Stress bleeding potential in post-op instructions
Stress bleeding potential in post-op instructions
Same-day surgery programs need to emphasize the potential for post-tonsillectomy hemorrhaging in the post-op instructions, managers advise.
"We make sure it’s on the discharge instruction sheet they take home: If anything like that happens, they should notify their physicians immediately, or, if they can’t reach them, come to the hospital ED," says Celine Belling, RN, BSN, CNOR, director of nursing at Children’s Hospital of Buffalo/Kaleida Health in Buffalo, NY.
The Mayo Clinic in Rochester, MN, recently presented a 13-year retrospective review of 4,662 inpatient and outpatient tonsillectomy patients. The review indicated 90 (1.93%) cases of bleeding. Most of the bleeding occurred five to seven days after surgery. Approximately half (47%) of the 90 bleeders had to receive a second general anesthetic. The study, "Evaluation of Post-tonsillectomy Hemorrhage and Risk Factors," was presented at the September meeting of the Alexandria, VA-based American Academy of Otolaryngology — Head and Neck Surgery.
"If a child is spitting bright red blood, the child should come to the ED. Sometimes we can cauterize it, but if it doesn’t stop, you have to go back to the OR," says Julie L. Wei, MD, resident in the department of otorhinolaryngology at the Mayo Clinic and one of the study authors.
Ask patients or their parents about bleeding in the post-op phone call, Belling suggests. "We specifically ask, Have you noticed any bright red blood on your child’s tongue, teeth, or lips?’" she says.
Bette Nelson, RN, day surgery nurse manager at Driscoll Children’s Hospital in Corpus Christi, TX, advises patients that they might experience bleeding around the seventh day. The teaching begins with the pre-op visit, she says.
"We tell them they’ll need to take it easy," Nelson says. The postoperative instructions also address bleeding, she says. (See samples enclosed in this issue.)
Nelson has worked with other nurses to develop post-op instructions for children for specific surgeries, including tonsillectomy. The instructions are the same as with adults, but in a cartoon format. (See sample enclosed in this issue. To order, contact Nelson. See source box, p. 128.)
Don’t cause patients and parents to panic if they see blood, Nelson advises. "We tell them, It’s like a scab that comes off too soon. It’s not healed, so there’s bleeding underneath. You just need to stop the bleeding,’" by obtaining assistance from the physician or emergency department, Nelson says.
It’s also important to tell patients who drink to abstain from alcohol for a minimum of seven to 10 days, Wei says. "After two weeks, the throat should be back to normal," she adds.
The Mayo study showed 11 (12%) of the 90 bleeders had more than one episode of bleeding, usually three to four days after the initial bleeding at five to seven days. The reason is uncertain, Wei says.
"We want surgeons, parents, and patients to be aware that if your child has one episode of bleeding, be alert and aware," Wei says. "We always tell parents, it’s not up to them to decide how serious bleeding is. It should not be up to the patient." Tell them to follow up with the surgeon, she advises.
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