Postoperative care Mosby items and derived items 2005

Postoperative Phase Mosby items and derived items © 2005 by Mosby, Inc.

Postoperative Care • Immediate care: PACU Post Anesthesia Care Unit – Surgical information – Nursing assessments – Interventions – Discharge criteria: ambulatory and acute care surgical settings Mosby items and derived items © 2005 by Mosby, Inc.

Examination • Observations & trend • Cardio-respiratory examinations • Abdominal examination – Abdominal signs – Wounds – Drains • Calf tenderness • Vascular access sites • Blood transfusion Mosby items and derived items © 2005 by Mosby, Inc.

• Overall assessment –Vital signs –Condition of dressings and drains –Comfort level –IV

• Assessment –Respiration –Circulation –Temperature control –Fluid and electrolyte balance –Neurological function –Skin integrity and wound condition Mosby items and derived items © 2005 by Mosby, Inc.

• Assessment –Genitourinary function –Gastrointestinal function –Comfort –Client expectations Mosby items and derived

• Respiratory complications –Atelectasis –Pneumonia –Hypoxemia –Pulmonary embolism Mosby items and derived items

Maintaining a Patent Airway • Maintain ventilation and oxygenation! • Supplemental oxygen as indicated. • Keep head of bed elevated 15 -30 o unless contraindicated. • Use of Oral Airway • May require suctioning. Mosby items and derived items © 2005 by Mosby, Inc.

• Circulatory complications –Hemorrhage –Hypovolemic shock –Thrombophlebitis –Thrombus formation –Embolus Mosby items and

• Gastrointestinal & Urinary complications; –Abdominal distention –Paralytic ileus –Nausea and vomiting –Urinary

• Integumentary complications –Wound infection –Dehiscence –Evisceration –Skin breakdown –Pain Mosby items and

TREATMENT OF POSTOPERATIVE PAIN • • • Analgesic Drug Therapy Opioids Local anaesthetic agents Paracetamol NSAIDS Volatile/Gaseous agents Fentanyl • Routes; • Oral/Transdermal • Rectal • Parenteral (IV, SC) • Spinal/ Epidural/ Regional techniques • Non pharmacological methods Mosby items and derived items © 2005 by Mosby, Inc.

Paraceramol N S A I D S Mosby items and derived items © 2005

Mosby items and derived items © 2005 by Mosby, Inc.

Patient Controlled Analgesia (PCA) Advantages • • Safe Effective good analgesia reduces delay saves nursing time high patient satisfaction, few complications Mosby items and derived items © 2005 by Mosby, Inc.

• Maintaining respiratory function –Positioning and turning –Suctioning –Deep breathing (incentive spirometer), coughing –Comfort –Early ambulation –Oral hygiene –Oxygen Mosby items and derived items © 2005 by Mosby, Inc.

• Preventing circulatory stasis –Leg exercises –TED stockings (Thrombo Embolic Deterrent) –Early ambulation –Positioning –Anticoagulants –Fluid intake Mosby items and derived items © 2005 by Mosby, Inc.

• Achieving rest and comfort –Analgesics –PCA –Pain assessment Mosby items and derived

• Temperature regulation –Warmed blankets –Monitoring for hypothermia and malignant hyperthermia –Assessment for

Time since surgery • 3 -7 days • First 24 hours – Systemic response to trauma – Pre-existing infection • 24 -72 hours – Atelectasis – Urinary tract infection – Chest infection – Wound infection – Intra-abdominal sepsis – Anastomotic leak – Thromobophlebitis – Cl. Diff colitis • 7 -10 days – DVT/PE – Prosthetic infection Mosby items and derived items © 2005 by Mosby, Inc.

Fever • Common after surgery – 27 -58% in first 24 hours – Incidence of infection • Underlying cause dependent on: – Time since surgery – Type of surgery – Associated clinical features Mosby items and derived items © 2005 by Mosby, Inc.

Non infectious causes – Medications (drug fever, malignant hyperthermia) – Blood transfusion reactions – Haematoma – Adrenal insufficiency – AMI (acute myocardial infarction) – Thyrotoxicosis – Alcohol withdrawal – Pancreatitis/acalculous cholecystitis Mosby items and derived items © 2005 by Mosby, Inc.

Treatment options 1. Urine & blood culture 2. CXR 3. Iv A/B 4. Call

• Neurologic function –Orientation to the environment –Level of consciousness Mosby items and

• Maintaining fluid and electrolyte balance –IV therapy –Oral intake when appropriate –Urin

Fluid & electrolyte balance • Fluid replacement 1. Maintenance requirement 2. Replacement of losses

Replacement of losses 1. Actual losses – Bleeding – Vomiting/diarrhoea 2. Ongoing losses –

IV fluids • Crystalloids – N/S – Hartmann’s/Ringer’s lactate – Dex N/5 – 5%

Crystalloids Compos. Hartman N/S 4% Dex N/S Na 131 150 30 Cl 111 150

• Promoting normal elimination and adequate nutrition – Gradual progression of dietary intake – Ambulation and exercise – Adequate fluid and food intake – Elimination aids: fiber, medications – Control of nausea and pain Mosby items and derived items © 2005 by Mosby, Inc.

• Promoting urinary elimination –Normal positioning –Frequent assessment –Assess bladder distention –Input &

Post operative oliguria • Pre-renal: – Hypovolaemia • Blood loss • Under resuscitation – Shock • Sepsis • Cardiogenic • Post-renal: – Calculi – Blood clot – Ureteric injury – BPH – Blocked catheter Renal: ATN- Hypovolaemia -Contrast Nephrotoxic drugs - Acute pyelonephritis Acute glomerulonephritis Mosby items and derived items © 2005 by Mosby, Inc.

Management • Treat underlying cause • Volume resuscitation – Aim U/O ≥ 0. 5 ml/kg/hr (adult) – Monitor vital signs • ICU – ? Inotropic support – Invasive monitoring • Art line • CVL Mosby items and derived items © 2005 by Mosby, Inc.

• Promoting wound healing –Protect surgical site –Prevent strain –Observe healing –Provide wound

• Maintaining/enhancing self-concept – Provide privacy – Maintain client’s hygiene – Maintain a pleasant environment – Offer opportunities for client and family to express feelings and participate in care Mosby items and derived items © 2005 by Mosby, Inc.

Discharge • written and verbal instructions; regarding follow-up care, complics. , wound care, activity, medications and diet. • Give prescriptions and phone numbers. • Discuss actions if complications occur. Mosby items and derived items © 2005 by Mosby, Inc.