initial post-op assessments for C/S moms

[babynurse357]

The old facility where i worked required a head to toe assessment & vitals initially when a c/s mom came out of PACU, then we did another set of vitals and another assessment every 15 minutes x2 every 30 x2 and 1 hour after that. The new place I am working only does 1 head to toe initially after PACU then follows vitals per protocol with only fundal and lochia checks. I think these pts are just as much a "surgical" pt as anyone else having surgery and deserve the same care. Many have questioned the way I do my post op checks wondering why I do it that way. How does everyone else do it? (I tried without success to find a policy covering post op assessments). They also chart the initial post-op c/s vitals/assessment on the same post-partum vag recovery form.

[Jolie, BSN]

What are you including in your frequent head-to-toe assessments that your co-workers omit?

[Elvish, BSN, DNP, RN, NP]

Head to toe on a fresh c/s for me includes:

neuro status

heart/lung sounds

bowel sounds

incision/dressing

lochia

foley

epidural (if she has one)

pedal pulses/edema

I don't do Homan's anymore but do ask about calf pain and assess their legs.

Not all my coworkers do all these things, but I agree that they should be assessed like surgical patients, because they are surgical patients.

Our checks are q15min x4, q30 x 3, then q4 x 48 hours. After 48 hours they go to qshift. I think that if my license is on the line in caring for them, I should know how they are doing.

[BirthCenterRN]

Our patients do not go to PACU we are the PACU on the unit.

Pt arrives on unit

loc and reflexes, lungs, aldrete score, skin, incision, breasts, heart, calf tenderness, bowels sounds, urinary (foley), fundus/lochia, perineum if pt pushed before c/s, coping/bonding

Then q15x4, q30 x2, q1h x2 with vitals

loc, lungs, inc, foley, fundus. lochia, perineum

Then q4 until 24 hours out with vitals

loc and reflexes, lungs, ability to move/ambulate, skin, incision, breasts, heart, calf tenderness, bowels sounds, urinary (foley), fundus/lochia, perineum if pt pushed before c/s, coping/bonding

The patient is on continuous pulse ox for 24hours documentedd q1/2h x12h and then q1h x 12.

[babydoll99_99]

We work this a little differently on our floor. We have our own ORs on the L&D floor (We actually have our own building for L&D and Postpartum) and the recovery area is not really a PACU. L&D nurses work the recovery area (I think they take turns) and so the 15 x 2 and 30 x 2 and q 1 h is all done before they get to the floor to us. They are down in recovery for 4 hours or until they can transfer themselves to the bed whichever comes first.

That being said, I do my initial head to toe and vitals and if everything is WNL I do another one in 1 hour. If that is WNL I do q 2 h fundal and lochia checks where I also clean and change the pt. If there is anything out of the ordinary in my first or second assessment that doesn't warrant calling the doc immediately I will do Q 15-30 minute checks of that particular thing (like b/p or numbness, that sort of thing). I hope this helps some.

[mom2michael, MSN, RN, NP]

We do the initial head to toe assessment, then VS Q15x4, Q30x2, then Q1 until we feel they are stable, then Q4 hours. Each VS check we check surgical site, lochia, and pain. We are required to do continuous pulse Ox and Q1hour RR on all C/S patients d/t their spinal and those orders are for 12 hours post spinal. Once the spinal has worn off, the foley has been removed and the IV locked and the patient has proved to be able to ambulate thru out the room, eat and drink like normal and bowels and bladder are working okay, we go to Qshift VS unless we just really feel they need closer monitoring.

Our docs are odd about us checking the fundas over and over on a C/S patient so we generally check with the initial assessment and then we check it Qshift UNLESS of course we feel it's necessary to check it more often and then by all means we do.