Surgical Ward Nursing Guide for GCC

Pre-operative Care

Assessment & Preparation

🔍 Pre-operative Assessment

History Taking

Presenting complaint and planned procedure
Past medical and surgical history
Previous anaesthetic history (including complications, family history of anaesthetic reactions)
Bleeding disorders, haematological conditions
Cardiovascular and respiratory history
Renal and hepatic function
Diabetes, thyroid, and endocrine disorders
Smoking, alcohol, recreational drug use

Allergies

Document ALL allergies — drug, food, latex, contrast dye, adhesive
Record type of reaction (anaphylaxis vs intolerance vs side effect)
Ensure allergy band applied BEFORE entering theatre
Alert anaesthetist to latex allergy — theatre must be latex-free

Current Medications — Critical Review

AnticoagulantsWarfarin: stop 5 days prior, check INR. DOAC (rivaroxaban, apixaban): stop 24–48hr. LMWH bridging per anaesthetist plan.

AntiplateletsAspirin: may continue for cardiac stents. Clopidogrel: stop 5–7 days — discuss with surgeon and cardiologist. NEVER stop dual antiplatelet without cardiologist input if recent stent.

Diabetic MedicationsMetformin: withhold day of surgery (lactic acidosis risk with contrast). Insulin: sliding scale protocol. SGLT2 inhibitors: stop 3 days prior (euDKA risk). GLP-1 agonists: discuss with team re: delayed gastric emptying.

Other Key MedicationsNSAIDs: stop 3–5 days. ACEi/ARBs: often held morning of surgery (hypotension). Herbal supplements: stop 2 weeks prior (garlic, ginkgo, ginseng increase bleeding).

ASA Physical Status Classification

ASA Grade	Classification	Examples	Anaesthetic Risk
Grade 1	Normal healthy patient	No medical conditions, non-smoker, non-obese	Minimal
Grade 2	Mild systemic disease	Well-controlled DM, HTN, mild asthma, smoker, BMI <40	Low
Grade 3	Severe systemic disease	Poorly controlled DM/HTN, COPD, morbid obesity, active heart failure	Moderate
Grade 4	Severe, life-threatening disease	Recent MI (<3mo), CVA, ongoing cardiac ischaemia, renal failure on dialysis	High
Grade 5	Moribund — not expected to survive	Ruptured aortic aneurysm, massive trauma, intracranial bleed	Very High
Grade 6	Brain-dead organ donor	Organ retrieval surgery	—

✅ Interactive Pre-operative Checklist

Click each item to mark complete. Progress is saved locally.

Pre-op Checklist Progress0 / 12

Informed consent signed — procedure explained, patient verbally confirms understanding, consent form signed by surgeon and patient
NBM confirmed — solids ≥6hr, clear fluids ≥2hr, medications taken as instructed
Surgical site marking — correct site verified with patient awake, initials by operating surgeon
Compression stockings applied — correct size TED stockings fitted, no contraindications (PVD, open wounds)
Pre-op bloods reviewed — FBC, U&E, LFTs, coagulation, group and screen (G&S) or cross-match
ECG reviewed — particularly for patients ≥40 years or cardiac history
Chest X-ray available — if indicated (respiratory history, cardiac disease, age policy)
Allergy band applied — red allergy band confirmed; "NKDA" band if no known drug allergies
Jewellery, nail polish, makeup removed — rings taped if cannot be removed, pulse ox confirmed functional
Prosthetics removed — dentures, hearing aids, spectacles, contact lenses, prosthetic limbs stored safely
Pre-medication given — anxiolytic/pre-med administered as prescribed, time and route documented
Patient ID verified — name, DOB, MRN confirmed against wristband and consent form (two identifiers)

🚀 Enhanced Recovery After Surgery (ERAS)

ERAS Standard in GCC JCI HospitalsERAS protocols are now standard of care in JCI-accredited hospitals across UAE, Saudi Arabia, Qatar, and Kuwait. Nurses must understand and facilitate all components.

Pre-operative ERAS

Patient education and goal-setting
Carbohydrate loading: 800mL high-CHO drink the evening before, 400mL 2–3hr before surgery
Minimise fasting: solids 6hr, clear fluids 2hr only
Stop smoking and alcohol 4–8 weeks before elective surgery
Optimise medical conditions pre-op (anaemia, nutrition, diabetes control)
Avoid bowel preparation unless absolutely necessary (colorectal)

Intra-operative ERAS

Goal-directed fluid therapy (avoid over/under hydration)
Avoid hypothermia: warming blankets, warmed IV fluids
Minimally invasive surgery (laparoscopic where possible)
Avoid routine use of nasogastric tubes
Regional anaesthesia preferred to reduce opioid requirements
Short-acting anaesthetic agents for rapid emergence

Post-operative ERAS

Early oral intake — fluids within 2–4hr of recovery
Early mobilisation — sit out Day 0, ambulate Day 1
Multimodal analgesia — avoid high-dose opioids
Prophylactic antiemetics (PONV protocol)
Remove catheters and drains early
Daily targets documented (fluid, mobility, diet)
Discharge when criteria met — not by day number

🌍 WHO Surgical Safety Checklist

Sign In (Before Anaesthesia)

Patient confirmed identity, site, procedure, consent
Site marked (if applicable)
Anaesthesia machine and medication check complete
Pulse oximeter on and functioning
Allergies known?
Difficult airway/aspiration risk?
Risk of blood loss >500mL?

Time Out (Before Skin Incision)

All team members introduced by name and role
Surgeon, anaesthetist, nurse verbally confirm patient, site, procedure
Antibiotic prophylaxis given within 60 min?
Anticipated critical events reviewed
Imaging displayed if needed?
Sterility confirmed

Sign Out (Before Patient Leaves Theatre)

Nurse verbally confirms: procedure recorded
Instrument, sponge, needle counts correct
Specimen labelled correctly
Equipment problems identified and addressed
Surgeon, anaesthetist, nurse review key recovery concerns

💉 VTE Prophylaxis

Caprini Risk Score

Score	Risk Level	Recommendation
0–1	Low	Early mobilisation only
2	Moderate	Mechanical + consider LMWH
3–4	High	LMWH + mechanical
≥5	Very High	LMWH + mechanical + extended prophylaxis 4 weeks

Caprini Score Factors

1 point each: age 41–60, minor surgery, BMI >25, varicose veins, swollen legs, oral contraceptive/HRT, recent MI/CHF/sepsis
2 points each: age 61–74, arthroscopy, malignancy, confined to bed >72hr, plaster cast, central venous access
3 points each: age ≥75, previous VTE, family history DVT, Factor V Leiden, prothrombin mutation
5 points each: stroke <1mo, elective arthroplasty, hip/pelvis/leg fracture, acute spinal cord injury

Mechanical Prophylaxis

TED (thrombo-embolic deterrent) stockings: ensure correct sizing, apply pre-operatively, remove and reapply daily, inspect skin
Pneumatic compression devices (IPC): apply in theatre, run continuously until mobile
Contraindications: peripheral arterial disease, leg ischaemia, open wounds, suspected DVT

Pharmacological Prophylaxis

LMWH (Low Molecular Weight Heparin) Enoxaparin 40mg SC daily (standard) or 20mg if CrCl <30. First dose 6–12hr post-op. Continue until mobile or as per protocol (extended to 28 days for major cancer/orthopaedic surgery).

Monitoring No routine anti-Xa monitoring except renal impairment, extremes of weight, or pregnancy. Monitor platelets — HIT risk (rare with LMWH). Check renal function for dose adjustment.

Patient Education

Explain rationale for stockings and injections
Encourage foot and ankle exercises in bed
Encourage early ambulation — most effective VTE prevention
Teach signs of DVT (calf pain, swelling) and PE (chest pain, dyspnoea)

📚 Pre-operative Patient Education

Breathing Exercises

Teach pre-op to reduce post-op pulmonary complications

Deep Breathing

Inhale slowly through nose, hold 3 sec, exhale through pursed lips. Repeat 10 times hourly post-op.

Incentive Spirometer

Slow, deep inhalation to achieve target volume. 10 repetitions hourly while awake.

Effective Coughing

Splint wound with pillow. Deep breath → hold 2 sec → huff cough (2 short) → strong cough. Clears secretions without wound strain.

Expected Recovery

Pain is expected but will be managed — report pain score >4/10
IV fluids initially, then oral fluids when tolerated
Catheter may be present — usually removed Day 1
Drains if present — do not pull or adjust
First mobilisation with nurse support Day 0 or Day 1
Wound will be checked daily — some ooze normal initially
Possible post-op nausea — medications available

GCC-Specific Education Points

Cultural Considerations Many GCC patients prefer family involvement in decision-making. Ensure patient's own consent is obtained with interpreter if needed. Family pressure for early discharge must be balanced against safety — document clearly.

Ramadan Considerations Muslim patients may refuse pre-op medications during Ramadan. Consult Islamic scholar guidance — injections for treatment purposes are generally permissible. Document patient's preferences and escalate to surgeon if fasting compromises safety.

Post-operative Care

Recovery & Monitoring

🩺 ABCDE Post-operative Assessment

Airway

Airway patent?
Talking clearly?
Secretions/stridor?
Airway adjunct in situ?
Swallow reflex returned?

Breathing

SpO2 — target ≥94%
Respiratory rate (12–20)
Breath sounds equal?
Oxygen delivery device
Signs of respiratory distress

Circulation

Heart rate and rhythm
Blood pressure
CRT <2 seconds?
Peripheral perfusion
Wound/drain bleeding
IV access patent

Disability

GCS / AVPU
Pain score (0–10 NRS)
Sedation score (RASS)
Blood glucose (DM)
Pupils if neurological

Exposure

Temperature
Fluid balance (input/output)
Drain output and character
Urine output ≥0.5mL/kg/hr
Wound inspection
Pressure areas

📊 Vital Signs Monitoring Frequency

Standard Post-operative Observation ProtocolFollow locally agreed escalation thresholds. Increase frequency if patient deteriorates at any stage.

Every 15 minutes × 1 hour (first hour post-op)

Highest monitoring intensity. Patient most at risk in immediate post-operative period. Monitor: BP, HR, SpO2, RR, pain, level of consciousness, wound/drain output.

Every 30 minutes × 2 hours

Vital signs stabilising. Continue analgesia titration. First mobilisation may commence. Catheter and drain output charted.

Every 1 hour × 4 hours

Patient more stable. Oral fluids commenced if tolerated. Pain managed on oral regimen if possible. Physiotherapy review for breathing exercises.

Every 4 hours if stable

Routine post-operative monitoring. MEWS ≤2. Preparing for ward ambulation and ERAS milestones.

⚠️

Escalation Thresholds

Escalate immediately if: HR <40 or >130, SBP <90 or >200, SpO2 <90%, RR <8 or >30, GCS drop ≥2 points, urine output <30mL/hr for 2 hours, temperature <35°C or >38.5°C, MEWS ≥5.

💊 Post-operative Pain Management

WHO Analgesic Ladder (Modified for Post-op)

Step 1 — Non-opioid (Regular)

Paracetamol 1g IV/oral QID (max 4g/24hr). Celecoxib or ibuprofen if no contraindications (renal, GI, cardiac risk assessment first).

Step 2 — Weak Opioid/Adjunct PRN

Tramadol 50–100mg oral/IV PRN Q6H. Codeine 30–60mg oral PRN (avoid in poor metabolisers). Ketamine sub-anaesthetic doses (opioid-sparing).

Step 3 — Strong Opioid PRN/PCA

Morphine or oxycodone IV. PCA: morphine 1mg bolus, 5 min lockout, 4hr limit 20–30mg. Fentanyl PCA for renal impairment.

Regional / Epidural

For major abdominal, thoracic, orthopaedic surgery. Reduces systemic opioid requirements significantly.

PCA Monitoring

Check: drug, concentration, bolus dose, lockout interval — against prescription
Monitor sedation score (RASS/Ramsay) EVERY observation cycle
Respiratory rate ≥8 before each PCA top-up
Pain score at rest and on movement
24hr usage — if >30 attempts with <50% delivery, pain may be uncontrolled
Naloxone 0.4mg IV available at all times

Epidural Management

Epidural Monitoring Essentials Sensory level check (ice/cold) every 4hr. Motor block (Bromage scale) — if ≥2, reduce rate and alert anaesthetist. Hypotension common (sympathetic blockade) — ensure adequate IV fluids. Monitor for epidural haematoma: back pain + bilateral motor weakness = EMERGENCY.

PONV Management

Ondansetron 4mg IV Q6–8H (serotonin antagonist)
Metoclopramide 10mg IV TDS (prokinetic)
Cyclizine 50mg IV/IM TDS
Dexamethasone 4–8mg IV (reduces PONV and inflammation)
Position: semi-recumbent, avoid sudden movement
Ginger tea (patient preference — culturally accepted in GCC)

💧 Post-operative Fluid Management

IV to Oral Transition (ERAS)

Recovery / Day 0

IV maintenance fluids running. Offer sips of water when swallow confirmed. Antiemetics given prophylactically.

Day 1

Oral fluids freely if tolerating. IV fluids reduced — use IV only for drug administration. Document all intake.

Day 1–2

Soft diet commenced. IV cannula removed. Full oral hydration target ≥1500mL/day minimum.

Fluid Balance Monitoring

Strict input/output: all IV fluids, oral intake, blood products, NG output, drain output, urine, stool
Target urine output ≥0.5mL/kg/hr (30–40mL/hr minimum)
12hr and 24hr cumulative balance calculated
Positive balance >2L = alert team (fluid overload risk)
Daily weights recommended in high-risk patients

Post-operative Urinary Retention

Risk Factors Male gender, prostate enlargement, epidural analgesia, opioid analgesia, anticholinergic medications, pelvic or perineal surgery, prolonged catheterisation prior to surgery.

Management Protocol

Bladder scan if patient unable to void 4–6hr post-op
Scan volume >400mL: in-out (straight) catheterisation
Scan volume >600mL or patient symptomatic: IDC insertion
Document volume drained, colour, character of urine
Review epidural — reduce rate if possible
If haematuria: flush 3-way catheter, alert urology

DVT Assessment

Post-operative DVT Signs Calf pain, unilateral leg swelling, warmth, erythema. Homan's sign (pain on dorsiflexion) is unreliable — positive in only 50% of DVTs. Use Wells Score. If Wells ≥2: arrange Doppler USS urgently. If PE suspected: CTPA urgently. Treat with therapeutic LMWH while awaiting imaging.

🩸 Peri-operative Diabetic Management

GCC ContextDiabetes prevalence is extremely high in the Gulf region (20–25% in some GCC states). Expect frequent post-operative hypoglycaemia and hyperglycaemia management on surgical wards.

Blood Glucose Targets

Phase	BGL Target
Pre-operative (Type 1)	6–10 mmol/L
Pre-operative (Type 2)	6–12 mmol/L
Intra/post-operative	6–10 mmol/L
ICU post-op	6–8 mmol/L (strict)

Hypoglycaemia Protocol (BGL <4 mmol/L)

If conscious: 15g oral glucose (juice/glucose gel)
If NBM/unconscious: 100mL 10% dextrose IV or 1mg glucagon IM
Recheck BGL in 15 minutes
Document and review insulin sliding scale
Alert surgical team if recurrent

Insulin Sliding Scale Monitoring

Blood glucose monitoring hourly in PACU, then 4-hourly on ward
Variable rate insulin infusion (VRII) for Type 1 DM and uncontrolled Type 2
Dextrose 5% or 10% infusion running alongside insulin
Never stop dextrose without reviewing insulin
Check potassium: insulin drives K+ into cells — monitor for hypokalaemia

⚠️

SGLT2 Inhibitor Warning

Euglycaemic DKA can occur post-surgery in patients on SGLT2 inhibitors (empagliflozin, dapagliflozin). Check urine/blood ketones if unwell even with normal blood glucose. Stop SGLT2 inhibitors 3 days pre-op.

Wound & Drain Management

Assessment & Care

🔬 Surgical Wound Assessment — REEDA Scale

Component	0 (Normal)	1 (Mild)	2 (Moderate)	3 (Severe)
Redness	None	Within 0.25cm of incision	0.25–0.5cm from incision	>0.5cm from incision
Edema	None	<1cm from incision	1–2cm from incision	>2cm from incision
Ecchymosis	None	Within 0.25cm bilateral	0.25–1cm bilateral or unilateral	>1cm bilateral or unilateral
Discharge	None	Serum only	Serosanguineous	Bloody / purulent
Approximation	Closed	Separated <3mm	Separated 3–6mm	Separated >6mm

Scoring Interpretation0 = perfect healing. Score ≥3 = significant concern — document, photograph if facility available, escalate to medical team. Track trend over consecutive dressing changes.

Dressing Change Protocol

First dressing change: 24–48 hours post-operatively (wound sealing occurs at 24hr)
Aseptic non-touch technique (ANTT) — strict sterile field
Cleanse with 0.9% normal saline or chlorhexidine per protocol
Dry dressings for healing wounds; moisture-retentive for slow-healing wounds
Document: REEDA score, wound dimensions, exudate character
Photograph wounds weekly (with patient consent)

Do NOT remove adherent dry eschar without surgical team guidance
Negative pressure wound therapy (NPWT/VAC) for complex wounds — change every 2–3 days
Antimicrobial dressings (silver-containing) for infected wounds
Teach patients wound care prior to discharge — demonstration + return demonstration
Document patient education in nursing notes

🩹 Surgical Drain Management

Types of Surgical Drains

Closed Suction Drains Jackson-Pratt (JP) / Redivac / Blake drain. Connected to sealed reservoir under negative pressure. Compress reservoir to maintain suction. Measure output every 4–8hr. Empty when ½ full. Keep below wound level. Strip tubing if clot present (per protocol). Common in: abdominal, breast, orthopaedic surgery.

Open Drains Corrugated drain / Penrose drain. Allows passive drainage by gravity/capillary action. Change overlying dressing frequently (soaks quickly). Assess for skin maceration. Common in: superficial wounds, infected cavities.

Active Drains (Sump) Requires suction attachment. Used for high-output cavities (abscesses, bile leaks). Monitor output closely — sudden reduction may indicate blockage not resolution.

Drain Output Documentation

Document: date, time, volume, character (serous, serosanguineous, bloody, bilious, turbid)
Normal day 1: moderate serosanguineous drainage acceptable
Fresh red blood: immediate surgical review
Turbid / bile-stained: anastomotic leak concern
Milky white: chyle leak (lymph) — alert surgical team

Drain Removal Criteria

Closed Suction Drain — Remove When: Output <30 mL per 24 hours. No signs of leak or infection. Usually Day 3–5 post abdominal surgery. Earlier for orthopaedic/breast (Day 1–3 if <30mL). Surgeons may leave longer if concern about anastomotic leak.

Drain Removal Technique

Explain procedure to patient
Analgesia 30 min prior (PRN opioid or paracetamol)
Remove securing suture with stitch cutter
Patient exhales or performs Valsalva (abdominal drains)
Withdraw in one smooth motion
Apply pressure dressing to drain site
Document volume, character of final output

🔴 Stoma Formation — Immediate Post-operative Assessment

GCC ContextStoma formation increasing with bowel cancer, IBD surgery, and colostomy following trauma. Many patients require extended stoma education — language barrier common in GCC. Use stoma nurse specialist early.

Immediate Post-op Stoma Assessment

Feature	Expected (Normal)	Concern
Colour	Pink to red (beefy red)	Dark purple/black = ischaemia
Oedema	Moderate swelling expected D0–5	Marked peri-stomal oedema
Output	Colostomy: minimal D0–2. Ileostomy: 500–1000mL/day from D2	High output >2000mL/day ileostomy
Adhesion	Mucocutaneous junction intact	Separation at skin junction
Retraction	Spout should protrude 2–3cm	Retraction below skin level

Stoma Care Protocol

Apply correct size appliance — measure stoma at each change (reduces oedema for 6–8 weeks)
Protect peri-stomal skin — barrier cream/ring
Ileostomy: empty bag when ⅓–½ full to avoid weight separation
Colostomy: change every 2–4 days or when detaching
Dark stoma/ischaemia: emergency surgeon review — possible stoma revision required

🚨

Stoma Ischaemia — Emergency

Dark purple/black stoma: compromised blood supply. Do NOT pack or apply pressure. Urgent surgical review. May require return to theatre.

🦠 Surgical Site Infection (SSI)

Superficial SSI (<30 days) Involves skin and subcutaneous tissue only. Signs: redness, warmth, pain, purulent discharge from incision. No fever or systemic upset usually. Management: wound swab, open wound (remove sutures), daily dressing, oral antibiotics per culture.

Deep Incisional SSI (30–90 days) Involves deep soft tissue (fascia, muscle). Signs: purulent drainage from deep wound, spontaneous dehiscence, deep abscess. Fever, systemic symptoms common. Management: wound swab + blood cultures, IV antibiotics, surgical debridement/washout often required.

Organ/Space SSI (30–90 days) Involves any organ or space opened during surgery (e.g., intra-abdominal abscess, anastomotic leak, liver abscess). Requires CT scanning for diagnosis. Management: IV antibiotics, CT-guided drainage or re-operation.

SSI Nursing Management

Perform wound swab before starting antibiotics where possible
Blood cultures ×2 sets if temperature >38.5°C or patient systemically unwell
Strict hand hygiene and ANTT for all wound care
Isolate patient if MRSA confirmed — contact precautions
Document wound assessment with REEDA scale at each dressing change
Notify infection control team if cluster of SSIs identified

Wound Dehiscence

⚠️

Wound Dehiscence Management

Cover wound with sterile saline-moistened gauze immediately
Make patient nil by mouth — possible return to theatre
Urgent surgical team review
Record vital signs — assess for sepsis
Do NOT attempt to close or re-approximate edges

🚨

Evisceration — SURGICAL EMERGENCY

Bowel/organ protruding from wound:

Call for immediate help — do not leave patient
Cover bowel with large sterile saline-moistened drape (NOT dry gauze)
Keep bowel moist — re-moisten every 10–15 minutes
Nil by mouth immediately
IV access — IV fluids running
Lie patient flat or semi-recumbent — do not allow sitting up
Urgent surgical review — IMMEDIATE return to theatre required
Document time, events, vital signs, and actions taken

Post-operative Complications

Recognition & Escalation

🩸 Post-operative Haemorrhage

Primary Haemorrhage (0–6 hours) Occurs during or immediately after surgery. Usually from inadequate haemostasis or ligature failure. Signs: fresh blood from wound/drain, falling BP, rising HR, pallor, restlessness. Management: direct pressure, IV access ×2 large bore, IV fluids, urgent surgical review, likely return to theatre.

Reactionary Haemorrhage (6–24 hours) Caused by clot displacement due to rising BP as anaesthetic wears off, or patient movement. Same signs as primary. Management: as above — escalate urgently. Group and save, cross-match blood.

Secondary Haemorrhage (7–14 days) Caused by wound infection eroding vessel walls. Presents as sudden fresh bleed from wound or drain, often with fever/sepsis signs. Management: wound swab, blood cultures, IV antibiotics, surgical review. May require vessel ligation/embolisation.

🚨

Haemorrhage Escalation Thresholds

Escalate IMMEDIATELY if: SBP <90 mmHg with tachycardia >100, drain output >200mL/hr ×2 consecutive hours, falling Hb on repeat bloods, signs of haemodynamic compromise. Activate major haemorrhage protocol if applicable.

⚠️ Anastomotic Leak

Timing: typically Day 3–7 post bowel anastomosis surgeryAnastomotic leak is one of the most serious post-operative complications — mortality can reach 20–30% if delayed. Early recognition by ward nurses is critical.

Subtle Early Signs (Day 3–5)

Persistent or rising CRP — CRP >150 on Day 3 or continuing to rise is most sensitive marker
Unexplained tachycardia (HR >100) — early warning sign
Low-grade fever (38–38.5°C)
Prolonged ileus beyond expected
Patient "not feeling right" — take subjective complaints seriously

Overt Signs

High fever (>38.5°C)
Peritonism: guarding, rigidity, rebound tenderness
Faeculent or turbid drain output
Drain output change from serous to turbid/brown
Haemodynamic instability: septic shock pattern

Investigations

Urgent bloods: FBC, CRP, U&E, LFTs, blood cultures ×2
CT abdomen and pelvis WITH IV contrast — modality of choice
Water-soluble contrast enema if CT equivocal

Nursing Actions

Make patient nil by mouth immediately
IV access ×2 large bore — IV fluid resuscitation
Urinary catheter — hourly urine output monitoring
Escalate to senior nurse and surgical registrar immediately
Do not administer further oral medications until reviewed
Prepare for possible return to theatre

🔵 Post-operative Ileus vs Bowel Obstruction

Feature	Post-op Ileus	Mechanical Obstruction
Bowel sounds	Absent or very quiet	Tinkling / high-pitched / hyperactive early
Onset	Immediately post-op (Day 0–5)	Usually Day 3+ or later
Distension	Uniform, generalised	Localised or asymmetric
Pain	Dull, generalised discomfort	Colicky, intermittent
Vomiting	Common, bilious	Profuse, faeculent in late obstruction
X-ray findings	Gas throughout small and large bowel	Distended loops with air-fluid levels, cut-off point
Management	NBM, IV fluids, prokinetics (metoclopramide), early mobilisation, chewing gum ERAS	NG tube decompression, IV fluids, surgical review — may need operative intervention

🫁 Pulmonary Complications

Atelectasis (Most Common)

Most common post-op pulmonary complication

Collapse of alveoli due to retained secretions, shallow breathing, splinting from pain. Occurs in 24–72hr post major surgery.

Deep breathing exercises every hour
Incentive spirometry 10 reps hourly
Effective coughing with wound splinting
Adequate analgesia — pain prevents breathing
Early mobilisation — sitting up improves lung volumes
Chest physiotherapy if not resolving

Post-operative Pneumonia

Usually Day 3–5 post major surgery
Signs: fever, productive cough, purulent sputum, hypoxia (SpO2 <94%), consolidation on CXR
Risk factors: prolonged ventilation, aspiration, immunosuppression, COPD
Management: sputum culture, IV antibiotics per local protocol, physiotherapy, O2 therapy
Prevention: ventilator care bundles (if ventilated), head of bed 30–45°, oral hygiene

Pulmonary Embolism (PE)

Clinical Signs Sudden dyspnoea, pleuritic chest pain, haemoptysis, tachycardia, hypoxia, hypotension (massive PE). ECG: sinus tachycardia, S1Q3T3 pattern.

PE Management

O2 — high flow (15L NRB) immediately
IV access, urgent bloods: ABG, D-dimer, troponin, BNP
ECG, CXR (to exclude other diagnoses)
CTPA — definitive diagnosis
Therapeutic anticoagulation: LMWH or IV heparin
Massive PE with haemodynamic compromise: thrombolysis consideration

🧠 Post-operative Delirium — THINK Framework

High Risk in GCC Surgical WardsElderly patients, post-cardiac surgery, post-major abdominal surgery. Common and often unrecognised. Use CAM (Confusion Assessment Method) screening tool.

T — Toxic (drugs, opioids, anticholinergics) H — Hypoxia I — Infection / Intracranial N — Non-pharmacological K — K+ (electrolytes)

Assessment

CAM positive: acute onset + fluctuating + inattention + disorganised thinking/altered consciousness
Check vital signs: SpO2, temperature, blood glucose, BP
Urgent bloods: FBC, U&E (Na, K, Mg), LFTs, TFTs, blood cultures if febrile
Review medication chart — opioids, anticholinergics, benzodiazepines, steroids
ECG (AF can precipitate delirium)
Urinalysis — UTI common precipitant

Non-pharmacological Management (First Line)

Reorientate calmly and repeatedly — avoid arguing with patient
Familiar faces: family at bedside (encouraged in GCC)
Ensure hearing aids and glasses are in place
Maintain day/night cycle: lights on by day, dim at night
Minimise unnecessary cannulas, catheters, restraints
Early mobilisation
Haloperidol 0.5–1mg oral/IM if safety risk (last resort — document consent)

📉 Post-operative Hypotension (SBP <90 mmHg)

Cause	Key Features	Initial Management
Haemorrhage	Tachycardia, pale, cold, drains active	IV fluids, blood products, surgical review
Epidural effect	Warm peripheries, bradycardia, high block	IV fluid bolus, reduce epidural rate, leg elevation, ephedrine if not resolving
Septic shock	Fever, warm flushed skin initially, rising WCC, source of infection	IV fluids 30mL/kg, blood cultures, IV antibiotics within 1hr, ICU review
Cardiac (MI, failure)	Chest pain, ECG changes, raised troponin, pulmonary oedema	ECG, troponin, cardiology review, avoid fluid overload
Anaphylaxis	Urticaria, bronchospasm, angioedema, temporal relation to new drug/transfusion	Adrenaline 0.5mg IM, IV fluids, antihistamines, corticosteroids, stop trigger
Pulmonary embolism	Sudden dyspnoea, tachycardia, hypoxia, no obvious bleeding	O2, IV access, CTPA, therapeutic anticoagulation

Discharge Planning

Safe Discharge & Follow-up

🏠 Discharge Criteria

ERAS Discharge — Criteria-Based (Not Day-Based)In ERAS protocols, discharge is determined by meeting specific criteria, not a fixed length of stay. This enables safe early discharge while maintaining quality outcomes.

Clinical Discharge Criteria

MEWS <3 on 2 consecutive observations
Tolerating oral intake (fluids ± diet as appropriate for procedure)
Pain controlled on oral analgesia (NRS ≤3/10 at rest)
Mobile and independent (or to pre-op level with support)
Wound dry and intact — no acute signs of infection
Urine output adequate — catheter removed if inserted
Bowel function returning — flatus or bowel movement (if bowel procedure)
Patient/carer understands discharge instructions

Suture/Staple Removal Timing

Site	Removal Timing
Face / scalp	5–7 days
Neck	5–7 days
Chest / upper back	7–10 days
Abdomen	10–14 days
Lower extremity	10–14 days
Joints (knee, elbow)	14 days
Diabetic / immunosuppressed	Add 2–4 extra days

Dissolvable Sutures Vicryl/Dexon absorb in 3–8 weeks (deep layers). Monocryl absorbs in 3–4 months (subcuticular). These do NOT require removal — inform patients if they feel/see suture material.

📄 Discharge Letter Content (JCI Standard)

Mandatory Discharge Letter Components

Patient details: full name, DOB, MRN, date of admission and discharge
Diagnosis: primary diagnosis and any secondary diagnoses identified
Procedure performed: full surgical procedure name, date, surgeon
Hospital course summary: significant events, complications, treatments
Current clinical status: condition at discharge
Discharge medications: full list with doses, frequency, duration, route
Allergies: prominently listed
Follow-up: date, clinic, surgeon name, what will be reviewed
Wound care instructions: dressing type, change schedule, suture/staple removal date
Red flag symptoms: when to return to Emergency Department immediately

Red Flag Symptoms — Teach Every Patient

🚨

Return to ED Immediately If:

Temperature >38.5°C or <36°C
Increasing wound redness, swelling, or pus from wound
Fresh bleeding that does not stop
Severe or worsening abdominal pain
Nausea/vomiting — unable to keep anything down
Difficulty breathing or chest pain
Calf pain, unilateral leg swelling (DVT)
Urine not passing or blood in urine
Confusion or severe drowsiness
Wound edges separating / opening

💊 Discharge Medications

Analgesia

Regular paracetamol 1g QID × 5–7 days
NSAID (ibuprofen/diclofenac) if no contraindications × 5 days
Weak opioid (codeine/tramadol) PRN — max 3–5 days
Counsel on opioid: do not drive, no alcohol, constipation side effect

Anticoagulants

LMWH injection: major pelvic/orthopaedic/cancer surgery — up to 28 days
DOAC: as per thromboprophylaxis guideline
Teach self-injection technique before discharge
Return to prior anticoagulant when safe (per surgeon)

Laxatives

If on Opioids at DischargePrescribe lactulose 10mL BD + senna 2 tabs nocte. Opioid-induced constipation is universal — prevents post-discharge readmission for constipation/ileus.

Antibiotics

Complete course if SSI confirmed — typically 5–7 days oral
Do not prescribe prophylactic antibiotics without indication
Document allergy profile — use alternative if penicillin allergy

GCC-Specific: Travel-Safe Discharge

Inter-Emirate / International Travel Many GCC surgical patients travel from other emirates or countries (medical tourism). Ensure: adequate medication supply for journey, written summary for treating physician at home, medical clearance for flying if within 10–14 days of surgery (especially DVT risk with long-haul flights), emergency contact number provided.

📚 Discharge Patient Education

Activity Restrictions

Surgery Type	Driving	Light Activities	Exercise	Heavy Lifting
Laparoscopic (minor)	1–2 weeks	Immediately	2–4 weeks	6 weeks
Open abdominal	4–6 weeks	2 weeks	6 weeks	8–12 weeks
Orthopaedic (joint)	Per physiotherapist	Immediate (assisted)	6–12 weeks	Per surgeon
Cosmetic/plastic	1–2 weeks	48hr	6 weeks	6 weeks

Diet Instructions

Bowel surgery: low-fibre initially (white rice, pasta, bread), avoiding nuts, seeds, skins × 4–6 weeks
Upper GI surgery: small frequent meals, avoid lying down after eating, nutritional supplements may be required
General surgery: normal diet as tolerated — protein-rich foods aid wound healing
Bariatric surgery: liquid → purée → soft diet → normal (months); vitamin supplementation essential

GCC Family Involvement

Discharge Education with Family In GCC culture, family plays a central role in patient care. Include key family member in discharge education — teach wound care, medication schedule, and red flag symptoms. Document who was educated. However, respect patient autonomy — confirm patient's own wishes regarding information sharing.

Surgical Ward Nursing Quiz

15 Questions

Test your knowledge of surgical ward nursing principles. Select the best answer for each question.

0/15

Questions Correct

Surgical Ward NursingGuide for GCC

⚡ Quick Reference