Ortho and Post-Surgical
Weight-bearing status and precautions, incision assessment, the complications to catch early, and pain control that lets therapy happen.
Post-surgical patients are usually the most straightforward on your caseload and the fastest to go badly wrong. The episode is short, the trajectory should be upward, and any deviation from that is a signal.
Know the precautions before you touch the patient
Get these from the operative note or the discharge summary, and write them where every clinician will see them.
| Weight-bearing status | NWB, TDWB, PWB with a percentage, WBAT, or FWB |
| Which limb | Confirm against the operative note, not the patient's memory |
| Range-of-motion restrictions | Especially after hip and shoulder surgery |
| Brace or immobiliser | When worn, when it may come off, and who adjusts it |
| Activity limits | Lifting, driving, stairs, showering |
| Dressing instructions | Who changes it, how often, and when it may get wet |
Posterior hip precautions — no hip flexion beyond 90 degrees, no adduction past midline, no internal rotation — apply to the toilet, the car, the recliner, and how they put their socks on. Teach them in the actual rooms.
If you cannot establish weight-bearing status, do not guess. Call.
Every visit
- Incision — see below
- Neurovascular status distal to the surgery — colour, warmth, pulses, capillary refill, sensation, movement
- Swelling, and whether it is improving
- Pain — at rest and with activity, and whether control is adequate for therapy
- Calf assessment for DVT
- Precautions and weight-bearing actually being followed — ask and observe
- Assistive device fit and use
- Function against last visit — this should be moving
The incision
Describe it, do not just say it looks fine.
- Approximation — edges together, any separation
- Drainage — amount, colour, odour
- Surrounding skin — redness extent, warmth, induration
- Closure — staples, sutures, steri-strips, glue; note when removal is due and who is doing it
- Pain out of proportion to the stage of healing
Expect mild redness along the incision line and a small amount of serosanguinous drainage early. Expect it to reduce.
Signs of infection: spreading redness, increasing pain after an initial improvement, purulent or malodorous drainage, warmth, induration, fever, or separation of the wound edges.
A surgical incision is a surgical wound on OASIS — and is a scar once fully epithelialized for more than 30 days. See Is It a Surgical Wound? (M1340 / M1040).
Complications to catch
DVT and PE
The highest-stakes thing you are watching for.
- DVT: unilateral calf or thigh pain, swelling, warmth, redness. Compare both legs every visit.
- PE: sudden breathlessness, pleuritic chest pain, tachycardia, hypoxia, haemoptysis, a feeling of impending doom
Suspected PE is a 911 call, immediately.
Check that prophylaxis — anticoagulant, compression stockings, or a device — is actually being used as ordered. Stockings in a drawer are not prophylaxis.
Infection
Surgical site, and also urinary and respiratory. In an older adult, new confusion is often the first sign.
Dislocation after hip surgery
Sudden severe pain, shortening, rotation of the limb, inability to bear weight. Do not move the patient; call 911.
Compartment syndrome
Rare and an emergency. Pain out of proportion, pain on passive stretch, tightness, paraesthesia. Call 911.
Anaemia
Post-operative patients are often anaemic. Fatigue, dizziness on standing, pallor, tachycardia. Check any ordered labs and follow them up — see Labs, Specimens, and Results Follow-Up.
Pain control is a therapy issue
A patient in uncontrolled pain will not move, and a post-surgical patient who does not move gets a poor outcome and a complication.
- Time analgesia before therapy and before the exercise programme
- Teach ice and elevation properly
- Ask about constipation — opioids plus reduced mobility plus poor intake is a predictable problem, and an impaction will put them back in hospital
- Watch for over-sedation, and for a patient who has stopped taking anything because they are afraid of the medication
- If pain control is inadequate, that is a call to the surgeon, not something to work around
Bowels
Unglamorous and genuinely important. Anaesthesia, opioids, immobility, and reduced intake combine to cause constipation in a large share of post-surgical patients. Ask about the last bowel movement at every visit, and act before it becomes an impaction.
Discharge is usually close
These episodes are short. Discharge planning starts at the first visit — see Discharge.
The patient is ready when the incision is healing, the precautions are understood and followed, they are managing their function safely at home, pain is controlled, and they know what would make them call. Do not extend the episode past that point.
When to call
- Any sign of infection
- Suspected DVT
- Suspected dislocation
- Sudden increase in pain
- Fever
- Inability to bear weight when they previously could
- Incision separation
911 for suspected PE, suspected compartment syndrome, or a suspected dislocation with severe pain.