When caring for a post operative patient what should be included in the post operative assessment?
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By visiting this site you agree to the foregoing terms and conditions. If you do not agree to the foregoing terms and conditions, you should not enter this site. IntroductionThe ability to assess a post-operative surgical patient is an important skill to develop during medical school and your foundation years. It is commonly tested in OSCEs and almost all foundation doctors will have at least one surgical rotation. Furthermore, assessing the post-operative surgical patient is also assessed at postgraduate surgical interviews. This article will provide you with:
OSCE stations vary in their focus:
A-E assessment of an acutely unwell surgical patientAs with all OSCE stations, you should first introduce yourself, confirm the patient’s details and gain consent to proceed. The examiner of the station may then ask you to describe how you would approach an acutely unwell surgical patient. An example of a response could be: “I would approach the patient using a structured A-E approach according to Advanced Life Support guidelines, initiating immediate management as required and escalating appropriately.” The A-E assessment is not in the scope of this article, however, it is an essential skill that all doctors should possess. See our A-E assessment guide for more details. Once the A-E assessment has been completed and the patient has been stabilised, it is important to think more broadly about a thorough surgical assessment. In an OSCE, after performing an A-E assessment, it is often sensible to suggest escalating to a senior member of the team. The examiner will then often state: “Your senior is on the way” Having been through the A-E assessment, you may have decided the patient needs to return to theatre urgently. You may be asked at this point: “What would you do whilst you wait for your senior?” A good answer in this situation would be:
A broader assessment of a post-operative surgical patient [SHE BOXED approach] 2,4It may be that in an OSCE scenario you complete your A-E assessment and the examiner then asks you “Now what would you do?”. If there is no clear indication to take the patient to theatre for an emergency operation, a further, more detailed assessment is required. In this situation, the SHE BOXED approach can be utilised. SHE = Summary of History and Examination findingsHistory“I would take a focused history from the patient and ask specifically about…” A useful structure for quickly covering the salient features of a surgical history is the acronym AMPLE:
Tip for surgical patientsReview the operation note and anaesthetic chart. Was the operation straightforward? Were there any complications? What were the post-operative instructions? What drugs were used during the operation? How has the patient been in recovery? ExaminationYou then need to complete a focused examination of the relevant system. For example, if the patient is post-thyroidectomy then it would be worth stating that you would want to carry out a complete neck examination, inspecting for any visible swelling/airway compromise (e.g. in the event of a haematoma). BOXEDB = Bedside tests & bloodsBedside:
Bloods:
TipIsolated figures often are difficult to interpret. Therefore the TREND in blood test values and observations is important to pay attention to. O = OrificesAre there any results for:
TipWork from the head downwards to help remember these! Also, don’t forget the TREND in the drain or catheter output. X = Xray, imaging and special testsExamples include:
E = Escalation planIs there a documented escalation plan? Would this patient be appropriate to receive HDU or ITU level care? Who should you escalate to within your team? What other specialities should you escalate to (for example critical care team, medical registrar, anaesthetics etc)? TipWhat organ support may be required from HDU/ITU (e.g. non-invasive ventilation/inotropic support/intubation)? D = Do not attempt CPR (DNACPR) statusDoes the patient have a valid DNACPR form in place? Is this something worthwhile highlighting with seniors to discuss? ExampleYou are the on-call doctor and are asked to see a 61-year-old male who is day 3 post laparoscopic cholecystectomy. He has spiked a temperature of 38 degrees celsius and is tachycardic at 120bpm. How would you approach this situation? In an OSCE you may initially state… “I would approach the situation using a structured A-E approach, initiating immediate management to stabilise the patient. If required, I would also escalate appropriately.” After a provisional A-E assessment, the patient is deemed stable. How would you now approach performing a comprehensive post-operative assessment? Summary of history and examination findings (SHE) “I would take a history, focusing on the patient’s allergies, medications, past medical history and when they had last eaten or had something to drink. In addition, I would clarify the recent events of the hospital stay, including admission date, the current diagnosis and any operation that has taken place. With regard to the surgery, I would want to review the operation note for post-operative instructions and evidence of complications. In addition, I would want to read over the most recent ward review. Given that this patient has undergone gastrointestinal surgery, I would focus my examination on their gastrointestinal system.” BOXED “I would review the patient’s recent bedside observations, input/output charts, imaging and laboratory results (including blood tests and microbiology results). I would also ensure the patient had a valid group and save, should they need to return to theatre.” “If the patient was potentially in need of HDU/ITU input, I would clarify the escalation plan with senior team members and ensure it was discussed with the patient and family as appropriate. I would also check if a DNA CPR form was present and if not, consider if this needed further discussion with senior team members and the patient/family.: “Based on the findings of my assessment, I would then formulate a differential diagnosis and management plan accordingly.” Documentation exampleDate: 05/01/19 Time: 18:30 Title: General Surgery Review Doctor name and role: Rakesh Mistry FY2 Asked to see patient regarding temperature (38 °C) and tachycardia (120bpm). A:
B:
C:
D:
E:
Summary of history and examination 61-year-old male Allergies – NKDA Medications:
Past medical history:
Last intake of food/fluid:
Events Admitted 01/01/19:
03/01:
06/01:
Bedside (previous results in brackets):
Bloods:
Orifices:
Imaging:
Escalation plan: Discussed on ward round this morning – would be for HDU care and potentially inotropic support if required DNACPR status: No DNACPR status recorded Issues:
Impression: Likely anastomotic leak post laparoscopic cholecystectomy Plan:
Rakesh Mistry FY2 General Surgery GMC: 1234567 Bleep: 1311 Surgical risk factorsWhen assessing any patient, it is important to have an awareness of possible surgical complications that may affect them. Each patient’s risk of surgical complications differs depending upon the presence or absence of various factors. Below are two different ways of applying a structured approach to considering surgical risk factors. Method ARisk factors can be broken down into the following categories:
For example: “You are called to see an obese diabetic 50-year-old patient following their open mesh inguinal hernia repair. The patient is 3 days post-op and is complaining of pain around his surgical site in his groin. The nurse reports some swelling at the site and a foul odour.”
Method BAnother simple way of categorising these risk factors is:
For example, risk factors for a post-operative infection may be categorised as shown below.
Post-operative complicationsIn an OSCE, you may be in a situation whereby you need to identify the most likely post-operative complication and manage the patient appropriately. Complications may be classified by time or underlying cause. TimeComplications can be classified by time as follows:
Underlying causeComplications can be classified by the underlying cause (i.e. aetiology) as shown in the table below.
Both time and aetiology may also be combined to categorise complications as shown in the table below.
Post-operative pyrexiaPost-operative pyrexia is a common issue and the differential diagnosis is highly dependent on the timescale. The trend of the pyrexia is also very important (i.e. new, persistent, swinging). The 7 C’s of post-operative pyrexia is a helpful way to remember potential sources of post-operative pyrexia:
Timeline of pyrexia
ReviewerMr Mustafa JaffarENT Registrar St. Mary’s Hospital, Imperial College Healthcare Trust References
What is post operative nursing assessment?A. Nursing interventions that are required in postoperative care include prompt pain control, assessment of the surgical site and drainage tubes, monitoring the rate and patency of IV fluids and IV access, and assessing the patient's level of sensation, circulation, and safety.
What are the priority nursing assessments for a postoperative patient?ESSENTIAL POSTOPERATIVE OBSERVATIONS. Airway patency.. Respiratory status (rate and oxygen saturation). Cardiovascular status (blood pressure and pulse). Circulatory status (strict fluid balance and central venous pressure where available). Temperature.. Haemorrhage/drainage volumes/ vomiting/fluid balance.. Mental state.. What should you assess after surgery?Routine post anaesthetic observations should include:. HR, RR, SpO2, BP and Temperature.. Neurological Assessment (AVPU, Michigan sedation score or formal GCS as indicated). Pain Score.. Assessment of Wound Sites / Dressings.. Presence of drains and patency of same.. What are steps for post operative care?The recovery from major surgery can be divided into three phases: (1) an immediate, or post anesthetic, phase; (2) an intermediate phase, encompassing the hospitalization period; and (3) a convalescent phase.
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