Post Op Care and Surgical Complications PT1

Post- Op Care Goals

-examine for early complications
-remove surgical drains and tubes ASAP
-ambulation
-pain management
-monitor fluid and electrolyte balance

Post-Op Care Phases

1. PACU: Immediate
2. Hospitalization: Intermediate
3. Home or Long-term care: Convalescent (transition to full recovery)

________ and ________ phases are directed at maintaining homeostasis, treatment of pain, prevention and early detection of complications

immediate and intermediate

PACU (post anesthesia care unit) is also known as the ___ post op period

immediate

**BP, HR, and RR: heavily monitored vitals
**ins and outs: monitored

PACU

-trained personnel and equipment
-recovery area after surgery
-discharged when CV, pulm, and neuro functions at baseline

typical time a patient is in the PACU

1-3 hours

The intermediate post-op period occurs after ___ ____ until hospital discharge

anesthesia recovery

Intermediate Post- Op Period

-wound care
-drain management
-pulmonary care
-fluid and electrolyte care
-GI tract care
-pain management

Wound Care

-healing starts within hours after operation
-deeper structures sealed off from environment within 48 hours

wounds should be healed with ______________

aseptic technique

dressings can be removed post-op day ______

3 or 4 (**removed sooner if wet/ contaminated or symptoms of infection)

sutures/ staples removed post-op day ______ and replaced with tape

5

a full shower can be done on post-op day ______ if incision healing well

7

Surgical Drains

-prevent or treat unwanted accumulation of fluid
-evacuate air from pleural cavity
-placed in separate incision
-handle in aseptic technique and remove ASAP

Closed Surgical Drains

-preferred type

-connected to a suction device

-Jackson-Pratt and Blake drains

Open Surgical Drains

-more prone to contamination
-Penrose drain

Decreased Vital Capacity

-common after abdominal surgery

-Immediate: 40% of pre-op values

-POD 7: 60-70% of pre-op values

Decreased Funcitonal Residual Capacity

POD 1: 70% of pre-op levels and gradually returns to normal over 10 days

Change in Pulmonary Function

-due to pain, neural reflexes, abdominal distention, shallow breathing
-decreased vital capacity and decreased functional residual capacity

Decreased Pulmonary Function RFs

-obesity
-smoking
-pre-existing lung disease
-elderly

Pulmonary Concerns

-atelectasis (biggest concern; MC complication)

-pulmonary edema

-pneumonia

Pulmonary Preventative Measures

-deep breathing and coughing
-incentive spirometers
-early mobilization
-manage comorbidities appropriately

Deep Breathing Exercise Example

slow deep breath, hold for 2-5 seconds, slowly exhale

Fluid Maintenance Requirement

-weight (kg) x 30
-normal: 1500-2500 mL/day

Conditions requiring need for extra fluids

-fever

-hyperventilation

-loss during surgery

-condition increasing catabolic rate

-loss from drains

-from tissue edema and ileus (third space loss)

Conditions requiring need to measure electrolytes

-extra fluid losses than expected
-sepsis
-pre-existing electrolyte abnormality
-renal insufficiency (kidney disease)

Weight should be taken before surgery and can be used after surgery to evaluate ___ ____

fluid status

with a laparotomy GI peristalsis temporarily _________

decreases

peristalsis in the small intestine usually returns within _________

24 hours

peristalsis in the right colon usually returns within _________

48 hours

peristalsis in the left colon usually returns within ____________

72 hours

used if patient develops gastric distention, vomiting or ileus

NG

Advancing the diet

-fully conscious, NG tube out, GI function returned
-start with liquids and advance to soft foods

Antiemetics

-Ondansetron
-Prochlorperazine

Post-Op Pain Control

-Morphine
-Hydrocodone/ APAP
-Ketorolac
-PCA

PCA

-patient controlled analgesia
-med administration under patients control but within safe limits

Post- Op Bowel Protocols

-usually implemented before a patient has a problem

-Docusate

-Bisacodyl

-Milk of Magnesia

Post-Op Fever are usually ___ if in the immediate phase

benign

5 Ws of post op fever

-wind (pulm)
-water (UTI)
-wound (infection)
-walking (DVT/PE)
-wonder drug (meds)

Wind

-fever occurring on POD 0-2

-atelectasis

-pneumonia (secondary to atelectasis, ventilator, aspiration)

UTI

-fever occurring on POD 3-5

-MC due to indwelling catheter

Wound

infection or abscess causing a fever on POD 5

DVT/PE

fever on POD 7

Post-Op Pulm Complications

-most common single cause of morbidity
-2nd MC cause of death in patients >60 yo

med interactions and adverse reactions can cause a post-op fever ___________

anytime

Atelectasis S/S

-fever
-tachypnea
-tachycardia
-low O2
-scattered rales
-decreased breath sounds

prevention of atelectasis

deep breathing and incentive spirometry

Atelectasis diagnostics

CXR

Atelectasis Treatment

-chest percussion
-coughing
-deep suctioning

Pneumonia

-secondary to atelectasis and or stagnant fluid
-can be ventilator associated or aspiration related

Pneumonia Diagnosis

-CXR
-CBC
-+/- sputum culture

treatment for pneumonia

abxs

Pneumothorax

-accidentally by procedure
-spontaneously in patients with underlyng lung disease

pneumothorax diagnostics

CXR

treatment for pneumothorax

thoracostomy

Pulmonary Embolus

-blood, air, fat
-thromboembolism from DVT MC (fat emboli MC if long bone fx or joint replacement)

PE diagnostics

-if stable: CTA
-if contrast allergy or dec kidney function: V/Q scan

PE treatment

-if stable: anticoagulation
-if unstable: tx shock, thrombolysis or suction embolectomy

UTI can be caused by pre-existing ___, ____, or ____

contamination, urinary retention, or instrumentation

UTI S/S

-fever
-dysuria
-urinary frequency or urgency
-flank pain

UTI diagnostics

urinalysis and urine culture

UTI treatment

abxs

Urinary Retention

due to interference with neural pathways responsible for normal emptying of bladder or over distention of bladder

urinary retention diagnostics

bladder US

urinary retention treatment

catheter