General CareGeneral Careof the Surgical Patientof the Surgical Patient

Presenter: R1 Presenter: R1 鄭瑋之鄭瑋之Instructor: VS Instructor: VS 陳靜容醫師陳靜容醫師

Date: 2012/3/9Date: 2012/3/9

OutlinesOutlines

Surgical patientsSurgical patients In-patientIn-patient Out-patientOut-patient

In-patient CareIn-patient Care

Surgical PrioritiesSurgical Priorities Emergency Emergency — requires instant admission— requires instant admission ex: acute infection, traumatic injuryex: acute infection, traumatic injury Urgent Urgent — can progress to emergency— can progress to emergency ex: subacute infection, neoplasmex: subacute infection, neoplasm RoutineRoutine — admitted the day before — admitted the day before preparation: blood investigation, consultation, preparation: blood investigation, consultation,

chest xray, EKG…chest xray, EKG…

In-patient CareIn-patient Care

Pre-OP carePre-OP care1. Visits the patient within a few hours of admission.

2. Review and revise the findings at the out-patient exam.

3. Record the pulse, temperature, blood pressure, haemoglobin estimation and urinalysis.

4. Check those teeth beyond conservation to be extracted.

5. Replace insecure dressings in case they are dislodged into a socket or wound.

In-patient CareIn-patient Care

Pre-OP carePre-OP care6. Warn the anaesthetist about the loose teeth.

7. Extensive haemorrhage?

8. Explain to the patient about the nature of the operation and likely complications.

9. Informed consent obtained in writing for both the anaesthetic and the operation.

10. Not only to carry out the local treatment but also to supervise the day-to-day care.

In-patient CareIn-patient Care

DietDiet1. 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 CareIn-patient Care

DietDiet2. 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 CareIn-patient Care

DietDiet3. 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

night before. No food taken for 4 hours nor clear fluids for 2

hours before operation!

In-patient CareIn-patient Care

DietDiet4. Post-operative diet

Feeding should be started as soon as possible to avoid nausea.

Tenderness/tismus specially prepared food

In-patient CareIn-patient Care

ExcretionExcretion1. 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 CareIn-patient Care

ExcretionExcretion2. 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 CareIn-patient Care

ExcretionExcretion3. 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 CareIn-patient Care

SleepSleep 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 CareIn-patient Care

HygieneHygiene 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 and the mould to clean the dead space

In-patient CareIn-patient Care

Post-OP carePost-OP care1. Put into bed with a pillow behind

shoulders to enable drainage from mouth.

2. Arms kept folded over chest.

3. Nurse sits by to watch the airway, suck out the mouth and oro-pharynx

4. Watch for vomiting and haemorrhage, and records the vital signs and level of consciousness.

In-patient CareIn-patient Care

Post-OP complicationsPost-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.

> 39.4°C: sponged down with tepid water at 27°C

In-patient CareIn-patient Care

Post-OP complicationsPost-OP complications2. 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

3. Conjunctivitis Gently irrigated with normal saline. Chloramphenicol eye-drops

In-patient CareIn-patient Care

Post-OP complicationsPost-OP complications4. Sore throat or pharyngitis

Trauma from the endotracheal tube, excoriation from a dry pack

TX: gargles and inhalations

5. Pulmonary conditions Routine post-OP breathing exercises will reduce

the incidence. TX: antibiotics, physiotherapy, humidified oxygen,

sedatives and mucolytic drugs, frequent hot drinks

In-patient CareIn-patient Care

Routine monitoringRoutine monitoring1. Vital signs: temperature, pulse, blood pressure2. Fluid balance chart3. Bloods: full blood count, haemoglobin,

electrolytes4. Bowel habit5. Dietary intake6. Drug requirements: analgesics, antibiotics,

normal medications

Out-patient CareOut-patient Care

Day casesDay cases Minor operations under endotracheal

anaesthesia Morning Suitable transport must be available

Out-patient CareOut-patient Care

Pre-OP instructions for out-patientsPre-OP instructions for out-patients1. The nature of the operation must be explained.2. Permission obtained in writing for both general

anaesthetic and surgery.3. Told to come accompanied4. Light and easily digested diet5. Wear no restrictive clothing6. Fast from food or drink for at least 4 hours before OP7. Before entering the surgery, remove their dentures,

contact lenses and earrings, and to empty bowel and bladder.

Out-patient CareOut-patient Care

Post-OP carePost-OP care1. Adequate instructions: diet, oral hygiene,

analgesics and the rest period required before return to work.

2. The operator must be easily available to the patient to deal with any surgical complications.

Follow UpFollow 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.

ReferrenceReferrence

Principles of Oral and Maxillofacial

Surgery, 5th edition, UJ Moore

Thank youThank youfor your attention!for your attention!