POST OP ORDERS
Post-op Responsibilities
· When a patient arrives on unit from PAR all surgical forms will be at the front of the patients chart, not in any order
NUC ROLE;
1. File old chart at nursing station
2. Remove addressograph plate from chart and file in holder at nursing station
3. File all surgical forms in “OR SECTION” of chart
4. Transcribe the operations performed from OR NURSES RECORD to Kardex and any other required information
5. Process all doctor’s orders
· After a patient’s surgery, when they have recovered from anesthesia in PAR (post-anesthetic recovery) they are transported to their room on the surgical unit. The patients nurse will receive a report on the patient’s condition from the PAR nurses and will take vital signs and post-op assessments. After she will bring the patients’ chart to the nursing station and the NUC processes all post-op orders
· The surgeon/anesthesiologist may write the orders and may have specific PPO’s (pre-printed orders) so there may be several PPO sheets containing postop protocols
· NUC role is to process all post-op orders and relay any information needed to the correct people
PROCESSING POST OP ORDERS
· All pre-op orders are invalid after a patient is done with surgery or will be replaced with a postop order
· All post-op orders must have a date written in when transcribed to the Kardex, even if there is no column for the date
Post-Op Orders may consist of;
Ø Post-op diet
Ø Post-op activity
Ø Vital Signs
Ø Lab/Diagnostic
Ø Medication
Ø IV catheters, drains, packs sutures
Ø Treatments/rehabilitative medication
· Some orders are done on the 1st/2nd day postop. The NUC must be aware that the day the patient has surgery is referred to as their day of OR or post-op day, the next day referred to first day post-op or post-op day 1 and so on
POST OP DIETS
If there isn’t a specific diet order, the NUC asks the nurse what should be ordered
Progressive Diet
· Most post-op patients will be unable to eat a full meal on the day of surgery as they can be sedated/nauseous. When a post-op patient has an order for “DAT” or “clear fluids to DAT” their diet is slowly progressed as follows;
1. Sips of water (no tray)
2. Clear fluids
3. Full fluids
4. Transitional (or soft) diet
5. Regular diet
· Before each meal time the NUC checks the patients Kardex to see if the nurse has changed the patient’s diet – if it has been change the NUC enters the new diet in the computer or changes on diet form/K before sending to the kitchen
Post-Op Activities
If no post-op activities are orders, leave blank on the Kardex for the nurse/physiotherapist to fill in after assessment.
Ø If there is anything written in activities section pre-op it should be erased
Ø Dangling = patient sits at the end of the bed awhile before standing to assess the patient’s state of alertness post-op – if not dizzy by this point a nurse will observe/assist them out of bed
Physiotherapist
A physiotherapist will perform various types of treatment for post-op patients such as chest physio, post-op exercises and post-op mobilization
Ø When processing requisitions for physiotherapy the NUC puts in a physio referral, circles PT on the Kardex with the date beside it
Vital Signs
Ø Most surgeons don’t write specific orders for vital signs post-op but are satisfied with the nurse following their routine procedures for vital signs (usually q4h)
Ø Some surgeries like tonsillectomy/septoplasty require more frequent vital signs post-op due to risk of unseen bleeding (patient ends up swallowing blood that seeps into the back of their throat with these surgeries)
Lab & Diagnostics
· Most commonly ordered post-op lab is Hgb (hemoglobin) as patient might bleed during surgery – usually ordered 1-2 days post-op
· The NUC enters the order in the computer with the date of collection or fills out a paper requisition – OE, RMO date
· Paper req’s are kept at the nursing station until the evening before the test is done, the NUC will take the req to lab with other daily blood req’s @ end of shift
· Orthopedic procedures usually require post-op x-rays to ensure proper bone alignment. When NUC completes a requisition for this she states the reason for the x-ray as “post-op _name of surgery performed”
Medications
Ø The surgeons/anesthesiologist must re-order all the patients medications post-op as all pre-op orders are invalid when patient goes to OR
Ø When re-ordered post-op the NUC erases pre-op date next to each med order on the Kardex and replaces with post-op date
Ø If any medication are not re-ordered post-op the NUC will erases the pre-op date but does not erase the original medication order from the Kardex but instead notates “not re-ordered” in pencil next to the med order
Post-op IV Antibiotics
Antibiotics are frequently ordered post-op to prevent infections, usually by IV for a short period of time (1-2 days)
· When ordered post-op the NUC must determine if the first dose of antibiotics was initiated by the anesthesiologist in OR or by the nurse in PAR by reading over the anesthetic record or PAR record – if the first dose was given before patient returned to the unit she must time the next dose according to when the first one was given
EX; patient is ordered “ANCEF 500MG IV Q8H” and anesthesiologist gave first dose @ 1000, the NUC would write second dose for 1800 and third dose for 0200 (8 hrs later)
Post-op Pain Control
- Some patients who have major surgeries may have more then one method of pain control orders (only one gives at a time)
- Pain meds given IV, IM, or PO are usually PRN medications especially if they are narcotics
Intrathecal/Epidural
· Narcotic analgesics administered into the patients spinal column (intrathecal or epidural) for surgery
· There will be a PPO containing post-op intrathecal/epidural analgesia protocols that could be placed in the patient’s chart in the OR if this type of anesthesia/analgesia is used
PCA Pumps (Patient controlled analgesia)
Ø PCA pumps are frequently ordered for post-op pain
Ø Patient has some control over administering their own pain meds
Ø PCA pumps = narcotic analgesic is mixed in an IV bag and run through a PCA pump for continuous infusion. The patient can push a button for added pain meds when needed called a “bolus dose”
Ø The PCA pumps are programmed to prevent accidental overdose by controlling the flow rate of the basal dose and amount a bolus dose can be used in a time period
IV,IM,PO may be ordered in conjunction with epidural or PCA but will not be administered until the patient is no longer receiving any pain control by any other method
Post-Op Anticoagulant Therapy
Patients who have major surgery may have orders for anticoagulants post-op to prevent blood clots as they are confined to bed for a few days after surgery.
- Orthopedic Surgeons have developed a PPO for post-op anticoagulant therapy
- The NUC will order post-op lab tests when a patient is receiving anticoagulant therapy
Intravenous
Patients will have an IV infusing when they return from surgery
· The NUC finds the IV information on the anesthesia record/PAR record and transcribes to IV SECTION of Kardex
· Surgeons/anesthesiologists may write post-op orders specifying what type of IV solution/flow rate of infusion. If there is a discrepancy between post-op order and type of IV solution that is already infusing from OR the NUC transcribed the post-op order and the nurse changes the solution to type requested
· Patient’s with IV solutions require “INTAKE/OUTPUT FORMS” – the NUC checks off the intake box on the patients Kardex
Catheters, Drains, Packs, Sutures
When completing post-op chart the NUC transcribes information from the OR records to the Kardex. The information may include orders for catheters, drains, packs and sutures to be placed on patients after surgery
· Patients with catheters or drains require an I&O sheet (INTAKE/OUTPUT FORM) at their bedside and the NUC would check off the output box on Kardex
(Sometimes catheters/drains are ordered to be emptied by the nurse according to a specific time frame EX;q2h – so the NUC would write “q2h” next to the output box on the Kardex
Catheters
Indwelling = stays in the bladder continuously
Foley Catheter = indwelling & connected and continuously draining to a drainage bag. When it gets full/or at end of shift the NURSE records the output on a fluid balance sheet (intake/output form)
3way Foley Catheter = used for patients who require continuous bladder irrigation (CBI) after bladder surgery. Output urine is collected in a large drainage bag and recorded on a CBI form
French Catheter = used for in/out (intermittent) catheterization. It is placed in bladder, urine is drained and catheter is removed. Urine drained is collected in a sterile container for measuring/discarding or sent for testing (no drainage bag is used as catheter is not kept in (indwelling)
· The NUC transcribes type/size of catheter to “CATHETER SECTION” of the Kardex and any orders to remove are also transcribed to this section
Drains
There are four basic drain types used after surgery;
1) HEMOVAC = frequently used in orthopedic surgery. The drain tube has multiple holes and is laid along the surgery wound before closing. The tubing protrudes from the stab wound near the incision which is connected to a drainage bag with gentle suction. Drains old blood/serous fluid to prevent swelling/infection
2) PENROSE = frequently used in abdominal surgery. A flat latex tube is placed in the surgery area, protrudes through stab wound to drain fluid. This is sometimes ordered to be shortened on a daily basis EX: the tube is pulled out of wound 1 inch and cut off
3) JACKSON-PRATT (JP) = similar to HEMOVAC in design but smaller and used like penrose to remove fluid build up
4) NASOGASTRIC (NG) = threaded through the patient’s nose, down the esophagus into the stomach for drainage of gastric contents. NG’s are sometimes hooked up a gentle suction when primed to help with drainage
The NUC transcribes DRAIN orders by transcribing the type, size and placement of the drain to the “DRAIN SECTION” of the Kardex EX: hemovac #18 Lt Hip – any orders referring to the care of the drain such as intermittent suction, clamping or shortening is also transcribed here
Packs
The NUC transcribed the size/type of pack (packing) and area it is situated EX: merocel sponge Lt Nare or ½ inch sterile gauze Rt leg wound – this is transcribed to “TREATMENT SECTION” of Kardex and any packing removal orders
Repacking a Wound
- If ordered to remove/repack a wound this is considered a dressing change and transcribed to TREATMENT SECTION
Sutures/Staples
· NUC transcribes the type of sutures used and where on the body they are located to the “TREATMENT SECTION” of the Kardex and well as any orders to remove.
Treatments
The surgeon and/or the anaesthetist may order various treatments post-op for the care of the patient.
Post-op treatments can include the following:
oxygen therapy,
dressing changes,
sitz baths,
bowel care,
application of slings, tensors and splints, etc.
Orders for post-op treatments are transcribed to the Treatment section of the patient’s Kardex.
Daycare Admission
Sometimes, a patient who has come to the hospital for daycare surgery is ordered to be admitted overnight or longer. This occurs for several reasons, such as the patient bleeding excessively during surgery, the surgery being more extensive than originally planned, the patient having excessive post-op pain, or difficulty recovering after the anaesthetic.
When this occurs Admitting will make the necessary changes in the computer file and new papers for the patient’s chart. The NUC compiles a new admission chart with a new addressograph/ID labels and admitting papers. The original addressograph/ID labeles are discarded (shredder box). The daycare chart forms and surgical forms are added to the patient’s new admission chart.