Policies & Procedures for Nursing Department

Issue Date: 01/01/2005

Revision Date: 31/05/2015
Code #: ND/GNSURG/002
Page 1 of 12

1.0 TITLE: POST OPERATIVE CARE

2.0 POLICY:

Patient’s safety and comfort is observed throughout the immediate and subsequent post
operative care. Postoperative patients must be monitored and assessed closely for any
deterioration in condition and relevant post operative care must be implemented. Post
operative evaluation is done and signed by the Anesthetist that the patient is safe for
transfer from the Recovery Room to the Ward.

3.0 INTRODUCTION:

During the first 24 hours after surgery, nursing care of the hospitalized patient on the
general medical-surgical unit involves continuing to help the patient recover from the
effects of anesthesia, frequently assessing the patient’s physiologic status, monitoring
vital signs and for complications, managing pain, and implementing measures designed
to achieve the long range goals of independence with self-care, successful management
of the therapeutic regimen, discharge to home, and full recovery. In the initial hours after
admission to the ward/unit, adequate ventilation, hemodynamic stability, incisional pain,
surgical site integrity, nausea and vomiting, neurologic status, and spontaneous voiding
are primary concerns. Nurses have to ensure patient’s safety, and to be vigilant in
providing holistic, age-specific nursing care during this recovery stage because
postoperative patients are at risk of clinical deterioration, and it is vital that this is
minimized and identified so they could be referred for a higher level of care.

4.0 PURPOSE:

4.1 To assess the patient’s condition immediately upon return to the ward.

4.2 To prevent post operative complications.

4.3 To promote patient’s comfort and safety after the surgery.

4.4 To provide continuity of care to patient after surgery.

5.0 PROCEDURES:

5.1 Prepare patient’s room by assembling the necessary equipment and supplies e.g.
IV pole, suction equipment, oxygen, emesis basin, tissues, disposable pads,
necessary linens, and postoperative documentation forms (e.g. Nurse’s
Observation Chart)

KAAH ND-GNSURG-002
Policies & Procedures for Nursing Department
Issue Date: 01/01/2005
Revision Date: 31/05/2015
Code #: ND/GNSURG/002
Page 2 of 12

5.2 Inquire regarding other items needed when the call comes to the unit about the
patient transfer from the recovery room to the ward/unit.

5.3 Proceed to the Operating Room (Receiving Area) to receive patient and verbal
handover from the Recovery Nurse.

5.3.1 Ascertain to bring along appropriate stretcher or bed with clean linens as
top sheet and other equipment and supplies (e.g. extra linen, pillow)
needed for the transfer of the patient.

5.4 Check for correct patient’s identity using two identifiers:

5.4.1 Patient’s Name – positive identification by asking patient or

watcher/relatives to state patient’s name

5.4.2 Medical Record Number – verification of patient’s medical record number

5.5 Make a brief and thorough assessment of patient airway, breathing and circulation
and level of consciousness (LOC).

5.5.1 Level of consciousness will be impaired in patients who have had recent
sedation or are receiving opioid analgesia.

5.6 Ensure appropriate information regarding the post surgical condition of the
patient are obtained from and relayed by the Recovery nurse.

5.6.1 Patient name, gender, age

5.6.2 Pre and Post Operative Diagnosis

5.6.3 Type of surgery performed

5.6.4 Anesthetic options (agents and reversal agents used)

5.6.5 Any changes in the Patient’s anatomical structure and function

5.6.6 Appropriate documentations are complete ( e.g. Time out procedure form
is complete)

5.6.7 Any information relayed to patient and family

5.6.8 Wound Condition

KAAH ND-GNSURG-002
Policies & Procedures for Nursing Department
Issue Date: 01/01/2005
Revision Date: 31/05/2015
Code #: ND/GNSURG/002
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5.6.9 Wound drains and dressing

5.6.9.1 Type

5.6.9.2 Attached to suction or drainage container, check for patency.

5.6.9.3 Appearance, amount and odor of the drainage.

5.6.9.4 Any discomforts or problem

5.6.9.5 Amount of any drainage

5.6.10 Incision and dressing requirements

5.6.11 Complications encountered (anesthetic or surgical)

5.6.12 Fluid Therapy

5.6.13 Types of lines and location (e.g. peripheral IV, central line, arterial line)

5.6.14 Catheter or tubes, such as urinary catheter or T-Tube

5.6.15 Urine output and color

5.6.16 Blood loss

5.6.17 Administration of blood, colloids, and fluids and electrolytes

5.6.18 Vital signs status, including Pain and Fall (trends and most recent set)

5.6.18.1 Ascertain that the vital signs are within the acceptable normal
range.

5.6.18.2 Ascertain to consider patient’s baseline parameters to compare

it with the most recent set.

5.6.19 Neurological observations if appropriate.

5.6.20 Considerations for immediate postoperative period (e.g. pain

management, ventilator settings

5.6.21 Medications received

KAAH ND-GNSURG-002
Policies & Procedures for Nursing Department
Issue Date: 01/01/2005
Revision Date: 31/05/2015
Code #: ND/GNSURG/002
Page 4 of 12

5.6.22 Laboratory investigation sent from OR (e.g. Complete Blood Count)

5.6.23 Any specimen sent (e.g. for histopathology, microbiology investigation

5.6.24 Any specimen to be given to the patient

5.7 Visually inspect and observe post surgical condition of the patient and compare as
endorsed.

5.7.1 Relay to and inquire from the Recovery Nurse any inconsistency noted.

5.8 Review Physician/Surgeon’s post-operative orders

5.8.1 Inquire from the Recovery nurse clarification of any vague orders.

5.8.2 Ensure necessary request for post-operative X-ray prior to transporting

patient from OR to unit/ward was done through the hospital computerized
system.

5.8.3 Carry out immediately STAT orders e.g. post operative x-ray before
transporting patient back to the ward/unit.

5.9 Check patient’s file and ensure that it is complete and belonging to the patient.

5.10 Adhere to patient safety, comfort and privacy while transporting or positioning
patient (e.g. from bed / trolley to another bed/trolley, from OR to another unit).
Transporting/positioning the patient involves special consideration of the incision
site, potential vascular changes, drain/s, and exposure.

5.10.1 Transfer patient gently onto a clean, appropriately prepared bed/trolley in

a comfortable position.

5.10.2 Consider the surgical incision every time the postoperative patient is
moved/repositioned, many wounds are closed under considerable tension,
and every effort is made to prevent further strain on the incision.

5.10.3 Positioned patient properly so that he or she is not lying on and

obstructing drains or drainage tubes.

5.10.4 Orthostatic hypotension may occur when a patient is moved/transfer too

quickly from one position to another position.

KAAH ND-GNSURG-002
Policies & Procedures for Nursing Department
Issue Date: 01/01/2005
Revision Date: 31/05/2015
Code #: ND/GNSURG/002
Page 5 of 12

5.10.5 Raise the side rails and lower the bed/trolley to the lowest level with
bed/trolley wheels lock at all times to prevent fall.

5.10.6 Arrange IV pole, tubes, drains, monitoring devices in an orderly manner

(e.g. not over and across the patient).

5.10.7 Place call light/bell, emesis basin, bedpan, urinal within reach.

5.11 Assess breathing and administer supplemental oxygen, if prescribed.

5.11.1 Encourage deep breathing and coughing every 2 hours unless

contraindicated.

5.11.1.1 Encourage careful splinting of abdominal or thoracic incision

sites to help the patient overcome the fear that the exertion of
coughing might open the incision.

5.11.2 Encourage early mobilization if not contraindicated, to prevent respiratory

complications.

5.11.3 Position patient that will aid in enhancing lung expansion.

5.12 Reassess patient using necessary re-assessment forms and tools.

5.12.1 Take all precautionary and preventive measures to maintain patient's

comfort (to ease pain ) and safety (prevent fall).

5.13 Carry out post operative orders including those coming from other healthcare
team as indicated.

5.14 Develop a nursing care plan .

5.15 Continuously reassess and monitor patient accurately and do the necessary
interventions as well as appropriate documentation for the following:

5.15.1 Check and record vital signs as follows:

5.15.1.1 Patients transported directly from Operation Theater to the

General Wards will be monitored every 15 minutes for the first
hour, then every 30 minutes for the next hour and every hour
for the next 4 hours or until stable.

KAAH ND-GNSURG-002
Policies & Procedures for Nursing Department
Issue Date: 01/01/2005
Revision Date: 31/05/2015
Code #: ND/GNSURG/002
Page 6 of 12

5.15.1.2 Patient transported directly from Operation Theater to the

Critical Care Units (e.g. ICU, CCU, PICU, NICU and Burns)
will be monitored as follows: every 5 minutes for 15 minutes,
then every 15 minutes for the first hour, then every 30 minutes
for the next hour and every hour for next 4 hours or until
stable.

5.15.1.2.1 Consider airway, respiration (regular and

effortless), rhythm and depth (chest movement
symmetrically.

5.15.1.2.2 Observe for any respiratory depression, indicated

by hypoventilation or bradypnea and whether opiate
induced or due to anesthetic gases.

5.15.1.2.3 Oxygen saturation should be above 95% on air,

unless the patient has lung disease, and maintained
above 95% if oxygen therapy is prescribed to
prevent hypoxia or hypoxemia.

5.15.1.2.3.1 Ensure that the finger probe is clean

and that the position of the probe is
changed regularly to prevent fingers
from becoming sore.

5.15.1.3 Check the following for Heart rate, blood pressure and
capillary refill:

5.15.1.3.1 Rate and rhythm and volume of pulse.

5.15.1.3.2 Pay attention to systolic blood pressure as a

lowered systolic reading and tachycardia may
indicate hemorrhage and/ shock. Hypertension and
or tachycardia may indicate pain, fluid overload, or
anxiety or inadequate analgesia.

5.15.1.3.3 Capillary refill time should be ≤ 2 seconds to assess

circulatory status along with the color and
temperature of limbs which help identify reduce
peripheral perfusion.

KAAH ND-GNSURG-002
Policies & Procedures for Nursing Department
Issue Date: 01/01/2005
Revision Date: 31/05/2015
Code #: ND/GNSURG/002
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5.15.1.4 Observe the following for Body Temperature:

5.15.1.4.1 Shivering which might be due to anesthesia.

5.15.1.4.2 High temperature could be indicative of infection.

5.15.1.4.3 Drop in temperature might indicate bacterial

infection or sepsis.

5.15.1.4.4 Patient’s temperature should be monitored closely

and action taken to return to within normal
parameters.

5.15.1.4.5 Use blanket to warm the patient if their temperature

is too low.

5.15.1.5 Compare vital signs taken with the baseline observations taken
before surgery, during surgery and in the post-operative period.

5.15.1.6 Inform immediately to the Physician for any deviation from the
normal parameters, or for any instability.

5.15.2 Mental status and Level of consciousness (e.g. speech, orientation , and
ability to move extremities or as ordered), and compare with the
preoperative baseline.

5.15.3 Pain level, pain characteristic (location, quality) , and timing, route of last
dose of ordered analgesia.

5.15.3.1 Administer analgesia as prescribed and assess the effectiveness

in relieving pain.

5.15.3.2 Assess the patient’s pain level using a verbal or visual

analogue and behavioral scale as well as the characteristics of
the pain.

5.15.3.3 Manage patient’s pain to ensure patient has adequate analgesia,

but alert enough to be able to communicate and cooperate with
clinical staff in the post operative period.

5.15.4 Fall risk as per policy and procedure.

KAAH ND-GNSURG-002
Policies & Procedures for Nursing Department
Issue Date: 01/01/2005
Revision Date: 31/05/2015
Code #: ND/GNSURG/002
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5.15.5 Surgical site, wound dressing and wound drainage

5.15.5.1 Skin, especially areas surrounding the surgical site (e.g. Color,
i.e. pallor, Temperature i.e. cold, Condition i.e. shiny, taut,
edematous)

5.15.5.2 Observe for any active bleeding from the operative site and
drainage tube.

5.15.5.3 Connect all drainage tube to gravity or suction as indicated.

5.15.5.3.1 Ensure patency of the wound drainage

5.15.5.4 Integrity of the dressing

5.15.5.4.1 Observe for constrictive dressing

5.15.6 Observe/undertake and record on the fluid balance chart the following

5.15.6.1 I VF as ordered

5.15.6.2 Oral intake as ordered

5.15.6.3 Nausea and vomiting

5.15.6.3.1 Administer antiemetic as ordered.

5.15.6.3.2 Vomit bowls and tissues should be within easy

reach of the patient.

5.15.6.4 Provide oral care, if not contraindicated.

5.15.6.5 Color and amount of wound drainage, if any.

5.15.6.5.1 If there is no wound drainage, check that the drain

has not fallen out.

5.15.6.6 Observe and record for the urinary output hourly as it may
indicate insufficient circulatory fluid volume.

5.15.6.6.1 Observe for any bladder distension.

KAAH ND-GNSURG-002
Policies & Procedures for Nursing Department
Issue Date: 01/01/2005
Revision Date: 31/05/2015
Code #: ND/GNSURG/002
Page 9 of 12

5.15.6.6.2 Check that the catheter is not kinked or that the

patient is nor lying on the tubing if urine output is
reduced.

5.15.6.7 Immediately inform for any deviations from the normal to the
Physician.

5.16 Observe for any immediate post operative complications :

5.16.1 Signs of hemorrhage

5.16.2 Shock

5.16.3 Sepsis

5.16.4 Effects of analgesia and anesthetic.

5.16.4.1 Patients receiving intravenous opiates are at risk of their vital

signs and consciousness level being compromised if the rate of
infusion is too high.

5.17 Change patient’s position every two hours to promote circulation, unless
contraindicated.

5.18 Resume patient’s diet as ordered.

5.18.1 Give sips of water as ordered.

5.18.1.1 Ascertain to assess presence of gag reflex prior to allowing

patient to take sips of water.

5.19 Encourage early ambulation if not contraindicated. The patient may be allowed to
ambulate in the evening of the surgery day.

5.20 Follow up laboratory investigation ordered sent through OR/ward or unit,

immediately inform results to the Physician.

5.21 Update the Nursing Kardex for proper endorsement.

5.22 Make all necessary documentation using appropriate forms of all observations and
interventions in the as well as patient’s response to interventions.

KAAH ND-GNSURG-002
Policies & Procedures for Nursing Department
Issue Date: 01/01/2005
Revision Date: 31/05/2015
Code #: ND/GNSURG/002
Page 10 of 12

6.0 FORMS/EQUIPMENT:

6.1 Electronic Monitoring Devices (e.g. Dynamap)

6.2 Pulse oximeter

6.3 Stethoscope

6.4 Suction Equipments and Adjuncts

6.5 Oxygen source and delivery device

6.6 Emesis basin

6.7 Other necessary post-surgical specific equipment and supplies

6.8 Nurse Observation Chart

6.9 Nurse’s Notes

6.10 Fluid Balance Form

6.11 Reassessment Form

6.12 Nursing Care Plan Form

6.13 Patient/Family Education Form

6.14 Fall Assessment and Care Plan Form

7.0 REFERENCE(S):

7.1 Brunner and Suddarth’s (2010). Textbook of Medical Surgical Nursing.

(12th Ed.). Lippincott William and Wilkins, Philadelphia.

7.2 Ministry of Health, General Directorate of Nursing (2011) Manual of

Nursing Policy and Procedure (2nd Ed).

7.3 Suzzanne C. Smeltzer and Brenda G. Bare (2013). Textbook of Medical-

Surgical Nursing. (13thEd.). Lippincott Williams and Wilkins,
Philadelphia , New York.

KAAH ND-GNSURG-002
Policies & Procedures for Nursing Department
Issue Date: 01/01/2005
Revision Date: 31/05/2015
Code #: ND/GNSURG/002
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7.4 Liddle, Cathy (2013). Principles of monitoring postoperative patients.

Postoperative Nursing Care Part 1. Nursing Times, Volume 109 No22.
Retrieve from www.nursingtimes.net

8.0 REVISION:

8.1 This policy shall be reviewed every two years.

KAAH ND-GNSURG-002
Policies & Procedures for Nursing Department
Issue Date: 01/01/2005
Revision Date: 31/05/2015
Code #: ND/GNSURG/002
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9.0 APPROVALS:

9.1 Prepared by: ___________________________ ______________

Ms. Maria Eustelle S. Vergara Date
Nursing Quality Staff

9.2 Reviewed by: __________________________ ______________

Dr. Eiman Hawary Date
Director of Quality Improvement

9.3 Approved by: ___________________________ ______________

Ms. Fawziah Bakheet Al Mowalad Date
Director of Nursing Services

9.4 Approved by: ___________________________ ______________

Dr. Faisal Mahmoud Tallab Date
Supervisor General

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