Post Operative Handover and Observations - Adult … · Web viewThis document pertains to the...

CHHS18/200

Canberra Hospital and Health ServicesClinical ProcedurePost Operative Handover and Observations - Adult Patients (First 24 hours)Contents

Contents...................................................................................................................................1

Purpose.................................................................................................................................... 2

Alerts........................................................................................................................................2

Scope........................................................................................................................................2

Section 1 – Before the Patient is transferred from PACU to Ward...........................................2

Section 2 – Clinical Handover from PACU to Ward Staff..........................................................3

Section 3 – Ward Observations................................................................................................6

Section 4 – Post-Anaesthetic Observation...............................................................................7

Implementation........................................................................................................................8

Related Policies, Procedures, Guidelines and Legislation.........................................................9

References................................................................................................................................9

Definition of Terms.................................................................................................................10

Search Terms..........................................................................................................................10

Doc Number Version Issued Review Date Area Responsible PageCHHS18/200 1.0 10/07/2018 01/04/2022 Surgery and Oral

Health1 of 10

CHHS18/200

Purpose

The purpose of this clinical procedure is to ensure: The effective management of post operative adult patients in the first 24 hours post

surgery Patients are transferred from Post Anaesthetic Care Unit (PACU) when conscious and

appropriate for a ward environment Post operative observations are performed in accordance with best practice Complications of surgery are identified and managed effectively Interventions are implemented to maximise the opportunity to ensure that the patient

has a stable, comfortable and pain free postoperative period.

Alerts

In the event of any deviation from the normal anticipated recovery from an anaesthetic, the anaesthetist or anaesthetic registrar must be notified immediately.

Scope

This document pertains to the post-operative clinical handover and management of adult patients through their post anaesthetic post-operative journey to their allocated inpatient accommodation. The document excludes day surgery patients approved for discharge by a Medical Officer prior to this time.

This document applies to the following staff who are working within their scope of practice: Medical Officers Nurses and Midwives Students under direct supervision Wards persons.

Section 1 – Before the Patient is transferred from PACU to Ward

Alert: All postoperative patients will be transferred from PACU with a nurse/midwife and/or medical officer escort and wards person (with PACU transfer pack).

Equipment required on Ward receiving a post-operative patient Patient clinical record, observation charts and medication charts Personal protective equipment (PPE) including safety goggles or shield and clean gloves Stethoscope Watch with a second hand Sphygmomanometer (blood pressure cuff)


Health2 of 10

CHHS18/200

Oxygen saturation monitor Thermometer Intravenous (IV) pole – mobile Emesis basin / bag Bedside emergency equipment Specific equipment if required, e.g. bed cradle Automated observation machine where available Torch for Neurological Observations, where required

Procedure PACU Nursing staff to ensure:1. Receiving ward has been informed of and has accepted patients admission/return to

ward2. Patient meets the PACU discharge criteria (Refer to PACU post anaesthetic observation

chart available on the Clinical Forms internet page) or the patient has been signed out by the Anaesthetist and a medical management plan has been documented by the Anaesthetic Team

3. Patient oxygen delivery system has the patient’s identification label on it

Ward Nursing/Midwifery Staff to ensure:1. Patient bed area has been cleaned2. All emergency equipment is functioning and available, including oxygen and suction.

Back to Table of Contents

Section 2 – Clinical Handover from PACU to Ward Staff

The PACU nurse hands over verbally to the ward nurse at the patient bed side using ISBAR and including the patient in the handover process.

Ward Nursing/Midwifery Staff:1. Don PPE and attend hand hygiene using Alcohol Based Hand Rub as per Healthcare

Associated Infections Procedure.Introduction2. Nursing staff to introduce self and role to each other and the patient and any

family/carers present.3. Patient identification and allergy band is checked against the patient ID label in the

clinical notes. The patient, where possible, is asked to confirm their identity using 3 core identifiers (As per Identification and Procedure Matching policy).

Situation4. Clarify the operative procedure performed 5. Review operative report with PACU staff 6. Discuss the patient’s medical history and impacting co morbidities


Health3 of 10

CHHS18/200

Background7. Check patient’s airway is clear and observe for effort of breathing (i.e. use of accessory

muscles, tracheal tug).

Alert: If airway is compromised place the patient in the lateral position (if not contraindicated), and consider Medical Officer review.

8. If oxygen therapy insitu ensure the oxygen is attached to wall oxygen outlet9. Confirm flow rate as ordered (PACU staff responsibility on arrival at ward – checked by

ward staff to ensure correct flow rate)10. Handover should include:

10.1. Oxygen requirements including type of oxygen delivery system and flow rate (e.g. Nasal prongs, 4 litres of oxygen per minute)

10.2. Tracheostomies including size, type, cuff inflated or deflated, a site check for blood and/or discharge, frequency and type of secretion suctioned (refer to Tracheostomy Management Adult Patients clinical procedure)

10.3. Any peri and post-operative breathing difficulties and interventions10.4. Review of peri and post-operative vital signs, including any interventions

required for stabilisation 10.5. Any peri and post-operative neurological concerns including behavioural

difficulties10.6. Review the fluid balance chart, IV fluid orders, check all IV fluid insitu, received

in theatre and continuing orders, check IV device e.g. Central Venous Catheter (CVC), Peripheral Inserted Central Cather (PICC), Intravenous Cannula (IVC) (date of insertion, patency, site, and is appropriately secured). Ensure all IV lines are labelled as per the National Standard for User Applied Labelling of Injectable Medicines, fluids and lines and secured appropriately

10.7. Urinary drainage devices e.g. Indwelling Catheters (IDC), Urostomies, supra-pubic catheter (SPC), Ureteric Stent (ensure hand hygiene is attended after contact with these devices), if no urinary drainage device insitu confirm last time patient voided

10.8. Check any drains insitu e.g. wound drains; chest drain and output10.9. Any nasogastric tube for drainage or feeding. Check output. Ensure orders are

clearly documented in the notes as to purpose, use and position of tube10.10. Ensure all output is documented on the Fluid Balance chart 10.11. Medications administered in theatre and medication chart reviewed10.12. Any intravenous medications ordered and given (e.g. antibiotics,

antihypertensive)10.13. Any wounds, dressings, wound packing or vaginal loss documented10.14. Post Partum observations, including vaginal loss and fundal height10.15. Any pain management devices and associated medication orders, including

Patient Controlled Analgesia (PCA), Epidurals, Pain Busters, Continuous Opioid infusions, regional local anaesthetic infusions, etc. This includes single shot analgesia technique without pain management device i.e. single shot local


Health4 of 10

CHHS18/200

anaesthetic block or intrathecal/epidural morphine single dose administration for post-operative pain relief (refer to Acute Pain Management Techniques Procedure )

10.16. Neurovascular observations (if applicable, e.g. orthopaedic, vascular & plastic surgery)

Assessment

Alert: All initial observations on transfer to ward should be attended in the presence of the PACU nurse to ensure any abnormalities are identified and managed as soon as possible. If the patient does not meet the PACU discharge criteria (Refer to PACU Post Anaesthesia Observation Chart), ward staff are to request the patient be reviewed by the Anaesthetic Registrar or Medical Officer and/or returned to PACU for further recovery.

10.17. Perform and document a full set of Vital signs and Modified Early Warning Score (MEWS) including: Respiratory Rate (RR) Oxygen Saturation Temperature Blood Pressure (BP) Pulse (P) Level of Consciousness (LOC)

10.18. All observations are to be recorded on the Modified Early Warning Score (MEWS) charts and appropriate adjunct charts (i.e. neurovascular, neurological, PCA, Epidural, Intrathecal/ Epidural etc.)

Alert: If the patient meets the MET criteria, activation of MET should occur.

11. State any problems identified for the patient

Recommendation1. State ongoing care requirements as including specific post-operative and anaesthetic

orders2. State who the patients care is under if the patient requires review.

3. Ensure all of the above are completed prior to PACU nurse leaving ward area and patient care is accepted (Ensure that PACU post anaesthetic observation chart is signed by PACU and ward nurse)

4. Ensure all observation requirements are documented on the Nursing Care Plan5. Attend hand hygiene after by either hand washing or using alcohol based hand rub.


Section 3 – Ward ObservationsDoc Number Version Issued Review Date Area Responsible PageCHHS18/200 1.0 10/07/2018 01/04/2022 Surgery and Oral

Health5 of 10

CHHS18/200

Procedure 1. Record vital signs (RR, oxygen saturation, temperature , BP, P, LOC and UOP) as per post

anaesthetic/ operative observation regime or more frequently as prescribed2. Continue to monitor patients’ skin for colour and temperature changes. 3. Perform formal neurological observations if ordered using the Glasgow Coma Scale

(GCS) or if not returned to previous LOC4. Observe the wound dressing for ooze or blood loss when vital signs are recorded. Note

colour, amount and odour (if any), reinforce wound dressing if required. Do not remove theatre dressing.

5. Inspect the surgical area for swelling or discolouration/ bruising (with dressing intact)6. Inspect the condition and contents of any drainage tube and equipment. Note volume

and type of the drainage (be descriptive e.g. large, haemoserous, chyle, purulent). Inspect drain site for change and ensure that the drain tube is secured in place.

7. Contact the Medical Officer for review if excessive swelling, discolouration or blood loss is observed

8. Monitor IV therapy and intravenous cannula site (record IVT on fluid balance chart)9. Encourage deep breathing and coughing exercises and limb movements with routine

observations (unless contraindicated)10. Unless contraindicated (patient either Nil By Mouth (NBM) or on modified texture diet),

offer ice to suck or sips of water (record on the fluid balance chart)11. Before initial dose of analgesia check recovery records noting if and when analgesia had

been administered 12. Assess pain and administer analgesia as prescribed (unless contraindicated by

Intrathecal/Epidural Morphine, Continuous Opioid infusion, Patient Controlled Analgesia or Epidural, refer to Acute Pain Management Techniques procedure)

13. Reassess effectiveness of analgesia hourly or when vital signs observations are completed (or as per Acute Pain Management Techniques procedure), and request review as required.

14. Orientate the patient to their surroundings on admission or return to ward, and reorientate as required when attending to observations

15. Review with the patient the expectations of the post-operative recovery phase16. Inform the patient of the presence of drains or infusions17. If no urinary drainage devices encourage the patient to void. Measure and record on

the patient's fluid balance chart

ALERT: If the patient does not pass urine in the first six (6) hours postoperatively, assess the patient for bladder distension and notify the Medical Officer.

18. Offer / attend to bed bath 19. Dress in personal nightwear if desired20. Offer / attend to mouth care, replacing dentures if applicable21. Position the patient in accordance to post-operative instructions22. Ensure that the call bell is within reach


Health6 of 10

CHHS18/200

23. Lower bed and elevate bed rails to maintain patient safety if required. Note: where patients are disorientated consider hi low bed. Complete pressure injury and falls risk assessments if not previously completed or reassess risk.

24. Commence diet and fluids as ordered (continue to monitor tolerance of diet)25. Document all observations on the appropriate charts, e.g. MEWS, fluid balance chart, in

the patient's clinical record and escalate if required. 26. Record in the patient's clinical record all post-operative nursing care provided and the

patients response27. Notify next of kin of patient’s return to ward and document in the patient’s clinical

record.Back to Table of Contents

Section 4 – Post-Anaesthetic Observation

Procedure General/Epidural/Spinal AnaestheticFull set of Vital Signs: On return to ward, then Half hourly for two (2) hours (30mins x 2 hours), if MEWS ≥ 4 continue half hourly (Refer

to Vital Signs and Early Warning Scores procedure (excluding Day Surgery Unit) or When MEWS <4, hourly for four (4) hours (60 mins x 4 hours), then 4th hourly for a minimum of 24 hours. Particular attention to level of motor and sensory blockade.

ALERT: If respirations are eight (8) or less per minute or if the patient complains of headache following spinal or epidural anaesthetic within the first 24 hours, notify the Anaesthetist or Anaesthetic Registrar immediately and document in the patient’s clinical record.

Regional Nerve Block (Brachial, Ulna, Femoral or Digital)Full set of Vital Signs: On return to ward, then If MEWS ≥ 4 continue half hourly (Refer to Vital Signs and Early Warning Score

Procedure) or When MEWS <4, hourly for four (4) hours (60 mins x 4 hours), then 4th hourly for a minimum of 24 hours (or until discharge).

Observe Injection site and sensation of area: On return to ward, then Hourly for four (4) hours until sensation and movement have completely returned. Notify Medical Officer if any concerns regarding return of sensation or movement.

Local AnaestheticFull set of Vital Signs: On return to ward, then If MEWS < 4 and patient is a Day Surgery patient, the patient can be discharged home


Health7 of 10

CHHS18/200

If MEWS ≥ 4 continue half hourly (Refer to Vital Signs and Early Warning Score procedure) or

When MEWS <4, hourly for four (4) hours (60 mins x 4 hours), then 4th hourly for a minimum of 24 hours (or until discharge).

Observe Injection site, capillary return and sensation of area: On return to ward Hourly until sensation and movement has completely returned Notify Medical Officer if any concerns regarding return of sensation or movement.

ALERT: In the event of any deviation from the normal anticipated recovery from an anaesthetic, a Medical Officer/ Anaesthetist or Anaesthetic Registrar must be notified immediately.

Finger and Hand Surgery ALERT: Review RN Theatre Report to determine location and length of time the tourniquet was in place and what time the tourniquet was removed.

All dressings must remain dry and intact unless post-operative notes state otherwise Observe finger tips for change in colour Monitor for persistent numbness or pins and needles. Check if a local anaesthetic was

injected into the wound Monitor hand/ fingers for pain, bleeding and swelling The nurse discharging the patient is responsible for delivering and explaining the “Finger

and Hand Surgery” fact sheet to the patient Additional post-operative instructions patient fact sheets, located on the policy register,

can be given to the patient Document in the patient’s clinical record that the information has been provided and

explained to the patient.


Implementation

This procedure will be made available to all staff via the clinical policy register.New staff will be informed of this procedure during orientation to the operating theatre and surgical wards.

In-services will be conducted to nursing, midwifery and medical staff in relation to postoperative handover.

Related Policies, Procedures, Guidelines and Legislation

Policies


Health8 of 10

CHHS18/200

Patient Identification and Procedure Matching Policy Nursing and Midwifery Continuing Competence Policy Medication Handling Policy

Procedures Healthcare Associated Infections Procedure Clinical Handover Procedure Patient Identification and Procedure Matching Procedure Acute Pain Management Techniques Procedure Patient Identification and Procedure Matching Procedure Vital Signs and Early Warning Scores Procedure Code Blue (Medical Emergency) – ACT Health Emergency Management Plans Tracheostomy Management Adult Patients Procedure Drain Management procedure Urology – Catheter insertion and management, bladder irrigation, nephrectomy and

trans urethral prostatectomy(TURP) procedure Patient Escort and Transport within Canberra Hospital Campus procedure

Legislation Health Records (Privacy and Access) Act 1997 Human Rights Act 2004 Work Health and Safety Act 2011


References

1. Hand Hygiene Australia (2018) 5 moments of Hand Washing. Available at: http://www.hha.org.au/

2. The Joanna Briggs Institute, Canberra Hospital – Acute Care Practice Manual 2008, Post-Operative Care, 21 October 2005, pp 579-582

3. Kozier B Erb G Blais K et al, Fundamentals of Nursing, 5th Edition, 1998, Addision-Wesley Publishing, Redwood. p 1397-1424

4. World Health Organisation (WHO) (2018) Guidelines on Hand Hygiene in Healthcare (2009). Available at: http://www.who.int/gpsc/5may/tools/9789241597906/en/

5. Nursing and Midwifery Board of Australia (2015) Professional codes and Guidelines. Available at: http://www.nursingmidwiferyboard.gov.au/Codes-and-Guidelines.aspx


Definition of Terms

PPE – Personal Protective Equipment (i.e. mask, gown, goggles)PACU – Post Anaesthetic Care Unit

Back to Table of ContentsDoc Number Version Issued Review Date Area Responsible PageCHHS18/200 1.0 10/07/2018 01/04/2022 Surgery and Oral

Health9 of 10

http://www.who.int/gpsc/5may/tools/9789241597906/en/

http://www.hha.org.au/

CHHS18/200

Search Terms

Patient transfer, Handover, Anaesthetics, PACU, Post-operative Care UnitBack to Table of Contents

Disclaimer: This document has been developed by ACT Health, <Name of Division/ Branch/Unit> specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Policy Team ONLY to complete the following:Date Amended Section Amended Divisional Approval Final Approval 09 Jul 2018 New Document Daniel Wood, ED SOH CHHS Policy Committee

This document supersedes the following: Document Number Document Name


Health10 of 10

Post Operative Handover and Observations - Adult … · Web viewThis document pertains to the...

Documents

Transcript of Post Operative Handover and Observations - Adult … · Web viewThis document pertains to the...