Bowel Resection Open (with or without Ostomy) Résection intestinale Chirurgie ouverte (avec ou sans Ostomie)

Transcription

1 CLINICAL PATHWAY PLAN CLINIQUE GENERAL SURGERY CHIRURGIE GÉNÉRAL Bowel Resection Open (with or without Ostomy) Résection intestinale Chirurgie ouverte (avec ou sans Ostomie) Cancer Assessment Clinic (CAC) Initiate Pre-operative education Initiate Pre-operative testing as per pathway Addressograph/Plaque yyaa mm dj Day of Surgery Pre-op SDA Jour de la chirurgie pre-opératoire PAU Unité pré-admission yyaa mm dj yyaa mm dj Assessment & teaching per same day admission standard of care and procedure specifi c education material. Pre-operative diagnostic testing as per Medical Directive for Pre-Admission Diagnostic Testing for Elective Surgery. If patient seen in CAC, reinforce pre-operative education and verify and complete all pre-op testing. Assessment & teaching as per PAU standard of care and procedure specifi c education material. Pre-operative diagnostic testing as per Medical Directive for Pre-Admission Diagnostic Testing for Elective Surgery. Tests Liver function tests: ALP, AST, ALT, GGT, Total bilirubin Electrolytes, BUN, creatinine CBC Type and screen ECG if over 65 or has cardiac condition PT/PTT/INR for patient on warfarin Chest X-ray if signs of lower respiratory infection Urinalysis if signs of urinary tract infection Pregnancy test if pregnancy possible Additional Orders Review bowel prep using PICO-SALAX. NOTE: If patient has history of heart disease, kidney disease, or is on a low salt diet COLYTE must be used. Measure for TEDs For ostomy patients: Verify if Enterostomal Therapy (ET) nurse has been arranged & ostomy site marked on abdomen. If not call Stoma Clinic to make an appointment Make sure patient has a copy of Ileostomy or Colostomy booklet given by ET nurse No special skin prep needed Discuss expected length of stay of 4 days without ostomy and 5 days with ostomy As per patient history, identify issues that could cause delay of discharge & discuss discharge preparation. Consult social work if needed. Ensure patient has Bowel Resection Open (with or without ostomy) CP55B (2009)patient education booklet. Additional testing if required Glucose meter: for diabetic patient PTT/INR: for patient normally taking warfarin (Coumadin) Unless normal result obtained after warfarin discontinued per pre-op instructions Electrolytes: for dialysis dependant patient unless acceptable post-dialysis results obtained within 24 h of surgery CBC if autologous blood donor Additional Orders IV NS at 50 ml/h if IV medications to be given in SDA/SDCU If patient is insulin dependent diabetic: IV D5W at 100 ml/h Apply TEDS Antibiotics: If No history of allergy to penicillin or to other beta-lactam antibiotics; or History of non-life threatening reaction to penicillin or other beta-lactam antibiotics (e.g. rash, diarrhea, stomach upset) For weight < 60 kg: IV Metronidazole 500 mg AND IV Cefazolin 1 g on chart to OR For weight 60 kg: IV Metronidazole 500 mg AND IV Cefazolin 2 g on chart to OR OR If patient has a history of life threatening reaction (hypotension, bronchospasm, urticaria, angioedema) to penicillin or other beta-lactam antibiotics IV Vancomycin 1 g if weight < 90 kg (infuse over 60 minutes pre-op) 1.5 g if weight 90 kg (infuse over 90 minutes pre-op) AND IV Gentamicin on chart for administration in Operating Room: 100 mg if weight < 60 kg 140 mg if weight 60 kg but less than 80 kg 160 mg if weight 80 kg IV Metronidazole 500 mg on chart to OR or Patient Teaching Understands pre-op instructions and events Understands usual post-op course, plan for pain management, and usual self care measures to prevent post-op complications per patient education booklet Understands usual lenth of stay and expected discharge time of 10:00 Appropriate discharge plan in place or if no suitable discharge plan in place social work has been consulted Patient progress corresponds with clinical pathway: CAC: Yes No Signature: Initial: Time: NTV circle above, VC _ PAU: Yes No Signature: Initial: Time: NTV circle above, VC _ Patient Teaching Adherence with pre-op instructions Understands usual events/expectations of operative day Understands usual post-op course, plan for pain management, and usual self care measures to prevent post-op complications per patient education booklet Patient progress corresponds with clinical pathway: Yes No Signature: _ Initial: Time: NTV circle above, VC _ CP 55 A (REV 07/2009)

2 Patient(e) Chart No. N o du dossier Day of Surgery Post-op PACU Jour de la chirurgie post-opératoire O 2 sat monitoring and O 2 administration per PACU protocol VS, assessment, treatment, and teaching per PACU standards Additional Orders Urinary catheter TEDs May transfer to ward when PACU discharge criteria is achieved Pain Control Indicates adequate pain control achieved per APS guidelines. Pain control 3 at rest, 5 with activity; pain not preventing movement; patient satisfi ed with pain Achieves PACU criteria for transfer to ward D Yes No Signature: Initial: _ Time: _ NTV circle above, VC E Yes No Signature: Initial: _ Time: _ NTV circle above, VC N Yes No Signature: Initial: _ Time: _ NTV circle above, VC CP 55A (2 8)

3 Patient(e) Chart No. N o du dossier Day of Surgery Post-op Ward Jour de la chirurgie post-opératoire Assessment/ Treatments VS & SPO 2 q4h and prn Epidural/IV PCA Pain Management Systems assessment q12h & prn Monitor q4h and prn Urine output Dressing Stoma (if applicable) Pain assessment Monitor q12h (if applicable) Ostomy output Closed drainage system (e.g. Jackson Pratt) TEDs Dangle x 1 h, for min, Initials AAT As ordered/tolerated Pain Control Indicates adequate pain control achieved per APS guidelines. Pain control 3 at rest, 5 with activity; pain not preventing movement; patient satisfi ed with pain Physiological SPO 2 within limits of titration protocol Effective deep breathing and coughing If stoma: pink-red and moist Temperature within normal limits Wound Drainage from closed drainage system: serosanguinous Dressing dry and intact Urine output: Minimum 0.5 ml/kg/h when trended over 4h Drainage from closed drainage system: serosanguinous Stoma output (if applicable): serosanguinous and minimal volume Urinary catheter Patient/Family teaching Deep breathing and coughing Foot and ankle exercises Pain management Identify issues that could cause delay of discharge & discuss discharge preparation D Yes No Signature: Initial: _ Time: _ NTV circle above, VC E Yes No Signature: Initial: _ Time: _ NTV circle above, VC N Yes No Signature: Initial: _ Time: _ NTV circle above, VC Others: Signature: Initial: Signature: Initial: CP 55A (3 8)

4 Patient(e) Chart No. N o du dossier Post-op Day 1 Jour 1 post-opératoire Assessment/ Treatment VS & SPO 2 q4h until 24h post-op, then q12h and prn Epidural/IV PCA Pain Management Systems assessment q12h & prn Monitor q4h and prn Urine output Dressing Pain assessment Monitor q 12 h and prn (if applicable) Stoma Ostomy output Closed drainage system (e.g. Jackson Pratt) TEDs Up in chair x 2: Ambulate x 1 2 AAT As h for min; h for min; h; h; initials Monitor for abdominal distention, fl atus, bowel sounds Urinary catheter Pain Control Indicates adequate pain control achieved per APS guidelines. Pain control 3 at rest, 5 with activity; pain not preventing movement; patient satisfi ed with pain Physiological SPO 2 within limits of titration protocol Effective deep breathing and coughing If stoma: pink-red and moist Temperature within normal limits Wound Drainage from closed drainage system: serosanguinous Dressing dry and intact Tolerating diet Urine output: Minimum 0.5 ml/kg/h when trended over 4h May be bowel sounds and/or passing fl atus per rectum or ostomy Tolerating activity level Patient/Family Teaching Deep breathing and coughing Foot and ankle exercises Pain management Ensure patient has: Bowel Resection Open patient education booklet Ileostomy or Colostomy Teaching booklet if applicable Identify issues that could cause delay of discharge & discuss discharge preparation D Yes No Signature: Initial: _ Time: _ NTV circle above, VC E Yes No Signature: Initial: _ Time: _ NTV circle above, VC N Yes No Signature: Initial: _ Time: _ NTV circle above, VC Others: Signature: Initial: Signature: Initial: CP 55A (4 8)

5 Patient(e) Chart No. N o du dossier Post-op Day 2 Jour 2 post-opératoire Assessment / Treatment VS & SPO 2 q12h and prn Epidural/IV PCA Pain Management Systems assessment q 12h & prn Monitor q4h and prn Urine output Pain assessment Monitor q12h and prn (if applicable) Incision: remove dressing, cleanse incision with N/S and leave open to air. Apply dressing if drainage present Ostomy output Stoma Closed drainage system (e.g. Jackson Pratt): remove if output < 30 ml in past 12 hours TEDs Ambulate in hall x 3 (minimum): AAT (should be encouraged to be up in chair for several hours of day) As ordered/ tolerated Monitor for abdominal distention, fl atus, bowel sounds Remove urinary catheter unless otherwise ordered by physician If unable to void post-catheter removal, assess residual volume with bladder scanner; perform in and out catheterization if volume > 300 ml urine Pain Control Indicates adequate pain control achieved per APS guidelines. Pain control 3 at rest, 5 with activity; pain not preventing movement; patient satisfi ed with pain Physiological SPO 2 within limits of titration protocol Effective deep breathing and coughing If stoma: pink-red and moist Temperature within normal limits Incision No evidence of wound redness, swelling, excessive drainage or dehiscence Tolerating diet Urine output: Minimum 0.5 ml/kg/h when trended over 4h Bowel sounds present and/or passing fl atus per rectum or ostomy. May be minimal volume per ostomy. Tolerating activity level Patient/Family teaching Able to open and close ostomy clamp Patient/Family Teaching Deep breathing and coughing Foot and ankle exercises Pain management Teaching as per Bowel Resection Open patient education booklet If applicable, initiate teaching re basic care of pouch as per Ostomy booklet Identify issues that could cause delay of discharge & discuss discharge preparation D Yes No Signature: Initial: _ Time: _ NTV circle above, VC E Yes No Signature: Initial: _ Time: _ NTV circle above, VC N Yes No Signature: Initial: _ Time: _ NTV circle above, VC Others: Signature: Initial: Signature: Initial: CP 55A (5 8)

6 Patient(e) Chart No. N o du dossier Post-op Day 3 Jour 3 post-opératoire Assessment / Treatment VS & SPO 2 q12h and prn Wean Epidural and IV PCA as per APS guideline if patient meets weaning criteria Pain assessment q4h Discontinue IV or convert to saline lock when drinking well Systems assessment q12h & prn Monitor q12h and prn (if applicable): Incision/dressing q12h Stoma Ostomy output If applicable, closed drainage system (e.g. Jackson Pratt): remove if output < 30 ml in past 12 hours TEDs Ambulate in hall x 3 (minimum): AAT (should be encouraged to be up in chair for several hours of day) As ordered/tolerated If no urinary catheter, voiding Urinary catheter if ordered Monitor for abdominal distension, fl atus, bowel sounds Pain Control Indicates adequate pain control achieved per APS guidelines. Pain control 3 at rest, 5 with activity; pain not preventing movement; patient satisfi ed with pain Weaning completed by bedtime Physiological SPO 2 within limits of titration protocol Effective deep breathing and coughing Temperature within normal limits Incision No evidence of wound redness, swelling, excessive drainage or dehiscence Tolerating diet Urine output adequate Bowel sounds present and/or passing fl atus per rectum or ostomy. May be minimal volume per ostomy. Tolerating activity level Patient/Family teaching For ostomy patients empty and rinse pouch in bathroom with supervision Patient/Family Teaching Deep breathing and coughing Foot and ankle exercises Pain management Teaching as per Bowel Resection Open patient education booklet If applicable Continue teaching re basic care of pouch as per Ostomy booklet Identify issues that could cause delay of discharge & discuss discharge preparation D Yes No Signature: Initial: _ Time: _ NTV circle above, VC E Yes No Signature: Initial: _ Time: _ NTV circle above, VC N Yes No Signature: Initial: _ Time: _ NTV circle above, VC Others: Signature: Initial: Signature: Initial: CP 55A (6 8)

7 Patient(e) Chart No. N o du dossier Post-op Day 4 / Expected discharge day for patient without Ostomy Jour 4 post-opératoire Assessment / Treatment VS & SPO 2 q12h and prn Remove saline lock if discharged today Systems assessment q12h & prn Pain assessment q 4h ET nurse performs stoma assessment including pouch fi tting, changes appliance and provides supplies for discharge Monitor q12h and prn (if applicable): Incision/dressing q12h Stoma Ostomy output If applicable, closed drainage system (e.g. Jackson Pratt): remove if output < 30 ml in past 12 hours TEDs; remove if discharged today Ambulate in hall x 3 (minimum): AAT (should be encouraged to be up for several hours of day) As ordered/tolerated Monitor for abdominal distention, fl atus, bowel sounds If no urinary catheter, voiding Urinary catheter if ordered Patient/Family Teaching Pain management Teaching as per Bowel Resection Open patient education booklet If applicable Continue teaching re basic care of pouch as per Ostomy booklet Confi rm CCAC referral completed if being discharged today with catheter to be removed post-op day 5 Confi rm CCAC referral completed for all Ostomy patients including date for rod removal (if applicable), date for suture or staple removal, ET referral Inform patient of 10:00 h discharge time Complete Surgery Discharge Instructions if applicable Pain Control Indicates adequate pain control achieved per APS guidelines. Pain control 3 at rest, 5 with activity; pain not preventing movement; patient satisfi ed with pain Weaning completed by bedtime Physiological SPO 2 within limits of titration protocol Effective deep breathing and coughing Temperature within normal limits Incision No evidence of wound redness, swelling, excessive drainage or dehiscence Tolerating diet Urine output adequate Bowel sounds present and/or passing fl atus per rectum or ostomy. May be minimal volume per ostomy. Tolerating activity level Patient/Family teaching For ostomy patients - empty and rinse pouch in bathroom with supervision May be discharged Post-op Day 4 if patient meets following Discharge Criteria: Adequate pain control allowing progression of activity Passing fl atus per rectum or ostomy Tolerating Surgery diet (at minimum adequate fl uid intake but progressing with diet) No evidence of wound redness, swelling or drainage Understands: Signs & symptoms requiring immediate medical attention, i.e. Signs & symptoms of sepsis Signs & symptoms of wound infection Discharge instructions per patient education booklet If applicable able to manage urinary catheter care at home D Yes No Signature: Initial: _ Time: _ NTV circle above, VC E Yes No Signature: Initial: _ Time: _ NTV circle above, VC N Yes No Signature: Initial: _ Time: _ NTV circle above, VC Others: Signature: Initial: Signature: Initial: CP 55A (7 8)

8 Patient(e) Chart No. N o du dossier Post-op Day 5 / Discharge Day Jour 5 post-opératoire / Jour de congé Assessment/ Treatment VS daily Pain assessment q4h Discontinue TEDs Discontinue saline lock AAT As ordered/ tolerated If applicable, remove urinary catheter by 08:00 h unless otherwise ordered by physician Ensure patient can void adequately prior to discharge Discharge Criteria Indicates adequate pain control achieved per APS guidelines. Pain control 3 at rest, 5 with activity; pain not preventing movement; patient satisfi ed with pain Passing fl atus per rectum or ostomy Tolerating Surgery diet (at minimum adequate fl uid intake but progressing with diet) No evidence of wound redness, swelling, excessive drainage or dehiscence Understands: Signs & symptoms requiring immediate medical attention, i.e. Signs & symptoms of sepsis Signs & symptoms of wound infection Discharge instructions per patient education booklet If applicable Has Ostomy supplies Able to empty Ostomy pouch Patient/Family Teaching Review discharge instructions as per Bowel Resection Open patient education booklet Reinforce Diet Wound care Pain management When to seek medical attention without delay (review signs and symptoms of sepsis) Confi rm CCAC referral completed for all Ostomy patients including date for rod removal (if applicable), date for suture or staple removal, ET referral Inform patient of 10:00 h discharge time Complete Surgery Discharge Instructions sheet and provide copy to patient If not discharged by end of pathway enter appropriate variance code D Yes No Signature: Initial: _ Time: _ NTV circle above, VC E Yes No Signature: Initial: _ Time: _ NTV circle above, VC N Yes No Signature: Initial: _ Time: _ NTV circle above, VC Others: Signature: Initial: Signature: Initial: CP 55A (8 8)

9 Patient(e) Chart No. N o du dossier Urine Output Chart KG Patient Weight Lbs Amount of Urine at 0.5 ML/KG/HR 40 KG 88 lbs 20 ML/HR 45 KG 99 lbs 23 ML/HR 50 KG 110 lbs 25 ML/HR 55 KG 121 lbs 28 ML/HR 60 KG 132 lbs 30 ML/HR 65 KG 143 lbs 33 ML/HR 70 KG 154 lbs 35 ML/HR 75 KG 165 lbs 38 ML/HR 80 KG 176 lbs 40 ML/HR 85 KG 187 lbs 43 ML/HR 90 KG 198 lbs 45 ML/HR 95 KG 209 lbs 48 ML/HR 100 KG 220 lbs 50 ML/HR 105 KG 231 lbs 53 ML/HR 110 KG 242 lbs 55 ML/HR 115 KG 254 lbs 58 ML/HR 120 KG 265 lbs 60 ML/HR 125 KG 276 lbs 63 ML/HR

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