1.

MEDICAL MANAGEMENT OF PHYSIOLOGIC OUTCOMES

When the patient wake up from surgery, the patient will be transported to the recovery room (PACU), where would spend about 30 minutes to an hour, until you are fully awake and stable for transportation to his room.

The patient will be asked to speak to find out if your voice is hoarse. Many patients, especially smokers, have a raspy or hoarse voice when they wake up from anesthesia. Smokers have a tendency to cough.

The patient will notice a dressing wrapped around your neck and drain tubes attached to your clothes or a necklace. These are usually removed the next day. Instruct the patient do not pull on them or try to empty the attached plastic bulbs.

For 2 3 days after the surgery, it is not unusual to have pain or difficulty on swallowing.

The nurses have standing orders to give you antibiotics, pain killers, thyroid replacement hormone and medications for nausea and vomiting. If there are no

contraindications, the patient will also receive the usual home medications.

Most patients develop a transient hypocalcemia (low calcium) in the immediate post-operative period. That is why calcium, phosphorus and magnesium levels will be monitored every six hours and sometimes more frequently. If the patient develop Tingling

hypocalcemia, he will be given calcium by mouth and / or intravenously.

around the mouth and face, muscle spasms of the hands and feet, involuntary grimacing and sometimes difficulty in breathing and gasping for air (stridor) are signs of hypocalcemia.

If he feel up to it, he is allowed to stand up, walk and go to the bathroom, with assistance and always, with someone present in the room. Do not attempt at walking

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or going to the bathroom if the patient is alone in the room. The patient may be too groggy from the pain killers or you may pass-out and fall down.

The day after surgery, the doctor will remove the drains and dressing. In general, the wound is sealed with a thin clear acrylic layer (Dermabond) and the sutures are buried under the skin. There is no need to apply antibiotic ointment on the wound. The patient is allowed to take a shower without covering the wound. This acrylic film will peal off in a couple of weeks. When the patient goes home, warn the patient to keep the wound exposed and do not hide it with a dressing or scarf. A little antibiotic

ointment may be used at the site of the drains for a day or two. In general the drain wound heals and stops oozing in 24 hours.

1. Intravenous Fluids they are replacement that changes the composition of the serum by adding fluid and electrolytes. Preoperative IVF Medical Management or Treatment IVF D5 LRS

General Description It is a hypertonic solution that has a higher osmolarity than the serum. It pulls fluid and electrolytes from the intracellular and interstitial. Lactated Ringers Solution contains sodium, chloride, potassium, calcium, and lactate. Lactate is metabolized in the liver to form bicarbonate

Indications It is indicated and prescribed for patients postthyroidectomy for it provides 170 cal/L and helps maintain or replace body store of water and electrolytes.

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Saline and balanced electrolyte solutions commonly are used to restore vascular volume, particularly after trauma or surgery. Regulation= 30 gtts/min It minimizes glyconeogenesis and promotes anabolism in patients who cannot receive sufficient oral caloric intake. It is a hypertonic solution which has an increased osmotic pressure than that of the blood serum.

NURSING RESPONSIBILITIES: Before: y y y y y Check for the doctors order. Explain the procedure to the patient/SO with its purpose and importance. Wash hands and observe other appropriate infection control procedures. Provide client privacy. Always observe and check for the correct type of IVF as well as the clarity of the fluid.

During: y y Be sure to clean the site of entry with cotton and alcohol in a circular motion. Ensure appropriate infusion flow.

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Adhere to standard precautions, then regulate flow rate as per doctors order.

After: y y y Check and observe the puncture site for bleeding, edema, or thrombophlebitis. Make sure that the IVF is patent and properly regulated. Check regularly. Document relevant data.

2.

Oxygen Inhalation an intervention necessary to facilitate breathing and

relief from difficulty of breathing. It increases gas diffusion across the alveolar capillary membranes. Postoperative order Medical Management Treatment OXYGEN THERAPY

or

General Description

Indications

It increases the supply of oxygen to the lungs and thereby increases the availability of oxygen to the body tissues. Given initially to postoperative patients on reversal anesthesia to encourage transport of anesthetic gases across the alveolar or capillary membrane in the lungs and out of the body.

Indicative fro postoperative patients for the reversal anesthesia to encourage transport of anesthetic gases out of the body.

NURSING RESPONSIBILITIES:

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Before: y y y y Check for the doctors order. Explain the procedure to the patient/SO with its purpose and importance. Wash hands and observe other appropriate infection control procedures. Check patency and appropriate size of cannula.

During: y y y y Lubricate nares using water-based substance. Ensure appropriate infusion flow. Check for level of Oxygen tank. Check for effective flow of oxygen.

After: y y y Regulate oxygen flow rate according to the doctors order. Secure cannula properly. Make sure that the cannula is patent and the flow is properly regulated. Check regularly.

3.

Drainage is a surgical device placed in a wound to drain fluid. It consists

of a soft rubber tube placed in a wound area, to prevent the build up of fluid. Postoperative order Medical Manegement Treatment Penrose or General Description Removes fluid from a wound area. Frequently it is put in place by a surgeon after a procedure is complete to prevent the area from accumulating Indications

To remove pus, blood or other fluids from a wound.

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fluid, such as blood, which could serve as a medium for bacteria to grow in.

NURSING RESPONSIBILITIES: Before: y y y Check for the doctors order. Explain the procedure to the patient/SO with its purpose and importance. Wash hands and observe other appropriate infection control procedures. During: y Ensure the patency of the drainage. After: y y Monitor the patient after it has been transferred in the recovery room. Instruct the patient and the SO not to touch the drainage if their hands are dirty.

4.

Dietthe sum of food consumed by a person.

Preoperative diet Medical Management Treatment

or

General Description To withhold oral food and fluids from a patient for various reasons

Indications

Nothing per orem/Nil per os

May be indicated preoperatively to prevent the risk of aspirating the patient especially when anesthetics are going to be administered. Because anesthesia depresses the CNS

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and the reflexes of the body.

Postoperative diet

Medical Management or Treatment General Description Foods that is tolerable to the patients appetite. To gradually nourish the patients body after a night long abstinence from food. Indications

Diet tolerated when awake

as

fully

NURSING RESPONSIBILITIES:

y y y

Instruct the patient about the type of diet his on. Frequently monitor the patients intake of foods. Inform the SO to elevate the patients head when going to give foods.

5.

Drugs These are licensed medications taken to cure or reduce symptoms

of an illness or medical condition. The following are a list of drugs usually administered in Philippine settings:

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Preoperative medications

Name of Drugs: GENERIC BRAND GENERAL ACTION

Specific Action:

Indications Contraindicati on Route of Administration / Dosage/ Frequency

Adverse Effects

Nursing Responsibilities

Generic name: nalbuphine Brand name: Nubain General Action: Opioid analgesicantagonist analgesic

Binds to opiate receptors in the CNS. Alters the perception of and response to painful stimuli while producing generalized CNS depression.

>Managemen t of moderate to severe pain. Also provides sedation before surgery and supplement to balanced anesthesia.

>CNS: Sedation, clamminess, sweating, headache, dizziness, vertigo >CV: Hypotension, hypertension,bradyc ardia, tachycardia >Dermatologic: Pruritus, burning, urticaria >GI: Nausea, vomiting, cramps, dyspepsia, bitter taste, dry mouth

>Taper dosage when discontinuing after prolonged used to avoid withdrawal symptoms. >Keep opioid antagonist and facilities for assisted or controlled respiration depression. >Reassure patient about addiction liability; most patient who

>Contraindica ted with hypersensitivit y to nalbuphine,

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sulfafites. And use cautiously with emotionally unstable patients or those with a history of opioid abuse. Route: Intramuscular Dosage: 10 mg Frequency: Prior to OR procedure

>GU: urinary urgency >Respiratory: respiratory depression, dyspepsia, asthma

receive opiates for medical reasons do not develop dependence syndromes.

Generic name: hydroxyzin e Brand name: Vistaril General Action: >Antianxiet y >antihistam

>Acts as a CNS depressant at the subcortical level of the CNS. Has an anticholiner gic, antihistamini c and antiemetic properties.

>Preoperative sedation, antiemetic and may be combined with opioid analgesic. >Contraindica ted with allergy to hydroxyzine or cetirizine. And

>CNS: drowsiness, involuntary motor activity including tremors and seizures. >GI: Dry mouth, reflux, constipation >GU: urinary retention >Hypersensitivity: wheezing, dyspnea,

>Determine and treat underlying cause of vomiting. Drug may mask signs and symptoms of serious condition, such as brain tumor, intestinal obstruction, or appendicitis. >Do not

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ine >sedative

use cautiously with uncomplicate d vomiting in children. Route: Intramuscular Dosage: 50 mg Frequency: Prior to OR procedure.

chest tightness.

administer parenteral solution subcutaneously, IV, or intraarterially; tissue necrosis has occurred with subcutaneous and intra- arterial injection, and hemolysis with IV injection >Give IM injections deep into a large muscle: In adults, use upper outer quadrant of buttocks or midlateral thigh muscles; use deltoid area only if well develop.

Generic name: cefuroxime Brand name: Zinacef General

>Bind to bacterial cell wall membrane, causing cell death.

>Treatment of respiratory tract infections, skin and skin structure infections, bone and joint infection,

. >CNS: headache, dizziness, lethargy, paresthesia >GI: nausea, vomiting, diarrhea, anorexia, abdominal pain, flatulence, pseudomembranous

>Culture infection, and arrange for sensitivity tests before and during therapy if expected response is not seen.

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Action: >antiinfective

UTI and gynecologic infection; septicemia. >Contraindica ted with allergy to cephalosporin s or penicillins. And cautiously with renal failure. Route: Intravenous Dosage: 750 mg Frequency: 1 hour prior to OR procedure

colitis >Hematologic: bone marrow depression. >Hypersensitivity: ranging from rash to fever to anaphylaxis. > Local: phlebitis pain,

>Give oral drug with food to decrease GI upset and enhance absorption. >Have vit K available in case hypoprothrombin emia occurs. >Discontinue if hypersensitivity reaction occurs.

>Other: superinfection, disulfiram like reaction with alcohol.

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Intraoperative medications

Name of Drugs: GENERIC BRAND GENERAL ACTION

Specific Action:

Indications Contraindication Route of Administration/ Dosage/ Frequency

Adverse Effects

Nursing Responsibilitie s

Generic name: propofol Brand name: Diprivan Disoprofol General Action: >general anesthetic

>Mechanism of action: A short acting hypnotic. Mechanism of action is unknown. Produces amnesia and has no analgesic effect.

>Maintenance of balanced anesthesia when used with other agents in children, 2 month and adults. Induction of general anesthesia in children, 3 yr. and adults. Route: Intravenous Dosage: 100 mg

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Frequency: Depend on the estimation of the anesthesiologist

Generic name: fentanyl Brand name: Sublimaze General Action: >opioid analgesic

>Mechanism of action: Binds to opiate receptors in the CNS, altering the response to and perception of pain. Produces CNS depression.

>Analgesic supplement to general anesthesia. >Contraindicated with hypersensitivity to opioids, diarrhea caused by poisoning, acute bronchial asthma, upper airway obstruction and use cautiously with bradycardia, history of seizures, renal impairement; history of drug addiction. Route: Intravenous Dosage: 0.025 mg

>CNS: sedation, clamminess, sweating, headache, vertigo, floating feeling, dizziness, lethargy, confusion, light headedness. >CV: cardiac arrest, shock >Dermatologic : rash, hives, pruritus >GI: Nausea, vomiting, constipation.

>Keep opioid antagonist and facilities for assisted or controlled respiration readily available during parenteral administration ; ensure appropriate use of drug because it is potentially dangerous. >Note that the patch doesnt work quickly. It may take up to 12 hr to get the

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Frequency: Depend on the estimation of the anesthesiologist

full therapeutic effect. Breakthrough medications may need to be used. >Do not drink grapefruit juice while using this drug. If using the patch, do not use any patch that has been torn or damage. Remove old patch before applying a new one.

Generic name: isoflorane Brand name: Forane General Action: >anestheti

>Permits a rapid induction of and recovery from anesthesia. The mild pungency of isoflurane may limit the rate of induction, although excessive salivation or

>Induction and maintenance of general anesthesia. Adequate data have not been developed to establish its application in obstetrical anesthesia.

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tracheobronchia l secretions do not appear to be stimulated. The level of anesthesia may be changed rapidly with isoflurane.

>CONTRAINDICATIO N Route: Inhalation Dosage: .3 cc Frequency: Depend on the estimation of the anesthesiologist

Postoperative medications

Name Drugs: GENERIC BRAND GENERAL ACTION

of Specific Action: Indications Contraindication Route of Administration/ Dosage/ Frequency Adverse Effects Nursing Responsibilities

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Generic name: DICLOFENAC SODIUM Brand name: Voltaren NovoDifenac General Action: >Non-opioid analgesics >Nonsteroidal antiinflammatory agents

>Inhibits prostaglandin synthesis Therapeutic effect: Suppression of pain and inflammation.

>For acute pain after a procedure. >Contraindicated with allergy to NSAIDs, significant renal impairment and use cautiously with impaired hearing, allergies, hepatic, CV, GI condition, and in elderly patients. Route: Intravenous Dosage: 75 mg Frequency: Stat dose (PRN)

>CNS: headache, dizziness. >GI: nausea, dyspepsia, GI pain, diarrhea, constipation. >Other: anaphylactic reactions to fatal anaphylactic shock.

>Be aware that patient may be at increased risk for CV events, GI bleed, renal insufficiency; monitor accordingly. >Administer drug with food or after meals if GI upset occurs. >Arrange for periodic ophthalmologic examination during long term therapy. >Institute emergency procedures if overdose occur

Generic name:

>Unknown: Produces

>Also given for mild to moderate pain

>CNS: Headache,

>Give with milk or food to

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Mefenamic Acid Brand name: Ponstan Ponstel General Action: >NSAID >Nonnarcotic analgesics >Anti-pyretic >Antiinflammatory

antiinflammatory , analgesic and antipyretic effect possible by inhibiting prostaglandin synthesis.

after the procedure. >Contraindicated with hypersensitivity to mefenamic acid, aspirin allergy and as treatment of perioperative pain with coronary artery bypass grafting. And use cautiously with asthma, renal or hepatic impairement, peptic ulcer disease, GI bleeding, hypertension, heart failure. Route: Per orem Dosage: 500 mg Frequency: Usually every 4 hours

dizziness, insomnia, >Dermatologic: rash >GI: Nausea, dyspepsia, GI pain, diarrhea, constipation >GU: renal impairment. >Other: anaphylactoid reactions to fatal anaphylactic shock.

decrease GI upset. >Arrange for periodic ophthalmic examination during long term therapy. >Be aware that patient may be at increased risk for CV events, GI bleeding; monitor accordingly. >If overdose occurs, institute emergency procedures supportive therapy and induced emesis, activated charcoal , and an osmotic cathartic.

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Generic name: Cefalexin Brand name: Panixine General Action: >antiinfective

>Bind to bacterial cell wall membrane, causing cell death.

>Treatment of respiratory tract infections, skin and skin structure infections, bone and joint infection, UTI and gynecologic infection; septicemia. >CONTRAINDICATION Route: Per Orem Dosage: 500 mg Frequency: Every 4 hours

The following are a list of important drugs usually administered as management for long term complications of thyroidectomy, such hypothyroidism, hypoparathyroidism, Thyroid Storm and Hypocalcemia:

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Levothyroxine a daily treatment for hypothyroidism with the use of a synthetic thyroid hormone, which restores adequate hormone levels in the body.

   

Intravenous Calcium Infusion is regularly prepared with thyroid surgeries as an inclusion in the emergency cart. Beta adrenergic blockers used to control heart rate and tremors. Acetaminophen prescribed for fever. Propylthiouracil (PTU) or Radioactive Iodine administered for recurrent hyperthyroidism related to hormonal replacements.

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