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Post-Operative Check — Workflow

Step 1. Chart Check (before entering the room)

  • Immediate post-op/procedure note
  • Procedure type, laterality, anastomosis present, drains/tubes (where is the drain placed intraoperatively?), intra-op complications.

  • Estimated blood loss and transfusion given. If PEG placed: note bumper distance at skin.

  • Vitals trends (since OR/PACU)

  • Tachycardia: may signal pain, hypovolemia, bleeding, PE, infection.
  • Hypotension: consider bleeding, sepsis, anesthetic effect, hypovolemia.
  • Hypertension: uncontrolled pain, urinary retention, missed home meds.
  • Tachypnea/SpO₂ <92%: atelectasis, PE, pneumonia, volume overload.

  • Fever: <48h atelectasis, most likely physiological after surgery.

  • Labs

  • CBC: drop in Hgb/Hct (bleeding).
  • BMP: electrolytes (Na, K, Ca, Mg, Phos), renal function (UO correlation).
  • LFTs: if HPB or biliary surgery.
  • Coags: if bleeding or liver disease.

  • Glucose: hyperglycemia post-op, diabetics, stress response.

  • Intake/Output

  • Adequate urine output? (goal ≥0.5 mL/kg/hr).

  • Drain outputs: character (serosanguinous vs bilious vs feculent) and volume.

  • Comorbidities

  • Cardiac: CAD, CHF, arrhythmias → influences fluids, pain, beta-blocker use.
  • Pulmonary: COPD/OSA → higher risk of hypoxia/retention.
  • Renal: CKD → careful fluids, drug dosing.
  • Hepatic: cirrhosis → coagulopathy, ascites, encephalopathy risk.

  • Endocrine: diabetes (glucose control), thyroid/adrenal meds.

  • Home medications

  • beta-blocker (avoid rebound tachycardia), statin, thyroid meds, seizure meds, antidepressants.
  • anticoagulants, antiplatelets, ACEi/ARB, SGLT2 inhibitors, metformin (renal risk), insulin (adjusted).
  • Pain regimen baseline (opioid-tolerant vs opioid-naïve).

Step 2. Patient Examination + Nursing Check

  • Airway: Patent, voice clear, aspiration risk addressed.
  • Breathing: SpO₂ _% on _ (RA/NC/NRB/HFNC); RR ____. Incentive spirometer at bedside with goal set.
  • Circulation: HR _ BP /_ MAP . Telemetry rhythm ____. Cap refill/warmth. Check dressings/drains for bleeding/hematoma.
  • Neuro (Disability): Mental status at baseline? Focal deficits? Pain/sedation documented.
  • Exposure/Wound: Incisions intact/dry, no erythema/crepitus. Do not remove sterile dressing unless ordered; reinforce if needed.
  • Foley/Fluids: Foley present? Y/N. UO _ mL/hr (goal ≥0.5 mL/kg/hr). IV fluids running at ; assess need for bolus.
  • GI: Abdomen soft/firm? Distension, tenderness, peritonitis? N/V? Anti-emetic plan. NG/OG/stoma function; drain character.
  • Hematology/VTE: SCDs in place and functioning.
  • Extremities/Integument: Pulses/motor/sensation distal to operative site; compartments soft.
  • Lines, Tubes, Drains:
  • IVs/central lines.
  • Chest tube(s): suction/water seal; output ___ mL; air leak? Y/N.
  • Surgical drains: number ___; last-hour output ___ mL; character.
  • Foley: keep/remove per protocol; bladder scan if low UO.

  • Prevena/wound vac if present.

  • Check with nurse: Ask for concerns re: pain, urine output, N/V, hemodynamics.

Step 3. Post-Op Orders and Documentation

  • Write/post-op check note (S/O/A/P).
  • Update orders if needed: labs (CBC, BMP, Mg/Phos, lactate if needed, glucose), meds, diet advancement, IVF adjustments.

Procedure-Specific Add-Ons:
- Colorectal/anastomosis: Monitor for leak (rising pain/tachycardia/fever, drain amylase/bilirubin).
- HPB: Check bile in drains, trend LFTs.
- Vascular: Doppler distal pulses, compartments, antiplatelet/anticoag plan.
- Thoracic: Chest tube management, daily CXR, air-leak check.
- Endocrine/Thyroid: Calcium/hypocalcemia symptoms, voice, airway.
- Hernia/Abdominal wall: Binder use, seroma/hematoma watch.

Step 4. Red Flags — Call Senior Immediately

  • SpO₂ < 92% on O₂, escalating work of breathing, new chest pain.
  • SBP < 90 or MAP < 65, HR > 120 sustained, new arrhythmia.
  • UO < 0.5 mL/kg/hr, anuria, or dark/bloody urine.
  • Rapidly expanding hematoma or soaked dressings; bright-red drain output.
  • Rigid abdomen, peritonitis, or pain out of proportion.
  • Fever ≥ 38.5°C with peritonitis, severe tachycardia, or hypotension.
  • New focal neuro deficit, delirium, or severe agitation.