POSTOPERATIVE CARE 2

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 bloodsoaked dressings should be properly disposed of in a biohazard 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.