Preoperative Care: Coughing and Positioning

The Surgical Client: Preoperative Care

• Client education aims to prevent infection and injury after surgery through coughing, positioning, and deep breathing exercises.

Coughing and Deep Breathing Exercises

• These exercises prevent atelectasis, pneumonia, and improve post-surgery oxygenation.
• Instruct clients to perform deep breathing and coughing exercises every hour while awake, starting before surgery if possible.
• Deep breathing involves inhaling through the nose, holding for a few seconds, and exhaling slowly through the mouth.
• Coughing should be gentle to avoid injury but clear airways.
• Use the "splinting" technique which involves holding a pillow over the surgical area when coughing to reduce pressure and pain.
• Incentive spirometry can help reestablish lung function.
• Coughing and deep breathing should occur every 2 hours.

Positioning

• Proper positioning promotes lung expansion, reduces blood clot risk, and improves circulation.
• Teach clients to change positions regularly (every 1-2 hours), especially after surgery.
• Encourage a semi-upright position to improve lung function.
• Discuss repositioning every 2 hours to avoid pressure ulcers for at-risk clients.
• Post-surgical positioning, like Fowler's for abdominal surgeries or side-lying after hip surgery, aids comfort and prevents complications.

Infection Prevention

• Pre-surgical hygiene includes instructing the client on proper skin cleansing, especially around the surgical site, using antiseptic solutions like chlorhexidine wipes or soap.
• Hand hygiene is crucial, especially before touching the surgical site or wounds after surgery.
• Explain the role of prophylactic antibiotics, if prescribed, in preventing infections and emphasize taking all antibiotics as directed.
• Provide wound care education to the client and family, teaching them about infection signs (redness, warmth, swelling, drainage, fever) and proper wound care, including keeping it clean and dry.

Injury Prevention

• Educate on the importance of early mobilization after surgery to reduce blood clot risk, improve circulation, and prevent muscle atrophy; start with ankle pumps or leg lifts before full mobilization.
• Depending on the surgery, educate clients on the correct use of assistive devices (crutches, walkers, braces) to prevent falls or injury.

Pain Management

• Ensure the client understands how to manage post-operative pain to avoid strain during recovery, including prescribed medications and non-pharmacological methods like relaxation techniques, ice packs, or positioning.
• Informed consent involves formal permission granted with knowledge of consequences and alternatives; the nurse verifies the client/representative signed willingly, is of legal age, competent and has adequate information to make the decision.

Risks of Surgical Complications

• Regular alcohol consumption increases the risk for complications during or after surgery, including bleeding, infections, heart problems, and longer hospital stays.
• Tobacco use increases the risk of blood clots, myocardial infarctions, and death. Clients should be educated on the benefits of tobacco and alcohol cessation prior to surgery.

Nursing Responsibilities

• Verification and witnessing of consent.
• Ensuring airway patency through maintaining an open airway, adequate hydration, coughing, and interventions like assistance with coughing, hydration, positioning, humidification, nebulizer therapy, chest physiotherapy, and suctioning for gas exchange and lung expansion.
• Providing comfort measures like reassurance, clear explanations about the surgery, active listening, comfortable positioning, ice chips or mouth swabs (if allowed), and a calm environment.
• Explain the pain management plan for postoperative care and comfort measures like deep breathing or relaxation techniques.
• During surgery, the nurse ensures patient monitoring, effective pain management, proper positioning and environmental control (temperature, noise, and lighting).
• Ensure the patient is being cared for by the surgical team.
• Include prescribed medications as well as any other substances when assessing allergy status. If allergies are identified, the nurse should ensure that an allergy band is placed on the client according to facility policy.

Postoperative Phase

Pain Management:

• Regularly administer prescribed analgesics, assess effectiveness, and proactively manage pain.

Positioning:

• Position clients to promote comfort and reduce strain and use supports to align the body and alleviate pressure points.

Heat and Cold Therapy

• Warm blankets or heating pads can reduce shivering or muscle tension and cold compresses or ice packs reduce swelling or discomfort.

Psychological Comfort

• Monitor for anxiety, confusion, or disorientation and encourage family visits.

Preventing Nausea and Vomiting

• Offer anti-nausea medications and ensure safe positioning to avoid aspiration.

General Comfort Measures

• Practice effective communication, holistic care, and environmental control to address client's comfort.

Managing Nausea

• Prescriptions for antiemetics should be given.

Assessing Allergy Status

• Identify allergies and ensure an allergy band is placed.

Client Education should include:

• General information about the day of surgery, what time to arrive, where to check in, what to bring, the policy for visitors, and how long the client can expect to stay.
• NPO status
• Skin preparation
• Medication: The client may be asked to stop taking certain medications and supplements prior to surgery.
• Tobacco and alcohol cessation: Clients should be educated about the benefits of tobacco and alcohol cessation prior to surgery. Resources should also be provided if needed.

Post operative expectations

• What to expect immediately following surgery
• How pain will be rated and controlled immediately postoperatively and once at home
• The importance of coughing and deep breathing after surgery, including techniques for incision splinting and how to use an incentive spirometer.
• Activity following surgery, including the importance of early mobility
• Activity following surgery, including the importance of early mobility as well as any restrictions the client may have following surgery.

Post-Operative Complications

Respiratory system

• Assess breath sounds, respiratory rate, respiratory pattern, and oxygenation level
• Frequently monitor the client's oxygen saturation
• May need to provide assistance with clearing of secretions
• Encourage them to engage in incentive spirometry, coughing and deep breathing (every 2 hours), and early ambulation ASAP (promotes deep breathing, expands chest wall, clears the airway, and decreases risk of comps)

Cardiovascular system

• Monitor for fluid and electrolyte imbalances
• Closely and frequently assess vital signs, noting trends
• Evaluate extremities for pulses and signs of DVT

DVT Prevention:

• Implement early interventions such as: Proper positioning, early ambulation, ankle pump exercises, SCD's and antiembolism stockings
• Watch for signs of bleeding and intervene
• Monitor vital signs closely and observe for changes in mental status.

Neurologic system

• Monitor level of consciousness and mental status and ensure baseline is re-established
• Watch for postoperative delirium.
• Continue assessing neurologic changes beyond the immediate postoperative phase.
• Use the Aldrete Score to evaluate post anesthesia recovery.

Pain management

• Use an appropriate pain scale

Pharmacologic Pain Management:

• Opioids: Used immediately postoperatively (oral or parenteral).
• Nonopioids: NSAIDs may be used if renal function is acceptable.

Patient-Controlled Analgesia (PCA) Pump:

• Allows client to self-administer pain medication.
• Connected to an IV line with a computerized pump.
• Can provide medication via: Small constant flow, As-needed basis, Combination of both

Nonpharmacological Pain Management:

• Distraction
• Music therapy
• Breathing techniques
• Heat and cold application
• Repositioning

Integumentary system

Dressing considerations

• Applied sterile
• Typically remains in place between 24 - 48 hours (per surgeon's discretion).

Monitoring

• Watch for pain, redness, or drainage.
• Remove dressing if infection signs appear.
• Check site frequently

Drain Tube

• Placed during surgery to monitor drainge
• Monitor drainage collection.

Wound Closures

• Skin staples, sutures, or other closures remain for 5-14 days

Documentation

• record findings in the EMR

Positioning

• Positioning varies based on the type of surgery - positioning
• Avoid improper movement to prevent dislocation - hip surgery
• Lung Auscultation can assist
• Reposition frequently to prevent muscle weakening, blood clots, and lung infection

Splinting

• Splinting for Chest/Abdominal Incisions and provide support of incision
• Holding a pillow over the incision reduces pain when coughing or moving and provides support for the incision and surrounding tissue.

Gastrointestinal system

Assessment

• Auscultate for active bowel sounds.
• Assess for nausea or vomiting.

GI Considerations

• Anesthesia and bowel surgery may limit gastric motility.
• Early ambulation promotes return of normal GI function.

Medications

• Laxatives may be prescribed - no surgery on the GI
• Stool softeners (e.g., docusate) may be used for constipation.

Renal Systems

Monitor

• Closely monitor and documenting urine output postoperatively.

Hydration

• Track all intake (oral, IV, enteral) and output and assess if catheterizing is required
• Check mucous membranes in the oral cavity and eyes for pallor and dryness.
• Examine skin for tenting, a potential sign of dehydration.

Intermittent Catheterization:

• Involves inserting a catheter to empty the bladder, then removing it after use.

Use of opioids

• Monitor for respiratory depression

Oxygen saturation status

• Monitor O2 saturation status and give more oxygen if necessary