13/06/2013

POST-OPERATIVE CARE

Titis Kurniawan, MNS

Outline

Criteria for Discharge from RR

Post-operative Pain
Post-Operative Bleeding & Shock
Post-operative Hypothermia
Post-operative Fever
Post-operative Nausea-vomiting
Post-opertaive UTI
Post-Operative DVT
Post-operative Wound complication
Post-Operative discharge planning

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Post Anesthetic Criteria For Discharge

Post-Operative Pain

Consider as normal  positive impacts;

Warning tissue damage

Induce immobilization  improve wound healing

Negative impacts:

Physical & emotional suffering

Sleep disturbance
>> Oxygen consumption
<< bowel movement  Nausea & vomiting
Immobilization  thromboembolism, pneumonia
Unmanaged  chronic pain

Assessment

Very important 5th vital sign Persistent/increase postoperative pain  abnormal

Utilize the appropriate pain measurement

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..Post-Operative Pain

Related factor

Patients related factors; culture,
gender, anxiety, experience

Surgical factor; incision, type of
surgical (abdominal, thoracic,
supeficial

Management

See pain management material

Opioid  anticipate side effect
(tolerant/addiction)

Patients controlled analgesia (PCA )

Post-Operative Bleeding & Shock

Sign & symptoms  poor tissue perfusion (hypotension,
pallor, sweating, tachycardia, oliguria, peripheral
vasoconstriction)  progressive metabolic acidosis 
shock  multiple organ failure  death.

Causes of Hypotension in early post-operation:

Early onset  Over sedation/Effect of anesthesia or Continuous
Bleeding

Late onset  Sepsis

Type of Shock

Hypovolemic  volume deficit (dehidration/bleeding)

Cardiogenic  cardiac problem (miocard infarct/tamponade)

Septic  infection

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Post-Operative Hypothermia

Hypotermia (body temperature < 35oC)

Causes:

Exposes to hypothermic environment (operating
room, exposed body surface, surgical duration, etc)

Anesthesia  vasodilatation  >> lost of calor

Age related factor (too old/young risk for
hypothermia)

Complication  When body temperature <

32oC  coagulopathy (<< platelet , fibrinolitic,
cascade function)

Post-Operative Fever

Six Ws

Wind = pneumonia
Wound = infection
Walking = thromboembolism (DVT)
Water = Urinary tract infection (UTI)
Waste = abscess
Wonder drug = medication

Other causes; blood transfusion reaction, dehidration, thyrotoxicosis

Work up

Wound examination & pus/discharge culture

Urine analysis & culture
Routine blood exam & Blood culture
X-ray
Sputum examination
Infection  Broad spectrum antibiotic

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Post-Operative Nausea & Vomiting (PONV)

Risk factors;

Patients related factors; women, non-smoker, history of
motion sickness/PONV, young (16 years old), >> anxiety

Anesthesia related factors; Nitrous oxide, intra-post surgery
opioids

Surgical related factors; duration or surgery, type of surgery
(uurology, gynecology, strabismus, THT)

Management

Prevention  Use regional anaesthesia, Use of intraoperative
supplemental oxygen, Use of intraoperative hydration,
Minimize intra-post surgical opioids

Propilaxis; Ondansetron , dolasteron, graniseton,
dexamethason,

Post-Operative Urinary Retension (POUR) &

Urinary Tract Infection (UTI)

POUR;

Causes; procedural (anorectal, pelvic injury, &
anesthesia related causes

Risk factor; older age, male, drug (anticholinergic)
co-morbid diseases (neurology), over hydration
during the surgery procedure

Impact; << reflux  damaging nephron/kidney
function

Management; urinary catheter & bladder training

UTI

Side effect of urinary catheterization

Management; labeling & daily urinary catheter care

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Post-Operative Ileus (POI)

Is disruption of the normal propulsive ability of the gastrointestinal

tract  obstruction  >> Post operative pain, >> nausea & vomiting,
delay enteral nutrition  hospitalization

Pathophysiology;

Spinal and local sympathetic neural reflexes

Local and systemic inflammatory mediators

Exacerbating factors: opioid analgesics, intraperitoneal surgery,
degree of bowel manipulation, open (vs. laparoscopic) surgical
procedures, hypokalemia

Sign & symptoms; abdominal distension, lack of bowel

sounds, and lack of passage of flatus or stool, abdominal pain,
nausea, vomiting, anorexia,

Management

Nonpharmacological; early enteral feeding, chewing gum, early
ambulation

Pharmacological; NSAID, laxative, epidural anesthesia

Post-Operative Thromboembolism

Deep Vein/Venous Thromboembolism (DVT)

Is is the formation of a blood clot (thrombus) in a deep vein, predominantly leg

Sign; pain, swelling, redness, warmness, and engorged superficial veins,
sometimes asymptomatic

Causes; Virchow's triadvenous stasis, hypercoagulability, and changes in the
endothelial blood vessel lining (such as physical damage or endothelial
activation)

Risk Factors; older age, immobilization, major surgery, central venous
catherization, smooking

Treatment; anticoagulant, thrombolysis, mobilization, stocking, surgery,

Pulmonary Embolism (PE)

Is blockage of the main artery of the lung or one of its branches by a substance
that has travelled from elsewhere in the body through the bloodstream
(embolism)  late DVT impact

Signs; sudden in onset and include dyspnea (shortness of breath), tachypnea
(rapid breathing), chest pain of a "pleuritic" nature (worsened by breathing),
cough and hemoptysis (coughing up blood), cyanosis

Causes & risk factors; see DVT

Treatment; anticoagulant, thrombolysis, vena cava inferior filter, surgery

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Post-Operative Wound Complication

Wound Evisceration

Is rupture of all layers of the abdominal wall & extrusion
of abdominal viscera

A surgical emergency, cover the intestine with sterile
saline moistened towel.

Wound Infection

Signs; excess discharge, pus, necrotic tissues,
malodor, fever

Causes; malnutrition, dirty/contaminated wound,
improper wound dressing, DM, age, medication

Wound Dehiscence

Is Separation of an abd. wound involving the
anterior fascial and deeper layers

Causes ; infection, malnutrition, DM, age,
obesity, surgical techniques (vertical incision,
drain insertion)

Incisonal Hernia

Is a type of hernia caused by an incompletely-healed
surgical wound

Causes ; infection, delayed wound healing, >>
intraabdominal pressure (cough)

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Post-Operative Discharge Planning

Assessment

Learning need; knowledge, motivation/skill

Level of dependency; minimal, partial, totally

Squele; disabilities, loss of body part,
loss/reduce function of body part 
psychological problem

Life style adjustment

Planning

Provide information; follow up care, wound care,
pain management, complication (sign-symptoms
& immediate action needed), medication, diet,
activities, etc

Provide info related support group

Maintain patients self-concept  provide
privacy, hygiene, family involvement, pleasant
environment

Phone number/staffs