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PERIOPERATIVE MANAGEMENT

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IMPACT ON PATIENT MORBIDITY AND MORTALITY. OPTIMISE PATIENT ... Deep breathing (incentive spirometer), coughing. Comfort. Early ambulation. Oral hygiene ... – PowerPoint PPT presentation

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Title: PERIOPERATIVE MANAGEMENT


1
PERIOPERATIVE MANAGEMENT
  • DR. CLEMENT R S D SOUZA,
  • ASSOCIATE PROF.,
  • DEPT. OF SURGERY,
  • FR MULLER MEDICAL COLLEGE,
  • MANGALORE
  • clement62_at_rediff.com

2
PERIOPERATIVE MANAGEMENT
  • DEFINITION
  • MANAGEMENT BEFORE, DURING AND AFTER A SURGICAL
    OPERATION

3
PERIOPERATIVE MANAGEMENT
  • PREOP ASSESMENT
  • INTRAOP MANAGEMENT
  • POSTOP MANAGENENT

4
PREOP ASSESMENT
  • AIMS
  • OUTLINES RATIONALE FOR PREOP ASSESMENT
  • ADVERSE EFFECTS OF PREOP MORBIDITIES SUCH
    ASDIABETES, HYPERTENTION ETC., ON POSTOP OUTCOME
  • FAVOURABLE/ UNFAVOURABLE OUTCOMES
  • RESOURSE IMPLICATIONS OF OVERINVESTIGATIONS
  • COMMONLY PRESCRIBED DRUGS
  • OPTIMISING HEMODYNAMIC PARAMETERS

5
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6
PREOP ASSESMENT
  • OBJECTIVES
  • IMPACT ON PATIENT MORBIDITY AND MORTALITY
  • OPTIMISE PATIENT PHYSICALLY AND MENTALLY TO
    REDUCE RISK
  • TO RETURN PATIENT TO A HEALTHY STATE AS EARLY AS
    POSSIBLE
  • MANAGING EXISTING DRUG ADMINISTRATION
  • TEAM APPROACH WITH THE PATIENT, RELATIVES, GP,
    SURGICAL TEAM, MEDICAL/DIAGNOSTIC/NURSING/PARAMEDI
    CALS

7
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8
Classification of Surgery
  • Seriousness
  • Major
  • Minor
  • Urgency
  • Elective
  • Urgent
  • Emergency

9
PREOP ASSESMENT
  • IDENTIFICATION OF HIGH RISK PATIENT
  • OPTIMISING HIGH RISK PATIENT

10
PREOP ASSESMENT
  • HIGH RISK PATIENT
  • RISK OF DEATH AFTER OPERATION IS 0.7 TO 1.7
  • 1/3 ON OR BEFORE 2 DAYS OF SURGERY
  • EMERGENCY 15, URGENT 52, ELECTIVE 31
  • 87 gt60 YRS . 71gt70YRS.
  • 84 gt3 ASA SCORE.

11
PREOP ASSESMENT
  • HIGH RISK PATIENT
  • 85 ONE OR MORE COMORBIDITIES.
  • 23 HAD THEIR OPN. DELAYED TO IMPROVE HEALTH .
  • 32 ICU, 8 IN HIGH DEPENDANCY WARD.
  • CAUSE OF DEATH 37 RESP., 36 CARDIAC , 22
    RENAL.
  • ELECTIVE SURGERY MORTALITY 5-10, EMERGENCY
    23-55

12
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13
PREOP ASSESMENT
  • TO SUMMERIZE
  • POST OP DEATHS ARE USUALLY IN ELDERLY, WITH
    COMORBIDITIES, IN EMERGENCY OPERATIONS, IN
    ABDOMINAL , COLORECTAL, ORTHO.SURGERIES.

14
PREOP ASSESMENT
  • HIGH RISK PATIENT IDENTIFICATION BY CLINICAL
    ASSESMENT
  • USING 1) ASA SCORING SYSTEM
  • 2)GOLDMAN INDEX SCORE

15
PREOP ASSESMENTHIGH RISK FACTORS
  • H/O SEVER CARDIORESP. ILLNESS.
  • EXTENSIVE ABLATIVE SURGERY FOR MALIGNANCY
  • SEVERE MULTIPLE TRAUMA(3 OR MORE ORGANS/2 OR MORE
    CAVITIES)
  • MASSIVE ACUTE BLOOD LOSS gt8 UNITS.
  • AGE gt 70YRS

16
PREOP ASSESMENTHIGH RISK FACTORS
  • CLINICAL SHOCK
  • SEPTICAEMIA
  • SIGNIFICANT RESP. FAILURE. PO2 lt60mmHg.
  • ON MECHANICAL VENTILATOR FOR gt 48HRS
  • ACUTE ABD. CATASTROFE WITH HEMODYNAMIC
    INSTABILITY.
  • ACUTE RENAL FAILURE

17
PREOP ASSESMENT
  • IDENTIFICATION BY PHYSIOLOGICAL ASSESMENT
  • BY IDENTIFYING LOW CARDIOVASCULAR RESERVE

18
PREOP ASSESMENT PREOP VISIT
  • TO ASSES IF PATIENT IS FIT FOR THE PROCEEDURE
  • RISKS AND BENEFITS IN DELAYING THE PROCEEDURE
  • ADEQUTE TIME SHOULD BE SPENT ON PREOP ASSESMENT

19
PREOP ASSESMENT General Aspects
  • CHECK NAME, PROPOSED OPERATION, HOSP. NO., PT.
    CHART FOR ANY PREVIOUS PROBLEMS AND PATHOLOGY

20
PREOP ASSESMENT
  • COMLICATIONS WITH PREVIOUS ANAESTHESIA
  • NAUSEA, VOMITING TO ANAPHYLAXIS TO ANAESTHETIC
    DRUGS
  • ANY SPECIFIC PROBLEM WITH ANY RELATIVES

21
PREOP ASSESMENT SMOKING
  • gt20/DAY
  • INCREASED CARDIOVASCULAR AND RESP. PATHOLOGY
  • 70 CHANCES OF RESP. INFECTION
  • CARBONMONOXIDE LEVELS IN SERUM ARE RAISED 3 FOLD
    THEREBY DECREASING O2 CARRYING CAPACITY

22
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23
PREOP ASSESMENT SMOKING
  • SHOULD PATIENT STOP SMOKING?
  • 3 TO 6 MONTHS OF ABSTINANCE IS NEEDED TO REDUCE
    THE RISK OF RESP. INFECTION
  • HOWEVER CO LEVELS DECREASE WITH ACUTE CESSATION
    OF SMOKING THEREBY O2 CARRYING CAPACITY INCREASES

24
PREOP ASSESMENT..ALCOHOL AND DRUG ABUSE
  • HIGH ALCOHOL INTAKE AND DRUG (ANALGESICS/SEDATIVES
    ) INCREASES AMOUNT OF DRUG ADMINISTRATION DURING
    ANAESTHESIA
  • STOPPING INTAKE 1 MONTH BEFORE IS BENIFICIAL

25
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26
PREOP ASSESMENT.. OBESITY
  • PRACTICAL PROCEEDURES LIKE VENOUS ACCESS/
    INTUBATION/LOCAL ANAESTHESIA/MOVING THE PT.
  • INCREASED DEMAND ON HEART
  • DECREASED FUNCTIONAL RESIDUAL CAPASITY DUE TO
    PRESSURE ON DIAPHRAGM FROM ABD. WALL
  • SLEEP APNOEA

27
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28
PREOP ASSESMENTRESPIRATORY PROBLEMS
  • ACUTE RESP. TRACT INFECTION
  • BRONCHIAL ASTHMA
  • CHRONIC OBSTRUCTIVE PULM. DISEASE

29
PREOP ASSESMENTRESPIRATORY PROBLEMS
..MANAGEMENT
  • APPROPRIATE ANTIBIOTIC
  • BRONCHODILATORS
  • CHEST PHYSIO
  • REVERSAL OF BORDERLINE CORPULMONALE
  • DEHYDRATION AND ELECTROLYTE IMBALANCE CORRECTION
  • CESSATION OF SMOKING

30
PREOP ASSESMENT DIABETES
  • ON DIET ALONE
  • ON ORAL DRUGS
  • ON INSULINE

31
PREOP ASSESMENT DIABETES
  • QUALITY OF GLUCOSE CONTROL
  • ASSTD. CARDIOVASCULAR, NEUROLOGIC, AND RENAL
    COMLICATIONS

32
PREOP ASSESMENT DIABETES MANAGEMENT
  • IN MINOR SURGERYOMIT DOSE PRIOR TO SURGERY
  • IN MAJOR SURGERY.DAILY INSULIN REQUIREMENT IS TO
    BE MONITORED

33
PREOP ASSESMENT RENAL DISEASE
  • INVESTIGATIONS TO DETECT COMPLICATIONS OF SUCH
    AS HYPERTENSION, IHD.
  • ANAESTHETIC PROBLEMS MAY ARISE IN PTS WITH RENAL
    IMPAIRMENT

34
PREOP ASSESMENT RENAL DISEASE
MANAGEMENT
  • DIALYSE PT. ON DIALYSIS 1 HR. BEFORE SURGERY
  • ACTIVATED COAGULATION TIME PRIOR TO SURGERY

35
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36
PREOP ASSESMENTANATOMICAL DIFFICULTIES
  • TO IDENTIFY DIFFICULTY IN AIRWAY
  • INTUBATION DIFFICULTY?
  • NECK MOVEMENTS

37
PREOP ASSESMENT PREGNANCY
  • AVOID ELECTIVE SURGERY
  • SPONTAEOUS ABORTION
  • ORGANODYSGENESISDRUGS
  • SAFE ANAESTHETIC AGENTS

38
PREOP ASSESMENT OVERALL ASSESMENT
  • ASA SCORE
  • ASA 1 NORMAL
  • ASA 2MILD SYST. DISEASE
  • ASA 3SEVER SYST. DISEASE
  • ASA 4INCAPACITATING SYST. DISEASE
  • ASA 5...MORIBUND
  • E EMERGENCY SURGERY

39
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40
Intraoperative Care of Patient
  • Nursing roles
  • Holding area preparation
  • Admission to OR

41
Intraoperative Care of Patient(cont'd)
  • Assessment
  • Verification of patient, necessary assessments
    and documentation, and procedure
  • patient comfort

42
Intraoperative Care of Patient(cont'd)
  • Physical preparation
  • Patient positioning
  • Application of support and monitoring equipment
  • Introduction of anesthesia general, regional,
    local, conscious sedation
  • Documentation

43
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44
Postoperative Care of Surgical Patient
  • Immediate care PACU
  • Surgical information
  • Nursing assessments
  • Interventions
  • Discharge criteria ambulatory and acute care
    surgical settings

45
Postoperative Care of Surgical Patient(cont'd)
  • Overall assessment
  • Vital signs
  • Condition of dressings and drains
  • Comfort level
  • IV fluid status
  • Urinary output

46
Postoperative Care of Surgical Patient (cont'd)
  • Assessment
  • Respiration
  • Circulation
  • Temperature control
  • Fluid and electrolyte balance
  • Neurological function
  • Skin integrity and wound condition

47
Postoperative Care of Surgical Patient(cont'd)
  • Assessment
  • Genitourinary function
  • Gastrointestinal function
  • Comfort
  • Client expectations

48
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49
Postoperative Care of Surgical Patient (cont'd)
  • Respiratory complications
  • Atelectasis
  • Pneumonia
  • Hypoxemia
  • Pulmonary embolism

50
Postoperative Care of Surgical Patient(cont'd)
  • Circulatory complications
  • Hemorrhage
  • Hypovolemic shock
  • Thrombophlebitis
  • Thrombus formation
  • Embolus

51
Postoperative Care of Surgical Patient(cont'd)
  • Gastrointestinal complications
  • Abdominal distention
  • Paralytic ileus
  • Nausea and vomiting
  • Urinary retention
  • Urinary tract infection

52
Postoperative Care of Surgical Patient(cont'd)
  • Integumentary complications
  • Wound infection
  • Dehiscence
  • Evisceration
  • Skin breakdown

  • Pain

53
Postoperative Care of Surgical Patient (cont'd)
  • Nursing diagnoses
  • Impaired physical mobility
  • Impaired skin integrity
  • Disturbed body image

54
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55
Postoperative Care of Surgical Patient (cont'd)
  • Planning
  • Goals and outcomes
  • Airway is patent and respirations are even
    and unlabored
  • Vital signs return to preoperative baseline
  • Setting priorities
  • Continuity of care

56
Implementation of Postoperative Care for Surgical
Patient
  • Maintaining respiratory function
  • Positioning and turning
  • Suctioning
  • Deep breathing (incentive spirometer), coughing
  • Comfort
  • Early ambulation
  • Oral hygiene
  • Oxygen

57
Implementation of Postoperative Care for Surgical
Patient (cont'd)
  • Preventing circulatory stasis
  • Leg exercises
  • TED stockings
  • Early ambulation
  • Positioning
  • Anticoagulants
  • Fluid intake

58
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59
Implementation of Postoperative Care for Surgical
Patient(cont'd)
  • Achieving rest and comfort
  • Analgesics
  • PCA
  • Pain assessment

60
Implementation of Postoperative Care for Surgical
Patient(cont'd)
  • Temperature regulation
  • Warmed blankets
  • Monitoring for hypothermia and malignant
    hyperthermia
  • Assessment for signs of infection

61
Implementation of Postoperative Care for Surgical
Patient (cont'd)
  • Neurologic function
  • Orientation to the environment
  • Level of consciousness

62
Implementation of Postoperative Care for Surgical
Patient (cont'd)
  • Maintaining fluid and electrolyte balance
  • IV therapy
  • Oral intake when appropriate

63
Implementation of Postoperative Care for Surgical
Patient (cont'd)
  • Promoting normal elimination and adequate
    nutrition
  • Gradual progression of dietary intake
  • Ambulation and exercise
  • Adequate fluid and food intake
  • Elimination aids fiber, medications
  • Control of nausea and pain

64
Implementation of Postoperative Care for Surgical
Patient (cont'd)
  • Promoting urinary elimination
  • Normal positioning
  • Frequent assessment
  • Assessment of bladder distention

65
Implementation of Postoperative Care for Surgical
Patient (cont'd)
  • Maintaining/enhancing self-concept
  • Provide privacy
  • Maintain Patient s hygiene
  • Prevent drainage devices from overflowing
  • Maintain a pleasant environment
  • Offer opportunities for Patient and family to
    express feelings and participate in care

66
THANK YOU
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