HSE West ( Full Text) Post Operative Care (Adult) J Feidhmeanrw:li na Seirl:iUse SWnae TITLE : IIeahh ScniI:c Ex cuine File Name: NG Gon FT NC P 025 Page 1 of 5 EDITION NO: 2 DATE OF ISSUE: 10 m November, 2008 REVIEW INTERVAL: COPY: 43 Every 2 Years UTH RIZ~~ ~Y:J2. N', erardine Ken~edy..J M~ ~ ~~ Maura Fitzg~ AUTHOR(S) Ann Reidy Date:;111 '01 0'1> TITLE: ADON/Nurse Practice Development Unit Date: ;20' 10, a; ~Director of Nursing TITLE: Clinical Placement Coordinator Reviewed By: Breda Fitzpatrick Laffan Alison Burgess CNM 11 Main Theatre Recovery Room CNS Pain Management LOCATION OF COPIES: RELATED DOCUMENTS: 1B; 1C; 1D;AlE,;2B; 2C; 2D; 3A; 3B; 3C; 3D; 4B; Trauma, ICU; HDU; CCU; HODU; AMAU; XRAY; 1. Nursing Care Plan Guideline (2008) Endoscopy Haemodialysis; SDW; Sunshine; 2. General Surgery /Procedure Care Plan (2007) Rainbow; Caterpillar; OPD & Denmatology; ; Main 3. Orthopaedic SurgeryfTrauma Care Plan (2007) Theatres; Day Theatres; Eye Theatres; NPDU; 4. Patient Controlled Analgesia (PCA) Mu~i- ADON Office; DON Office; Allocations Office :. Disciplinary Policy-Mid-Western Regional Oncology CNS, Haematology CNS, Palliative Hospitals, 2007 Care CNS, Breast Care CNS, Stoma Care CNS, 5. Report Writing Policy (2004) Clinical Trials, Haemovigilance, Smoking 6. Report Writing for the Mid-Western Regional Cessation. Hospital, (2004) (Nursing/Midwives Guidelines) 7. Nursing and Midwifery Organisational Communication Guideline (2008). 8. Staff-patienURelative Communication Guideline, (MWRH, 2008). DOCUMENT REVIEW HISTORY Review Date Reviewed/Edited By Signature September 2010
J FedJuneannadn na Seirbhi'se S1iinte licahh Scrvir.c Excculilol! TITLE : ( Full Text) Post Operative Care (Adult) Page 20f5 1.0Purpose 1.1 This guideline is intended to give guidance to nursing staff on the post operative care and management of patients. 2.0 Scope 2.1 The guideline applies to all Nursing Staff and Student Nurses under supervision. 3.0 Definition 3.1 Post operative care is the holistic care and management of a patient post surgery, and is directed towards the prevention of complications resulting from surgery and anaesthesia. 4.0 Roles and Responsibilities 4.111 is the nursing staff's responsibility to assess, plan, implement and evaluate care in conjunction with the multidisciplinary team. 4.2 Optimal management of patients throughout the post operative phase requires appropriate clinical assessment and monitoring as well as pre-emptive management, (Scottish Intercollegiate Guidelines Network, 2004). 5.0 Process: Recovery Room Nurse 5.1 The recovery room nurse ensures that the following criteria are fulfilled before a patient is transferred to the ward: the patient should be conscious, responding to voice or light touch, able to maintain a clear airway and have a cough refiex. Vital signs should be stable and oxygen saturations should generally be at about 96% or above. Pain and emesis should be controlled. Ensure that oxygen and fluid therapy are prescribed. 5.2 The recovery Room nurse transfers the care of the patient to the ward nurse giving a complete hand over report including: The nature of surgery performed, type of anaesthetic, length of time under anaesthetic, type of incision and wound dressing and any ooze from same, presence of drainage tubes, catheters and output from same, intravenous fiuids record, output of urine and estimate of blood loss, any complications during surgery, medications given including analgesia, (Drain 2003). 5.3 The recovery room nurse ensures that the operative record, anaesthetic record and recovery room notes are complete and hands over the patient in a stable condition. 2
te feldhmeannachl na Seirt:ruse Samte Health Service ExecutM: Oooradoyle, Limerick, Ireland Page 30f5 6.0Transferring the Patient To the Ward: The role of the ward nurse 6.1 The ward nurse ensures that patient is transferred to the ward on a theatre trolley with a tilt mechanism, brakes, cot side and oxygen. with a post operative tray containing a laerdael mask, guedel airway, emesis bowl, disposable gloves, tissues and any other equipment deemed necessary. 6.2 The nurse positions him/herself at the patients head, monitoring patient's colour and respirations during transfer. The patient should be transferred to a suitably prepared post operative bed using safe moving and handling techniques. Ensure a safe environment for the patient and that Oxygen, Suction, Call bell are within reach of patient, in working order and that the cot sides are up until the patient is fully conscious. 7.0 Immediate Post Operative Assessment, Nursing Management and Care Plan 7.1 Position the patient in the recovery position or an appropriate safe position as indicated by the type of surgery and any specific post operative medical instructions. 7.2The nurse completes and documents the first post-operative assessment immediately on return to the ward. This assessment should include: the patient's airway, colour and level of consciousness. all vital signs, including pain. 7.30xygen saturations should be monitored if the patient is on oxygen therapy and should generally be 95% or above. while on oxygen. Patients with respiratory dysfunction (e.g. COPO) must be monitored carefully in consultation with the medical and anaesthetic teams with regard to acceptable oxygen saturation levels, respiratory effort and oxygen therapy. 7.4 Monitor and fi uid intake and output, including intravenous fluids while the patient is fasting. urinary output, wound drains, nasogastric tube drainage and any nausea or vomiting. Ensure that appropriate prescribed anti-emetics are administered when required. 7.5 Monitor circulation and sensation in extremities following vascular or orthopaedic surgery and following epidural or spinal anaesthesia. 7.6 Check wound sites from the operation, and other sites such as the IV cannula site, Epidural site etc. 7.7 Repeat the Waterlow Pressure Risk Assessment. 7.8Attend to the patient's oral hygiene as needed. 7.9 Document the Post Operative plan of care in the Care Plan and document the outcome of all assessments in the patient's progress notes. 8.0. First 24 Hours post operative 8.1 Post- operative assessment will continue for 24 hours post surgery and according to anaesthetic or medical instructions. The monitoring regime should be reviewed daily for clinical decision making. Continue to monitor the patient as clinically indicated based on clinical assessment and medical orders, (See section 7 above). 8.2 Assist the patient in gaining independence following surgery and allow her or him the opportunity to ask questions. 3
fe fei1hmeannachl na Seirtmlse SlamlC Ilc2lth Scnice Executive Page 40f5 8.3 Check wound for increasing tenderness and any ooze. Do not change the wound dressing unless indicated, for example: saturated dressing, increasing tenderness at the wound site or after removal of any drains where medically ordered. 8.4 Encourage resumption of oral fluids and diet when indicated. 8.5 Encourage deep breathing, passive and active limb movements. Encourage the patient to mobilise as soon as appropriate. 8.6 Monitor the patient to ensure that anti embolic stockings are of the correct size and worn properly. 8.7 Report any significant changes to medical team, taking appropriate actions and documenting care needs and evaluation in the post operative care plan and outcomes/evaluation in the progress notes. 8.8 Provide assistance with activities of living, promoting independence. 9.0 Pain Management 9.1 Carry out regular pain assessments. 9.2 Encourage the patient to verba lise pain severity so that early interventions can be initiated. 9.3 Reinforce the use of Patient Controlled Analgesia (PCA) if appropriate. 9.4 Administer regular analgesia as prescribed and monitor its effectiveness. Offer non pharmacological comfort measures i.e. distraction, change in position, breathing techniques and ensure as quiet an environment as possible. 9.5 If problems persist, refer to the Clinical Nurse Specialist (CNS), in pain management or a member of the pain management team 4
1 Feiihmeannadll na Seitblti'se SWntc lkalth Servio.: Exceuli'lc HSE West Page 5 of 5 Bibolography: Alexander, M.F, et al (2006) Nursing Practice Hospital and Home 3rd Edition Churchill Livingston Elsever AORN (2000) Recommended practices for safety through identification of potential hazards in the peri-operative environment, 72(4), 690-8. Dougherty, L. & Lister, S. (2004) The Royal Marsden Hospital Manual of Clinical Nursing Procedures. 6 th edition. Blackwell Publishing. Oxford. Drain,C. B. (2003). Perianaesthesia Nursing: A Critical Care Approach, 4th edition Saunders, U.S.A. Hanney B (1992) Post operative observations, in Journal of Clinical Nursing, 1 (4):174. Hughes, E.(2004) Principals of Post- operative patient care, in Nursing Standard, 19 (5): 43-51 Meeker, M. H. & Rothrock, J. C. (1999) Alexander's Care of the Patient in Surgery 11th edition MosbY,lnc, Scottish Intercollegiate Guideline Network (2004) Postoperative management in adults, from the internet: www.sign.ac.uk Taylor MS., (2001) Managing postoperative pain, in Hospital Medicine. 62: 560-563. 5