Pre & Post Operative Nursing Care PDF

Pre and Post operative nursing care Prof. dr. Fathia Attia Prof. dr. Fathia attia 1   Contents Outline 1. Objectives. 9. Preoperative teaching. 2. Introduction. 10. Informed consent. 3....

Pre and Post operative nursing care Prof. dr. Fathia Attia Prof. dr. Fathia attia 1   Contents Outline 1. Objectives. 9. Preoperative teaching. 2. Introduction. 10. Informed consent. 3. Phases of perioperative care. 11.Nursing diagnosis and 4. Types of surgery. intervention in preoperative 5. Categories of surgery based phase. on urgency. 12. Intra-operative care. 6. Preoperative assessment. 13. Postoperative care. 7. Surgical risk factors. 14. Discomfort & complications. 8. Preoperative preparation. Prof. dr. Fathia attia 2  Caring for perioperative clients Objectives: At the end of this lecture, the student must be able to: 1. Differentiate the phases of perioperative care. 2. Define the types and categories of surgery. 3. Identify the preoperative assessments. 4. Develop a preoperative teaching plan. 5. Identify surgical risk factors. 6. Describe the preoperative preparation. 7. Discuss assessments needed in immediate and later postoperative period. 8. Identify the postoperative complications. Prof. dr. Fathia attia 3 What is meant by perioperative? Perioperative is a term used to describe the entire span of surgery, including what occurs before, during, and after the actual operation. Surgery is the using of an instruments during an operation to treat injuries, diseases, and deformities. Prof. dr. Fathia attia 4 Prof. dr. Fathia attia 5 Surgical procedures are named according to o The involved body organ, part, or location o The suffix that describes what is done during the procedure: - ectomy- Removal by cutting Surgery is done for several reasons  Preventive surgery removes tissue before it causes a problem as in mole to prevent cancer development. Scars exceation  Diagnostic, or exploratory, surgery takes tissue samples for study to make a diagnosis Breast biopsy  Curative surgery involves the removal of diseased or abnormal tissue as in an inflamed appendix Mastectomy  Palliative surgery is done when an underlying condition cannot be corrected but symptoms need to be alleviated. Colostomy  Cosmetic, : surgery is done to improve appearance Rhinoplasty example example on each types Prof. dr. Fathia attia 6 Surgery according Urgency Level  Emergent: Immediate surgery needed to save life  Urgent: Surgery needed within 24–30 hours  Elective: Planned/scheduled, with no time requirements Surgery according Degree of Risk of Surgery o Minor Procedure without significant risk; often done with local anesthesia o Major Procedure : greater risk, usually longer and more extensive than a minor procedure Prof. dr. Fathia attia 7  Categories of Surgery Emergency Urgent Elective Required Prof. dr. Fathia attia 8 Bloodless surgery  Uses a combination of techniques to minimize blood loss and maximize blood volume and function.  Epoetin alfa (Epogen) given before surgery to stimulate red blood cell production  During surgery, the surgeon may request induced hypotension or hypothermia to decrease oxygen demand.  Ambulatory surgery includes outpatient, same-day, or short-stay surgery that does not require an overnight hospital stay but may entail an admission to an inpatient hospital setting for less than 24 hours Prof. dr. Fathia attia 9 Ambulatory surgery, sometimes referred surgery that requires fewer than 24 hours of hospitalization  Quickly and comprehensively assess and anticipate the patient‟s needs and at the same time begin planning for discharge and follow-up home care A client admitted for ambulatory surgery must meet the following criteria: The client is not critically ill. The surgical procedure is not extensive and does not require many hours of general anesthesia. The client has few coexisting illnesses. Recovery is expected to be quick, with minimal specialized care after surgery. The client \ family can provide adequate postoperative care. Prof. dr. Fathia attia 10  Emergency Surgery Emergency surgeries are unplanned and occur with little time for preparation for the patient or the perioperative team It is important for the nurse to communicate with the patient and team members as calmly and effectively as possible in these situations, A quick visual survey & suitable Preparation of the patient is essential , condensed time frame Informed consent and essential information, such as pertinent past medical history and allergies, need to be obtained from a family member Extra support and explanation of the surgery Prof. dr. Fathia attia 11  Laparoscopic and endoscopic procedures have replaced many “open” surgeries.  A medical robot is operated from a nearby computer while the surgeon views magnified three-dimensional images of the surgical field on the computer's screen.  Surgeries can be transmitted via videoconferencing to locations around the world to enhance skill levels of surgeons everywhere. Prof. dr. Fathia attia 12  Perioperative Surgical Phases Preoperative: begins with the decision to perform surgery and continues until the client has reached the operating room Intraoperative: includes the entire duration of the surgical procedure, until transfer of the client to the recovery area. Postoperative: Begins with admission to PACU and continues until recovery is complete Prof. dr. Fathia attia 13 Prof. dr. Fathia attia 14  1.Preoperative Phase The primary roles in preoperative phase are to: Assist in data collection for developing the patient‟s plan of care. Reinforce explanations and instructions given to the patient and family Provide emotional and psychological support Factors Influencing Surgical Outcomes Diabetes Stress of surgery may cause swings in blood glucose mellitus levels that are difficult to control. and other Patients may receive intravenous insulin during and chronic after surgery. diseases Wound healing tends to be delayed in patients with diabetes, making the risk of dehiscence (wound separation) greater. The incidence of infection in surgical wounds is higher. Liver and kidney disease makes it more difficult to metabolize and eliminate anesthesia and waste products. Prof. dr. Fathia attia 15 Advanced age  Healing is slower in older adults. with inactivity  The risk of hypostatic pneumonia, (inflammation and consolidation in the lungs), and thrombus formation is higher in inactive older adults. Very young  Infants have difficulty with temperature control and in person maintaining normal circulatory blood volume; they are at risk of dehydration Dehydration  Reduced circulating volume reduces kidney perfusion and urine output and thrombus formation. Alters electrolyte values.  A more at risk for problems with pressure areas during surgery. Malnutrition  Inadequate nutritional stores lead to poor wound healing and skin breakdown. Prof. dr. Fathia attia 16 Obesity  An extremely heavy patient does not breathe as deeply and is at risk of hypostatic pneumonia.  Excessive fatty tissue also is a factor in poor wound healing. Regular use  Aspirin, non-steroidal anti-inflammatory drugs, of certain and anticoagulants make the patient more prone drugs to excessive bleeding.  Corticosteroids reduce the body's response to infection and delay the healing process. Excessive  Stimulates the sympathetic nervous system, fear swings in the body's chemistry and vital signs.  Increased muscle tension makes surgery more difficult. Prof. dr. Fathia attia 17 Preoperative teaching: All surgical patients should receive information related to: o Preoperative procedures: Enemas, skin preparation, restriction of food and liquid intake, and administration of bedtime sedatives and preoperative medication; time to come to the hospital o Technical information: Anticipated surgical procedure; location of incisions; dressings, tubes, drains, catheters, or other equipment that is expected o Day of surgery: Time surgery is scheduled; time to arrive at the hospital or leave room, probable length of procedure, effects of preoperative medications, where family will wait, when and where family can see the patient after surgery, pain control, and postoperative routine o Post-anesthesia care unit (PACU): General environment (noise, lights, equipment), frequent taking of vital signs, pulse oximetry, and administration of oxygen o Surgical intensive care unit (SICU) (if patient go to PACU): Location of the unit, expected length of stay, and visiting privileges Prof. dr. Fathia attia 18 Preoperative Instructions:  To reduce the risk of aspiration when anesthesia is started, as well as postoperative nausea and vomiting, fluid and food restrictions.  The patient is told when to stop fluid and food intake (NPO), usually after midnight the night before surgery.  If surgery is scheduled for the afternoon, clear liquids in the early morning  Brush teeth  Cancellation of surgery may result if the patient has not been NPO as ordered.  Special preparations, such as an enema, to empty the bowel to reduce fecal contamination preoperatively and straining or distention postoperatively. Prof. dr. Fathia attia 19  Instructions for postoperative care: how to report their pain level using a pain rating scale, before surgery so the patient is alert when being taught and has time to learn.  Postoperative exercises are taught to decrease complications, include : o Deep breathing helps prevent the development of atelectasis o Leg exercises improve circulation & help prevent complications related to stasis of blood, such as emboli formation. o Coughing moves secretions to prevent pneumonia Prof. dr. Fathia attia 20  Preoperative Assessment I. Health History and Psychosocial Assessment II. Laboratory and Diagnostic Test Data : III. Physical Assessment IV. Cultural Assessment Prof. dr. Fathia attia 21 Preoperative Data Collection\ Nursing Assessment  Health History and Psychosocial Assessment  Physical Assessment  Laboratory and Diagnostic Test Data Subjective Data:  Demographic information: Name, age, marital status, occupation, roles?  History of condition for which surgery is scheduled: Why are you having surgery?  Medical history: Any allergies, acute or chronic conditions, current medications, pain, or prior hospitalizations?  Surgical history: Any reactions or problems with anesthesia? Previous surgeries?  Tobacco use: How much do you smoke? Pack-year history (number of packs per day _ number of years)?  Alcohol use: How often do you drink alcohol? How much?  Coping techniques: How do you usually cope with stressful situations? Support systems?  Family history: Hereditary conditions, diabetes, cardiovascular, anesthesia problems?  Female patients: Date of last menses and obstetrical information why ? Prof. dr. Fathia attia 22 Objective Data: Body System Review Vital signs, oxygen saturation Height and weight Emotional status: calm, anxious, tearful, affect Neurological: ability to follow instructions Skin: color, warmth, bruises, lesions, turgor, dryness, mucous membranes Respiratory: infection: cough; breath sounds; chronic obstructive pulmonary disease; respiratory rate, pattern, and effort; barrel chest Cardiovascular: angina, MI, heart failure, hypertension Gastrointestinal: bowel sounds, date of last bowel movement, abdominal distention….. Musculoskeletal: deformities, weakness, ROM Prof. dr. Fathia attia 23 Immediate Preoperative Care:  Make sure that the client is wearing his or her ID band. Surgery will be cancelled if the client is not properly identified.  Record the client‟s VS,. Report immediately any deviation from normal to the surgeon.  Determine and document the client‟s fall risk status  Check that the client is wearing two special blood identification when possibility of receiving blood.  Help the client with bathing and other hygiene measures. Be sure the client removes all clothes and wears clean gown Prof. dr. Fathia attia 24  Remove any prostheses, braces, splints, wigs, hair pins, contact lenses, hearing aids, false eyelashes, and glasses.  Remove the client‟s jewelry and valuables, itemize them, and put them in the vault or give them to the client‟s family.  Help the client to void immediately before going to the OR.  Pull the hair back and cover it with a surgical cap  Remove partial dentures and place them in a denture cup with clear water.  Remove makeup, and nail polish & artificial nails  Make sure the preoperative checklist in the client‟s health record is complete and signed Prof. dr. Fathia attia 25 Preoperative medications may be given to: o Reduce anxiety and promote a restful state o Decrease secretion of mucus and other body fluids o Counteract nausea and reduce emesis o Enhance the effects of the anesthetic Prof. dr. Fathia attia 26  Informed Consent Informed consent is the patient‟s autonomous decision Before surgery, sign a surgical consent form \a permit to surgery done. Required for any procedure that requires anesthesia and has risks of complications. If an adult client is confused, unconscious, a family member must sign the consent form. If younger than 18 years, a parent must sign the consent form. It is voluntary and written informed, protect the patient from unapproved surgery and protect the surgeon from legibility. It is the surgeon‟s responsibility to provide a clear and simple explanation of what the surgery benefits, alternatives, possible risks, complications, and removal of body parts as well as what to expect in the early and late postoperative periods. What is a criterion for Valid Informed Consent? Prof. dr. Fathia attia 27 Preoperative Preparation — 1. Physical Preparation. o Skin preparation, following hospital policy, to prevent post- operative wound infection. shaving hair and clean with antiseptic solution 10cm round surgical site then covered by sterile dressing o Elimination, indwelling catheter and enema as physician orders o Food and fluids, fasting based on type of anesthesia o Care of valuables , Clothing/ grooming , Prostheses — 2. Psychosocial Preparation. —Careful preoperative teaching can reduce fear and anxiety of the clients. Prof. dr. Fathia attia 28  —General nursing goals for all preoperative patients  Prepared for surgery physically and emotionally  Able to demonstrate deep breathing, coughing, and leg exercises  Able to verbalize understanding of the procedure and the expectations for the postoperative period  Able to maintain fluid and electrolyte balance throughout the perioperative period Prof. dr. Fathia attia 29  2. Intraoperative The Surgical Team: The surgeon is the head of the surgical team, determining the preoperative diagnosis, perform of the surgical procedure, the explanation of the risks and benefits, obtaining inform consent and the postoperative management Surgeon assistant assists surgeon in performing homeostasis, tissue retraction, and wound closure). Anesthesiologist: Anesthesia provider. Prof. dr. Fathia attia 30  Scrub nurses : Role and responsibilities  Checks prior to beginning of the operating list (in collaboration with circulating nurses): Cleanliness of the theatre environment Temperature and humidity levels, and efficient air-conditioning, taking the appropriate action if necessary to adjust the levels  Preparation of instrument sets and accessories: Swabs Needles Extra instruments Accessories (e.g. sutures and dressings)  Scrubbing-up procedure: wash hands and arms, don sterile gown and gloves  Preparation of instrument trolley and Mayo stand  Passing instruments to the surgeon  Anticipation of the surgeon‟s needs  Maintenance of the sterile field  Swab, needle and instrument checks  Handling and passing of instruments Specimens  Documentation (electronic and hard copy)  Cleaning between surgical procedures and at the end of the operating list Prof. dr. Fathia attia 31  Circulating nurses: Role and responsibilities  Assisting the scrub practitioner in the preparation of the instrument sets, accessories, swabs, needles and instruments  Preparation of sterile surgical gowns and gloves  Tying donned sterile gowns  Opening instrument sets  Passing accessories to the scrub practitioner  Maintenance of the sterile field  Swab, needle and instrument checks with the scrub practitioner  Anticipation of the scrub practitioner‟s needs  Safe practice in placing specimens into appropriately sized specimen containers  Documentation (electronic and hard copy)  Cleaning between surgical procedures and at the end of the operating list Prof. dr. Fathia attia 32 Sterile technique is maintained at all times. Intra operative team must be  Applying surgical hand scrub  Gloves are worn  Enhance aseptic technique.  Wears shoe covers, caps, masks, and goggles  Surgical case cart preparation  Count needles and sponges & others surgical instruments  Ensure safety, electrical equipment is checked Prof. dr. Fathia attia 33 Anesthesia Agent used to alter sensation so that surgery can be done painlessly & safely Type of Description anesthesia General Blocks awareness centers in the brain Produces unconsciousness, body relaxation, and loss of sensation Is administered by inhalation or I.V. infusion Regional Inhibits excitatory processes in nerve endings or fibers Provides analgesia over a specific body area Doesn‟t produce unconsciousness Is administered by nerve block, I.V. regional block with tourniquet, spinal block, or epidural block Local Blocks nerve impulse transmission at the site of action Provides analgesia over a limited area Doesn‟t produce unconsciousness Is administered topically or by infiltration Prof. dr. Fathia attia 34 There are three stages of general anesthesia: 1. Induction: Unconsciousness is induced. 2. Maintenance: Period during which the surgical procedure is performed. 3. Emergence: Surgery is completed and the patient is prepared to return to consciousness; neuromuscular blocking agents are reversed. The Operating Room Environment \ characteristics  The OR environment is physically isolated from other areas of the hospital, air is filtered and positive pressure is maintained to reduce the number of possible microbes that can cause infection.  OR are designed to be efficient, in that the needed equipment and supplies are immediately available for use  Usually the furniture is made of stainless steel for easy cleaning and disinfecting.  The temperature in the OR is kept below 70 F to provide a cooler environment that does not promote bacterial growth, more comfort for OR personnel working in bright lights and wearing and enhances client comfort and safety. Prof. dr. Fathia attia 35 Prevention of Intraoperative Complications 1. Infection: Strict aseptic technique is absolutely necessary before and during surgery. If a nurse notes a break in technique, immediately notifies the surgeon 2. Fluid volume excess or deficit: The circulating nurse is responsible for recording and keeping a running total of IV fluids administered Prof. dr. Fathia attia 36 3. Injury related to positioning:  The OR staff positions the client on the OR table according to the type of surgery.  Careful positioning and monitoring help to prevent interruption of blood supply secondary to prolonged pressure, nerve injury related to prolonged pressure, postoperative hypotension, dependent edema, and joint injury related to poor body alignment 4. Hypothermia: o The client may be at risk for hypothermia related to the low temperature in the o The OR, administration of cold IV fluids, inhalation of cool gases, and exposure of body surfaces for the surgical procedure, opened incisions/wounds, and prolonged inactivity. o For some surgeries, the body temperature is purposely lowered to make the procedure safer Prof. dr. Fathia attia 37 5.Malignant hyperthermia (MH)  Occurs when body temperature, muscle metabolism, and heat production increase rapidly, progressively, and uncontrollably in response to stress and some anesthetic agents.  There are two tests that indicate if a client is susceptible to MH: skeletal muscle biopsy, which determines muscle contractile qualities, and a blood test for a genetic mutation linked to MH.  Certain anesthetic agents trigger uncontrolled calcium release within skeletal muscle cells, which leads to muscle rigidity and a hyper-metabolic state Signs and symptoms  jaw muscle rigidity, rapidly rising temperature, elevated Paco2 and serum potassium levels, metabolic acidosis, tachycardia, tachypnea, diaphoresis, mottled skin, hypotension, irregular heart rate, decreased urine output and , cardiac arrest. Prof. dr. Fathia attia 38 Prevention is essential because the mortality rate is high. Clients at risk include „„those with bulky, strong muscles, a history of muscle cramps or muscle weakness and unexpected temperature elevation and an unexplained death of a family member during surgery that was accompanied by a febrile response‟‟ The circulating nurse  Closely monitors the client for signs of hyperthermia.  If the client‟s temperature begins to rise rapidly, anesthesia is discontinued and the OR team implements measures to correct physiologic problems, such dysrhythmias. Prof. dr. Fathia attia 39 Potential Adverse Effects of Anesthesia Cardiac dysrhythmia from electrolyte imbalance or adverse effect of anesthetic agents Myocardial depression, bradycardia, and circulatory collapse Central nervous system agitation, seizures, and respiratory arrest Over sedation or under sedation Agitation or disorientation, especially in elderly patients Hypoxemia or hypercarbia from hypoventilation and inadequate respiratory support during anesthesia Laryngeal trauma, oral trauma, and broken teeth from difficult intubation Prof. dr. Fathia attia 40  3. Postoperative Transport of the Client  Immediately after the surgical procedure is complete, the client is transported to the post-anesthesia care unit (PACU), known as the post-anesthesia recovery room.  The nursing staff there is specifically knowledgeable in the care of clients recovering from anesthesia.  Specialized equipment is available to monitor and treat the client.  Patients may remain in a PACU unit for as long as 4 to 6 hours, depending on the type of surgery and any preexisting conditions Prof. dr. Fathia attia 41  The nurse receiving the client from the OR needs the following information Medical diagnosis and surgical procedure done Past medical history and allergies Age, general condition, airway status, and current vital signs Anesthetic agents and medications given during surgery Complications during surgery Any pathology found and if so whether family members are informed Amounts of fluids & blood administered or lost Any tubes connected Prof. dr. Fathia attia 42 Immediate Postoperative Initial Assessment: Initial Assessment  Airway patency  Effectiveness of respiration  Presence of artificial airways  Mechanical ventilation, or supplemental oxygen  Circulatory status, vital signs  Wound condition, including dressings and drains  Fluid balance, including IV fluids, output from catheters and drains and ability to void  Level of consciousness and pain  The nurse’s major responsibilities during the client’s PACU are to  ensure a patent airway  help maintain adequate circulation  prevent or assist with the treatment of shock  maintain proper position and function of drains, tubes, and IV infusions; monitor for potential complications. Prof. dr. Fathia attia 43  An important assessment is determining how the client is recovering from anesthesia.  A useful assessment tool is the Aldrete scale, used to determine readiness for transfer patient from PACU to department which rates the client‟s mobility, respiratory status, circulation, consciousness, and pulse oximetry  A score of 9 or greater indicates that the client has recovered from anesthesia. Prof. dr. Fathia attia 44  Modified Aldrete Scale for Assessing Recovery from Anesthesia Score 0 1 2 Activity Unable to move Able to move two Able to move all extremities extremities extremities voluntarily or on voluntarily or on command voluntarily or on command command Respiration Apneic Dyspnea or limited Able to breathe breathing deeply and cough freely Circulation BP+/- 50mmHg of BP+/ - 20-49mmHg of BP+ ‫‏‬/- 20mmHg of Pre-anesthesia level Pre-anesthesia level Pre-anesthesia level Consciousness Unresponsive Arousable with verbal Fully awake stimuli SpO2 < 90% with Needs supplemental > 92% on room air supplemental oxygen oxygen to maintain > 90% Surgical recovery can take from 2 to 6 hours Assessments are performed at least every 15 minutes for the first hour Prof. dr. Fathia attia 45 Immediate nursing interventions o Assess breathing and administer supplemental oxygen, if prescribed. o Monitor vital signs and note skin warmth, moisture, and color. o Assess the surgical site and wound drainage systems. o Assess level of consciousness, orientation, and ability to move extremities. o Connect all drainage tubes to gravity or suction as indicated and monitor closed drainage systems. o Assess pain level, pain characteristics (location, quality) and timing, type, and route of administration of last pain medication. o Administer analgesics as prescribed and assess their effectiveness in relieving pain. o Position patient to enhance comfort, safety, and lung expansion. o Assess IV sites for patency and infusions for correct rate and solution. o Assess urine output in closed drainage system or the patient‟s urge to void and bladder distention. o Place call light, emesis basin, ice chips (if allowed), and bedpan or urinal within reach. o Provide information to patient and family Prof. dr. Fathia attia 46 Measures are used to determine the patient’s readiness for discharge from the PACU Stable vital signs Orientation to person, place, events, and time Uncompromised pulmonary function Pulse Oximetry readings indicating adequate blood Oxygen saturation Urine output at least 30 mL/h Nausea and vomiting absent or under control  Minimal pain Prof. dr. Fathia attia 47 Early warning score (EWS), a tool that is used throughout ward areas as an alert system for deteriorating patients Ongoing Assessment Prof. dr. Fathia attia 48 Post-operative discomfort Prof. dr. Fathia attia 49 Post-operative discomfort Prof. dr. Fathia attia 50  Prevent Postoperative Complications Problem Signs & Symptoms Preventive Interventions Atelectasis Decreased breath sounds Deep breathing and coughing; use of over areas not aerating; incentive spirometer; early dyspnea ambulation; teach to cough properly. Pneumonia: Fever, malaise, increased Deep breathing, coughing, and hypostatic, sputum, purulent sputum, frequent turning; early ambulation; aspiration, or cough, flushed skin, incentive spirometer use; range-of- bacterial dyspnea, pain on motion exercises if unable to inspiration; abnormal breath ambulate; medication if bacterial. sounds, crackles, rhonchi Paralytic No bowel sounds 24-36 hr Monitor bowel sounds; encourage ileus after surgery or fewer than early ambulation; nothing by mouth 5 sounds/min as ordered. Do not feed until bowel sounds return. Prof. dr. Fathia attia 51 Pulmonary Shortness of breath, anxiety, Anti-embolism stockings, adequate embolus chest pain, rapid pulse and fluid intake, frequent turning or respirations, ambulation, preventive anticoagulant cyanosis, cough, bloody if ordered; leg exercises sputum Wound Redness, swelling, pain, Assess wound characteristics and infection warmth, drainage, fever, drainage. Monitor white blood cell increased leukocytes, count and rapid pulse and respirations temperature. (fever 72 hr after surgery Use aseptic technique for wound care; indicates infection in some encourage adequate nutrition and system or in the wound) fluids; encourage activity. Wound Discharge of serious Teach to splint properly for coughing. dehiscence drainage from wound and Place patient supine with knees flexed; or sensation that separation of cover wound with sterile saline-soaked evisceration wound edges with intestines gauze or towels; return to operating visible through abdominal room for repair; monitor for shock incision Prof. dr. Fathia attia 52 Fluid Signs of over Control intravenous flow rate. imbalance hydration: crackles in Monitor intake and output; lungs, edema, weight correct imbalances. gain Output will be less than intake Signs of dehydration: for first 72 hr after surgery with weight loss, diminished general anesthesia. pulse, dry mucous Auscultate lungs each shift. membranes, decreased Monitor weight; check for tissue turgor edema. Hemorrha Evidence of copious Give blood or volume ge bleeding; decreased expander; stop bleeding. Place and blood pressure, in shock position with feet and shock elevated pulse, legs elevated and head flat; cold clammy skin, administer ordered medications decreased urinary to raise blood pressure; output administer oxygen; measure vital signs frequently. Prof. dr. Fathia attia 53  THANKS Prof. dr. Fathia attia 54