general post operative care

summarizing whole topic briefly.

1. General Post Operative care Dr.VIMI JAIN Oral And Maxillofacial Surgery

2. Contents Introduction Post anesthesia care unit Vitals monitoring Fluid ,electrolyte & acid base balance Post operative medication Local wound examination Nutrition Renal/urinary assessment Gastrointestinal assessment Laboratory assessment Bed care Adjunct care Discharge Follow up

3. INTRODUCTION Care in immediate postoperative period, including the operating room, postanesthesia care unit (PACU)& unit. Extent depends on the individual's pre-surgical health status, type of surgery,day -surgery setting or in the hospital. Goal - prevent complications such as infection . - promote healing of the surgical wound - return the patient to a state of health.

4. Postanesthesia care unit (PACU) Assessment in PACU. -patient's airway patency, -vital signs -level of consciousness Discharged from the PACU - Aldrete scale

5. Respiratory System Assessment Patient airway ,adequate gas exchange Rate,pattern,dept of breathing Breath sounds Accesory muscle use Snoring stridor Respiratory depression or hypoxemia

6. Respiratory care -Mechanical ventilation -Pain control -Simple breathing exercises -Correction of humidity deficit Prevention Respiratory Complications .

7. Pulse oximetry Oxygen saturation should be above 95% on air Oxygen canula-44% O2 Oxygen mask-60% O2 at 6 to 10L/MIN Oxygen mask with reservoir-90-100% O2

8. CARDIOVASCULAR ASSESSMENT Heart Rate Tachycardia: hemorrhage &/or shock pain fluid overload anxious Blood Pressure Hypotension- hemorrhage &/or shock Hypertension -anesthetic , inadequate pain control.

9. Capillary refill time Assess circulatory status Colour & temperature of limbs Identification reduced peripheral perfusion.

10. Body temperature Hypothermia : -Children & older adults are at risk. -Bacterial infection or sepsis. -Shivering :- anaesthesia Use a bair hugger(forced-air blanket) and blankets Hyperthermia -infection Antipyretics , fanning ,tepid sponging.

11. Level of consciousness -should respond to verbal stimulation, -be able to answer questions and -aware of their surroundings Assessment of consciousness - The AVPU scale . Change in the level of consciousness -shock

12. Fluid,electrolyte &acid- base balance I & O Hydration status IV fluids Vomitus Urine Wound drainage NG tube drainage Acid-base balance

13. Three principles: 1.Correct any abnormalities 2.Provide the daily requirements 3.Replace any abnormal & ongoing losses. Variation – age, gender, weight , body surface area.

14. ELECTROLYTE MONITORING Hyponatremia - water excess- restrictrion of , electrolye free nutrition. Hypernatremia - abnormal Na retention or abnormal Na reabsorption due to inceases ADH Hyperkalemia -severe trauma, renal failure- causes arrythmias

15. Maintenance fluids calculation For the first 0 to 10 kg - 100 mL /kg per day For the next 10 to 20 kg - 50 mL /kg per day For remaining kgs - 20 mL /kg per day (Schwartz's) 4 ml/kg/hr – first 10 kg 2 ml/kg/hr – second 10 kg 1 ml/kg/hr – additional kg (Fonseca) 1000 ml RL 1500ml D5 2000 ml of 5% dextrose(in water) 500 ml of 5% dextrose (in saline) 40 mEq of K, Cl ( G.O.Kruger ) (Schwartz's) 30-100 mEq Na, K

16. Post operative medication To prevent infection. Pain control Anti-inflammatory To promote wound healing Supplementary

17. Local Wound Examination Immediate post operative Healing & healthy infected unhealthy site

18. Hemorrhage Localised Generalised . Reactionary Secondary

19. Sutures Intact & healthy suture Infected Loss of continuity No approximation

20. Topical medicine Povidone iodine ointment Neosporine powder Betadine spray Antiseptic ointment Clotrimazole powder

21. Drains Corrugated rubber drain Suction unit drain Intraoral rubber drain

22. pressure dressing gauze dressing Dressing Intact Frequency of change Removal

23. Nutrition NPO (nothing by mouth) at least until their cough and gag reflexes have returned. Dry mouth following surgery- oral sponges dipped in ice water or lemon ginger mouth swabs. Oral- soft cold liquid Parentral-protein,carbohydrate & vitamin rich through feeding tubes

24. Renal /Urinary System Assesments -Check for urine retention -Other sources of output( sweat,vomitus,diarrhoea stools) - Report urine output Micturition - After GA when this reflex acts the pressure in the bladder rises sufficiently to cause the sphincter to relax and the detrusor muscle to contract. -Encouraged by mobilisation - Catheterisation

25. GASTROINTESTINAL SYSTEM Assessments -Post operative nausea/vomiting common -Peristalsis may be delayed up to 24 hrs -monitor bowel sounds Constipation : organic or functional? Organic -partial obstruction of the lumen. Functional -defective movements of the colonic musculature, -deficiency in bulk of faeces due to feeding with fluid diets. Rx-Feeding fruit, vegetables and whole meal cereals ,laxatives.

26. Laboratory assessments Analysis of electrolyte CBC Specimen for C &S ABGs Urine & renal lab tests Others( ECG, seum amylase,blood glucose)

27. Bed care Bed making Mouth care Bed bath Back care Hair,fingernail,toe nail care Perineal care Position of patient

28. Mobilisation Aim To encourage good pulmonary ventilation . To reduce venous stasis. For those who cannot mobilise , - Physiotherapy - Pneumatic calf compression devices - Heparin

29. Physiotherapy Respiratory exercises Pneumonia Blood clots Clear lungs circulation to the extremities pain control. Increases venous flow

30. Cold And Hot Application Cold application compression therapy pain control prevention of swelling Warm application after 48 hrs increases circulation reduction of swelling

31. Communication Reassurance in the immediate post-operative period Procedure Any unexpected finding or complication encountered during the procedure Presence of the patient's relatives.

32. 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. Discharge note 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 . (WHO/EHT/CPR: WHO Surgical Care at the District Hospital 2003)

33. Followup To assume responsibility for the patient's after-care until all possibility of post-OP complications is past. Long-term follow-up

34. RECENTS Additional wound management products/therapies that may be considered: Topical negative pressure (TNP) therapy Growth factors (such as platelet-derived growth factor) Antibacterial honey Larva therapy (maggots) Anti-scarring agents (such as transforming growth factors) Antiseptic-impregnated  sutures  (such as triclosan coating).

35. NAME OF DRUGS DOSE INDICATIONS/ USES Atropine Sulfate ( anticholinergic ) 0.6 mg IM/IV Vasovagal shock Prevention of Bradycardia Preanesthetic medication To reduce salivary secretions. Adrenalin tartarate 1:1000 0.5-1mg IV/SC or intracardiac to be repeated every 5 min. Cardiac arrest Anaphylactic shock Sever laryngobrancheal spasm. Dexamethasone 4-20mg of base IM/IV 5-50mg per day orally Cereberal edema Allergic conditions Antiinflamatory Shock Immunosupperession Sodium hydrocortisones sodium succinate / hemisuccinate TN- Lycortin S 100mgIM/IV Stat; may be repeated once or twice Shock Status asthmaticus Acute adrenal insufficiency Anaphylactic reaction Allergic reactions

36. NAME OF DRUGS DOSE INDICATIONS/USES Pheniramine maleate . TN- Avil Orally-25-50mg tabs. 25 mg tid 50mg bid Ampule /vial 1-2ml IM 12 hrly Allergic reaction Rigors Sedatives Anaphylactic shock Angioneurotic edema Diazepam Orally 5-40mg Inj. 2ml Antianxiety Acute muscle spasm Spastic neurological disease Tetanus Orthopedic manipulation Deriphyllin ( bronchodialator ) 2-4ml 2-3 times IV Broncheal asthma Cardiac insufficiency Central respiratory disorder Renal & cardiac edema Frusemide . TN- lasix Orally 40 mg tabs. In edema 20-80 mg single dose daily. IV-10 to 20 mg over 1-2min Edema in congestive heart failure Hepatic or renal disease Toxemia of pregnancy Mild & moderate hyertension Cerebral edema Isosorbide dinitrate Sublingual 5-10 mg for immediate action, orally 5-10 mg 6 hrly Angina pectoris

37. NAME OF DRUGS DOSE INDICATIONS/USES Pheniramine maleate . TN- Avil Orally-25-50mg tabs. 25 mg tid 50mg bid Ampule /vial 1-2ml IM 12 hrly Allergic reaction Rigors Sedatives Anaphylactic shock Angioneurotic edema Diazepam Orally 5-40mg Inj. 2ml Antianxiety Acute muscle spasm Spastic neurological disease Tetanus Orthopedic manipulation Deriphyllin ( bronchodialator ) 2-4ml 2-3 times IV Broncheal asthma Cardiac insufficiency Central respiratory disorder Renal & cardiac edema Frusemide . TN- lasix Orally 40 mg tabs. In edema 20-80 mg single dose daily. IV-10 to 20 mg over 1-2min Edema in congestive heart failure Hepatic or renal disease Toxemia of pregnancy Mild & moderate hyertension Cerebral edema Isosorbide dinitrate Sublingual 5-10 mg for immediate action, orally 5-10 mg 6 hrly Angina pectoris

38. NAME OF DRUGS DOSES INDICATIONS/USES Oxygen 3-5 lit/min Hypoxia Shock Cardiorespiratory failure Pethidine 50mg IM Severe pain Preanesthetic medication

39. References Principles of monitoring postoperative patients Cathy Liddle ,school of professional practice, department of skills and simulation, Birmingham City University.31 May, 2013 Barone , C. P., M. L. Lightfoot, and G. W. Barone . "The Postanesthesia Care of an Adult Renal Transplant Recipient." Journal of PeriAnesthesia Nursing 18, no.1 (February 2003): 32 41.

40. Smykowski , L., and W. Rodriguez. "The Post Anesthesia Care Unit Experience: A Family-centered Approach." Journal of Nursing Care Quality 18, no. 1 (January-March 2003): 5-15. Wills, L. "Managing Change Through Audit: Post-operative Pain in Ambulatory Care." Paediatric Nursing 14, no.9 (November 2002): 35-8.