PREOPERATIVE PREPARATION

AND POSTOPERATIVE CARE

T~
PRE- OPERATIVE PREPARATION

Lecture by

MAJOR (R) MUHAMMAD AFZAL

CHAUDHARY
MBBS (Dow). FCPS (Gen Surgery)
Consultant Gen & Laparoscopic Surgeon
 OVERVIEW

• PATIENT ASSESSMENT

• RISK ASSESSMENT AND CONSENT

• ARRANGING THE THEATRE LIST.

 PATIENT ASSESSMENT

• Aims:
— look actively at risks
— proper management of risks
— enabling safe surgery.

• Standard history taking

• Proper physical examination
• Investigations.
• Airway assessment and evaluation
Figure 9. Mallampati Scalers]

Class I Class II Class Class IV

Full visibility of tonsils. Visibility of hard and soft Soft and hard palate Only hard palate visible
uvula, and soft palate palate, upper portion of and base of the uvula
tonsils and uvula are visible
 RISK ASSESSMENT AND CONSENT

• ASA classification
• Explain on the advantages, side effects and, and
prognosis

• Taking comprehensive valid consent - given

voluntarily by a competent and informed person
Class Physical status Example

1 A healthy patient A fit patient with an inguinal

hernia
11 A patient with mild systemic
disease
Essential hypertension, mild
diabetes without end organ
damage
111 A patient with severe systemic
disease that is a constant threat
to life
Angina, moderate* to-severe
chronic obstructive pulmonary
disease (COPD)
IV Advanced COPD, cardiac
failure
A patient with an
incapacitating disease that is a
constant threat to life
V Ruptured aortic aneurysm,
massive pulmonary embolism
A moribund patient who is not
expected to live 24 hours with
or without surgery
acute peritonitis.
E Emergency case
Source: Adapted from American Society of Anesthesiologists (2013).
•
 BEFORE THEATRE
• Mustbe seen by anesthetist and
operating surgeon in charge.

• Keep in view for specific requirement

Arrange the theatre list appropriately

 SURGICAL SAFETY CHECKLIST
a guideline to reduce rate of preventable surgical complications

• Antibiotic • Torniquets
• Monitoring • Time outs
• Operating theatre • Temperature control
environment • Hair removal
• Diathermy
• Glycaemic control
• Infection control
•
• Hat, mask and eye protection should be worn and
jewellery should be removed
• Nails and deep skin crease should be clean for 1-2
mins using brush
• Hands and forearms wash systematically 3 times
• Hands and arms are dried from distal to proximal using
sterile towel
• Folded gown lifted away from trolley, allowed to unfold
• Arms inserted into armholes, hands remain inside
gowns until gloves are donned, secure the gown
• Gloves are put on, hands remain above waist level at
all times.
 INTRODUCTION
• Preoperative problems - certain specific
medical conditions encountered during
preoperative assessment

• be treated to the best possible level to

eliminate serious complications.

O Patients with severe disease will be referred to

specialists.
OCARDIOVASCULAR DISEASE
OHYPERTENSION, IHD AND
STENTS
ODYSRHYTHMIAS
OVALVULAR HEART DISEASE
OANAEMIA AND BLOOD
TRANSFUSION
ORESPIRATORY DISEASE
* *

• Identify patients who have preoperative high

risk of MI and arrangements to reduce the risk

• esp those who have suffered CAD, CCF ,

arrhythmias , severe PVD.
• Patients with IHD - left ventricular status be
evaluated BEFORE SURGERY.
 •Patients with symptomatic valvular heart
disease or poor left ventricular function – an 2D
echo should be done
• ejection fraction less than 30% - poor outcome

Refer to cardiologist if:

• murmur heard and patient is symptomatic
• poor left ventricular function or cardiomegaly
• ischaemic changes on ECG even if patient
is not asymptomatic.

• abnormal rhythm on ECG , tachy/bradycardia

 HYPERTENSION , IHD AND
STENTS
OPrior to surgery blood pressure should be
controlled to 160/90 mmHg
OStabilisation period of 2 weeks if new
antihypertensive is introduced
O Patients with angina
- investigated further by a cardiologist if not
well controlled
- some may need thrombolysis , stents or
bypass surgery prior to non-cardiac surgery
O Patients who have had stents inserted for IHD,
should be asked for the effectiveness of the
treatment and concurrent antiplatelet medication
(clopidogrel and/or aspirin)
ORisk of stent thrombosis with consequences of
MI and death is reduced if elective surgery is
postponed until after dual antiplatelet therapy is
stopped
OIf cannot be postponed and risk of perioperative
bleeding is low - dual antiplatelet therapy can be
continued during surgery
 -B-blockers, digoxin and CCB started
preoperatively
- warfarin stopped 5 days preoperatively
O Implanted pacemaker and cardiac defibrillator
checks and appropriate reprogramming done
OSymptomatic heart blocks and asymptomatic
second and third degree heart blocks need
cardiology consultation
 VALVULAR HEART DISEASE

O Patients with severe mitral and aortic stenosis

may benefit from valvuloplasty before elective
non-cardiac surgery
O Patients with mechanical heart valves-
- warfarin stopped 5 days prior to surgery and
infusion of unfractionated heparin (INR <1.5)
- APTT kept at 1.5 times normal and stopped 2
hours before surgery
- Heparin and warfarin postoperatively and
heparin
^iiiiiiiistopped once full effect of warfarin realised
 ANAEMIA AND BLOOD

OChronic anaemia well tolerated in the

perioperative period

O if major procedure, preoperative

transfusion if Hb below 8g/dL
 RESPIRATORY DISEASE
OCurrent respiratory status should be compared
with their normal state
ORegular treatment, PEFR , steroids use , CPAP
should be taken note of
O Encourage patients to be compliant with
medications, exercise , consume balanced diet
and stop smoking
*
k-
REFER TO RESPIRATORY PHYSICIANS IF

- Severe disease or significant deterioration from

usual condition
- Major surgery is planned in a patient with
significant respiratory comorbidities
- Right heart failure is present
- Patient is young with COPD
 Smoking : provide information regarding perioperative
risks associated with smoking
O Asthma : establish severity of asthma, PEFR ,
precipitating causes, frequency of steroid and
bronchodilator use and any previous intensive care unit
admission. Use regular inhalers until the start of
anaesthesia
O COPD : Patients with significant COPD who are
undergoing major surgery will need to be referred to
physicians to optimise their condition. ABG also useful

O Infections : elective surgery postponed if chest

infection. Treated with antibiotics and operation
rescheduled after 4-6 weeks.
 GASTROINTESTINAL
DISEASE
Nil by mouth and regular medications
- Not to take solids within 6 hours and fluids within
2 hours before anaesthetic
- Infants allowed a clear drink up to 2 hours ,
mother’s milk up to 3 hours and cow or formula
milk up to 6 hours before anaes
- If surgery delayed, oral (until 2 hours of
surgery) or IV fluids started in the vulnerable
group of patients
 Regurgitation risk
- High risk of pulmonary aspiration if patients
with hiatus hernia, obesity, pregnancy and
-diabetes
Antacids, H2-receptor blockers or PPI given
Liver disease
- Cause of the disease , clotting problems, renal
involvement and encephalopathy should be
known
- LFT, coagulation , blood glucose, urea and
electrolyte levels
Ascitis, hypoalbuminaemia, sodium and water
retention should be noted
THANK
YOU.....
(but to be continue.)
SPECIFIC
PREOPERATIVE
PROBLEMS ,
REFERRALS AND
MANAGEMENT (2)
BY :
M.Krishna
vaathi
01201110
0086
Genitourinary disease

1) Renal disease

- Diabetes mellitus, hypertension and ischemia

heart disease should be stabilised
( leading to chronic renal failure )
- Apporiate measures to treat acidosis,
hypocalcemia and hyperkalemia > 6mmol/L
- Continue peritoneal or hemodialysis until a few
hours before surgery
- Blood sample sent for FBC and U & E ( after final
dialysis before surgery )
- Chronic renal failure patients often suffer chronic
microcytic anemia that is well tolerated
- Acute renal failure can present with acute surgical
problems ; eg bowel obstruction needing emergency
surgery ( simultaneous medical , surgery treatments and
critical care unit )
2) Urinary tract infection

- Uncomplicated urinary infections are common in

female
- Outflow uropathy with chronically infected urine is
common in men
- For elective surgery * infection should be treated
because it carries dire consequences eg joint
replacements
- For emergency surgery * give antibiotics, ensure
good urine output before, during and after surgery
Endocrine and metabolic disorders

1 ) Malnutrition

- BMI < 18.5 kg/m2 ( nutritional

impairment )
- BMI < 15 kg/m2 ( significant hospital
mortality )
-2) Obesity
Nutritional support for 2 weeks before
surgery
Advice on healthy eating and taking regular exercise
Use CPAP device for obstructive sleep apnea and
cholesterol reducing agents
If possible, delay surgery until patients more active
and lost weight.
Preventative measures for acid aspiration , DVT and
associated risks explained prior to surgery
 Diabetes mellitus

- Check HbA1c level

- Start lipid lowering medication in high risk
group of cardiovascular complications of
diabetes
- Morning operation { advice to omit morning dose
medication and breakfast, tight control of blood sugar
not needed }, check blood sugar for every 2 hrs
- Afternoon operation { breakfast + half regular dose
of insulin or full dose of oral anti - diabetics, check blood
sugar for every 2 hrs
- Intravenous insulin sliding for insulin dependent
diabetes mellitus undergoing major surgery or if blood
sugar difficult to control for other reason

4 ) Adrenocortical suppression

- Ask oral adrenocortical steroid dose and duration

to avoid Addisonian crisis
Coagulation disorders

1) Thrombophilia

- Thrombophylaxis needed if present of risk factors

Risk factors for thrombosis
- Increasing age
- Significant medical comorbidities (particularly
malignancy)
- Trauma or surgery (especially of the abdomen,
pelvis and lower limbs)
- Pregnancy/puerperium
- Immobility (including a lower limb plaster)
- Obesity
- Family/personal history of thrombosis
- Drugs (e.g. oestrogen, smoking)
- Hormone replacement therapy ( HRT ) should be stopped 6
weeks prior to surgery
- Low risk patients can be given thromboembolism deterrent
stockings
- Give warfarin for patients with high risk patients with history of
recurrent DVT, pulmonary embolism and arterial thrombosis
- Stop warfarin before surgery and replaced with low molecular
weight heparin or factor Xa inhibitor

Neurological and psychiatry disorders

- History of stroke, pre existing neurological deficit patients may be

on antiplatelet or anticoagulants.
- Low risk of cardiovascular thrombosis, antiplatelet withdrawn
( 7days for aspirin, 10 days for clopidogrel)
- High risk patients, use aspirin alone
- Anticonvulsant and antiparkinson continued to help early
mobilization
- Stop lithium 24 hours prior to surgery, measure blood level to
avoid toxicity
- Inform anaesthetist if psychiatric medications such tricyclic
antidepressants or monoamine oxidase inhibitors to avoid drug
interactions.
Musculoskeletal and other disorders

- Rheumoid arthritis , flexion and extension lateral cervical spine x

ray should be taken. ( lead to unstable cervical spine with spinal cord
injurt during intubation )
- Rheumatologist will advice on steroids and disease modifying drugs
so as to balance immunosuppression against need to stabilise disease
preoperatively
- In ankylosing spondylitis, technique of spinal or epidural
anaesthesia often challenging
- Patients with systemic lupus erthematosis may
exhibit hypercoagulable state along with airway difficult

Airway assessment
Samsoon and Young modified Mallampati test

Fauces, pillars, soft palate and uvula seen Grade 1

Fauces, soft palate with some part of uvula seen Grade 2
Soft palate seen Grade 3
Hard palate only seen Grade 4
 Patient’s mouth open and tongue protruding
Higher the grade, higher the risk in obtaining and
securing
airways
Look for loose teeth, obvious tumors, scars,
infections, obesity, thickness of neck which will
indicate difficulty in obtaining airway Modified
Mallampati class
Jaw protrusion, neck movement and thyromental
Thyromental Distance

distance
Sonti:0 3 cm
Conran: < 0 cm
Hard D
Soft palate

......I ,

Mandibular Protrusion Test

• Class A: Lower incisors can be protruded Class 1 Class 3 Class 4

anterior to the upper incisors etna a

• Class B: I he lower incisors can be

brought edge to edge with upper incisors 'igure 1. The Mallampati score:
Class 1. Complete visualization of the soft palate
Class 2. Complete visualization of the uvula
visualization uvula
incisors visible
brought
Preoperative assessment in emergency surgery

- Start similar principle to that for elective surgery

- Constraints : time, facilities available
- Consent : may be not be possible in life saving
emergencies
- Organisational efforts : for example, local/ national
algorithms for treatment of multi-trauma patients
SABRINA TAMILMANY
 PURPOSES
To enable a successful and faster recovery of
i-

the patient post operatively.

To reduce post operative mortality rate.
i-

i^To reduce the length of hospital stay of the

patient.
*

i- To provide quality care service. *

i- To reduce hospital and patient cost during post

operative period.
 GENERAL
MANAGEMENT

m^
 WHAT IS NEEDED?
the immediate recovery and requires to detect
early signs of complication.
Receive a complete patient record from the
operating room which to plan post operative
care. Patient’s name
•Age
•Surgical
•Existing
procedure
medical problem
•Allergies
•Aneasthetic & analgesics given
•Fluid replacement •Blood loss
•Urine output
Any surgical/ anaesthetic
problems
encountered
Assessing the patient
Monitor vitals-pulse volume
and regularity, depth and
nature of respiration.
Assessment of patient’s 02
saturation. ' •
KEEP MONITORING VITALS
 PROTECT
AIRWAY

❖ By proper positioning
of patient’s head.
❖ By clearing airway.
❖ Oxygen therapy.
Maintaining IV Stability

Hypovolemic shock: can be avoided by

timely administration of IV Fluids,
blood and blood products and
medication.
Replacement of fluids.[colloids and
crystalloids]
Keep the patient warm.
Monitor intake and output balance.
Monitor the vitals continuously with the
patient condition.

*
v
ASSESSMENT OF THE SURGICAL SITE
Haemorrhage
It is a serious complication
of surgery that resulting
death.
It can occur in immediate
post operatively or upto
several days after surgery.
If left untreated,cardiac
output decreases and blood
pressure and Hb level will
fall rapidly.
Blood transfusion if necessary.
The surgical site+incision
should always be inspected.
If bleeding,pressure dressing
are placed.
If the bleeding is concealed,the
patient is taken in OR for
emergency exploration of
concealed haemorrhage in
body cavity.
RELIEVING PAIN +ANXIETY
Catheter
S Administer opioid analgesia as
Epidural per Doctor’s order.
space
S Epidural analgesia.
S NSAIDS.
S Psychological support to relieve
fear+To give support.
CONTROLLING NAUSEA+VOMITTING
S These are common
problem in post operative
period.
S Medication can be
administered as per
doctor’s order.
« _%

Example:
Inj Metaclopramide Inj
Ondansetron ( Emeset )
 WHEN TO BE DISCHARGED
FROM RR?
• When patient fulfill following criterias,
S Fully concious
S Respiration and oxygenation are satisfactory S Not in
pain or nausea S CVS parameters are stable S Oxygen,
fluids and analgesics prescribed S No conceren related
to surgical procedure
SYSTEM SPECIFIC
COMPLICATION
RESPIRATORY COMPLICATION
• most common are
hypoxaemia
hypercapnia
aspiration

late complication
Pneumonia
♦> ♦> k ♦> ♦> ♦>

pulmonary embolism
 POSTOPERATIVE HYPOXIA
• Present as shortness of breath, or agitated due to
upper airway obstruction
• Signs

> Absence of air movements

> Seesaw movement of chest
> Suprasternal recession
> cyanosis
 Laryngeal
edema due to
tracheal
• i i i •
 TREATMENT
• Should be treated urgently
• Administer oxygen at 15L/min using a
nonrebreathing mask + head tilt, chin lift and
jaw thrust
• Suctioning of any blood or secretions
• Tracheal intubation and manual ventillation
• If pneumonia : antibiotics, chest
physiotherapy and bronchodillators %

• If pulmonary edema : start on diuretics and

cardiology opinion sought
• Hypotension is common due to inadequate fluid
replacement, vasodilatation from anesthesia
•||Other causes
> Surgical bleeding
> Sepsis
> Arrythmias
> Myocardial infarction
> Cardiac failure
> Tension pneumothorax
> Pulmonary embolism

w-
• Signs
> Cold clammy extremities
> Tachycardia
> Low urine output ( < 0.5 ml/kg )
> Low CVP
* —%
•
 TREATMENT
• Start with oxygen, glyceryl trinitrate, morphine and
aspirin
• Beta blockers or calcium antagonist may be
started
• Cardiologist should be involved.
 ARRYTHMIA
• Cause hypotension and ischemia
• Need continuous monitoring

• Treated according to Resuscitation Council peri-

arrest guideline,
> Correct the cause including acid-base and
electrolyte imbalance, hypoxia, and hypercapnia
RENAL AND URINARY
COMPLICATIONS
 ACUTE RENAL FAILURE
• Any perioperative events like sepsis, bleeding,
hypovolaemia, rhabdomyolysis and abdominal
compartment syndrome precipitates
• Treatment,
> If urine output < 0.5ml/kg for 6 hrs, check the catheter if
its blocked
> Correct hypovolaemia, metabolic and electrolyte
disturbance and stop nephrotoxic dugs

♦
 URINARY RETENTION
• Common in pelvic and perineal operations

• Catheterisation should be performed if an ope

expected to last more than 3 hours or longer or when
large volumes are administered
 URINARY INFECTION
• Patient present with dysuria or pyrexia

• Immunocompromised, diabetis and patient with

h/o urinary retention are at higher risk
• Treatments
> Adequate hydration
> Proper bladder drainage
> antibiotics
 Complicatons Related to
Specific Surgical Specialities

Anna Alisha Mathew Simon

 Abdominal Surgery
• The abdomen should be examined for
distension, tenderness, drainage
• Sites/wounds :
- Paralytic illeus
• following surgery, bowel
movements may reduce temporarily
• adequate hydration and
electrolytes
- Localised infection
- Anastomotic leakage
 Orthopeadic Surgery
• Neurovascular status of limbs must be checked
regularly

• External fixator-pin site should be checked

Compartment syndrome-remove circumferential

dressings-fasciotomy
 Neck Surgery
• Accumulation of blood = asphyxia

• Recurrent laryngeal nerve damage-pre and post

op
 Thoracic Surgery
• Regular review of chest drain
• Continous ECG monitoring
• Bronchopleural fistula
• Heamothorax
• Pleural effusion
Neurosurgery

• Raised intracranial pressure-monitored closely

Vascular Surgery

• Regular clinical assessment and Doppler

ultrasound post op
Plastic Surgery

• Viability of flaps and perfusion needs to be monitored

regularly

Urology
• Catheter patency must be check regularly

• TURP-continous bladder irrigationpulmonary

oedema
 GENERAL POSTOPERATIVE
PROBLEMS AND MANAGEMENT
NUR NABILAH ISZA BT ISMAIL JA'FAR
Pain
Nausea and vomiting
Bleeding
Deep vein thrombosis
Hypothermia and shivering
Fever
Prophylaxis against infection
Confusional state
Drains
Wound care
Wound dehiscence
Enhanced recovery
 Pain
• Most feared problem among patients
• More than 80% of patients experience post
operative pain
World Health Organisation Pain Ladder

Severe pain
Local anaesthetics, Opioids + Paracetamol ±
NS AIDS

Moderate pain
Local anaesthetics. Paracetamol ± NSAIDs, Paracetamol +
Codeine

Mild pain
± Paracetamol ± NSAIDs
 Nausea & Vomiting
• Postoperative nausea and vomiting (PONV) can
precipitate bleeding and dehiscence of wounds by
dislodging the clots and bursting suture lines.
• In neurosurgical patients -> raised intracranial pressure
• Risk factors:
- Women
- Non smoker
- Past h/o PONV, motion sickness, migraine
- Use of volatile anesthetic agents, opioids & NO
- Duration and type of surgery
• Management
- Adequate treatment for pain, anxiety, hypotension &
dehydration
- Antiemetic (eg. Ondansetron, dexamethasone)
 Bleeding
• Primary hemorrhage:
- either starting during surgery or following
postoperative increase in blood pressure -
replace blood loss and may require return to
theatre to reexplore the wound
• Secondary hemorrhage:
- often as a result of infection.
 Deep Vein Thrombosis
• Presentation:
— Calf pain
— Swelling
— Warmth
— Redness
— Engorged veins
• Venography or duplex Doppler ultrasound is used to
assess flow and the presence of thromboses
• Management :
— Use of stockings, calf pumps
— Low molecular weight warfarin
 Stratification of risk of DVT
Low Medium High
Maxillofacial surgery Inguinal hernia repair Pelvic elective
and trauma
surgery
Neurosurgery Abdominal surgery Total knee and
hip replacement
Cardiothoracic surgery Gynecological surgery

Urological surgery
 Hypothermia and shivering
• Anesthesia induces loss of thermoregulatory control.
• Exposure of skin and organs to a cold operating
environment, volatile skin preparation, infusion of cold
IV fluids
• Leads to increased cardiac morbidity, a
hypocoagulable state, shivering with imbalance of O2
supply and demand, immune function impairment with
possibility of wound infection.
• Management active warming devices
 Fever
• Causes of a raised temperature postopertively
include:
- Day 2-5 : atelectesis of lung
- Day 3-5 : superficial & deep wound infection
- Day 5 : chest infection, UTI and thrombophlebitis
- > 5 days : wound infection, anastomotic leakage,
abscess
• Management : treat possible causes
 Prophylaxis against infection
• Patients who had foreign material insertion :
— Hip or knee prosthesis
— Aortic valve
• Bacteria can be incorporated into the biofilm that
forms on the surface of the implant.
• Management :
— Prophylactic antibiotic should be administered,
usually one dose 30 mins before 'knife to skin'
and two postoperatively.
 Confusional state
• Acute confusional states occur on recovery
from anesth or few days after surgery.
• Higher in elderly with hip fractures & is
associated with increased morbidity and
mortality.
• Present as :
- Anxiety
- Incoherent speech
- Clouding of consciousness
- Destructive behavior (eg. pulling off cannula)
 Cause
Renal

S Renal failure S
Hyponatraemia S UTI
S Urinary retention
Respiratory

S Hypoxia S Atelectesis
Cardiocvascular

S Pulmonary embolism S
Dehydration S Septic
shock S Myocardial
infarction S Chronic heart
failure S Arrhythmia
Drugs

S Opiates S Hypnotics S
Cocaine
S Alcohol withdrawal S
Hypoglycemia
Neurological S Epilepsy S Encephalopathy
S Head injury S
Cerebrovascular accident

Idiopathic (rare) S Hypothyroidism S

Hyperthyroidism S Addison's
disease
• Risk factors: Precipitating Management
factors •
- Pre-existing - Treat
- Physical underlying
cognitive
restraints
impairment medical
- Use of - Addition of new problems
narcotics, medications - Involve
benzodiazepin - Electrolyte & relative,
es, alcohol fluid friends
- Renal abnormalities - Pain control
impairment - Intraoperative
- Depression blood loss
- Admission to
ICU
 Drains
• Used to prevent
— Accumulation of blood, serosanguinous or
purulent fluid
— To allow the early diagnosis of a leaking
surgical anastomosis
• Quantity & character of drain fluid can be used
to identify any abdominal complication such as
fluid leakage (eg. bile or pancreatic fluid) or
bleeding
— Additional IV fluids with same electrolyte
contents
• Removed if drainage stopped or become less
than 25 ml/day
 Wound care
• Within hours, dead space cells fills up with an
inflammatory exudate.
• Within 48 hours, a layer of epidermal cells from wound
edge bridges the
gap.
• Inspect wound only if there is any concern or the
dressing needs changing (under sterile condition)
• Inflamed wound ^ swab and sent for Gram staining &
culture
• Infected wound & hematoma -> treat with antibiotics
• Contaminated/nonviable tissue remains -> packed &
return to theater every 24-48 hours for cleaning
• Skin sutures/clips are usually removed between 6-10
days after surgery.
• Delayed wound healing -> patients who are
malnourished, or have vitamin A & C deficiency
• Causes of inhibition of wound healing :
- Steroids
- Diabetes (uncontrolled)
 Wound dehiscence
Is a disruf in a wound
Commonl »ostoperative t
day when the weakest.
It may he ;ually presents
with sero
Managerr
-> Return
-> Leave' ings or vacuum
assiste

Dehiscence Evisceration
 Risk factors
General Local
Malnourishment Inadequate or poor closure of wound

Diabetes Poor local wound healing

Increased intra-abdominal pressure

Obesity Renal

failure Jaundice

Sepsis
 Enhanced recovery
• An approach to the perioperative care of patients
undergoing surgery.
• Designed to speed clinical recovery of patient, reduce the
cost and length of stay in the hospital.
• Strategies include :
— Early planned physiotherapy & mobilisation (reduce
risks of DVT, urinary retention, pressure sores)
— Early oral hydration & nourishment
— Good pain control NSAIDs
— Discharge planning (support from stoma care nurses,
physiotherapists)
DISCHARGE OF PATIENTS
 Discharge Letter
• IT include:
• Diagnosis
• Treatment
• Laboratory results
• Complications
• Discharge plan
• Follow up
 Follow Up in Clinic
• Reviewed in clinic when a key decision on
management needs to be made
• Letter to patient's GP:
Care plan agreed with patient
Advise ABOUT
of complications
• Discharge patient from clinic