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signs
Review
●This article has been double-blind
Surgery peer reviewed
Principles of monitoring
postoperative patients
In this article... 5 key
he principles of postoperative care
T points
Reasons for vital signs monitoring 1 It is crucial to
follow
guidelines and
Considerations for transferring postoperative patients
policies on
postoperative care
Author Cathy Liddle is senior lecturer,
school of professional practice,
department of skills and simulation,
volume of high-risk patients and help
to plan the provision of facilities,
reporting to the trust board annually.
2 Using
evidence-
based tools can
Birmingham City University. make a stressful
Abstract Liddle C (2013) Postoperative Immediate postoperative care situation calmer
care 1: principles of monitoring Postoperative patients must be monitored and more
postoperative patients. Nursing Times; 109: and assessed closely for any deterioration in controlled
22, 24-26.
Postoperative care is provided by peri-
operative nurses. They are often
condition and the relevant postoperative
care plan or pathway must be implemented.
The NCEPOD (2011) report found that
3 Proficiency and
patient safety
should be
experienced in a specialised area of patients whose condition was deteriorating maintained by
surgery that requires specific care for the were not always identified and referred for updating
intervention performed. This article, the a higher level of care. Patients should be knowledge and
first in a two-part series, identifies the made as comfortable as possible before understanding
principles of postoperative nursing care.
These remain reasonably consistent over
the years but nurses must ensure they
postoperative checks are performed.
Postoperative patients are at risk of
clinical deterioration, and it is vital that
4 All vital signs,
observations
and assessments
keep up to date with guidelines, policies this is minimised. Knowledge and under- performed must be
and evidence-based practice. standing of the key areas of risk and local recorded
5
A
policies will help reduce potential prob- Patients should
report by the National Confi- lems (National Patient Safety Agency, be educated
dential Enquiry into Patient 2007; National Institute for Health and on how to prevent
Outcome and Death identified Clinical Excellence, 2007). postoperative
a need for a UK-wide system Track and trigger or early warning sys- complications
that would enable health professionals to tems are widely used in the UK to identify
identify high-risk surgical patients easily deteriorating patients. These have been
and quickly and for their care to be man- adapted by trusts for adults and children
aged appropriately (NCEPOD, 2011). This and are based on the patient’s pulse and
was accompanied by a number of other respiratory rate, systolic blood pressure,
recommendations: temperature and level of consciousness.
» Elective high-risk patients should be Additional monitoring may include pain
seen at a pre-assessment clinic; assessment, capillary refill time, per-
» Mortality risk should be assessed and centage of oxygen administered, oxygen
explained to the patient; this should be saturation, central venous pressure, infu-
documented on the consent form and sion rates and hourly urine output.
in the notes; The National Early Warning Score
» Trusts should provide sufficient critical (NEWS) was developed by a working party
care beds or care pathways to provide to provide a national standard for
support during the postoperative assessing, monitoring and tracking
period; acutely and critically ill patients (not for Automatic monitoring: many trusts insist
Alamy
» Surgical teams should calculate the use with children under 16 years or in vital signs are done manually as well
Times.net
go to nursingtimes.net/pain
and blankets to warm the patient if Box 2. AVPU scale Outcome and Death (2005) An Acute Problem?
London: NCEPOD. www.ncepod.org.uk/2005aap.
their temperature is too low; htm
» Choose an appropriate method to cool ● Alert National Institute for Health and Clinical
the patient if their temperature is too ● Responds to Voice Excellence (2007) Acutely Ill Patients in Hospital:
high (antipyretics/fanning/tepid ● Responds to Pain Recognition and Response to Acute Illness in
Adults in Hospital. www.nice.org.uk/CG50
sponging). ● Unconscious National Patient Safety Agency (2007) Safer
Caring for the Acutely Ill Patient: Learning from
Level of consciousness Serious Incident. 5th Report from the Patient
Safety Observatory. London: NPSA. tinyurl.com/
Postoperative patients should respond to Protection Scotland, 2012) or 72-96 hours NPSA-serious-incidents
verbal stimulation, be able to answer ques- (Department of Health, 2011). NHS Institute for Innovation and Improvement
tions and be aware of their surroundings A phlebitis scale can be used to help (2008) Situation, Background, Assessment,
before being transferred to the ward and assess the PVC site; the Visual Infusion Recommendation. London: NHS III. tinyurl.com/
NHSIII-SBAR
throughout the postoperative period. Phlebitis Scale (Jackson, 1998) is frequently Nursing and Midwifery Council (2009) Record
A change in the level of consciousness used and recommended by the RCN (2010). Keeping: Guidance for Nurses and Midwives.
can be a sign that the patient is in shock. These national guidelines should be used London: NMC. tinyurl.com/NMC-record-keeping-
guidance
The AVPU scale (Box 2) is appropriate for as resources in caring for PVCs. The fol- Royal College of Nursing (2011) Standards for
assessing consciousness in adults, chil- lowing should be checked and recorded: Assessing, Measuring and Monitoring Vital Signs in
dren and young people unless they have » The PVC site when changing IV fluids, Infants, Children and Young People. London: RCN.
tinyurl.com/RCN-vital-signs
had neurosurgery (RCN, 2011). before administering IV medication; Royal College of Nursing (2010) Standards for
» Signs of phlebitis (redness, heat and Infusion Therapy. London: RCN. tinyurl.com/
Fluid balance swelling). RCN-infusion-standards
The NCEPOD (2011) found, in 30% of Royal College of Physicians (2012) National Early
Warning Score (NEWS): Standardising the
patient data reviewed, there was insuffi- Conclusion Assessment of Acute-Illness Severity in the NHS.
cient recording of postoperative fluid bal- The postoperative healthcare team is Report of a Working Party. London: RCP. tinyurl.
ance. Nurses should observe/undertake under constant pressure to discharge com/RCP-early-warning
and record on the fluid balance chart the patients quickly. This can lead to vital
following: signs being missed and result in a delay in
» IV fluids (colloids and crystalloids used recovery. in this series
to replace fluid loss postoperatively) Patients can be discharged quickly only
and infusions; when they do not experience any post- ● Postoperative care 1: principles of
» Oral intake; operative complications, many of which monitoring postoperative patients,
» Urine output: catheter urine measure- can be avoided or identified with correct 5 June 2013
ments should not be less than 0.5ml/kg/ and thorough monitoring of signs and ● Postoperative care 2: how to reduce
hour. Oliguria can be a sign of hypovol- symptoms. the risk of deterioration after surgery,
aemia and should be reported to All health professionals must continu- 12 June 2013
medical staff immediately. Check that ally update their theoretical knowledge
the catheter is not kinked or that the and clinical skills; those working in post-
patient is not lying on the tubing if operative care can do this by relying less on
urine output is reduced; electronic equipment and developing their Unlimited access
» Colour of stoma (where appropriate) ability to combine the use of assessment to learning units
and whether there is any bleeding; tools with good observational skills;
» Nausea and vomiting: if necessary, feeling, listening for abnormal sounds and Nursing Times
administration of antiemetics should closely observing their patients.
be checked and vomit bowls and tissues Part 2 of this series, to be published in
subscribers can now CPD
should be within easy reach of the next week’s issue, discusses postoperative enjoy unlimited FREE
patient; pain control and patients’ care up to dis- access to learning units,
» Oral care; charge from hospital. NT each worth £10+VAT!
» Nasogastric tube drainage (aspirate if
patient feels nauseous unless otherwise References l Over 30 units to choose from and
indicated); Department of Health (2011) High Impact new ones added monthly
» Colour and amount of wound drainage: Intervention No 2: Peripheral Intravenous Cannula l Each provides at least 2 hours’
Care Bundle. London: DH. tinyurl.com/DH-cannula-
large amounts of fresh blood could be bundle
CPD to count towards your
an indication of haemorrhage; if there Health Protection Scotland (2012) Targeted PREP requirement
is no wound drainage, it is advisable to Literature Review: What are the Key Infection l Units focused on case-based
check that the drain has not fallen out. Prevention and Control Recommendations to scenarios to help you transfer
Inform a Peripheral Vascular Catheter (PVC) theory into clinical practice
Maintenance Care Quality Improvement tool?
Intravenous infusions Glasgow: Health Protection Scotland. tinyurl.com/
The RCN (2010) and Health Protection HPS-PVC
Jackson A (1998) Infection control: a battle in vein To subscribe visit:
Scotland (2012) recommend that periph- infusion phlebitis. Nursing Times; 94: 4, 68-71. subscription.co.uk/nurstimes/nvcw
eral venous catheters (PVC) are checked National Confidential Enquiry into Patient Subscribers – activate your
daily as a minimum, and consideration Outcome and Death (2011) Knowing the Risk. A unlimited access:
Review of the Peri-Operative Care of Surgical nursingtimes.net/activate-now
given to removing any PVC that has been Patients. tinyurl.com/NCEPOD-knowing-risks
in situ longer than 72 hours (Health National Confidential Enquiry into Patient