Upload
chhabilal-bastola
View
144
Download
3
Embed Size (px)
Citation preview
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