • Daily requirements.

  • Losses from G.I.T and U.T.

  • Losses from stomas and drains.

  • Insensible losses.

  • Care of renal patients.

  • If care of drainage tubes.


P0st operative care

G) Medication:

  • Antibiotics.

  • Pain killers.

  • Sedatives.

  • Pre-operative medication.

  • Care of patients on Pre-Op. Steroids.

  • H2 Blockers specially in ICU patients.

  • Anti-Coagulants.

  • Anti Diabetics.

  • Anti Hypertensives.

    H) Lab. Tests and Imaging:

  • To detect or exclude Post-Op. complications.


The intermediate post operative period

The Intermediate Post-Operative period

Starts with complete recovery from anaesthesia and lasts for the rest of the hospital stay.


Care of the wound

Care of the wound

  • Epithelialisation takes 48 hs.

  • Dressing can be removed 3-4 days after operation.

  • Wet dressing should be removed earlier and changed.

  • Symptoms and signs of infection should be looked for, which if present compression, removal of few stitches and daily dressing with swab for C & S.

  • R.O.S. usually 5-7 days Post-Op.

  • Tensile strength of wound minimal during first 5 days, then rapid between 5th 20th day then slowly again (full strength takes 1-2 years).

  • Good nutrition.


Management of drains

Management of drains

  • To drain fluids accumulating after surgery, blood or pus.

  • Open or closed system.

  • Other types (Suction, sump, under water etc.)

  • Should be removed as long as no function.

  • Should come out throw separate incision to minimize risk of wound infection.

  • Inspection of contents and its amount.

  • Soft drains e.g. Penrose should not be left more than 40 days because they form a tract and acts as a plug.


Post operative pulmonary care

Post-Operative pulmonary Care

  • Functional residual capacity ( FRC) and vital capacity (VC) decrease after major intra-abdominal surgery down to 40% of the Pre-Op. Level.

  • They go up slowly to 60-70% by 6th -7th day and to normal Pre-Op. Level after that.

  • FRC, VC, and Post-Op. pulmonary oedema (Post anaesthesia) Contribute to the changes in pulmonary functions Post-Op.

  • The above changes are accentuated by obesity, heavy smoking or Pre-existing lung diseases specially in elderly.


P0st operative care

  • Post-Op. atelectasis is enhanced by shallow breathing, pain, obesity and abdominal distension (restriction of diaphragmatic movements)

  • Post-Op. physiotherapy especially deep inspiration helps to decrease atelectasis. Also O2 mask and periodic hyperinflation using spirometer.

  • Early mobilization helps a lot.

  • Antibiotics and treatment of heart failure Post-Op. by adequate management of fluids will help to reduce pulmonary oedema.


Respiratory failure

Respiratory failure

  • Early :

    • Occurs minutes to 1-2 hs. Post-Op.

    • No definite cause.

    • Occurs suddenly.

  • Late :

    • Occurs 48 hs. Post-Op.

    • Due to pulmonary embolism, abdominal distension or opioid overdose.

      Manifestation :

    • Tachypnea > 25-30/min.

    • Low tidal volume < 4ml /kg

    • High Pco2 > 45mmHg.

    • Low Po2 < 60mmHg.


P0st operative care

  • Treatment :

    • Immediate intubation and mechanical ventilation.

    • Treatment of atelectasis, pneumonia or pneumothorax if any.

  • Prevention:

    • Physiotherapy (Pre. & Post-OP.) to prevent atelectasis.

    • Treatment of any Pre-existing pulmonary diseases.

    • Hydration of patient to avoid hypovolaemia and later on atelectasis and infection.

    • May be hyperventilation to compensate for insufficiency of lungs.

    • Use of epidural block or local analgesia in patients with COPD to relieve pain and permits effective respiratory muscle functions


Post operative fluid electrolytes management

Post-Operative fluid & Electrolytes management

  • Considerations:

    • Maintenance requirements.

    • Extra needs resulting from systemic factors e.g. fever, burn diarrhea and vomiting etc.

    • Losses from drains and fistulas.

    • Tissue oedema (3rd space losses)

  • The daily maintenance requirements in adult for sensible and insensible losses are 1500-2500mls. depending on age, sex, weight and body surface area.

  • Rough estimation of need is by body weight x 30/day. e.g. 60 KG x 30 = 1800ml/day.

  • Requirements is increased with fever, hyperventilation and increased catabolic states.


P0st operative care

  • Estimation of electrolytes daily is only necessary in critical patients.

  • Potassium should not be added to IV fluid during first 24hs. Post-Op. (because Potassium enters circulation during this time and causes increased aldosterone activity).

  • Other electrolytes are corrected according to deficits.

  • 5% dextrose in normal saline or in lactated Ringer’s solution is suitable for most patients.

  • Usual daily requirements of fluids is between 2000-2500ml/day.


Post operative care of git

Post-Operative Care of GIT

  • NPO until peristalsis returns.

  • Paralytic ileus usually takes about 24hs.

  • NGT is necessary after esophageal and gastric surgery.

  • NGT is NOT necessary after cholecystectomy, pelvic operation or colonic resections.

  • Gastrostomy and jujenostomy tubes feeding can start on 2nd Post-Op. day because absorption from small bowel is not affected by laparotomy.

  • Enteral feeding is better than parenteral feeding.

  • Gradual return of oral feeding from liquids to normal diet.


Post operative pain

Post-Operative Pain

  • Factors affecting severity :

    • Duration of surgery.

    • Degree of Operative trauma (intra-thoracic, intra-abdominal or superficial surgery).

    • Type of incision.

    • Magnitude of intra-operative retraction.

    • Factors related to the patient :

      • Anxiety.

      • Fear.

      • Physical and cultural characteristics.

  • Paintransmission:

    • Splanchnic nerves to spinal cord.

    • Brain stem due to alteration in ventilation, BP and endocrine functions.

    • Cortical response from voluntary movements and emotions.


P0st operative care

  • Complications of Pain:

    • Causes vasospasm.

    • Hypertension.

    • May cause CVA, MI or bleeding.

  • Management of Post-Op. pain:

    • Physician – patient communication (reassurance).

    • Parenteral opioids.

    • Analgesics (NSAIDS).

    • Anxiolytic agents (Hydroxyzine) potentiates action of opioids and has also an anti-emetic effects.

    • Oral analgesics or suppositories e.g. Tylenol.

    • Epidural analgesia (for pelvic surgery).

    • Nerve block (Post-thoracotomy and hernia repair).


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