a p p r o a c h to post operative patient

Question 1

a differential diagnosis

Answer 1

VITAMIN C D E F

vascular
infection/inflammation
trauma 
autoimmune 
metabolic 
idiopathic
neoplastic 
congenital 
degenerative 
endocrine 
functional

Question 2

initial approach to patient post surgery to determine how unwell patient is

Answer 2

1. look at patient (pale, unconscious, jaundiced, pain)
2. look at observation chart (are they scoring on NEWS, tachycardic, hypoxic)
3. speak to nurse (especially if this is the first time meeting patient)

Question 3

is patient well or unwell

Answer 3

if well = history, examination, investigation, management

unwell = A-E

Question 4

system of 5 for examination

Answer 4

1. consent
2. inspection
3. palpation
4. percussion
5. auscultation

Question 5

systems of 5 for history

Answer 5

onset (when, where)
progression (is it getting worse, better)
duration (have you ever had this before, how long)
associated symptoms (urinary, bowel)
risk factors

pmh
past surgical history 
drugs and allergies 
family 
social - functional mobility and baseline, morning routine (getting up, washing, walking up stairs, cooking), recent travel, sick contracts in the family

Question 6

investigations system of 5

Answer 6

bedside tests
blood tests
microbiology - cultures
imaging 
specialist tests

Question 7

management in points of 5

Answer 7

1. Does the patient need oxygen? titrate to sats
2. Fluid balance: IV fluids? Urinary catheter? NBM? NGT?
3. Drugs: Analgesia, Anti-emetic, Antibiotics
4. VTE prophylaxis - TEDS, LMWH injections
5. Escalation - who and where would they be best managed, do they need higher dependency areas

Question 8

what are the 5 w’s to ask in post operative patient

Answer 8

wind = post op day 2 
water
walking
wound
wonder about drugs

Question 9

wind = cause of post infective fever

Answer 9

ventilator/ instrumentation to the airway

basal atelectasis, air stasis, increase risk of infection

pain = hypoventilation = atelectasis = infection risk

Question 10

water =

Answer 10

day 3-5

UTI ESP if urinary catheter

Question 11

walking

Answer 11

day 5-7

VTE risk

due to stress response to surgery and reduced mobility

Question 12

wound =

Answer 12

day 10

surgical site infection

Question 13

wonder about drugs/ iatrogenic

Answer 13

cannula sites

blood - transfusion reaction

Question 14

importance of post op pain

Answer 14

1. compassionate care
2. reluctant to deep breath - hypoventilation
3. reduced mobility = vte risk

Question 15

SE of morphine/ opiates

Answer 15

resp depression =
constipation = prn laxative
nausea and vomiting = anti emetic

Question 16

common sources of pyrexia in surgical pt

Answer 16

Chest (infection)
Cut (wound infection)
Catheter (UTI)
Collections (abdomen, pelvic etc.)
Calves (DVT)
Cannula (infection, if applicable)
Central line (infection, if applicable)

Question 17

examples of empiracle regimes per infection source

Answer 17

Lower Respiratory Tract Co-Amoxiclav 1.2g IV +/- Amikacin

Upper Urinary Tract
Catheter-Association
Co-Amoxiclav 1.2g IV +/- Amikacin
Nitrofurantoin 50mg PO + Change of Catheter

Surgical Site Infection Flucloxacillin 1g IV

Central line (or any vascular catheter infection)
Replace line (trial antibiotic line lock with vancomycin if not able to replace line)

Question 18

NSAID’S contraindications

Answer 18

Interactions with other medications (such as Warfarin)

Gastric ulceration (consider adding a PPI when prescribing NSAIDs long-term)

Renal impairment (use NSAIDs sparingly in those with poor renal function)

Asthma sensitivity (triggers 10% of individuals with asthma)

Bleeding risk (due to their effect on platelet function)

Question 19

delirium causes

Answer 19

ypoxia (post-operatively)
Infection (commonly UTI or LRTI)
Drug-induced (benzodiazepines, diuretics, opioids, or steroids) or drug withdrawal (alcohol or BZNs)
Dehydration or pain
Constipation or urinary retention
Electrolyte abnormalities (e.g. hyponatraemia, hypernatraemia, or hypercalcaemia)

Question 20

delirium mnx

Answer 20

1. treat cause
2. oxygen if hypoxic, laxatives if constipation
3. oral fluid intake, provide analgesia as necessary, and monitor bowels.
4. sedatives - haloperidol, lorazepam in elderly