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pulse (rate, rhythm and amplitude): 51–100 bpm

respiration rate (rate, depth, effort and pattern): 9–14 rpm

peripheral oxygen saturation: >95%

temperature: 36.1–37.9°C

blood glucose (if clinically indicated): 4–7 mmol/L

central venous pressure (if clinically indicated): 5–10 cmH2O

neurological response (Glasgow Coma Scale) (see Chapter 11).

accurate fluid balance (to include input and output).

(Bickley et al. 2009, DH 2000)

The regularity of these postoperative observations will be determined by the type of surgery performed as well as the method of pain control (e.g. epidural). A clear physiological monitoring plan should be made for each patient, detailing frequency of observations and parameters (NCEPOD 2005). If obtaining blood pressure measurements using electronic sphygomomanometers, the operator should also be aware that errors in measurement (for example, if there is a weak, thready or irregular pulse) may not readily obvious to the operator and that manual blood pressure measurement may be indicated. It is therefore essential that nurses develop the skill and dexterity to monitor patients’ vital signs with traditional manual equipment (see Chapter 12). It has also been reported that pulse oximeters can be open to misinterpretation and therefore should not replace a respiratory assessment (NCEPOD 2005). Respiratory assessment is an early and sensitive indicator of deterioration (NCEPOD 2005).

Furthermore, it is imperative that nurses are able to interpret the results of postoperative observations and, if reliant on care assistants to take the observations, that nurses themselves interpret the results, thereby ensuring that patients who require it are given immediate priority. Studies reported by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) (2005) established that 41% of patients admitted to intensive care units from other parts of the hospital following cardiac arrest had abnormal clinical observations up to 24 hours prior to admission, suggesting that a cardiac arrest could potentially have been avoided if ward staff had responded to the abnormal clinical parameters (Goldhill and McNarry 2004, McQuillan et al. 1998, NCEPOD 2005, NPSA 2007). The Modified Early Warning System (MEWS) has been found to be a useful tool for referral of clinically deteriorating postoperative patients (Gardner-Thorpe et al. 2006). The MEWS is a simple physiological scoring system, based on the postoperative measurements previously outlined, that identifies patients at risk of deterioration who require increased levels of care (DH 2000, NICE 2007) (see Chapter 12). The primary purpose is to prevent delay in intervention or transfer of critically ill patients. The MEWS enables early identification of patient deterioration and, in conjunction with the SBAR (Situation, Background, Assessment, Recommendation) tool, is intended to improve communication between nursing staff and junior doctors/critical care outreach teams to ‘flag up’ patients who need to be given immediate priority, as recommended by the NHS Institute for Innovation and Improvement (NHSIIP 2008). The call-out algorithm is intended to ensure that appropriate immediate management is started and that the need for critical care expertise should be considered at an early stage.

Routine postoperative respiratory observations will include:

listening for audible stridor, wheeze, secretions

respiratory assessment including rate, depth, pattern (ensure greater than 10 rpm)

observing for increased effort of breathing

observing any changes in the patient’s colour, that is, peripheral/central cyanosis

pulse oximetry

use of oxygen therapy – flow and method of delivery

any chest drains in situ

airway adjuncts.

Deep breathing exercises (DBE), coughing exercises and early mobilization may be undertaken. DBE helps remove mucus which can form and remain in the lungs due to the effects of general anaesthetic and analgesics (which depress action of cilia of the mucus membranes lining the respiratory tract and the respiratory centre in the brain).