Day surgery

Day surgery, which started with children, has increased steadily in the treatment of adults. Many minor surgical procedures, such as cataract extraction, hernia repair, vasectomy or endoscopy, may be carried out as day cases.

Day surgery patients are admitted for elective proced-ures, invasive investigations, minor operations or endoscopy (Box 24.1) and the majority return home again the same evening. Some day surgery units provide care for up to 23 hours. Many people prefer to have the shortest stay possible in hospital for several reasons, including:

The Audit Commission (2001) outlined advantages of day surgery for the NHS, which include:

There are also disadvantages of day surgery. Some procedures are not suitable for day surgery and neither are some patients. For example, some people may not be fit enough, or not fit enough on the day of surgery, due to exacerbation of an underlying medical condition, e.g. hypertension (high blood pressure). Each unit has its own criteria for acceptable travelling distance and availability of medical assistance should complications arise, and therefore people who live far from the unit may not be suitable candidates for day surgery. Some people, who although fit for day surgery, may refuse it for several reasons, including:

On discharge after day surgery, all patients – adults and children – must have a responsible adult to care for them for at least 24 hours afterwards. The patient must also have a suitable home environment within which to recover and no need to use public transport. The need for care by a significant other can cause financial hardship due to loss of earnings or high travel costs.

Smoking cessation

Patients who smoke should be advised to give up as smoking is a risk factor for many postoperative complications, e.g. chest infections, deep vein thrombosis (DVT, p. 698), poor wound healing and pressure ulcers (see Ch. 25). Smoking cessation should start at least 2 weeks before surgery; however, this advice can have either a negative or a positive effect as withdrawal of nicotine can increase people’s stress levels. Some people find nicotine replacement therapy helpful. Nurses must not be judgemental or critical if a patient cannot heed this advice; however, information about potential postoperative complications related to smoking should always be provided.

Benefits of providing preoperative information

Lin and Wang (2005) studied the effect of pain information given before abdominal surgery, and concluded that this information-giving could reduce pain intensity experi-enced in the immediate postoperative period (at 4 and 24 hours). Several authors have noted other postoperative benefits of providing preoperative information, including fewer postoperative complications and reduced patient anxiety (Hayward 1975, Boore 1978, Wilson-Barnett 1979, Bysshe 1988, Devine 1992), as well as improved job satisfaction for nurses who were given the opportunity to meet their patients before the day of surgery (Crawford 1999, Holmes 2005).

Common sources of preoperative anxiety

Patients are encouraged to express their fears and concerns using good interpersonal communication skills (see Ch. 9). It is important to recognize that apprehension can build up while waiting for an operation despite effective planning (Box 24.3). Fear of the unknown and loss of independence are common anxieties that can causea person to develop either introverted or extroverted behaviour. In children, this may manifest itself by a change in behaviour, e.g. withdrawal, regression, overactivity or parent dependence. Reduced contact with family and changes in daily routines can instil a feeling of lossor abandonment, especially in young children and older adults. These feelings can become exaggerated, especiallyif someone will have few, or no, visitors. The nurse can discuss these potential problems and offer suggestions such as making phone calls to their friends and family from the ward.

Sometimes a recovery room nurse visits patients on the ward preoperatively. These visits facilitate seamless care from the ward to theatre and back again, and help the patient cope with an essentially unpleasant experi-ence (Weins 1998). The nurse can talk to the patient about any fears about the anaesthetic or other issues they would like clarified, e.g. relating to fear of needles or the wearing of dentures and hearing aids until induction of anaesthesia. Patients who need initial postoperative care in a high dependency or intensive care unit may find visiting the area useful but this should not be imposed as it may increase their anxiety (Skacel & McKenna 1990).

Many people prefer to have intimate care carried out by professionals of the same gender. Cultural norms can be a source of anxiety, especially to older women, who may have had little personal contact with men, and those whose religion or culture dictates restriction of physical contact with a male who is not their husband. Nurses need to be sensitive to people’s needs and preferences by ensuring they are taken into account whenever possible. For women, a female chaperone is arranged when this is not possible. Similarly, many men prefer not to have intimate care carried out by female staff.

Surgery that changes body appearance will affect people’s body image (see Ch. 11), e.g. removal of a breast due to cancer is often a source of great preoperative anxiety. However, to other people the same surgery may bring positive outcomes despite postoperative discomfort, e.g. breast reduction or amputation of a painful gangrenous extremity.

Mitchell (2000) advocates that ideally the amount of information provided for a patient should match their preferred coping strategies (see Ch. 11). Some patients use their spirituality to help them cope. Coping strategies can be observed and discussed at the pre-assessment clinic and also at the time of admission (see Box 24.4). Identifying postoperative coping strategies beforehand may help patients to work through postoperative problems using their own stress-reducing mechanisms, e.g. yoga exercises that reduce tension may be used to assist postoperative pain management (see Ch. 23). Other strategies may include arranging a meeting with an ex-patient who has undergone the same type of surgery or a parent may be put in contact with another family that has been in the same situation. This can be of great help, as many people benefit from a personal approach.

Hair removal

Nurses must be sensitive to patients’ dignity and recognize that body hair contributes to people’s body image and cultural identity, and therefore hair removal may be distressing. The reasons for hair removal are explained and patients should be encouraged to do this them-selves when possible, although the outcome should be checked prior to the final preparations for surgery (Box 24.7).

Chest infection

This can be both life threatening and debilitating, and people at increased risk include:

At the pre-assessment clinic patients are given information about deep breathing exercises that minimize the risk of chest infection (see Ch. 17). Some people attend physiotherapy classes to learn these exercises and how to support their wounds when they need to cough postoperatively. Others are provided with written instructions to follow at home. People’s knowledge is assessed on admission to ensure it is adequate and appropriate.

Deep vein thrombosis

A deep vein thrombosis (DVT) is the formation of a thrombus (clot) in the deep veins of the legs or pelvic veins (see Ch. 17). Pulmonary embolism (blockage of a pulmonary artery by a detached thrombus that has travelled there in the bloodstream) is a potentially fatal consequence of DVT that must be prevented when possible and is the reason for the care described below.

Several aspects of surgical treatment increase the risk of DVT. Immobility is a major risk factor that occurs during invasive procedures and surgery, and also postoperatively to a greater or lesser extent depending on the nature and length of the intervention. The nurse explains the leg exercises that will reduce the incidence of a DVT (see Ch. 18) so that patients can practise them preoperatively and implement them postoperatively to improve and maintain venous return and also to prevent stiffness of the joints. Further measures, e.g. stopping hormone replacement therapy (HRT), prophylactic heparin and anti-embolism stockings (see Box 24.8) may also be implemented to minimize occurrence of a DVT.

Emptying the bladder

The bladder is emptied before showering so that the perineal area is clean. An empty bladder will prevent urinary incontinence during surgery and damage to the bladder during pelvic surgery. For patients having extensive surgery, pelvic surgery and epidural or spinal anaesthesia, a urinary catheter is passed (usually in theatre) to ensure that the bladder remains empty and that urinary output can be measured accurately postoperatively (see Ch. 20). However, if there is a long delay and/or the patient becomes anxious, they may need to pass urine again before transfer to theatre.

Theatre clothing

After showering or bathing, the patient wears a clean hospital gown. As the skin continuously sheds dead surface cells and commensal bacteria (see Ch. 15), a clean gown ensures that the skin is exposed to the minimum pos-sible number of bacteria after showering. The bed is madeusing clean sheets for the same reason. Theatre gowns usually open down the back so that they can be easily removed during surgery if necessary. Female patients can wear disposable paper pants or clean cotton knickers for some procedures, depending on local policy. If anti-embolism stockings are needed, the correct size should be used (see Box 24.8).

James (1995) advocates that children should be able to choose what to wear, arguing that theatre gowns are not necessary and removal of underwear can be distressing and bewildering.

Removal of cosmetics, jewellery and prostheses

Cosmetics are removed so that skin colour changes, e.g. pallor, can easily be observed. Nail varnish is also removed so that the nail beds can be assessed for early signs of cyanosis (see Ch. 17).

Jewellery, hairclips or ornaments are removed and stored safely according to hospital policy and taking into consideration cultural and religious needs. Plain rings that cannot be removed, or for patients who prefer them not to be removed, are taped securely to the finger using hypoallergenic tape. Removal of metal objects prevents:

Patients may be asked to remove prostheses such as wigs, false eyes or artificial limbs on the ward to prevent their damage or loss. Removing a wig may cause embarrassment and a patient’s dignity can be maintained by allowing it to be worn until after they are anaesthetized. If the wig has to be removed, the patient should be offered a paper cap to cover their head. Patients who have long hair should have this tied back on the top of their head so that it does not hinder extension of the neck during induction of anaesthesia.

Contact lenses are removed to prevent corneal abrasions during anaesthesia and are stored safely on the ward. Spectacles may also be removed and stored on the ward although many people are less anxious if any prosthesis can be worn to the anaesthetic room.

Hearing aids are worn to theatre to maintain effective communication and only removed after the patient is anaesthetized, when they are carefully removed, labelled and stored in the recovery room until consciousness is regained.

The presence of loose teeth, caps or bridges is written on the preoperative checklist as these can be damaged or dislodged during intubation or insertion of an airway. Removal of dentures can be a source of embarrassment and dignity should be considered by offering patients the option of keeping them in place until they are anaesthetized (Wood 2002). Dyke (2000) also considers their removal on the ward to be unnecessary as they maintain effective interpersonal communication.

Allergies

Any allergies must be checked with the patient and clearlyentered on the preoperative checklist to prevent administration of harmful medication or skin preparations. Common allergies include adhesive tape, antibiotics (especially penicillin), iodine and anaesthetic gases.

Identity bands

These are worn to ensure that patients can always be easily identified, especially when they are unable to communicate effectively, e.g. due to anaesthesia or sedation. Sometimes local policy requires identity bands on both wrists, ensuring that if one is cut off, a patient can still be easily identified. Identity bands must be checked for legibility and accuracy each time a patient is moved between environments and when medication is administered. Patients having upper limb surgery may have identity bands round their ankles.

Premedication

Premedication is rarely used before day surgery. Other patients may be prescribed premedication, usually a light sedative or hypnotic (see Ch. 22), to reduce preoperative anxiety. Sometimes an anticholinergic drug such as hyoscine is given to reduce oral and bronchial secretions and vagal overactivity. Reducing secretions lessens the incidence of their inhalation during induction of anaesthesia when the gag reflex is lost. Premedication is administered approximately 1 hour before transfer to the anaesthetic room. When preoperative prophylactic heparin is prescribed, it is administered at the same time as the premedication.

Patients who have been given sedative drugs must remain in bed afterwards as the effects can make them unstable should they stand up. It is essential to check that the patient has signed their consent form before administering sedation. The call button is placed within easy reach and bedrails may be raised depending on local policy. When bedrails are used, the nurse must explain that this is for safety reasons as use of bedrails for restraint is unethical (see Ch. 7).

Preparation for intravenous cannulation

Preparation for i.v. cannulation is especially important in children and those who have needle phobia. Topical anaesthetic cream such as EMLA (eutectic mixture of local anaesthetic) minimizes pain during i.v. cannulation and takes approximately an hour to act (Fitzsimmons 2001; also see Ch. 23).

Final preoperative checks

The completed preoperative checklist and the patient’s documentation, including their current observation charts, are collected together so that they are ready to accompany the patient to theatre. Doctors are responsible for preparation of the medical notes, which must include the signed consent form, relevant blood test results and X-rays. The nurse may also check that these are available on the day of surgery. The nursing records include the completed preoperative nursing checklist, nursing care plan and medicine records. Patients who have an i.v. infusion in progress or specific medication such as insulin may also have other records, e.g. a fluid balance chart.

Prior to transfer to the operating theatre the registered nurse and the theatre porter ensure that the correct patient is taken by checking their identity band for the correct:

The bed space is then prepared to receive the patient on their return from surgery (see Box 24.9). Carrying out the activities in Box 24.10 will help you understand a patient’s perioperative experience.

Anaesthesia

Anaesthetics block sensation from the operative site so that surgery or investigations are not painful. There are three different types:

Discharge from the recovery room

A scoring system is normally used to assess when patients are fit enough to be transferred safely from the recovery room. Prior to discharge the equipment needed for safe transfer back to the ward is assembled, e.g. a portable oxygen system or drip stand. Extra blankets may be needed to prevent heat loss. The notes are checked and assembled, ensuring prescriptions for oxygen, i.v. fluids and analgesia, if needed, are completed. The ward nurse identifies the correct patient. The recovery room nurse provides a handover to the ward nurse prior to transfer.

Airway

Assessment begins with checking that the airway is clear and that breathing is quiet. The airway is maintained by ensuring that the head is positioned so that air entry into the lungs is not impeded. The position of the head should allow the tongue to drop forward so that secretions can drain or pool in the side of the mouth where they can be removed using suction. Adequate oxygenation is assessed using a pulse oximeter to measure oxygen saturation levels. Patients are not discharged from the recovery room until they can maintain their own airway.

Breathing

Respiratory rate is recorded every 15 minutes initially to ensure that it is stable, regular and within acceptable limits for the particular patient.

Circulation

This is assessed by feeling the skin, which should be warm to touch, and observing the nail beds, which should be pink. Insufficient oxygen in the blood (hypoxaemia) can give the skin a bluish tinge, especially around the lips and nail beds.

Measurement of blood pressure and pulse also indicate whether the circulation is adequate. Changes that suggest development of shock are:

There are different causes of shock but postoperatively the most common is due to hypovolaemia, which occurs when the circulating blood volume is reduced following excessive blood loss. For more detail, see Further reading suggestions (e.g. Adam 2003).

Observations

The intervals between recordings (see above) must be clearly stated on the care plan. Initially these may be every 15 minutes for the first hour then adjusted when they are within an acceptable range for that patient.

Drains should be supported to avoid traction on the tubing and to prevent potential dislodgement or poor drainage. The amount, consistency and type of drainageinto the drain, as well as any fresh staining on the theatredressing, are noted during the initial postoperative assess-ment so that subsequent loss can be measured. Drains are checked for flow and patency if a vacuum system is used (see Fig. 24.2). If patency is lost, leakage from the wound may increase. The type of drain and volumes draining dictate the frequency of checking.

Fig. 24.2 Wound drains

(reproduced with permission from Brooker & Nicol 2003)

Urinary catheter drainage tubing should be positioned to allow free drainage, ensuring that the collecting bag doesnot come in contact with the floor (see Ch. 20). Urinary output may be measured hourly depending on the patient’s condition and the type of surgery. All drainage is recorded on the fluid balance chart as per local protocol.

Postoperative care is outlined in Table 24.2, the most important principles of which are explored in more detail below.

Communication

When the patient is safely settled, the nurse reorientates them to the ward and explains that the procedure is complete. The environment may be full of unfamiliar sounds which will have been explained preoperatively but this is often forgotten in the immediate postoperative period and should be included in the reorientation information. For patients who wear hearing aids, it is important to check that they have been reinserted and are working correctly. Hearing is the first of the senses to return after a period of unconsciousness and for this reason staff must avoid discussing patients’ conditions near the bedside. At this stage, children often ask for their parents. The sound of the parent’s voice gives reassurance and comfort that allows a child to rest and recover.

Maintaining dignity

Patients are vulnerable postoperatively and it is important to maintain their dignity at all times. Replacing a patient’s prosthesis aids their dignity and also improves their body image. Dentures are usually returned in the recovery room when the patient regains consciousness. However, if this was not the case, then oral hygiene should be given and their freshly rinsed dentures returned. Xavier (2000) points out that people who have worn dentures for a long time are able to manoeuvre them into the correct place even when they are very drowsy.

Pain management

Chapter 23 addresses this topic in depth and should be consulted for further information about all aspects of pain management. Postoperative pain management begins preoperatively when the available options are discussed with the patient. Postoperatively, the nurse must ensure the patient is comfortable and given adequate pain relief. Effective pain management reduces postoperative anxiety (Hayward 1975) and aids mobility. Patients expect to encounter some pain following a surgical intervention but only to their degree of tolerance. Carr and Thomas (1997) found that although patients expected to have pain following day surgery, some stated this was significantly greater than expected. Furthermore, Coll and Ameen (2006)found that many patients have inadequate pain relief after discharge. Pain is not necessarily wound related and can be due to dehydration, a full bladder or the after-effects of being on the operating table. Pain may adversely affect postoperative recovery and is assessed and documented using a pain assessment chart.

Individual coping mechanisms in relation to pain vary widely. Some people lie as still as possible, hoping that the pain will subside, whereas others become very vocal. Other people cannot verbalize their pain, e.g. young children and those with learning disabilities, and nurses need to be alert to behavioural cues. Drugs used in pain management range from mild analgesics such as ibuprofen for mild pain to opioids, e.g. morphine, for moderate to severe pain. Several routes may also be used, including:

PCA devices deliver preset doses of analgesic drugs and allow patients to give themselves analgesia by pressing a button on the handset. Tye and Gell-Walker (2000) suggest that PCA reduces patients’ anxiety about experi-encing postoperative pain. It can be used by people of all ages provided they have sufficient understanding and the manual dexterity to push the delivery button. Some patients may use non-pharmacological methods of pain relief, such as visual imaging or yoga exercises (see Chs 10, 23), which may reduce the amount of analgesic drugs needed. The activities in Box 24.11 will help you understand postoperative pain management.

By anticipating the need for analgesia and speaking to patients about their pain levels well before increased activity is needed, e.g. chest physiotherapy, bed bathing/ showering, getting out of bed and mobilizing, nurses can minimize pain experienced during these activities.

Patients should be encouraged to change their position in bed and to carry out their therapeutic exercises, e.g. leg and deep breathing exercises. This helps to reduce general discomfort and enables people to feel more in control of their postoperative recovery. The nurse will help the patient feel safe at all times by leaving the call button within reach and answering it promptly.

Fluid balance

All intakes and outputs are recorded accurately on the fluid balance chart until urine output and oral fluids are re-established. Fluid balance charts are explained fully in Chapter 19 and this section outlines the fluid intakes and outputs recorded postoperatively.

Preventing chest infections

Patients are encouraged to take deep breaths hourly postoperatively and to cough as necessary to aid lung expansion and to expel anaesthetic gases and pooled respiratory tract secretions. Poor lung expansion and pooling of secretions predispose to chest infections. The physiotherapist educates patients preoperatively (see p. 688) about these exercises. Chest physiotherapy and/or early mobilization can help to reduce the incidence of chest infection and the need for antibiotics (see Ch. 17). In order to carry out deep breathing and coughing, the patient should have enough pain relief and support for chest or abdominal wounds. Placing a hand or pillow firmly over the wound can provide support.

Signs of chest infection include:

A sputum specimen may be required for culture and testing of sensitivity to an appropriate antibiotic (see Ch. 17).

Prevention of deep vein thrombosis

Preoperative preparation helps to reduce the incidence of DVT (see p. 688). Preventative postoperative measuresinclude:

The incidence of DVT is higher after major surgery of the lower abdomen, pelvis and hip joints than other surgery. Not all patients who undergo surgery need these interventions as early mobilization and day surgery reduce the incidence of DVT.

The presence of pain, swelling or redness in the lower limbs is reported urgently, as these may be early signs of a DVT. It is important, however, to realize that the majority of DVTs cause no local signs and that some arise in the pelvic veins.

Nutrition

Preoperative nutritional assessment is carried out so that nutritional intake can be adjusted to meet each patient’s needs. Poor nutrition affects many body processes and has widespread postoperative consequences, including:

Patients who are not undergoing major surgery are usually able to eat normally again within 12 hours. Those who have been fasting for some time may be reluctant to recommence solid food for fear that their preoperative symptoms will return. Patients may need assistance to select a diet that meets their nutritional needs in the postoperative period. Meals and snacks should be served appropriately, taking people’s medical and cultural needs into consideration (see Ch. 19).

Sometimes it will not be possible for patients to eat for several days or even weeks, such as after removal of large parts of the GI tract, and a preoperative referral to the dietitian should be made. Others cannot eat sufficient food to meet their energy requirements and food fortification or nutritional support may be used to prevent malnutrition (see Ch. 19).

Preventing constipation

Patients may not pass faeces or flatus (gas) for several days postoperatively, especially when there is paralytic ileus or following preoperative bowel cleansing. Paralytic ileus occurs after surgery that involves extensive hand-ling of the bowel when peristalsis (the muscular movements that normally move contents along the intestines) is temporarily lost. Flatus is passed when peristalsis returns. Before then many patients experience discomfort caused by trapped wind.

Opioid drugs predispose to firm stools or constipation. Postoperative passing of faeces is recorded in the nursing notes. The faeces may be watery at first and stools may take time to form normally again, even after a normal diet has been re-established. Laxatives (oral or rectal, see Ch. 21) are not normally necessary when patients are well hydrated, eating normally and ambulant again.

Regaining mobility

The type of surgery dictates the level of mobility and the timescale over which this can be achieved. Nurses must be aware of a patient’s preoperative mobility when planning their postoperative mobility goals. Patients having day surgery are mobilized soon after the procedure is completed. Those who undergo major surgery without complications can usually walk to the bathroom the day after surgery; however, following some specific types of surgery, e.g. major vascular surgery (femoral popliteal bypass), bed rest for 24–48 hours may be required.

Preoperatively, patients are supplied with information about exercises that they can practise and implement soon after surgery (see p. 688). The nurse should encourage the patient to carry out these exercises to reduce limb stiffness and aid venous return. When patients are unable to exercise by themselves the physiotherapist and nurse perform passive exercises (see Ch. 18).

Postoperative mobility extends from moving around in bed to walking independently and being able to climb stairs. Gradual mobilization (Fig. 24.3) may start with a short walk from the bed to a chair when the patient is able to sit out of bed for short periods. When a patient stands up too quickly, this can cause faintness due to postural hypotension (a rapid drop in blood pressure on standing upright). The patient should be moved slowly from a semi-recumbent position to the edge of the bed before being helped to stand up (see Ch. 18). Moving from the bed to a chair must be assessed and carefully planned, especially when assistance of nurses or a hoist is needed (see Ch. 18). Walking distances and periods spent out of bed are increased gradually as the patient’s condition allows until independence is regained. Patients who have had orthopaedic surgery may have specific mobil-ization programmes. The physiotherapist implements the planned activities with the nurse in a supporting role until the patient is confident and can mobilize safely.

Fig. 24.3 Steps of mobility

Wound care

On completion of surgery, the incision is usually covered with a light dressing that consists of a thin non-adherent pad with a hypoallergenic adhesive cover if the skin is healthy and intact. The pad absorbs any exudate, which is usually minimal in a surgical wound and may be bloodstained initially. The dressing provides an ideal environment for healing and protects the wound from minor trauma and entry of bacteria (see Ch. 25). The aim of wound care is to promote healing and prevent infection. Healing can be compromised by many factors, including:

According to local protocol, the theatre dressing should be left in situ for at least 24–72 hours unless there is excessive staining as this has been shown to reduce infection rates following surgical interventions. If the wound is clean and dry after the initial dressing has been removed, the patient can shower and carefully pat the wound area dry with a clean towel to prevent trauma or potential infection.

Surgical wounds normally heal by primary intention because skin closures, e.g. sutures, staples, glue or clips (Fig. 24.4), are used to hold and support the skin edges together as healing takes place. The superficial layers close within 24–72 hours as epithelial cells migrate across the wound and initially the wound may appear inflamed, e.g. red and swollen. Wound healing is discussed in detail in Chapter 25.

Fig. 24.4 Removal of skin closures

Both adults and children may find the removal of skin closures frightening and the procedure is explained to reduce fear and anxiety. Distraction, e.g. talking to the patient while removing skin closures, often greatly reduces anxiety.

Sutures are usually removed after 5–10 days unless theyare absorbable whereas staples are normally removed after 2–5 days. More specifically, their removal depends on the reason for surgery, its location and the patient’s age and general condition. If a patient is discharged before skin closures are removed, then arrangements must be made for their removal by a community nurse.