Post-op vital signs and assessments

Sarah, RNBScN · Jun 19, 2003

Ditto:

We do q 15min X 4 --- then q 30 min x 2 --- then q 1 x 1 ----- then q4 then routine or whatever the physician orders.

HTT included and dependent upon the surgery.

SmilingBluEyes · Jun 19, 2003

I would look at AORN standards. (any AORN-cert nurses here?). I believe there, you will find outlined the standard of care for post-op, post- anesthesia patients. I know we recover our Csection patients according to those standards, no exceptions.Be sure you are up to standards in case something untoward should happen in recovery; you butt will be covered that way. Otherwise....well you know.......

Tweety, BSN, RN · Jun 19, 2003

PACU does the frequent monitoring of vitals immediately post-op. Unless there's a problem when they come to the med-surg unit they are q4h for at least 24 , hours. We skip the q1h x 4 that you do and I can't remember in 11 years a major problem with that.

blue280 · Jun 20, 2003

Thanks to all for their replies! I think monitoring vital signs frequently is a good thing and a complete head to toe on arrival to the unit is appropriate. We were wondering if a complete assessment is necessary as often as we were doing it. We wanted to do a focused assessment instead and our CNS told us to find out how its done else where. Thanks again for the valuable info.

moonshadeau, ADN, BSN, MSN, RN, APN, NP, CNS · Jun 20, 2003

Complete assessment. Q15x4 then Q30x2 then Q4 in a perfect world for vitals. Heart caths get vitals, groin check and CMS check as above. The thing I hate the most, especially on night shift is the urine output monitoring which ends up being q1 hour.

peaceful2100, BSN, RN · Jun 20, 2003

I just started this past week on a Post-op surgical care floor and here is what I was told yesterday and I did not like this attitude at all. The preceptor told me that they are suppose to do a full head to toe right away including checking the post op site, then vital signs Q15x4. then Q30x2 then Q4 for 72 hours post op and then after 72 hours if they are still there then it is routine but my preceptor asked me do you think that really happens, I said yes I do because it should and she told me think again when you get so many post ops back then you will probably rarely have time to do ALL that on everyone with all the number of patients you have. She said the first hour is definitely most important and most critical.

stella123 rn · Jun 20, 2003

We do q1/2 hour x 4, q 1hour x4, then q4 hour for 24 hours. Head to toe assessments. Sometimes I do think this is overkill for a stable patient. Especially when they do not get any sleep if it was a late surgery. I do wish sometimes that we could some more discretion.

gwenith, BSN, RN · Jun 22, 2003

Was browsing the Joanna Briggs Institute website. The JBI is a big Australian Evidence Based Practice website. They have done an EBP report on vital sign assessments that is well worth the read.

here is the link http://www.joannabriggs.edu.au/best_practice/bp8.php#anchor30289160

Hope this helps