Chapter 16: Perioperative care
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Source: Adapted from Bickley et al. ([31]), DH ([47]), Liddle ([104]).
Post‐operative observations
Evidence‐based approaches
Principles of care
Regular monitoring and accurate reporting of patients’ clinical observations in the post‐operative period are essential parts of the planned surgical care pathway and can serve to identify potential complications. Post‐operative observations are outlined in Table 16.11. A clear physiological monitoring plan should be made for each patient, detailing frequency of observations and parameters (NCEPOD [128]). All nurses should be aware of the parameters for these observations and what is normal for the patient under observation. Post‐operative observations should be compared with baseline observations taken pre‐operatively, during surgery and in the recovery area (Liddle [104]). The frequency of post‐operative observations should be determined in accordance with local policies and guidelines and will be affected by the type of surgery performed, the method of pain control (e.g. epidural) and the patient's clinical condition. All vital signs and assessments should be documented in accordance with guidelines for record keeping (NMC [152]).
Table 16.11 Post‐operative observations
| Observations | Normal range |
|---|---|
| Routine post‐operative observations | |
| Blood pressure | 101–149 mmHg systolic |
| Pulse (rate, rhythm and amplitude) | 51–100 beats per minute |
| Respiration rate (rate, depth, effort and pattern) | 9–14 respirations per minute |
| Peripheral oxygen saturation | >95% on room air (less if patient has chronic obstructive pulmonary disease) |
| Temperature | 36.1–37.9°C |
| Accurate fluid balance (input and output) | Desired balance guided by surgeons and surgery performed |
| Pain score | Verbal numeric pain scale: 0–1/10 at rest; 3/10 on movement/coughing |
| Sedation score | Sedation score: 0/4 (see Chapter c14: Observations) |
| Additional observations (if clinically indicated) | |
| Blood glucose | 4–7 mmol/L |
| Central venous pressure | 5–10 cmH2O |
| Neurological response | Glasgow Coma Scale: 14–15/15 |
Critical care outreach and acute care teams have long encouraged the use of early warning scoring (EWS) systems to enable a more timely response to, and assessment of, acutely ill patients (RCP [175]). EWS is a simple physiological scoring system, based on the observations outlined in Table 16.11, that identifies patients at risk of deterioration who may require increased levels of care (NHS England [135]) (see Chapter c14: Observations).
Clinical governance
The National Confidential Enquiry into Patient Outcome and Death (NCEPOD [128]) report established that patients whose clinical condition was deteriorating post‐operatively were not always identified and referred for a higher level of care. When assessing post‐operative patients, it is vital to observe for signs of haemorrhage, shock, sepsis, and the effects of analgesia and anaesthetic (Liddle [104]). It is therefore imperative that nurses are able to interpret the results of post‐operative observations and, if they are reliant on appropriately trained healthcare assistants to take the observations, that nurses themselves interpret the results, thereby ensuring that patients who require a higher level of care are given immediate priority. Refer to Chapter c14: Observations for further details on methods of obtaining observations and for troubleshooting.
