Supportive Care

Supportive care involves caring for people around the time they have surgery. NAs play important roles before and after a person has had surgery.

Surgery

People have surgeries for many different reasons. Surgeries are classified as either elective, urgent, or emergency.

• An elective surgery is a surgery that is medically recommended or desired by the patient. Some elective surgeries are medically necessary but not in an immanently time-sensitive way.
• An urgent surgery is a medically necessary surgery that needs to be performed soon. Urgent surgeries can be scheduled in advance.
• An emergency surgery is a medically necessary surgery that needs to be performed immediately. Emergency surgeries may not be schedulable with much, or any, advanced notice.

Surgeries may cause somebody anxiety or distress. This is not unwarranted; surgeries come with risks, especially those that require anesthesia. The doctor or nurse will provide the patient with information about what will happen before, during, and after their surgery.

The NA’s role includes listening to the concerns of the person without belittling or minimizing those concerns. Be calm, compassionate, and attentive to the person’s worries, and answer any questions that fall within the NA scope of practice. If the person’s anxiety escalates or they ask questions that NAs cannot answer, notify the nurse so they can converse with the patient further.

Where and when?

Surgeries are either classified as in-patient or same-day.

In-patient surgeries involve a person staying in the hospital for at least one fully day after their surgery, though in-patient surgery stays may be longer depending on the kind of surgery and post-surgical complications. A person undergoing an in-patient surgery may need to be admitted to the hospital one or two days prior to their surgery for pre-operative care.

Same-day surgery is also referred to as outpatient or ambulatory surgeries. For same-day surgeries the person can go home the same day, or may need to stay until the next day, depending on how they respond to the surgery. Surgeries are usually done in hospitals or another specifically equipped location.

If a person goes to the emergency room and it is determined they need surgery then they may go right to surgery from the hospital’s emergency department.

What happens?

When a person is prescribed surgery, the doctor will be the member of the care team that explains the diagnosis and prescribed surgical procedure to the person and their family^[1].

The doctor will inform the person and their family about the surgery, the risks associated with the surgery, and possible post-operative complications. They will also be informed about the risks posed by not having the surgery and following other courses of treatment, or no treatment. Entering into a medical decision fully informed and aware is part of giving informed consent.

Questions about surgeries should be left for the doctor or nurse; NAs can provide a listening ear, but should not answer any questions outside of their scope of practice.

After the surgery the doctor will let the person and family know about the results of the surgery. Even if the rest of the care team learns the results before the family does, they should not answer any questions about the surgery’s results and should instead let the doctor have that conversation with the person and family. It is outside the NA scope of practice to discuss or answer technical questions about surgeries.

Preoperative care

A person about to have surgery will need to be taught a couple of protocols before they receive their operation. The person should learn how to perform deep breathing, coughing, and incentive spirometer exercises. These exercises should be performed every 1 to 2 hours post-surgery when the person is awake. They will also learn how to do their leg exercises, which must be done every 1 – 2 hours post-surgery when the person is awake.

If the person will require anesthesia for their surgery then they should be informed about the post-anesthesia care unit (PACU) where a person recovers from anesthesia immediately post-surgery. Once the person’s condition is deemed stable, they will be transferred out of the PACU for the remainder of their recovery.

Preparing for surgery

The person may have food and fluid restrictions during the hours or day leading up to the surgery. NA must follow fluid and food orders meticulously. The person may have an NPO (nothing by mouth) order for 8 hours or more leading up to the surgery. Going into a surgery with an empty digestive system can help to prevent vomiting and aspiration while under anesthesia.

The person will be taught the type and amount of pain to expect while recovering from the surgery. Every surgery, and every person, has a different recovery process with different kinds and levels of pain and discomfort.

A person should be briefed on all of their post-operative treatments and recovery equipment before they go into the surgery. Having this knowledge beforehand is an important part of holistic, person-centered care, and will allow the person to be more cooperative with the healthcare team during recovery.

Learning all of these facts about surgery is included in obtaining the patient’s informed consent for the procedure.

Preparing the person for surgery

Elimination

NAs should assist with voiding and bowel elimination as needed. If a person is about to receive bowel surgery, they may require bowel prep. Bowel prep involves cleansing the bowels of feces by drinking special fluids. Bowel cleansing is an important preoperative practice for bowel surgery patients because an open intestine that has not been cleansed may spill waste into the abdominal cavity, which would be bad.

When a person receives pre-operative care NAs will measure and record their urinary output. The person will void before their preoperative drugs are administered by the nurse; if they are already using a urinary catheter, their drainage bag should be emptied. A urinary catheter may be inserted in the operating room for accurate output measurement during and after surgery. A person should go into surgery with an empty bladder because a full bladder is more vulnerable to injury.

Thorough and cleansing personal care prior to surgery is an important infection control practice because it removes microbes from the body. Being as clean as possible going into a surgery will also help someone be more comfortable during their recovery^[2].

Preoperative personal care

• NAs should help the person with a complete bed bath, shower, or tub bath depending on their mobility. A special soap or cleanser may be ordered for the preoperative bath to reduce the risk of surgical wound infection.
• The person should not go into surgery with makeup, nail polish, or artificial nails.
• Remove all jewelry and hair adornment; the NA can place valuables in a secure place. Make sure to write down exactly what valuables the person has in facility safekeeping.
• The NA should administer oral hygiene care before surgery. Make sure the person does not swallow any water while receiving oral hygiene.
• NAs should remove and store a person’s dentures before the are taken in for surgery. Always store a person’s belongings, including their dentures, according to facility policy.
• People who have imperfect circulation may need to wear elastic stockings, also called compression or anti-embolism stockings, to promote healthy circulation during and after surgery. Elastic stockings are used to create even compression across the legs for smooth blood flow.
  • The risk associated with elastic stockings is that they will block circulation, rather than make it easier. NAs should regularly check the feet and toes of persons using elastic stockings for discoloration and cyanosis.
  • There should be no wrinkles or uneven areas in the sock.

Videoplasty.com, CC BY-SA 4.0

Communication is key

One of the most important roles NAs play in preoperative care is an emotional and communicative role. People preparing for surgery may be worried, anxious, apprehensive, or experiencing another negative emotion. NAs can help alleviate these feelings by providing reassurance and a listening ear. Refer any of the person’s questions NAs cannot answer to the nurse, and report signs of fear and anxiety.

Roberts, B. (2008, October 11). Pre- and Postoperative Care [Video]. Youtube. https://www.youtube.com/watch?v=XZq1gExGh8k

Anesthesia and Sedation

A person will likely receive either sedation or anesthesia for their surgery. Sedation and anesthesia allow procedures to be performed that would otherwise be intolerable in a person’s fully conscious state. Sedation is used to put somebody into a state of calm and relaxation or sleep, while anesthesia is a drug that causes a loss of feeling and sensation.

Sedation may either be minimal, moderate, or deep. Minimal sedation is given to relieve anxiety and agitation, and does not usually impact a person’s awareness. Moderate sedation involves calmness and a depression of conscious awareness, but still allows the person enough awareness to respond to verbal and tactile stimuli. Deep sedation puts somebody in a state of unconsciousness; they will be unresponsive and/or asleep.

Anesthesia is drug-induced loss of feeling or sensation. Drugs that produce anesthesia are anesthetics. The three common forms of anesthesia are general anesthesia, regional anesthesia, and local anesthesia.

• General anesthetics are usually administered through IV lines. General anesthesia induces a lack of consciousness and a total loss of feelings and sensation.
• Regional anesthesia induces a loss of feeling in a region of the body, such as below the waist, for a hand or foot surgery, or during joint replacement surgeries. The person stays awake when under regional anesthesia. Regional anesthesia is administered by injection into a regional body part.
• Local anesthesia induces a loss of feelings and sensation in a small area of the body. For example, local anesthesia would be used when removing a mole, pulling a tooth, or when stitching a wound.

A person recovering from a surgery where anesthesia was used will begin their recovery in the post-anesthesia care unit (PACU). They will be transferred out of the PACU when their condition has stabilized, which usually means at minimum that they are awake and alert with regular and consistent vitals.

Postoperative care

Postoperative care is the care that somebody requires while recovering from a surgery. Once the person’s condition has stabilized the PACU staff will notify the nursing team.

The PACU team will usually be responsible for transporting the person to their next room on a stretcher. NAs can assist with transferring the person from the stretcher to their bed, and with positioning the person comfortably.

The nurse will check the person’s incision site for damage or bleeding. The nurse will also double check the person’s catheter, IV, and tubing placement and function. Once the person has been carefully observed and checked, then their family can come be with the person as they continue recovering.

Preparing the room

NAs may be asked to prepare the person’s room for recovery from surgery. This will include making a surgical bed for easy transfer from a stretcher and moving any furniture that might get in the way of a stretcher transfer. NAs can also assist by making sure all necessary equipment is in the room. The necessary equipment includes all equipment that is always in a person’s room, such as a bedpan, and any special equipment that the person requires following surgery like an incentive spirometer or ventilator.

Repositioning

A person should be repositioned and/or turned every 1 – 2 hours to prevent pressure areas and to stimulate circulation. NAs should be aware of any positions the person cannot be put in due to their surgery.

The person is usually positioned so they can easily breathe (Fowler’s or semi-Fowler’s), and to prevent stress or pressure on the incision site. Positioning is also important for preventing aspiration by arranging the bed so that the head is slightly raised.

Fowler’s:

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Semi-Fowler’s:

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Nurses will communicate when and how often to reposition, and in which positions to place them. If questions remain, always follow up and check the care plan.

Turning or repositioning can be painful for the person. NAs should provide as much support as they can, and use smooth and gentle motions so as not to jostle the person or any of their equipment. If unsure about completing a motion smoothly NAs should always ask for help from other members of the nursing team.

Breathing

NAs should work with post-operative surgery patients on their ordered breathing exercises, usually every 1 – 2 hours. Keeping up a breathing and coughing exercise routine will help prevent the development of respiratory complications.

Closely observe any tubing and breathing devices to make sure they remain clean and free of kinks; if a person’s tubing looks like it needs to be cleaned, or a person using additional oxygen is making a gurgling sound when they breathe, the NA should alert the nurse right away.

Breathing exercises will usually include “turn, cough, deep breath” (TCDB) exercises, as well as the ordered use of an incentive spirometer to help with lung capacity and breath control. .

TCC ADN RN Program: Nursing Skills. (2014, December 31). Demonstrating postoperative exercises [Video]. Youtube. https://www.youtube.com/watch?v=flIV8c38zDE

Circulation

Circulation must be stimulated in the person’s legs. Circulation can slow after surgery, leaving someone at risk of developing blood clots. Thrombus is the term for a blood clot that is currently stationary in the blood stream. The risk with thrombi is that they will become an embolus, or a blood clot that travels through the vascular system until it lodges somewhere in a blood vessel, the lungs, the heart, or the brain^[5].

Signs and symptoms of thrombus include:

• a warm swollen area of the leg
• pain and tenderness in the leg
• skin discoloration
• chest pain
• shortness of breath

If the NA notices these symptoms they should alert the nurse at once.

Techniques for promoting healthy circulation

NAs should assist a person with their postoperative leg exercises every 1 – 2 hours. Doing so prevents muscle degeneration and stimulates healthy circulation^[6]. Doing range-of-motion exercises with the person can also help stimulate circulation in other parts of the body.

Stimulating circulation after surgery is necessary to prevent thrombi, or blood clots, from forming. Remaining stationary in bed or sitting for a long period of time puts someone at risk for developing blood clots, which are dangerous if they aren’t caught. The best thing to do is prevent them from forming in the first place.

Leg exercises and early ambulation are some ways thrombi are prevented in advance. A person may have difficulty the first times they try to walk. NAs should assist the person with early ambulation according to the care plan, even if only a little bit.

UNH Patient Education. (2013, May 13). My Surgery Guide: Improving Leg Circulation Exercises [Video]. Youtube. https://www.youtube.com/watch?v=SA_f0bj7oIE

Elastic stockings are used following a surgery to equalize pressure across the leg, promoting even and smooth circulation. Elastic stockings, or anti-embolism stockings, have a small hole in the seams near the toes so that NAs can check a person’s toes and feet for discoloration or swelling, which may indicate a lack of proper circulation.  Check a person’s toes regularly and report any abnormalities to the nurse.

A person receiving postoperative care should not sit or stand for prolonged periods of time, since this can slow the flow of blood and make circulation more difficult.

Nutrients and elimination

A person returns from surgery with an IV in place for nutrients and fluids, and begins on an NPO diet. If all goes well, the person’s diet will progress from NPO to a clear liquid diet, then to a full liquid diet, and then to a regular diet. How long the IV needs to be continued depends on the type of surgery performed and the person’s condition during recovery.

Frequent oral hygiene care is especially important when someone is NPO; provide regular oral care on a schedule and when requested.

Anesthesia, surgery, and being NPO affect normal bowel and urinary elimination. NAs should do what the nurse and doctor order, and what is in the care plan, to promote elimination following surgery. Enemas may given to ease post-surgical constipation, and catheters may be necessary if the person does not void soon after surgery.

A person’s intake and output are measured following surgery. NAs should note the time and amount of the first voiding, and continue to keep track after that.

Rest and care

A person requires substantial rest and comfort to fully recover from a surgery.

Continuing pain is a common experience while recovering from a surgery. The type and degree of pain depend on the extent of the surgery and the type of surgery performed and the site and size of the surgical incision.

The presence of tubing, casts, and other devices can be painful and uncomfortable. Depending on how the person was positioned during surgery and how long the surgery lasted there may be lingering discomfort from muscle soreness.

The doctor will order pain relief drugs to promote comfort following a surgery, and the care team will use the nursing process to find ways to make the person more comfortable and allow them to rest. Always follow the person’s care plan.                                                                                                                                                                                             Image by sOER Frank, CC BY 2.0

Excellent personal hygiene is import for the person’s comfort, mental wellbeing, and for infection control. Frequent oral care, hair care, and a complete bed bath following surgery help a person feel refreshed and comfortable. Always change any wet or soiled clothing or linens immediately.

Observing and reporting

NAs must closely observe people in postoperative care. Even though their condition has stabilized, changes can occur quickly. The NA should report any of these symptoms to the nurse immediately:

• An opening of the incision or the presence of excessive bleeding
• Uncontrolled pain
• Respiratory distress or complications
• Increased swelling or discoloration
• Uncontrolled vomiting
• Concerning changes to the person’s vital signs
• Any drastic change in the person’s condition

Cooling and Warming treatments

Sometimes doctors will order heat or cold applications for postoperative patients. NAs may not be permitted to perform hot and cold applications depending on facility policy. NAs should remember never to perform tasks they are not assigned or trained for.

Neel, K. (2020, October 3). Heat and cold application [Video]. Youtube. https://www.youtube.com/watch?v=B77CXAHKewE

Heat application

The primary benefit of heat application is that is dilates (widens) the blood vessels, which promotes increased circulation. By increasing circulation, heat application promotes the removal of excess fluids and waste products, and promotes the provision of oxygen and nutrition to cells throughout the body. Heat can relieve pain, relax the muscles, promote healing and blood flow, reduce swelling, and decrease joint stiffness^[7].

Some risk factors associated with heat application are burns and skin damage from the heat. People with diminished sensitivity to temperature, such as elderly persons, are especially vulnerable to negative side effects from heat application. Remember that after 15 – 20 minutes blood vessels contract rather than dilate, which is the opposite of the intended effect.

Types of heat application

Heat applications are either “moist” or “dry.” When using a moist heat application the warm water is in direct contact with the person’s skin. Water that is directly applied has a more potent and fast-acting effect than dry applications such as a warm pack. . Examples of moist heat applications include a hot compress, a hot soak, a sitz bath, and a hot pack.                                                                                                                                                                                                                                                                        “heat miser!” by picturemommy                                                                                                                                             is licensed under CC BY-NC-ND 2.0.

• A hot compress involves laying a warm and moist compress or washcloth over an area for 15 – 20 minutes, or until the area is red and/or uncomfortable. NAs should check the skin under a hot compress at least once every five minutes.
• A hot soak involves soaking an area of the body, such as a person’s feet, in warm water for 15- 20 minutes, or until red and/or uncomfortable.
• A sitz bath involves soaking the perineal region using a specific basin. This may be done following a perineal surgery, to promote perineal hygiene, or to reduce perineal pain or swelling.

Dry applications are heat applications where water does not come into direct contact with the person’s skin. Examples include hot packs and heating pads. Always follow the care plan and the nurse’s instructions when administering heat application treatments.

NAs must always record the time of heat application, when the heat application is removed, and any changes to the person’s condition.

Safety

Safety is one of the Big Three, so NAs should consistently reflect, “What safety concerns do I need to consider while giving this care? Am I missing anything?” Heat application come with some safety concerns NAs should keep in mind to avoid complications.

• Heat applications can cause burns. NAs should check the person’s skin regularly.
• Be wary of blood pressure changes caused by heat applications. NAs should take vitals as ordered, and report symptoms such as dizziness and lightheadedness, nausea, and other changes in the person’s condition.
• If the heat application is left on too long, blood vessels will constrict as a counter-response to prolonged heat exposure. When blood vessels constrict, the person’s skin will become pale. Remember that heat applications left on too long perform the opposite of their intended effect.
• NAs should be aware of metal implants such as pacemakers and joint replacements. Metal responds to heat differently than tissue does. NAs should always check with the nurse and the person’s care plan if unsure how to proceed with a heat application to a person with metal implants.

Cold application

Cold applications are useful when the doctor or nurse want a person’s blood vessels to constrict and decrease blood flow. Cold applications are useful right after surgery to help stop bleeding, and decrease swelling and pain. Cold applications are also used to treat conditions like sprains, fractures, and blunt force trauma to prevent swelling and excessive bleeding.

Moist cold applications include cold compresses (cold washcloth or similar), cold sponge baths and soaks, and any treatment where the cold water comes into direct contact with the person’s skin. Dry cold applications include ice bags and ice packs, and cooling blankets.

Cold applications come with potential complications that NAs must observe for. Cold applications may cause pain; if a person reports pain from their cold application, NAs should either stop the cold application or give the person a short break before trying the cold application again.

InjuryMap, CC BY-SA 4.0

• Cold applications reduce circulation, which means they may produce a numbing effect, or make the person’s skin pale, red, blue, or otherwise discolored. If the person reports numbness, or if the NA observes notable discoloration on the area of application, then the cold treatment should be paused or stopped.
• If cold is applied too long, or if the treatment is too cold, it can cause cold burns and blisters to occur. Early indication that somebody has been overexposed to cold are shivering and discomfort.

Safety

When using hot and cold applications, keep some basic safety information in mind^[8].

• Hot and cold applications are only applied for 15 – 20 minutes at a time, and the person’s skin needs to be checked at least every 5 minutes.
• Check the water temperature before starting a hold or cold application; make sure the temperature of the water matches the temperature listed in the care plan.
• Hot packs must never be placed under a person. Hot packs placed under a person are more likely to cause burns, and are less likely to be checked frequently.
• A person with a cold application should be offered blankets to help them stay comfortable.

Cooling and warming blankets

Cooling and warming blankets may be used when a person experience hyper- or hypothermia, respectively.

A person is considered hyperthermic when they have a body temperature significantly higher than the normal range. Cooling blankets may be used to cool someone down, and to quickly lower their body temperature if it reaches hyperthermic levels. Most cooling blankets used in healthcare facilities are electrically powered and can be set to a particular temperature. NAs must regularly check vitals to see how the treatment is affecting the person’s body temperature.

Hypothermia occurs when somebody’s body temperature is excessively low. Warming blankets may be used for persons experiencing hypothermia. Warming blankets are similar to cooling blankets in that they are powered and can be set to a specific temperature; in this case, the powered blanket is used to warm somebody up rather than cool them down.

NAs must frequently measure a person’s vitals while they are using a warming blanket. Once a person’s temperature has been brought back to normal levels heat application should cease until it is required again. Overuse of heat and cold applications can have the opposite of their desired effect.

Comprehension Questions

1) Why is supportive care necessary?

a. To help a person realize that they need surgery

b. To help a person regain financial stability after surgery

c. To help a person’s family plan for care following a surgery

d. To help a person heal fully and holistically from a surgery

2) Why are preoperative fluids restricted?

a. To prevent vomiting and aspiration while under sedation or anesthesia

b. To prevent vomiting and aspiration from nervousness

c. To prevent vomiting from happiness when the surgery is over

d. To prevent water retention edema

3) Please describe the nursing assistant’s emotional and communicative role during preoperative care. How should NAs interact with preoperative residents? What should they avoid doing, especially when communicating with residents who are anxious about surgery?

4) A person recovering from surgery where anesthesia was used will begin their recovery … where?

a. The PDCU, or the pre-discharge care unit

b. The PICU, or the post-incision care unit

c. The PACU, or the pre-anesthesia care unit

d. The PACU, or the post-anesthesia care unit

5) Respond to the following sentences with T (true) or F (false).

____ NAs will go and get the person from the PACU after they have reached a stable condition.

____ Postoperative patients should be repositioned regularly to promote respiration and keep pressure off of their incision site.

____ If a person’s tubing appears clogged or dirty, NAs should gently clean it according to facility protocol.

____ Laying someone flat on their back promotes easy respiration.

____ Patients should be encouraged to ambulate after surgery to promote healthy circulation and respiration.

6) Please list at least three, and up to five, signs and symptoms of thrombus.

7) What are some techniques NAs can use to promote healthy circulation following a surgery? Select all that apply.

a. Assisting with prescribed leg exercises

b. Encouraging the person to embrace bed rest

c. Providing support during ambulation soon after surgery

d. Practice Standard Precautions

e. Closely observe the person’s skin when they use anti-embolism stockings

8) Excellent personal hygiene, including oral and skin care, is important following a surgery. Why? Select all that apply.

a. It is an infection control measure

b. Having bad breath is embarrassing

c. It helps a person feel refreshed and comfortable

d. It speeds the healing process by up to 2x

9) Please list at least 4 and up to 7 observations about someone recovering from surgery that NAs should immediately report to the nurse.

10) Respond to the following sentences with T (true) or F (false).

____ The primary benefit of heat application is that it dilates blood vessels, which promotes circulation, relieves pain and swelling, and relaxes the muscles.

____ Moist hot or cold applications are when water comes in direct contact with the skin.

____ Only hot applications can cause burns or blisters if left on for too long.

____ Cold applications, when properly used, increase circulation to the impacted area.

____ Hot packs are sometimes most effective when placed under a person.

11) Describe the importance of the Big Three to supportive care, with a focus on Infection Control and Safety. Why are infection control measures extra important when somebody is preparing for or recovering from surgery? How can NAs ensure excellent infection control when providing supportive care? What sort of safety considerations must NAs keep in mind when assisting recent postoperative patients with their ADLs (bathing, repositioning, changing clothes, etc)?

12) You are caring for a resident before their surgery; as the surgery approaches, they are uncomfortable due to hunger, and are expressing anxiety about how the surgery will go. You try to listen, but eventually become annoyed by the regular complaints of hunger and displays of anxious thinking for what you know is a routine and low-risk surgery. After a certain point, your replies go from “I’m sure it’ll all be fine” to simply “mmm-hmm” in response. When the resident gets back from surgery, you can tell by their face and movements that they are in pain, and they seem withdrawn and depressed. How might the resident’s emotional and social wellbeing impact their ability to receive good care? What would you do at this point in this scenario? How could you have communicated differently with the resident to make them feel more cared for?