Post Op Care Flashcards
Immediately post-op
the post op note: includes
orders
assessment
Immediately after leaving OR
Post Op Note: within 4 hours of finsihing in the OR
Note Includes the following
- vitals
- I/Os (blood, fluids, meds.)
- tubes/lines/draines (T/L/D)
- blood loss
- full exam
Orders
- labs
- imaging
- EKG
- diet
- activitiy
- ventilation
- medications
Wound Assessment
PACU phases
PACU pahse 1: patinet recoverying from anesthesia back to baseline vitals
PACU phase 2: preparing pt. for D/C home/admitted/etc.
PACU Complication: N/V
PONV
- the most common complication as a result of anesthesia
Apfel’s risk criteria
- female
- non smoker
- motion sickness
- opioids
- get Clinical Assessment of pt.
Prvention and Treatment
- opioid sparing pain control
- antiemeitcs (ondansetron and dextamethasone)
PACU Complications: Respiratory
Upper airways
- edema, phayrngeal msucle weakness
- vocal cord paralysis
Lower Airway
- aspiration
- edema
- bronchospasm
- tension PTX
Central/periphearl NS
- opioids
- poor reversal of NM block
- stroke
what to do
- PE
- CXR
- ABG
Treatment
- supplement O2
- ventilation
- suction
- chest tube
- reversal agents
- stroke protocol
PACU Complications: Cardiac
Cardiac
- hypotension/hyper
- arrythmias
- MI
- HF
What to Do
- EKG
- continuous tele.
- labs
- bedside echo
Treatment
- HTN = IV hydralazine, labetaol
- hypotension = fluids, pressors (phelyephinr, epi)
- arrythmia = ACS
- MI = MONA (morphin, o2, nitrate, asprin)
- HF: consult
PACU Complications: Neruo and homeostasis related
Neuro
- delirum on emergence can wear off
- visual disturbances
- hematoma from epidural
hypo/hyperthermia = anesthesia
Urinary retention = need to pee before leaving
what to do when transferring from PACU to Floor
PACU –> Floor
- stable VS
- Post-Op check
- N/V controlled
- pain controlled
- ICU v Floor decided
Post-Op Pain control
- what to use
Narcotics = mainstay
PCEA: pt. controlled epidural
PCA: pt. controlled analgesia via IV
IV push: from nurse
transition to oral!! (IV wears off quick)
ERAS protocol = pain control without narcotics if possible and early ambulation
Other management s
- Tylenol (4g max.daily)
- Ketorlac (watch NSAID in CKD and bleeding pt.)
- nerve blockes
look at pt. hisotry of med use and opioid use: migt need more or less
IV Fluids Post-Op
(pt. weight (kg) X 30) / 24 = maitnence per hour
Need fluid for
- maitnence
- fever, burns, losses
- drain losses
- third spacing
type of IV fluid: depends on pt. (commonly LR)
increase oral intake decrease fluids
Post Op Floor Care
- what are the things you need to manage
- types of drains for TLD
Floor Care: Post OP
- pain control
- fluids
- electrolytes
- diet
- PT/OT
- TLD everyday
TLD
- closed tubes: connected to their own suction (JP or Blake)
- always report amount and color of draingage
- open: no suction (penrose)
- sump drain: for large drainges (DAvol)
- chest tube: closed pressure drain
- foley cath.
- epidural
- NG tube (decomp.)
- feeding tube
Discharge Planning
criteria to leave
Criteria to leave
- pain controlled on oral meds
- tolerating diet within IV fluids
- voding and BM returned
- PT/OT evaluated
- home care placement if needed
Hemorrhagic Complications POst OP
what to do
- differentiate: is it surgical or other source (like a GI bleed)
Labs (trend them!!!)
- CBC
- coags
- active T&S
Treatment alwasy depends on stability of pt
example: if GI source: PPI, stop anticoags and transfuse if needed
asses need to go to OR to surgical control
Hematoma Post Op
etiology
- a collection of blood from failure of priamry hemostasis or bleeding condition
Clincial signs
- pain
- draingage
- swelling
- asymptomatic but labs? (thinkg retroperitoneal)
Treament
- depends on presentationand size
- can go back to OR
Transfustion Thearpy
what types of blood can be given
Packed RBCs: usually given
- 1 unit = 1g/dL hemogloblin
- should increase hgb by 1
- come as washed, leukocyte reduced or irradiated
Platlets
- for active bleeding or low platlets
FFP
- those with deficient clotting factors
Crypoprecipitate
- uremic or dilutional coagulopathy
ensure T & S is UTD
Post Op Complication: Atelectasis
Etiology
- MC post op comp.
- decreased compliance of the lung
- retained secretions
- post op pain
Symptoms
- dyspnea
- hypoxemia
Diagnosis and Treatment
- clincal + CXR
- prevention is key!! get them up and waking
- incentive spirometry etc.
Bronchospams
etiology
- simialr to like COPD or asthma exacerbation
Symptoms
- dyspnea
- chest tightness and wheezing
Diagnosis
- clinical presenation
- hypercapneia
- prolonged expiratory
Treatment
- find underlying cause (opioids or anesthesia induced)
- SABA: albuterol
- SAMA: ipratropium
Pleural Effusion
Etiology: commong after abd. surgery: typically spontaneous resolution
- can be due to fluid shifting during surgery
- holding excess fluid in the lungs
Treatment
- could just IV duiresis
- may just need to restart their at home meds! (diuretics)
if clincally concerned about the origin of teh effusion: can thoracentesis and do lights criteria
Pulmonary Edema
Etiology
- can be cardiogenic, noncardiogenic r mixed
Cardiogenic: most often within 36 hours of OR due to fluid retention
- get CRX and elevated Pulm. art pressures
Noncardiogenic: concenr for negative pressure pulm. edema
- can be due to larygeaspasm from extubation
Treatment
- supportive and dueresis
PTX (Tension)
Etiology
- postive pressure in the pleural space causeing hemodynamic compromise
Symptoms
- Dyspena
- hypotesnion
- decreased BS
- tracheal dev. if tension
CRX if not tension - if tension you should know
Treatment
- need decomp and chest tube
- 4th-5th midax. space for needle decomp.
- 5-6th midax. for chest tube
Pulmonary Embolism
etiology
- obstruction of pulm. artery or branch of artery via thrombus, air, tumor or fat
those at high risk
- malignancy
- pregnant
- hosptialzied
- disorders (like coag.)
- obesity
- smoker
- recent surgery
Symptom s
- Dyspnea
- pleuritic CP
- cough
- DVT! look at the legs
determine if stable or unstable
Wells Criteria : post op will be high so youll need to decide via imaging
LE US
D Dimer (surgery will be high anyway)
VQ scan
CT PE protocol CT with contrast is first line for surgery
CTA is the GS overall
Pulmonary Embolism
Treatment
Anticoag. (watch risk for re bleed in post op. pt.)
- start with Heparin drip (PTT 60-80)
- d/c with warfarin or DOAC
- history and RF determine length of treatmen t
PNA post op
etiology
- post-op day 5
Symptoms
- fever
- leukocytosis
- secretions
- infiltrates on imaging
- hyoxemia
Diagnosis
- MC organsims: gram neg. and staph. aureus
- collect culutre and give HAP or VAP abx.
- consider anaerboci coverage in thoracoabd. cases
Wounds Post OP
Etiolgoy
inflammation post op
POD 2: 48 hours = deep structures should stay sealed the the OR dressing can be removed
Signs of INfection
- erythema
- pus
- edema
- warmth
SSI: surgical site infection
- infective process near the surgical site within 30 days of the operation (90 if implant)
VAC dressing can be good for complicated wounds (24-72 hours)
remebr taht proper nutrtion really helps with wound healing!!!
Hypotension Post Op Care
a systolic BP < 90 or MAP < 65 or a relative decrease in systolic from baseline > 20
Causes
- hypovolemia
- opioids
- adrenal insuff.
Treatment is based on the signs : think about wahts causing it
- review post op labs: HGb and electrolytes
- address surgical site
- fluid bolus to help
- products (blood if needed)
- pressors
if shock develops: pressors and ICU
Hypertension Post Op Care
systolic > 180 and diastlic > 110
Cuases
- poorly controlled preop HTN
- noxious stimuli
- hypervolemic
- withdrawal!
- HTN emergency
- poorly controlled pain
Treatment
- IV agents (metoprolol, hydralzaine)
- nicardipine drip
- address withdraw or noxious stimuli
Sinust Tachycardia Post Op
narrow complex regualr tachycardia with HR > 100
Causes: common in post-op
- pain
- hypovolemia
- anemia
Treatment
- depends on causes
A Fib
narrow complex arrythmia of focal atrail foci triggering a beat
- ireregularl irregualr
Causes
- preexisitng a fib
- electrolye issues
- high risk with pulm. and esopageal surgery
Treatment
- stable: IV metoprolol ; then amioderone to help rhythm
- unstabel: cardioversion
MI post Op
- rise in troponin with symptoms or EKG cahnges
- MI after non cardiac surgery can be up to 30 days post op
Due to
- obstruction
- CAD
Symptoms
- ACS
- atypical!
Goldman Risk Criteria
Treatment
- stable or unstable?
- stat labs and trops
- EKG
management depends if STEMI or NSTEMI
Heart Failure Post OP
PAthology
- fluid admin
- surgical postion
- stress induced cardiomyopathy
Clinical
- respiratory distress
- hypertension 2/2 hypervolemia
- hypotension if ins chok
Dx.
- EKG
- CXR
- Echo
Treatment
- supp. O2
- IV diureiss
- vasodilators (nitro)
- inotropes (ifdecreased EF)
UTI post op
Risk
- catheter
- DM
- female
Symptoms
- dysuria
- hematuria
- frequency/urgency
Dx.
- urinalysis & culutre
Treatment
- abx.
POst Op Fever
5 Ws
Fever: > 100.4 For > 38C
if its IMMEDIATE, think
- inflammation
- immune rxn
- malignant hyperthermia
- bacteremia
- gangrene
5 W’s
Wind: atelectasis (24-48hr)
Water: UTI
Walking: PE/PNA
Wound: infection
Wonder Drug: other drug
24-48: atelectasis
3-7 days: unresolved atelctasis = PNA
POD 3: UTI
POD 5: thrombophelbitis
POD 5-10 :wound infection
POD 7: Pulm. embo.
POD 10: deep infection (CT or IR and OR)
4 weeks = fever? = skin/soft tissue or viral illness
