Postoperative Phase 3 Stages Immediate Stage - (1-4hrs) after surgery Intermediate Stage - (4 -24hrs) after surgery Extended Stage - (1-4days) after surgery/last follow-up visit with the attending physician Dr.Karim Shaarawy, MD

Immediate Postoperative Period Respiratory Position - left lateral with neck extended and upper arm supported on a pillow. - supine with head to side and chin extended forward b) Check presence of gag reflex c) Maintain artificial airway until gag reflex returned d) Oxygen e) Assess rate and depth of respiration f) Assess breath sounds g) Monitor for signs of atelectasis, pneumonia, pulmonary embolism Dr.Karim Shaarawy, MD

Assess skin and check capillary refill Assess peripheral edema Cardiovascular Assess skin and check capillary refill Assess peripheral edema Monitor for bleeding Assess pulse rate and rhythm Monitor for hypo/hypertension Monitor for cardiac dysrhythmias Dr.Karim Shaarawy, MD

Intermediate Post –op Period Monitor Respiratory Status - coughing/deep breathing / 1-2 hrs - turning in bed / 2hrs - early ambulation - auscultate lungs / 4hrs Monitor Cardiovascular Status - leg exercises / 2hrs - apply anti-embolic stockings - vital signs, color, temp of skin Dr.Karim Shaarawy, MD

Promote Fluid and Electrolyte Balance Promote Optimum Nutrition - maintain IV infusion as ordered - Assess return of peristalsis -Progressive increase in diet Promote Return of Urinary Function - Assess ability to urinate/ bladder distention - Report to surgeon if client has not urinated after 8hrs post-op Dr.Karim Shaarawy, MD

Transferring the patient from the post anesthesia care unit PACU افاقة Transfer Criteria: Patient coming out of General Anesthesia Vital signs are stable for at least 30 mins and are within normal range Patient is breathing easily Reflexes has returned to normal Patient is responsive and oriented to time and place Dr.Karim Shaarawy, MD

Patient who had regional anesthesia Sensation is restored and circulation is intact Reflexes has returned Vital signs have stabilized for at least 30mins  Adequate urine output Control of pain Control or absence of vomiting Dr.Karim Shaarawy, MD

Post-operative Complications A. Respiratory: Atelectasis - a collapse of the alveoli with retained mucus secretions - Usually develop 1-2days post-op 2. Aspiration - caused by inhalation of food, gastric contents, water or blood into the tracheobronchial system. - anesthetics and narcotics depress the CNS, causing inhibition of cough and gag reflex Dr.Karim Shaarawy, MD

3. Pneumonia an inflammatory response in which cellular material replaces alveolar gas. - may develop 3-5 days post-op Assessment: Dyspnea, increased Respiratory Rate Crackles over involved lung area Elevated temp Productive cough and chest pain Hypotension Decreased breath sounds Dr.Karim Shaarawy, MD

4. Pulmonary Embolism -An embolus blocking the pulmonary artery disrupting blood flow to one or more lobes of the lungs Assessment: Dyspnea Sudden sharp chest/upper abdominal pain Cyanosis Tachycardia A drop in blood pressure Dr.Karim Shaarawy, MD

B. Cardiovascular Complications 1. Thrombophlebitis Inflammation of the vein, often accompanied by clot formation 7-14 days post-op Assessment: Vein inflammation Aching or cramping pain Vein feels hard and cordlike and is tender to touch Elevated temperature Positive Homan’s sign Dr.Karim Shaarawy, MD

Intervention hydrate patient adequately Avoid massaging to calves or thighs Avoid standing or sitting in one pace or crossing legs Avoid inserting IV’s into legs Assess for Homan’s Sign Dr.Karim Shaarawy, MD

C. Circulatory Complications 1. Hemorrhage -The loss of a large amount of blood externally/internally for a short period of time 2. Shock -Loss of circulatory fluid volume caused by hemorrhage  Assessment: Restlessness Weak rapid pulse Hypotension Tachypnea Cool skin Reduced urine output Dr.Karim Shaarawy, MD

E. Paralytic Ileus توقف حركة الامعاء D. Constipation E. Paralytic Ileus توقف حركة الامعاء - paralysis of intestinal peristalsis F. Wound Infection - occurs 3-6 days post op G. Wound Dehiscence - Separation of wound edges on the suture line - occurs between 5th and 8th day post op H. Wound Evisceration - Protrusion of the internal organs and tissues through an opening in the wound edges Dr.Karim Shaarawy, MD

I- Urinary Retention -Involuntary accumulation of urine in the bladder as a result of loss of muscle tone - Due to effects of anesthetics/narcotics Assessment: Inability to urinate Restlessness Lower abdominal pain, distended bladder Elevated BP Dr.Karim Shaarawy, MD

Postoperative Discharge Teaching Focus on: Proper wound dressing Medications Diet Follow-up visit – removal of sutures in (7-10 days Abdomen), / removal of staples in7-14 days Activity levels-no lifting for 6 weeks not to lift anything (>10lbs) Return to work in 6-8 weeks Signs and symptoms of complications Dr.Karim Shaarawy, MD

Drains placed in wounds only when abnormal fluid collections are present/expected Are placed near the incision site: In compartments that are intolerant to fluid accumulation In areas with large blood supply In infected draining wounds Areas that have sustained large superficial tissue dissection Greatest accumulation is expected during the first 24 hrs removed when amount of drainage decreases < 50 ml/day Dr.Karim Shaarawy, MD

Types of Drains A.Gravity B.Mechanic 1. Penrose Drain 2. T-Tube 1. Jackson-Pratt Drain 2. Hemovac Dr. K. Shaarawy Penrose Drain T-Tube Jackson -Pratt Dr.Karim Shaarawy, MD

B. Mechanical - these are portable self contained closed wound mechanical devices that suction fluid after collapsing them and closing the valve thus forcing the fluid to be pulled into the collection chamber. examples: Hemovac, Jackson- Pratt Dr. K. Shaarawy Hemovac drain Dr.Karim Shaarawy, MD

Other types: Negative pressure drain (VAC) Nelaton drain Corrugated Rubber drain Pigtail drain Davol Dr.Karim Shaarawy, MD Rubber drain

Care and Handling of Surgical Specimens Types of Surgical Specimen Routine specimen specimen that doesn’t require immediate attention placed in a preservation fluid labeled and sent to Pathology Department feat. conclusion of the procedure scrub nurse should separate like specimens from different locations specimens not immediately passed off the field should be kept moist in saline calculi should not be placed in formalin, same with foreign bodies amputated extremities are wrapped before sending them to the pathology/morgue للدفن Dr.Karim Shaarawy, MD

2.Diagnostic Specimen Frozen Section Requires special handling and immediate examination by the pathologist With verbal report of the findings communicated to the surgeon during the surgical procedure Examples include breast biopsy/any organ, tumor or lesion Specimen is sent dry and is properly labeled. Dr.Karim Shaarawy, MD

Cultures Are taken on a patient who comes to the OR with a known/suspected infection 2 types: aerobic and anaerobic, requires different medium for growth This will determine the antibiotic that will specifically affect the microbes Are obtained under sterile condition, using appropriate collection tube. Exact procedure for collecting cultures for specific test will vary from each institution Must be sent to the lab immediately for accurate processing Dr.Karim Shaarawy, MD

Thank you God Bless You All! Dr.Karim Shaarawy, MD