Post Operative Handover and Observations - Adult Patients ...



Canberra Hospital and Health ServicesClinical ProcedurePost Operative Handover and Observations - Adult Patients (First 24 hours)Contents TOC \h \z \t "Heading 1,1" Contents PAGEREF _Toc520713868 \h 1Purpose PAGEREF _Toc520713869 \h 2Alerts PAGEREF _Toc520713870 \h 2Scope PAGEREF _Toc520713871 \h 2Section 1 – Before the Patient is transferred from PACU to Ward PAGEREF _Toc520713872 \h 2Section 2 – Clinical Handover from PACU to Ward Staff PAGEREF _Toc520713873 \h 3Section 3 – Ward Observations PAGEREF _Toc520713874 \h 6Section 4 – Post-Anaesthetic Observation PAGEREF _Toc520713875 \h 7Implementation PAGEREF _Toc520713876 \h 8Related Policies, Procedures, Guidelines and Legislation PAGEREF _Toc520713877 \h 9References PAGEREF _Toc520713878 \h 9Definition of Terms PAGEREF _Toc520713879 \h 10Search Terms PAGEREF _Toc520713880 \h 10PurposeThe purpose of this clinical procedure is to ensure:The effective management of post operative adult patients in the first 24 hours post surgeryPatients are transferred from Post Anaesthetic Care Unit (PACU) when conscious and appropriate for a ward environmentPost operative observations are performed in accordance with best practiceComplications of surgery are identified and managed effectivelyInterventions are implemented to maximise the opportunity to ensure that the patient has a stable, comfortable and pain free postoperative period. AlertsIn the event of any deviation from the normal anticipated recovery from an anaesthetic, the anaesthetist or anaesthetic registrar must be notified immediately.ScopeThis document pertains to the post-operative clinical handover and management of adult patients through their post anaesthetic post-operative journey to their allocated inpatient accommodation. The document excludes day surgery patients approved for discharge by a Medical Officer prior to this time.This document applies to the following staff who are working within their scope of practice:Medical OfficersNurses and Midwives Students under direct supervisionWards persons.Section 1 – Before the Patient is transferred from PACU to WardAlert: All postoperative patients will be transferred from PACU with a nurse/midwife and/or medical officer escort and wards person (with PACU transfer pack).Equipment required on Ward receiving a post-operative patient Patient clinical record, observation charts and medication chartsPersonal protective equipment (PPE) including safety goggles or shield and clean glovesStethoscopeWatch with a second handSphygmomanometer (blood pressure cuff)Oxygen saturation monitorThermometerIntravenous (IV) pole – mobileEmesis basin / bagBedside emergency equipmentSpecific equipment if required, e.g. bed cradleAutomated observation machine where availableTorch for Neurological Observations, where requiredProcedure PACU Nursing staff to ensure:Receiving ward has been informed of and has accepted patients admission/return to wardPatient meets the PACU discharge criteria (Refer to PACU post anaesthetic observation chart available on the Clinical Forms internet page) or the patient has been signed out by the Anaesthetist and a medical management plan has been documented by the Anaesthetic TeamPatient oxygen delivery system has the patient’s identification label on itWard Nursing/Midwifery Staff to ensure:Patient bed area has been cleanedAll emergency equipment is functioning and available, including oxygen and suction. Back to Table of Contents Section 2 – Clinical Handover from PACU to Ward StaffThe PACU nurse hands over verbally to the ward nurse at the patient bed side using ISBAR and including the patient in the handover process.Ward Nursing/Midwifery Staff:Don PPE and attend hand hygiene using Alcohol Based Hand Rub as per Healthcare Associated Infections Procedure.IntroductionNursing staff to introduce self and role to each other and the patient and any family/carers present.Patient identification and allergy band is checked against the patient ID label in the clinical notes. The patient, where possible, is asked to confirm their identity using 3 core identifiers (As per Identification and Procedure Matching policy).SituationClarify the operative procedure performed Review operative report with PACU staff Discuss the patient’s medical history and impacting co morbiditiesBackgroundCheck patient’s airway is clear and observe for effort of breathing (i.e. use of accessory muscles, tracheal tug).Alert: If airway is compromised place the patient in the lateral position (if not contraindicated), and consider Medical Officer review. If oxygen therapy insitu ensure the oxygen is attached to wall oxygen outletConfirm flow rate as ordered (PACU staff responsibility on arrival at ward – checked by ward staff to ensure correct flow rate)Handover should include:Oxygen requirements including type of oxygen delivery system and flow rate (e.g. Nasal prongs, 4 litres of oxygen per minute)Tracheostomies including size, type, cuff inflated or deflated, a site check for blood and/or discharge, frequency and type of secretion suctioned (refer to Tracheostomy Management Adult Patients clinical procedure)Any peri and post-operative breathing difficulties and interventionsReview of peri and post-operative vital signs, including any interventions required for stabilisation Any peri and post-operative neurological concerns including behavioural difficultiesReview the fluid balance chart, IV fluid orders, check all IV fluid insitu, received in theatre and continuing orders, check IV device e.g. Central Venous Catheter (CVC), Peripheral Inserted Central Cather (PICC), Intravenous Cannula (IVC) (date of insertion, patency, site, and is appropriately secured). Ensure all IV lines are labelled as per the National Standard for User Applied Labelling of Injectable Medicines, fluids and lines and secured appropriatelyUrinary drainage devices e.g. Indwelling Catheters (IDC), Urostomies, supra-pubic catheter (SPC), Ureteric Stent (ensure hand hygiene is attended after contact with these devices), if no urinary drainage device insitu confirm last time patient voidedCheck any drains insitu e.g. wound drains; chest drain and outputAny nasogastric tube for drainage or feeding. Check output. Ensure orders are clearly documented in the notes as to purpose, use and position of tubeEnsure all output is documented on the Fluid Balance chart Medications administered in theatre and medication chart reviewedAny intravenous medications ordered and given (e.g. antibiotics, antihypertensive)Any wounds, dressings, wound packing or vaginal loss documentedPost Partum observations, including vaginal loss and fundal heightAny pain management devices and associated medication orders, including Patient Controlled Analgesia (PCA), Epidurals, Pain Busters, Continuous Opioid infusions, regional local anaesthetic infusions, etc. This includes single shot analgesia technique without pain management device i.e. single shot local anaesthetic block or intrathecal/epidural morphine single dose administration for post-operative pain relief (refer to Acute Pain Management Techniques Procedure )Neurovascular observations (if applicable, e.g. orthopaedic, vascular & plastic surgery)AssessmentAlert: All initial observations on transfer to ward should be attended in the presence of the PACU nurse to ensure any abnormalities are identified and managed as soon as possible. If the patient does not meet the PACU discharge criteria (Refer to PACU Post Anaesthesia Observation Chart), ward staff are to request the patient be reviewed by the Anaesthetic Registrar or Medical Officer and/or returned to PACU for further recovery. Perform and document a full set of Vital signs and Modified Early Warning Score (MEWS) including:Respiratory Rate (RR)Oxygen SaturationTemperatureBlood Pressure (BP)Pulse (P)Level of Consciousness (LOC)All observations are to be recorded on the Modified Early Warning Score (MEWS) charts and appropriate adjunct charts (i.e. neurovascular, neurological, PCA, Epidural, Intrathecal/ Epidural etc.)Alert: If the patient meets the MET criteria, activation of MET should occur.State any problems identified for the patientRecommendationState ongoing care requirements as including specific post-operative and anaesthetic ordersState who the patients care is under if the patient requires review.Ensure all of the above are completed prior to PACU nurse leaving ward area and patient care is accepted (Ensure that PACU post anaesthetic observation chart is signed by PACU and ward nurse)Ensure all observation requirements are documented on the Nursing Care PlanAttend hand hygiene after by either hand washing or using alcohol based hand rub.Back to Table of ContentsSection 3 – Ward ObservationsProcedure Record vital signs (RR, oxygen saturation, temperature , BP, P, LOC and UOP) as per post anaesthetic/ operative observation regime or more frequently as prescribedContinue to monitor patients’ skin for colour and temperature changes. Perform formal neurological observations if ordered using the Glasgow Coma Scale (GCS) or if not returned to previous LOCObserve the wound dressing for ooze or blood loss when vital signs are recorded. Note colour, amount and odour (if any), reinforce wound dressing if required. Do not remove theatre dressing. Inspect the surgical area for swelling or discolouration/ bruising (with dressing intact)Inspect the condition and contents of any drainage tube and equipment. Note volume and type of the drainage (be descriptive e.g. large, haemoserous, chyle, purulent). Inspect drain site for change and ensure that the drain tube is secured in place.Contact the Medical Officer for review if excessive swelling, discolouration or blood loss is observedMonitor IV therapy and intravenous cannula site (record IVT on fluid balance chart)Encourage deep breathing and coughing exercises and limb movements with routine observations (unless contraindicated)Unless contraindicated (patient either Nil By Mouth (NBM) or on modified texture diet), offer ice to suck or sips of water (record on the fluid balance chart)Before initial dose of analgesia check recovery records noting if and when analgesia had been administered Assess pain and administer analgesia as prescribed (unless contraindicated by Intrathecal/Epidural Morphine, Continuous Opioid infusion, Patient Controlled Analgesia or Epidural, refer to Acute Pain Management Techniques procedure) Reassess effectiveness of analgesia hourly or when vital signs observations are completed (or as per Acute Pain Management Techniques procedure), and request review as required. Orientate the patient to their surroundings on admission or return to ward, and reorientate as required when attending to observationsReview with the patient the expectations of the post-operative recovery phaseInform the patient of the presence of drains or infusionsIf no urinary drainage devices encourage the patient to void. Measure and record on the patient's fluid balance chartAlert: If the patient does not pass urine in the first six (6) hours postoperatively, assess the patient for bladder distension and notify the Medical Officer.Offer / attend to bed bath Dress in personal nightwear if desiredOffer / attend to mouth care, replacing dentures if applicablePosition the patient in accordance to post-operative instructionsEnsure that the call bell is within reach Lower bed and elevate bed rails to maintain patient safety if required. Note: where patients are disorientated consider hi low bed. Complete pressure injury and falls risk assessments if not previously completed or reassess mence diet and fluids as ordered (continue to monitor tolerance of diet)Document all observations on the appropriate charts, e.g. MEWS, fluid balance chart, in the patient's clinical record and escalate if required. Record in the patient's clinical record all post-operative nursing care provided and the patients responseNotify next of kin of patient’s return to ward and document in the patient’s clinical record.Back to Table of ContentsSection 4 – Post-Anaesthetic ObservationProcedure General/Epidural/Spinal AnaestheticFull set of Vital Signs: On return to ward, thenHalf hourly for two (2) hours (30mins x 2 hours), if MEWS ≥ 4 continue half hourly (Refer to Vital Signs and Early Warning Scores procedure (excluding Day Surgery Unit) orWhen MEWS <4, hourly for four (4) hours (60 mins x 4 hours), then4th hourly for a minimum of 24 hours.Particular attention to level of motor and sensory blockade.Alert: If respirations are eight (8) or less per minute or if the patient complains of headache following spinal or epidural anaesthetic within the first 24 hours, notify the Anaesthetist or Anaesthetic Registrar immediately and document in the patient’s clinical record.Regional Nerve Block (Brachial, Ulna, Femoral or Digital)Full set of Vital Signs: On return to ward, thenIf MEWS ≥ 4 continue half hourly (Refer to Vital Signs and Early Warning Score Procedure) or When MEWS <4, hourly for four (4) hours (60 mins x 4 hours), then4th hourly for a minimum of 24 hours (or until discharge).Observe Injection site and sensation of area:On return to ward, thenHourly for four (4) hours until sensation and movement have completely returned.Notify Medical Officer if any concerns regarding return of sensation or movement.Local AnaestheticFull set of Vital Signs: On return to ward, thenIf MEWS < 4 and patient is a Day Surgery patient, the patient can be discharged homeIf MEWS ≥ 4 continue half hourly (Refer to Vital Signs and Early Warning Score procedure) or When MEWS <4, hourly for four (4) hours (60 mins x 4 hours), then4th hourly for a minimum of 24 hours (or until discharge).Observe Injection site, capillary return and sensation of area:On return to wardHourly until sensation and movement has completely returnedNotify Medical Officer if any concerns regarding return of sensation or movement.Alert: In the event of any deviation from the normal anticipated recovery from an anaesthetic, a Medical Officer/ Anaesthetist or Anaesthetic Registrar must be notified immediately.Finger and Hand Surgery ALERT: Review RN Theatre Report to determine location and length of time the tourniquet was in place and what time the tourniquet was removed. All dressings must remain dry and intact unless post-operative notes state otherwiseObserve finger tips for change in colourMonitor for persistent numbness or pins and needles. Check if a local anaesthetic was injected into the woundMonitor hand/ fingers for pain, bleeding and swelling The nurse discharging the patient is responsible for delivering and explaining the “Finger and Hand Surgery” fact sheet to the patient Additional post-operative instructions patient fact sheets, located on the policy register, can be given to the patientDocument in the patient’s clinical record that the information has been provided and explained to the patient. Back to Table of ContentsImplementation This procedure will be made available to all staff via the clinical policy register.New staff will be informed of this procedure during orientation to the operating theatre and surgical wards. In-services will be conducted to nursing, midwifery and medical staff in relation to postoperative handover.Related Policies, Procedures, Guidelines and LegislationPoliciesPatient Identification and Procedure Matching PolicyNursing and Midwifery Continuing Competence PolicyMedication Handling PolicyProceduresHealthcare Associated Infections ProcedureClinical Handover ProcedurePatient Identification and Procedure Matching ProcedureAcute Pain Management Techniques ProcedurePatient Identification and Procedure Matching ProcedureVital Signs and Early Warning Scores ProcedureCode Blue (Medical Emergency) – ACT Health Emergency Management PlansTracheostomy Management Adult Patients ProcedureDrain Management procedureUrology – Catheter insertion and management, bladder irrigation, nephrectomy and trans urethral prostatectomy(TURP) procedurePatient Escort and Transport within Canberra Hospital Campus procedureLegislationHealth Records (Privacy and Access) Act 1997Human Rights Act 2004Work Health and Safety Act 2011Back to Table of ContentsReferencesHand Hygiene Australia (2018) 5 moments of Hand Washing. Available at: Joanna Briggs Institute, Canberra Hospital – Acute Care Practice Manual 2008, Post-Operative Care, 21 October 2005, pp 579-582Kozier B Erb G Blais K et al, Fundamentals of Nursing, 5th Edition, 1998, Addision-Wesley Publishing, Redwood. p 1397-1424World Health Organisation (WHO) (2018) Guidelines on Hand Hygiene in Healthcare (2009). Available at: Nursing and Midwifery Board of Australia (2015) Professional codes and Guidelines. Available at: to Table of ContentsDefinition of Terms PPE – Personal Protective Equipment (i.e. mask, gown, goggles)PACU – Post Anaesthetic Care UnitBack to Table of ContentsSearch Terms Patient transfer, Handover, Anaesthetics, PACU, Post-operative Care UnitBack to Table of ContentsDisclaimer: This document has been developed by ACT Health, <Name of Division/ Branch/Unit> specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.Policy Team ONLY to complete the following:Date AmendedSection AmendedDivisional ApprovalFinal Approval 09 Jul 2018New DocumentDaniel Wood, ED SOHCHHS Policy CommitteeThis document supersedes the following: Document NumberDocument Name ................
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