Pre-OP and Post-OP Cares - 手術

A. Pre-operation General orders要點: a. Pre-OP NPO時抗癲癇, 氣喘藥物與降血壓藥物不可停藥. 甲、抗凝血藥物藥需停藥10-14天. b. 2小時內的手術不必on Foley. Pre-OPandPost-OPCares要點 Pre-operationorders要點 Pre-OP範本 BrainPost-OP SHI/Strokes/poporders Cranioplasty 備血量 L-SpinePost-OPCare L-Spine(TPS,Cages,多節數)   A. Pre-operationGeneralorders要點: a.    Pre-OPNPO時抗癲癇,氣喘藥物與降血壓藥物不可停藥 甲、抗凝血藥物藥需停藥10-14天     b. 2小時內的手術不必onFoley    c.所有手術下刀前半小時內要注射一劑Cefamezine    d.Pre-OPData.EKG, CXR要主動去追.如果有異常請通知主治醫師特別注意凝血功能及有心臟/肺部疾病史的病患   g.TimeofNPOpre-operatively:    1.< 3yr:禁waterpre-op4hr;禁milkpreop6hr    2.> 3yr:禁waterpre-op6hr;禁milkpreop8hr   h.小於兩歲且NPO 時IV.Fluid每500mlfluid要加兩支50% Glucose      waterie.D5D1/4500ml+50%G/W2amprun xxxcc/hr i.               年紀大的及有Pulmonary,cardiacdisease history的患者,在spineinstrumentation手術後,可以住加護病房  j.手術日自動到開刀房幫忙 C-Spine手術 1.    Pre-op與general/L-spine雷同 2.    Post-OP特別注意 1.    傷口有否腫脹甚至影響患者呼吸 2.    注意患者手腳力量.感覺.神經系統是否與術前一樣 3.    躺在床上不需要戴頸圈.要起床前記得戴頸圈至少3個月 4.    hemovac<5cc可拔 L-Spine(TPS,Cages,多節數) B.   Pre-OPsurvey: 1.    CBC,D/C,Platelet,,PT,APTT,Sugar,Na,K,Cl,BUN,Cr,GOT.GPT, CXR,EKG,L-spinedynamicXR:AP+lat+  Flex+Ext自己開單並勾選以免護士沒勾到 2.    SpineforOPage>60  甲、Cardiacecho 乙、Pulmonaryfunctiontest 丙、Consult麻醉 丁、ConsultCVifproblems k.備血量: TPS,cages PRBC6u,FFP6u   S-SAH(Aneurysm) PRBC6u,FP6u L-HIVD,VPshunt 只要Hb大於10就不必備血     HypertensiveICH PRBC6u,FP6u C-andL-laminec-tomy>2-level PRBC2u   SpontaneousICH PRBC6u,FP6u C-Spineinjury PRBC2u   IVHforEVDonly Nobloodneeded MVDforTN/HFS PRBC2u,FFP2u   TraumaticEDH,SDH,ICH PRBC6u,FFP6u 6.  L-SpinePost-OPCare: Cefamezine1vialiv.Q6h,voren, dorsiflex,iwell,sennocort 甲、首要注意患者手腳力量.感覺.神經系統是否與術前一樣 乙、手術後在床上可以正常活動 丙、訂背架 丁、拔除後Hemovac才開始換藥 戊、術後裝置PCA的患者在拿掉PCA之前勿拔掉Foley,注意有否腹脹,便秘,嘔吐….如果發生要call麻醉 己、Hemovac少於30-50cc即可拔除最多放4天,如果Hemovac內有CSF則Hemovac改為不加壓,重力引流,一天後拔掉.拔掉時記得帶3-0Nylon把hemovac的洞縫緊. 庚、RemoveHemoVac連串步驟                      i.            CheckL-spineAP+Lat(限於有內固定器)                     ii.            Changedressing                   iii.            DCiv.CM.                   iv.            DCantibiobicsCM.                     v.            RemoveFoley 辛、Spine有打內固定器的患者,要等穿上背架以後才能下床活動 壬、一般7天拆線 如果是redo的要等14天所以乾脆門診回來再拆 **.BrainPost-OP: a.Removescalpandspinesuturesat7thday如果是Re-Opencase最好等兩星期 b.頭上裝有EVD,ICPmonitor,hemovac及spine有Hemovac 的患者一定要給第一線抗生素,等到拆除管線後才開始換藥並DCantibiotics c.IV抗生素停掉以後不需要給口服抗生素 e.術後裝置PCA的患者在拿掉PCA之前勿拔掉Foley f.Hemovac少於30-50cc即可拔除,如果Hemovac內有CSF則Hemovac改為不加壓,重力引流,一天後拔掉.拔掉時記得帶3-0Nylon把hemovac的洞縫緊. i.Strokeandbraininjury患者住院中不可以開外傭申請書,勞保傷病診斷,殘障診斷書等 ．Cranioplasty 1.    antibioticsiv.x7days 2.    Dilantinivx3daysthenchangetooral 3.    hemovac<50ml可拔 4.    傷口等拔掉HV才開始換藥 5.     住院7天.一般14天拆線, SevereHeadinjuryorStrokeICHs/pop routineorders 1.    GCS,ICP,VSq1h 2.    I/Oq2h 3.    Headup30degree 4.    N/Srun60cc/hr 5.    Cefamezine1vialiv.Q6h 6.    Zantac1ampiv.Q12hx3days 7.    Mannital75ccivq4hifICP>20mHg 8.    KeepCPP>70ifICP>20mmHg 9.    CallmeifICP>30mmHg 10. Dilantin6vialiv.Slowlyst. 11. Dilantin1vialIVdripq8h 12. checkserumOSMqdifusemannitol,keepSosm<300 13. RecordHVq8h 14. 傷口等拔掉HV/ICP才開始換藥 15. 一般7天拆線 16.Moringcare,抽痰前5分鐘Dormincum1ampiv.   Pre-OP範本   1.Orderforheadinjury      = SignOP&Anesthesiapermit      = NPO視手術時間及年齡而定      = D5S500ml+50%G/W2amprun___cc/hr(<2歲)      =剃光頭      = PreparePRBCxunits,FFPxunits      = Cefamezine1vialtoOR      = Take DilantinxamptoOR      = ICUorientation      = SendpatienttoORoncall 2.OrderforVertebroplasty      = SignOP&Anesthesiapermit      = NPOpost-midnight      = D5Srun90cc/hr      = 不必備血      = Cefamezine1vialtoOR      = SendpatienttoORoncallcomingmorning   3.OrderforLumbar Laminectomy&microdisectomy,Cranioplasty      = SignOP&Anesthesiapermit      = NPOpost-midnight      = D5Srun90cc/hr      =PreparePRBC2units(兩節以上的Laminectomy)      = Cefamezine1vialtoOR      =SendpatienttoORoncallcoming morning 4.OrderforLumbarTPSand Cages   =SignOP(脊椎手術and椎體護架同意書)&Anesthesiapermit      = NPOpost-midnight      = D5Srun90cc/hr        =signPCA,Cages,Burr自費同意書      = PreparePRBC6units,FFP6units      = Cefamezine1vialtoOR         =Sendpatientto ORoncallcomingmorning   6.OrderforCervical spine*.PatientwithSkulltraction      = SignOP&Anesthesiapermit      = NPOpost-midnight      = D5Srun90cc/hr      = PreparePRBC4units,FFP4units      = Cefamezine1vialtoOR      =睡翻轉床coming morningoncall      =SendpatienttoORwithsoftneck collaroncallcomingmorning 5.OrderforCervicalspine*.Posteriorfixation/Halifax/Laminoplasty      = SignOP&Anesthesiapermit      = NPOpost-midnight      = D5Srun90cc/hr      = PreparePRBC4units,FFP4units      = Cefamezine2vialtoOR   =睡翻轉床 comingmorningoncall      =SendpatienttoORwithsoftneck collaroncallcomingmorning   7.Orderfor MVD(Microvasculaedecompression)forTrigeminalneuralgia/Hemifacialspasm      =SignOP(腦部手術)&Anesthesiapermit      = NPOpost-midnight  =不剃頭    =術後轉SICU訂床      = D5Srun90cc/hr      = PreparePRBC4units,FFP4units      = Cefamezine1vialtoOR         =Sendpatientto ORoncallcomingmorning 8.OrderforV-Pshunt, EVD,      = SignOP&Anesthesiapermit(V-Pshunt)      = NPO視手術時間及年齡而定      =D5S500ml+50%G/W2amprun___ cc/hr      =剃光頭      = Cefamezine1vialtoOR      = *.(IfHb>10不必備血)      =SendpatienttoORoncallcoming morning 9.Post-VertebroplastyOrders             1.Vitalsignq30minx2,Q2hx2,Q4hx2thenq8h             2.CheckNeurologicalstateq30minsx4:evaluatelowerextremities for  anymotororsensorydeficit             3.IVF:D5Srun60cc/hrx1day             4.Cefamezine1vialq6hx4 doses             5.NotifyDr.莊活力immediatelyforanyof followingconditions                acuteshortofbreath                Increasedbackorextremitiespain                Anyneurologicalchange             6.Checkgaugeq30minsx4             7.Lieflatfor2hours             8.CheckL-SspineX-rayCM 10.Orderforsupratentorialcraniotomy:braintumor,Aneurysm,AVM      = SignOP&Anesthesiapermit      = NPO視手術時間及年齡而定      =D5S500ml+50%G/W2amprun___ cc/hr      =剃光頭   =PreparePRBC6units,FFP6units      = Cefamezine1vialtoOR      =Take Dilantin4amptoOR      = SICUorientation      =SendpatienttoORoncallcoming morning 11.Orderfortranssphenoid hypophysectomy      = SignOP&Anesthesiapermit      = NPOpost-midnight      = D5Srun75cc/hr      =Solucortef2ampinD5W500mlrun 20cc/hr      =剪鼻毛      = PreparePRBC4units,FFP4units      = Cefamezine1vialtoOR      = SICUorientation      =SendpatienttoORoncallcoming morning 12.Orderforstereotactic biopsy      = SignOP&Anesthesiapermit      = NPO視手術時間及年齡而定      =D5S500ml+50%G/W2amprun___ cc/hr      =不剃頭      = Cefamezine1vialtoCTroom      =SendpatienttoCTroomoncallcoming morning    13.OrderforCervicalspine*.Anteriordisectomy/Casparplate      = SignOP&Anesthesiapermit      = NPOpost-midnight   = D5Srun90cc/hr   =PreparePRBC2units =Cefamezine1vialtoOR      =SendpatienttoORwithsoftneck collaroncallcomingmorning  7.Orderforhyperhidrosis,Scalpmass, Carpaltunnelsyndrome.....      =WewilldoPre-OPChestXRCBCat OPD      =Post-OPorder:Cefamezine1vial stat      = Cataflam1#qidx5days       = Gowell1#qidX5days      = Keflex1#qidx3days      = ReturntoClinic1weeklater