Post Operative Handover And Observations - Adult Patients ...
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Canberra Hospital
Standard Operating Procedure
|Post Operative Handover and Observations - Adult Patients (First 24 hours) |
Purpose
To ensure:
• Management of post operative adult patients in the first 24 hours post surgery
• Patients are transferred from Post Anaesthetic Care Unit (PACU) when conscious and appropriate for a ward environment
• Post operative observations are performed in accordance with best practice
• Complications of surgery are identified and managed effectively
• Interventions are implemented to ensure that the patient has a stable, comfortable and pain free postoperative period.
Scope
This document pertains to adult patients requiring post operative clinical handover and observations at the Canberra Hospital (TCH). Excluding patients approved for discharged by a medical officer prior to this time.
This document applies to:
• Medical Officers
• Nurses and Midwives who are working within their scope of practice (Refer to Nursing and Midwifery Continuing Competence Policy)
• Students under direct supervision
• Wardspersons.
Equipment:
• Alcohol based hand rub (ABHR)
• Patient clinical notes and observation charts
• Personal protective equipment (PPE) including safety goggles or shield and clean gloves
• Stethoscope
• Watch with a second hand
• Sphygmomanometer (blood pressure cuff)
• Oxygen saturation monitor
• Thermometer
• Intravenous (IV) pole – mobile
• Emesis basin / bag
• Bedside emergency equipment
• Specific equipment if required, e.g. bed cradle
• Automated observation machine where available
• Torch for Neurological Observations, where required
Procedures
|Before the Patient is Transferred from PACU to Ward |
PACU Nursing staff to ensure:
1. Receiving ward is aware of and has accepted patients admission/return to ward
2. Patient meets the PACU discharge criteria (Refer to PACU postoperative observation chart)
3. Patient oxygen delivery system has the patients identification label on it
Ward Nursing / Midwifery Staff to ensure:
1. Patient bed area has been cleaned
2. All emergency equipment is functioning and available, including oxygen and suction.
| |
|ALERT: All patients will be transferred from PACU with a nurse / midwife and/or medical officer escort and wardsperson (with PACU |
|transfer pack). |
|Clinical Handover from PACU to Ward Staff |
Ward Nursing / Midwifery Staff:
1. Attend hand hygiene before touching the patient by either hand washing or using alcohol based hand rub
2. Don PPE
3. Patient identification and allergy band is checked against clinical notes/stickers
4. Check patient’s airway is clear and observe for effort of breathing (i.e. use of accessory muscles).
|Note: If airway is compromised place the patient in the lateral position (if not contraindicated), and consider Medical Officer review. |
5. Ensure the oxygen is attached to wall oxygen outlet
6. Confirm flow rate as ordered (PACU staff responsibility on arrival at ward – checked by ward staff to ensure correct flow rate)
7. Ensure equipment has been plugged in and cords are positioned safely under bed or off the floor
8. Attend hand hygiene before touching the patient again by either hand washing or using alcohol based hand rub
9. Clarify the operative procedure performed
10. Review operative report with PACU staff including specific post operative orders
11. Discuss the patients’ medical history and impacting co morbidities
12. The PACU nurse hands over verbally to the ward nurse at the patient bed side
13. Handover should include:
13.1. Oxygen requirements including type of oxygen delivery system and flow rate (e.g. Nasal prongs, 4litres of oxygen per minute)
13.2. Tracheostomies including size, type, cuff inflated or deflated, a site check for blood and/or discharge, frequency and type of secretion suctioned (refer to Tracheostomy Management SOP)
13.3 Any peri and post operative breathing difficulties and interventions
13.4 Review of peri and post operative vital signs, including any interventions required for stabilisation
13.5 Any peri and post operative neurological concerns including behavioural difficulties
13.6. Review the fluid balance chart, check all intravenous fluid insitu, received in theatre and continuing orders, check IV device e.g. CVC, PICC, IVC (date of insertion, patency, site, and is appropriately secured). Ensure all IV lines are labelled appropriately
13.7. Urinary drainage devices e.g. Indwelling Catheters (IDC), Urostomies, SPC, Ureteric Stent (ensure hand hygiene is attended after contact with these devices), if no urinary drainage device insitu confirm last time patient voided
13.8. Check any drains insitu e.g. wound drains; chest drain and output (ensure hand hygiene is attended after contact with these devices)
13.9. Any nasogastric tube for drainage or feeding. Check output. Ensure orders are clearly documented in the notes as to purpose, use and position of tube (ensure hand hygiene is attended after contact with these devices)
13.10 Ensure all output is documented on Fluid Balance chart
13.11. Medications administered in theatre and medication chart review
13.12. Any intravenous medications ordered and given (e.g. antibiotics, antihypertensive)
13.13. Any wounds, dressings, wound packing or vaginal loss
13.14 Post Partum observations, including vaginal loss and fundal height
13.15. Any pain management devices including Patient Controlled Analgesia (PCA), Epidurals, Pain Busters, Continuous Opioid infusions, regional local anaesthetic infusions, etc and single shot analgesia technique without pain management device i.e. single shot local anaesthetic block or intrathecal/epidural morphine single dose administration for post operative pain relief (refer to appropriate Pain Management Unit [PMU] policies or SOPs)
13.16. Limb neurovascular observations (if applicable, e.g. orthopaedic, vascular & plastic surgery)
13.17. Perform and document a full set of Vital signs and Modified Early Warning Score (MEWS) including:
o Respiratory Rate (RR)
o Oxygen Saturations
o Temperature
o Blood Pressure (BP)
o Pulse (P)
o Level of Consciousness (LOC)
o Urine Output (UOP)
14. All observations are to be recorded on the Modified Early Warning Score (MEWS) charts and appropriate adjunct charts (i.e. neurovascular, neurological, PCA, Epidural, Intrathecal/ epidural morphine etc)
15. Ensure all of the above are completed prior to PACU nurse leaving ward area and patient care is accepted (Ensure that PACU post operative chart is signed by PACU and ward nurse)
16. Ensure all observation requirements are documented on the Nursing Care Plan
17. Attend hand hygiene after by either hand washing or using alcohol based hand rub.
| |
|ALERT: All observations should be attended in the presence of the PACU nurse to ensure any abnormalities may be identified and managed as|
|soon as possible. If the patient does not meet the PACU Discharge Criteria (Refer to PACU observation chart), ward staff are to request |
|the patient be reviewed by the anaesthetic registrar or medical officer and/or returned to PACU for further recovery. |
| |
|If the patient meets the MET criteria, activation of MET should occur. |
|Ward Observations |
1. Record vital signs (RR, oxygen saturation, temperature , BP, P, LOC and UOP) as per post anaesthetic observation regime or more frequently as prescribed
2. Continue to monitor patients’ skin for colour and temperature changes. Note any increased sweating or clammy skin
3. Perform formal neurological observations if ordered using the Glasgow Coma Scale (GCS) or if not returned to previous LOC
4. Observe the wound dressing for ooze or blood loss. Note colour, amount and odour (if any),
reinforce wound if required. Do not remove theatre dressing
5. Inspect the surgical area for swelling or discolouration (with dressing intact)
6. Inspect the condition and contents of any drainage tube and equipment. Note volume and type of the drainage (be descriptive, e.g. large, haemoserous, chyle, purulent)
7. Contact the Medical Officer for review if excessive swelling, discolouration or blood loss is observed
8. Monitor intravenous therapy and intravenous cannula site (record IVT on fluid balance chart)
9. Encourage deep breathing and coughing exercises and limb movements with routine observations (unless contraindicated)
10. Unless contraindicated, offer ice to suck or sips of water (record on the fluid balance chart)
11. Before initial dose of analgesia check recovery records noting if and when analgesia had been administered.
12. Assess pain and administer analgesia as prescribed (unless contraindicated by Intrathecal/Epidural Morphine, Continuous Opioid infusion, Patient Controlled Analgesia or Epidural, refer to Pain Management Unit (PMU) SOPs).
13. Reassess effectiveness of analgesia hourly (or as per PMU SOPs), and request review as required.
14. Orientate the patient to their surroundings on admission or return to ward, reinforce when attending to observations
15. Review with the patient the expectations of the post-operative recovery phase
16. Inform the patient of the presence of drains or infusions
17. If no urinary drainage devices encourage the patient to void. Measure and record on the patient's fluid balance chart
| |
|Alert: If urine is not passed in the first six (6) hours postoperatively, assess the patient for bladder distension and notify the |
|medical officer. |
17. Offer / attend to bed bath
18. Dress in personal nightwear if desired
18. Offer / attend to mouth care, replacing dentures if applicable
19. Position the patient in accordance to post operative instructions
20. Ensure that the call bell is within reach
21. Lower bed and elevate bed rails to maintain patient safety if required. Note: where patients are disorientated consider hi low bed.
21. Commence diet and fluids as ordered (continue to monitor tolerance of diet)
22. Document all observations on the appropriate charts, e.g. MEWS, fluid balance chart, in the
patient's clinical record and escalate if required according to MEWS and MET criteria
23. Record in the patient's clinical record all post-operative nursing care provided
and the patients response
24. Notify next of kin of patient’s return to ward and document in the Clinical Record
|Post-Anaesthetic Observation Regimes |
| |
|ALERT: A full set of Vital signs includes Respiratory Rate, Oxygen Saturations, Temperature, Blood Pressure, Pulse, Level of |
|Consciousness and Urine Output. A full set of Vital Signs must be performed every time vital signs are taken in the post operative period|
|(Refer to Adult Vital Signs and Early Warning Scores). |
General/Epidural/Spinal Anaesthetic
Full set of Vital Signs:
• On return to ward, then
• Half hourly for two (2) hours (30mins x 2 hours), if MEWS ≥ 4 continue half hourly (Refer to “Adult Vital Signs and Early Warning Score SOP”) (excluding Day Surgery Unit)
• When MEWS ................
................
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