Post-op assessment tips for the subtle signs of complications

[tsm007]

Hi, we did a simulation lab on a post-op patient. All of his vital signs were normal, but he was repeatedly complaining of being tired. It wasn't until I was driving home from the clinicals that I thought of myself in the hospital after I hemorrhaged from childbirth. When I thought about the way the patient was acting I thought oh my gosh how didn't I catch that. That is exactly how I acted. That was the only thing I could remember was it was a profound fatigue. We have a simulation test this weekend and I want to come well prepared. I have studied all the signs and symptoms of post-op complications, but this one slipped through my fingers because I was looking at the vital signs which did not line up with the other symptoms. Can you ladies/gentlemen help me please with your best post-op assessment tips? I'm also trying to be very thorough in my assessment, but not wasting time with it either because for us it's supposed to be a focused assessment not a full head to toe. What things do you ALWAYS include in your post-op assessment - particularly things that a new nurse might forget to check? What are subtle signs of a post-op complication that might not line up with what you've memorized in a textbook? I feel good that I did recognize the symptoms once I got home and outside the lab, but wish I had caught it sooner.

[nurseprnRN, BSN, RN]

Always ask how the patient feels. Always listen to that, and take some cues for further assessment from it. In the case of fatigue, the obvious choices are anemia, hypovolemia, and CHF, but electrolyte imbalance, sleep deprivation, some medications, and hunger will do that too.

Subtle changes-- look at preop VS; you can find them in the holding area charting. VS may be "normal" but not normal for this patient. The classic example is the athlete whose baseline resting heart rate is somewhere in the 50s, or even less, with a BP in the 100-110 systolic range. If postop his heart rate is 80-ish and his BP is 104 systolic, who's gonna worry? You are, if you're careful. He has increased his heart rate by 60% (and he has a big athlete's heart so that's a big increase in cardiac output) but his BP hasn't gone anywhere. Danger, danger, Will Robinson ...

You also want to look at trends. A very teeny, small change repeated every hour adds up to a big one, and you might not think much of it unless you look at the whole sequence of events. An SpO2 that starts at 99%, an hour later is 98%, an hour later is 97%, then 95%... all normal, but dropping. Who remembers to look back at four or six hours ago? You do, that's who.

A BP that creeps down, a HR that creeps up, a resp rate that creeps up (and we know that nobody really counts RR, but we also know how wrong that is) -- all of these can be telling you about compensation mechanisms starting to fail. You don't want to see those in retrospect with a forehead-slap moment, you want to maintain a decent index of suspicion from the beginning.

This isn't necessarily a post-op-specific tip, but if your patient ever tells you he feels like he's going to die, or even that "something's not right," pay close attention. A lot of the time when someone says that, he/she is right.

[tsm007]

Thank you as usual GrnTea. Very helpful information particularly paying close attention to the trends. I had thought of that, but not in the way you wrote it. I am going to try real hard to match up what the patient tells me with what I know clinically and follow that further even if the vital signs or other objective data doesn't perfectly line up.

[Esme12, ASN, BSN, RN]

Listen to your patients....many can have vague complaints......something isn't right. I don't "feel well". Some patients will talk of a "sense of impending doom". Like Grntea says......look at your trending data. Know what their "baseline is".....take the time to hear them.

Patients are human and they are not perfect. They will not fit any "real picture" totally.....elderly patient may become slightly confused. Many patients will just get restless......they "can't get comfortable"...they feel anxious.....not themselves.