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Postoperative care

Clinical Discipline(s)/Organ System(s)
Anaesthesiology, Cardiovascular System, Renal Medicine
Progress Test Topic(s)
General duties, Homeostasis
Description
An 80 year old NZ European woman is on the orthopaedic ward after a complicated operation to fix her fractured hip. She is nauseated, her catheter is no longer draining urine and she is in a lot of pain.
Applied Science for Medicine 
   - Anatomy of vertebral column, kidneys, ureters, bladder, spinal cord
   - Physiology of heart, lungs, body fluid compartments, nerve and pain conduction
   - Aetiology and pathogenesis of deep vein thrombosis and hospital-acquired pneumonia
   - Microbiology of hospital-acquired pneumonia, wound infection
   - Pharmacology of opioids, paracetamol, non-steroidal anti-inflammatory drugs
Clinical and Communication Skills 
   - History from a postoperative patient with hypotension, urinary retention, pain (communicative and non-communicative), respiratory distress
   - Perform examination of cardiovascular, respiratory and neurological systems, abdomen
   - Perform urethral catherisation, arterial blood gas, blood pressure measurement, peripheral cannulation, ECG, nasogastric tube placement
   - Perform pain assessment
   - Recognise distended bladder, shock, respiratory distress, delirium, ischaemic heart disease, cardiac arrthymias
   - Interpret a full blood count, electrolytes, renal function tests, coagulation screen, chest X-ray, troponin
   - Differential diagnosis of postoperative hypotension, urinary retention, pain, delirium and respiratory distress
   - Classify severity of shock and renal impairment
   - Diagnostic criteria for sepsis, SIRS (systemic inflammatory response syndrome) and septic shock
   - Indications for CT pulmonary angiogram
   - Management of postoperative problems including thromboembolic disease, haemorrhage, urinary retention, oligouria/anuria, pain, delirium, hypo- and hypertension, electrolyte abnormalities, reduced Glasgow Coma Score (GCS), ischaemic heart disease, cardiac arrhythmias
   - Outline management of patient-controlled analgesia (PCA), nerve blocks and nausea
   - Complications of intravenous fluid, anticoagulant medication and urinary catheterisation
   - Role of anaesthetist, pain team, surgeon, high dependency unit nursing and geriatrician
Personal and Professional Skills 
   - Empathise with a patient in pain
   - Awareness of appropriate medical roles with a severely unwell patient, including contacting the team to provide assistance
Hauora Māori 
   - Consider ethnic disparities in adverse events during hospitalisation and the management of pain in New Zealand
   - Appropriate engagement and consultation with whānau
   - Ability to cater for differential health literacy needs of Māori and whānau
   - Consider access to cultural/spiritual support for patient and whānau
Population Health 
   - Epidemiology in New Zealand of postoperative complications
Conditions to be considered relating to this scenario
Common
postoperative nausea and vomiting, acute urinary retention, atelectasis, pneumonia, inadequate analgesia, urinary tract infection, hyponatraemia, hyperkalaemia
Less common but 'important not to miss'
bleeding, deep vein thrombosis, pulmonary embolism, ileus, epidural haematoma, myocardial infarction, cardiac arrhythmias