What nursing assessments are priorities during the postoperative period?

• Introduction
• Aim
• Definition of terms
• Assessment
• Management once transferred to an Inpatient Unit
• Escalation of care
• Special Considerations
• Companion documents
• Evidence Table
  

Introduction

Routine post anaesthetic observations are an requirement for patient assessment and the recognition of clinical deterioration in post-operative patients; acknowledging that children are at a high risk of complications post anesthetics, surgeries and procedures. 
There is disparity in the literature as to what constitutes ‘standard’ routine post anaesthesia observations, so in line with the Observation and Continuous Monitoring Guideline, this guideline designates clinical observations for the immediate post-operative period and assists in the recognition of clinical deterioration through use of the Victorian Children’s Observation and Response (ViCTOR) graph  containing unshaded zones in which normal observations are expected and shaded zones above and below the normal limits.. 

Aim

This guideline applies to all patients after a general anaesthetic for whom the ‘ Post-Operative Discharge Criteria Following General Anaesthesia for Minor Surgical Procedures’ does not apply.

This guideline provides guidance for:

• Measurement of clinical observations in the immediate post-operative period
• Role of continuous cardio-respiratory monitoring and pulse oximetry monitoring 
• Use of the inpatient victor graphs
• Links to the process for escalation of care in response to abnormal physiological observations 

Note that this is a guideline only and does not replace the need for clinical judgment on an individual basis.

Definition of terms

• GA - General Anaesthetic
• MET- Medical Emergency Team 
• MR - Muscle Relaxants (De-polarizing and Non De-polarizing) 
• PACU- Post Anaesthetic Care Unit 

Assessment

Initial assessment - PACU

When admitting a patient to PACU patient identification and handover should occur utilising the Handover Flowsheet. Post-operative orders must be communicated both verbally and documented in the EMR. Post-operative orders are additional to the operation report. Clinical handover should highlight any issues throughout the intra-operative period, acknowledge the process for escalation of care, should this be required and allow for clarification of any instructions before accepting care of the patient. 
Once care is accepted in the PACU the initial assessment should include:

• Physical Assessment 
  • Airway, Breathing, Circulation & Disability Assessment (link to Nursing Assessment Guideline)
    
  • Baseline Observations including, RR, Respiratory effort, SpO2, HR, BP and Temperature
    
  • Oxygen requirements
    
  • IV Fluids
    
  • Analgesia
    
  • Urine Output
    
  • Reportable Blood Loss
    
  • Assessment of Wound Sites / Dressings
    
  • Presence of drains and patency of same
    
  • NGT In situ
    

Observations continue at least 15 minutely, or more frequently as clinically indicated

• HR, RR, SpO2, Temperature and BP 
  
• Sedation Score (AVPU, Michigan sedation score or formal GCS as indicated)
  
• Pain Score
  
• Nausea Score
  

Continuous Oximetry monitoring should be initiated for all patients admitted to PACU
Cardiorespiratory monitoring should be applied to all patients under 6 months of age and as clinically indicated for all other patients  

Patients are ready to transfer to the ward once they meet the PACU ‘Discharge Criteria’ (see below) and ‘Ready for Discharge’ both of which are timestamped on EMR. 

PACU ‘Discharge Criteria’

• Clinical Observations within age appropriate limits
  
• Observations which fall within shaded areas of clinical observation chart, should be managed following the Medical Emergency Response Procedure, please note appendix 4 specifically refers to transfer of patients from PACU to ward.
  
• Core temperature ≥ 36 degrees or ≥36.6 degrees for neonates
  
• Sedation score 2 or less (UMSS)
  
• No active vomiting 
  
• Pain Managed

If there is a delay in transfer of patient related to inability of inpatient unit to accept care, then observations in the PACU will continue to be 15 minutely as per ACORN standards.
If there is a delay in transfer PACU nurses will handover the time the patient met the PACU ‘Discharge Criteria’.

Management once transferred to an Inpatient Unit

• Physical Assessment of patient including Airway, Breathing, Circulation & Disability (Link to Nursing Assessment)
  
• Clinical Handover 
  
• Actual Complications / Potential Complications Identified 
  
• Documentation that Handover has been given/received between PACU Nurse and Ward Nurse accepting care
• Documentation of altered MET Criteria if required (please see the Medical Emergency Response Procedure)
  

The time frame for routine post anaesthetic observations should commence once the PACU nurse has deemed the patient ‘Ready for Discharge’. See special considerations for how to locate this on EMR.
Note: if there is a delay in transferring a patient to the ward due to bed availability, the time the patient met the PACU ‘Discharge Criteria’ and ‘Ready for Discharge’ should be noted, so as the routine post anaesthetic observation period need not be reset.

Frequency of routine post anaesthetic observations:

• Immediately on transfer from PACU to ward
  
• Continue ½ hourly for 4 hours if the patient had an Endo Tracheal Tube placed
  
• Continue ½ hourly for 2 hours if the patient had a Laryngeal Mask placed 
• RPAO can be placed as an order in EMR
  

Routine post anaesthetic observations should include:

• HR, RR, SpO2, BP and Temperature
  
• Neurological Assessment (AVPU, Michigan sedation score or formal GCS as indicated)
  
• Pain Score
  
• Assessment of Wound Sites / Dressings
  
• Presence of drains and patency of same
  
• Other complications/assessment findings as patient condition dictates (refer to Nursing Assessment guideline)

Consider the need for continuous pulse oximetry and/or cardio-respiratory monitoring as indicated by patient’s condition. 
All Patients with altered conscious, respiratory and/or cardiovascular status should receive continuous pulse oximetry and/or cardio-respiratory monitoring throughout the routine post anaesthetic period outlined above and as indicated by patient condition.
Refer to the Observation and Continuous Monitoring guideline for more information.

Whilst all postoperative orders need to include both post anaesthetic and post-surgical orders, some patient groups may need modified post-operative orders +/- modification of MET criteria, these may include:

• Patient factors; examples include increased risk of hypothermia including children with Cerebral Palsy or family history of Malignant Hypothermia
  
• Surgical factors; examples include major surgery where there has been significant blood loss
  
• Social factors; examples include a child with autism who may not be well supervised post operatively 
  

For further information regarding modification on the MET criteria please see the Medical Emergency Response Procedure.

Ongoing observation

At the completion of the RPAO’s, the type and frequency of clinical observations must reflect the clinical status, therapies and interventions being delivered to the child and be consistent with requirements of other individual guidelines and procedures.

• As per the Observation and Continuous Monitoring guideline, observations should be performed at least once per hour if the patient:
  
  • Has previous observations within the shaded orange or red zone (unless modified) 
    
  • Was transferred from PICU/NICU (as clinically indicated) 
    
  • Is receiving PCA, Epidural, or Opioid infusion 
    
  • Is receiving an Insulin infusion 
    
  • Has ICP monitoring
    
  • Is receiving oxygen therapy
    

Note, other children may require hourly observations and continuous monitoring as clinically indicated. Observation frequency can be ordered in the EMR. 

• The registered nurse responsible for the child's care will determine the type and frequency of observations based on the results of previous observations and the child's clinical condition, in consultation with others involved in the child's care
  
• Clinical observations must be recorded before transfer from one area to another, for example from ED to ward, PICU to ward or PACU to ward
  
• If a child's observations are transgressing MET criteria (i.e., in the shaded zones) this must be addressed prior to transfer. Please see the Medical Emergency Response Procedure.
  

Escalation of care

If you are concerned about the child for whom you are caring, please refer to the Medical Emergency Response Procedure.

If immediate review is required in a deteriorating child, call a MET (dial 22 22 and state building, level, ward and room number).

Special Considerations 

• If the patient has been administered Flumazenil or Naloxone in either theatre or recovery, this increases the risk of an adverse complication/event such as respiratory depression/compromise and increased sedation/or altered conscious state. 
  
• The time frame for routine post anaesthetic observations should commence once the PACU nurse has deemed the patient ‘Ready for Discharge’. This documentation can be located in the EMR under the ‘Chart Review’ Activity tab – ‘Anaesthetics and Perfusion’ – Click to open the procedure report and scroll down to ‘Recovery’ ‘Case Tracking Events’. The ward nurse should confirm the time when the patient was deemed ‘Ready for Discharge’ during handover. 

Companion documents

• Observation and Continuous Monitoring Guideline
• Medical Emergency Team Policy & Procedure
• Met Criteria - Call 22 22 for help - Clinical Practice Guideline
• Clinical Handover - Policy & Procedure
• Patient Identification - Policy & Procedure
• Nursing Assessment Guideline     

Evidence table

Routine Post Anaesthetic Observation Guideline Evidence Table

Please remember to  read the disclaimer

The development of this nursing guideline was coordinated by Stacey Richards, Nursing Research, CNC, and approved by the Nursing Clinical Effectiveness Committee. Updated November 2019.  

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