Post operative care

post operative care

The aim of postoperative care is to provide the patient with as quick, painless and safe a recovery from surgery as possible

Patient recovery

Once patients are fully conscious and comfortable and their vital functions are stable they are transferred to the general ward;
however, patients who are at high risk may be transferred to a high-dependency or intensive care unit.

POSTOPERATIVE CARE OF THE PATIENT

After the operation the patient should be safely transferred to the
bed from the operating table, under the supervision of the anaesthetist
and surgeon.
A clear operative note should be written immediately. This should include instructions on the postoperative care, including the thresholds for calling back the surgeon.
The following details should be included in the operative
note:
1 Patient’s details – full name, date of birth, hospital number,
address, ward.
2 Date (and start/finish time) of operation.
3 Operating room.
4 Name of operation.
5 Surgeon, assistant, anaesthetist.
6 Anaesthetic type.
7 Patient positioning and set-up.
8 Was a tourniquet used, were antibiotics given, was the patient catheterised, type of skin preparation, method of draping.
9 Tourniquet time, if applicable.


10 Operative details including:
• incision;
• approach;
• findings;
• procedure (appropriate illustration, if appropriate);
• complications, untoward events;
• implants used;
• closure, including suture material used;
• dressing;
• postoperative state (e.g. distal neurovascular status);
• type of dressing used.
11 Postoperative instructions relevant to surgery:
• observations required and frequency, e.g. 4-hourly pulse
and blood pressure measurements for 24 hours;
• possible complications and action to be taken if complications
occur, e.g. if blood loss exceeds 500 ml in a drain
call the surgeon;
• treatment, e.g. intravenous fluids;
• time lines for patient recovery, e.g. when to mobilise,
when to resume normal oral intake, the need for physiotherapy,
allowable movements, dressing changes.
12 Discharge and follow-up details; instruction for sutures,
splints, casts


SOAP Subjective Objective Assessment Plan

• Subjective Ask the patient how he is.

- Objective
Check the patient’s charts for temperature, pulse and respiration
(TPR), fluid balance
Specific examinations also need to be recorded, such as
- Bowel sounds after abdominal surgery or
- Distal neurovascular status after orthopaedic procedures.
- Regularly review nutritional status in those patients who may
be in negative nitrogen balance.
- Review all laboratory results and investigations.
- Review the drug chart to ensure that drugs are not being continued unnecessarily.
- Record all relevant findings (both negative and positive) clearly in the notes

Assessment

Review all of the information obtained under S and O and list the
problems that the patient is now facing
.
Plan
Formulate and agree a plan with the patient and the staff and
record that plan in the notes.
This includes anticipating when discharge from hospital might occur and ensuring that everything is in place (e.g. social services) to prevent any unnecessary delay.
This is the minimum set of notes required on each patient every day.
These notes should be dated, signed and legible.


Pain management
Optimal management of acute postoperative pain requires planning,
patient and staff education and tailoring of the regimen to
the type of surgery and the needs of the individual patient.

Patients vary greatly (up to eightfold) in their requirement for analgesia, even after identical surgical procedures.
Under treatment results in unacceptable levels of pain with tachycardia
hypertension, vasoconstriction .
Painful abdominal and thoracic wounds restrict inspiration, leading
to tachypnoea, small tidal volumes and inhibition of effective
coughing and mobilisation. This predisposes to chest infection
delayed mobilisation, deep venous thrombosis, muscle wasting
and pressure sores
Pain,the fifth vital sign’
requires regular pain measurement, with staff to be alerted in the
event of high scores .
The joint working party report also encouraged
the use of combined ‘multimodal’ analgesia comprising local anaesthesia and simple analgesics such as paracetamol (acetaminophen)and non-steroidal anti-inflammatory drugs (NSAIDs)
with opioid drugs

Simple analgesic agents

In minor surgery and when the patient is able to eat after surgery,
NSAIDs and paracetamol may be sufficient
- Codeine phosphate is commonly favoured after intracranial surgery
because of its intermediate respiratory depressant effect; however,
it should not be given intravenously as it can then cause profound
hypotension. Constipation is also not uncommon with codeine
- Rectal and intravenous diclofenac or intravenous
ketorolac are commonly used NSAIDs in the perioperative
period.
Stronger analgesic agents
With adjuvant analgesics in combination, regular intramuscular
morphine injection can provide effective treatment for the majority
of surgical patients

Techniques for postoperative pain relief

■ Regular intramuscular injections – may get pain
breakthrough
■ - Local anaesthetic block – ideal if it works
■ Indwelling epidural – good pain control
-opioids may depress respiration
■ Continuous infusions – reduce oscillations in pain relief
but risk overdose
■ Patient-controlled analgesia – pain relief titrated to
patient’s needs

Fluid ,electrolyte management

1- give daily requirement
2- add fluid lost by
bleeding,
NGT,
drains

SPECIFIC POSTOPERATIVE

COMPLICATIONS
Respiratory complications
Shortness of breath
The commonest cause of postoperative dyspnoea (shortness of
breath) and rapid shallow breathing is alveolar collapse or atelectasis.
The diagnosis is confirmed by clinical examination and
radiography). Atelectasis usually responds to chest Physiotherapy
Causes of acute postoperative shortness of breath
■ Myocardial infarction and heart failure
■ Pulmonary embolism
■ Chest infection
■ Exacerbation of asthma or chronic obstructive airway
Disease


Cyanosis
In patients whose airway is clear but who develop cyanosis the problem may be in the lungs or in the circulation.
Common problems in the lung may be acute bronchospasm

Cardiovascular complications

Hypotension
Whatever the cause of hypotension, the emergency treatment
requires an increase in the fluid input with administration of high-flow oxygen
Low blood pressure postoperatively
■ dehydration
■ anaesthetic
■ blood loss
■ morphine
■ myocardial infarct

Hypertension

High blood pressure may be dangerous in patients with ischaemi heart disease or cerebrovascular disease as it may precipitate infarction or stroke.
Most causes of hypertension relate to inadequate
pain relief or anxiety and usually settle with appropriate
analgesia.


Deep vein thrombosis
There are several risk factors for deep vein thrombosis (DVT).
Most patients with postoperative DVT show no physical signs;
however, they may present with calf pain, swelling, warmth, redness and engorged veins.
On palpation the muscle may be tender
and there is a positive Homans’ sign (calf pain on dorsiflexion of the foot); however, it must be emphasised that this sign is neither
specific nor sensitive

Gastrointestinal complications

Postoperative nausea and vomiting
This is a common problem

Urinary complications

Urine output (oliguria/anuria)
Oliguria may be defined as urine output less than the minimum obligatory volume (0.5 ml kg–1h–1).
The commonest cause of oliguria postoperatively is reduced
renal perfusion resulting from perioperative hypotension or inadequate fluid replacement