Postoperative Assessment

Postoperative Assessment

Equipment and Preparation
■ Anticipate all necessary equipment and arrange to have in room prior to Pt arriving from recovery or the OR.
■ If Pt is on a ventilator, notify RT and coordinate RT arrival as soon as the Pt arrives to the room.
■ Suction equipment hooked up (turned on), oxygen source, oxygen delivery equipment available and working, emesis basin.
■ IV poles and infusion pumps available and plugged in.
■ Traction equipment, abductor pillows, bed trapeze, etc.

Initial Assessment
■ Assess and ensure patency of airway, breathing, and circulation.
■ Inspect surgical site dressing for abnormal drainage or bleeding.
■ Assess and establish a baseline neurological status.
■ Assess circulation, sensation, and motor activity distal to the operative site (distal CSM) and compare right to left.

Tubes and Lines
■ Ensure that all drains, tubes, and lines remain patent and intact throughout transfer (stretcher to bed) and reassess after transfer!

■ Place drainage collection containers (urometer bag, hemo-vac, chest tubes, etc.) to facilitate optimal drainage. Avoid placing underneath bed—risk of crushing container when bed is lowered.
■ Record initial fluid LTC in IV bag and urine/drain output on  postop assessment record/flow sheet.
■ Ensure IV is patent and rate is correct as ordered.

Postop Orders
■ Review postop orders and note any changes compared to preop orders (e.g., new or d/c’d meds, fluids, diet restrictions, activity).
■ Consult with charge nurse if orders seem incomplete or inappropriate.

Subsequent Assessments
■ Assess ABCs, LOC, vital signs, pain, and distal CSM every 15 minuntil stable or as otherwise indicated in the postop orders.
■ Inspect surgical site for bleeding, drainage, and signs of infection including redness, tenderness, swelling, and localized warmth.
■ Monitor and record I/O (oral intake, voiding, IVs, and drains).

Nursing
■ Perform routine assessments and dressing changes as ordered.
■ Turn and reposition routinely assess for signs of pressure sores.
■ Encourage deep breathing and coughing, incentive spirometry.
■ Provide routine hygienic care and assist Pt with ADLs p.r.n.
■ Provide Pt and family teaching. Include home care and follow-up.