Post Operative Assessments

[RiverOne]

Hello,

I am a nursing student, and I was curious how you organize your post op assessments. I think I would like to write everything down, however I want to use an efficent method. I bet most of you can keep track of it in your head.

So I have a couple of questions:

Do you do your assessment by system after assessing ABC's, LOC , and VS? Or do you do your ABC's, LOC, and VS then a focused assessment of the reason for surgery(ie hip replacement, bowel resection etc) then do a systems based assessment.

Everything ties into each other, so my main question is how you keep it organized, efficient and don't forget anything?

I am thinking that I will be creating a chart for myself with the systems so i don't forget anything, like :

Respiratory,

Cardiovascular,

CNS,

musculoskeletal,

GI,

Renal,

Skin,

Diagnostic tests.

I know you're all busy and any help is appreciated!:loveya:

[Halinja, BSN, RN]

Two biggies (of course you do the ABC's first) in post op are pain and nausea. You have be be mindful of LOC, and VS's, but once you've gotten your patient stabilized...be looking for pain and nausea. Pain caught before it's bad is easier to handle than playing catch-up.

[Fiona59]

OK, first, you might want to try posting in the Canadian forum for answers concerning how we do it up here.

So, your unit has a routine. Mine is monitor q15minx3, q30minx2, q1hx4

Ask how the pain control is,

Hook patient up to vitals machine, take temperature.

Look at the patient

--if foley in place is there output

--listen to chest sounds (adjust O2 if needed)

--listen to bowel sounds

--examine dressing, mark shadowing if any

--note contents of JP, Perc, if present

--if epidural running can patient move limbs

--if pca running does patient know how to use

--how sedated are they

--look for any abrasions or skin tears (you can do this while getting them off the stretcher).

Repeat per unit routine.

[RiverOne]

I didn't know where I should post it, in student forum, Canadian forum, so sorry for any redundancy:imbar

Thank you both for your answers. It helps a lot.

[Fiona59]

No worries. It's just that Canadian and American Nursing while very similiar is also very different. Education, attitude towards healthcare, and routines.

Americans seem to use different approaches to pain than we do. So you might as well get advice from those who work in the hospital system you will be learning in.

[RiverOne]

We have practical testing soon, and I fear the worst then. So not following our hospital's policy because it is a bit more relaxed than our labs! LOL I am trying to prepare myself for the test, and don`t want to miss anything, so it is geared towards testing.

so i created a chart, not sure how to attach to this message so I will paste(not sure if it will work, and i previewed, it doesn`t!)

If you wouldn't mind taking a look for me, it is appreciated.

, sans-serif]VS:

, sans-serif]Temp

, sans-serif]Pulse

, sans-serif]Resp

, sans-serif]BP

, sans-serif]O2 Room air

, sans-serif]Elimination:

, sans-serif]Void (colour, odour, amount) 30 ml/ hr min

, sans-serif]BM

, sans-serif]Foley

, sans-serif]Ostomy Stoma- appearance

, sans-serif]Flatus

, sans-serif]Drains/ output- Colour, amount, odour

, sans-serif]Serous, sero- sanguineous, sanguineous, purulent

, sans-serif]JP

, sans-serif]Penrose

, sans-serif]Hemovac

, sans-serif]T- tube

, sans-serif]Dressing/ Wound- staples- sutures

, sans-serif]Colour

, sans-serif]Odour

, sans-serif]Amount

, sans-serif]Bleeding VAG?

, sans-serif]Tubes

, sans-serif]NG

, sans-serif]O2

, sans-serif]Trach

, sans-serif]Meds:

, sans-serif]Oral

, sans-serif]IV:

, sans-serif]Rate:

, sans-serif]Pain VAS (0-10)

, sans-serif]PQRSTU

, sans-serif]Last pain meds:

, sans-serif]PCA:

, sans-serif]Activity/ M/S- Leg exercises, ROM, ambulation, assistive devices, stiffness

, sans-serif]LOC- alert, oriented, drowsy, asleep, awake, conscious

, sans-serif]Deep Breathing and coughing

, sans-serif]Incentive Spirometer

, sans-serif]q1h

, sans-serif]Splinting prn

, sans-serif]Breath Sounds adventitious sounds?

, sans-serif]Bowel Sounds - present in all quads?

, sans-serif]Skin- Pallor, pink, warm, pedal pulse, cap refill in feet, tugor

, sans-serif]bruising? Anit- ems?

, sans-serif]INPUT - Diet:

, sans-serif]Fluids:

[Fiona59]

Take a deep breath and relax. Labs are usually set up around scenarios. They will tell you what type of surgery your example is set around.

Now are you talking about immediate post op care or patients that would be 2 days post op.

Fresh post-ops are all different. Depends on the surgery and how well they did in recovery. Vag bleeding checks are usually on done in gynie units. Bowel sounds depend on the surgery. Some don't return for hours. Diet in a fresh postop are relevant for orders and the first check (know if they can get ice chips or sips). Many aren't capable of IS use for a few hours and teaching at that point is better, but set up the IS at the bedside. Nor are they going to be up to ROM exercises. Better just check for pneumatic TEDs (on the patient or on the orders)

[RiverOne]

Thanks for the reassurance.

I like feeling prepared, which is good most times, but others, can drive me crazy!

They have given us several practice scenarios, all different surgeries and all varying from 1 day post op- to 2 days post op. So there is a wide variety of procedures, and some variance in timelines I am preparing for. Since I am in school for RPN, no PACU assessments.

I think if I study enough, I can adapt, improvise, and overcome any scenario they give. I have another week to prepare, and have been preparing for a couple weeks. I made up careplans as well for each scenario, and have practiced any relevant skills. So hopefully I can better control my nerves and take deep breaths!