Post-op vital signs and assessments

Nurses General Nursing

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Specializes in geriatrics.

just a quick question. I just came back from a staff meeting and we were discussing our protocol for post op pts. We do vital signs and full head to toe assessments q1hr x4, then q4 for 24hr and then q shift. Many nurses at the meeting thinks this may be overkill in a stable pt. Any thoughts?

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We do q 15min X 4 --- then q 30 min x 2 --- then q 1 x 1 ----- then q4 then routine

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Specializes in Step down, ICU, ER, PACU, Amb. Surg.

Darn,

This is how we do it where I work. Pt arrives in PACU: V/S are as follows: q5minx4, q15minx4 and q30 until transfer to the ward. Once on the ward: q4hr x24 then q8hr. If they go to the unit from PACU they are q1hr till transfer to the med/surg ward then q4hr....and so forth. The frequency is changed depending upon the patient's status at any given time. It is not over kill in the least as you will see residual side effects from some forms of ansthesia for up to 8 hours after they come out of the OR. Better safe than sorry. Hope this helps you some.

Christie

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Sounds like careing for a post-op patient is a lot of work. What all are you looking for?

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Specializes in ORTHOPAEDICS-CERTIFIED SINCE 89.

Head to toe, wound, CSM etc on arrival then q30x2, q4x2 q 1hx2 then q4. As long as stable. People w/epidurals have resp checked q1 and pain assessed w/vitals.

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Specializes in midwifery, ophthalmics, general practice.

oh boy!!

when I worked in ophthalmics(ok long time ago!) we only did one set of post op obs! no-one ever died!! guess part of it was the sheer number of ops we did- usually a ward full every day- they came in- had the op, went home! might depend on the surgery as well- day case stuff is only one set of obs- then its time for a cup of tea! (hey this is england!) In ITU I would expect it to totally different!

Karen

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Originally posted by karenG

oh boy!!

when I worked in ophthalmics(ok long time ago!) we only did one set of post op obs! no-one ever died!! guess part of it was the sheer number of ops we did- usually a ward full every day- they came in- had the op, went home! might depend on the surgery as well- day case stuff is only one set of obs- then its time for a cup of tea! (hey this is england!) In ITU I would expect it to totally different!

Karen

Where they getting anethesia???

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We do q 15 x 1 hr, q 30 x 1 hr, q 1 x 4 hr and q 4 x 24 hr. A full head to toe is done on admit to unit and prn. Otherwise, we address the system pertaining to the DX/surgery site. I agree that rest is therapeutic too but vitals, I&O's, pain ---- so many reasons to stay close for 24 hr.

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Specializes in midwifery, ophthalmics, general practice.
Originally posted by New CCU RN

Where they getting anethesia???

oh yes they got anaethesia!! but they were awake very quickly, sitting up drinking tea!!! :D

karen

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Specializes in Step down, ICU, ER, PACU, Amb. Surg.
Originally posted by P_RN

Head to toe, wound, CSM etc on arrival then q30x2, q4x2 q 1hx2 then q4. As long as stable. People w/epidurals have resp checked q1 and pain assessed w/vitals.

Okay...I figured the head to toe assess, wound/dsg check and neurovascular checks were a given....lol cause we do all that too. if there is an epidural or a PCA involved, the V/S monitoring stays q4h and LOC is monitored as well.

nrw, we are looking for s/s of hemmorhage, wound dehissance, depressed resperations, increase or decrease in pulse/BP, quality of pain and effectiveness of pain meds, pupilary reactions, presence of BSx4 quads, neurovascular checks and neuromuscular blockade from epidural........I am sure I missed something but one must be on top of their game to avoid and avert post op complications.

Yes, it is alot but a nurse with excellent assessment and organizational skills can do all that with in 10 minutes and pick up on the slightest change.

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Specializes in ORTHOPAEDICS-CERTIFIED SINCE 89.

With those q5's arent you going backwards from what they've already had in PACU?

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Interventional patients (angios) are q15x4, q30x2, q1x2, then q4 -- check vitals, angio site, and pedal pulses in addition to the initial assessment. Postops are recovered in the PACU -- then usually q1x4 -- full assessment on arrival to floor (I ALWAYS do the first set of vitals before the PACU nurse leaves my unit.)

I do not feel the frequent vitals are overkill -- it truly depends upon the patient, surgery. Q1hour full assessment for four hours may not be "overkill" but QUITE CHALLENGINGfor a nurse, with a full patient load and multiple post-ops, to do the assessments & chart them.

Q5minute anything does not belong on the floor.

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