Returning Home After Surgery - A Ptients Guide

It is not at all unusual to feel apprehensive about returning home. Some- times these feelings are prompted by concerns about leaving the security of the hospital, with its expert medical team and equipment. Remember that no patients are allowed to go home until the doctor thinks their condi- tion is satisfactory for them to continue their safe recovery at home. Dependinq on your recovery, the surqical team will organize your discharge. Since you have been through a major operation, the preparation of the discharge summary may take some time, as it has to be checked and re-checked to ensure that an accurate account of your treatment has been stated. One of the members of the team will go through the discharge summary with your relatives. You should also read the discharge summary in details and any factual error should be brought to the hospital's notice immediately. Once the discharge summary has been issued, no changes can be made in it under any circumstance. Also one of your relatives will need to go to the accounts department on the ground floor to get the final clearance of accounts.

The hospital normally makes it possible for you to check out by 10 AM. Transport will have to be arranged by your relatives or friends and it is perfectly safe for you to travel home sitting in the car.

Long distance journeys should not be taken for a week or so. This is only to ensure that help is close at hand should you need it.

Recovery from heart surgery usually takes 4-6 weeks. During this time, you start to build up your strength and get back to your normal routine. When you first get home, your activities should be the same as they were in the hospital. Do a little more each day. Rest when you are tired. Don't overdo it. Don't set goals. Face each day as it comes. Do things pragmatically and within your capabilities. Do not compare yourself to some one else. No two people are alike, neither in their looks, nor be- havior, so how can they be alike in their recovery?

It's normal after surgery to have a "let down" or depressed feeling. You may be tearful or cry. At times you may be irritable. Some people have bad dreams. Others have a loss of memory or can't concentrate. These emotions should go away by the end of your recovery (4-6 weeks). There is no embargo on speaking or interacting socially, as long as you do not feel tired & exhausted.

During the first week after surgery, your chest incision may be bruised. It may also itch, feel numb or be sore. At times your back or shoulder may also feel sore. All of these things are common and will go away slowly.

For back and shoulder soreness, maintain good posture and move your neck & shoulder muscles in a normal way. A good posture means sitting or walking straight, without resorting to a slump. Do not raise your hand above the shoulder height and do not lift heavy weights. A mild pain reliever may also help. If a vein graft was taken from your leg, you may notice some swelling. Elevating your legs will help. If an arterial graft was used from your arm (radial artery), you may notice some numbness in your thumb and index finger. This will improve with time. It takes 6-12 weeks for the breastbone to heal completely. Wires hold this bone together, but you can't feel them. During this healing time you may notice slight clicking or movement of sternum (breast bone) when you breathe or turn. This is common and should go away when your sternum heals. Women may find that wearing a brassier can add support and reduce parn.' Choose a comfortable but a firm and fitting brassier that is not binding.

Take several short walks between times of rest. This keeps you from getting too tired while you are building your strength. You can climb stairs, but take your time and go slowly. Sit down and rest if you become tired, short of breath or dizzy. Do not cross your legs while sitting as it hampers blood circulation in the legs and increase the chances of clot formation in legs. Do the amount and kind of exercise your doctor or physiotherapist suggests. Exercise improves muscle tone and strength after surgery. You can start going out of your house for short walks, but always keep help at hand.

At first you may be weak, so have someone close by to help you if needed. Until you feel stronger, it may help to place a stool in the shower. Wash your incisions gently with soap but DO NOT SCRUB. Pat dry. Leave wounds open, unless they are weeping & wet. Taking bath daily is desirable and strongly recommended.

Eating well-balanced meals will speed your healing and make you less tired after surgery. Your appetite may be down but it will pick up as you start to recover. Try eating small meals more often rather than two or three large ones. If you have diabetes, it is important to keep your blood sugar under control. A healthy heart diet is low in cholesterol, saturated fats, sugar, salt and calories. The doctor (cardiologist), dietitian or nursing staff will explain how to modify your eating habits. It is wise to reduce coronary risk factors as much as possible by reducing saturated fats, cholesterol and salt in the diet. It is very important to avoid being overweight. Obesity is bad for any heart patient. Generally the same food as the rest of family can be taken, if tolerated. Avoid salty foods such as potato chips. Salt should not be added to your plate but normal cooking salt is all right. Fatty foods are best avoided, so are aerated drinks. Take plenty of fruits, fresh vegetables & roughage in diet. Avoid confectionary and bakery products. Do keep track of invisible fats and calories especially in the form of major snacks between meals

Nutrition experts generally agree that keeping blood cholesterol at normal levels reduces the risk of heart complications in persons who have coronary artery disease. It is a good idea to check your blood cholesterol periodically. If it is high you will have to reduce it by proper diet and exercise. If diet and exercise don't do the job, medication may be needed.

Use small amounts of vegetable oil in cooking. Corn, Soy, Sunflower, Peanut and Olive oils are better to use. Bake, boil, steam or grill. Don't fry and don't add salt at the table. Don't refry food & don't reuse oil after it has been used once as repeated heating of oil leads to production of transfatty acids which are harmful to your heart and lead to cholesterol deposition in the arteries of the heart.

Do not drive a car or scooter for about 4-6 weeks after surgery. During recovery your reaction time will be slowed due to weakness, fatigue or medicines. If you unfortunately meet with an accident, even while wearing a seat belt, you could hit the steering wheel and re-injure your sternum.

Wait until after 4 to 6 weeks to begin household duties (child care, making meals etc). During the first two weeks at home, as you get stronger, you may feel like:

• Setting and clearing the table
• Dusting furniture
• Potting plants
• Shopping!

Any thing that is very tiring or causes discomfort should be stopped until after recovery. Do not lift more than 2-4 kg at a time for 4 to 6 weeks after surgery.

For some of you, surgery forced you to stop smoking. It is very important that you continue to not smoke. It may be hard not to smoke again, but you can do it. Stopping to smoke is one of the best things you can do for your heart and your health. Smoking has a bad effect on the heart, as well as on other parts of the body. It is a major risk factor for additional heart dis- ease after your surgery. If you smoke, quit and if you don't, please don't start.

You may be asked to wear support stockings or crepe bandages during the first part of your recovery when you are less active. These stockings/ bandage aid blood flow and help reduce swelling in the legs. Keep wearing the stockings/crepe bandages for 4-6 weeks or till your activity is back to normal and swelling of the legs has disappeared.

If you have a problem with leg swelling

• Raise your legs when sitting or lying down so that your toes are above the level of your heart
• Don't stand for long periods of time.

Alcohol

Drink only if you have no addiction problem. You may drink alcoholic beverages, in moderation only, NEVER exceeding two drinks per day (60ml of 80% proof whisky or 200-300ml of red wine). Too much alcohol can weaken the heart muscles.

Recommended Food Products after Coronary Artery Surgery

• Skimmed milk and its products.
• Lentils.
• Low cholesterol butter.
• Poultry, fish, white of egg.
• Soups.
• Butter milk, coconut water, lime juice.
• Wheat flour with bran, besan.
• Green leafy vegetables.
• Fruits - apple, orange, sweet lime, grape, pears, water melon, musk melon.
• Grilled, baked, sesamed and roasted foods.
• Dry Fruits - 15-20 gm / day

You should take only those medicines, which have been prescribed in the discharge summary. Don't keep taking medicines that you took before the operation unless they are specifically prescribed. Before you leave hospital make sure you know which medication you have to take and what each tablet is for. This is most important. If you are to take anticoagulants (blood thinning tablets) you must understand how often the follow-up blood tests are to be done.

Some people get blood clots inside an artery, a vein or the heart. This may be a problem in people with irregular heartbeats, previous blood clots or heart valves that have been replaced. To lower the chance of having blood clots, an anticoagulant (such as Acitrom) is prescribed. Anticoagulants (often called "blood thinners") prolong the time it normally takes for blood to clot. If you are taking a blood thinner, keep appointments for regular blood tests (Prothrombin time/INR). This test tells your doctor how long it takes your blood to clot. This time is used to decide the right dose of blood thinner for you. While you are in the hospital, your blood will most likely be checked daily. When you first go home, PT/INR should be done twice a week for the 1't week, then once a week for the next two weeks. Later this test may be needed only once a month. The level of anticoagulation for you will be mentioned in your discharge summary.

Caution: Watch for signs of bleeding, if you are taking a blood thinner. Let your doctor know right away if you have:

• Black stools
• Pink or red urine
• A lot of bruising or unexplained swelling
• Severe headaches or abdominal pain
• Vomit that looks dark coloured
• Bleeding from nose or gums
• More than the usual menstrual periods

If any dental work or surgery is planned, let the dentist or surgeon know that you are on anticoagulants. Your doctor may ask you to stop taking them for some time

Some people get blood clots inside an artery, a vein or the heart. This may be a problem in people with irregular heartbeats, previous blood clots or heart valves that have been replaced. To lower the chance of having blood clots, an anticoagulant (such as Acitrom) is prescribed. Anticoagulants (often called "blood thinners") prolong the time it normally takes for blood to clot. If you are taking a blood thinner, keep appointments for regular blood tests (Prothrombin time/INR). This test tells your doctor how long it takes your blood to clot. This time is used to decide the right dose of blood thinner for you. While you are in the hospital, your blood will most likely be checked daily. When you first go home, PT/INR should be done twice a week for the 1't week, then once a week for the next two weeks. Later this test may be needed only once a month. The level of anticoagulation for you will be mentioned in your discharge summary.

Caution: Watch for signs of bleeding, if you are taking a blood thinner. Let your doctor know right away if you have:

• Black stools
• Pink or red urine
• A lot of bruising or unexplained swelling
• Severe headaches or abdominal pain
• Vomit that looks dark coloured
• Bleeding from nose or gums
• More than the usual menstrual periods

If any dental work or surgery is planned, let the dentist or surgeon know that you are on anticoagulants. Your doctor may ask you to stop taking them for some time

After any open-heart surgery, there is water retention in the body. Even the lens of the eye gets swollen and therefore you may get haziness of vision and inability to read small prints. Please do not change the lens of your glasses as this problem will go away automatically in 4-6 weeks time and you will be able to see normally once your lens tension returns to base line.

Usually patients are called for follow up on Saturdays in the OPD, room No.19, ground floor in front of the Echo lab, but you can always contact us any time during the day or night if there is any problem. The surgeon's role is very specific and technical, so usually only one or two postoperative visits need to be made with us. Your cardiologist shall do your regular follow up & risk factor control. Also your referring cardiologist will wish to follow your progress. So after your visit to the surgeon, make sure you have appropriate appointments with your cardiologist. Call the Doctor on duty if there is any problem (phone numbers have been provided in the booklet and in the discharge summary), viz if there is any sign of infection (redness or discharge from the incision), fever, chills, increased fatigue, shortness of breath, increased swelling on ankles, weight gain over 2 Kgs in 5 days, change in heart rate or rhythm or any other sign or symptom that seems disturbing. Please always contact the surgeon on duty in the hospital and refrain from ringing consultants directly at their residence numbers or mobile phones. If need be, the surgeon on duty shall contact the consultants who are available 24 hours and would visit you in the hospital.

For sedentary workers, the average recovery time is four to six weeks. For persons who must perform heavy work, the time is six weeks or longer, varying from patient to patient.

• Patients should follow these principles
• Get up at your normal waking time
• Bathe or shower daily if possible
• Always dress in regular clothes (don't stay in sleeping clothes during the day) & take interest in personal grooming.
• Take a rest period in the mid morning, at mid afternoon or after a period of activity.

Week 1

• Light activities
• Avoid any heavy lifting, stooping or bending
• Limit visitors
• Frequent 5-10 meters walks around house and garden
• Stairs - when essential, go slowly, and rest mid way

Week 2

• Gradually increase to moderate activities, more moving and for longer times
• Walking 10-15 minutes twice daily at a comfortable pace
• Start receiving visitors

Week 3

• Continue increasing activities
• Half day outings and small social outings, but not till late at night
• Walk 15-20 minutes twice daily

Week 4 - 5

• Longer activity times, faster walking
• Carrying light weights
• Walking 20-30 minutes, aim to walk 1 mile twice daily
• Social outings; such as cinema/theatre/temple
• You can visit a restaurant up to 3 hours

Week 6

• Most activities, unless exceptionally heavy
• Drive your car
• Normal sexual activities
• Return to job