Question

when giving a patient post operative instructions, what are the warning signs that the patient should report immediately

Answer 1

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 postanesthesia care unit (PACU), as well as during the days following surgery.

Purpose

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

Postoperative care involves assessment, diagnosis, planning, intervention, and outcome evaluation. The extent of postoperative care required depends on the individual's pre-surgical health status, 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)

The patient is transferred to the PACU after the surgical procedure, anesthesia reversal, and extubation (if it was necessary). The amount of time the patient spends in the PACU depends on the length of surgery, type of surgery, status of regional anesthesia (e.g., 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. For example, patients who have had coronary artery bypass grafting are sent directly to the critical care unit.

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

Assessment of the patient's airway patency (openness of the airway), 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 (intact dressings with no signs of overt bleeding)

patency (proper opening) of drainage tubes/drains

body temperature (hypothermia/hyperthermia)

patency/rate of intravenous (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 he or she meets established criteria for discharge, as determined by a scale. One example is the Aldrete scale, which scores the patient's 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 the hand and side rails up. Patients in a day surgery setting are either discharged from the PACU to the unit, or are directly discharged home after they have urinated, gotten out of bed, and tolerated a small amount of oral intake.

First 24 hours

After the hospitalized patient transfers from the PACU, the nurse taking over his or her care 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 assessment of lung sounds (auscultation) and chest excursion, and presence of an adequate cough. Fluid intake and urine output should be monitored every one to two hours. If the patient does not have a urinary catheter, the bladder should be assessed for distension, and the patient monitored for inability to urinate. The physician should be notified if the patient has not urinated six to eight hours after surgery. 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 or vomiting, as well as pain.

Patients with a patient-controlled analgesia 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. The patient should be asked to rate his or her pain level on a pain scale in order to determine his or her acceptable level of pain. Controlling pain is crucial so that the patient may perform coughing, deep breathing exercises, and may be able to turn in bed, sit up, and, eventually, walk.

Effective preoperative teaching has a positive impact on the first 24 hours after surgery. 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; 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 (e.g., after hip replacement ). Patients who are not able to sit up in bed due to their surgery will have sequential compression devices on their legs until they are able to move about. These 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 any 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 lemon ginger 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 caregivers) should be included in preoperative teaching so that they can assist the patient at home. The patient should be reminded to call his or her physician if any complications or uncontrolled pain arise. 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 a dressing change during the first postoperative day; this 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. Respiratory exercises are still be performed every two hours, and incentive spirometry values should improve. Bowel sounds are 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 complications, such as leg edema, redness, and pain (deep vein thrombosis), shortness of breath (pulmonary embolism), dehiscence (separation) of the incision, or ileus (intestinal obstruction). The surgeon should be notified immediately if any of these occur. If dehiscence occurs, sterile saline-soaked dressing packs should be placed on the wound.

Preparation

Patients receive a great deal of information on postoperative care. They may be offered pain medication in preparation for any procedure that is likely to cause discomfort. Patients may receive educational materials such as handouts and video tapes, so that they will have a clear understanding of what to expect postoperatively.

Aftercare

Aftercare includes ensuring that patients are comfortable, either in bed or 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. Pain medication should be offered before any procedure that might cause discomfort. Patients should be given the opportunity to ask questions. In some cases, they may ask the nurse to demonstrate certain techniques so that they can perform them properly once they return home.

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