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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’

  • 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

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Reviewing inpatients