32588_p0st-Operative Care (1)

8/13/2019 32588_p0st-Operative Care (1)

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P0ST-OPERATIVE CARE


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PHASES IMMEDIATE ( POST-ANAESTHETIC )

PHASE (1)

INTERMEDIATE ( HOSPITAL STAY )PHASE (2)

CONVALESCENT ( AFTER DISCHARGETO FULL RECOVERY )


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AIM OF PHASES 1 2 HOMEOSTASIS

TREATMENT OF PAIN

PREVENTION & EARLYDETECTION OF COMPLICATIONS


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IMMEDIATEPOST-OPERATIVEPERIOD


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CAUSES OFCOMPLICATIONS DEATH

ACUTE PULMONARY PROBLEMS

CARDIO-VASCULAR PROBLEMS

FLUID DERANGEMENTS


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PREVENTION RECOVERY ROOM :

ANAESTHETIST RESPONSIBILITIESTOWARDS CARDIO-PULMONARY

FUNCTIONS.SURGEONS RESPONSIBILITIESTOWARDS THE OPERATION SITE.

TRAINED NURSING STAFF :T0 HANDLE INSTRUCTIONS.

CONTINUOUS MONITORING OFPATIENT (VITAL SIGNS etc.)


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DISCHARGE FROM RECOVERYSHOULD BE AFTER COMPLETE

STABILIZATION OF CARDIO-VASCULAR PULMONARY AND

NEUROLOGICAL FUNCTIONS WHICHUSUALLY TAKES 2-4 HOURS.

IF NOT SPECIAL CARE IN ICU.


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Post-Operative OrdersA) Monitoring

Vital sign (pulse, BP, R.R, Temp) every15-30 min.

C.V.P (? Swangins for pulmonaryartery wedge pressure) and arterialline 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 afterneurosurgery.


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Post-Operative Orders

B) Respiratory Care: O2mask.

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 calfcompression).


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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.


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G) Medication: Antibiotics. Pain killers.

Sedatives.

Pre-operative medication.

Care of patients on Pre-Op. Steroids.

H2Blockers specially in ICU patients. Anti-Coagulants.

Anti Diabetics.

Anti Hypertensives.

H) Lab. Tests and Imaging: To detect or exclude Post-Op. complications.


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The Intermediate Post-Operative periodStarts with complete recovery

from anaesthesia and lasts for

the rest of the hospital stay.


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Care of the wound Epithelialisation takes 48 hs. Dressing can be removed 3-4 days after

operation.

Wet dressing should be removed earlier andchanged.

Symptoms and signs of infection should belooked for, which if present compression,removal of few stitches and daily dressing withswab 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 20thday thenslowly again (full strength takes 1-2 years).

Good nutrition.


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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 tominimize risk of wound infection.

Inspection of contents and its amount.

Soft drains e.g. Penrose should not be leftmore than 40 days because they form a tractand acts as a plug.


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Post-Operativepulmonary 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 dayand to normal Pre-Op. Level after that.

FRC, VC, and Post-Op. pulmonary oedema

(Post anaesthesia) Contribute to the changesin pulmonary functions Post-Op.

The above changes are accentuated byobesity, heavy smoking or Pre-existing lung

diseases specially in elderly.


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Post-Op. atelectasis is enhanced byshallow breathing, pain, obesity and

abdominal distension (restriction ofdiaphragmatic movements)

Post-Op. physiotherapy especially deepinspiration helps to decreaseatelectasis. Also O2 mask and periodichyperinflation using spirometer.

Early mobilization helps a lot.

Antibiotics and treatment of heartfailure Post-Op. by adequatemanagement of fluids will help to

reduce pulmonary oedema.


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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, abdominaldistension or opioid overdose.

Manifestation : Tachypnea > 25-30/min.

Low tidal volume < 4ml /kg

High Pco2 > 45mmHg.

Low Po2 < 60mmHg.


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Treatment: Immediate intubation and mechanical ventilation. Treatment of atelectasis, pneumonia or

pneumothorax if any.

Prevention: Physiotherapy (Pre. & Post-OP.) to preventatelectasis.

Treatment of any Pre-existing pulmonary diseases.

Hydration of patient to avoid hypovolaemia and lateron atelectasis and infection.

May be hyperventilation to compensate forinsufficiency of lungs.

Use of epidural block or local analgesia in patientswith COPD to relieve pain and permits effectiverespiratory muscle functions


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Post-Operative fluid Electrolytesmanagement 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 forsensible 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, hyperventilationand increased catabolic states.


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Estimation of electrolytes daily is onlynecessary in critical patients.

Potassium should not be added to IV fluidduring first 24hs. Post-Op. (becausePotassium enters circulation during this timeand causes increased aldosterone activity).

Other electrolytes are corrected according todeficits.

5% dextrose in normal saline or in lactatedRingers solution is suitable for most patients.

Usual daily requirements of fluids is between2000-2500ml/day.


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Post-Operative Care of GIT NPO until peristalsis returns.

Paralytic ileus usually takes about 24hs.

NGT is necessary after esophageal and gastricsurgery.

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

Gastrostomy and jujenostomy tubes feeding canstart on 2ndPost-Op. day because absorption fromsmall bowel is not affected by laparotomy.

Enteral feeding is better than parenteral feeding.

Gradual return of oral feeding from liquids to normaldiet.


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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 andendocrine functions.

Cortical response from voluntary movements andemotions.


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Complications of Pain: Causes vasospasm.

Hypertension.

May cause CVA, MI or bleeding.

Management of Post-Op. pain: Physicianpatient communication (reassurance).

Parenteral opioids.

Analgesics (NSAIDS).

Anxiolytic agents (Hydroxyzine) potentiates actionof 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).

32588_p0st-Operative Care (1)

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