General Patient Management
- Surgical patients
- Inpatient care
- Intensive care
- Outpatient care
The management of surgical patients can be considered under three headings: preoperative, operative and postoperative. These should form a programme planned to meet the patient’s therapeutic need. This chapter is concerned with the pre- and postoperative care, excluding the medically compromised patients, who are the subject of Chapter 3.
Once the treatment has been planned it must be decided whether the patient requires admission to hospital or can be treated on a day-case basis or as an outpatient. Admission as an inpatient ensures more comprehensive care, which can be extended both pre- and postoperatively until the patient is both fit for the procedure and able to be discharged home. Much of the responsibility for the provision of care is entrusted to the nursing staff. Optimal conditions can be maintained with administration of intravenous drugs and appropriate nutrition catering for the particular patient needs. This provides an environment that can seldom be achieved at home, although early discharge is to be encouraged to increase efficient bed use. With this in mind, day-stay facilities where the patient is admitted in the morning to return home postoperatively, some hours after recovery, are increasingly popular. The advantage of this is postoperative supervision by nursing staff during the period when complications related to surgery or anaesthesia may occur, while allowing the patient to return home as soon as possible. However, the home circumstances must allow the patient to be adequately looked after and the patient must be within reasonable distance of help postoperatively should unexpected complications occur. In oral surgery, the majority of outpatients are treated using local anaesthesia, sometimes in conjunction with sedation techniques. Inpatients usually have endotracheal general anaesthesia of a longer duration than should be administered on a day-stay basis.
The indications for admitting patients to hospital are surgical, medical and social.
The length of surgery – a day case should ideally be around 30 minutes in duration, anything longer than this may require overnight admission, although improvements in general anaesthetic agents have allowed more rapid recovery. If there is a risk of complications such as haemorrhage or fracture of the jaw, or if major surgery is being undertaken with consequent increased morbidity, the need for admission increases.
The patient requires collateral management by a physician (e.g. management of diabetes), needs special therapy or skilled nursing care.
The patient’s home conditions are poor, they are living alone, live far away or are anxious to be treated as an inpatient.
Inpatient care demands a wider application of the general principles that underlie the management of surgical patients. It is therefore considered first, though no important difference is implied between the needs of in- and outpatients.
The date of admission to hospital can be arranged at the time of consultation and waiting lists thereby avoided. Where a waiting list is used it is important to give adequate warning that a bed is available and also to recognise certain surgical priorities, such as the following.
Conditions requiring instant admission, such as acute infections or traumatic injuries.
Conditions that can progress to emergencies if treatment is long delayed, for example subacute infections and neoplasms.
Those of no urgency who may take their turn in chronological order.
A patient who is fit and only requires routine surgery is normally admitted the day before the operation, although pre-admission clinics (PAC) can usefully highlight management issues that can be addressed prior to the actual admission date. Problems related to the administration of a general anaesthetic should be anticipated and an anaesthetic opinion sought (see below). Where special preparation is needed, such as blood investigation, or consultation with other specialists, the time of admission must be calculated to allow for these procedures to take place first.
The patient should be visited by the surgical team within a few hours of admission and findings made at the outpatient examination reviewed and revised if necessary. The pulse, temperature and blood pressure are recorded. Blood tests may be required and should be sent off in time to allow analysis before surgery. The mouth must be carefully examined and the area of surgery reassessed. If teeth are to be removed, any change to the dentition should be noted to enable those beyond conservation to be extracted under the same anaesthetic. Insecure dressings should be replaced to prevent their being dislodged into a socket or wound. Before a general anaesthetic, loose or crowned teeth are noted and the anaesthetist warned. Where extensive haemorrhage is anticipated blood is taken for grouping and cross-matching, and the necessary amount for replacement is ordered. Where grouping is done only as a precautionary measure the serum may be kept for cross-matching if required, but no blood ordered. The nature of the operation and likely complications should be explained to the patient and informed consent obtained in writing for both the anaesthetic and the operation.
It is the role of the surgeon not only to carry out the local treatment but also to supervise the day-to-day care.
Relations with the Nursing Staff
The surgeon must understand the routine of the wards and the way the patients are nursed. Though it is essential to make daily visits to assess progress and give treatment, these must be arranged to avoid awkward times when the wards are normally closed. The nursing staff spend much time with the patient and have opportunities to hear complaints and observe minor changes that the surgeon may overlook. Their role in motivating the patient during the postoperative period should not be underestimated and their comments can therefore be of great help. They are an essential member of the ward round and should be consulted about progress daily.
Before any procedure is undertaken the patient’s informed consent must be obtained. The proposed operation or investigation should be explained in simple language which can be understood by the lay person. The more common complications must be mentioned without causing undue distress. Where a general anaesthetic or sedation is proposed the consent should be in writing. For those under 16 years of age, it must be given by their parent or guardian.
Major points on informed consent:
- It is required for any surgical procedure on children under 16.
- It is required for all patients undergoing general anaesthesia or sedation.
- It requires careful explanation by staff who fully understand the procedure.
- Full warnings of recognised complications must be noted.
- Nervous patients may have little recall of information given.
A knowledge of the principles of nutrition is essential to understand the dietetic problems of the patient, and the following summary is presented with this in mind. The diet can be broadly divided into its fluid and solid content.
Fluid Intake and Output
The water intake is approximately the sum of the weight, expressed in grammes, of fluid and of solid food ingested, because solid food when digested and metabolised yields three-fifths its own weight as water. The water intake should be about 2500 ml daily, half of which is taken as drinks.
Water is excreted as exhaled air (400 ml), evaporation including sweat (500–1000 ml), urine (1200 ml) and faeces (200 ml). Water lost by exhalation and evaporation is used for heat regulation and the quantity lost varies widely according to the circumstances. Insufficient fluid intake shows as a decrease in urine output. The absolute daily minimum of urine is the 600 ml required to carry the 50 g of urinary solids excreted daily; below this volume toxic metabolites are returned to the blood. At this concentration the specific gravity is raised from 1.015 to 1.030. All patients who have difficulty in feeding because of acute trismus or mouth injuries should have a fluid balance chart. This shows on the credit side all fluid taken in 24 hours, including metabolic water, and on the debit side the urine passed plus an estimate for water lost by evaporation, which may be very high in febrile states. For all practical purposes the urine output is a measure of the water balance.
In the adult, the daily output should be at least 1000–1500 ml. This simple but accurate criterion is satisfactory unless cardiovascular or renal disease is present, when overenthusiastic pressing of fluids beyond the power of the kidney to excrete may result in fluid overloading and excessive stress on the heart. Fluids may be administered by several routes, of which only the oral and intravenous are much used. The safest, most convenient and effective way of giving fluids is by mouth if not contraindicated, and should be preferred to all others. Up to three litres of water, flavoured attractively, can be taken each day. Where the intraoral route cannot be used, fluids may be given intravenously.
A balanced diet includes carbohydrates, fats, proteins, vitamins and mineral salts.
Fats, the highest calorie provider, are not easily digested by the sick and their intake may have to be markedly reduced. They are, however, important as a vehicle for the fat-soluble vitamins A, D, E and K. In starvation, the body’s fat reserves may be mobilised, but a certain minimum daily quantity of carbohydrate is needed for their physiological use and to prevent ketosis. Only 100 g of glycogen is stored in the liver, which is less than a one-day requirement. Protein is essential for the repair of tissues and for maintaining the circulation. A deficiency may occur after extensive haemorrhage or burns and may increase the susceptibility to shock, impede the healing of wounds, impair circulatory efficiency and lower resistance to infection. Patients in bed undergo protein wastage, which is best prevented by a high carbohydrate and protein diet. Vitamins and mineral salts are essential and are supplied therapeutically, if deficient.
Food must be attractively prepared, and even if sieved or in fluid form it should not lose its identity. Each meal should bear some resemblance to its usual form; most foods can easily be liquidised and baby foods, though expensive, are useful in this respect.
Special dietary requirements must be discussed with the dietitian and the ward sister. The total calories, the amount of water, protein and vitamins, together with proprietary preparations and the number and the kind of supplementary feeds, must be specified. The rule ‘a little and often’ will help to avoid indigestion and ensure an adequate intake, particularly when the jaws are wired together. Supplementary feeds should be considered so that the daily routine includes early morning tea, breakfast, ‘elevenses’, lunch, tea, dinner, supper and nightcap.
Certain patients may have to be fed through a nasogastric (Ryle’s) tube. This is a small-bore plastic tube passed through the nose so that about 5 cm lies in the stomach. The normal length of tube from the nose is 50 cm; any excess interferes with gastric/>