Post-Operative Change
Also Consider: Constipation, Fever, Nausea/Vomiting, Rash, Shortness of Breath, Weakness (general)
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Situations arising in patients after surgical procedures
Wound changes: bleeding, infection, pain, drainage, odor, swelling, redness/erythema, dehiscence, delayed healing; need for removal of stapes/sutures.
Other changes: fever, chills, weakness, lightheadedness, pain, breathing problems, nausea/vomiting, rash
Patient’s adherence to treatment and any dietary or activity restrictions; Holding or restarting medications
Changes or monitoring specific to the type of surgery performed -- requires implementation of the surgeon’s postoperative instructions
1. Take Vital Signs
Temperature:
Blood Pressure:
Heart Rate:
Respiratory Rate:
Oxygen Saturation:
2. Evaluate Symptoms and Signs
Symptoms and signs noted in the surgeon’s postoperative instructions
Acute mental status change
Not eating or drinking as much as usual
Unrelieved pain. Note: exact locations, pain scale, description (sharp, dull, burning), persistent or intermittent
Fainting, dizziness or lightheadedness when standing up
Acute decline in ADL abilities
Thirst, signs of dehydration
Diaphoresis: Cold, clammy, pale skin
Respiratory: New cough, abnormal lung sounds, Accessory muscle breathing, pursed lip breathing, Respiratory distress
Cardiovascular: Chest pain, new irregular pulse, cyanosis, mottling, edema
GI: Nausea, vomiting, diarrhea, constipation, heartburn, abdominal distention or tenderness, rebound tenderness, bowel sounds
GU: New or worsened incontinence, pain with urination, blood in urine, urinary retention / bladder scan
Neurologic changes: consciousness/alertness, orientation, weakness, gait changes (unsteadiness, loss of coordination or balance)
Circulation - Motion - Sensation (CMS) Check
Very low urinary output (<30cc/hr)
Skin: wound appearance (measurements, redness, drainage dehiscence/separation), rash, infection/cellulitis
Response to any ordered PRN medications (inhalers, nebs, nitroglycerin, oxygen) or repositioning
Fingerstick glucose (patients with diabetes)
3. Take Action using SBAR Report:
Presence of other, significant symptoms or signs of illness
Refer to appropriate Situation-Specific Evaluation for the identified symptoms and signs.
Immediately contact the surgeon for instructions, then notify the medical staff & resident representative
Wound separation/dehiscence, significant bleeding that doesn’t stop, Changes in Circulation - Motion - Sensation (CMS) Check
Within the next 16 hours, contact the surgeon, then notify the medical staff & Designated Representative.
New symptoms or signs of infection, worsening pain
Notify medical staff on the next business day
New or persisting postoperative symptoms
Notify medical staff at the next regular rounds
Suture/Staple removal issues, delayed wound healing
SBAR Report
Situation: "Postoperative changes involving the patient’s” (wound), (clinical status), (treatment)
Background:
Reason the patient is in the nursing home (rehab for___, long term care for __).
When the problems started, how severe they are, getting worse or staying the same, what treatments have been used.
Abnormal vital signs
Surgery date, type of surgery, surgeon’s name and contact information
Wound appearance
MOLST / Advance Directives
Unrelieved pain
General observation of patient condition
Very low urinary output (<30cc/hr)
Diet restrictions, fluid restriction, thickened liquids
Blood glucose, if elevated
Abnormal findings on lung, cardiovascular, abdomen, neurologic or skin observations.
Signs or symptoms of pain, constipation, infection, dehydration, head trauma
Assessment: I am concerned about: __________
Recommendations/Requests:
Labs: CBC with manual diff, Lactic Acid, CMP/Chem14, Blood cultures
INR if patient is on warfarin
Antibiotic if infection is diagnosed
Conference call with surgeon, nurse, and medical staff
Telemedicine consultation
Change in wound treatment
Pain Medication
Other:
Clarify expectations for care, interventions, and illness course/prognosis. Repeat any telephone orders back to the provider to ensure that they are correct and complete
4. Implement Management Plan
Review and implement the surgeon’s post-operative instructions and any revisions
Monitor wound appearance every 4-8 hours for 2 to 3 days
Monitor vital signs every 4-8 hours for 2 to 3 days
Place on 24-hour report for 2-3 days
Obtain lab results (if ordered), and notify medical as needed of significantly abnormal values in lab tests (refer to appropriate Situation)
Update care plan regarding fall risk, pressure ulcer prevention, assistance needed with ADLs, supervision for safety, restorative needs
Review status and plan of care with designated representative daily or with any changes
Review status and plan of care with surgeon with any changes.
Hospital transfer is only appropriate to facilitate patient treatment; transfer solely as a convenience to the surgeon is not acceptable.
2025-04-27
Page updated
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