TAKING CARE OF THE PRE-OPERATIVE AND POST- OPERATIVE CLIENT INTRODUCTION Taking care of a client who is going to have surgery or who recently had surgery can be two of the most important responsibilities you will have as a Certified Nursing Assistant (CNA). Even for relatively young and healthy individuals, surgery is a psychologically and physically stressful experience and the stress does not end after the operation is completed. Surgery may be a cure for an illness, but being cured is not the end of the story. In the hours and days after a surgical procedure, clients are often in pain and they often feel weak, nauseous, etc. There are also many possible complications that can happen after surgery. These can delay the client s recovery and they can be dangerous. If the client is elderly or has many medical problems, both the operation and the post-operative period can be risky. Surgery, unless it is a very minor procedure, is serious. OBJECTIVES When the student has finished this module, he/she will be able to: 1. Correctly identify three important pre-operative tasks. 2. Identify the first source of information for a client about his/her surgery. 3. Identify what the initials NPO indicate. 4. Identify the healthcare professionals who can witness a surgical consent form. 5. Identify three post-operative exercises that help prevent post-operative complications. 6. Correctly identify a method used to help clients perform post-operative exercises. 7. Identify the preferred methods for removing body hair before an operation. 8. Correctly identify four sources of post-operative infections. 9. Identify three common post-operative problems. 10. Identify three post-operative emergencies TAKING CARE OF THE CLIENT BEFORE SURGERY The period of time before a surgical procedure is called the pre-operative period. The time after surgery is called the post-operative period. The clients must be prepared for both because surgery and the hours and days after surgery can be very stressful. Good preparation before an operation will make the post-operative period more comfortable for the client and it will go a long way towards preventing the complications that can happen after surgery. Preparing a client for surgery in the pre-operative period should focus on these areas: pre-operative tasks and education, and psychological preparation and support.
PREOPERATIVE TASKS AND EDUCATION The client must be prepared for surgery and there are a variety of things that need to be accomplished in the areas of pre-operative tasks and education. Pre-Operative Tasks Before the client can go to surgery, a surgical consent form must be signed. The consent form states that the operation and the possible consequences of the operation have been explained to the client and that he/she understands that information. The physician or a nurse will witness the client sign the consent, and document that they witnessed the client sign. Do not act as a witness to a client signing the consent. That responsibility belongs to the physician or a nurse. The pre-operative checklist must also be completed. The pre-operative checklist is a list outlining everything that must be done before the client can go to surgery. Some of the items on the list are standard: the client must have an identifying bracelet, it must be documented that the client has been NPO, vital signs must be obtained and recorded. Other items are ordered by the physician for that particular case: an IV line must be in place, the area that will be operated on should have been prepared, a urinary catheter should be in place, an enema should have been administered, etc. Skin preparation may be required depending on what type of surgery is being performed. Skin preparation involves cleaning the area and removing hair from the area that will be cut during surgery. Cleaning the surgical area is done so that the incision will not become infected, and hair is removed because it can interfere with procedure, hair harbors bacteria, and the bacteria cannot be removed. The surgeon will write orders that will specify what part of the body is to be cleaned, how it should be cleaned, and when and where it should be done. Do not clean any other area and only clean it using the method(s) that have been ordered. Learning Break: Removing body hair and removing it by shaving was once standard procedure. Now, for many procedures body hair is not removed. If it is removed, clippers or a depilatory cream are the preferred methods. Shaving can damage the skin and increase the chances that an infection will develop. Education Pre-operative education prepares the client for all parts of the experience of surgery. The most important areas to cover are the a) surgical procedure, b) the operative day, c) the post-operative period, and d) post-operative exercises The surgical procedure: The client should know what type of operation is being performed and why it is being done. The first person to give this information and the primary source for this information should be the surgeon. However, you should know what type of surgery is being done and why so you can provide the clients with some basic information if he/she has questions. Ask your immediate supervisor what is permissible for you to discuss with the clients. If
clients ask you about the operation and it seems as if they need more education or have questions you cannot/should not answer, tell your immediate supervisor; he/she will notify the surgeon. Do not discuss details such as the risks of the procedure, how the procedure is done, how long before the client will go home, etc. Operative day: The client should be educated about what will happen the day of the surgery. Check the chart to see what has been ordered. Typically, the client will not be allowed to eat or drink anything, and many times the client will not be allowed to eat or drink anything after midnight. This should be noted in several places such as in the client s chart, a sign at the head of the bed, etc., with the initials NPO. NPO means nothing by mouth: no food, no water, nothing. An IV line will often be inserted and the client may be given some medication that will prepare them for the operation: these medications frequently cause drowsiness and may even put the client to sleep. Post-operative period: The client also should be informed about what to expect during the post-operative period. Check the chart to see what has been ordered.. Each case is different, but it is very common for clients to feel drowsy, nauseated, and in pain after the operation. Clients will want to know how long the drowsiness, pain, etc. will last. They will want to know when they can get out of bed, when they can have food and water, how long they will be in the hospital, and when they can go home. They may ask you if the operation was successful. After speaking with your supervisor and checking the post-operative orders on the chart, you can give the client some basic information. However, use common sense. Do not offer any information beyond what is specified in the post-operative orders or what your supervisor has approved. The post-operative exercises are intended to prevent post-operative complications. They include turning, coughing, and deep breathing. Turning: Clients will benefit from being turned from side to side every two hours after surgery. Turning from side to side prevents skin damage, increases circulation, and prevents secretions from pooling in the lungs and causing an infection. Moving after an operation can be painful, so take your time and don t rush the client. Coughing: In many cases, clients are lying completely immobile during surgery, and they have been on bedrest before the operation. Because the client has not been moving for a long time, secretions can pool in the lungs and cause an infection. Coughing exercises are a very effective way to prevent these lung infections. Coughing will help expand the lungs and bring up secretions, and they are very simple to teach and to do. Instruct the client to take a deep breath, hold the breath for a second or two, and then give a forceful cough. Repeat the procedure. Let the client know that he/she will be asked to do coughing after the surgery and explain why the exercise is important.
Deep breathing: Deep breathing can be performed by itself but it is usually done along with the coughing exercise, and like coughing it expands the lungs and prevents lung infections. Instruct the client to take a very deep breath, hold the breath for a second or two and then exhale. Again you will want to tell the client that he/she will probably be asked to do deep breathing exercises after surgery and explain why the exercise is important. Learning Break: A strong, forceful cough and deep breathing may be painful if the client had abdominal or chest surgery. Splinting can help. Simply place a folded towel or a firm pillow over the chest or abdomen and when the client coughs/deep breaths, push down firmly. This will stabilize the area, help prevent pain, and allow the client to perform the exercises. Most often clients are instructed to perform 10 coughs and 10 deep breaths every two hours. Check the chart; the surgeon will write an order specifying how he/she wants the exercises to be done. A spirometer can also be used for deep breathing. A spirometer is a plastic tube and an attached hose with a mouthpiece at its end and a plastic ball inside the spirometer. The client takes deep breath and then exhales into the spirometer. As the client exhales, the plastic ball will move up the spirometer so you can actually measure how deeply the client is breathing. PSYCHOLOGICAL PREPARATION AND SUPPORT Surgery is a stressful experience and it can be frightening. The client is often having surgery because he/she has a serious illness. Surgery involves risks, complications, and pain and discomfort before and after the operation. There is the possibility that the client s life will be drastically changed. So, psychological preparation and support are important in the pre-operative period. It is impossible to make a general statement about the best way to psychologically prepare someone for surgery and how to provide that person support. However, there are several things to consider: What does the client want to know? Some clients will want a lot of detailed information about the operation, the pre-operative period, the recovery period, and what life will be like after the surgery. Some clients want to know very little, and they feel most comfortable when all the decisions are made for them. There is no right or wrong way: the client must the decision. What does the client need to know? It is up to each person to decide how much they know about their surgery. However, even for people who prefer to know almost nothing, they should be informed about what type of surgery they are having, when it is being done, and why. Remember, the surgeon is the first source of these facts, but if the surgeon has told the client this information, you are allowed to repeat it to the client as needed.
What are the client s fears? Fear is a normal feeling associated with surgery. Clients should be allowed to talk about their fears to the extent that they want to. The best approach is simply to let the client know that there are people who will listen and can provide support if they want to talk. After that, the client can decide who he/she wants to confide in and what they want to express. TAKING CARE OF THE CLIENT AFTER SURGERY Post-operative care is just as important as pre-operative care. The client has just been through a very stressful experience, serious complications are possible, and pain, vomiting, and discomfort are common. Knowing what to look for and what to do for a post-operative client is crucial. Focus on these areas. Vital signs: The surgeon will write an order that specifies how often to check vitals signs; checking the pulse and blood pressure every 15 minutes in the first hour after the operation is not unusual. Always to let someone know about a fever or an abnormal pulse or blood pressure, but it is especially important when caring for a post-operative client. Watching for infection: Infections are always possible after surgery, and you must watch the client closely for signs and symptoms of an infection. The client has been immobile so secretions in the lungs begin to pool, the bladder is not emptied and bacteria can grow in the urine, and blood stagnates and may become infected in the extremities. Also, when intact skin is disrupted an infection can happen, so the surgical incision can become infected. Help prevent infection by using the coughing and deep breathing exercises. Watch for signs of infection such as a fever, rapid pulse, rapid respirations, or a high or low blood pressure. You should also make sure the clients passes urine some time soon after the surgery (notify the nurse or your supervisor if they don t) and look for redness, swelling, or pus at the incision. Learning Break: The lungs, the surgical incision, the bladder, and the lower legs are the common places infections occur after surgery. The four Ws is a easy way to remember this: Wind, Wound, Water, and Walk. Surgical dressing: A surgical dressing is a sterile cover applied over the incision (Incision is the technical term for the cut the surgeon makes in the skin). The dressing can be a small bandage, but it may be a large, complicated affair with gauze pads, tape, etc. The surgeon will write orders that specify how to care for the dressing. It is very important to follow these orders exactly: Do not change or adjust the dressing in any way that has not been ordered. Check the dressing frequently to make sure it is intact, and that here is no bleeding or unusual drainage.
Pain: Clients who are in pain do not recover from surgery as well. Also, modern pain medications are very effective so there is no need for someone to suffer. Some clients will tell you about their pain, some will not. Look for non-verbal cues that the client is having pain. A rapid pulse and a high blood pressure are also signs that the client may have pain. Bleeding: Some bleeding is expected after surgery. The skin has been cut and tissue has been removed. Watch the client closely for signs of serious bleeding. Check the dressing, monitor the vitals signs, assess skin color and temperature, etc. Nausea and Vomiting: Clients often have some nausea and vomiting after surgery. Learning Break: Pain, bleeding, and nausea and vomiting are the most common postoperative problems. POST-OPERATIVE EMERGENCIES The following situations that can occur in the post-operative period are emergencies or may indicate something is seriously wrong. If any of them occur, notify someone immediately. Dehisence: When a surgical incision splits open, that is called dehisence and it is an emergency. Prolonged vomiting. Bleeding at the surgical incision. Severe pain. Urinary retention. Abnormal changes in the client s vital signs or mental status.