General Care of the Surgical Patient

Presenter: R1 Instructor: VS Date: 2012/3/9

Outlines

Surgical patients
In-patient Out-patient

In-patient Care

Surgical Priorities

Emergency requires instant admission

ex: acute infection, traumatic injury

Urgent can progress to emergency

ex: subacute infection, neoplasm

Routine admitted the day before

In-patient Care

Pre-OP care
1. 2. 3.

Visits the patient within a few hours of admission. Review and revise the findings at the outpatient exam. Record the pulse, temperature, blood pressure, haemoglobin estimation and urinalysis. Check those teeth beyond conservation to be extracted. Replace insecure dressings in case they are

4. 5.

In-patient Care

Pre-OP care
6. 7. 8. 9. 10.

Warn the anaesthetist about the loose teeth. Extensive haemorrhage? Explain to the patient about the nature of the operation and likely complications. Informed consent obtained in writing for both the anaesthetic and the operation. Not only to carry out the local treatment but also to supervise the day-to-day care.

In-patient Care

Diet
1.

Fluid intake and output

Daily intake: 2500 ml; Daily output: 1000~1500ml Water is excreted as exhaled air (400 ml), sweat (500~1000 ml), urine (1200 ml), and faeces (200 ml) Insufficient fluid intake urine output (minimum: 600 ml) If difficulty in feeding fluid balance chart Fluid given by mouth or intravenously

In-patient Care

Diet
2.

Solid food

Balanced diet: carbohydrates + fats + proteins + vitamins + mineral salts Fats are not easily digested. Carbohydrate to prevent ketosis. Protein for the repair of tissue. Discussed with the dietitian. NG tube: brought out and cleaned every 2 or 3 days. Replaced through the other nostril. Weighed weekly

In-patient Care

Diet
3.

Pre-operative diet

LA: normal meal

If the patient has missed a meal he should be given a glucose drink before the injection is given.

GA: light meal

Chiefly of protein and carbohydrate, is advised the

In-patient Care

Diet
4.

Post-operative diet

Feeding should be started as soon as possible to avoid nausea. Tenderness/tismu s specially prepared food

In-patient Care

Excretion
1.

Micturition

This reflex act occurs when the pressure in the bladder rises sufflciently to cause the sphincter to relax and the detrusor muscle to contract. It may occur after GA. Micturition can be encouraged by getting the patient up but if this fails catheterisation may be necessary.

In-patient Care

Excretion
2.

Sweat

Sweat contains 0.5 percent of solids (NaCl). In fever or in hot weather sweating 10 g of NaCl can be lost in an hour

In-patient Care

Excretion
3.

Defaecation

Constipation: organic or functional? Organic is due to partial obstruction of the lumen. Functional is due to defective movements of the colonic musculature, or a deficiency in bulk of faeces due to feeding with fluid diets. Feeding fruit, vegetables and wholemeal cereals or by giving laxatives.

In-patient Care

Sleep

Pain: analgesics/hypnotics External stimuli: keep the wards dark and quiet at night Worry or change of habit: dozing by day lead to insomnia, hypnotic drugs, but only if really necessary for they are habit-forming.

In-patient Care

Hygiene

Oral hygiene instruction Mouth rinse with 0.2% CHX after every meal Intraoral sutures: debris removed each day Arch bars: brush with toothpaste, rinse Gutta-percha moulds: after the first 10 days, a syringe between the graft

In-patient Care

Post-OP care
1.

Put into bed with a pillow behind shoulders to enable drainage from mouth. Arms kept folded over chest. Nurse sits by to watch the airway, suck out the mouth and oro-pharynx Watch for vomiting and haemorrhage, and records the vital signs and level of consciousness.

2. 3.

4.

In-patient Care

Post-OP complications
1.

Fever

Natural reaction to infection, common for 2~3 days Chest complaint sputum culture Symptomatic treatment: confinement to bed, more fluid intake and a high carbohydrate diet to prevent the breakdown of body proteins. > 39.4C: sponged down with tepid water at 27C

In-patient Care

Post-OP complications
2.

Vomiting

due to the anaesthetic or swallowed blood > 8 hours upset of the acid base equilibrium TX: give milk or alkaline drinks with glucose. sipped very slowly but frequently or antiemetic Gently irrigated with normal saline. Chloramphenicol eye-drops

2.

Conjunctivitis

In-patient Care

Post-OP complications
4.

Sore throat or pharyngitis

Trauma from the endotracheal tube, excoriation from a dry pack TX: gargles and inhalations Routine post-OP breathing exercises will reduce the incidence. TX: antibiotics, physiotherapy, humidified oxygen, sedatives and mucolytic drugs, frequent hot drinks

4.

Pulmonary conditions

In-patient Care

Routine monitoring
1. 2. 3. 4. 5. 6.

Vital signs: temperature, pulse, blood pressure Fluid balance chart Bloods: full blood count, haemoglobin, electrolytes Bowel habit Dietary intake Drug requirements: analgesics, antibiotics, normal medications

Out-patient Care

Day cases

Minor operations under endotracheal anaesthesia Morning Suitable transport must be available

Out-patient Care

Pre-OP instructions for outpatients

1. 2. 3. 4. 5. 6.

The nature of the operation must be explained. Permission obtained in writing for both general anaesthetic and surgery. Told to come accompanied Light and easily digested diet Wear no restrictive clothing Fast from food or drink for at least 4 hours before OP

Out-patient Care

Post-OP care
1.

2.

Adequate instructions: diet, oral hygiene, analgesics and the rest period required before return to work. The operator must be easily available to the patient to deal with any surgical complications.

Follow Up

To assume responsibility for the patient's after-care until all possibility of post-OP complications is past. Long-term follow-up will benefit both the surgeon and his patients.

Referrence

Principles of Oral and Maxillofacial Surgery, 5th edition, UJ Moore

Thank you for your attention!