POST OPERATIVE CARE

OF PATIENTS

A PRESENTATION BY

DR.SULEMAN MUMTAZ
POSTGRADUATE
SURGICAL UNIT-II

JINNAH POSTGRADUATE MEDICAL CENTER

 OBJECTIVES
 The purpose of this presentation is to review
Common methods of post-operative care in the
ward at list day.
 In this we will discuss how to use Common
Medications and investigations ,it is not
entitiled to discussion on postop
complications.
 This review is not comprehensive but is intended
to summarise current thought about the practical
management of postoperative care in most
hospital of our Country like JPMC
 Finally specific considerations.
 INTRODUCTION
Post operative care of the patients is most important
part of the management:

 It gives a complete outline of actions to be taken

immediately after surgery to discharge of patient and
follow up.

 Plan laid and followed properly will optimize recovery

and enable early detection of complications.
 Postoperative Care of
Surgical Patient

 Overall assessment
 Vital signs(BP+TPR)
 Condition of dressings and drains
 IV fluid status(Freqeuncy+Amount)
 Urinary output(I/O Charting)
 Temprature Control
 wound condition
 Postoperative Care of
Surgical Pt (cont'd)
 Systemic Assessment
 Respiration(R/R,Chest
Movement,Ressession)
 Circulation(Pulse Character n Volume,Cap
Refill)
 Neurological Status(GCS,Sleep)
 Postoperative Care of
Surgical Pt (cont'd)
 Systemic Assessment
 Genitourinary function(Any Discomfort)
 Gastrointestinal function
Ask for Nausea,Vomiting,Flatus
Look for abdominal distention
Feel for tenderness & rigidity
Listen for bowel sounds
DPR Examination
 Usually we encounter paralytic Ileus.It is a Tympanitic silent
Distended abdomen.
 Keep pt NPO,iv Fluids,NG Intubation.
 ROUNTINE POST OPERATIVE
CARE
 MONITERING
 INTRAVENOUS FLUIDS
 NUTRITION
 DEEP VENOUS THRMBOSIS PROPHYLAXIS
 WOUND CARE
 MEDICATION
 INVESTIGATIONS
 1.MONITERING

•Temperature, Pulse, Blood Pressure and Respiratory Rate

should be monitored.
• Usually done 4 hrly.
 2.INTRAVENOUS
FLUIDS
 Insensible fluid loss and redistribution is
responsible for intravascular volume
depletion.

 Surgical patients, as a general rule, are given

intravenous infusion until and unless they are
not able to take per oral
 INTRAVENOUS FLUIDS
(conti…)

Three way Stoper with HepLock Should be

atthached
 2.INTRAVENOUS FLUIDS(CONT:)
 Fluid input must match Loses & Urine
output.
 Replace with 2.5 to 3 L of iv infusion.
 Crystaloids are the mainstay.
 Na+ is provided as Normal saline.
 K+ suppliments should starts at arround 24th
hour.20 mmol of potassium
chloride/Ampoule is added in 1 L of infusion.
 5% dextrose given as calories.
 MUST FOLLOW
INPUT=30-60ml URINE/HOUR
 3.NUTRITION
 Parenteral Nutrition
 It is basically directed towards caloric
and Protien requirnments.
 Fatty acids are adjuvant to metabolic
heomosatasis.
 In this pedigree we have infusions
like nutralized 25% dextrose and
Panamin SG.
 Amount and Frequency are given
accordingly.
 3.NUTRITION
 Aim is to achieve positive nitrogen
balance
and to provide adequate calories for
energy.
 Nitrogen Requirement=
nitrogen loss,3-6g/d(24-hr urinary
urea in mmol into 0.028)
 Energy requirnment=
5%Dextrose+30%Fat(Liposyn
infusion)
4.Deep Venous Thrombosis
Deep Thrombosis (CONT:)
 DEEP VENOUS THRMBOSIS
PROPHYLAXIS
 In patients going through major procedures there are chances
of venous stasis.

 These patients are classified as low risk, moderate risk, high

risk and highest risk patients on the basis of age and nature
of procedure.

 Patients belonging to different risk groups are provided with

prophylaxis with different modalities (i.e. Mechanical
prophylaxis,heparin, Low molecular weight heparin).
(Conti…..)
 DEEP VENOUS THRMBOSIS PROPHYLAXIS
(conti…)

 Low risk=Age less than 40 years+no risk factor

 Moderate risk=Major surgery & age less than 40 years or minor

surgery with risk factor or age between 40 & 60 years.

 High risk=Major surgery+age over 40 years or with risk factor

or minor procedure with age over 60 years with risk factor.

 Highest risk=Age over 60 years with multiple risk factors or

with major procedure

(Conti…..)
DEEP VENOUS THRMBOSIS PROPHYLAXIS
(conti…)
Patient Group Surgery Prophylaxis
Type
Low risk Minor None;Erley
Mobilization
moderate risk Major Erly
Mobalize;Hydratio
n;Compression
Stockings
High Major All the Above
+Unfractioned
Heparin
Highest Major Add LMWH instead
of
heparin:Deltaperin
e Na
 5.WOUND CARE
 After surgery the wound care is one of the
important considerations.

 In order to keep the wound clean, dressing is

being done in our wards with topical
applications,wound should be left undisturbed for
48 hours to prevent contamination.

 Clinical Indicator_ Sockage of the Dressing or

Leakege from the Drian

(conti…
)
 Wound Care and
 Treatments
Postop Assessment
 Suture Care
 Dressings Changes+Sterile
Precuations.
 Drains
 STOMA Care_Critical aspect

 Rx_Cleansing of Wounds with sterile

measures
 Wound Care/Rx continued
…
 Irrigation

 Wound Packing
Dressings/Bandages/V.A.
C system
 Good Dressing
Appliances
 Use of separate
Instruments.

 Specimen Collection
 WOUND CARE (Conti…)

•Bed Sores maybe avoided in bed ridden

patients by changing the position of patient
time to time.
6.MEDICATION
 MEDICATION (CONTI…)
 Antibiotics

 Antiemetics

 Pain control
 Ulcer Prophylaxis
 MEDICATION (CONTI…)
 Antibiotics are needed as Planed and also to prevent
nosocomial infections.Route is IV.
 Antiemetics are given as postoperative nausea is
common after general anesthesia.
 Pain control is necessary for early mobility.
 Ulcer Prophylaxis:Patients with or without peptic ulcer
disease on prolonged stay are prescribed with acid-
reducing agents(PPI) or cytoprotective agents like
sucralfate
7.INVESTIGATIONS
 INVESTIGATIONS (conti…)

• As a routine practice it is required that blood cp,

serum electrolytes, blood urea, creatinine and
coagulation studies should be done.
 Investigations(Cont:)
 CBC _TLC_Wound Infection(SSI)
 S/U/C/E_IV Aminoglycosides Like Amikacin
 Urine D/R_UTI_Prolong Cathetrization
 PT/INR_if Drain is pouring blood
 Drain Collection C/S_Antibiotic
Modification
 Protien/AG Ratio_Response to Surgical
Nutrition
 ABGs_Metabolic Response to Surgery
 INVESTIGATIONS (conti…)
 X-ray is required, particularly of chest, in procedures in which
the thoracic cavity is entered or when central venous access is
attempted.OR If pulmonary complication is suspected.
 UltraSound is required In certain cases like that of Perforated
appendix or peritoneal collection, ultrasound is required to
assess the intraperitoneal melliue.
 Contrast Studies, for outcome of Anastomosis surgically made.

 CT Scan is required in cases of hematoma development

intraabdominally or Consealed Hemorrhage or when ultrasound
donot help much.
 General Complications
 1.Blood tranfusion Reactions.
 2.Fever.
 3.Drains,Stomas,Tubes.
 4.Wound care and Dehiscence.
 5.Imobilization and pressure sores.
 FEVER.Refer to TPR chart.
Day1=Surgical trauma or blood
transfusion reaction.
Day2=Basal atelectasis.
Day3=SSI(Superficial deep wound
infections)
 General Complications(Cont:)
Day4=Thrombophlebitis or UTI.
Day5=As above +Chest infection.
>Day5=As above Anastomotic leakage or
Intracavitary Collections/Abscesses.
 DRAINS.Drainage of bile or feacal matter
indicates biliary or intestinal
anastomotic leakage.Blood then hemorrhage
thru vascular leaks or coagulopathy.Drains
should be removed ifn the drainage is stoped
or become less than 25ml/day,only serous
fluid.Drains in abscesses or placed alongside
Gut Anastomosis are left for upto 5 days.
 GENERAL
 COMPLICATIONS(Cont:)
Wound Dehiscence.It is the partial or
complete disruption of any or all of yhe layers in
wound.
Presents with serosanguinous discharge.
Occurs on 5th or 8th postop day.
Reasons is weakining of strength of wound.
Comonly occurs in abdominal wounds where
there is underlying intra-abdominal adscess.
Most pts require Resuturing.
OR leave wound open with daily dressing or
Wound V.A.C system.
Diabetes,sepsis,malignancy,steroids,poor
closure of wound,increased intraabdominal
pressure lead to this complication.
 GENERAL
COMPLICATIONS(Cont:)
 IMMOBILISATION & Pressure sores.
 Risk for DVT,Pressure sores,atelectasis.
 Comonly adapted by the pt post Lapratomy.
 Pressure sores occures at sacrum,greater
trochanter,heels,gluteal region,elbow.
 Unconcious pts are victums.
 Early mobilisation is prevention.
 High risk pts can be nursed on Air Filter
Mattress.
 Usually localy made air cushions or water
filled surgical gloves are used in our setup.
 GENERAL
COMPLICATIONS(CONT:)
 Early Mobilization speed up the
recovery.
 It prevents Pressure sores, Pulmonary
complications,DVT.
 Analgesia is essential to enable early
mobilization.
 SPECIFIC CONSIDERATIONS .

POST OPERATIVE CARE OF PATIENT

ROUNTINE POSTOPERATIVE CARE SPECIFIC CONSIDERATIONS

 SPECIFIC
CONSIDERATION
 CNS DISORDERS
 CARDIOVASCULAR DISEASES
 RENAL DISEASES
 DIABETES
 TUBERCLOSIS

 Should involved relevent departments

 CNS DISORDERS
 Management of patients with known seizure disorders be
directed by keeping in view the type of seizure (i.e. general
versus partial, simple partial versus complex partial),
frequency and degree of control of disorder.

 Standard precaution may be taken including medication.

 Phenytoin and Phenobarbital are available in parenteral form.

 Involve Neuromedicine department
 CARDIOVASCULAR
DISEASES
 Involve General Medicine or NIVCD departement

 In case of coronary artery disease the control of

precipitants is required.

 Stresses that exacerbate the ischemia are required to

be avoided.

(Conti…
)
 CARDIOVASCULAR DISEASES
(Conti…)

 Hypertension must be controlled as it

increases the oxygen requirement and
exacerbates ischemia.

(Conti…
)
 CARDIOVASCULAR DISEASES
(Conti…)

•Pain is required to be controlled with

analgesics as it can cause tachycardia and
hypertension.

(Conti…
 CARDIOVASCULAR DISEASES
(Conti…)

•Oxygen is required to be given

continuously in postoperative patients to
increase the oxygen content of the blood.
(Conti…
)
 CARDIOVASCULAR DISEASES (Conti…)

•Anemia should be avoided as it decreases the

oxygen carrying capacity of the patients.
Transfusion should be considered when
hemoglobin falls below 9.0 (Conti…
)
 RENAL DISEASES
 Involve Nephro department
 I/O Charting is key role

 Fluid replacement in postoperative patients having chronic renal

disease should be done cautiously

 Care must be taken to avoid excessive fluid replacement.

 Maintenance fluids should not contain potassium.

 Serum electrolytes should be measured time to time.

(Conti…
 RENAL DISEASES (conti…)

•Patient should be catheterized to monitor

the urine output.
•Should be done in Theater.
(Conti…
 RENAL DISEASES (conti…)

 In patients having renal insufficiency and

decreased creatinine clearance the dosages
of the drugs should be adjusted.

 Some medications such as Aminoglycosides

are contraindicated.
 DIABETES

•Postoperative management of diabetic surgical

patient centers on maintenance of euglycemia and
management of chronic complications.
•The blood glucose levels should be measured time
to time.
(Conti…
 DIABETES (conti…)
 Involve General medicine

 Diet controlled diabetic patients infrequently need glucose or insulin

therapy after minor surgeries.

 Diabetic patients who are receiving oral hypoglycemic agents frequently

need insulin postoperatively.

 Intermittent dosing of subcutaneous insulin can be given as intermediate

acting insulin twice a day, with hyperglycemia managed by supplemental
dosing of regular insulin.
 For example Dextrose Water titrated with insulin.
 SLIDE SCALE is key role.
 Use of GLUCOMETER is a wise thing to do.
 DIABETES (conti…)
 Must do FBS and RBS
 TUBERCLOSIS
 Modility is DOTS.
 IV ATT is recommendation in our setup.
 Rule is 2 months of Intiation & next 7
months of continuation phase.
 D.O.C that should be added is IV
Streptomycin untill hospitalized.
 Second line Drugs can be used in septic
cases.
 LEAP-FROG
 After Surgery.Dont discharge the patient
until LEAP-FROG is established
 Lucid,not vomiting,cough reflex established
 Easy breathing,easy urination
 Ambulant without Fainting
 Pain relief+Postop drugs dispensed +
given.Does pt understand doses.
 Follow-up arranged
 Rhythm,pulse rate,BP checked.It is a Trend.
 Operation site checked thoroughly
&explained to pt
 LEAP-FORG(Cont:)
 GP letter sent with pt.He must know
what happened+Stoma Care is
Educated to pt.+ATT Status
explained+Tube Feeding is
thoroughly educated.
 SUMMARY

 Proper postop care is key feature in

management.
 Patient realize that he is been treated by
good doctor.
 Management Choices in case of
Comorbidities.
 Usage of LAB Work.
 Clinical importance of DVT Prevention.
 Also measures to prevent complications
 MCQS
 1.Insensible loss of fluid from skin &lungs over 24 hours,in a
temperate climate,is normally in range
a.100-250ml
b.250-500ml
c.500-700ml
d.750-1000ml
e.1000-1500ml
 2.In postop phase
a. endogenous water released during oxidation of ingested food
amounts to 1000-2000ml in 24hrs.
b. small amounts of highly coloured urine with high specific gravity
mean poor renal function.
c. in pure water depletion leading sign is anuria.
d. diuresis must be watched for as it means that enough water has
been given.
e. water intoxication is likely when continuous hypertonic solution is
given iv.
 MCQs
 3.Sodium depletion
a. can be caused by increased secretion of
aldosterone.
b. occurs during the first 48 hrs after operation.
c. can follow prolonged gastric incubation.
d. causes subcutaneous tissue to feel hard.
e. results in urine containing little or no chlorine.
 4.Potassium depletion is related to
a. increased excretion of potassium for about three to
four days postoperatively.
b. tumour of colon.
c. prolonged gastric incubation.
d. muscular spasms.
e. calculous anuria.
 MCQs
 5.Ringer lactate contains specifically
a. sodium
b. k+
c. Cl-
d. HCO3+
e. albumin.
 6.All postoperative pts, after gastric surgery,require
a. intravenous alimentation.
b. 2000-4000 calories in 2000-4000ml of fluid given
daily.
c. high concentration of iv CHO.
d. amino acids taken in after iv CHO.
e. elemental diet.
 MCQs
 7.Feeding by tube enterostomy.
a. is a form of parenteral nutrition.
b. is indicated in cases when then passage
of large bore NG tube is required.
c. is applicable to all cases of intestinal
obstruction.
d. if by gastrostomy, the tube should be
inserted towards the antrum.
e. is more satisfactorily accomplished by
jejunostomy than by gastrostomy.
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