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NOTE:
5. Post-op observations
On return to ward (RTW), a full assessment is done and documented.
A B C D D D E - steps to full post-op assessment
a. check patency of airway
b. head and neck position
c. evidence of obstruction eg tongue in posterior position, blood, secretions , surgical packing
a. rate > 12,
b. rhythm
c. depth and quality,
d. O2 requirements, O2sats >96%,
e. presence of stridor, wheeze, use of accessory muscles etc
a. BP compare to baseline
b. pulse, rhythm, rate
c. temperature
d. skin colour & moistness
e. capillary refill
f. ability to move extremities
a. IV fluids check volume, time, prescription, infusion rate – drip factor
b. Infusions – GIK infusion, blood, Epidural
c. PCA and epidural
d. Oral intake, commencement of food
a. Redivacs or monovacs: check for patency, label & document the drainage and note type.
b. Observe wound site: check for silent bleeding, measure and record drainage.
c. Nasogastric tube drainage
d. Vomit amount and contents
e. Urinary indwelling catheter (IDC) drainage, colour and amount
a. check all medications prescribed and the time given
b. document on time management plan
c. check protocols for infusions
d. PRN and regular medications: e.g. opioid, routine analgesia, antiemetics, anti-inflammatory, anti-histamine, sedatives, etc..
a. Family notified
b. Patient comfort cares: post op wash, mouth cares
c. Pressure area care
d. Plaster of paris, CWMS, elevation,
e. Splints
f. Special requirement: sedative request, post-op exercise, nutrition.
a. Drowsiness
b. Alertness
c. Disorientation
d. Confusion