Postoperative Care In Major Gynaecological Surgery

The postoperative days provide the nurse opportunity to give patients good nursing care, with physical, psychological and emotional support.

Immediate care and observations

The nurse who receives the patient from theatre needs to ascertain certain information from the theatre or recovery room nurse, to satisfy herself that she knows the exact condition of the patient for whom she is caring. Indeed, without this knowledge she is blindly taking responsibility for a patient who needs thorough and specific care.

Information to ask for

1.Name of the patient.

2.Nature of the operation.

3.Drugs which have been given (ensure that these were signed for).

4.Particular problems encountered or any complication to be looked for.

5.When oral feeding can recommence.

Observation to make with the theatre nurse

1.Blood loss: on wound dressing and / or on vulval pad.

2.Catheter or drainage tubes.

3.Intravenous infusion: rate of flow, site of needle.

4.Vaginal pack.

In the ward the patient is received into a clean bed and placed in the left lateral position, the nurse taking care to see that the airway is not obstructed at any time.

The following additional observations are now recorded.

5.Skin---color and feel. Note Cyanosis, pallor, or clamminess.

6.Respiration---rate. Note gurgling sounds which indicate early obstruction of airway.

7.Pulse---volume, rate. Note tachycardia or poor volume.

8.Temperature ---of axilla. Note pyrexia; prevent coldness.

9.Blood pressure---Note gradual or sudden fall in pressure.

These observations, combined with those listed above, will be repeated and recorded at frequent intervals, and at least half-hourly until they are stable within normal limits.

Care of the patient’s general well-being

Once the patient shows signs of rejecting the airway and it is finally removed, she may be given a pillow; after this it is unnecessary for the nurse to stay at the bedside, but she should observe the patient frequently. An intramuscular narcotic may be given to alleviate pain and promote a sense of well-being.

When the drugs have had time to take effect, the patient’s face and hands may be washed, her nightgown put on and her mouth rinsed.

If she is not feeling nauseated, sips of water are welcome at this stage.

The patient should be encouraged to moved her legs every hour in bed, and to continue with her breathing exercises. She must also be informed about the operation as soon as she is sufficiently alert. This will need to be repeated on more than one occasion as a certain amount of amnesia is associated with anaesthetics and the regular use of narcotics.

Local care

The vulval pad should be observed and replaced with a sterile one as necessary. Any heavy loss is recorded on the chart, and if severe the doctor should be informed.

Care of the bladder

Special care of the bladder is vital after gynaecological surgery, because of the close proximity of the urethra (in vaginal operations) or the ureters and the bladder itself (in abdominal operations).

A fluid intake and output chart must always be kept accurately in order to check that the urinary system is resuming its normal function.

If there is no indwelling catheter, as after most abdominal operation, micturation is usually re-established within 12 to 16 hours.

Accuracy in measurement and recording of fluid balance is vital in order for the nurse to assess at a glance at the chart whether the patient is passing urine normally, or if there is retention, or retention with overflow.

If there is an indwelling catheter, as in most vaginal operations involving the anterior vaginal wall, management will depend upon the surgeon’s wishes. Usually the bladder is drained continuously, thus preventing distension and drain on the new suture line. Clear urine should begin to drain shortly after the patient returns to the ward; this must be checked frequently because kinking of the catheter or tubing causes back pressure and harmful distension, as well as intense discomfort.

The morning after operation

By the morning after the operation the patient should be in the upright position supported by pillows.

At sometime during the first 24 hours she will be assisted out of bed helped to walk a few steps. She will probably enjoy some tea and toast at breakfast time, although this should be withheld if there is vomiting or if bowel sounds are not beginning to re-establish themselves.

During the day, a bed bath should be given and pressure areas attended to; the hair should be brushed and combed, the teeth cleaned and the bed made as necessary.

A vulval toilet should be performed to help the patient to feel fresh. She will appreciate having the area swabbed with an antiseptic solution. Each swap is used once only, working from above downwards and from the labia majora inwards to the labia minora and vestibule. Gloves or forceps may be used.

Care after the first 24 hours

Þ Analgesia

The injections of the first 24 hours will now gradually be replaced by oral analgesia such as paracetamol 1 g four-hourly. The speed at which this is achieved will vary from patient to patient. The nurse must use her skill and discretion in assessing the degree of pain and evaluating with the patient the appropriate treatment to meet that need.

Intelligent anticipation of the patient’s needs will prevent the pain becoming too severe to be treated by milder analgesics, and will add to the patient’s feeling of security. Most patients will not ask until the pain becomes unbearable.

Þ Diet

Small helpings of a light diet will be given. After abdominal surgery this will gradually be increased to a full diet rich in protein by about the fourth day. After vaginal surgery the diet may be low in residue for the first three to four days, and a full diet resumed once there has been a normal bowel action.

Vitamin C will be resumed to aid the healing of tissues. The fluid intake should be at least 3 liters inm24 hours; this is especially important if there is an indwelling catheter.

Þ Physiotherapy

Leg movements and deep breathing exercises will be continued. The patient should be reminded not to lie with her legs crossed or knee bent for prolonged periods, and that sitting upright assists lung expansion. She will be out of bed for longer intervals each day, and after a few days she will probably be sitting at the table for all meals.

Continuous bladder drainage need in no way prevent her getting up and a the plastic drainage bag can be pinned unobtrusively inside her dressing-gown; care must be taken to prevent urine siphoning back by keeping the bag below the level of the bladder.

This is a particularly good time to teach pelvic floor exercises, partly because they especially helpful at this time, and partly because the patient is very receptive to learning about anything which will aid her recovery.

Care of the bowel

During anaesthesia, peristalsis is reduced with a subsequent delay in the passage of feces: this in part accounts for the abdominal distension which occurs before normal peristalsis is resumed.

After abdominal surgery, a glycerin suppository may be given as early as the second morning, the main result being the passage of flatus which will bring considerable comfort to the patient during the coming day.

After vaginal surgery, it is preferable, but not essential, to confine the bowel for three days; straining must be avoided and a gentle bowel action may be assisted by a mild aperient given on the second day or third evening, followed the next day by rectal suppositories.

Care of the bladder

Care of the bladder continues to be very important, and must be planned and evaluated as in the first 24 hours after surgery.

Urinary output usually reverts to normal within 48 hours of the operation or the removal of an indwelling catheter, although most patients are aware of a bruised feeling at the end of micturation.

An indwelling catheter is removed as instructed by the surgeon; this is usually the seventh day after vaginal surgery, or 48 hours after catheterization in abdominal surgery. It should be removed in the morning to allow bladder function to be assessed before nightfall. There will be three possible outcomes:

¨ some patients will pass urine normally;

¨ others may appear to do so but have a moderate amount of residual urine; and

¨ the third group will have obvious signs of retention.

Careful observation, accurate recording and interpretation of fluid charts are essential to identify problems.

If the patient complain of burning at the onset of micturation, a midstream specimen of urine should be sent to the laboratory.

Care of the abdominal wound

If a drainage tube has been inserted to prevent formation of a haematoma, this is removed as the surgeon instructed, usually after 24 hours.

The dressing would remain undisturbed until sutures are removed.

These are removed from a transverse incision earlier than from a midline incision.

Following their removal, the patient may have a bath and the wound is left dry.

Care of the vulva

All patients who have a gynaecological operation need to keep the vulva as clean and fresh as possible, so a vulval and perineal toilet should be carried out three times per day and following defecation.

This is a simple wash of the vulva, groins and perineum with soap and warm water.

The nurse must ensure that the patient has sufficient pads to change often; sterile ones are only really necessary for the first 48 hours after operation.

Specific vulval care will depend on the vaginal discharge present and whether or not there are any perineal sutures.

Vaginal discharge

Following ovarian cystectomy or myomectomy there should be no vaginal loss unless the patient has a normal menstrual period.

Following hysterectomy or vaginal operations where there is no vaginal pack, vaginal discharge is a small bloodstained loss which gradually decreases until the ninth or tenth day; then an internal sutures dissolve it becomes yellow and increases in amount.

This may continue for five to six weeks and will be profuse if there has been much repair work to the vaginal walls.

The patient must be warned about this as an unexpected discharge could cause her great anxiety. If it become bright red, her doctor must be informed immediately.

Perineal sutures

The sutures line must be kept as clean and dry as possible. If discomfort is severe, anaesthetic gel applied around the urethral orifice and over the suture line gives relief. Because of its rich blood supply the perineum is healed by about the fifth postoperative day

Insertion of soluble pessaries

Vaginal pessaries are sometimes prescribed postoperatively for use either in hospital or once the patient has been sent home, for example nystatin for the treatment of monilial infection, or oestrogen-containing pessaries for post-menopausal patients.

Pessaries may be inserted by either the nurse or the patient, but the nurse is responsible to ensure that it is done correctly and she must therefore be certain that the understands where and how to insert them.

The patient should empty her bladder. If an applicator is used, she lies in the dorsal position and gently inserts the pessary high up into the posterior fornix of the vagina.

Alternatively, she can lie in the left lateral position and the nurse inserts the pessary with her gloved right hand.

A vulval pad is applied and the patient remains in bed until the morning.

Complications after Gynaecological surgery

Any complication of an anaesthetic or of general surgery is possible after a gynaecological operation.

Early complications	later complications
Postoperative vomiting	Chest infection
Shock	Wound haematoma
Respiratory failure	Local infection
Abdominal distension	Burst abdomen
Paralytic ileus	Deep vein thrombosis (DVT)
	Pulmonary embolus