POST OPERATIVE CARE POST OPERATIVE CARE OF PATIENTSOF PATIENTS

A PRESENTATION BY A PRESENTATION BY

DR.SULEMAN MUMTAZ DR.SULEMAN MUMTAZ POSTGRADUATEPOSTGRADUATESURGICAL UNIT-IISURGICAL UNIT-II

JINNAH POSTGRADUATE MEDICAL CENTERJINNAH POSTGRADUATE MEDICAL CENTER

OBJECTIVESOBJECTIVES

The purpose of this presentation is to The purpose of this presentation is to review Common methods of post-review Common methods of post-operative care in the ward at list day. operative care in the ward at list day.

In this we will discuss how to use Common In this we will discuss how to use Common Medications and investigations ,Medications and investigations ,it is not it is not entitiled to discussion on postop entitiled to discussion on postop complicationscomplications..

This review is not comprehensive but is This review is not comprehensive but is intended to summarise current thought intended to summarise current thought about the practical management of about the practical management of postoperative care in most hospital of our postoperative care in most hospital of our Country like JPMCCountry like JPMC

Finally specific considerations. Finally specific considerations.

INTRODUCTIONINTRODUCTION

Post operative care of the patients is Post operative care of the patients is most important part of the most important part of the management:management:

It gives a complete outline of actions to It gives a complete outline of actions to be taken immediately after surgery to be taken immediately after surgery to discharge of patient and follow up.discharge of patient and follow up.

Plan laid and followed properly will Plan laid and followed properly will optimize recovery and enable early optimize recovery and enable early detection of complications.detection of complications.

Postoperative Care of Postoperative Care of Surgical Patient Surgical Patient

Overall assessmentOverall assessment Vital signs(BP+TPR)Vital signs(BP+TPR) Condition of dressings and drainsCondition of dressings and drains IV fluid status(Freqeuncy+Amount)IV fluid status(Freqeuncy+Amount) Urinary output(I/O Charting)Urinary output(I/O Charting) Temprature ControlTemprature Control wound conditionwound condition

Postoperative Care of Postoperative Care of Surgical Pt (cont'd)Surgical Pt (cont'd)

Systemic AssessmentSystemic Assessment Respiration(R/R,Chest Respiration(R/R,Chest

Movement,Ressession)Movement,Ressession) Circulation(Pulse Character n Volume,Cap Circulation(Pulse Character n Volume,Cap

Refill)Refill) Neurological Status(GCS,Sleep)Neurological Status(GCS,Sleep)

Postoperative Care of Postoperative Care of Surgical Pt (cont'd)Surgical Pt (cont'd)

Systemic AssessmentSystemic Assessment Genitourinary function(Any Discomfort)Genitourinary function(Any Discomfort) Gastrointestinal functionGastrointestinal function Ask for Nausea,Vomiting,FlatusAsk for Nausea,Vomiting,Flatus Look for abdominal distentionLook for abdominal distention Feel for tenderness & rigidityFeel for tenderness & rigidity Listen for bowel soundsListen for bowel sounds DPR ExaminationDPR Examination Usually we encounter Usually we encounter paralytic Ileus.paralytic Ileus.It is a Tympanitic It is a Tympanitic

silent Distended abdomen.silent Distended abdomen. Keep pt NPO,iv Fluids,NG Intubation.Keep pt NPO,iv Fluids,NG Intubation.

ROUNTINE POST OPERATIVE ROUNTINE POST OPERATIVE CARECARE

MONITERINGMONITERING INTRAVENOUS FLUIDS INTRAVENOUS FLUIDS NUTRITION NUTRITION DEEP VENOUS THRMBOSIS DEEP VENOUS THRMBOSIS

PROPHYLAXISPROPHYLAXIS WOUND CARE WOUND CARE MEDICATIONMEDICATION INVESTIGATIONSINVESTIGATIONS

1.MONITERING1.MONITERING

•Temperature, Pulse, Blood Pressure and Respiratory Rate should be monitored.

• Usually done 4 hrly.

2.INTRAVENOUS 2.INTRAVENOUS FLUIDSFLUIDS

Insensible fluid loss and Insensible fluid loss and redistribution is responsible for redistribution is responsible for intravascular volume depletion.intravascular volume depletion.

Surgical patients, as a general rule, Surgical patients, as a general rule, are given intravenous infusion until are given intravenous infusion until and unless they are not able to take and unless they are not able to take per oralper oral

INTRAVENOUS FLUIDS INTRAVENOUS FLUIDS (conti…)(conti…)

Three way Stoper with HepLock Should be atthached

2.INTRAVENOUS FLUIDS(CONT:)2.INTRAVENOUS FLUIDS(CONT:) Fluid input must match Loses & Urine Fluid input must match Loses & Urine

output.output. Replace with 2.5 to 3 L of iv infusion.Replace with 2.5 to 3 L of iv infusion. Crystaloids are the mainstay.Crystaloids are the mainstay. Na+ is provided as Normal saline.Na+ is provided as Normal saline. K+ suppliments should starts at arround K+ suppliments should starts at arround

2424thth hour.20 mmol of potassium hour.20 mmol of potassium chloride/Ampoule is added in 1 L of chloride/Ampoule is added in 1 L of infusion.infusion.

5% dextrose given as calories.5% dextrose given as calories. MUST FOLLOWMUST FOLLOW

INPUT=30-60ml URINE/HOUR INPUT=30-60ml URINE/HOUR

3.NUTRITION3.NUTRITION Parenteral NutritionParenteral Nutrition It is basically directed towards It is basically directed towards

caloric and Protien requirnments.caloric and Protien requirnments. Fatty acids are adjuvant to Fatty acids are adjuvant to

metabolic heomosatasis.metabolic heomosatasis. In this pedigree we have infusions In this pedigree we have infusions

like nutralized 25% dextrose and like nutralized 25% dextrose and Panamin SG.Panamin SG.

Amount and Frequency are given Amount and Frequency are given accordingly. accordingly.

3.NUTRITION3.NUTRITION Aim is to achieve positive nitrogen Aim is to achieve positive nitrogen

balancebalance

and to provide adequate calories for and to provide adequate calories for energy.energy.

Nitrogen Requirement=Nitrogen Requirement=

nitrogen loss,3-6g/d(24-hr urinary nitrogen loss,3-6g/d(24-hr urinary urea in mmol into 0.028)urea in mmol into 0.028)

Energy requirnment=Energy requirnment=

5%Dextrose+30%Fat(Liposyn 5%Dextrose+30%Fat(Liposyn infusion)infusion)

4.Deep Venous Thrombosis4.Deep Venous Thrombosis

Deep Thrombosis (CONT:)Deep Thrombosis (CONT:)

DEEP VENOUS THRMBOSIS DEEP VENOUS THRMBOSIS PROPHYLAXISPROPHYLAXIS

In patients going through major procedures there In patients going through major procedures there are chances of venous stasis.are chances of venous stasis.

These patients are classified as low risk, These patients are classified as low risk, moderate risk, high risk and highest risk patients moderate risk, high risk and highest risk patients on the basis of age and nature of procedure.on the basis of age and nature of procedure.

Patients belonging to different risk groups are Patients belonging to different risk groups are provided with prophylaxis with different provided with prophylaxis with different modalities (i.e. Mechanical prophylaxis,heparin, modalities (i.e. Mechanical prophylaxis,heparin, Low molecular weight heparin). Low molecular weight heparin).

(Conti…..)(Conti…..)

DEEP VENOUS THRMBOSIS PROPHYLAXIS DEEP VENOUS THRMBOSIS PROPHYLAXIS (conti…)(conti…)

Low risk=Age less than 40 years+no risk factorLow risk=Age less than 40 years+no risk factor

Moderate risk=Major surgery & age less than 40 Moderate risk=Major surgery & age less than 40 years or minor surgery with risk factor or age years or minor surgery with risk factor or age between 40 & 60 years.between 40 & 60 years.

High risk=Major surgery+age over 40 years or High risk=Major surgery+age over 40 years or with risk factor or minor procedure with age over with risk factor or minor procedure with age over 60 years with risk factor.60 years with risk factor.

Highest risk=Age over 60 years with multiple risk Highest risk=Age over 60 years with multiple risk factors or with major procedurefactors or with major procedure

(Conti…..)(Conti…..)

DEEP VENOUS THRMBOSIS PROPHYLAXIS DEEP VENOUS THRMBOSIS PROPHYLAXIS (conti…)(conti…)

Patient Patient GroupGroup

Surgery Surgery TypeType

ProphylaxiProphylaxiss

Low riskLow risk MinorMinor None;Erley None;Erley MobilizationMobilization

moderate riskmoderate risk MajorMajor Erly Erly Mobalize;HydratiMobalize;Hydration;Compression on;Compression StockingsStockings

HighHigh MajorMajor All the Above All the Above +Unfractioned +Unfractioned HeparinHeparin

HighestHighest MajorMajor Add LMWH Add LMWH instead of instead of heparin:Deltaperiheparin:Deltaperine Nane Na

5.WOUND CARE5.WOUND CARE

After surgery the wound care is one of the After surgery the wound care is one of the important considerations.important considerations.

In order to keep the wound clean, dressing is In order to keep the wound clean, dressing is being done in our wards with topical being done in our wards with topical applications,wound should be left undisturbed for applications,wound should be left undisturbed for 48 hours to prevent contamination.48 hours to prevent contamination.

Clinical IndicatorClinical Indicator_ Sockage of the Dressing or _ Sockage of the Dressing or Leakege from the DrianLeakege from the Drian

(conti…)

Wound Care and Wound Care and TreatmentsTreatments Postop Assessment Postop Assessment

Suture Care Suture Care Dressings Changes+Sterile Dressings Changes+Sterile

Precuations.Precuations. DrainsDrains STOMA Care_Critical aspect STOMA Care_Critical aspect

Rx_Cleansing of Wounds with sterile Rx_Cleansing of Wounds with sterile measuresmeasures

Wound Care/Rx continued Wound Care/Rx continued ……

Irrigation Irrigation

Wound Packing Wound Packing Dressings/Bandages/V.A.Dressings/Bandages/V.A.C systemC system

Good Dressing Good Dressing AppliancesAppliances

Use of separate Use of separate Instruments. Instruments.

Specimen Collection Specimen Collection

WOUND CAREWOUND CARE (Conti…)(Conti…)

•Bed Sores maybe avoided in bed ridden patients by changing the position of patient time to time.

•Also localy made Liquid containing Cushions.

6.MEDICATION6.MEDICATION

MEDICATIONMEDICATION (CONTI…)(CONTI…)

AntibioticsAntibiotics AntiemeticsAntiemetics Pain controlPain control Ulcer Prophylaxis Ulcer Prophylaxis

MEDICATIONMEDICATION (CONTI…)(CONTI…) AntibioticsAntibiotics are needed as Planed and also are needed as Planed and also

to prevent nosocomial infections.Route is IV.to prevent nosocomial infections.Route is IV. AntiemeticsAntiemetics are given as postoperative are given as postoperative

nausea is common after general anesthesia.nausea is common after general anesthesia. Pain controlPain control is necessary for early mobility. is necessary for early mobility. UlcerUlcer ProphylaxisProphylaxis:Patients with or without :Patients with or without

peptic ulcer disease on prolonged stay are peptic ulcer disease on prolonged stay are prescribed with acid-reducing agents(PPI) or prescribed with acid-reducing agents(PPI) or cytoprotective agents like sucralfatecytoprotective agents like sucralfate

7.INVESTIGATIONS7.INVESTIGATIONS

INVESTIGATIONS INVESTIGATIONS (conti…)(conti…)

• As a routine practice it is required that blood cp, serum electrolytes, blood urea, creatinine and coagulation studies should be done.

Investigations(Cont:)Investigations(Cont:)

CBC _TLC_Wound Infection(SSI)CBC _TLC_Wound Infection(SSI) S/U/C/E_IV Aminoglycosides Like AmikacinS/U/C/E_IV Aminoglycosides Like Amikacin Urine D/R_UTI_Prolong CathetrizationUrine D/R_UTI_Prolong Cathetrization PT/INR_if Drain is pouring bloodPT/INR_if Drain is pouring blood Drain Collection C/S_Antibiotic Drain Collection C/S_Antibiotic

Modification Modification Protien/AG Ratio_Response to Surgical Protien/AG Ratio_Response to Surgical

Nutrition Nutrition ABGs_Metabolic Response to SurgeryABGs_Metabolic Response to Surgery

INVESTIGATIONS INVESTIGATIONS (conti…)(conti…)

X-rayX-ray is required, particularly of chest, in procedures is required, particularly of chest, in procedures in which the thoracic cavity is entered or when central in which the thoracic cavity is entered or when central venous access is attempted.OR If pulmonary venous access is attempted.OR If pulmonary complication is suspected.complication is suspected.

UltraSoundUltraSound is required In certain cases like that of is required In certain cases like that of Perforated appendix or peritoneal collection, Perforated appendix or peritoneal collection, ultrasound is required to assess the intraperitoneal ultrasound is required to assess the intraperitoneal melliue.melliue.

Contrast StudiesContrast Studies, for outcome of Anastomosis , for outcome of Anastomosis surgically made. surgically made.

CT ScanCT Scan is required in cases of hematoma is required in cases of hematoma development intraabdominally or Consealed development intraabdominally or Consealed Hemorrhage or when ultrasound donot help much.Hemorrhage or when ultrasound donot help much.

General ComplicationsGeneral Complications 1.Blood tranfusion Reactions.1.Blood tranfusion Reactions. 2.Fever.2.Fever. 3.Drains,Stomas,Tubes.3.Drains,Stomas,Tubes. 4.Wound care and Dehiscence.4.Wound care and Dehiscence. 5.Imobilization and pressure sores.5.Imobilization and pressure sores. FEVERFEVER..Refer to TPR chart.Refer to TPR chart.

Day1=Surgical trauma or blood Day1=Surgical trauma or blood transfusion reaction.transfusion reaction.

DDay2=Basal atelectasis.ay2=Basal atelectasis.

Day3=SSI(Superficial deep wound Day3=SSI(Superficial deep wound infections)infections)

General Complications(Cont:)General Complications(Cont:) Day4=Thrombophlebitis or UTI.Day4=Thrombophlebitis or UTI. Day5=As above +Chest infection.Day5=As above +Chest infection. >Day5=As above Anastomotic leakage or >Day5=As above Anastomotic leakage or

Intracavitary Collections/Abscesses.Intracavitary Collections/Abscesses. DRAINSDRAINS.Drainage of bile or feacal matter .Drainage of bile or feacal matter

indicates biliary or intestinal indicates biliary or intestinal anastomotic leakage.Blood then anastomotic leakage.Blood then hemorrhage thru vascular leaks or hemorrhage thru vascular leaks or coagulopathy.Drains should be removed coagulopathy.Drains should be removed ifn the drainage is stoped or become less ifn the drainage is stoped or become less than 25ml/day,only serous fluid.Drains in than 25ml/day,only serous fluid.Drains in abscesses or placed alongside Gut abscesses or placed alongside Gut Anastomosis are left for upto 5 days. Anastomosis are left for upto 5 days.

GENERAL GENERAL COMPLICATIONS(Cont:)COMPLICATIONS(Cont:) Wound DehiscenceWound Dehiscence..It is the partial or It is the partial or

complete disruption of any or all of yhe layers complete disruption of any or all of yhe layers in wound.in wound.

Presents with serosanguinous dischargePresents with serosanguinous discharge.. Occurs on 5Occurs on 5thth or 8 or 8thth postop day. postop day. Reasons is weakining of strength of wound.Reasons is weakining of strength of wound. Comonly occurs in abdominal wounds where Comonly occurs in abdominal wounds where

there is underlying intra-abdominal adscess.there is underlying intra-abdominal adscess. Most pts require Most pts require ResuturingResuturing.. OR leave wound open with daily dressing or OR leave wound open with daily dressing or

WoundWound V.A.C systemV.A.C system.. Diabetes,sepsis,malignancy,steroids,poor Diabetes,sepsis,malignancy,steroids,poor

closure of wound,increased intraabdominal closure of wound,increased intraabdominal pressure lead to this complication.pressure lead to this complication.

GENERAL GENERAL COMPLICATIONS(Cont:)COMPLICATIONS(Cont:) IMMOBILISATION & Pressure soresIMMOBILISATION & Pressure sores..

Risk for DVT,Pressure sores,atelectasis.Risk for DVT,Pressure sores,atelectasis. Comonly adapted by the pt post Comonly adapted by the pt post

Lapratomy.Lapratomy. Pressure sores occures at sacrum,greater Pressure sores occures at sacrum,greater

trochanter,heels,gluteal region,elbow.trochanter,heels,gluteal region,elbow. Unconcious pts are victums.Unconcious pts are victums. Early mobilisation is prevention.Early mobilisation is prevention. High risk pts can be nursed on High risk pts can be nursed on Air Filter Air Filter

Mattress. Mattress. Usually localy made Usually localy made air cushionsair cushions or or

water filled surgical gloveswater filled surgical gloves are used in are used in our setup.our setup.

GENERAL GENERAL COMPLICATIONS(CONT:)COMPLICATIONS(CONT:)

Early Mobilization speed up the Early Mobilization speed up the recovery.recovery.

It prevents Pressure sores, Pulmonary It prevents Pressure sores, Pulmonary complications,DVT.complications,DVT.

Analgesia is essential to enable early Analgesia is essential to enable early mobilization.mobilization.

POST OPERATIVE CARE OF PATIENT

SPECIFIC CONSIDERATIONSROUNTINE POSTOPERATIVE CARE

SPECIFIC CONSIDERATIONS .SPECIFIC CONSIDERATIONS .

SPECIFIC SPECIFIC CONSIDERATIONCONSIDERATION

CNS DISORDERS CNS DISORDERS CARDIOVASCULAR DISEASESCARDIOVASCULAR DISEASES RENAL DISEASESRENAL DISEASES DIABETESDIABETES TUBERCLOSISTUBERCLOSIS

Should involved relevent Should involved relevent departmentsdepartments

CNS DISORDERSCNS DISORDERS Management of patients with known seizure Management of patients with known seizure

disorders be directed by keeping in view the type disorders be directed by keeping in view the type of seizure (i.e. general versus partial, simple partial of seizure (i.e. general versus partial, simple partial versus complex partial), frequency and degree of versus complex partial), frequency and degree of control of disorder.control of disorder.

Standard precaution may be taken including Standard precaution may be taken including medication.medication.

Phenytoin and Phenobarbital are available in Phenytoin and Phenobarbital are available in parenteral form.parenteral form.

Involve Neuromedicine departmentInvolve Neuromedicine department

CARDIOVASCULAR CARDIOVASCULAR DISEASESDISEASES

Involve General Medicine or NIVCD Involve General Medicine or NIVCD departementdepartement

In case of coronary artery disease the In case of coronary artery disease the control of precipitants is required.control of precipitants is required.

Stresses that exacerbate the ischemia are Stresses that exacerbate the ischemia are required to be avoided.required to be avoided.

(Conti…)

CARDIOVASCULAR DISEASES CARDIOVASCULAR DISEASES (Conti…)(Conti…)

HypertensionHypertension must be controlled as must be controlled as it increases the oxygen requirement it increases the oxygen requirement and exacerbates ischemia.and exacerbates ischemia.

(Conti…)

CARDIOVASCULAR DISEASES CARDIOVASCULAR DISEASES (Conti…)(Conti…)

•Pain is required to be controlled with analgesics as it can cause tachycardia and hypertension.

(Conti…)

CARDIOVASCULAR DISEASES CARDIOVASCULAR DISEASES (Conti…)(Conti…)

•Oxygen is required to be given continuously in postoperative patients to increase the oxygen content of the blood.

(Conti…)

CARDIOVASCULAR DISEASES CARDIOVASCULAR DISEASES (Conti…)(Conti…)

•Anemia should be avoided as it decreases the oxygen carrying capacity of the patients. Transfusion should be considered when hemoglobin falls below 9.0 (Conti…

)

RENAL DISEASESRENAL DISEASES Involve Nephro departmentInvolve Nephro department I/O Charting is key roleI/O Charting is key role

Fluid replacement in postoperative patients having Fluid replacement in postoperative patients having chronic renal disease should be done cautiouslychronic renal disease should be done cautiously

Care must be taken to avoid excessive fluid Care must be taken to avoid excessive fluid replacement.replacement.

Maintenance fluids should not contain potassium.Maintenance fluids should not contain potassium.

Serum electrolytes should be measured time to time.Serum electrolytes should be measured time to time.

(Conti…)

RENAL DISEASES RENAL DISEASES (conti…)(conti…)

•Patient should be catheterized to monitor the urine output.

•Should be done in Theater.(Conti…)

RENAL DISEASES RENAL DISEASES (conti…)(conti…)

In patients having renal insufficiency In patients having renal insufficiency and decreased creatinine clearance and decreased creatinine clearance the dosages of the drugs should be the dosages of the drugs should be adjusted.adjusted.

Some medications such as Some medications such as Aminoglycosides are contraindicated. Aminoglycosides are contraindicated.

DIABETESDIABETES

•Postoperative management of diabetic surgical patient centers on maintenance of euglycemia and management of chronic complications.

•The blood glucose levels should be measured time to time.

(Conti…)

DIABETES DIABETES (conti…)(conti…) Involve General medicineInvolve General medicine

Diet controlled diabetic patients infrequently need glucose Diet controlled diabetic patients infrequently need glucose or or insulin therapyinsulin therapy after minor surgeries. after minor surgeries.

Diabetic patients who are receiving oral hypoglycemic Diabetic patients who are receiving oral hypoglycemic agents frequently need insulin postoperatively.agents frequently need insulin postoperatively.

Intermittent dosing of subcutaneous insulin can be given as Intermittent dosing of subcutaneous insulin can be given as intermediate acting insulin twice a day, with hyperglycemia intermediate acting insulin twice a day, with hyperglycemia managed by supplemental dosing of regular insulin.managed by supplemental dosing of regular insulin.

For example Dextrose Water titrated with insulin.For example Dextrose Water titrated with insulin. SLIDE SCALESLIDE SCALE is key role. is key role. Use of Use of GLUCOMETERGLUCOMETER is a wise thing to do. is a wise thing to do.

DIABETES DIABETES (conti…)(conti…)

Must do Must do FBSFBS and and RBSRBS

TUBERCLOSISTUBERCLOSIS Modility is Modility is DOTSDOTS.. IVIV ATT ATT is recommendation in our setup. is recommendation in our setup. Rule is 2 months of Intiation & next 7 Rule is 2 months of Intiation & next 7

months of continuation phase.months of continuation phase. D.O.C that should be added is IV D.O.C that should be added is IV

Streptomycin untill hospitalized.Streptomycin untill hospitalized. Second line Drugs can be used in septic Second line Drugs can be used in septic

cases.cases.

LEAP-FROGLEAP-FROG After Surgery.Dont discharge the patient After Surgery.Dont discharge the patient

until until LEAP-FROGLEAP-FROG is established is established LLucid,not vomiting,cough reflex ucid,not vomiting,cough reflex

establishedestablished EEasy breathing,easy urinationasy breathing,easy urination AAmbulant without Faintingmbulant without Fainting PPain relief+Postop drugs dispensed + ain relief+Postop drugs dispensed +

given.Does pt understand doses.given.Does pt understand doses. FFollow-up arrangedollow-up arranged RRhythm,pulse rate,BP checked.It is a hythm,pulse rate,BP checked.It is a

Trend.Trend. OOperation site checked thoroughly peration site checked thoroughly

&explained to pt &explained to pt

LEAP-FORG(Cont:)LEAP-FORG(Cont:)

GGP letter sent with pt.He must know P letter sent with pt.He must know what happened+what happened+StomaStoma CareCare is is Educated to pt.+Educated to pt.+ATTATT StatusStatus explained+explained+Tube FeedingTube Feeding is is thoroughly educated. thoroughly educated.

SUMMARYSUMMARY

Proper postop care is key feature in Proper postop care is key feature in management.management.

Patient realize that he is been treated by Patient realize that he is been treated by good doctor.good doctor.

Management Choices in case of Management Choices in case of ComorbiditiesComorbidities..

Usage of Usage of LAB WorkLAB Work. . Clinical importance of Clinical importance of DVT PreventionDVT Prevention. . Also measures to prevent complications Also measures to prevent complications

MCQSMCQS 11.Insensible loss of fluid from skin &lungs over 24 hours,in a .Insensible loss of fluid from skin &lungs over 24 hours,in a

temperate climate,is normally in range temperate climate,is normally in range

a.100-250mla.100-250ml

b.250-500mlb.250-500ml

c.500-700mlc.500-700ml

d.750-1000mld.750-1000ml

e.1000-1500mle.1000-1500ml 22.In postop phase .In postop phase

a. endogenous water released during oxidation of ingested food a. endogenous water released during oxidation of ingested food amounts to 1000-2000ml in 24hrs.amounts to 1000-2000ml in 24hrs.

b. small amounts of highly coloured urine with high specific gravity b. small amounts of highly coloured urine with high specific gravity mean poor renal function.mean poor renal function.

c. in pure water depletion leading sign is anuria.c. in pure water depletion leading sign is anuria.

d. diuresis must be watched for as it means that enough water has d. diuresis must be watched for as it means that enough water has been given.been given.

e. water intoxication is likely when continuous hypertonic solution is e. water intoxication is likely when continuous hypertonic solution is given iv. given iv.

MCQsMCQs 33.Sodium depletion.Sodium depletion

a. can be caused by increased secretion of a. can be caused by increased secretion of aldosterone.aldosterone.

b. occurs during the first 48 hrs after operation.b. occurs during the first 48 hrs after operation.

c. can follow prolonged gastric incubation.c. can follow prolonged gastric incubation.

d. causes subcutaneous tissue to feel hard.d. causes subcutaneous tissue to feel hard.

e. results in urine containing little or no chlorine.e. results in urine containing little or no chlorine. 44.Potassium depletion is related to.Potassium depletion is related to

a. increased excretion of potassium for about three to a. increased excretion of potassium for about three to four days postoperatively.four days postoperatively.

b. tumour of colon.b. tumour of colon.

c. prolonged gastric incubation.c. prolonged gastric incubation.

d. muscular spasms.d. muscular spasms.

e. calculous anuria. e. calculous anuria.

MCQsMCQs 55.Ringer lactate contains specifically.Ringer lactate contains specifically

a. sodiuma. sodium

b. k+b. k+

c. Cl-c. Cl-

d. HCO3+d. HCO3+

e. albumin.e. albumin. 66.All postoperative pts, after gastric surgery,require.All postoperative pts, after gastric surgery,require

a. intravenous alimentation.a. intravenous alimentation.

b. 2000-4000 calories in 2000-4000ml of fluid given b. 2000-4000 calories in 2000-4000ml of fluid given daily.daily.

c. high concentration of iv CHO.c. high concentration of iv CHO.

d. amino acids taken in after iv CHO.d. amino acids taken in after iv CHO.

e. elemental diet. e. elemental diet.

MCQsMCQs

77.Feeding by tube enterostomy..Feeding by tube enterostomy. a. is a form of parenteral nutrition.a. is a form of parenteral nutrition. b. is indicated in cases when then passage b. is indicated in cases when then passage

of large bore NG tube is required.of large bore NG tube is required. c. is applicable to all cases of intestinal c. is applicable to all cases of intestinal

obstruction.obstruction. d. if by gastrostomy, the tube should be d. if by gastrostomy, the tube should be

inserted towards the antrum.inserted towards the antrum. e. is more satisfactorily accomplished by e. is more satisfactorily accomplished by

jejunostomy than by gastrostomy. jejunostomy than by gastrostomy.

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