What should be included in a nursing order for standard post-operative care?

Standard Post-Operative Nursing Care Order

All post-operative patients require systematic monitoring of vital signs (respiratory rate, heart rate, blood pressure, oxygen saturation, level of consciousness, and surgical site assessment) with documented reassessment at regular intervals, combined with multimodal pain management starting with scheduled acetaminophen, early mobilization protocols, and fluid balance optimization. 1

Vital Signs Monitoring

• Monitor respiratory rate, heart rate, blood pressure, oxygen saturation, level of consciousness, and surgical site at standardized intervals per institutional protocol 1
• Implement Modified Early Warning Scores for all patients to enable early detection of deterioration 1
• Reassess patients after any pain intervention at appropriate intervals based on the anticipated effect of the intervention 1
• When significant worsening pain occurs, especially with tachycardia, hypotension, or hyperthermia, immediately perform comprehensive patient assessment as this may indicate postoperative complications (bleeding, anastomotic leaks, deep vein thrombosis) 1

Pain Management Protocol

Multimodal opioid-sparing analgesia is mandatory, following this stepwise approach:

• First-line: Scheduled acetaminophen (not as-needed) - this is safer and more effective than other drugs when started at the beginning of postoperative analgesia 1
• Second-line: Add NSAIDs if acetaminophen insufficient and no contraindications present, using lowest effective doses with proton pump inhibitor gastric protection 1
• Third-line: Opioids only as last resort in low doses for breakthrough pain, with age-adjusted and renal function-adjusted dosing 1
• Pain assessment using validated scales (such as VAS) must be documented as part of routine nursing observations, though recognize VAS alone does not provide multidimensional pain evaluation 1
• For elderly or cognitively impaired patients who may not report pain adequately, use structured pain assessment algorithms designed for all cognitive abilities 1

Common pitfall: Administering pain medications only as-needed rather than at regular scheduled intervals leads to inadequate pain control 1. Scheduled dosing prevents pain rather than chasing it.

Respiratory Support

• Administer supplemental oxygen for at least 24 hours postoperatively, particularly in older patients at risk of hypoxia 1
• Encourage pulmonary physiotherapy and incentive spirometry to prevent respiratory complications, as postoperative pain inhibits deep breathing and coughing, increasing risk of respiratory infections 1
• Oxygenation improves with mobilization 1

Fluid and Nutrition Management

• Encourage early oral fluid intake rather than routine IV fluid prescription 1
• Offer oral fluids as soon as patient is lucid after surgery 1
• Offer solid diet within 4 hours after surgery 1
• Discontinue IV fluids by postoperative day 1 in most cases 1
• Remove urinary catheters within 24 hours in majority of cases to reduce urinary tract infection risk, individualized only for patients at high risk of retention 1

Common pitfall: Routine prolonged IV fluid administration and catheter retention increase complications without benefit 1.

Mobilization Protocol

• Mobilize patient for 30 minutes on day of surgery 1
• Progress to 6 hours of mobilization daily thereafter 1
• Early mobilization prevents postoperative complications including delirium, venous thromboembolism, and respiratory complications 1
• Inadequate analgesia is a major barrier to mobilization and must be addressed proactively 1

Temperature Management

• Maintain core temperature ≥36°C 1
• Document patient's core temperature before leaving operating theater 1
• Hypothermia contributes to coagulopathies and poor outcomes 1

Postoperative Nausea and Vomiting (PONV)

• Continue PONV prophylaxis postoperatively as required based on preoperative risk assessment 1
• High-risk patients should have received 2-3 antiemetics perioperatively 1

Venous Thromboembolism Prophylaxis

• Continue VTE prophylaxis (compression stockings and/or intermittent pneumatic compression with LMWH or unfractionated heparin) throughout hospital stay 1

Wound and Drain Management

• Avoid routine use of nasogastric tubes and surgical drains unless specifically indicated 1
• Monitor surgical site as part of vital signs assessment 1

Documentation Requirements

• 24-hour monitoring with regular assessment and documentation provides better pain treatment outcomes 1
• Document all vital signs, pain scores, interventions, and patient responses at each assessment 1

Escalation Criteria

• Immediately notify physician team for: sudden increase in pain, tachycardia, hypotension, hyperthermia, change in level of consciousness, irritability, confusion, headache, altered pupillary reactivity, or deterioration in lower extremity motor/sensory function (if applicable) 1
• These signs may herald serious postoperative complications requiring urgent intervention 1

Special Considerations for Elderly Patients

• Assess for postoperative cognitive dysfunction/delirium (occurs in 25% of hip fracture patients) through multimodal optimization: adequate analgesia, nutrition, hydration, electrolyte balance, appropriate medication review, bowel management, and mobilization 1
• Screen for complications such as chest infection, silent myocardial ischemia, and urinary tract infection that may present atypically 1
• Use haloperidol or lorazepam only for short-term symptom control if absolutely necessary; avoid cyclizine due to antimuscarinic effects 1