6. post operative care with all that us required pptx

Covers post operative teaching, nursing roles, initial management

1. POST OPERATIVE CARE

2. 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 the surgical team especially in the: 1. Post Anaesthetic C are U nit (PACU) 2. Surgical intensive care unit (SICU)

3. P URPOSES 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.

4. 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.

5. PHASES OF POST OP UNIT Two phases- Phase I Phase II

6. P hase 1 (Immediate )/ post- anesthetic 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 to enable you plan post operative care. It is designated for care of surgical patient immediately after surgery and patient requiring close monitoring

7. IMMEDIATE PHASE cont. D ischarge from recovery should be after complete stabilization of cardio-vascular, pulmonary and neurological functions which usually takes 2 – 4 hours S pecial cases should be cared for in ICU.

8. phase ii(Intermediate)/ H ospital stay Care of the surgical patient who has been transferred from the 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. N.B . convalescent phase is after discharge to full recovery

9. AIM OF PHASE I & II Homeostasis Treatment of pain Prevention of complications E arly detection o f complications

10. 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 . And assess the Skin colour.

11. KEEP MONITORING VITALS

12. Continue to check the level of consciousness. Ability to respond to commands . M aintain intake and output Protect airway, By proper positioning of patient’s head, By clearing airway and Oxygen therapy . NB. Be aware of Pharyngeal obstruction as it can occur when the patient lies on the back as there are chances for tongue to fall back.

13. 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.

14. K eep assessing the surgical site Haemorrhage: It is a serious complication of surgery that results into death. It can occur in immediate post operatively or up to several days after surgery . If left untreated, cardiac output decreases and blood pressure and Hb level will fall rapidly .

15. KEEP THE PATIENT WARM   Use warm lights Use warmer( Bair Hugger ) blankets

16. Ensure that you relieve pain and Anxiety Administer opioid analgesia as per Doctor’s order. Epidural analgesia. NSAIDS . Psychological support to relieve fear and to give support.

17. MAINTAIN NEUROLOGICAL FUNCTION Orientation to environment is important in maintain the clients mental status. The nurse should reorient the clients experience that surgery is completed and describe procedure by nursing measure

18. Ensure that you control Nausea + Vomiting Nausea and vomiting occur when there is stimulation of vomiting centre by multiple factors . Adequate treatment of pain, anxiety, hypotension and dehydration will minimize the risk of the patient developing PONV . Medication can be administered as per doctor’s order. Example: Inj. Metoclopramide Inj. Ondansetron ( Emeset )

19. Administer other post operative medication mainly to: To prevent infection. Pain control Anti-inflammatory To promote wound healing Supplementary

20. Take care of the Renal /Urinary System Assessments -Check for urine retention -Other sources of output(sweat, vomitus, diarrhoea stools) - Report urine output • Micturition - After General Anaesthesia when this reflex acts the pressure in the bladder rises sufficiently to cause the sphincter to relax and the detrusor muscle to contract. Ensure that the patient is Catheterized..

21. Ensure Bed care especially: Bed making Mouth care Bed bath Back care Hair, fingernail, toe nail care Perineal care Position of patient

22. Ensure effective communication. Reassurance in the immediate post-operative period should be done before, during and after the Procedure. Any unexpected finding or complication encountered during the procedure should be effectively communicated to both the patient and to the patient's relatives . ACHIEVING REST AND COMFORT Ensure that post operative patients have enough sleep and rest for quick physiological recovery

23. GENERAL POST-OPERATIVE CONCERNS Pain IV nutrition Nausea & vomiting Bleeding Deep vein thrombosis Hypothermia / shivering Fever Prophylaxis against I nfection Pressure sores Confusional states Drains Wound care Wound dehiscence Enhanced recovery Discharge of patients Follow-up in clinic

24. PAIN Nociceptive pain arises from inflammation and ischemia Neuropathic pain arises from a dysfunction in the central nervous system Psychogenic pain is modified by the mental state of the patient Surgical patients may have persistent pain from a variety of disorders including chronic inflammatory disease, recurrent infection , degenerative bone or joint disease, nerve injury and sympathetic dystrophy. Effective analgesia is an essential part Important injectable drugs for pain are opiate analgesics. NSAIDS such a diclofenac, ibuprofen and paracetamol can also be given orally. Commonly inexpensive opiates are pethidine and morphine.

25. FLUID AND NUTRITION Fluid therapy and nutritional support are fundamental to good surgical practice. This requires knowledge of the consequences of surgical intervention and, in particular, intestinal resection. Malnutrition is common in hospital. All patients who have sustained or who are likely to sustain 7days of inadequate oral intake should be considered for nutritional support. The success or otherwise of nutritional support should be determined by tolerance to nutrients provided and nutritional end points, such as weight.

26. BLEEDING The patient’s blood pressure, pulse, urine output, dressings and drains should be checked regularly in the first 24 hours after surgery. If bleeding is more than expected for a given procedure, then pressure should be applied to the site and blood samples should be sent for blood count, coagulation profile and crossmatch. Fluid resuscitation should also be started. Ultrasound or CT scan may need to be arranged to determine the size and extent of the hematoma. If immediate control of bleeding is essential, the patient may be taken back to the operating theatre. If surgical hemostasis is not successful using conservative methods, hemostatic dressings or surgical glue may be tried .

27. DEEP VEIN THROMBOSIS Patients suffering postoperative deep vein thrombosis ( DVT) may present with calf pain , swelling , warmth , redness and engorged veins. However , most will show no physical signs. On palpation, the muscle may be tender and there is a positive Homans ’ sign (calf pain on dorsiflexion of the foot) Venography or duplex Doppler ultrasound is used to assess flow and the presence of thromboses.

28. MANAGEMENT OF DVT Initially starts with intravenous heparin followed by longer term warfarin , should be started. Most hospitals have a DVT prophylaxis protocol. use of stockings calf pumps pharmacological agents, such as low molecular weight heparin

29. INFECTION Prophylactic antibiotics should be administered, in patients who have had foreign material inserted during the operation, including a hip or knee prosthesis in orthopedic surgery or aortic valves in cardiovascular surgery, up to three dose . Prophylactic antibiotics appear to reduce the risk of any contamination developing into infection by destroying bacteria before they are incorporated into the biofilm . Aseptic technic during procedures should be maintained to prevent spread of infections.

30. PRESSURE SORES These occur as a result of friction or persisting pressure on soft tissues They particularly affect the pressure points of a recumbent patient , including the sacrum, greater trochanter and heels Risk factors are : Poor nutritional status Dehydration and lack of mobility Use of a nerve block anesthesia technique Early mobilization prevents pressure sores, while those who are unable to turn in bed should be turned every 30 minutes to prevent pressure sores from developing High-risk patients may be nursed on an air lter mattress, which automatically relieves the pressure areas

31. DRAINS Drains are used to prevent accumulation of blood , purulent fluid or to allow the early diagnosis of a leaking surgical anastomosis . The complications are trauma to surrounding tissues, and act as a opening for infection. The quantity and character of drain fluid can be used to identify any abdominal complication, such as fluid leakage (e.g. bile or pancreatic juice) or bleeding. This lost fluid should be replaced with additional intravenous fluids with the same electrolyte contents. Continued loss of blood through the drain should be investigated for the source. Drains should be removed as soon as possible and certainly once the drainage has stopped or become less than 25 mL/day.

32. WOUND CARE Epithelialization takes 48 hours 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 Tensile strength of wound minimal during first 5 days, then rapid between 5th to 20th day then slowly again (full strength takes 1-2 years) Good nutrition is vital, promotes wound healing

33. WOUND DEHISCENCE Wound dehiscence is disruption of any or all of the layers in a wound . Dehiscence may occur in up to 3 per cent of abdominal wounds and is very distressing to the patient. Wound dehiscence most commonly occurs from the 5th to the 8th postoperative day when the strength of the wound is at its weakest. The patient may have felt a popping sensation during straining or coughing. Most patients will need to return to the operating theatre for resuturing . In some patients, it may be appropriate to leave the wound open and treat with dressings.

34. RESPIRATORY COMPLICATIONS The most common respiratory complications in the recovery room are: Hypoxemia Hypercapnia Aspiration (occurs when unconscious) Pneumonia (later) Pulmonary embolism may occur later in the postoperative period Atelectasis

35. CARDIOVASCULAR COMPLICATIONS Life threatening, but incidence is reduced by appropriate preoperative preparation Postoperative Dysrhythmias Postoperative Myocardial Infarction Postoperative Cardiac Failure Severe hypertension NB: non-cardiac complications ( hypoxia, sepsis ) increase incidence of cardiac complications

36. RENAL AND URINARY COMPLICATIONS 1) Acute Renal Failure : Patients with chronic renal disease, diabetes, liver failure , peripheral vascular disease and cardiac failure are at high risk . ARF is characterized by a sudden reduction in renal output that results in the systemic accumulation of nitrogenous waste. Diagnostic criteria : i. Increase in serum creatinine level > 1.5x baseline ii. Decrease urine output <500 ml/day (20ml/ hr )

37. MANAGEMENT ARF Ascertain cause of ARF If urine output decrease ; Ensure Catheter is not Blocked Correct Hypovolemia And Hypotension Correct Metabolic And Electrolyte Imbalance Treat the cause Stop nephrotoxic drugs Hemodialysis

38. 2) URINARY RETENTION Common with pelvic and perineal operation. Causes : Pain Fluid deficiency Problems with access urinals and bed pans Lack of privacy in the ward

39. 3) URINARY INFECTION Most common due to acquired infection. Patient can come with dysuria and/ or pyrexia. Treatment Adequate hydration Proper bladder drainage Antibiotic

40. 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 . 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