After Going Home from Hospital: Home Rehabilitation After Surgery

The moment of discharge is often a great relief: the operation went well, the tubes are out and the patient can finally go home. Yet many patients and families find only two or three days after getting home that they have the same problem: in hospital, nurses and therapists guided activity, but at home that support suddenly disappears. The family wants to help the older person out of bed but fears pulling on the wound, wants the person to walk a few more steps but fears a fall, and so the safest thing seems to be staying in bed to rest. These few days of not daring to be active are exactly what easily lets the rehabilitation gains made in hospital slip away.

First, the most central idea: the first few days after discharge are not a rest period but a bridging period. Staying in bed without moving is itself what breeds the complications of surgery. In healthy adults, just 5 days in bed without putting the feet on the floor lose nearly 10% of leg muscle strength, and two weeks in bed lose more than 20% (Wall et al. 2014). This article takes up three practical questions: how to arrange the first few days after discharge, what caregivers should note and how to check the home environment. It finishes by setting out clearly which work must be left to a nurse.

This gap after discharge is especially common in Hong Kong. The length of stay in public hospitals keeps getting shorter, so patients often have to leave before their fitness has fully recovered, and then cannot necessarily arrange a follow-up visit or community rehabilitation straight away. Rather than leave questions for the doctor until the next appointment, it is better to ask the therapist on the day of discharge which movements the patient can practise alone, when to add more, and which warning signs mean the patient must stop. Having this awareness that rehabilitation should link straight on from discharge is the key to stopping progress from going backwards.

Activity and care after discharge: who does what

The first decision on getting home is not how much exercise to do but to separate what family members can lead every day and what must be left to professionals. If the two are confused, neither is done properly: activity that should be kept up every day is skipped, and a wound that should be left to a nurse is dealt with at home. The three lines below help to draw the distinction.

The third line is the one most easily confused. Physiotherapy is about how to move safely, while nursing is about how to observe and clean the wound, and a clear division of the two is what makes things safe. Cleaning the wound, observing discharge and caring for drains should be followed up by a visiting registered nurse, and readers can refer to wound and pressure sore carein the nursing area for how dressings and assessment are done. If the patient's strength falls sharply after getting home, to the point that the patient cannot even get up with support, this is a matter of deconditioning and needs assessment by a therapist.

The difference between a family member practising alongside and professional home guidance

Many caregivers ask: since the therapist has already taught the exercises at discharge, is it enough for the family to lead the practice at home? The answer is that the family’s daily leading is extremely important, but professional supervision and adding load step by step are what decide the result. The two complement each other and are not an either-or choice.

Daily care arrangements for the first week after discharge

Arrangements in the first week need not be complicated. Keeping up a few basic activities every day is enough to get through the gap. A practical daily framework is below, and the actual amount of exercise follows the therapist’s instructions at discharge.

1. 1
   Deep breathing every two to three hours

   After surgery it is especially important to prevent pneumonia and collapse of the lungs. The caregiver can have the patient sit upright, breathe in slowly and deeply, breathe out slowly, repeat five to ten times, and then encourage the patient to cough up any sputum. Research shows that the evidence for a three-ball breathing device alone is weak (do Nascimento Junior et al. 2014), and it works only together with deep breathing and getting active early.
2. 2
   Sit up at the bedside and stand while holding on at regular times

   The patient should avoid lying in bed for long periods. The caregiver can help the patient to sit on the edge of the bed at regular times with both feet flat on the floor, and once the body has adjusted, help the patient to stand for a while while holding on. This step lays a foundation for later walking and also helps to reduce falls from postural hypotension.
3. 3
   Short walks, a little longer each day

   The patient can try to walk from the bedside to the toilet or the living room, and it does not matter if support is needed or the walking is slow. Really getting out of bed and bearing weight on the feet to walk does more for venous return from the lower limbs and for preventing blood clots than just moving the legs in bed. The walking distance can be increased a little each day, and there is no need to hurry.
4. 4
   Build activity into daily life

   Getting up for a drink of water, putting on socks and stepping out to the balcony are already activity in themselves. It is not always necessary to deliberately do exercise. Building activity into daily life makes it easier for the patient to accept and less tiring for the caregiver.
5. 5
   Check the wound and general state once a day

   When the dressing is changed, also note whether the wound is red or has pus, whether one calf is swollen or painful, and whether the patient’s state of mind is off. Wound care is the nurse’s job, but daily observation still depends on the caregiver paying attention.

A tip on arranging the space: many Hong Kong homes have limited room, and there may not be enough space beside the bed to get down. The family can move the bedside cabinet beforehand to clear a barrier-free route to the toilet and put an armchair at the end of the walking route for the patient to rest. This kind of adjustment to the environment is often what is dealt with first at a home assessment. Demonstrating a hundred times in hospital is not as good as adjusting once in the real home setting.

How to check the home environment

A patient in the weak period after surgery who falls can easily lose everything gained. A simple fall-prevention check at home after discharge is far better than putting things right afterwards. The most common hazards at home are:

These details look simple, but the body’s reactions after surgery are very different from usual. Weakness, postural hypotension and a changed gait caused by pain can make even a familiar route risky. Patients whose cognition or alertness fluctuates are at higher risk. If, after discharge, the patient becomes confused or does not recognise the people nearby, watch for delirium after surgery, which is covered in delirium after surgery and early activity.

The activity principles above apply to all kinds of surgery. The pace of rehabilitation differs, though, by site of surgery. For example, after a joint replacement the approach is not to get enough rest before being active, but to have clear targets for range of movement and weight-bearing in the first few weeks.

When to ask a therapist for help

Daily leading is enough for basic activity, but in the following situations the family should no longer feel the way alone: walking getting less steady after discharge, pain in the joints or wound during exercise, a sharp decline in fitness, or no progress at all after a week of following the practice. The home physiotherapy provided by Nova Health’s registered physiotherapists assesses the patient’s recovery and the home environment on the spot, draws up a safe progression of activity graded by the site of surgery, and demonstrates the right ways to support the patient in person, so that the caregiver can take over safely in daily life and rehabilitation after discharge is seamless. Acute warning signs such as fever, a wound that opens and discharges pus, sudden swelling and pain in one calf, or breathlessness and chest pain are not matters of rehabilitation, and the family must contact medical staff at once or go to the emergency department.

Frequently asked questions