Post operative care

Presenters:1.

2.

3.

4.

5.

Why

I99 strumectomies for exopthalmic

goitre with 14 deaths

: eight of them in acute post-operative

hyperthyroidism (during the last four years we

have had four such deaths, despite the fact that

these years

practically all the serious cases of

exophthalmic goitre had been pre-operatively

treated with Lugol's solution).

In four cases the cause of death is pneumonia,

although local anaesthesia was invariab'y

used.

457 operations for gall-stone

Pulmonary embolism and pneumonia play

here a very large part as cause of death (24)

Peritonitis (6)

2192 appendicitiscomprises

Peritonitis (most cases )

Pulmonary embolism and pneumonia

266 kidney and ureter

operations

Uremia

Respiratory complications

777 prostatectomies for prostate

hypertropy

uraemia,

pneumonia,

infection and hoemorrhage.

INTRODUCTION

The post operative period begins from the time the patient leaves the operating room and ends with the follow up visit by the surgeon.

The post operative care is provided by -

PACU

SICU

PURPOSES

To enable a successful and faster recovery of the patient post operatively.

To reduce post operative mortality rate.

To reduce the length of hospital stay of the patient.

To provide quality care service.

To reduce hospital and patient cost during post operative period.

SCOPE

All the patients who

are undergoing surgery

Responsibility And Authority

Registered Nurse

POST OPERATIVE CARE UNIT

OR POST ANESTHETIC CARE

UNIT[ PACU]

Patients still under anesthesia or

recovering from anesthesia are placed in

the unit for observation by highly skilled

nurses,anesthetist and surgeon.PACU should be sound proof, painted in

soft colour, isolated and these features will

help the patient to reduce anxiety and

promote comfort.

PHASES OF POST OP UNIT

Two phases-

Phase I

Phase II

Phase I

It is the immediate recovery phase and requires intensive nursing care to detect early signs of complication.

Receive a complete patient record from the operating room which to plan post operative care.

It is designated for care of surgical patient immediately after surgery and patient requiring close monitoring

Phase II

Care of the surgical patient who has been

transferred from the Phase I post op unit.

Patient requiring less observation and less

nursing care than Phase I

This phase is also known as Step down or

progressive care unit.

Common system specific

post operative

complications

Nursing interventions

1.Respiratory :post operative

Hypoxia

• Upper airway obstruction :due to the residual effect of

general

anaesthesia, secretions or wound haematoma after neck

surgery.

• Laryngeal oedema from traumatic tracheal intubation,

recurrent laryngeal nerve palsy and tracheal collapse after

thyroid surgery.

• Hypoventilation related to anaesthesia or surgery.

• Atelectasis and pneumonia especially after upper

abdominal and thoracic surgery (Figure 21.2).

• Pulmonary oedema of cardiac origin or related to fluid

overload.

• Pulmonary embolism: this often presents with the sudden

onset of chest pain and shortness of breath. In the presence of

Protect airway

By proper positioning of patient’s head.

By clearing airway.

Oxygen therapy.

Pharyngeal obstructioncan occur when the patient lies on the back as there are chances for

tongue to fall back.

KEEP MONITORING VITALS

Cardiovascular

1.Hypotension: inadequate fluid replacement,

vasodilatation from sub-arachnoid and epidural

anaesthesia or rewarming of the patient.

However, other causes of hypotension such as

Surgical bleeding,sepsis, arrhythmias, myocardial

infarction,

cardiac failure, tension pneumothorax, pulmonary

embolism, pericardial tamponade and anaphylaxis

should be also sought

2.MI

3.Arrythmia

NURSING MANAGEMENT IN POST

OP UNIT

To provide care until the

patient has recovered from

the effect of anesthesia.

Assessing the patient

Monitor vitals-pulse volume

and regularity, depth and

nature of respiration.

Assessment of patient’s O2

saturation.

Skin colour.

Check the level of consciousness.

Ability to respond to commands.

Maintaining IV Stability

Hypovolemic shock: can be avoided by timely administration of IV Fluids, blood and blood products and medication.

Replacement of fluids.[colloids and crystalloids]

Keep the patient warm.

Monitor intake and output balance.

Monitor the vitals continuously with the patient condition.

Shock PositionKeep the patient in shock position, flat on back, legs

elevated at 20 degree+knee kept straight.

Renal and urinary

complications Acute renal failure

1.Prerenal :Hypotension

Hypovolaemia

2. Renal : Nephrotoxic drugs (gentamicin, diuretics,

nonsteroidal anti-inflammatory agents)

Sepsis

Surgery involving renal vessels

Myoglobinuria

3.Postrenal :Ureteric injury

Blocked urethral catheter

Post op urinary retention

Post op urinary infection

MAINTAIN INTAKE AND OUTPUT

The main complications after

Abdominal surgery

Paralytic ileus

Bleeding or abscess

Anastomotic leakage

Orthopedic surgery

Compartment syndrome

Thyroid &neck surgery

Asphyxia

Plastic surgery

Viability of flaps

Thoracic surgery

fluid overload

haemothorax or pleural effusion

Neurosurgery

Increased ICP

Urology

Catheter patencey

Bladder irrigation

Vascular surgery

patency of grafts and

anastomoses(Doppler

ultrasound)

General complication &

management protocol

Pain

Fluid &nutrition

Nausea and

vomiting

Bleeding

DVT

Hypothermia

&shivering

Fever

Infection

&prophylaxis

Pressure sore

Confusional

state

Drain

Wound care

Wound

dehiscence

KEEP THE PATIENT WARM

Use warmer(Bair

Hugger) blankets

Use warm lights

Controlling Nausea+Vomitting

These are common problem in post operative period.

Medication can be administered as per doctor’s order.

Example:

Inj Metaclopramide

Inj Ondansetron

( Emeset )

Relieving pain +Anxiety Administer opioid

analgesia as per

Doctor’s order.

Epidural analgesia.

NSAIDS.

Psychological support to

relieve fear+To give

support.

WHO analgesic ladder

The WorldHealth Organization’s booklet

advises use of a ‘pain step ladder’:

First step. Simple analgesics: aspirin,

paracetamol, non-steroidal anti-inflammatory

agents, tricyclic drugs or anticonvulsant drugs.

Second step. Intermediate strength opioids:

codeine, tramadol or dextropropoxyphene.

Third step. Strong opioids: morphine

(pethidine has nowbeen withdrawn).

ASSESSMENT OF THE SURGICAL SITE

Haemorrhage

It is a serious complication of surgery that resulting death.

It can occur in immediate post operatively or uptoseveral days after surgery.

If left untreated,cardiacoutput decreases and blood pressure and Hb level will fall rapidly.

Blood transfusion if necessary.

The surgical site+incisionshould always be inspected.

If bleeding,pressuredressing are placed.

If the bleeding is concealed,the patient is taken in OR for emergency exploration of concealed haemorrhage in body cavity.

Post operative confusion

Discharge from the Post Operative

UnitA patient remains in the post op unit, until the patient has fully recoverd from anesthesia.

Following measures are used to determine the patient ready for disharge from post operative unit.

Stable vital signs

Orientation to Person

Place

Time or events

Adequate oxygen saturation level.

Urine out put at least 30ml/hour

Minimal pain.

Adequate respiratory function.

Aldrete score more than ‘ 9 ‘ before shifting from

Post Operative Anaesthesia Care Unit

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

Teaching, Patient Self Care

Expected out comes

Immediate post

operative changes

Written instructions

like

Wound care

Activity+dietary

recommendation

Medications

Follow up

References

ANNALS of SURGERYVOl. XCII JULY, 1930

NO

Bailey & Love’s Short Practice of Surgery

(26th Ed.)

Essential surgery PROBLEMS, DIAGNOSIS

AND MANAGEMENT 5th edition

THANK YOU