Postoperative care is the care you receive after a surgical procedure. The type of postoperative care you need depends on the type of surgery you have, as well as your health history. It often includes pain management and wound care. Postoperative care begins immediately after surgery. It lasts for the duration of your hospital stay and may continue after you’ve been discharged. As part of your postoperative care, your healthcare provider should teach you about the potential side effects and complications of your procedure. Before you have surgery, ask your doctor what the postoperative care will involve. This will give you time to prepare beforehand. Your doctor may revise some of their instructions after your surgery, based on how your surgery went and how well you’re recovering. Ask as many questions as possible before your surgery, and ask for updated instructions before you’re discharged from the hospital. Many hospitals provide written discharge instructions. Ask your doctor questions such as:
The answers to these questions can help you prepare ahead of time. If you expect to need help from a caregiver, arrange for it before your surgery. It’s also important to learn how to prevent, recognize, and respond to possible complications. Depending on the type of surgery you have, there are many potential complications that can arise. For example, many surgeries put patients at risk of infection, bleeding at the surgical site, and blood clots caused by inactivity. Prolonged inactivity can also cause you to lose some of your muscle strength and develop respiratory complications. Ask your doctor for more information about the potential complications of your specific procedure. After your surgery is complete, you will be moved to a recovery room. You’ll probably stay there for a couple of hours while you wake up from anesthesia. You’ll feel groggy when you wake up. Some people also feel nauseated. While you’re in the recovery room, staff will monitor your blood pressure, breathing, temperature, and pulse. They may ask you to take deep breaths to assess your lung function. They may check your surgical site for signs of bleeding or infection. They will also watch for signs of an allergic reaction. For many types of surgery, you will be placed under general anesthesia. Anesthesia can cause an allergic reaction in some people. Once you’re stable, you’ll be moved to a hospital room if you’re staying overnight, or you’ll be moved elsewhere to begin your discharge process. Outpatient surgeryOutpatient surgery is also known as same-day surgery. Unless you show signs of postoperative problems, you’ll be discharged on the same day as your procedure. You won’t need to stay overnight. Before you’re discharged, you must demonstrate that you’re able to breathe normally, drink, and urinate. You won’t be allowed to drive immediately following a surgery with anesthesia. Make sure you arrange transportation home, preferably ahead of time. You may feel groggy into the following day. Inpatient surgeryIf you have inpatient surgery, you’ll need to stay in the hospital overnight to continue receiving postoperative care. You may need to stay for several days or longer. In some cases, patients who were originally scheduled for outpatient surgery show signs of complications and need to be admitted for ongoing care. Your postoperative care will continue after you’ve been transferred out of the initial recovery room. You will probably still have an intravenous (IV) catheter in your arm, a finger device that measures oxygen levels in your blood, and a dressing on your surgical site. Depending on the type of surgery you had, you may also have a breathing apparatus, a heartbeat monitor, and a tube in your mouth, nose, or bladder. The hospital staff will continue to monitor your vital signs. They may also give you pain relievers or other medications through your IV, by injection, or orally. Depending on your condition, they may ask you to get up and walk around. You may need assistance to do this. Moving will help decrease your chances of developing blood clots. It can also help you maintain your muscle strength. You may be asked to do deep breathing exercises or forced coughing to prevent respiratory complications. Your doctor will decide when you’re ready to be discharged. Remember to ask for discharge instructions before you leave. If you know that you’ll need ongoing care at home, make preparations ahead of time. It’s very important that you follow your doctor’s instructions after you leave the hospital. Take medications as prescribed, watch out for potential complications, and keep your follow-up appointments. Don’t overdo things if you’ve been instructed to rest. On the other hand, don’t neglect physical activity if you’ve been given the go ahead to move around. Start to resume normal activities as soon as you safely can. Most of the time, it’s best to gradually return to your normal routine. In some cases, you may not be able to care for yourself for a while after your surgery. You may need a caregiver to help tend your wounds, prepare food, keep you clean, and support you while you move around. If you don’t have a family member or friend who can help, ask your doctor to recommend a professional caregiving service. Contact your doctor if you develop a fever, increased pain, or bleeding at the surgical site. Don’t hesitate to contact your doctor if you have questions or aren’t recovering as well as expected. Appropriate follow-up care can help reduce your risk of complications after surgery and support your recovery process. Ask your doctor for instructions before you have your surgery and check for updates before you leave the hospital. Contact your doctor if you suspect you’re experiencing complications or your recovery isn’t going well. With a little planning and proactive care, you can help make your recovery as smooth as possible.
The intermediate phase begins with complete recovery from anesthesia and lasts for the rest of the hospital stay. During this time, the patient recovers most basic functions and becomes self-sufficient and ready to continue convalescence at home. Transfer from the PACU/SICU to a less monitored setting usually occurs at the start of this period. Communication within the care team is important during this transition; this team can include surgeons, nurses, nutritionists, social workers and case managers, respiratory, physical and occupational therapists, residents and consulting physicians. Isolation and specialized management of patients colonized or infected with drug-resistant organisms or highly contagious infectious agents continues from the OR through stay in the PACU and then with appropriate barrier devices and room determination throughout the hospital stay.
Within hours after a wound is closed, the wound space fills with an inflammatory exudate. Epidermal cells at the edges of the wound begin to divide and migrate across the wound surface. By 48 hours after closure, deeper structures are completely sealed off from the external environment. Sterile dressings applied in the operating room provide protection during this period.
Removal of the dressing and handling of the wound during the first 24 hours should be done with aseptic technique. Medical personnel should wash their hands before and after caring for any surgical wound. Gloves should always be used when there is contact with open wounds or fresh wounds.
Dressings over closed wounds should be removed by the third or fourth postoperative day. If the wound is dry, dressings need not be reapplied; this simplifies periodic inspection. Dressings should be removed earlier if they are wet or placed in a contaminated setting, because soaked dressings increase bacterial contamination of the wound. Dressings should also be removed if the patient has new manifestations of infection (such as fever or increasing wound pain). The wound should then be inspected and the adjacent area gently compressed. Any drainage from the wound should be examined by culture and Gram-stained smear.
Vacuum dressings should usually be replaced within 24-72 hours. Pain management around the time of dressing change is important to consider, as proper prophylaxis can make the procedure less difficult for both the patient and the surgical team.
Generally, skin sutures or skin staples may be removed by the fifth postoperative day and replaced by tapes. Sutures should be left in longer (eg, for 2 weeks) for incisions that cross creases (eg, groin, popliteal area), for incisions closed under tension, for some incisions in the extremities (eg, the hand), and for incisions of any kind in debilitated patients. Sutures should be removed if suture tracts show signs of infection. If the incision is healing normally, the patient may be allowed to shower or bathe by the seventh postoperative day (and often sooner, depending on the incision).
Drains are used either to prevent or to treat an unwanted accumulation of fluid such as pus, blood, or serum. Drains are also used to evacuate air from the pleural cavity so that the lungs can re-expand. When used prophylactically, drains are usually placed in a sterile location. Strict precautions must be taken to prevent bacteria from entering the body through the drainage tract in these situations. The external portion of the drain must be handled with aseptic technique, and the drain must be removed as soon as it is no longer useful. When drains have been placed in an infected area, there is a smaller risk of retrograde infection of the peritoneal cavity, since the infected area is usually walled off. Drains should usually be brought out through a separate incision, because drains through the operative wound increase the risk of wound infection. Closed drains connected to suction devices (Jackson-Pratt or Blake drains are two examples) are preferable to open drains (such as Penrose) that predispose to wound contamination. The quantity and quality of drainage should be recorded and contamination minimized. When drains are no longer needed, they may be withdrawn entirely at one time if there has been little or no drainage or may be progressively withdrawn over a period of a few days.
Sump drains (such as Davol drains) have an airflow system that keeps the lumen of the drain open when fluid is not passing through it, and they must be attached to a continuous suction device. Sump drains are especially useful when the amount of drainage is large or when drainage is likely to plug other kinds of drains. Some sump drains have an extra lumen through which saline solution can be infused to aid in keeping the tube clear. After infection has been controlled and the discharge is no longer purulent, the large-bore catheter may be progressively replaced with smaller catheters as the cavity closes.
Drains that have clot or thick material within them or that have lost their drainage capacity can be stripped or flushed to restore function; this should be performed only under the supervision and approval of the attending surgeon as doing so could disrupt the operative bed in some circumstances.
The changes in pulmonary function observed following anesthesia and surgery are principally the result of decreased vital capacity, functional residual capacity (FRC), and pulmonary edema. Vital capacity decreases to about 40% of the preoperative level within 1-4 hours after major intra-abdominal surgery. It remains at this level for 12-14 hours, slowly increases to 60%-70% of the preoperative value by 7 days, and returns to the baseline level during the ensuing week. FRC is affected to a lesser extent. Immediately after surgery, FRC is near the preoperative level, but by 24 hours postoperatively, it has decreased to about 70% of the preoperative level. It remains depressed for several days and then gradually returns to its preoperative value by the tenth day. These changes are accentuated in patients who are obese, who smoke heavily, or who have preexisting lung disease. Elderly patients are particularly vulnerable because they have decreased compliance, increased closing volume, increased residual volume, and increased dead space, all of which enhance the risk of postoperative atelectasis. In addition, reduced forced expiratory volume in 1 second (FEV1) impairs the aged patient’s ability to clear secretions and increases the chance of infection postoperatively.
The postoperative decrease in FRC is caused by a breathing pattern consisting of shallow tidal breaths without periodic maximal inflation. Normal human respiration includes inspiration to total lung capacity several times each hour. If these maximal inflations are eliminated, alveolar collapse begins to occur within a few hours, and atelectasis with transpulmonary shunting is evident shortly thereafter. Pain is thought to be one of the main causes of shallow breathing postoperatively. Complete abolition of pain, however, does not completely restore pulmonary function. Neural reflexes, abdominal distention, obesity, and other factors that limit diaphragmatic excursion appear to be as important.
The principal means of minimizing atelectasis is deep inspiration and cough. Using an incentive spirometer can facilitate periodic hyperinflation. This is particularly useful in patients with a higher risk of pulmonary complications (eg, elderly, debilitated, or markedly obese patients). Early mobilization, encouragement to take deep breaths (especially when standing), and good coaching by the nursing staff suffice for most patients.
Postoperative pulmonary edema is caused by high hydrostatic pressures (due to left ventricular failure, fluid overload, decreased oncotic pressure, etc), increased capillary permeability, or both. Edema of the lung parenchyma narrows small bronchi and increases resistance in the pulmonary vasculature. In addition, pulmonary edema may increase the risk of pulmonary infection. Adequate management of fluids postoperatively and early treatment of cardiac failure are important preventive measures.
Systemic sepsis increases capillary permeability and can lead to pulmonary edema. In the absence of deranged cardiac function or fluid overload, the development of pulmonary edema postoperatively should be regarded as evidence of sepsis. Signs and symptoms of pulmonary complications include fever, tachypnea, tachycardia, and an alteration in mental status. Development of atrial fibrillation or an abnormal cardiac rhythm can often precede identification of pulmonary complications.
Patients who smoked tobacco up until the time of surgery should be considered at higher risk for postoperative pulmonary complications. Symptoms of withdrawal from nicotine can be managed with a nicotine patch or gum. |
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