Post-operative general surgical patient review

Clerking and reviewing patients > Reviewing inpatients

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’

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

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