Post-operative Flashcards
(41 cards)
What is early postoperative fever likely to be due to?
Early postoperative fever (within the first 24 hours after surgery) is most likely to be due to the systemic inflammatory response to surgical trauma.
–> symptom management e.g. antipyretic
If a patient still has a fever 4 days post-op, what investigations should you do?
- Take blood cultures
- Urinalysis for MC&S - UTI can be asymptomatic post-op
- Clinical resp exam and sputum culture
- Inspect surgical wound
DO NOT GIVE CEF - routine use of cephalosporins has been shown to increase rates of MRSA + C Diff so should be avoided.
What are the two types of hypovolaemia in peri-operative patients?
Absolute - due to blood loss and preoperative starvation
Relative - due to vasodilating effects of anaesthetic and inflammatory response to surgery
What does low BP in healthy patients signify? What about a slow HR?
Hypovolaemia
A slow heart rate is unlikely to be the cause of hypotension unless the rate is very slow (less than 50/min).
If you suspect low BP is due to hypovolaemia what should you do?
Elevate the legs - this will increase venous return to the heart and increase stroke volume which in turn increases BP
NB: pain increases BP
What is the equation for:
- MAP
- pulse pressure
Mean arterial blood pressure (MAP) = diastolic pressure + 1/3 (pulse pressure)
Pulse pressure = systolic pressure–diastolic pressure
Why is MAP important?
MAP is considered to be a useful number to represent the perfusion of organs. MAP above 60 is required to sustain adequate organ perfusion in a fit patient. Patients who are hypertensive may require a higher MAP.
What dose of morphine should you start with?
10mg ampules - start with this in case you start respiratory depression.
1-2mg for an elderly person
Causes of illeus.
- peritonitis
- electrolyte abnormalities
- opioid medication (so shoudl give epidural for a laparotomy)
What is atelectasis?
Alveolar collapse - may be caused by lying on our backs when sleeping. Collapses the bases of the lung.
Things that increase this are pain (–> splinting of the diaphragm)
Giving 100% oxygen can cause atelestasis quickly - nitrogen usually fills alveoli but is not absorbed across the membrane but oxygen is
When giving 40kPa of oxygen to a patient and their kPaO2 is 13 is this good?
They should have a kPa of about 30 so they are actually hypoxic.
You should never interpret the kPa of oxygen on ABG without knowing how much oxygen they are getting.
Why is metformin often stopped pre-op?
Can cause a lactic acidosis.
What is the difference between sedation and general anaesthesia?
Sedation is a component of general anaesthesia. The patient is sleepy but conscious.
In general anaesthesia, the brain is “switched off” and the patient is unconscious.
What parameters are measured in recovery? (NEWS)
NEWS: - if a patient deteriorates use SBAR
- Resp rate - assess airway, resp rate/regularity/symmetry. Look out for respiratory depression.
- Oxygen saturation - should be >95% unless lung disease
- Temperature - Bair Hugger if cold, antipyretics if too warm. Monitor as drop could mean bacterial infection
- Systolic BP - if SBP lowered and tachycardia could mean haemorrhage/shock
- HR - tachycardia could mean pain
- GCS (take into consideration that they have been sedated)
Also monitor fluid balance.
Observed for signs of :
- haemorrhage
- shock
- sepsis
What are the NEWS score ranges for low, medium and high risk?
How often should you monitor a patient with a NEWS score between 0 and 4?
0 - min 12hourly
1-4 - min 4-6 hourly - inform registered nurse who must assess pt and she can assess need for more frequent monitoring.
How often should you monitor a patient with a NEWS of >4 or 3 in one parameter
Min 1hourly monitoring and
- nurse to inform medical team
- urgent assessment by clinician with core competencies to assess acutely ill patient
- clinical care in an environment with monitoring facilities
How often should you monitor a patient with a NEWS score >6 and what is the next course of action?
Continuous monitoring AND
- registered nurse to immediately inform medical team caring for pt - this should be an SpR (specialist registrar at least)
- emergency assessment by clinical team with critical care competencies which also includes practitioners with advanced airway skills
- consider transfer of critical care to level 2 or level 3 care facility ie. higher dependacy or ITU
List the criteria for safe discharge from recovery.
Summary: to be discharged from recovery patients must
- be able to breathe properly without assistance
- have stable vital signs
- be awake and orientated (exc children)
Consciousness - patient responds to verbal stimulation, can move all 4 limbs, cough when asked, be easily roused by voice
Respiration - adequate gas exchange, maintain airway, cough and breathe deeply, RR 10-20, SpO2 >95%
Circulation - adequate perfusion of all organs, measure BP + HR, urine output and skin colour/temp. BP should be within 10-20% of pre-op baseline. UO should be 0.5-1ml/kg/hr
Pain control - comfortable+ sedated but still responsive to verbal stimulation; multimodal analgesia should be used; deep breaths, coughing without pain.
N&V - should not return to ward; may be due to drugs
Fluid balance - if significant bleed remain in recovery until further assessment by surgeon and anaesthetist.
Heat conservation - note peripheral and core temperature (shivering with elevated temp could mean infection)
Wound site, drains and dressings - keep them intact and dry. Check pulses.
From: https://www.nursingtimes.net/clinical-archive/public-health-clinical-archive/criteria-for-the-safe-discharge-of-patients-from-the-recovery-room-23-09-2003/
When can the patient leave recovery?
Once the effects of anaesthesia have worn off and the patient is stable.
This varies from 30mins to several hours depending on their state and the type of procedure done.
What types of surgeries are suitable for day case procedures? (give 4 examples)
They represent about 70% of all surgery in the UK
What criteria must be met for a surgery to be considered appropriate for day case?
For a surgical procedure to be considered for day case surgery, it must meet the following criteria:
- Minimal blood loss expected
- Short operating time (<1 hour)
- No expected intra-operative or post-operative complications
- No requirement for specialist aftercare
List 5 points on the discharge criteria for day cases.
Discharge Criteria – all criteria should be met
- Vital signs stable for at least one hour
- Correct orientation as to time, place and person
- Adequate pain control and has supply of oral analgesia
- Understands how to use oral analgesia supplied and has been given written information about these
- Ability to dress and walk where appropriate
- Minimal nausea, vomiting or dizziness
- Has at least taken oral fluids
- Minimal bleeding or wound drainage
- Has passed urine (if appropriate)
- Has a responsible adult to take them home
- Has agreed to have a carer at home for next 24 hours
- Written and verbal instructions given about postoperative care
- Knows when to come back for follow up (if appropriate)
- Emergency contact number supplied
What is the difference between HDU and ICU?
- HDU has one nurse for every 2 patients
- ICU has one nurse per patient
