Table of Contents
Summarise the patient’s case
- Demographics: name and age
- Operation: days post-op, type of operation, reason for operation
- Planned management: check operation note to ascertain post-operative plan, patient’s stage in plan, why they are still in hospital
Investigation results review
- Latest bloods and trends
- Inflammatory markers (WCC, CRP) – may rise for first 2 days post-operatively but should fall after that
- Haemoglobin
- Electrolytes
- Other relevant blood results
- Other new investigation results
Patient assessment
Questioning
- Any symptoms or issues?
- Eating and drinking? How much?
- Bowels opening? If not, passing flatus?
- Pain controlled?
- Mobilising?
Nursing charts
- Observations: review current condition and trends on observation chart/temperature spikes
- Fluid balance chart
- Urine output
- NG/NJ output (if used for drainage)
- Drains output
- Stool chart
- Food chart and note current oral intake limitations (see spectrum below)
Examination
- Tubes in situ
- Drains: e.g. Wallis drain, Redivac negative pressure drain, Pigtail drain etc. As output decreases, drains are usually ‘cut and bagged’, then removed when output has decreased to insignificant amounts (e.g. <25ml/d), whereupon the site is covered with a bag. This is later removed and the wound dressed when dry.
- Wound catheters: a local anaesthetic delivery system to provide analgesia – remove when pain controlled
- Urinary catheter: TWOC when fluid balance stable and patient is able to mobilise and control urination
- Central line: remove when no longer needed
- NG/NJ tubes or parenteral nutrition lines: remove when not needed for nutrition or drainage
- Patient-controlled analgesia: remove when oral analgesia is likely to control pain
- Drain quantity and output (e.g. serous, bloody, chyle etc.)
- Wounds (pain, erythema, discharge, leakiness)
- Focussed system examinations as relevant
Plan and medications review
- Make plan (including further tests/management)
- Review current medications (don’t forget about VTE prophylaxis!)
Tips!
The aim is to get the patient back to normal and then home. Take into consideration:
- Oral intake: may be limited in first few days post-operatively but is increased gradually if there is no distension/vomiting/nausea; if the patient is passing stool/flatus; and if there is no limitation due to bowel anastomosis
Oral intake spectrum
- NG/NJ with free drainage (i.e. NG/NJ is open-ended and will continually drain stomach contents into bag)
- Spigotted NG/NJ (where a bung is placed into the end of the NG/NJ) ± ‘2/4/6 hourly drainage’
- NBM
- Sips
- Clear fluids limited to ml/hour, e.g. ‘20s’ (i.e. 20ml/hour), ‘40s’, ‘60s’, ‘100s’
- Clear free fluids, e.g. water, tea without milk etc.
- Free fluids (anything liquid – includes soup, milk etc.)
- Light/soft diet
- Normal diet
- Analgesia: aim to gradually reduce as tolerated (e.g. patient-controlled analgesia → tramadol + paracetamol + Oramorph PRN → paracetamol)
- Tubes: take them out when possible
- Fluids and fluid balance: adjust to achieve good balance; reduce IV fluids when oral intake is adequate
- Nutrition: consider supplementation (e.g. Fortisip drinks and multivitamins) and dietitian input. Consider NG feeding or parenteral nutrition if patient will not be eating within 7 days.
- Any evidence of infection or other post-surgical complications requiring investigation/intervention
- Correct electrolyte abnormalities
- Mobilise: patient needs to increase mobility until they are at their pre-morbid level of independence. Consider physiotherapist input.
- Medications: change to oral when possible
- Breathing: ensure patient is breathing properly to prevent post-operative atelectasis/chest infections. Encourage deep breathing, keep pain well controlled (as this limits inspiration), and consider saline nebulisers and chest physiotherapy.
Other tips:
- Do not overuse IV fluids! If the patient can tolerate oral fluids then maintenance bags are rarely required (see prescribing notes on fluids).
- It can be difficult to build and maintain good patient relationships when you are busy and have a long list of jobs to do. Some tips:
- Introduce yourself properly
- Check what they like to be called and use that name throughout the consultation
- Ensure you check for their concerns/questions at the end
