PRE-OPERATIVE TEACHING

***
One goal of pre-operative nursing care is to teach the patient how to promote optimal lung expansion and blood oxygenation after anesthesia.

DEEP BREATHING EXERCISES

**The goal in promoting coughing is to mobilize secretions so they can be removed. Deep breathing before coughing stimulates the cough reflex. If the patient does not cough effectively, atelectasis (lung collapse), pneumonia, and other lung complications may occur.

DIAPHRAGMATIC BREATHING- this refers to a flattening of the dome of the diaphragm during inspiration with resultant enlargement of the upper abdomen as the air rushes in. During expiration, muscles of thee abdomen contract. a. Practice in the same position you would assume in bed after surgery: a semi-Fowlers position, b. c. d.
e. propped in bed with the back and shoulders well supported with pillows. With your hands in a loose-fist position, allow the hands to rest lightly on the front of the lower ribs, with your fingertips against lower chest to feel the movement. Breathe out gently and fully as the ribs sink down and inward toward midline. Then take a deep breath through your nose and mouth, letting the abdomen rise as the lungs fill with air. Hold this breath for a count of five. Exhale and let out all the air through your nose and mouth. Repeat this exercise 15 times with a short rest after each group of five. Practice this twice a day preoperatively.

f. g.
h.

COUGHING
a. b. c. d. e. Lean forward slightly from a sitting position in bed, interlace your fingers together, and place your hands across the incisional site to act as a splintlike support when coughing. Breathe with the diaphragm as described under Diaphragmatic Breathing. With your mouth slightly open, breathe in fully. Hack out sharply for three short breaths. Then, keeping your mouth open, take in a quick deep breath and immediately give a strong cough once or twice. This helps clear secretions from your chest. It may cause some discomfort but will not harm your incision.

MOBILITY AND ACTIVE BODY MOVEMENT ** The goals of promoting mobility postoperatively are to improve circulation, prevent
venous stasis, and promote optimal respiratory function.

LEG EXERCISES a. b. c. d. e.
Lie in a semi-Fowlers position and perform the following simple exercises to improve circulation. Bend your knee and raise your foothold it a few seconds, then extend the leg and lower it to the bed. Do this five times with one leg, then repeat with the other leg. Then trace circles with the feet by bending them down, in toward each other, up, and then out. Repeat these movements five times.

TURNING TO SIDE a. b.
c. Turn on your side with the uppermost leg flexed most and supported on a pillow. Grasp the side rail as an aid to maneuver to the side. Practice diaphragmatic breathing and coughing while on your side.

GETTING OUT OF BED

a. Turn on your side.

b. Push yourself up with one hand as you swing your legs out of bed.

POST-OPERATIVE TEACHING
PREVENT RESPIRATORY COMPLICATIONS
1. The nurse encourages the patient to turn frequently and take deep breaths at least every 2 hours. Coughing is also encouraged to dislodge mucus plugs. 2. Even if he or she is not fully awake from anesthesia, the patient can be asked to take several deep breaths. This helps to expel residual anesthetic agents, mobilize secretions, and prevent alveolar collapse (atelectasis). 3. Careful splinting of abdominal or thoracic incision sites helps the patient overcome the fear that the exertion of coughing might open the incision. Analgesic agents are administered to permit more effective coughing, and oxygen is administered as prescribed to prevent or relieve hypoxia *** Coughing is contraindicated in patients who have head injuries or who have undergone intracranial surgery (because of the risk for increasing intracranial pressure), as well as in patients who have undergone eye surgery (risk for increasing intraocular pressure) or plastic surgery (risk for increasing tension on delicate tissues).

ENCOURAGING ACTIVITY
**Gradual position change gives the circulatory system time to adjust. If the patient becomes dizzy, he or she should be returned to the supine position, and getting out of bed should be delayed for several hours. To assist the postoperative patient in getting out of bed for the first time after surgery, the nurse performs the following actions: 1. Help the patient to move gradually from the lying position to the sitting position until dizziness passes. This can be achieved by raising the head of the bed. 2. Position the patient completely upright (sitting) and turned so that both legs are hanging over the edge of the bed. 3. Assist the patient to stand beside the bed. When accustomed to the upright position, the patient may start to walk. The nurse should be at the patients side to give physical support and encouragement. Care must be taken not to tire the patient; the extent of the first few periods of ambulation varies with the type of surgical procedure and the patients physical condition and age. Whether or not the patient can ambulate early in the postoperative period, bed exercises are encouraged to improve circulation. Bed exercises consist of the following: Arm exercises (full range of motion, with specific attention to abduction and external rotation of the shoulder) Hand and finger exercises Foot exercises to prevent deep vein thrombosis, foot drop, and toe deformities and to aid in maintaining good circulation Leg flexion and leg-lifting exercises to prepare the patient for ambulation Abdominal exercises

PROMOTING WOUND HEALING Phase Inflammatory Duration 1-4 days

Events Blood clot forms Wound becomes edematous Debris of damaged tissue and blood clot are phagocytosed

Proliferative

5-20 days

Collagen produced Granulation tissue forms Wound tensile strength increases

maturation

21 days to months/years

Fibroblasts leave wound Tensile strength increases Collagen fibers reorganize and tighten to reduce scar size

CHANGING THE DRESSING

A dressing is applied to a wound for one or more of the following reasons: (1) to provide a proper environment for wound healing; (2) to absorb drainage; (3) to splint or immobilize the wound; (4) to protect the wound and new epithelial tissue from mechanical injury; (5) to protect the wound from bacterial contamination and from soiling by feces, vomitus, and urine; (6) to promote hemostasis, as in a pressure dressing; and (7) to provide mental and physical comfort for the patient.

Until Sutures Are Removed

1. Keep the wound dry and clean. If there is no dressing, ask your nurse or physician if you can bathe or shower. If a dressing or splint is in place, do not remove it unless it is wet or soiled. If wet or soiled, change dressing yourself if you have been taught to do so; otherwise, call your nurse or physician for guidance. If you have been taught, instruction might be as follows: Cleanse area gently with sterile normal saline once or twice daily. Cover with a sterile Telfa pad or gauze square large enough to cover wound. Apply hypoallergenic tape (Dermacel or paper). Adhesive is not recommended because it is difficult to remove without possible injury to the incisional site. 2. Immediately report any of these signs of infection: Redness, marked swelling exceeding 12 inch (2.5 cm) from incision site; tenderness; or increased warmth around wound Red streaks in skin near wound Pus or discharge, foul odor Chills or temperature higher than 37.7C (100F) 3. If soreness or pain causes discomfort, apply a dry cool pack (containing ice or cold water) or take acetaminophen tablets (2) every 46 hours. Avoid using aspirin without direction or instruction because bleeding can occur with its use. 4. Swelling after surgery is common. To help reduce swelling, elevate the affected part to the level of the heart. Hand or arm Sleepelevate arm on pillow at side Sittingplace arm on pillow on adjacent table Standingrest affected hand on opposite shoulder; support elbow with unaffected hand Leg or foot Sittingplace a pillow on a facing chair; provide support underneath the knee Lyingplace a pillow under affected leg

After Sutures Are Removed

Although the wound appears to be healed when sutures are removed, it is still tender and will continue to heal and strengthen for several weeks. 1. Follow recommendations of physician or nurse regarding extent of activity. 2. Keep suture line clean; do not rub vigorously; pat dry. Wound edges may look red and may be slightly raised. This is normal. 3. If the site continues to be red, thick, and painful to pressure after 8 weeks, consult the health care provider. (This may be due to excessive collagen formation and should be checked.)