During the period immediately following completion of the operation the patient requires close observation and care. Recovery from general anesthesia is not complete for several hours.
The patient is usually unconscious when first returned from the operating room, and the return to full consciousness is very gradual. Obviously the patient cannot take care of himself.
Many hospitals are now equipped with a recovery ward, or post-anesthesia ward, where the patient recovering from an anesthestic can be cared for. Here are maintained all the specialized equipment and the personnel especially qualified for care of the patient during this period. In other hospitals the patient is taken back to his own room and the necessary equipment brought in. An advantage of the former system is that less equipment and personnel are required, for all the responding patients are grouped together. When the patient in the recovery ward has regained consciousness, he is transferred to his own hospital room.
In either case the transport from the operating suite back to bed is made by hospital cart, just as in the transport to the operating corridors, and the anesthetist usually accompanies the patient. Meanwhile the room has been made ready. The room has been cleaned; unnecessary equipment removed; special equipment and oxygen brought in, and the bed prepared.
As soon as the operation is completed, the surgeon writes a new set of orders for the patient’s care. These are as complete as the initial admission orders and cover all aspects of the postoperative management of the patient. These are delivered to the nurse in charge of the patient as soon as possible, and she immediately begins to carry them out. During the immediate postoperative period the nurse keeps a detailed account of everything that transpires. This may be important information later and is a permanent part of the patient’s record.
The position in bed is prescribed by the surgeon on the basis of the physical state of the patient, the anesthetic, and the operation. Often it is advantageous to have the head or the foot of the bed elevated, or the patient lying on the abdomen rather than the usual position with face up, or in a semi-sitting position. Usually side rails are placed on the bed to prevent the patient from falling off the bed, and frequently restraining straps are required to keep him from injuring himself or disturbing the equipment. Care is taken to avoid chilling by covering with adequate blankets, and yet excessive perspiration is also to be avoided.
A close watch over the general condition is maintained. Recordings of the blood pressure and the respiratory and pulse rates are taken regularly. While the patient is still unconscious, an adequate air passageway to the lungs must be assured. For this reason the anesthetist may leave in place an anesthetic airway (usually the oropharyngeal type) for a short period while the patient is reacting from the anesthesia. Correct neck posture is kept. Occasionally excessive secretions are suctioned from the throat. If nausea develops as the patient awakens, aid is given by the attendant.
Oxygen may be given during this recovery period as a supportive measure. It hastens the exhalation of the anesthetic gases, thereby speeding the recovery from the anesthesia. Oxygen facilitates all the body’s processes and actually decreases the amount of work within the functioning tissues. The patient is allowed to rest more easily. Oxygen is commonly used during this period of surgery. Drugs may be given during this time as ordered by the surgeon, usually by injection since swallowing may still be impaired. Medication for pain, stimulants, sedatives, or any of a host of others may be indicated. Often infusions into the veins have to be given during this time, and not infrequently the patient is brought from the operating room with an infusion or transfusion already running. Other special devices and apparatus may require attention. Any tubes or catheters are connected to drainage bottles or vacuum machines as specified by the surgeon. Sometimes traction on an extremity must be attached. All such orders are carried out in the manner and time the surgeon has designated in the postoperative orders.
Visiting during the immediate postoperative period necessarily is restricted. A brief visit with the nearest of kin may be allowed, but often it is not advisable even during the usual visiting periods. Friends and relatives naturally become anxious, but they should not conclude that the condition of the patient is critical because they are not allowed to see him. Often it is not feasible to have visitors around and still render all the usual care. Usually rest is all-important to the patient and excitement caused by well- meaning visitors is to be avoided. And most surgeons make special effort to advise the family of the patient’s condition as soon as possible after surgery. Visitors must try not to be impatient, but co-operate with the hospital personnel with every effort. Visitors may not be allowed for several hours, but, on the other hand, congenial and understanding visitors are often a great adjunct to the care of a patient. A few words with a loved one in the immediate postoperative period may be very encouraging and reassuring to the patient, even though he has not fully reacted from the anesthetic. Willing relatives may also be a great asset to the nursing staff by sitting with the semi-conscious patient to see that he does not inadvertently disrupt some attached equipment, such as an intravenous infusion, or just to see that he rests comfortably. In such cases the visitor must be calm and follow directions specifically. It is not necessary for such visitors to volunteer their services, for the nurses assume such willingness to help when necessary.
Most of the time for a few hours after operation is spent sleeping. Pain and discomfort arc alleviated by medication and nursing care, and the patient feels very tired. He may sleep for hours. This period may also be accompanied by temporary amnesia (loss of memory) of many of the events that take place during this period. Some euphoria, or a feeling of extreme well-being and happiness, may also be apparent. Many patients enjoy the sensations of “coming out of anesthesia,” just as many do in the induction stage. Contrary to popular belief, talking uninhibitedly to reveal one’s secrets while responding from the anesthesia is not a common occurrence.
Later Postoperative Care
After recovery from the anesthetic and throughout convalescence everything is directed toward meeting optimal conditions for recovery, keeping the patient comfortable, and guarding against complications. To these ends, almost everything is obvious, or “second nature” to the hospital personnel; and yet, each case is different. To generalize regarding all postoperative patients is somewhat hazardous. Each patient requires individual evaluation and care.
Evaluation of the Patient
It has already been mentioned that the diagnostic phase of the therapy plan never ends. This is especially true of the postoperative period. A constant evaluation of the progress of the surgical illness must be maintained, and a continued lookout for concurrent disease and complications is vitally important. A search for new symptoms is continually made. Physical examination or certain parts of it may be repeated many times. Close watch is made of temperature, pulse, and respiratory rate. Laboratory tests and special studies may be ordered. Still, such investigation and evaluation are thoroughly planned and rationalized. Unnecessary expensive tests are not performed. The surgeon orders only those special tests which will afford him useful information in the evaluation of any new symptoms or physical findings. Again, of course, each event is registered in the patient’s chart.
Mention must again be made of the patient’s mental attitude. It is only logical to assume that the person in the correct frame of mind will be more co-operative and help more in his own behalf than one whose attitude about himself is passive or pugnacious. But such a disposition is not always easy to maintain during this period, for, no matter how calm and well poised in daily life, the surgical patient is a stranger in a most unfamiliar environment. His security and confidence in the outcome of treatment is too often placed in jeopardy by his own quick conclusions about events around him. Many things may happen which are a daily routine to the hospital staff, but for which the patient can see no apparent reason. Explanation for everything is not feasible, and it is so easy for the patient who is uncomfortable and bitter about his own misfortunes to draw irrational and even paranoid conclusions. Often it is difficult to remember that the hospital personnel are directing their attentions to the one goal of getting the patient back to normal health. To maintain the proper attitude takes great effort during this period. Needless to say, a sense of humor respectfully employed and properly limited is a great asset.
The first day after operation the surgical patient may feel perfectly normal except for pain at the operative site. This can be well controlled by the use of drugs which obtund the pain sensations. The surgeon chooses the drug and dosage best suited for each individual case and leaves specific written instructions for its administration. Often the frequency with which the drug may be used is left to the discretion of the medication nurse, provided that a certain frequency is not exceeded. The surgeon wants the patient to be as comfortable as possible, but naturally the use of such drugs must be restricted. Patients should be prompt in notifying the nurse when the pain begins to become unbearable, but the symptom of pain should not be exaggerated. Such drugs are given orally or by injection, and occasionally by other routes.
Many other medications may be employed in the postoperative period. Some of the commoner ones are those to combat infection, those that aid in the healing processes, those used for concurrent and complicating diseases, and sedatives. Frequently infusions are needed during this period. Use of the sedative drugs adds greatly to the patient’s comfort and assures adequate rest. The various drugs and combinations of drugs the surgeon may order in the postoperative period are numerous.
Not infrequently, the position the patient assumes in bed after operation should be specific. This may be to avoid certain complicating occurrences and to relieve strain on the operated tissues. Tension at the operative site is usually of no consequence as far as disrupting the wound or hindering healing is concerned since the operational repair is always made strong enough to allow for such, but it does add greatly to postoperative discomfort. Other positions may be indicated to avoid such things as stagnation of blood in the vessels of an extremity, or the disuse of a portion of the lungs so that secretions collect, or areas of pressure on the skin. In most instances the position is so arranged by adjustments of the bed to the proper levels and angles. Hospital beds are so designed that the attendants can easily make such adjustments. The most common position, of course, is simply with the bed flat.
Once the bed is properly adjusted, it is desirable for the patient to move around in bed to the most comfortable posture, and not assume one pose for too long a time. Movement in bed aids the flow of blood and the use of the full breathing system, as well as relieving pressure on certain areas. Such movement in bed seems quite difficult for some patients, especially for the first few days after operation. Each movement is painful, and they have the sensation that the incision will “tear apart.” But such is extremely unlikely. Surgeons do not depend on any bed position to keep tissues in apposition; rather the repair is made strong enough to withstand greater tension than normal tissues will be exposed to. Disruption of an operative wound is one of the rarer complications, and when it does occur, it is due to healing deficiencies rather than the patient’s activity. However, if movement in bed seems impossible, it is important for the patient to summon help and be moved from an uncomfortable position. But active movements by the patient are far better than passive changes. “Cramped” muscles should be stretched, and especially should the feet and the toes be moved. If there is any reason why certain movements or positions should not be used, the patient is given explicit instruction.
Formerly it was necessary for a patient who had a serious operation to remain in bed for a week or two afterward. For the past few years, however, this has been deemed unnecessary and almost all types of surgical patients are allowed and encouraged to get out of bed (ambulate) within a day or two after operation—frequently within just a few hours afterward. The advantages of this earlier ambulation are reflected in a great reduction of postoperative complications. Pulmonary (lung) and vascular (vessel) complications have been reduced to a minimum, because accumulations of bronchial secretions and stagnation of blood have been prevented. All organs re-establish their normal physiology more quickly as the patient gets out of bed and moves about. The intestinal tract, for example, resumes its normal movements to expel its contents sooner, and thereby avoid abdominal distention. Cathartics and enemata are required less often, and a normal diet can be started earlier. Another advantage of early ambulation is that the patient’s pain at the operative site disappears at an earlier date, necessitating fewer pain-relieving drugs and providing full comfort sooner. Naturally with early ambulation the hospital stay is shortened, meaning an economic advantage to the patient and a greater availability of hospital beds for other patients. Early ambulation has many other advantages with no apparent disadvantages whenever the surgeon deems it permissible.
Patients need never fear, however, that they will indiscriminately be suddenly ordered to get out of bed after their operation. Early ambulation is not overdone, as the condition of the patient as judged by the surgeon is the deciding factor. The young and agile naturally can proceed faster than the old or feeble patient. But for everyone the ambulation is done in stages. The first step is to sit up in bed; when this can be done readily, sitting on the edge of the bed may be tried. Next may be to sit in a chair at the bedside for a brief period, and finally to take a few steps. The initial steps and the rapidity of advancement of ambulation are prescribed by the surgeon. The hospital personnel make note of the patient’s tolerance to such, so that the surgeon can gauge the progression. In no case should ambulation be done without the doctor’s order, and help should always be available before the patient stands for the first time after prolonged periods of bed rest or after an anesthetic. Patients should make every effort to co-operate with those who are trying to carry out the ambulation orders. Much encouragement is needed in many cases, as lying comfortably in bed is much easier than the exertion of moving about, especially if the operative site is sore to movement. But each day of procrastination makes the act more difficult. In a few instances, however, the patient may feel like getting up before the surgeon gives the order; in such case it is wise indeed to ask for such permission, as the surgeon may also be anxious to start ambulation. Help must always be present with the first attempts; the patient is usually not so strong as he thinks he is, as the strength is slow to return after prolonged rest in bed.
Before ambulation begins or when ambulation is not feasible, bed exercises may to some extent accomplish the same desirable results. Attempts are made to exercise certain muscle groups at regular intervals as frequently as the patient’s condition permits. Convalescent bed exercise may be prescribed in a rather nonspecific fashion, such as telling and encouraging the patient to frequently roll from side to side, or to move the feet and toes regularly, or to take deep breaths. In other circumstances the bed exercises may be specifically prescribed to be executed in a very definite manner. A physiotherapist or other person especially trained may instruct and supervise such exercises. Active exerciscs, which require the subject to perform the movement, are usually superior to passive exercises, where the part is moved for him. All movements are to be performed in a definite fashion and a prescribed number of times, with proper relaxation between movements. Specific instructions are given.
Even after the patient becomes ambulatory, exercises may hasten convalescence and prevent untoward events. Here again they may be nonspecific, such as walking or participating in games; or, they may be very specific calisthenics.
When exercises, either bed or ambulatory, are indicated in the postoperative period, their importance cannot be exaggerated. In almost all cases they will quite definitely shorten the duration of the convalescent period, not to mention those cases where they make the difference between success or failure of the entire treatment plan. There are a multitude of different exercises, all devised with a particular motive; to describe these in detail is not within the scope of this book. Suffice it to say, the results from any convalescent exercise can be no better than the efforts spent in its execution.
Other forms of physical therapy may also be employed in the later postoperative period.
Breathing and Coughing
After an operation patients have a tendency to lie still in bed, making as little movement as possible. Even the breathing movements are restrained, so that the lungs do not fully expand. In the idle position of the lungs, secretions may collect and infection and other complications may ensue. Frequent full expansion of the lungs is so important in many cases that the surgeon orders frequent inhalations of special gases to produce deep breathing, or breathing exercises may be prescribed. But in any case the patient must make a practice of taking several deep breaths at regular intervals during the time he is confined to bed. This is particularly important for the first few days after inhalation anesthesia and while drugs which may suppress respiratory movements are employed. Habitually filling the lungs five or six consecutive times to full capacity each hour during the wakeful hours often avoids a complicating lung involvement.
Secretions which collect in the air passageways must be coughed up. As soon as they are coughed up to the throat, they may be swallowed or expectorated, but the secretions must not be allowed to accumulate. Mucus and other secretions which remain at one level in the respiratory apparatus or which descend to a lower level predispose to lung diseases. Whenever the urge to cough is experienced, it should not be restrained. After operations on the abdomen or the chest, coughing may be painful to the operative site. But this must not inhibit the patient from coughing. No matter how vigorous or forceful the cough, it will not injure the operative wound or impair healing. Often supporting the area by placing the flat of the hand over the dressing on the incision will minimize the discomfort. But this is not actually necessary as no harm can come to the operation by coughing. Great harm may result, however, from restraining the cough reflex. In some cases where coughing is difficult the surgeon may prescribe a medication to make the secretions less tenacious, so that coughing them up is less difficult. But he cannot obtund the cough reflex with drugs if secretions are apparent. Only when the cough is “dry” can an anti-cough drug be used.
If there is any reason why deep breathing and coughing should be curtailed, which is rare indeed, the patient is so instructed.
Diet and Fluids
After the patient has recovered from the anesthetic, the first thing that is usually offered is crushed ice. This is usually welcome as the mouth feels dry. Ice chips in the mouth begin the fluid intake but do not allay thirst. As the patient desires, water and other fluids may be taken. Frequent small quantities are usually better at first, rather than large amounts. The first meal after operation is usually just a light lunch of semi-solid foods, unless the patient desires more. The appetite gradually improves as recovery progresses.
It is desirable for the postoperative patient to be returned to a nutritious diet as soon as possible. An adequate intake of fluids, proteins, vitamins, and minerals is especially important during this period of tissue healing. In some cases this is not at all possible, and parenteral routes (other than mouth—e.g., intravenous infusions) have to be employed as a substitute or an adjunct to the diet. Special diets are often used to furnish the most essential nutriments with the most practical texture and appeal. Such dietary adaptations are very common after operations on the digestive system. A liquid or soft diet may be indicated for some time for such cases. Some special diets are progressive; at first limited quantities and consistencies are allowed, and, as the patient’s condition improves, additional foods are given. Others are so designed to be rich in certain elements or to be low in a particular substance. Dietetics is a science in itself, and the various principles applied in postoperative convalescence are often of invaluable benefit.
An adequate amount of proteins, vitamins, and minerals is essential for good health at all times and especially while recuperating from an operation. But of greatest concern in the first few days after operation is the sufficient intake of fluids. This is where infusions find their greatest usefulness in surgery, but such adjuncts are not needed if the oral intake is feasible. Accurate record of the volume of liquid consumed by a patient is frequently ordered by a surgeon to aid him in evaluating the state of tissue hydration, rather than relying solely on physical findings and laboratory tests.
The appetite may be poor in the early postoperative period, and the nursing staff may be requested to encourage the patient to drink and cat. Such prompting should be taken in good spirit, as nothing will be forced on the unwilling patient. Patients need not be afraid to eat, as nothing will be offered which has not been ordered by the surgeon. Simple desires should be made known to the nursing staff; fruit juices or other beverages may be preferred to water; ice water may be too cold, or a salt shaker may be desired. They will accommodate if possible.
The appetite during hospitalization does not usually reach normal, as the individual is less active than usual and appetite is principally controlled by energy utilization. As the patient improves, he becomes more active and uses more energy. The appetite improves; finally it becomes normal. An improving appetite is an indication of progressive recovery.
The nursing staff has the patient’s comfort foremost in mind at all times and is particularly thoughtful of those patients who cannot help themselves. Yet, many things will not come to the nurses’ attention except from the patient himself. The nurses never want their patients to become thirsty, to become chilled, or to lie in a cramped position for long periods. Such things frequently cannot be avoided, but when they are unnecessary, they should be avoided. Needless to say, unnecessary calls for the nurses are provoking, but, if one cannot help himself, the nurses want to comply with each request.
Most requests for personal comfort can be permitted. Of important concern is the room temperature. A patient should never allow himself to become chilled by inadequate blankets or low room temperatures. The body protects itself against certain germs with a temperature higher than these micro-organisms can tolerate. Even though the germs are present in the body and all around it, they do not cause disease because they are dormant in the high temperature environment. But when the body becomes chilled, even slightly or for a short period, the germs become active to cause a disease. (Many diseases of man are not prone to occur in other mammals because of the higher normal temperature in the other mammals. And one of the body’s responses to infection is to elevate the normal temperature to levels which the germs can no longer tolerate; fever is a defense mechanism against them.) A familiar example of chilling predisposing to disease is the common cold. This and other complicating infections must be avoided in the postoperative period.
On the other hand, overheating of the body must not occur. In efforts to bring the temperature back to normal, the body perspires to lose heat by evaporation of the perspiration on the skin. If the sweating becomes profuse, vital salts and fluids are lost. Other organs suffer from such losses if they are not replenished. Usually, however, the temperature within the hospital is kept comfortable at the desired level. Excessive heat in the summer months is more of a problem than the winter low levels, actually. Nevertheless, it sometimes requires individual attention. Windows can be opened or closed, electric fans adjusted, and thermostats dialed. Patients must always remember to check with the nurses and other patients in the room before such changes are made, however. When more blankets arc needed, there should be no hesitation for such a request.
Of concern in the patient’s general comfort is personal hygiene. In the postoperative period it is necessary to forego little of the routine care a person provides himself. Patients who are bedridden are given a bed bath daily. This is usually accompanied with clean bed linen and a fresh gown. After the patient is fully ambulatory, he can take a sponge bath at the sink. A tub bath can be allowed in due time, depending on the individual case. Prolonged soaking of the operative area must be avoided in the early stages of healing. but many surgeons allow a shower as early as the second or third day after operation, provided that the dressing is changed immediately afterward. If the operation was above the waist level, a tub bath may even be allowed this early. In general, the shower is preferred to the tub bath in most circumstances, however.
Accompanying the daily bed bath or shower is a change of bed linen and a fresh gown. Bedridden patients are afforded a back rub once to several times a day, to relieve aching muscles and to provide psychological relaxation. Except in those cases where operation has involved the lower half of the face, there is no reason why the teeth cannot be brushed regularly. Oral hygiene is to be encouraged, and often the use of a mouthwash is prescribed as a part of the routine postoperative care. The use of favorite cosmetics can be allowed if common sense is employed; naturally no patent cosmetic should be used near the operated area. All personal hygiene measures will add greatly to the general comfort and care of the postoperative patient. But each must be employed with knowledge and supervision of the surgeon and nursing staff. If there is any question regarding any personal care, the nursing staff can readily provide the answer.
During the period of operative recovery the usual body physiology continues, and with it, of course, are its waste products. It is particularly important that the fluid components of the body function in as normal a fashion as possible. The surgeon directs his attention to this and makes certain efforts to assure that the various liquid and salt constituents are kept in normal balance with one another. An adequate fluid turnover is required to maintain the normal chemical processes in all the cells of the body, to insure transport of the elements in the body, and to effect elimination of all the waste products. Thus, the body must be assured of an adequate intake of fluids, but also the urine must be properly eliminated. As the kidneys excrete the urine, it collects in the bladder. When the bladder is full the urge to urinate is experienced. Those patients who are confined to bed must use the urinal or bedpan, but the act of urination should not be deferred for any reason when the urge is sensed. The use of the bedpan is a common hospital procedure, and no embarrassment should accompany its use.
With early attempts at urination difficulty may be encountered in initiating the flow. This is due to the sedative effect on the bladder of bed rest, the anesthetic, and various drugs. In such case catheterization may be necessary for the first voiding or so after the anesthetic. Every effort is made to avoid the use of the catheter, however. Often the sound of running water, a hot water bottle applied to the lower abdomen, or ice chips in the mouth will initiate the flow; in some cases the patient can be allowed to sit up in bed or even go to the commode, or male patients may be allowed to stand at the bedside. After certain pelvic operations catheters are left in place to avoid tissue tension through distention of the bladder.
A change in the usual bowel habits may also be experienced in the postoperative period. Some patients become greatly concerned about this. The tragedies of constipation as presented to the public by many patent medicine manufacturers are most misleading, and millions of people have been led to worry needlessly about their bowel habits. To a great many people it is a great problem in everyday life and becomes an even greater one during hospitalization. People sometimes fail to realize that the bowel movement is composed of residue from the food which is eaten. Usually on the day of surgery there is little or no solid food taken. And for the first few days after operation the appetite is poor. With such decreased intake the usual amount of residue cannot be expected. Moreover, hospital meals for the most part are of the low residue foods. When an enema is given, and frequently one is given shortly before operation, the normal bowel movement cannot be expected for two or three days. This is also true, of course, when an enema is given later in the postoperative period. The purging action of the enema flushes out the entire colon of all its residue. To be sure, there is some laxity of the bowels with the bed rest and the inactivity of hospitalization, but there is little cause for worry by the patient about the bowel movements. Each is recorded in the chart by the nurses for the surgeon’s attention, and he can remedy the situation by medication or enema when he deems it necessary. It docs no harm, of course, to speak with the nurse or the surgeon about it, but one must not be dissatisfied if it is considered best to defer any intervention until the natural process ensues. Prolonged uses of artificial means of emptying the bowels makes re-establishment of the normal process more difficult. Constipation is sometimes a symptom of an underlying disease, but the only significant consequences from the constipation itself are the mental anguish and the mild abdominal discomfort it may produce.
Wounds are dressed with several layers of sterilized gauze which are held in place over the area with adhesive tape or bandages. The frequency of dressing changes depends entirely on the type of wound. For such discussion wounds may be classed as those made aseptically (under sterile conditions), those incurred accidentally and considered to be potentially infected, those that are infected, open wounds, and some special types.
Aseptic wounds made at the time of operation have been protected against bacterial invasion during operation to the fullest extent of the facilities of the operating room. The few germs that do gain entrance to the wound are soon destroyed by the body’s natural powers of resistance. Those clean wounds that have been sutured closed without any drainage become sealed within 24 hours by the clotting of serum at the cut edges and around each suture hole. These incisions actually would need no dressing change until time for the removal of sutures, except to inspect the area from time to time and to add to the patient’s comfort with a fresh dressing. Those wounds which have been drained because there was slight uncontrolled blood ooze but where there was no contamination with germs, are re-dressed after 24 hours and the drain removed. Rigid asepsis is employed in the care of all wounds whether they are considered already sealed or not, so as to preclude any germs from breaking through the barrier.
Accidental wounds are of several types. All are considered to be potentially infected. The immediate care of such wounds is to remove all infected and devitalized (dead) material and to trim all jagged edges for better reconstruction. A formal operation called debridement is performed for this purpose, and then the clean-cut edges may be closed by suturing. Often a small drain is left in place at the operation to prevent the collection of blood and tissue products which would retard healing if allowed to remain. Thereafter, these are treated essentially the same as infected wounds.
Infected wounds are dressed at least once every day. Rigid aseptic technique is just as important here as with the noninfected incision. The wound must be protected against further invasion of germs and especially against new types of organisms. The surgeon is concerned with the removal of as much of the infection, pus, and devitalized matter as possible. All must be expelled before healing can proceed to completion. and all that which is mechanically removed means less to be digested and eliminated by the inflammation processes. The proper time for removal of drains varies, of course, with the individual wound.
Open wounds, either accidental or operational, frequently require special dressing technique. These are managed as such whenever it is considered more advisable to allow the open cavity to heal from the bottom upward, rather than from side-to-side as in sutured wounds. This may be to avoid closing in an infected or potentially infected area, or because closure could not be accomplished without leaving an empty space at some level within the tissues, or because closure is not feasible. Open ulcers on the surface of the skin may also require the same special care as open wounds. These conditions usually require a dressing change every day and occasionally more often. With each dressing change, medications in the form of ointments, solutions, or pastes may be used. Sometimes wet dressings are prescribed; here the bandage is kept moist by certain salt solutions which are poured onto the dressing or instilled into the open wound through tubes incorporated in the dressings. Cold or hot water bottles may be placed over the dressing. All such special dressings and wound care are prescribed by the surgeon by standardized nomenclature, to be executed in a specific manner.
Special types of wounds may require particular care in their management. The dressings over skin grafts and burns may remain in place for a week or more. Often pressure dressings are applied so as to gently compress the tissues under them. They are not removed until healing is estimated to have reached a certain stage, so as not to disturb the underlying tissues. In some instances, where the operational repair necessitates tension on the tissues, the dressing may be incorporated within the sutures to prevent their tautness from cutting into the tissues; the dressing cannot be removed until it is time for the sutures to be removed.
Surgical dressings are usually done by the surgeon or hospital physician with the aid of a nurse. Whenever possible, the patient is notified ahead of time. There is no pain associated with the dressing, and usually it is accompanied by added comfort. In open wards the curtains arc drawn about the bed to insure privacy. The patient is not unduly exposed as the sense of modesty is respected, and whenever possible the surgeon avoids mealtime for dressing changes. Occasionally the patient is taken to the ward treatment room for the change of dressings.
A mobile dressing cart is ready for the use of each surgeon. On the cart are all the materials needed for the aseptic application of new dressings as well as the sanitary disposal of soiled dressings. The cart is wheeled to the patient’s bedside for use, and after each use the cart is cleaned and re-equipped in the preparation rooms for subsequent use.
The dressing is removed by releasing all adhesive tape or by cutting or unwinding the over- lying bandages, and lifting off all layers of gauze. Sometimes a solution to reduce the adherence of the adhesive tape is used, and frequently a solution is employed to release the gauze where it has become adherent to the wound. Usually these are unnecesary, however. Soiled dressings are wrapped and placed in the disposal section of the dressing cart. After cleaning the wound and the surrounding skin with solutions as needed, and applying the necessary disinfectants and medications, the clean sterile gauzes are placed over the wound. The new tapes or bandages are then applied to secure the gauze in place.
When the drainage from infected wounds is irritating to the surrounding skin, these areas are often treated with protective ointments and pastes before the gauze is reapplied. When frequent dressing changes are needed or when the adhesive tapes prove irritating to the skin, specially devised methods may be used. Protective solutions which do not hinder adhesion can be employed on the skin before the tape is replaced; or, tapes with perforated ends may be left in place and laced over the gauze with each change.
The design of the dressing naturally depends on the site of the wound. Certain anatomical locations require special dressings to insure their security and yet not inhibit any desired motions. On the arms and legs circular bandages often prove more advantageous than those secured by tape. Certain parts such as the eye or ear require specific design. When complete immobilization of a part is desired, plaster casts may be placed over the original operative dressing. In such cases openings or “windows” have to be cut in the cast to permit the necessary dressing changes. In other cases splints may be incorporated in the bandages. There is a great variety of dressings used in the care of surgical wounds.
Removal of Stitches
Many patients are more concerned about having their sutures removed from the skin than they are about the operation itself. After the stitches are removed, they soon realize how unfounded their fears were. There is usually no pain or other discomfort associated with the removal of sutures. This also applies to the removal of skin clips, when these small metal clamps were used to approximate the skin edges at the time of operation instead of sutures. The surgeon or hospital physician who removes them is just as gentle as possible. Naturally this entails a dressing change. The dressing is removed and the skin about the incision painted with a disinfecting solution. Each stitch is removed separately by elevating it with forceps (“tweezers”) and cutting it at one skin surface with pointed scissors. The loop is then lifted from its tract in the tissues. When all have been removed, a disinfectant may again be applied and a dressing placed. The small openings left from each suture become sealed within 24 hours, and a dressing may no longer be needed after this period.
The length of time the sutures remain in place before removal depends on the location and the tension of the individual incision. They may be left anywhere from 1 to 14 days, average about 5 to 7 days. Sometimes the stitches are removed part at a time rather than all at once. In some cases of cosmetic repair, the skin has been closed “from the inside” with no sutures coming through to the surface; such sutures need not be removed.
Mental diversion and passing of idle time during hospitalization has been discussed in Chapter 3 and in the section on preoperative care in this chapter. Actually, the postoperative convalescent period poses far less of a problem with mental and physical unrest than does a hospitalization period for preoperative treatment. The postoperative patient naturally is less apprehensive about impending events and is usually pleased with his progress. Nevertheless, time often lags during this period, and the patient will do well to occupy himself with interesting diversions. Many hospitals have a patient library service, and some have other recreational services as well.
Exception to hospital visiting regulations on the operative day have been mentioned. Except for visiting clergymen and in the case of critically ill patients, no other exemption from the rules can be permitted. Patients and visitors alike must observe good manners and respect the rights of others. It must be realized that hospital visiting is a privilege and not necessarily a right. It may have to be denied under certain circumstances.
Discharge from Hospital
Just how long a period of hospitalization is necessary after an operation is difficult to predict. As previously noted, no two cases are exactly alike, and often cases quite similar proceed at different rates of progress in the recovery period. Often a patient is hesitant to resume activity after operation; his progress is restrained for fear of discomfort and complications, or for fear of the unknown, or for fear of fear itself.
On the other hand, many patients amaze themselves and their surgeon as well with their agility and confidence in themselves. The latter group of patients are ready for discharge from the hospital sooner than the former, of course. The stage of progress the patient must reach before leaving the hospital depends mainly on the need for further evaluation and nursing care, but also in part on the conditions at home. If they are such that help is available, so that one need do nothing but take care of oneself, can be active but not become exhausted, and is free of emotional disturbances, there is less necessity for prolonged hospitalization. But some people—the mothers of small children, for example—often find it difficult to restrain their activity to the prescribed limitations. Also the ability to travel the necessary distance and the facilities of communication must be taken into consideration. All such factors are evaluated by the surgeon before he discharges the patient from the hospital.
The exact procedure for discharge varies from hospital to hospital. Usually the patient knows a day or so in advance when he will be going home. At the time of the last hospital call, the surgeon gives the patient final instructions regarding the care and restrictions at home and the first postoperative office visit. He then writes the order for discharge. The nursing staff will see that assistance is given in preparation for leaving and proper clearance of each administrative section. The procedure is usually quite simple.
Postoperative care does not end until the patient is restored to normal health, or until no further improvement is possible. In some cases this may take weeks or even months of continuous treatment; in others only a few days. In certain cases limited activity may be necessitated for some time; medications or special diets may be indicated, or specific exercises to restore function may be required. Frequently time is the only requirement. Any such measures may be a part of postoperative care.
In order to follow each case to completion and make certain that the benefit from treatment has been maximal, the surgeon will want to make postoperative evaluation or check-ups. One or several may be required. Such check-up may be a week, a month, or several months after discharge from the hospital. When maximal resuits have been obtained, the surgeon will then discharge the patient from his care. And the postoperative phase has ended.