Component Task: Immediate Post-Operative Care of a Patient

This is the nursing management of a patient after a surgical procedure. The nurse/midwife has a role to ensure that the patient recovers fully from the effect of anaesthesia.

Aims

·         Monitor the progress of patient’s recovery from anaesthesia after surgical procedure.

·         Note and report any abnormalities to the surgical team.

·         Relieve patient of pain

Requirements

·         Operation bed with side rails

·         Post anaethestic tray e.g. vomit bowl, wound dressing set, padded spatula or tongue holding forceps, receiver for soiled swab, adhesive tape, sterile gauze etc.

·         Oxygen apparatus

·         Suction machine

·         Vital signs tray

·         Medication tray

·         Infusion stand

·         Mouth care tray

·         Observation chart

Steps

1.        Assess patient level of consciousness by the use of stimulus e.g. pointed object or by calling patient by name

2.      Remove hot water bottles and receive patient gently into bed

3.      Place patient flat on bed with the head turned to one side or in the appropriate position according to the operation performed

4.      Reassure patient if conscious

5.      Provide side rails for safety if necessary

6.      Read through the patient’s case notes for post-operative instructions

7.       Observe operational site for bleeding and report for possible reinforcement

8.      Monitor vital signs for 15minutes for first one hour, 30 minutes for the next hour, 1 hour for the next 4 hours and 4 hourly intervals as condition stabilizes

9.      Ensure cannula is in situ, check the flow rate of the intravenous fluid and regulate as ordered

10.    Check and ensure that all drainage tubes e.g. naso-gastric tube and catheter are in situ and are draining well

11.      Record intake and output accurately

12.    Assess for pain, administer prescribed analgesics and record

13.    Check and administer all prescribed medication per the appropriate route

14.    Maintain personal and oral hygiene

15.    Observe any abnormality in the patient’s condition

16.    Put patient in a desirable position or as ordered by surgeon when he/she is fully conscious

17.    Follow nutritional orders as prescribed by the surgeon

18.    Educate patient and relatives on post-operative restrictions if any

19.    Document findings and nursing interventions in appropriate notes (manual or electronic)