Recovery from surgery

9 Recovery from surgery



Chapter aims




•  To ensure that the student understands the need for continuing safety of the patient


•  To increase students’ awareness of the potential for postoperative complications


•  To identify the nursing care and interventions that patients with actual and potential complications will require


•  To focus on care in the postoperative recovery stage of patients who have had major surgery requiring a hospital stay



Introduction


A patient’s recovery from surgery begins as soon as the actual surgical procedure is completed and the patient leaves the operating theatre. At this stage, the anaesthetist along with the team of nurses and other healthcare practitioners will be responsible for managing the immediate postoperative recovery of the patient. Once the anaesthetist in charge is satisfied that the patient has overcome the immediate effects of the surgery, he/she will decide whether the patient can be transferred safely back to their original ward.


In some cases, due to postoperative needs, the patient may be transferred to a high-dependency unit or intensive care unit. Under some circumstances, such as major chest surgery or prolonged anaesthesia, this will have been predicted and staff in those units will already be prepared to receive the patient.


This chapter focuses on two areas for postoperative recovery: the recovery room in the immediate postoperative period and recovery on the ward for the rest of the postoperative period until discharged home from hospital. Allvin et al (2006) cite studies about ambulatory (day care) surgery where these two areas are added to by a third one (what they call the late phase of postoperative recovery); ‘from discharge until the patients reach preoperative health and well-being’ (2006:553). We discuss this more fully in Chapter 10.



Care of the patient in the recovery room: immediately postoperative


The postoperative stage of patient care begins as soon as the patient is transferred from the theatre to the recovery area/room. These are normally purpose-built rooms set up with the right equipment and resources and staffed by experienced recovery room nurses. Gilmour (2010) cites the view of the Association of Anaesthetists of Great Britain and Ireland (AAGBI) ‘that patients must be observed on a one to one nurse:patient ratio until the patient has regained airway control, is cardiovascularly stable and can communicate’ (AAGBI 2002).


We can therefore identify that the nurse must focus on three areas of physiological monitoring in the immediate postoperative transfer period, namely airway, breathing and circulation. The handover from the theatre nurse/anaesthetist also includes detailed information about the patient, their surgery, their vital signs, any medication already given, any IVs in progress, any catheters or drains and any special instructions regarding their immediate monitoring and management (Gilmour 2010).


Depending on when you undertake this placement, most of you will have been taught some clinical skills in a safe environment such as a clinical skills laboratory at university. The main skills will initially be recording of temperature, pulse and respiration as well as blood pressure. These become vital skills in the immediate postoperative period, both manually and electronically where many patients are recorded by special monitors and equipment which you can observe.



image Activity


Discuss with your mentor your responsibilities in the immediate care of patients in the recovery room. This is an ideal opportunity to develop not only your clinical skills but also your communication skills in a different environment. Patients are very vulnerable at this time and many will wake up worried about what has happened during surgery. Make sure you focus on learning how to communicate with patients using various senses and also communicate any concerns the patient may experience with your mentor or a qualified member of the recovery team.


Read an up-to-date evidence-based book on clinical skills and postoperative care of the patient and aim to make maximum use of materials for students in the learning environment (see Further Reading list).



Observations in the immediate postoperative period


Amos and Waugh (2007) refer to the priorities of the immediate postoperative recovery as defined by the Scottish Intercollegiate Guidelines Network (2004) as airway, breathing and circulation (see http://www.sign.ac.uk/pdf/sign77.pdf (accessed May 2011)).



Airway


The patient’s airway must be kept clear at all times, and initially they may have an airway (Guedal) in place (in situ) to help keep the airway patent and to enable adequate ventilation and breathing.


It is important to ensure that the patient’s position is not hampering the airway and, unless contraindicated such as in a total hip replacement where rolling onto their side is not an option, the patient can be nursed in the recovery position – on their side or supine, depending on instructions from the surgical team.


Oxygen is given immediately either with a mask or nasal cannulae, ‘normally at 40%. Contraindications include chronic obstructive airways disease or when a prescribed percentage of oxygen is required. A pulse oximeter is attached to monitor oxygen levels’ (Gilmour 2010:28).



Breathing


It is important to check that the patient’s breathing is even and not noisy, which could indicate a possible obstruction, but take into account that ‘complete obstruction is characterised by silence’ (Gilmour 2010:29). It is important to check the skin colour, especially the lips and nail beds, which may indicate cyanosis. (Link this back to preoperative preparation where make up and nail varnish have to be removed – see Ch. 6.)


As well as checking for any airway/breathing obstruction and slow breathing, breathing may also become rapid and the patient might be gasping for breath. Any sudden change you observe must be reported immediately to the qualified nurse responsible for the patient and/or the anaesthetist in order that immediate remedial action can take place.



Circulation


Monitoring of the pulse and blood pressure is an essential observation and some patients will have electronic monitoring of their observations to aid you in maintaining patient safety postoperatively.


As the patient is likely to have wounds and drains, it is important that these are also checked as per instructions, obviously not disturbing any wound dressings while doing so. A dressing saturated with blood requiring additional dressings and packing is an indication that the patient may be haemorrhaging – this will be accompanied by a raised rapid pulse rate and a sudden drop in blood pressure.


If a patient has had a below-the-knee amputation, for example, the surface of the dressing may seem as if there is no increased blood loss despite physical signs of raised rapid pulse rate and dropping blood pressure. If the patient is supine, it is important to also check beneath the leg as blood may be pooling underneath, soaking the sheets rather than the dressing. This is an example from our own experience in nursing practice, with the result that the patient had to be immediately taken back to the operating theatre as a blood vessel required diathermy.


The anaesthetist will have written in the patient’s notes the exact postoperative care required with regards to observations and medications, and the medication (prescription) sheet will detail specific postoperative analgesia. Managing a patient’s pain is a major aspect of postoperative care, as pain can not only cause the patient some distress but also impact on postoperative physiological responses.



Pain management in the immediate recovery period


Pain is an unavoidable side effect following surgery, but how people cope with this will differ according to gender, age, psychological and cultural factors together with individual coping mechanism (Hughes 2004). The management of pain will already have been discussed with the patient preoperatively unless, of course, the patient was admitted as an emergency, when pain relief will already have commenced.


In the immediate postoperative period in the recovery room, the patient may not easily be able to articulate their pain levels, due to being drowsy or a fear of moving. Other non-verbal cues may be indicative of the need for pain relief, such as restlessness. A study by Heikkinen et al (2005) found that assessment of pain for prostatectomy patients in the recovery room was possible using pain assessment tools even though the patient may be sedated, but that there was inconclusive evidence as to which was best. They maintained that the key issue was ‘the pain is assessed systematically and that both nurse and patient understand the meaning of the assessment’ (2005:598).



image Activity


Discuss with your mentor whether they use a pain assessment tool in the recovery room and, if yes, agree to use this with a patient under supervision. If a pain tool is not used, discuss why not and how the nurses know if a patient is in pain.


You may choose to consider evaluating pain assessment and management in the immediate postoperative period as a topic for an evidence-based practice assignment or as a presentation to your peers.


Analgesia can be administered via a number of different routes and techniques (Gilmour 2010, Amos & Waugh 2007). These are:



•  intramuscular injection


•  intravenous bolus


•  intravenous patient-controlled analgesia (PCA)


•  epidural


•  rectally


•  orally


•  subcutaneously.


When caring for a patient either pre- or postoperatively, it is important that you familiarise yourself with all of these in order to ensure effective communication and discussion with the patient as well as ensuring evidence-based nursing care delivery. Knowing how each of these work in controlling pain should also be supported by knowing the physiological effects.



image Activity


Read about the physiology of pain and make notes about the impact of surgery on the body’s normal response to pain.


Determine which route for analgesia would be appropriate for a range of surgical situations.


Read Allen D (2005:133–148) (see References) to help you with this activity.


If the surgery is major, it is likely that the route of administration will be the intravenous PCA, given that this avoids use of injections and, importantly, the patient feels in control of their own pain management. The effectiveness of any pain management should be evident when the patient can move more easily and not be afraid to move, as well as being less anxious. In addition, there may be a change in the patient’s observations, for example the pulse rate might have been raised and rapid before being given pain relief due to the effect of the pain stressor on the body, and this will stabilise.


Regardless of the extent of the surgical intervention, the patient will experience some degree of pain. It is important at this stage to remember that some patients may not be able to articulate that they are in pain and that physiological signs and symptoms will be the first identification. Continual observation and reassurance by the nurse is essential to the patient’s wellbeing. We return to this topic again when the patient has been returned to the ward area.



Managing postoperative nausea and vomiting (PONV)


Following surgery, this remains a common complication (Gibson 2006) and is very distressing for the patient. It may add to any postoperative pain they have due to the ‘retching’ movements during vomiting and the heart rate and blood pressure may be increased (DeLeskey 2009). Anaesthetics used during surgery contribute to this postoperative problem but it can also be a side effect of strong analgesics used postoperatively such as those with an opioid base.



Monitoring the patient for other potential immediate postoperative complications


Two other main potential complications can occur in the immediate recovery period: hypothermia and wound haemorrhage (see above for one possible example affecting the circulatory system).


Wicker and Cox (2010:390) identify three possible causes of hypothermia postoperatively, namely ‘vasodilation or vasoconstriction, a recognised complication following surgery and a large infusion of blood and fluids’. Postoperatively, the patient must be kept warm and they advise that a ‘space blanket’ should be applied and that ‘the room environment should be kept at a warm temperature, above 21 degrees C’ (2010:387). However, patients must not be heated up too quickly either.


Wound haemorrhage can occur in the immediate postoperative recovery period through ‘inadequate wound closure, leaking vascular anastomosis and inadequate homeostasis’ (Wicker & Cox 2010:390) and you need to be careful to observe any wounds for signs of these. Inform your mentor immediately if you notice any signs of haemorrhage at the wound site or other indications (as discussed above) for tachycardia and hypotension.


Patients must be physiologically stable before they leave the recovery room and they must be awake and have normal airway reflexes (Wicker & Cox 2010) (see Box 9.1).



Box 9.1 Discharge from post-anaesthetic recovery




image  The patient is fully conscious and can respond to voice or light touch, is able to maintain a clear airway and has a normal cough reflex.


image  Respiration and oxygen saturation are satisfactory (10–20 breaths per minute and SpO2 is > 92%).


image  The cardiovascular system is stable with no unexplained cardiac irregularity or persistent bleeding. The patient’s pulse and blood pressure should approximate to normal preoperative values or should be at a value commensurate with the planned postoperative care.


image  Pain and emesis should be controlled and suitable analgesic and antiemetic regimens prescribed


image  Temperature should be within acceptable limits (> 36°C).


image  Oxygen and fluid therapy should be prescribed as required.


Prior to discharge, the recovery staff should record in the notes that patients have met these criteria. If a patient does not meet these criteria, they should be assessed by the anaesthetist responsible either for the procedure or post-anaesthetic recovery with a view to upgrade to level 2 or 3 care (see full document for further details).


(From Scottish Intercollegiate Guidelines Network 2002:3)



Discharge from the post-operative recovery room


The length of time spent in this area will depend on issues such as type of anaesthesia, type of surgery, length of surgery and the postoperative recovery of the patient. The anaesthetist will make that decision based on the recovery nurse’s assessment and observations (Smith & Hardy 2007). The ward nurse will receive the handover of the patient from the recovery nurse with a complete report of the surgery, the postoperative care instructions, the current condition of the patient and any medication he/she has been given. Explanations of what is going on will be given to the patient at this time, and many patients will recognise the nurse who has come for them from the ward, especially if it is their named nurse. This is an ideal opportunity for you to undertake a patient transfer back to the ward with your mentor or another member of the ward team.



Care of the patient postoperatively: back on the ward


Once a patient has left the ward for the operating theatre, the bed area is prepared for their return. If the patient’s bed has been taken to the recovery room, then he/she will be returning on that bed. The nurse collecting the patient from theatre must take with them a vomit bowl, a pair of gloves (universal precautions), a Guedal airway and a hand-held ventilation Ambu bag (or similar).


Preparation of the bed area in the ward includes checking the oxygen supply (and making sure there is an oxygen mask and proper tubing); checking the suction system/machine and its proper tubing; making sure there is equipment to take blood pressure; and, if necessary, a pulse oximeter to measure oxygen saturation levels. An IV stand may be required if a patient has undergone major surgery as they are most likely to return from the operating theatre with intravenous fluids.



image Tip


For details about this and a wide range of other excellent perioperative care resources, access the CETL website at City University London:



http://www.cetl.org.uk/learning/tutorials.html (accessed May 2011).


and this linked online resource:



http://www.cetl.org.uk/learning/perioperative-care/player.html (accessed May 2011).


This site has information sheets and video/audio material on all stages of the perioperative care journey and quizzes and tests to check out your learning.


On return to the ward, the nurse takes immediate postoperative observations. Charts are used to record details of temperature, pulse and respiration, fluid balance and, depending on the nature of the surgery, other charts as appropriate.


In patients who have been admitted for day care surgery, the same observations are undertaken on the patient’s return, but there will usually not be intravenous fluids to consider as patients having this kind of surgery don’t require them.


All observations are recorded on the charts and in the nursing care documentation.



General principles of care in the first 24 hours postoperatively


According to Endacott et al (2009), there are key care steps in the first 24 hours postoperatively and these can be used to help focus on the priorities for the ward nurse on the patient’s return from theatre. We return to these in Section 3 where we introduce you to three patients and their perioperative journeys along with learning opportunities that you can pursue in their care.



Steps for postoperative care in the first 24 hours (adapted from Endacott et al 2009)




Step 1: safe transfer and communication

This involves safe transfer of the patient from the recovery room staff to ward staff and return to the ward. Essential information has to be handed over at this time (see above). This is important in order to ensure there is effective communication between care areas but it is also important for patients to know they are going back to the ward and that the surgery is very much over.



Step 2: vital signs and consciousness

Before leaving the operating theatre, all vital signs related to airway, breathing and circulation will have been checked, and these are also checked during transfer and on immediate return to the ward. Consciousness levels are checked as well.



Step 3: early warning score systems

Many of these observations are also included in the early warning score systems (Johnstone et al 2007) which are designed as triggers to indicate a deterioration in a patient’s condition. Johnstone et al (2007:221) state that:



As a result of the reduction in the number of acute beds within the NHS trusts, medical and surgical wards are now tending to have a higher number of sicker and more dependent patients … These patients are at greater risk of having a period of critical illness within these general wards and there is a growing recognition that several indicators of acute deterioration are being missed by nurses and doctors.


There are short courses and longer modules that give training in use of these early warning score systems, and Preston and Flynn (2010) identified some key points in their review of the evidence of the effectiveness and use of these tools (see Box 9.2).



Box 9.2 Review of the evidence: observations in acute care – an evidence-based approach to patient safety




  1.  Doing observations in acute care is crucial for detecting early signs of deterioration.


  2.  Nurses need a sound knowledge of physiological compensatory mechanisms to facilitate accurate detection of changes in temperature, pulse and respiration, blood pressure, blood glucose levels, neurological function and blood oxygen saturation levels.


  3.  Recording the respiratory rate is a sensitive indicator of clinical deterioration.


  4.  Early warning systems, including the Glasgow Coma Scale, are tools to aid identification of patients at risk of adverse clinical situations (cardiac arrest, raised intracranial pressure, sepsis).


  5.  ALERT (Acute Life-threatening Events – Recognition and Treatment) courses and simulation exercises conducted in a safe environment and development of critical thinking skills that underpin appropriate recognition and reporting of clinical deterioration.


  6.  Observations should be assessed by a qualified nurse if detection of patient deterioration is to be consistent in acute care.


(From Preston & Flynn (2010:442–447))



image Activity


Determine how many different tools are available in your placement which give an indication of a change in the postoperative status of patients in that area.


Set a learning goal during your placement that you will observe the use of the main early warning score system, and make a contribution to assessing the status of a patient by completing this under the supervision of your mentor.



Step 4: other observations

Endacott et al (2009) recommend checking pulse rate and blood pressure every 15 minutes for the first hour, then every 30 minutes for 2 hours. After that, the observation rate can be increased or reduced according to the patient’s condition. At the same time, the skin should be observed for paleness, sweating and peripheral vasoconstriction (cold extremities). Patients who have had surgery will have surgical incisions (wounds) that will need to be observed for blood loss, and sometimes they will leave the recovery room with their external dressing marked for where the blood had been oozing through (this is undertaken carefully so as not to harm the patient). This line around the ‘blood mark’ can then be watched for any increase in size over the first 24 hours. Many surgical procedures, however, do not have large wounds so there is minimal dressing applied and minimal bleeding.



Step 5: major complications

One of the major complications to occur postoperatively is postoperative shock. Gibson (2006:921) makes the following observation with regards to this and its cause:



When the patient returns from theatre to the ward, they require frequent observations for signs of impending shock or haemorrhage. As blood pressure continues to rise, there is a continued risk of reactionary haemorrhage for the first 24 hours. Hypovolaemic shock may also occur due to a slow, continuous loss of fluid; this might be a slowly bleeding vessel or the pooling of fluid in the gastrointestinal tract during the paralytic ileus that occurs as a consequence of surgery. The loss of fluid may be detected as soakage on the dressing or blood in the wound drains, but if the patient is bleeding into a body cavity or losing fluid into the gut it may be less obvious. Distinction should also be made between hypovolaemic shock and other forms of shock, i.e. cardiogenic, septic, anaphylactic and neurogenic.


Undertaking nursing observations as prescribed in this first 24-hour period is therefore vital to detect shock and haemorrhage (see Gibson & Magowan 2011).



image Activity


Find out what cardiogenic, septic, anaphylactic and neurogenic shock are. Further discussion on these is found later in this book and in the case studies in Section 3.


Patients returning after major surgery may be prescribed intravenous fluids, and sometimes a blood transfusion may be in progress. If the latter, then it is essential to undertake appropriate observations to ensure any adverse reactions to the blood are noted. Transfusion reactions can vary from a mild to a severe life-threatening situation. Symptoms range from a mild fever and pruritus to rigors, tachycardia and respiratory distress – shortness of breath due to anaphylaxis (Oldham et al 2009).



image Activity


Find out the potential problems associated with a blood transfusion and visit the hospital blood bank to find out the correct procedure for checking out blood for patients. Discuss the procedure with your mentor and ask if you can participate in this activity.


The articles by Gray et al (2008) and Oldham et al (2009) will help you understand the evidence base to changes in blood transfusion practice.


The tutorial on this CETL website is an excellent resource as well:



http://www.cetl.org.uk/learning/blood-transfusion/player.html (accessed December 2011).


Fluid intake and output are also monitored. For many patients, it is difficult to pass urine in the immediate stage postoperatively, not least because many are frightened to move if they have a wound which causes them pain on movement. For some, this problem does not last very long and they will manage to pass urine. If they still haven’t passed urine 4–6 hours postoperatively (but their observations regarding circulation and breathing have been satisfactory during this time), this must be reported to the medical staff. If patients have a catheter in situ then it is easier to see if they are passing urine and, most importantly, how much per hour. If the output is less than 4 ml/kg of body weight per hour, this also needs to be reported. It is essential that the function of the kidneys is maintained postoperatively.


Drainage from any wound also needs to be observed as does any fluid loss from a nasogastric tube. If excessive, this needs to be reported as well.



Step 6: pain

Levels of postoperative pain depend on the nature of the surgery and, of course, the individual patient. Whatever the type of surgery, pain levels need to be assessed and recorded and medication given. Pain assessment tools can be useful such as the ‘faces’ scale or a numerical one to rate the level of pain between 0 and 10 where 0 = no pain and 10 = worst pain imaginable (Bell & Duffy 2009).


For patients who have had major surgery, a PCA system may be prescribed and inserted in the operating theatre/recovery room and the patient may already have been made aware of having this in the preoperative phase.


Bell and Duffy (2009:156), however, in their review on the issue of pain assessment and management in surgical nursing found that ‘despite all the research carried out on pain assessment and management, very little has changed in practice’. They conclude that there appears to be two significant barriers to effective practice (although cautioned that it was a multidisciplinary issue to solve), namely ‘the beliefs and attitudes of both patients and nurses towards pain management and nurses’ time management’.



image Activity


Read Bell and Duffy (2009) (see References) and decide if this is a good literature review or not and whether your experience in a surgical placement of any kind can be related to their findings. Discuss with your mentor and share with others in the placement your evidence base for pain assessment and management. This is a valuable topic to explore as pain management extends beyond the boundaries of surgery and the principles of care can be applied to other contexts.

Only gold members can continue reading. Log In or Register to continue

Related posts:

  1. Case study 1: caring for a patient in a day care unit
  2. Case study 2: caring for a patient in a general surgical ward
  3. Preparation for and undergoing an anaesthetic prior to surgery
  4. Undergoing surgery: the operating theatre experience

Stay updated, free articles. Join our Telegram channel
Tags:
Mar 18, 2017 | Posted by in NURSING | Comments Off on Recovery from surgery

Full access? Get Clinical Tree
Get Clinical Tree app for offline access