The Post-Operative phase starts when the patient is transferred out of the operating room and ends at the point of discharge. The first part of this stage is called the Post-Anaesthesia phase, where patients receive intensive nursing care to stabilise their physiology and avoid complications. Following that, the patient is either sent home or admitted into a surgical ward, which we’ll be discussing here. These notes will outline the Post-Operative Nursing Assessment done once the patient is admitted to a surgical unit/ward. But before reading this, make sure to read:
The Post-Operative Nursing Assessment is carried out to identify all of the patient’s medical and psychological needs and anticipate any future needs, particularly regarding the patient’s continued recovery upon discharge.
Post-Operative Nursing Assessment Part 1: Respiratory System
Assessing the respiratory system in a post-op patient should be your top priority. Start off by checking the patient’s airway, making sure it’s patent, and looking out for any laryngeal oedema signs. Next, assess the quality of the patient’s respiration, which means you need to examine their depth, rate and sound. And while you’re there, you should auscultate the chest and listen for any abnormal sounds, ensuring that the breathing is equal on both sides.
There are several things that you might spot when examining the patient’s breathing, but the most common include:
Slow breaths: Likely a side effect of the administered anaesthesia and analgesia
Shallow & rapid breathing: Might indicate pain, constricting dressing, gastric dilation, abdominal distention or obesity.
Noisy breathing: Often a sign of obstruction by secretions or the tongue
Crackles on auscultation and frothy pink sputum: Might indicate the presence of flash pulmonary oedema, which is a respiratory complication that happens when protein and fluid pile up inside the alveoli
In some cases, an ABG test might be required to evaluate the patient’s level of gas exchange.
Post-Operative Nursing Assessment Part 2: Cardiovascular System
The second point you’ll need to assess is the cardiovascular function, and you can do this by first checking the patient’s vital signs. This includes the temperature, SpO2, respiration rate, blood pressure, heart rate and level of consciousness. In addition, if the patient has a history of cardiovascular disease or had cardiac problems during the surgery, they will need regular ECG monitoring.
You should also note the patient’s skin colour, whether they seem adequate, pale, flush red, or cyanotic, and check if their skin is cold and clammy or warm and moist. Look at their fingers and toes, and assess their circulation by checking their capillary refill.
While you’re going around the patient, look at their incision site. Ensure that it’s kept clean and has no additional strain (for example, having the patient lying on it). Note down the type of dressing applied, and if the patient has a bandage or cast it’s important to make sure that they’re not done too tight.
But more importantly, look out for any signs of bleeding and swelling surrounding the area. Minor bleeding from the surgical site is a common occurrence in the post-op phase, but in rare instances, the bleeding can become severe and causes a life-threatening condition known as Haemorrhage.
Haemorrhage can also occur internally, which means that it would not be visible, but you can still detect it because it presents with several symptoms, including:
Hypotension
Hypothermia
Tachycardia
Tachypnoea and laboured breathing
Oliguria (low urine output)
Pallor and cyanosis of the lips, gums, and tongue
Disorientation and restlessness
If you notice any signs of Haemorrhage, you should take an ABG sample right away to determine the patient’s haemoglobin and haematocrit levels.
Post-Operative Nursing Assessment Part 3: Fluid Balance
After evaluating the patient’s circulation, you can assess the patient’s fluid balance. Start by locating any external devices such as drains, catheters, or NG tubes. Document their location and volume on admission, and note down any volume increase or output colour changes. Understanding the output volume can only make sense if we calculate the volume of fluids going in, so make sure to chart all IV fluids that the patient receives. This includes IV hydration fluids, blood product infusions, and IV medications.
Having both the input and output values allows you to identify any discrepancies and helps you understand the patient’s physiology. For example, low blood pressure might arise from the patient being dehydrated, while high blood pressure could result from fluid overload. If you notice that the patient is retaining fluids, you should examine their abdomen for bladder distention and check their limbs for oedema. Blood tests might also be required to check the patient’s electrolyte levels, kidney function and heart function.
On the other hand, if your patient has lost a lot of fluids, they are at risk of developing Hypovolemia. Hypovolemia is a very serious acute condition where the heart would not be able to pump sufficiently because the fluid level in the patient’s intravascular system is too low. In most cases, Hypovolemia occurs secondary to Haemorrhage. But it can be aggravated if the patient lacks lymphatic fluid. The symptoms of Hypovolemia are identical to those of Haemorrhage, so if you notice any of these signs, you should perform an urgent ABG to determine what is causing the Hypovolemia.
Post-Operative Nursing Assessment Part 4: Nutrition
Following the fluid assessment, you should assess your patient’s nutritional needs. Check how long they’ve been starved for the surgery and if they have any eating restrictions post-operatively. If your patient has diabetes, you should check their blood glucose level. Ask the patient about any food allergies and personal food limitations (vegetarian/vegan/religious restrictions). Measuring their weight and BMI can help you identify the patient’s nutritional needs, and when possible, you should work with the dietician to identify their recommended nutritional intake.
You should also look out for any factors that might intervene with the patient’s eating, such as feelings of nausea, chewing or swallowing difficulties, and limited mobility that might make it difficult for the patient to cut up and eat their food.
Post-Operative Nursing Assessment Part 5: Pain Score
Experiencing mild pain and discomfort in the post-op phase is expected. However, it does not mean that the patient has to endure it, as in most cases, it can be easily managed with medication. Ask your patient if they had been experiencing any pain before the surgery and whether it’s gotten better or worse. Ask them to locate the pain and if it’s radiating to any other part of their body, and have the patient score their pain on a scale of 1-10. You should also ask if there are any positions in which they feel more comfortable.
Post-Operative Nursing Assessment Part 6: Holistic Assessment
Having completed all the medical assessments, you can take a step back and look at the bigger picture of what your patient needs. Check if they require any help with their Activities of Daily Living (ADLs). Including bathing, toileting, walking needs and feeding assistance or supervision. Speak to them and assess their level of knowledge on the surgery and the recovery period. In addition, you should also evaluate their psychological status not only by asking the patient but by reading their body language. And understand their spiritual needs.
Post-Operative Nursing Assessment Part 7: Discharge needs
The last point you need to assess is the patient’s discharge needs. This means how the patient will cope once they’re sent home to continue their recovery. Do they have family or friends to support and help them? Are they capable of organising and taking their medications as prescribed, and will they be able to keep up with the recommended nutrition and exercise on their own?
Will they benefit from community services? And if so, which services? And lastly, check if they need help to attend their follow-up appointments.