Postoperative Care

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Postoperative care

Definition

Postoperative care is the management of a patient after surgery. This includes care given during the immediate postoperative period, both in the operating room and the postanesthesia care unit (PACU), as well as during the days following the surgery.

Purpose

The goal of postoperative care is to prevent such complications as infection , to promote healing of the surgical incision, and to return the patient to a state of health.

Precautions

Thorough postoperative care is crucial to ensuring positive outcomes for patients who have had surgery. There are no contraindications to providing this care. However, skill and careful monitoring are needed to prevent complications and to restore the patient to health as soon as possible.

Description

Postoperative care involves assessment, diagnosis, planning, intervention and outcome evaluation. The extent of postoperative care required by each patient depends on the original health status of the patient, type of surgery, and whether the surgery was performed in a day-surgery setting or in the hospital. Patients who have procedures done in a day-surgery center usually require only a few hours of care by health care professionals before they are discharged to go home. If postanesthesia or postoperative complications occur within these hours, the patient must be admitted to the hospital. Patients who are admitted to the hospital may require days or weeks of postoperative care by hospital staff before they are discharged.

Postanesthesia care unit (PACU)

After the surgical procedure, and anesthesia reversal and extubation if necessary, the patient is transferred to the PACU. The length of time the patient spends there depends on the length of surgery; the type of surgery; the status of regional anesthesia (for example, spinal anesthesia); and the patient's level of consciousness. Rather than being sent to the PACU, some patients may be transferred directly to the critical care unit instead. For example, patients who have had coronary artery bypass grafting (CABG) are sent directly to the critical care unit.

In the PACU, the anesthesiologist or the nurse anesthetist reports on the patient's condition; the type of surgery performed; the type of anesthesia given; estimated blood loss; and total input and output during the surgery. The receiving nurse should also be made aware of any complications during the surgery, including any variations in hemodynamic stability.

Assessment of the patient's airway patency, vital signs , and level of consciousness are the first priorities upon admission to the PACU. The following is a list of other assessment categories:

surgical site (check that dressings are intact and there are no signs of overt bleeding)
patency of drainage tubes/drains
body temperature (hypothermia/hyperthermia)
patency/rate of IV fluids
circulation/sensation in extremities after vascular or orthopedic surgery
level of sensation after regional anesthesia
pain status
nausea/vomiting

The patient is discharged from the PACU when they meet established criteria for discharge, as determined by use of a scale. An example is the Aldrete scale, which scores the patient on mobility, respiratory status, circulation, consciousness, and pulse oximetry. Depending on the type of surgery and the patient's condition, the patient may be admitted to either a general surgical floor or the intensive care unit. Since the patient may still be sedated from anesthesia, safety is a primary goal. The patient's call light should be in their hand and all side rails should be up. Patients in a day-surgery setting are either discharged from the PACU to the unit to their home, or are directly discharged home after they have voided, ambulated, and tolerated a small amount of oral intake.

First 24 hours

After the hospitalized patient transfers from the PACU, the receiving nurse should assess the patient again, using the same previously mentioned categories. If the patient reports "hearing" or feeling pain during surgery (under anesthesia) the observation should not be discounted. The anesthesiologist or nurse anesthetist should discuss the possibility of an episode of awareness under anesthesia with the patient. Vital signs, respiratory status, pain status, the incision, and any drainage tubes should be monitored every one to two hours for at least the first eight hours. Body temperature must be monitored, since patients are often hypothermic after surgery and may need a warming blanket or warmed IV fluids. Respiratory status should be assessed frequently, including auscultation of lung sounds, assessment of chest excursion, and presence of adequate cough. Fluid intake and urine output should be monitored every one to two hours. If the patient doesn't have a urinary catheter, the bladder should be assessed for distension and the patient monitored for inability to void. If they have not voided six to eight hours after surgery, the physician should be notified. If the patient had a vascular or neurological procedure performed, circulatory status or neurological status should be assessed as ordered by the surgeon, usually every one to two hours. The patient may require medication for nausea and/or vomiting, as well as for pain.

Patients with a patient-controlled analgesia (PCA) pump may need to be reminded how to use it. If the patient is too sedated immediately after the surgery, the nurse may push the button to deliver pain medication for them. The patient should be asked to rate their pain on a pain scale in order to determine their acceptable level of pain. Every attempt should be made by the nurse to keep the patient's pain under control. This often means that the nurse must offer pain medication every hour or two—many times before the patient requests it. Controlling pain is crucial so that the patient may perform coughing, deep breathing exercises, may be able to turn in bed, sit up, and, eventually, ambulate.

Effective preoperative teaching has a positive impact on the first 24 hours postoperatively. If patients understand that they must perform respiratory exercises to prevent pneumonia ; and that movement is imperative for preventing blood clots, encouraging circulation to the extremities, and keeping the lungs clear; then they will be much more likely to perform these tasks. Understanding the need for movement and respiratory exercises also underscores the importance of keeping pain under control. Respiratory exercises (coughing, deep breathing and incentive spirometry) should be done every two hours. The patient should be turned every two hours, and should at least be sitting on the edge of the bed by eight hours after surgery, unless contraindicated (for example, post-hip replacement). These patients will have sequential compression devices on their legs until they are able to ambulate. The sequential compression devices are stockings that inflate with air in order to simulate the effect of walking on the calf muscles and return blood to the heart . The patient should be encouraged to splint chest and abdominal incisions with a pillow to decrease the pain caused by coughing and moving. Patients should be kept NPO (nothing by mouth) if ordered by the surgeon, at least until their cough and gag reflexes have returned. Patients often have a dry mouth following surgery, which can be relieved with oral sponges dipped in ice water or by applying lemon ginger in mouth swabs.

Patients who are discharged home after a day-surgery procedure are given prescriptions for their pain medications and are responsible for their own pain control and respiratory exercises. Their families (or care-givers) should be included in preoperative teaching so that a caregiver can assist the patient at home. The patient should be reminded to call their physician if they have any complications or uncontrolled pain. These patients are often managed at home on a follow-up basis by a hospital-connected visiting nurse or home care service.

After 24 hours

After the initial 24 hours, vital signs can be monitored every four to eight hours if the patient is stable. The incision and dressing should be monitored for the amount of drainage and signs of infection; the surgeon may order the dressing to be changed during the first postoperative day. Postoperative dressing changes should be done using sterile technique. For home-care patients this technique must be emphasized. The hospitalized patient should be sitting up in a chair at the bedside and ambulating with assistance by this time period. Respiratory exercises should continue to be performed every two hours and incentive spirometry values should improve. Bowel sounds should be monitored and the patient's diet gradually increased as tolerated, depending on the type of surgery and the physician's orders.

The patient should be monitored for any evidence of potential complication, such as leg edema , redness, and pain (deep vein thrombosis); shortness of breath (pulmonary embolism); dehiscence (separation) of the incision; or ileus. If any of these occur, the surgeon should be notified immediately. If dehiscence occurs, sterile saline-soaked dressing packs should be placed on the wound. The patient and the family should be updated on the evaluation

KEY TERMS

Deep vein thrombosis (DVT) —Potentially life-threatening blood clot in one of the deep veins of the body, and often in the legs secondary to immobility after surgery. Symptoms include pain, warmth, swelling, and redness.

Dehiscence —Separation of a surgical incision or rupture of a wound closure.

Ileus —Obstruction in or immobility of the intestines. Symptoms include nausea and vomiting, absent bowel sounds, abdominal pain, and abdominal distension.

Incentive spirometer —Device that is used postoperatively to prevent lung collapse and promote maximum inspiration. The patient inhales until a preset volume is reached, then sustains the volume by holding their breath for three to five seconds.

PACU —The post-anesthesia care unit, where the patient is cared for after surgery.

Patient-controlled analgesia pump (PCA pump) —A pump which the patient uses to self-administer medication to control pain.

Pulmonary embolism (PE) —Potentially life-threatening blockage of a pulmonary artery by fat, air, or a blood clot that originated elsewhere in the body. Symptoms include acute shortness of breath and sudden chest pain.

of the patient, the patient's condition, and any teaching as often as necessary.

Preparation

Postoperative care involves many procedures and teaching topics. Preparation for procedures includes having all needed supplies at the bedside. Pain medication should be offered prior to any procedure that is likely to cause discomfort. Preparation for teaching includes having resources available. Many hospitals have patient education materials such as handouts and video tapes that can be used to assist in teaching the patient what to expect during the postoperative time period.

Aftercare

Aftercare includes ensuring that patients are comfortable, either in bed or in a chair, and that they have their call lights accessible. After dressing changes, blood-soaked dressings should be properly disposed of in a bio-hazard container. Again, pain medication should be offered before any procedure that might cause discomfort. After teaching a patient, or the caregiver, aftercare includes answering all of their questions; and, in some cases, having them demonstrate the techniques they will be using.

Complications

Postoperative care is indicated for all patients who have had an invasive procedure, regardless how minor. However, improper care can lead to complications. For example, changing a surgical dressing without sterile technique can lead to infection. Failure to monitor a patient closely, or failing to assist them with respiratory exercises and ambulation, can lead to pneumonia or deep vein thrombosis, and potentially pulmonary embolus. Patients who have not had thorough teaching on what to expect may resist attempts to assist them, leading to com plications and anger on the part of the patient or family.

Results

The goal of postoperative care is to ensure that patients have good outcomes after surgical procedures. A good outcome includes recovery without complications and adequate pain management . Another objective of postoperative care is to assist patients in taking responsi bility for regaining good health.

Health care team roles

Almost every member of the health care team has a role in postoperative care. The surgeon performs the sur gery and manages the patient's postoperative care. The patient's primary care doctor often helps manage the care of hospitalized patients as well. Nurses are at the bedside 24 hours a day, so they monitor the patient for complica tions; assist the patient with respiratory exercises and regaining mobility; provide postoperative teaching; and generally care for the patient. Respiratory therapists also provide instruction and assistance with respiratory exer cises, and monitor the patient's respiratory status. Radiology personnel take x-rays that are ordered by the physician, and laboratory personnel draw blood samples and perform blood tests. All team members must com municate with one another and with the patient to provide the best possible postoperative care.