Post-Operative Management and Nursing Care Using The Nursing Process Part 2

1. Common postoperative discomforts

What are some common postoperative discomforts?

• Nausea and vomiting from general anesthesia.
• Sore throat (caused by the tube placed in the windpipe for breathing during surgery).
• Soreness, pain, and swelling around the incision site.
• Restlessness and sleeplessness.
• Thirst.
• Constipation and gas (flatulence).

1.1. Haemorrhage

Haemorrhage

Haemorrhage can be classified as:

• ‘Primary’: occurring when a vessel is cut during surgery.
• ‘Reactionary’: occurring when rises in blood pressure at the end of the operation cause vessels that had previously not been bleeding to start to do so.
• ‘Secondary’: normally due to infection which causes damage to a vessel days after surgery.

The increased risk of haemorrhage may be multi-factorial in origin the management of haemorrhage depends on the cause but may include fluid and blood product resuscitation, reversal of anti-coagulant effect and surgical intervention. Some drugs and techniques may play a part in reducing blood loss and the need for blood transfusion. Risk factor Cause Drugs Heparin, warfarin, non-steroidal anti-inflammatory agents, anti-platele drugs Congenital bleeding disorder Haemophilia, von Willebrand disease Acquired bleeding disorder Sepsis, liver disease, disseminated.

1.2. Post-operative Pain

Post-operative Pain

Post-operative pain should be assessed and managed according to the WHO pain ladder. When prescribing an analgesic regimen, the expectations and fears of the patient, the nature of surgery, contraindications to certain analgesics and suitability for a regional anaesthetic block should be considered. Pre-existing chronic pain problems (eg being on analgesics before surgery) can make post-operative pain management more difficult. Surgical complications (e.g. bleeding or perforation) should be considered when pain is disproportionate to the clinical situation or new in onset. Additionally, chronic pain syndromes may develop as a complication of acute post-operative pain.

1.3. Nausea and Vomiting

Nausea and Vomiting

Post-operative nausea and vomiting (PONV) may cause an unplanned hospital admission. The risk factors are multifactorial Strategies to prevent PONV include considering regional anaesthesia, reducing the use of opioids, adequate hydration and a combination of anti-emetic drugs. Classes of anti-emetics include anti-histamines (cyclizine), 5HT3 antagonists (ondansetron), anticholinergics (hyoscine hydrobromide), steroids (dexamethasone) and D2 antagonists (metoclopramide). They act on receptors that have sensory afferents to either the vomiting centre (in the medulla) or the chemoreceptor trigger zone outside the blood brain barrier.

1.4. Post-operative Pyrexia

Post-operative Pyrexia

Post-operative pyrexia is common. Often inflammatory mediators released as the response to surgery will cause low-grade pyrexia within 24 hours of an operation and of course, any pre-existing pyrexia can leave some residual fever post-operatively. Other common causes of pyrexia can be remembered as the “seven Cs” below. Each of these causes should be sought and treated appropriately:

• Cut (Wound Infection)
• Collection (Pelvic or Subphrenic Abscess)
• Chest (Infection or Pulmonary Embolism)
• Cannula (Infection)
• Central venous catheter (Infection)
• Catheter (Urinary Tract Infection)
• Calves (Deep Vein Thrombosis) Infections

1.5. Post-operative Infections

Post-operative Infections

Post-operative infections can be classified by both site and cause. Discussed below are some of the most common causes. Surgical Site Infection (SSI): SSIs can complicate recovery in 5% of patients; risk factors include intra-operative exposure to endogenous organisms (e.g. during bowel surgery), prolonged surgery and impaired immunity (e.g. diabetes, immunosuppression) . Management may require antibiotics, suture removal and debridement with open wound care. Central Venous Catheter Infection: Infection of central venous catheters (CVC) may lead to catheter related blood stream infections (CRBSI) that can have a 25% mortality. CVCs should be reviewed daily and CRBSI should be suspected when there is a CVC and signs of bacteraemia; a positive blood culture and growth of the same organism from the CVC would support the diagnosis. CVC’s should always be removed as soon as they are not needed. Inflammation around the CVC insertion is relatively uncommon and its absence does not rule out CRBSI. Treatment usually requires antibiotics and removal of the line. All CVS’s should be inserted with meticulous aseptic technique: gown, mask, gloves, skin preparation, antibacterial dressing. Urinary tract infection: Urinary catheters are inserted perioperatively to facilitate surgery or to aid fluid balance management. They do, however, predispose patients to urinary tract infections that may need antibiotic treatment.

1.6. Abdominal Collections

Abdominal Collections

Abdominal collections are more likely if there is leak of bowel contents. They may present with nausea, malaise, pain, swinging fever, localised peritonitis or tenderness and altered bowl function and the onset of symptoms is determined by abscess location: pelvic abscesses tend to occur 4-10 days after surgery whilst subphrenic abscesses occur 7-21 days after surgery. Collections are typically investigated by ultrasound, CT or MRI scans and may subsequently require drainage under radiological guidance or possibly surgical intervention. Cannula: Peripheral cannula should be reviewed daily, and removed if there is evidence of redness or pain around the insertion site.

1.7. Pneumonia

Pneumonia

Risk factors for a post-operative chest infection include pre-existing co-morbidity, obesity, prolonged surgery, immobility and prior treatment with antibiotics (Nicholls and Wilson, 2000). Patients may complain of shortness of breath, malaise, a cough or even pleuritic chest pain and present with tachycardia, pyrexia, tachypnoea and hypotension. Treatment options include oxygen therapy, chest physiotherapy, antibiotics and intravenous fluids to treat any hypotension.

1.8. Deep Vein Thrombosis (DVT)

Deep Vein Thrombosis (DVT)

Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) Any change to Virchow’s triad (flow, endothelial integrity and constituents of blood) promotes venous stasis and thrombus formation; potentially leading to a DVT. When there is a suspicion of a DVT and a Wells score ≥ 2, a Doppler ultrasound scan of the proximal leg veins should be performed PE may complicate DVT and present with chest pain, shortness of breath, haemoptysis, hypoxia and pyrexia. If untreated, a PE may cause pulmonary infarction, right heart strain and even death. CT pulmonary angiography may be undertaken to confirm the diagnosis. Anticoagulation with heparin is necessary and occasionally surgical intervention may be indicated.

1.9. Cardiovascular Disease

Cardiovascular Disease

Cardiovascular Disease Postoperative cardiovascular complications include acute dysrhythmias (e.g. atrial fibrillation), ischaemic injury, infarction, and left ventricular failure (with associated pulmonary oedema). As such any new cardiovascular change including chest pain, should be appropriately investigated and specialist opinion sought.

1.10. Reduced Bowel

Reduced Bowel

Function Constipation may occur post-operatively due to opioids or anti-cholinergic. Management involves adequate hydration, appropriate nutrition and laxatives. Post-operative ileus may be caused by intra-operative bowel manipulation, pain, immobility, hypokalaemia and opioids. Features of ileus include reduced bowel function, abdominal distension, discomfort, nausea, vomiting and a reduced absorption of oral drugs. Ileus usually resolves within 24-36 hours and management involves insertion of a naso-gastric tube, analgesia and reduced oral intake.

1.11. Hematoma

Hematoma

• concealed bleeding occurs beneath the skin at the surgical site.
• several sutures are removed by the physician, the clot is evacuated and the wound is packed lightly with gauze.

1.12. Infection (Wound Sepsis)

Infection (Wound Sepsis)

Surgical site infection is the most common nosocomial infection. With 67% of these infections occurring within the incision and 33% occurring in an organ or space around the surgical site (CDC, 1999).

Wound infection may not present until at least postoperative day 5. Highlighting the importance of patient education regarding wound care. Staphylococcus aureus accounts for many postoperative wound infections. Wound Dehiscence and Evisceration. Ineffective wound healing can be seen most often between the 5th and 10th days after surgery.

2. Key Points

• Post-operative complications are an important cause of morbidity, mortality, extended hospital stay and increased costs.
• Complications can be general or specific to particular operations.
• There are many strategies to prevent postoperative complications.
• Assessment of surgical complications should include a focussed history with particular attention to risk factors

3. Post-operative education

Postoperative care begins immediately after surgery. It lasts for the duration of your hospital stay and may continue after you've been discharged. As part of your postoperative care, your healthcare provider should teach you about the potential side effects and complications of your procedure

Patient education can include many types of instruction, such as: Maintaining treatment outside of a medical facility, such as dressing a wound. Administering injections for medication like insulin. Practicing preventative care, such as diet modifications for sustained health.

The most important goal in patient education

Patient education promotes patient-centered care and increases adherence to medication and treatments. An increase in compliance leads to a more efficient and cost-effective healthcare delivery system. Educating patients ensures continuity of care and reduces complication.

How do nurses provide patient education?

A hands-on approach is instrumental in guaranteeing that a patient understands medical requirements. Nurses should perform a demonstration and have patients repeat back the information or carry out the procedure themselves. Nurses should also teach the patient's family members, friends or caregivers at home.

3.1. Post-Operative (After Surgery) General Instructions

• Following surgery, keep the wound clean and dry.
• The dressing should be removed and wounds covered with adhesive bandages on the first or second day after surgery.
• Do not remove the paper strips or cut any of the visible sutures.

3.2. Importance to educate patient

Patient education helps patient with learning and understanding of his/her diagnosis and treatment, gaining active self-care attitude, and getting rid of feeling “weakness” due to illness.

The aim of therapeutic patient education is the prevention of complications and the improvement of quality of life. Patients are trained in skills useful in self-management of their health condition and in adapting treatment to personal situations.

Therapeutic patient education is provided by health professionals trained in educating patients. Therefore, training of health professionals plays a central role in developing effective patient education.

Patient education is based on the principle of patient-centred approach. The patient-centred approach includes patient’s beliefs, cultural properties, expectations, hopes and thoughts on source of disease to the scope of healthcare.

In the trainings given, patients’ individual characteristics, their values, families and surroundings, conditions of perception of disease, their perspectives on illness, disease and hospital experiences are important.

Patient education requires consideration of interaction between individuals in the family.

The health problem that exists in one of the family members often influences rest of the family, result in changes in roles and lifestyle, which closely affects the patient’s recovery process. Therefore, the patient must with continuity and integrated with healthcare.

It contains patient-specific differences. This education must comply with patients’ lifestyle and his/her disease.

Patient’s attitudes towards adaptation process (coping with disease, health beliefs and socio-cultural perceptions), requirements, ability to maintain self-care, disease-related treatment, care, psychosocial support, information about hospital and other healthcare institutions.

Patient education is a team work, performed by healthcare professionals who are trained on this. It is important that healthcare workers have competent communication skills.

In studies conducted, it is indicated that patient education positively effects decreased anxiety, increased satisfaction reducing costs, decreasing morbidity and mortality, and shorten duration of hospitalization (an integral part of quality patient care.

In addition to many positive effects on patients, patient education also effects health care systems positively. Patient education also assists the success of knowledge and skill levels among health workers and the adequate financing and organization of the necessary programs in the current healthcare system.

Patient education is planned, organized learning experiences designed to facilitate voluntary adoption of behaviours or beliefs conducive to health. It is a set of planned educational activities that are separate from clinical patient care.

The activities of a patient education program must be designed to attain goals the patient has participated in formulating. The primary focus of these activities includes acquisition of information, skills, beliefs and attitudes which impact on health status, quality of life, and possibly health care utilization.

Patient training is not just a technical practice. At the same time, it is a set of objectives and values. It has a unique philosophy. With these qualities, education is an important issue for today’s society.

Postoperative care begins immediately after surgery. It lasts for the duration of your hospital stay and may continue after you've been discharged. As part of your postoperative care, your healthcare provider should teach you about the potential side effects and complications of your procedure.

3.3. What is the importance of postoperative education?

The goals of postoperative patient education are to ensure that the individual has the appropriate knowledge required for self-management in the home environment after discharge, to reduce the occurrence of symptoms and complications after discharge, and to enhance recovery and overall quality of life.

Applying correctly the postoperative instructions after surgery reduce morbidity, help a fast recovery and improve the quality of life of patient

3.4. Good patient education plan

Involve the patient from the very first treatment. Ask the patient to tell you how they would explain (step-by-step) their disease or treatment to their loved one. Make sure the patient understands the medications as you administer them. Make sure they understand how and when to refill medication.

The goal of the postoperative assessment is to ensure proper healing as well as rule out the presence of complications, which can affect the patient from head to toe, including the neurologic, cardiovascular, pulmonary, renal, gastrointestinal, hematologic, endocrine and infectious system.

Essentially, the discharge planning nurse serves as a connection between in-patient care and follow-up or out-patient care. They help to make sure that the patient and their family understand exactly what to do after discharge to prevent injury and encourage healing. They are a crucial part of proper patient care.