Post-Operative Care


 
POLICY:
 
All patients will be carefully monitored, as appropriate to 
the procedure performed and the orders of the surgeon.  
Unless approved by the physician, all patients shall remain 
in recovery period until discharge criteria are met and 
documented.
 
PROCEDURE: (for Patients Recovered in the Procedure Room/OR)
 
Patients undergoing simple procedures may require no pre-, 
intra-, or post-procedure monitoring.  
 
When, in the judgment of the surgeon, a patient recovering 
from local anesthesia requires post-procedure monitoring, 
that patient shall be observed per orders; vital signs shall 
be taken, at the least, at the completion of the procedure 
and at the time of discharge.  
 
Patients having local anesthesia may drive unless such 
privilege is denied via written order of the attending 
surgeon; patients having any level of anesthesia other than 
local will not be allowed to drive.  
 
PROCEDURE: (for Patients Admitted to the Recovery Process)
 
Patients may be admitted to the 'Recovery Process' whether 
the patient is moved to a designated recovery area or 
recovered in the procedure room/operating room.  Monitoring 
requirements for the 'Recovery Process' are identical 
regardless of the location where the patient is recovered.
 
1.  The Recovery Room staff person receiving the patient will 
    discuss patient status and clinical details with the
    nurse and/or staff member moving the patient.   
 
    The physical assessment at the time of the completion of 
    the procedure/admission to the Recovery Room will include;
 
    A.  Respiratory rate and competency
    B.  Blood pressure and pulse
    C.  Condition of dressing
    D.  Fluid therapy, if any
    E.  Level of consciousness
    F.  Level of comfort
 
2.  Staff will report any unusual observations and/or 
    readings to the Provider Staff member performing the 
    procedure immediately.
 
3.  Staff will
 
    A.  evaluate patient's level of consciousness and 
        orientation;  
    B.  record vital signs upon completion of procedure 
        and, when applicable, upon admission to 'Recovery', 
        and at appropriate intervals until the patient 
        is stable; and
    C.  document vital signs
 
4.  Staff will assess respiratory status and administer 
    oxygen upon the order of the Staff member; in an 
    emergency, oxygen will be administered as necessary.
 
5.  Staff will position patient for comfort, securing safety 
    straps and other restraints if necessary.
 
 
 
6.  Staff will assess status of any wounds or dressings; 
    drainage, if any, is documented.
 
7.  IV site, if any, will be checked, and IV volumes charted. 
 
8.  Patients recovering from general anesthesia shall have at 
    least 4 sets of vital signs recorded at specified 
    intervals (usually every 5 minutes) prior to discharge.
 
9.  Patients recovering from monitored anesthesia care shall 
    have at least 3 sets vital signs recorded at specified 
    intervals prior to discharge.
 
10. The patient may be discharged by a member of the Provider 
    Staff, or by a clinical staff member using standing 
    orders.
 
11. Unless denied by surgeon's orders, patients shall be 
    encouraged to take fluids prior to discharge.  Nausea and 
    vomiting will be charted and reported immediately to the 
    staff member.
 
12. Patients shall be encouraged to void prior to discharge.
 
13. Unless pre-operative condition or the type of surgery 
    precludes ambulation, patients will be expected to 
    demonstrate their ability to ambulate in a safe and 
    steady manner prior to discharge.
 
14. The person to whom the patient is released must be an 
    adult with the capacity of making informed judgments 
    regarding the care of a post-operative patient.  

    Instructions shall be given to the patient and to the
    caregiver prior to discharge; these will include
    information on how to cope with after-hours questions and
    emergencies.  
 
    Discharge instructions provided to each patient contain
    the surgeon's name and phone number.  
 
15. Patients undergoing major procedures, patients considered
    to be frail or cared for by a frail caregiver, or those
    patients who may have encountered problems during any
    procedure will be contacted by phone following surgery by
    a member of the staff and/or by the staff member
    performing the procedure.  Such contact will be 
    documented in the patient chart.

Approved By Governing Board    
PS.1    
Control #67.0
GUPTA GASTRO