Post-operative general surgical patient review

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