Care of a surgical patient

Pre and post operative care of surgical pateint

1. CARE OF A SURGICAL PATIENT Presented by: Sahar Afshan Kanza Islam

2. Successful results require proper pre-operative and post-operative care of the patient undergoing surgery. A definitive diagnosis , correct indication of the surgical procedure should be emphasized , all clinical skills and available investigations should be used to reach the diagnosis. Assessment of good health o f patient should be ensured , iron and other dietary deficiencies should be compensated before surgery.

3. PRE-OPERATIVE PREPARATION: Routine preparation includes : History-In addition to a detailed history , questions regarding co-existing diseases(diabetes , HTN etc),steroid or any other drug intake or allergies should be asked . Physical examination-a detailed physical examination should be carried out for important systems i.e cardiovascular , pulmonary, hepatic and renal . Investigations- Hb %,blood group , Rh factor , urinalysis should be carried out . For major gynaecological operation , BUN, creatinine and serum electrolytes are important .

4. Good general health, explanation of the process to the patient and informed consent from patient should not be avoided. Preparation of bowel-Preferably, bowel should be empty before a major surgery, one of the following are used : -Dulcolax suppository is given on the morning of operation . -Two Saline Enemas are given, first enema is given on evening prior to surgery and second on the morning of surgery.

5. Night Sedation-important to wipe off anxiety . Preparation of abdominal skin and vaginal walls-skin of abdomen and vaginal walls should be checked for infections . Omission of meals-Patient is advised to take fluids only up to 6 hours before surgery . Pre-operative medications-Tranquilizer,H2 receptor antagonist , antacids are given .

6. Prophylactic antibiotics-antibiotics are given either in a single dose or 2 hours prior to surgery or in three doses; first dose is given prior to surgery, second is given intraoperatively and last is given 8 hours after surgery. 1-Inj. Cephalosporins 2g I/V 2-Inj. Beta lactamase 2g I/V Fitness of the patient for anaesthesia should be assessed by anaesthesiologist . CARE IN OPERATING THEATRE: Anaesthesia : minor; for minor procedures( EUA,minilap , hysteroscopy ) require following: -Inj. Thiopentone sodium 250 to 300mg I/V -Inj. Propofol 100-150mg I/V -Inj. Ketamine HCL( Calypsol ) 500mg/ ampuole .

7. Major ; - general anaesthesia . - spinal anaesthesia -for lower abdominal and pelvic surgery - epidural and caudal anaesthesia -injected outside dural space . Route of administration in epidural anaesthesia is same as in spinal and in caudal anaesthesia , it is through sacral hiatus. Position of the patient Lithiotomy position – EUA,Laparoscopy , Hysteroscopy , vaginal operations. Trendylenberg’s position – for vaginal and abdominal operations on pelvic organs. Catheterisation – for abdominal operation , hysterectomy, colporrhaphies . Examination under anaesthesia – it is recommended that surgeon should examine the patient under anaesthesia .

8. Preparation of skin and vagina-abdominal skin and /or vagina should be properly cleaned with antiseptic solutions. Various antiseptics used for this purpose are: - Povidon -Iodine -Tincture iodine and Methylated spirit -Hexachlorophene suspension - Chlorohexidine cream - Bonneys blue and other dyes Preferrably , iodine preparation is used . Aseptic technique is employed , sterile gown and gloves should be used and patient is draped with sterile sheets . Daycare Surgery-patient is evaluated thoroughly in outpatient department , admitted on the day of operation and discharged on the same day.

9. POST-OPERATIVE CARE: It depends on type of anaesthesia and extent of surgery.Some instructions to be followed post-operatively include : Shifting of patient-patient should be kept in operating room or in recovery room until she recovers completely from anaesthesia . Breathing pattern of the patient should be monitored and a porter trained in first aid(CPR) should accompany the patient . Position in bed-patient is kept in dorsal position with head turned to one side.Intravenous Ringers solution is given to compensate expected fall in blood pressure as a result of anaesthesia .

10. Routine observations-pulse rate , blood pressure, R/R, temperature should be observed at half hourly intervals for initial 8 hours , then 2-4 hourly for 24 hours and after 24 hours , these signs should be observed 4 times a day . Analgesics-patient undergone major gyaecological operation should be kept well-sedated for the first 24 hours. -Narcotic analgesics: Inj . Pethidine 50-100mg I/M. Inj . Pentazocine ( Sosegon ) Inj . Buprenorphine ( Temgesic ) -Non-narcotic analgesics: Tab Mefenamic acid Tab Naproxen Tab Diclofenac 50mg

11. Patient needs injections during first and second days after operation , when she starts oral feeds , tablets are given then. Wound Catheter-a fine catheter is left in the wound and the other end is brought out through the wound and is attached to a syringe through a bacterial filter. Local anaesthetic ( Bupivacain or Lignocaine 0.25% 0.5%) are given in repeated doses . The catheter is removed on 2 nd or 3 rd day. Intravenous therapy-necessary to compensate fluid or electrolyte loss . Fluid loss is calculated by an estimation based on urinary output , fluid in drains or any insensible loss through skin and lungs.

12. Sodium salt intake should be restricted during first two days because there is sodium retention imediately after operation.When this retention subsides,there is an increased loss of salt,compensated by administration of normal saline or 5% dextrose water intravenously or through oral diet.Under average conditions,2-3 liters are given in 24 hours. Blood transfusion becomes inevitable during the operation or post-operatively if the blood loss is 1 liter or more during the operation. Leg exercises and deep breathing should be encouraged.They reduce the risk of thrombo -embolism and pulmonary complications.

13. Care of urinary bladder: Difficulty in micturition and retention of urine is seen in patients who have been given spinal anaesthesia and those who have undergone vaginal operations( colporrhapies , vaginal hysterectomy etc) Although catheterisation is not preferred and the patient should be encouraged to micturate on her own,but if necessary , it is better to catheterise early under aseptic measures . When catheterisation is frequently required,an indwelling catheter( Fooley’s catheter) is left for 24 -48 hours.

14. Diet-a regimen is followed after operation : -1 st day-after major surgery, oral feeds are avoided until bowel sounds return. If bowel sounds become audible on first post-operative day, oral fluid intake is allowed but in restricted amounts, in order to prevent paralytic ileus . -2 nd day-Oral feeding may be started on 2 nd day on listening to bowel sounds if already not started on 1 st day. If feeding has started on 1 st day and the patient has not developed distention, semi-solids may be given then.

15. - 3rd day onwards-despite anorexia, the patient should be encouraged to take protein and potassium containing foods . Ambulation: Early ambulation helps in reducing risks of developing respiratory and thrombo -embolic complications. On the day of operation, patient should be encouraged to turn to her side and sit up in bed and on 2 nd day, she should sit out and if she can manage, she may be encouraged to walk to the toilet.

16. Care of bowels-patients usually do not move their bowels 2-3 days after major gynaecological surgeries because of fluid diet , it is not required to give laxatives in this period. If constipation is there , a suppository mat be given on 5 th or 6 th post-operative day. Check up and Discharge-after major gynaecological operations, per abdominal and per vaginam examinations are carried out on 8 th to 10 th post-operative day. Stitches of abdominal wall should be removed on 7 th or 8 th post-operative day.

17. Healing of the wound should be rechecked and it should be ensured that there is no bleeding, pus or discharge in the vagina and pelvis. If the conditions are favourable , the patient can be discharged on 4 th to 8 th post-operative day. Follow-up: The protocol of follow-up depends upon the disease and type of treatment. Generally, after any surgery, the patient is seen for the first follow-up after four to six weeks.