Nursing Practical Guideline Procedure : Pre and post -operative care

Pre and post -operative care:

The success of every surgery depends on the type of nursing care given to the patient before (pre-operative) during (intra-operative) and after (post-operative) period of surgery. The preparation of the patient for surgery depends on the type of surgery, age of the patient, general health of the patient and the organ involved.

Pre-operative care of the patient begins as soon as the surgeon makes a diagnosis and decides that an operation is necessary for the patient.

Psychological preparation

Discuss with the patient to give full information about the surgery, such as:

1.     Type of surgery

2.     Consequences of surgery ( if it is done and if it is not done).

3.     The problems to be faced ( disabilities expected )

4.     Expected duration of hospitalization

5.     Expected time of resuming duty ( if employed)

6.     Cost of surgery

7.     Treatment / investigations done before surgery and its purpose

8.     Necessary arrangements to be made about the family, financial matters, work, hospitalization, etc.

Eradicate fear of operation from the patient:

Allow the patient to ask questions and clear all his doubts

1.     Introduce to the patient someone who had similar surgeries and successfully recovered from the symptoms.

2.     Explain what happens during anaesthesia.

3.     Explain how to get rid of pain after surgery.

4.     Tell the patient when he can have meals.

5.     Answer all questions asked by the patient in a language he can understand, so that the patient will have confidence to undergo surgery.

6.     Let the patient see the persons, places and equipment involved in his operation.

7.     Always start the procedures with an explanation, so that it will inspire confidence in the medical team. The patient has to feel that he will be safe in the hands of the competent people during surgery.

8.     For many patients, their admission to the hospital is a first experience in their lives. In such situation, the nurses should make them feel at home by eradicating their fear.

Meet the spiritual needs of the

1.     Let the patient meet the ministers of his religion, if requested

2.     Obtain inform consent.

3.     Build up the general health

4.     Preoperative teaching

5.     Surgical preparation.

6.     Preparation of the patient on the evening before operation enema and bowl wash.

7.     Preparation of the patient on the day of the surgery.

8.     Sending the patient to operating room

Preparation of skin:

Preliminary assessment:

1. Check the doctor' s orders for the diagnosis and the orders for operation.

2. Check the type of the operation to be done and the area to be prepared.

3. In doubt, clarify with the surgeon, or at least with the seniors.

4.     Check the orders for specific precautions.

5. Check the operative area for any skin lesion.

6. Check the cleanliness of the skin to be prepared.

7. Check the abilities and the limitations of the patient.

8. Check the consciousness of the patient and the ability to follow instructions.

9. Check whether the patient is getting any treatment and can be discontinued till the skin preparation is complete.

10.                        Check whether the articles are in working order. Check the articles in the patient' s unit.

Articles:

1. Clean razor with sharp blade in a container.

2. A bowl with the disinfectant.

3. Shaving cream or soap jelly.

4. Cotton tipped applicators.

5. Scissors

6. Kidney tray and paper bag.

7. Mackintosh and towel

Articles for cleaning the area and dressing the skin area.

1.     Basin with warm water.

2.     Wash clothes.

3.     Soap with soap dish

4.     Spirit, mercurochrome, iodine

5.     Binders and safety pin

6.     A sterile tray containing, sponge, holding forceps, cotton balls, dressing towel and gloves

Purpose

1.     To shave the skin without scratches.

2.     To disinfect the razor after shaving

3.     To lather the skin area for a wet shave. The skin is soft when it is wet.

4.     To smear the cream on the area.

5.     To cut long hair, if any, and to cut short the nails.

6.     To receive the wastes.

7.     To protect the bed and garment. dressing the skin area

8.     To clean the area after the shave.

9.     To use as antiseptics on the skin.

10.                        To secure the dressing towel in place

11.                        To clean and to paint the area.

12.                        To cover the area after cleaning.

13.                        To maintain the aseptic technique when dressing the area

Preparation of the patient and the environment

1.     Identify the patient and explain the procedure to win his confidence and co-operation.

2.     Explain the sequence of the procedure and tell him how he can co-operate with you.

3.     Provide privacy with curtains, and drapes.

4.     Place the patient in a comfortable and relaxed position according to the part to be prepared.

5.     Give proper support to the body parts, if the patient has to raise it from mattress and hold it in a position for a considerable time.

6.     Arrange the articles conveniently at the bedside.

7.     Close the doors and windows to prevent drought.

8.     Adjust the height of the bed according to the comfortable working of the nurse. Bring the patient to the edge of the bed.

9.     Fold back the upper bedding towards the foot end of the bed leaving a sheet or bath blanket over the patient. Expose the parts as necessary.

10.                        Protect the bed with a mackintosh and towel.

11.                        Remove the ornaments and the cosmetics used on the area to be prepared.

12.                        Inspect the finger and toe nails. If long, cut short.

Procedure:

1.     Wash hands To prevent cross infection

2.     Lather the area for the easy removal of the hair. The skin will be soft when it is wet.

3.     Shave the skin by holding the skin taut and the razor held at 45 o angle to the skin and moved in the direction the hair is growing. Use short, firm but gentle strokes.

4.     This approach decreases the skin irritation and ensure complete removal of hairs.

5.     Rinse the area with soap and water and then with water alone, using the wash clothes. Thorough cleaning will remove the dirt and soap residue from the skin.

6.     Repeat the steps 2 to 4 times until the entire area has been prepared clean and no hair is visible. Dry the area.

7.     Discard the razor into the bowl with antiseptic. disinfect the razor.

8.     Put on gloves, if available. Clean the area with spirit starting from the centre to the periphery. Paint the area with either iodine or mercurochrome spirit, iodine and mercurochrome are antiseptics. If iodine is used special care should be taken to prevent blistering

9.     Cover the operative area with the sterile towel and secure with binders.

After care of the patient and the articles

1.     Put on fresh gown.

2.     Adjust the position of the patient in bed. Rearrange the bed clothes.

3.     Remove the mackintosh and towel.

4.     Take all articles to the utility room. Remove the razor from the disinfectant solution, discard the blade, clean it thoroughly, dry it and replace it in its proper place. All the articles are cleaned, dried and replaced in their proper places.

5.     Wash hands

6.     Record the procedure on the nurse's notes with date and time.

7.     Record the area prepared and the condition of the skin.

8.     If there is time, send the patient for a thorough bath after shaving of the skin but before he is prepared for operation.

9.     Always entrust the patient to someone who will take responsibility of the patient while he is in the operation theatre.

Post-operative care (in general)

Preparation of post-anaesthetic bed and reception of the patient.

After sending the patient to operating room prepare a bed to receive the patient undergone surgery and anaesthesia. ( Refer in Principles and Practice of Nursing Vol. I )

There should be adequate number of people to. transfer the patient without disturbing the functioning of the devices attached with the patient; such as : i.v. infusion set, self retaining suction set, blood transfusion sets, naso-gastric tube, oxygen, urinary catheter, cardiac monitoring, water seal drainage system, plaster casts, traction sets.

Receive the patient without disturbing the devices attached to the patient. The recovery room nurse-incharge may give the necessary instructions to the personnel before transfering the patient.

Ask the theatre staff who has accompanied with the patien about any complications that has occurred in the operation room during surgery.

Before the theatre staff ( including anaesthetist ) return to operation theatre, check the vital signs blood pressure, pulse rate, respiration, colour of the skin and nails for any cyanosis etc. Compare it with the baseline data recorded before sending to operation theatre.

Check the operation site for bleeding, discharge etc., if draina tubes are fitted.

Keep the patient well covered to prevent draught.

Never leave the patient alone to prevent injury from falls.

Observe the patient for swallowing reflexes. If not present, keep the patient in a sidelying position to prevent the tongue falling back and obstructing the airway. After tonsillectomy, the patient may be kept in prone position to prevent blood aspirating in the lungs. The patient who had spinal anaesthesia, the foot it may be raised on bed blocks

Quickly observe the functioning of all devices and make sure that they are in its functioning order e.g., the drainage tubes connected with the drainage bottle, the IV sets are patent.

Check the doctor's orders for other instructions and treatment

Care of the patient who is under the effects of anaesthesia

Patient needs close and diligent observation until the patient fully recover from anaesthesia. This will help to detect the early

signs of complications after surgery and the nurse will be able to respond immediately.

A noisy breathing is indicative of airway obstruction that can occur, due to the tongue falling back and obstructing the pharynx, or fluid collected in the airway passages or fluids aspirated into the lungs. Apply suction immediately, send & call the surgeon and the anaesthetist.

Keep the patient in a suitable position that will be helpful to drain out the vomitus, blood and secretions collected in the mouth and will prevent them aspirating into the lungs. This position is maintained until protective reflexes are returned.

The oro-pharyngeal airway left in the mouth of the patient should be removed as soon as the patient has regained the cough and swallowing reflexes.

Excessive secretions in the mouth or anywhere in the respiratory passage can lead to airway obstruction. It should be sucked out. If intra-tracheal auctioning is necessary, always use sterile technique.

If the patient is cyanosed, administer oxygen inhalation. At the same time, find out the cause and remove the cause. Prolonged oxygen therapy should be guided • by arterial blood gas determinations.

A weak thready pulse with a significant fall in blood pressure may indicate circulatory failure. It may also indicate blood loss from the body. The surgeon and the anaesthetist should be informed.

In order to prevent injury from falls from bed, put on the side rails on the bed. Till the patient recover from the effects of anaesthesia, the nurse should not leave the patient alone. Even, when the patient has recovered from the effects of anaesthesia, entrust the patient to someone responsible for the care.

While awakening from anaesthesia, patients need frequent orientation as to where they are, what has been done to them, and reassurance that they are safe in the hands of the medical team. They also need to know that the operation is over and they are recovering from anaesthesia.

Although these patients, while they are under the effects of anaesthesia, appear to be unconscious, the nurses should be careful, not to make any statement about the patient or his disease conditions that may create anxiety in the patient.

When the patients under the effects of anaesthesia complain pain in the operation site, the narcotics/sedatives may be ordered by the surgeon and it should be given with caution.

The first post operative dose of a narcotic is usually reduced to half the dose the patient will be receiving after fully recovered from anaesthesia. This is because it can cause pronounced depression of the respiratory/circulatory/central nervous systems that may follow.

Patient recovering from anaesthesia may ask for drinking water.

Unless die patient has fully regained the swallowing reflex, drinking water may choke the patient; it should not be given.

As the patient is recovering from the effects of anaesthesia, the patient may become restless due to the discomfort caused by the presence of those devices attached to the patient, such as IV sets, urinary catheters, drainage tubes etc.

The nurse should help the patient by giving adequate explanations.

Keep the family informed of the successful completion of surgery, transfer of the patient from the operating room to recovery room etc. These informations will reduce their anxiety.

If possible, allow the relatives to meet surgeon to clear their doubts.

Observation of the patient in the postoperative period

Close and diligent observation by the nurses are important to detect complications in the early stages, and thus, save the patient.

On the first post operative day the patient needs close and frequent observations : e.g., the vital signs are checked every 15 minutes or more frequently ( during the period when the patient is in the recovery room ).

Once the vital signs are stabilized, the observations may be made every 2 hourly or 4 hourly according to the progress made by the patient.

The main points that should be observed are

Vital signs - blood pressure, pulse rate, respiratory rate, akin colour, skin temperature.

    Intake and output -I.V. fluids, oral fluids taken by the patient, naso-gastric aspiration, wound drainage, blood loss.

    Abdominal girth in patients with abdominal distension.

    Urinary output- time and amount.

    Bowel movements.

    Signs of hypo/ hypervolaemia

    Any breathing difficulties.

    Pain over the calf muscles.

    Operation site for bleeding, drainage.

    Any specific observation as told by the surgeon and according tthe operation done: e.g., vaginal discharge in patients whhad hysterectomy, any arrhythmias in patients whhad cardiac problem, motor and sensory functions in a patient with neurological problems.

Diet of the patient

All patients, except patients who had abdominal surgery, may start the normal diet, if desired so, on the first day. Remember to exclude nausea and vomiting due to the effect of naesthesia.

Patient who had abdominal surgery, but did not involved the intestine or stomach, can have the clear fluids on the day after the surgery.

Gradually, it can change into soft diet and then normal diet.

Patients who are with specific diseases, for which, they were taking special diets, should continue to observe the control of their diet as ordered by the doctor (e.g., a diabetic patient).

Remember, the patients who had undergone any type of surgery, need a diet rich in vitamins and minerals.

Post operative health teaching

All patients need health teaching according to the educational background pf the patient.

Teach the patient following points : o Maintenance of personal hygiene.

Diet that is allowed for the patient; any control on the diet.

Ambulation; activities that are permitted, as well as restricted.

Any adjustments to be made in the occupation of the patient.

Any drugs to be taken post operatively; the side effects and precautions.

Date on which the patient may resume duty.

Learning of any particular procedure to be carried out postoperatively, e.g., care of the colostomy. When the patient is unable to perform the procedure, teach the patient's relatives.

Further treatment that may be needed for the patient in any other hospital, e.g. radiation therapy for cancer patients.