CARING FOR THE PERIOPERATIVE PATIENT.

POSTOPERATIVE PATIENT CARE.

SURGICAL CARE
Care of the surgical patient (perioperative) can be divided into three
parts:
Preoperative(before surgery)
Operative(in the operating room)
Postoperative(after surgery)
During the Operative Period
While the patient is in the operating room, prepare the room for his or
her return
Prepare the surgical bed.
Remove everything from the top of the bed side stand except an
emesis basin, tissues, tongue depressors, equipment to check vital
signs, and a pen and paper.
Obtain needed equipment, such as oxygen, IV poles, or suction.
Watch for the return of your patient from surgery.
Video:
https://www.youtube.com/watch?v=B_hPK-QYP8I

Postoperative Care
During the immediate postoperative period, the patient recovers from
anesthesia. For this period, the patient is placed in a special area called
the recovery room. The recovery room is located next to the operating
room and is sometimes called the post anesthesia care unit (PACU).
When the patients condition is stabilized, the patient is returned to the
unit. Upon the patients return from the recovery room, you should:
Identify the patient
Assist in the transfer from stretcher to bed
Inform the nurse if you can not arouse the patient
Check with the nurse for special instructions
Notify the nurse if the patients temperature is below 97
F.
Have an extra blanket availablepatient soften feel cold
upon return


Patients receive many drugs before and during surgery. Some can alter
the patients mental status. They are excreted from the body
slowly. The patient may sleep soundly upon return to the unit. Keep
the side rails up and follow all safety precautions until the patient
is fully awake and the nurse instructs you that side rails ar e no
longer necessary. Do not leave liquids at the bed- side until the
nurse instructs you that it is safe to do so. Check on the patient
regularly.
Anesthesia reduces body temperatur e. Keep the patient warm. If
the patients temperature is below 97 F, inform the nurse promptly.

Nursing assistant observations related to the care of post-
operative patients that require immediate reporting.
Observe the patient carefully, especially during the first 24 hours,
for complications. You will assist with postoperative exercises,
such as:
Deep breathing and coughing
Leg exercises






POSTOPERATIVE OBSERVATION AND
REPORTING
Decreased responsiveness or unresponsiveness
Change in the level of responsiveness
Increased restlessness accompanied by complaints of
thirst
Changes in blood pressure
Weak, rapid, or irregular pulse
Changes in temperature
Changes in respiratory rate
Difficulty breathing; labored or noisy respirations
Nausea or vomiting
Complaints of pain
Increased drainage, wet or saturated dressings
Active bleeding
Coughing or choking

Postoperative Care
Apply the principles of standard precautions.
Take vital signs upon the patients arrival and every 15 minutes for
four readings. The patients temperature is not taken at this time.
Count pulse and respiration for one full minute. Most facilities have
specified frequencies for taking postoperative vital signs; the frequency
decreases if the patient is stable. For example:
every 15 minutes for 1 hour
if stable, every 30 minutes for 1 hour
if stable, every hour for 2 hours
if stable, every 4 hours for 24 hours. Check the vital signs regularly
until they are stable

Monitor the patients level of consciousness (drowsy, unresponsive,
alert) each time you check the vital signs.
Ask the patient if he or she is having pain each time you check the vital
signs. Inform the nurse if pain is present .
Check dressings for amount and type of any drainage.
Check IV solution for flow rate. Monitor other tubes.
Encourage the patient to breathe deeply, cough, and move in bed.
Change the patients position at least every 2 hours.
Turn the patients head to one side and support if vomiting. Assist with
oral car e after vomiting. Note the type and amount of vomitus and r
ecord on the output worksheet.
Measure and record the first postoperative voiding. Inform the nurse.
Video:
https://www.youtube.com/watch?v=sdnM5ZuPfl0
Safety ALERT
Some patients are very sensitive and will not let anyone
see them unless their dentures are in the mouth. Be sure they
do not insert their dentures before they are fully awake.
Remove dentures from an unconscious or comatose patient to
prevent accidental airway obstruction by the denture.

SURGICAL WOUNDS
Patients often return from surgery with a variety of tubes and
drains in place.
Some tubes may deliver materials into the patient. Examples are
oxygen tubes or intravenous tubes.
Other tubes may have been placed in the patient to provide
drainage from wounds or body cavities. Examples are drains in the
incision or urinary catheters.


Managing Wounds with Drains
Drains remove fluids that have collected below the skin. The drain exits
the skin through a small incision, and may be sutured in place. Some
drains are hollow, and empty directly to the outside of the body. Others
are connected closed containers, and must be emptied. Care of the
device varies with physician orders and the type of drain used. Wound
drains are considered sterile, and are usually man- aged by the nurse.
Use sterile technique when assisting with drains. Consider the drain as
a portal of entry through which pathogens can enter the body. Always
apply the principles of standard precautions.
Drains are used to remove body fluids, such as blood, pus, serous
drainage, or gastric contents before or after surgery. The drainage outlet
may be a:
Catheter
T-tube
Jackson-Pratt (J-P)

or Hemovac

drain
Penrose drain
Cigarette drain Special precautions in the care of patients with
drains include:
Always wear gloves if contact with drainage from the
tube is likely.
Learn the type, purpose, and location of each tube.
Check drainage for character and amount.
Check for obstructions to the tube system.
Check flow rate of infusions from intravenous lines.
Keep orifices (body openings) clear of secretion sand
discharge.
Never disconnect tubes or raise drainage bottles above
the level of the drainage site.
Never lower in fusion bottles below the level of the
infusion site.
Never put stress on the tubes when moving the patient or
giving care.
Monitor level so f infusions and report to the nurse
before they run out.
Report any signs of leakage or disconnected tubes
immediately.
Report pain, discoloration, or swelling at sites of
drainage and infusion.
Check with the nurse before changing or reinforcing a
dressing.
Use sterile technique whenever you manipulate or empty a tube or
drain or change a dressing. Be sure this is a permit- ted nursing
assistant procedure in your facility. Observations to make and report
for patients with drains are listed in.
Video:
https://www.youtube.com/watch?v=4SoKHIwW-_Q
OBSERVATIONS RELATING TO DRAINS TO
REPORT TO THE NURSE
Drain is not intact or patent
Drain appears blocked, dislodged, or kinked
Surrounding skin appears abnormal (erosion, red, hot,
swollen, macerated)
Drainage is eroding surrounding healthy skin
Drainage is purulent, cloudy, or foul smelling
Drainage color changes or appears abnormal
Amount of drainage decreases markedly or stops entirely
Amount of drainage increases markedly
Patient has fever, tachycardia, hypotension
Urinary output decreases
Dressings and Bandages
Dressings are gauze, film, or other synthetic substances that cover a
wound, ulcer, or injury. Some have an adhesive backing. Some are
affixed with tape. Bandages are fabric, gauze, net, or elasticized
materials that are wrapped around an extremity to hold a dressing
securely in place. Gauze bandages may be used to cover dressings.
Video:
https://www.youtube.com/watch?v=mon9-LXlh0A
Elastic bandages are used to reduce edema and support injured body
parts. Monitor bandages to be sure they do not restrict circulation.
Inform the nurse if wound drainage seeps through the bandage.
Montgomery straps are long strips of adhesive attached to the skin on
either side of the wound to hold dressings in place. They are less
traumatic than tape because the straps are not removed unless they are
soiled. After the dressing is in place, the straps are tied to hold the
dressing securely. Binders may also be used to hold dressings in place

video:
https://www.youtube.com/watch?v=XQN10xw-xas
DEEP BREATHING AND COUGHING
Deep breathing and coughing clear the air passages to prevent
respiratory complications. However, they in- crease discomfort when
the patient has a new incision and feels fatigued. You can best assist the
patient by:
Checking to see if pain medication is needed before the
exercise. If so, wait for 45 minutes after the medication has
been given before carrying out the exercise.
Learning how many deep breath sand coughs should be
attempted. The usual number is 5 to 10 breaths and 2 to 3
coughs.
Using a pillow or binder to support the incision during
the procedure.
POSTOPERATIVE COMPLICATIONS AND NURSING
ASSISTANT ACTIONS



ASSISTING THE PATIENT TO DEEP BREATHE AND
COUGH
1. Carry out initial procedure actions.
2. Assemble equipment:
Disposable gloves
Pillowcase-covered pillow
Binder, if ordered
Tissues
Emesis basin
3. Elevate the head of the bed and assist the patient to assume a
comfortable semi-Fowlers position.
4. Have the patient place his hands on either side of the rib cage or
over the operative site (Figure 29-11).
5. Ask the patient to take as deep a breath as possible and hold it for 3
to 5 seconds; then exhale slowly through pursed lips.
6. Repeat this exercise about 5 times unless the patient seems too
tired. If so, stop the procedure and report to the nurse.
7. Place the pillow across the incision line as a brace. Assist the
patient to hold the sides or interlace his fingers across the incision.
8. Provide tissues and instruct the person to take a deep breath and
cough forcefully twice with the mouth open, collecting any secretions
in the tissues.
9. Put on disposable gloves to handle the tissues.
10. Dispose of tissues in an emesis basin.
11. When finished, assist the patient to assume a comfortable
position.
12. Clean the emesis basin.13. Remove and dispose of gloves
according to
facility policy.
14. Carry out ending procedure actions.
15. Report to the nurse on the number of times the patient performed
each exercise, how the patient tolerated the exercise, and the type
and amount of sputum coughed up.

video:
https://www.youtube.com/watch?v=LVGWr3i83GQ

LEG EXERCISES

Leg exercises improve blood flow, preventing blood clots, which are
a serious postoperative complication. A blood clot or deep vein
thrombosis (DVT) could develop in the venous system and block the
essential blood flow. A small piece of thrombus broken off
(embolus) could travel throughout the vascular system and block a
vessel in the lungs.
A specific order must be written for leg exercises when a patient has
had leg surgery. Otherwise, leg exercises are done routinely. If the
patient is very weak, you may need to assist.
Encourage leg exercises and be sure they have been
performed.
Remind the patient to do each exercise 3 to 5 times
every 1 or 2 hours, or as specified on the care plan.
Have the patient carry out leg exercises during position
changes.
Apply or reapply support hose , as ordered.

Video:
https://www.youtube.com/watch?v=SA_f0bj7oIE

PERFORMING POSTOPERATIVE LEG EXERCISES
1. Carry out initial procedure actions.
2. Lower the side rail.
3. Cover the patient with a bath blanket and draw the top bedding to
the foot of the bed.
4. Explain how the exercise is to be performed. Have the patient:
a. Brace the incisional area with laced hands.
b. Dorsi flex (bring the toes toward the knee) and plantar flex (point the
toes and foot down) each ankle.
c. Rotate each ankle by drawing imaginary circles with the toes.
d. Flex and extend each knee .
e. Flex and extend each hip.
f. Repeat each exercise 3 to 5 times. Assist as needed.
5. Supervise exercises or assist. Apply or reapply support hose as
ordered.
6. Draw bedding up and remove the bath blanket.
7. Fold the bath blanket and place it in the bedside stand for reuse.
8. Carry out ending procedure actions. Report to the nurse on the
number of exercises done and how the patient tolerated them.

ELASTICIZED STOCKINGS
Elasticized stockings are called TED hose, anti-embolism hose,
or graduated compression stockings (GCS). This name refers to the
pressure, which is tightest at the foot and ankle and becomes looser as
the stockings extend up the leg. The hose are worn from the ankle or
foot to calf or mid- thigh. They are often applied during the
perioperative period to support the veins of the legs. This reduces the
incidence of thrombophlebitis, an inflammation of the veins that can
lead to blood clots. The stockings must be applied smoothly and evenly
before the patient gets out of bed. Remove and reapply them every 8
hours, or as specified on the care plan.
Several different types of anti-embolism hose are used. Some
have closed toes, but most have an opening near the toe end. The hole
is positioned on the top or the bot- tom of the foot, just proximal to the
toes. Use the heel of the stocking as a landmark so you can see where
to position the hole.
Video:
https://www.youtube.com/watch?v=7MxWFJ1_vdA

Preventing Complications
A physicians order is needed to apply special hosiery. The ordering
physician will specify if knee-high or thigh-high hose should be used.
The size is based on each patients leg measurements. Make sure you
apply the correct hosiery and the correct size.
The risk of complications from anti-embolism hosiery is low. However,
they are not totally risk-free. Ill-fitting hosiery is the most common
cause of complications. The greatest risk is a reduction in blood flow
from pressure, which increases the potential for blood clots. Other
complications are pressure ulcers, gangrene, and arterial occlusion.
These usually occur when the patient sits for a prolonged period
without moving. In one reported case, the tourniquet effect created by
bunched-up hosiery, combined with swelling of the leg, caused serious
skin break- down that led to amputation.

Applying Anti-Embolism Stockings

The care plan will specify the wearing schedule for the stockings.
For most patients, hosiery is removed at bedtime.
If the patient has a latex sensitivity , be sure the hosiery used is
latex free.
Apply the stockings before the patient gets out of bed in the
morning, because this is when the edema is least.
Make sure the legs are dry before applying the hosiery.
Never apply the hosiery over open areas, fractures, or
deformities.
Make sure the stockings are smooth and wrinkle free.
Every 8 hours (or as specified on the car e plan), monitor
circulation in the toes and be sure the hosiery tops have not
rolled down. Note color, sensation, swelling, temperature, and
ability to move.
Avoid contact with lotions, ointments, or oils containing lanolin
or petroleum products. These products deteriorate the elastic in
the hosiery .
video:
https://www.youtube.com/watch?v=3cecmBcoORE
APPLYING ELASTICIZE STOCKINGS
1. Carry out initial procedure actions.
2. Assemble equipment:
Elasticized stockings of proper length and size
3. Apply stockings with the patient lying down. Expose one leg at a
time.
4. Grasp the stocking with both hands at the top and roll it toward the
toe end.
5. Adjust the stocking, positioning the opening at the top or base of the
toes (unless the toes are to be covered).
6. Continue rolling the stocking upward toward the body.
7. Be sure the stocking is smooth, even, and wrinkle free.
8. Repeat the procedure on the opposite leg.
9. Carry out ending procedure actions.
SEQUENTIAL COMPRESSION THERAPY
Deep vein thrombosis and pulmonary embolism (blood clot in the
lungs) are serious postoperative complications. Approximately 10% of
all patients with DVT die from pulmonary embolism. Most have no
symptoms until they develop the pulmonary embolus. The femoral
vein, the large blood vessel in the groin, is particularly susceptible to
clot formation. Because of the high risk, the physician may order
sequential compression therapy. Sequential compression therapy
massages the legs and keeps blood flowing, making blood clots less
likely. The device is applied over anti-embolism hosiery, if the patient
is wearing them.
INITIAL AMBULATION
Some time after surgery, a patient is permitted to sit up with the legs
over the edge of the bed. This position is called dangling. Assist the
patient to assume the position slowly.
The first ambulation (walk) is usually short. The patient usually
dangles for a short time before ambulating. Dangling is an important
part of postoperative care because it stimulates circulation. The patient
may need assistance the first few times he stands to ambulate. Be
familiar with the location of tubes and move them with the patient.
ASSISTING WITH SEQUENTIAL COMPRESSION
HOSIERY
Be certain this is a nursing assistant procedure in your facility.
1. Carry out initial procedure actions.
2. Assemble equipment:
Hosiery of proper size
Compression controller
3. Open the hose, laying them flat on the bed with the markings
opposite the knee and ankle.
4. Lift the patients leg and slide the hose under it. Wrap the sleeve
smoothly around the leg with the opening in front, over the knee.
5. Beginning at the ankle, fasten the Velcro securely. Next, secure the
calf, then the thigh.
6. Check the fit by inserting two fingers between the sleeve and the
patients leg. The fit should feel snug and secure, but not tight.
7. Wrap the other leg in the same manner, beginning on the side opposite
the plastic tubing. Check the fit.
8. Attach the plastic tubing on each leg by lining up the arrows on the
tubing.
9. Plug the controller in and turn on the power.
10. Remain in the room for one complete cycle (usually 60 to 90 seconds)
to ensure that the patient tolerates the procedure.
11. Carry out ending procedure actions.
ASSISTING THE PATIENT TO DANGLE
1. Carry out initial procedure actions.
2. Assemble equipment: Bath blanket Pillow
3. Lower the side rail nearest to you. Lock the bed at the lowest
position.
4. Drape the patient with a bath blanket and fanfold the top bedcovers
to the foot of the bed.
5. Gradually elevate the head of the bed.
6. Help the patient to put on a bathrobe.
7. Place one arm around the patients shoulders and the other arm
under the knees.
8. Gently and slowly turn the patient toward you. Allow the patients
legs to hang over the side of the bed.
9. After putting slippers on the patient, ask the patient to swing the legs.
10. Have the patient dangle as long as ordered. If he becomes dizzy or
faint, help him lie down.
11. Rearrange the pillow at the head of the bed. Remove the patients
bathrobe and slippers.
12. Place one arm around the patients shoulders and the other arm
under the knees. Gently and slowly swing the patients legs onto the bed.
13. Check the patients pulse. Lower the head of the bed and raise the
side rails, according to the care plan.
14. Carry out ending procedure actions.


HEAT AND COLD APPLICATIONS
Heat and cold applications are used for many different purposes. A
localized application is used to apply heat or cold to a specific area of
the body. An example of this type of application is an ice bag applied
to a swollen ankle. A generalized application is used to apply heat or
cold to the patients entire body.
Heat applications dilate or enlarge the blood vessels, bringing oxygen
and nutrients to the area, relieving pain and speeding healing. They are
commonly used when IV fluid
has accidentally entered the tissue.
Local cold applications are used to control bleeding, relieve pain, and
prevent or relieve edema, which is common after an injury. Cooling
causes blood vessels to constrict, making them smaller. Generalized
cooling is used to reduce temperature. Blankets may also be used for
heating, but this is less common.
Dry or moist treatments may be ordered. Moist treatments (those in
which water touches the skin) penetrate more deeply than dry. Some
dry applications have water inside them, but the outer surface remains
dry. Dry applications may be used to maintain the temperature of moist
applications. Common types of heat and cold treatments are:
Ice bags , ice collars ,hot water bottles.
Aquamatic K-Pads. K-Pads come in many shapes and
sizes. Distilled water circulates through the pad continuously.
The temperature can be set by the user. They are commonly used
to apply heat. With a special attachment, they can also be used
for cooling.
Pre packaged , single use chemical packs for the
application of heat or cold.
the surface activates the contents, providing a controlled temperature.
Re usable gel packs that can be cooled or heated as
needed.
The hypothermia-hyperthermia blanket, a generalized
treatment that is usually used to cool the patient to reduce a high
fever. The blanket may also be used to warm a patient in cases of
hypothermia.
Warm or cool compresses or soaks (less commonly
used).
Video:
https://www.youtube.com/watch?v=GCBTqFG2_LA

APPLYING HEAT AND COLD
Before using a heat or cold application, be sure you know the:
type of applicationarea to be treatedlength of time for the treatment
proper temperature of the application safety precautionsside
effectsspecial precautions or monitoring
Follow safety rules to prevent spills and falls.
Apply the principles of standard precautions.
Always check the temperature of the treatment with a thermometer.
Cover the application with a protective cover. Covers may be flannel
or foam. Towels and pillowcases are also used.
Assist the patient into a comfortable position that he or she can
maintain during the treatment.
Cover the patient with a bath blanket.
Expose only the part of the body that you will be
treating.
A metal cap conducts heat and cold. Face it away from the
person.
Remove or reposition metal zippers, buttons, jewelry, or other
materials that may conduct heat or cold.
Check the skin under the application every 10 minutes or more
often.
If the skin under a heat application is very red, or if a dark area
appears, stop the application and inform the nurse.
If the skin under a cold application is blue, pale, white, or bright
red, or if the person is shivering, stop the application and notify
the nurse.
Treatments are usually applied for 20 minutes. Check the care
plan or with the nurse to learn the length of time the application is
to be applied.