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about the patient’s goals for pain relief, previous history with analgesics, and type of surgical procedure is used to guide decisions about analgesic regimens (Bell and Duffy 2009, Layzell 2008). Analgesics are selected based on the location of surgery, degree of anticipated pain and patient characteristics, such as co-morbidities, and routes of administration and dosing schedules are determined to maximize the effectiveness and safety of analgesia, while minimizing the potential for adverse events (Layzell 2008). (For further information concerning effective management of pain following surgery, including assessment tools, see Chapter 9.)

Methods for coping with immobility

Postoperatively, patients are at increased risk of developing DVT as a result of muscular inactivity, postoperative respiratory and circulatory depression, abdominal and pelvic surgery, prolonged pressure on calves (e.g. from lithotomy poles), increased production of thromboplastin as a result of surgical trauma and pre-existing coronary artery disease (Rashid et al. 2005). To prevent this complication, many patients undergoing surgery will be treated with anticoagulants, for example low molecular weight heparin subcutaneous injections or a continuous heparin infusion if the patient was previously anticoagulated (NICE 2010).

Postoperative instructions should describe any special positioning of the patient. Where a patient’s condition allows, early mobilization is encouraged to reduce venous stasis unless otherwise contraindicated. For patients on bed rest, nurses should encourage deep breathing and exercises of the leg (flexion/extension and rotation of the ankles). Where worn, nurses should ensure that antiembolic stockings are of the correct size and fit smoothly and should advise patients against the crossing of legs or ankles to prevent constriction of the blood supply and swelling. Furthermore, patients on bed rest should be encouraged to change position hourly to minimize atelectasis and circumvent the development of pressure sores (Terrence and Serginson 2000).

Anticipated patient outcomes

To ensure patient safety at all times and minimize postoperative complications by:

delivering the required nursing care for the postoperative patient

minimizing potential postoperative problems associated with:

– haemodynamic instability

– ineffective breathing pattern

– imbalanced fluid volume

– malnutrition

– pain

– immobility

– infection

– self-care deficit

– patient knowledge deficit

– psychological and emotional aspects of recovery.

Postprocedural considerations

Ongoing care

Self-care/knowledge deficit

The increase in same-day surgical admissions combined with shorter hospital stays means that more postoperative wound healing and recovery takes place at home. This means that patients need to be self-caring on discharge, having assimilated the knowledge of usual postoperative outcomes and management with the ability to recognize when professional intervention and/or advice are required.

Surgery can be physically and psychologically stressful for patients, resulting in patients forgetting up to 60% of any preoperative information/teaching (Swindale 1989). This demonstrates the need for nurses to reinforce preoperative education postoperatively, ensuring that any information and discussions are tailored to the patient’s individual needs, taking into account their level of anxiety and distress (Swindale 1989). Ongoing assessment of the patient’s understanding of the information given should be carried out and documented. Nurses should teach the patient and carers any necessary skills (including how to use equipment), allowing sufficient time to practise before discharge. This will enable the patient to be as independent as possible postoperatively and promote an understanding of any self-care initiatives required on discharge. This should be supported with centralized evidence-based written information concerning postdischarge care at home.

Observations

Postoperative observations include:

blood pressure: normal range <101–149 mmHg systolic