Specialized Nursing Care Procedures
Subtopic:
Post-operative nursing care
Post-operative nursing care encompasses the specialized care given to patients after they have undergone a surgical procedure. This focused care involves consistent monitoring, effective management, and providing support to the patient as they recover through various nursing actions and evaluations.
Aims or Principles of Post-Operative Care
Prevent, Identify, and Manage Complications: Utilizing keen observation and applying clinical expertise, actively work to prevent and swiftly recognize any possible complications that may arise during the recovery process, from the initial period of unconsciousness following anesthesia to the point of hospital discharge. Prompt intervention is key in addressing these issues.
Ensure Patient Comfort: Make patient well-being a priority by effectively managing pain, offering emotional reassurance, and cultivating a soothing and secure setting that encourages healing and overall wellness. This encompasses both physical and psychological comfort.
Restore Optimal Health and Independence: Assist the patient in their journey towards regaining their best possible physical condition and functional abilities. The goal is to empower them to reclaim their independence and facilitate their return to their preferred way of life.
Immediate Care of a Patient Recovering from Anesthesia
Transporting the Patient from the Operating Room to the Recovery Room
Once the surgery is complete, the operating room staff will dress the patient in a clean gown and carefully transfer them to a stretcher. Precautions are taken to avoid:
Exposing the patient: This can increase the risk of respiratory infections and shock due to heat loss.
Rough handling: This can put undue stress on the surgical sutures or incisions.
Hurried movements and rapid position changes: These can lead to a sudden drop in blood pressure (hypotension).
Recovery Room Care
Upon arrival in the recovery room (often called the Post-Anesthesia Care Unit or PACU), the patient is either moved from the stretcher to a bed or remains on the stretcher. The patient is positioned on their back (supine) with their head turned to one side and their chin tilted slightly upwards (extended). This specific positioning is crucial because the patient is still unconscious or semi-conscious from the anesthesia. It helps prevent airway obstruction caused by the relaxed tongue falling back into the throat and reduces the risk of aspiration (inhaling) of mucus, blood, or vomit. This position also facilitates the drainage of secretions and allows for easy suctioning if needed.
A baseline assessment of the patient is performed immediately, including:
Vital signs: Monitoring blood pressure, pulse rate, respiratory rate, the openness of the airway (patency), the depth of each breath, the symmetrical movement of the chest during breathing (chest expansion), and the color of the skin.
Visual assessment: Observing the patient’s overall condition, noting the presence of intravenous (IV) lines, drainage tubes, or any other specialized medical equipment.
Time of admission: Recording the exact time the patient arrives in the recovery room.
Absence of reflexes: Checking for the return of protective reflexes like the pharyngeal (gag) reflex and swallowing reflex. Until these reflexes return, the patient’s head must remain in the lateral position with the neck slightly extended.
Level of responsiveness: Assessing how the patient responds to stimuli such as touch, pain, sound, or commands upon arrival.
Temperature and vital signs monitoring: Taking and recording temperature and vital signs every 15 minutes initially until they stabilize, then every 30 minutes for the next 2-3 hours. Body temperature is typically monitored every 2-4 hours, depending on the hospital’s recovery protocols.
Quality and rate of respirations: Observing the breathing pattern for any signs of difficulty. If the patient shows signs of respiratory distress, supplemental oxygen is administered, and the anesthesiologist is immediately notified of any respiratory depression or changes in their breathing pattern. Arterial blood gas analysis may be performed, and respiratory support measures like intubation, tracheostomy, bag-valve-mask ventilation (ambu-ventilation), and suctioning may be necessary.
Presence of an airway/mouthpiece: Checking if an oral airway is in place to prevent the tongue from obstructing the airway. Patients may try to remove this as they regain consciousness.
Skin color and dryness: Observing the skin for pallor (paleness), coolness, and sweating, which can be signs of shock. Also, checking the lips and nail beds for pallor or cyanosis (bluish discoloration). The IV fluids are administered as prescribed.
Condition of the dressing: Examining any surgical dressings for drainage, noting the color, type, and amount of any discharge.
Presence of drainage tubes: Checking for any drainage tubes (e.g., chest tubes, abdominal drains, gastric catheters), ensuring they are patent (open and draining), whether they are clamped or need to be connected to a suction device, and if they are draining appropriately.
IV infusions: Noting the type of IV solution being administered, the amount remaining in the bag, the drip rate, checking for any signs of infiltration (fluid leaking into surrounding tissue), and reviewing orders for any subsequent fluids. Also checking for any medications that need to be added to the IV fluid.
Presence of a blood transfusion: If a blood transfusion is in progress or ordered, noting the flow rate and carefully monitoring for any signs of a transfusion reaction.
Unusual symptoms: Vigilantly observing for any concerning signs such as airway obstruction, irregular heartbeats (arrhythmias), signs of shock or hemorrhage, a significant elevation in temperature, or signs of fluid overload from excessive IV fluids.
Once the patient is stable (usually within 2-3 hours) and has recovered sufficiently from anesthesia, they are cleared for transfer from the recovery room by the anesthesiologist or surgeon. The nursing staff on the patient’s assigned ward is notified to come and collect them.
Patient Transfer from the Recovery Room Back to the Ward
The ward nurses are informed that the patient is ready to be transferred from the recovery room after their condition has stabilized.
A verbal handover report is given by the recovery room nurse to the two nurses who arrive to collect the patient. This report includes details about the surgical procedure performed, the patient’s vital signs, level of consciousness, the status of the surgical wound and any drains, details of IV infusions and blood transfusions, any resuscitation efforts required, the type of anesthesia used, any problems encountered during surgery (such as vomiting or breathing difficulties), urinary output, and any specific post-operative instructions.
The ward nurses briefly check the patient’s vital signs to confirm the information provided by the recovery room nurse and to ensure the patient’s well-being during the transfer.
During transport back to the ward, the patient is moved with their legs leading and their head trailing behind. This positioning allows the nurse at the head to easily monitor the patient’s airway and provide immediate assistance if any respiratory issues arise.
The patient is carefully lifted from the stretcher to the prepared bed. Post-anesthesia care protocols are immediately implemented upon arrival on the ward.
Immediate Post-Operative Care in the Ward
Care of the Anesthetized Patient in the Ward:
A patient who is still recovering from anesthesia requires constant observation and should never be left unattended. This is due to the significant risks of complications such as asphyxiation (suffocation), shock, falls, and hemorrhage (excessive bleeding).
Positioning:
The optimal position for the patient varies depending on the type of surgery they underwent. Common positions include:
Supine with the head turned to one side: This position helps prevent the tongue, which may be relaxed and bulky due to anesthesia, from falling back into the pharynx and obstructing the airway. It also facilitates the drainage of saliva from the mouth.
Head lower than the shoulders: This position can help prevent fluids from entering the trachea (windpipe), allowing secretions to pool in the cheek for easier removal. This helps prevent airway obstruction and the development of aspiration pneumonia. A commonly used position is the modified Sims’ position (a semi-prone position).
Respiratory Status:
Regularly assess the quality, depth, and rate of the patient’s respirations. Also, monitor the color and temperature of their skin, as these are important indicators of adequate oxygen exchange in the body.
Neurologic Status/Level of Responsiveness:
Evaluate the patient’s level of consciousness. Determine if they are alert and oriented (aware of their surroundings and able to answer questions appropriately), unconscious, confused, restless, or exhibiting any other changes in their neurological status.
Cardiovascular Status:
Monitor the patient’s cardiovascular function by regularly checking their vital signs (blood pressure, pulse rate). Also, assess the color and temperature of their skin, which can provide clues about their circulatory status.
Wound Assessment:
Carefully inspect the surgical wound for any signs of drainage or bleeding.
If there are any drainage tubes present, ensure they are properly connected to a suction machine or collection bag as ordered.
Check if the dressings are soiled with blood or other fluids. Also, gently feel underneath the patient to detect any pooling of blood that might not be immediately visible.
Tubes and Lines:
Ensure that all tubes and lines, such as urinary catheters, nasogastric tubes (NGTs), and intravenous infusion lines, are patent (open and functioning correctly).
Check the rate and amount of drainage or infusion.
Look for any signs of blockage or kinks in the tubing.
Verify that all connections to drainage systems or IV solutions are secure.
Discharge Advice/Health Education on Home Care of the Patient:
The time it takes for a patient to recover fully from surgery is variable and depends on several factors, including their pre-operative physical and mental health, the extent and complexity of the surgery, and whether any post-operative complications develop.
Before discharge, it’s crucial to:
Assess the patient’s (and their family’s) understanding of the surgery they underwent and the preventative measures they need to take at home.
Determine their readiness to learn and their ability (or that of their family members) to provide necessary care and perform any required procedures at home.
Teach the patient to report the following potential signs of complications immediately: pain in any area, elevated temperature, cough and sputum that is abnormally colored, loss of energy, nausea and vomiting, changes in urine characteristics, difficulty breathing, abnormal drainage from the wound, and sudden weight loss.
Emphasize the importance of proper hand hygiene: Instruct them on the need for thorough hand washing before meals, before performing any care procedures, and after using the toilet.
Practice pulmonary hygiene techniques: Work with the patient on coughing and deep breathing exercises to help prevent post-operative pulmonary complications.
Provide lifestyle advice: Advise the patient to avoid smoking and contact with individuals who have respiratory tract infections (RTIs).
Encourage gradual activity increase: Encourage the patient to continue with gentle physical exercises and gradually increase their activity levels as they recover, stopping if they feel tired. Exercise promotes circulation and helps restore normal bodily functions.
Promote adequate nutrition and hydration: Instruct the patient to drink plenty of fluids and consume a diet rich in vitamins and electrolytes to support hydration, nutritional status, wound healing, skin integrity, bowel function, and to help liquefy respiratory secretions.
Provide wound care education: Teach the patient how to properly care for their surgical wound, including how to change the dressing, cleanse the area, and maintain good skin care around the incision. If possible, allow them to practice aseptic (sterile) techniques for wound care and instruct them on how to protect the wound while bathing to keep it clean, dry, and promote healing.
Educate on medication management: Teach the patient how to take their prescribed medications correctly, emphasizing checking the medication’s action, correct dose, route of administration, frequency, potential side effects, and any possible food or drug interactions to ensure they take their medication safely and as prescribed.
Advise on home environment modifications: Instruct the patient on how to modify their home environment to reduce the risk of falls. This may include clearing pathways of rugs or clutter, ensuring good lighting, using assistive devices for support when walking, and wearing firm, well-fitting shoes.
Discuss the care of appliances: If applicable, discuss the proper care and safe usage of any appliances such as external fixators, plaster casts, or prostheses to ensure optimal benefit and prevent complications.
Provide resources: Give the patient information on where to obtain any necessary medical supplies and equipment for home care.
Provide contact information: Give the patient the contact information and phone number of their doctor and other relevant healthcare staff for easy follow-up or in case of emergencies.
POST-OPERATIVE CARE
Requirement:
As for a Postoperative bed (this implies the bed should be prepared with clean linens and any necessary equipment).
Procedure:
| Steps | Action | Rationale |
| 1 | Two ward nurses, a Senior and a Junior, will collect the patient from the operating theatre. | This ensures the patient’s safety during transfer and allows for shared responsibility. |
| 2 | Receive a comprehensive report on the patient’s condition from the Surgeon, Anaesthetist, and Theatre Nurse involved in the procedure. | To maintain consistent high-quality care for the patient and for documentation required by legal standards. |
| 3 | Transfer the patient to the ward, carefully monitoring their level of consciousness, skin color, and ensuring a clear and unobstructed airway. | Maintaining a patent airway is paramount, and observing these indicators allows for prompt detection of any immediate issues. |
| 4 | Screen the patient’s bed area with curtains or dividers. | To respect the patient’s dignity and ensure their privacy. |
| 5 | Position the prepared bed away from the wall and align the theatre trolley directly against the bed. Then, safely roll the patient from the trolley to the bed. | This technique facilitates a secure and controlled lift, minimizing strain and risk of injury during transfer. |
| 6 | Position the patient appropriately based on the specific surgical procedure performed, while ensuring the airway remains clear and open. | Maintaining an open airway is critical, and the positioning can also facilitate the drainage of any post-operative secretions. |
| 7 | Leave the artificial airway adjunct in place until the patient fully regains consciousness. | This prevents the tongue from obstructing the airway as the patient recovers from anesthesia. |
| 8 | Review the Surgeon’s detailed post-operative orders concerning the operation and subsequent care, including intravenous fluid therapy, medications, nutritional guidelines, and prescribed positioning. | This is crucial for providing consistent and effective patient care according to the medical team’s plan. |
| 9 | Remain with the patient continuously until they are fully awake and responsive. Regularly monitor and record vital signs as ordered, typically at intervals of 15 to 30 minutes, depending on the patient’s stability. | Continuous monitoring allows for the timely detection of any changes in the patient’s condition and prompt intervention if necessary. |
| 10 | Carefully inspect the surgical incision site for any signs of bleeding and check the functionality of any drainage tubes that are in place. | This is essential to identify and manage potential post-operative complications like hemorrhage or blocked drainage. |
| 11 | Perform any specific nursing procedures as prescribed by the medical team, such as suctioning secretions or administering intravenous fluids. | These interventions address the patient’s immediate needs and contribute to their recovery. |
| 12 | Ensure the patient is kept warm, providing blankets or other warming measures as needed. | This helps to prevent post-operative hypothermia, a common risk after anesthesia. |
| 13 | Accurately document all care provided to the patient, including observations and interventions, and report any significant findings or changes in condition. | This provides a record of the patient’s progress, facilitates communication among the healthcare team, and ensures appropriate follow-up. |
| 14 | Provide the patient with one pillow initially when they are fully conscious and offer additional pillows as they require for comfort. | Pillows can significantly improve patient comfort and support proper positioning once they are awake. |
| 15 | Monitor the patient’s fluid intake, administer prescribed intravenous fluids, encourage oral fluids as appropriate, and accurately measure and record all intake on a fluid balance chart. | Tracking fluid intake helps to assess hydration status and identify potential fluid imbalances. |
| 16 | Monitor the patient’s fluid output by encouraging them to void urine or empty drainage bags, and precisely measure and document the amount. | Monitoring output is vital for assessing kidney function and overall fluid balance. |
| 17 | Administer all prescribed post-operative medications according to the doctor’s orders. | Medications play a key role in promoting healing, managing pain, and preventing complications. |
| 18 | Assist the patient in performing the exercises they were taught before surgery. | These exercises are crucial in preventing post-operative complications like blood clots and promoting recovery. |
| 19 | Provide comprehensive general nursing care to the post-operative patient, addressing their various needs. | This encompasses a wide range of supportive care to ensure the patient’s comfort and well-being during the recovery period. |
Points to Remember:
Be vigilant for irregularities in vital signs:
A rising heart rate and/or a decrease in the strength of the pulse.
A drop in blood pressure or an inaudible blood pressure reading.
Respirations that are unusually slow, fast, or accompanied by abnormal sounds.
Regarding the skin, pay attention to its color and texture, noting if it feels cold or moist.
For the dressing covering the incision, observe for any seepage or active bleeding. If bleeding is noted, apply additional sterile dressings and secure them with a bandage, and immediately inform the nurse in charge or the doctor.
Patients receive specialized nursing care tailored to their specific surgical procedure and overall condition.
PERI-OPERATIVE CARE
PRE-OPERATIVE:
Admission procedures are carried out.
The nature of the planned surgery and its potential outcomes are explained to the patient in a clear and understandable manner.
Informed consent is obtained for both hospital admission and the surgical procedure itself.
Baseline vital signs are recorded, and essential laboratory and radiological investigations are performed to establish the patient’s pre-operative status.
The patient is prepared physically and emotionally through counseling and consistent reassurance. This helps to alleviate pre-operative anxiety.
Engage in conversation with the patient and address any questions or concerns they may have to lessen fear and anxiety.
Spiritual support is offered if desired by the patient; approved religious leaders are permitted to visit.
A thorough initial physical assessment is conducted, including recording weight, height, and evaluating nutritional status.
Preparation of the surgical site includes marking or labeling the intended incision area and, if the area is hairy, shaving the site approximately 48 hours prior to surgery.
The patient is instructed to remove all jewelry and rings.
Dentures and prosthetic devices are removed before surgery.
An intravenous (IV) line is inserted for fluid and medication administration.
Rehydration is initiated using IV fluids.
Pre-operative medications are administered as prescribed.
Necessary procedures are performed, such as inserting a nasogastric tube (NGT), urinary catheterization, or bowel preparation.
Ensure the patient gets adequate rest and sleep before surgery.
The patient is educated about the expected level of activity after the operation.
The patient is kept fasting (nil per os) according to medical orders.
A post-operative bed is prepared with all the necessary equipment readily available, such as oxygen and suction apparatus.
POST-OPERATIVE CARE:
The patient is received from the operating theatre with detailed instructions regarding their care.
Vital signs are closely and regularly monitored.
Monitor for any signs of bleeding or indications of shock.
The patient is transferred to a warmed post-operative bed upon arrival from the theatre.
Intravenous fluids and prescribed medications are administered via infusion.
A fluid balance chart is maintained to record and monitor fluid intake and output.
Post-operative medications are administered as prescribed on an ongoing basis.
Attention is given to bowel and bladder function.
The patient is encouraged to rest and sleep.
Drainage devices, such as abdominal drains, are managed appropriately.
The patient is positioned to maximize comfort and minimize pain.
Diet and nutritional needs are addressed as the patient recovers.
Wound care is provided to promote healing and prevent infection.
Pain is managed effectively through appropriate interventions.
Maintaining bed hygiene is essential for patient comfort and preventing infection.
Attention is given to body and skin hygiene.
Physiotherapy exercises, such as breathing exercises, are encouraged.
Psychological support is provided to aid in recovery.
POST-OPERATIVE COMPLICATIONS:
Hemorrhage, which can be immediate (primary) or occur later (secondary).
Pain following the surgical procedure.
Shock, a critical condition requiring immediate intervention.
Wound infection or sepsis, a serious systemic infection.
Hypostatic pneumonia, which can develop due to prolonged bed rest.
Delayed wound healing.
Paralytic ileus, a temporary paralysis of the intestinal muscles.
Adhesions, scar tissue that can form inside the body.