Nursing Management Plan Small or large bowel

Transcription

1 Nursing Management Plan Small or large bowel Highlight the procedure/s and add other details: Open / Laparoscopic Assisted Hemicolectomy / Right / Left / Extended Sigmoid Colectomy / Transverse Colectomy Total Colectomy / Subtotal Colectomy Formation of Ileostomy / Loop / End Formation of Colostomy / Loop / End Reversal of Hartmanns Reversal of Ileostomy / Colostomy Other procedure or additional change to surgery: This Nursing Management Plan is a guideline only for patients undergoing elective colorectal surgery within the ERAS pathway - use professional clinical judgement and decision making. Use Nursing Management Plan in conjunction with ERAS protocol: Capital Docs ID: CapitalDocs ID: SUR NMP-01 Issue date: January 2016 Review date: January 2019 Page 1 of 11

2 progression Laparoscopic procedures Date of surgery: Surgery: The symbol indicates the expected patient progression along the care plan PACU / RTW Stage One Stage Two Stage Three Discharge IV and Oral fluids IDC satis Pain score <5/10 Exercises Post-op wash and mouth cares Stop IV fluids/daily weigh Oral fluids and diet Oral analgesia IDC removed Assistance with mobilising and personal cares Commence stoma cares Initiate referrals Oral analgesia Tolerating most diet Oral fluids/daily weigh Continue stoma cares Minimal assistance with mobilising and personal cares Meeting most ERAS targets Tolerating diet Minimal pain Managing stoma cares Meeting ERAS targets complete Mobilising as pre-op Discharge criteria met Discharge plan in place Met ERAS targets Date Post op day Page 2 of 11

3 progression Open procedures Date of surgery: Surgery: The symbol indicates the expected patient progression along the care plan PACU / RTW Stage One Stage Two Stage Three Discharge IV and Oral fluids IDC satis Pain score <5/10 Exercises Post-op wash and mouth cares Stop IV fluids/daily weigh Oral fluids and diet Oral analgesia IDC removed Assistance with mobilising and personal cares Commence stoma cares Initiate referrals Oral analgesia Tolerating most diet Oral fluids/daily weigh Continue stoma cares Minimal assistance with mobilising and personal cares Meeting most ERAS targets Tolerating diet Minimal pain Managing stoma cares Meeting ERAS targets complete Mobilising as pre-op Discharge criteria met Discharge plan in place Met ERAS targets Date Post op day Page 3 of 11

4 Discussed length of stay: Support person on discharge: Relationship to patient: Barriers to discharge Action taken Date Discharge arrangements Details Date Transport on discharge District Nurse Referral CCC Home Help Referral Stoma Nurse Referral OT or PT equipment ordered Other: Other: ERAS discharge criteria met Discharge authorised by surgeon Discharge summary provided Prescription given to patient Discharge advice / instructions given to patient Dressing checked / changed IVC removed Discharge Checklist (to be completed on discharge) Yes District Nurse referral faxed Yes Yes Stoma Nurse referral faxed Yes Yes CCC Home Help referral faxed Yes Yes Other convalescent care arranged Yes Patients own medications returned Yes Yes Yes Patients valuables returned Yes Yes Follow up appointment made Yes Page 4 of 11

5 Date of surgery: Admission to Discharge Planner commenced Appropriate referrals initiated Length of stay discussed Pre-op education provided Patient booklet provided and explained Bowel preparation discussed Diet information given Pre-admission Nutricia preop drinks provided with administration instructions Completed Yes Yes Yes Yes Yes Yes Yes Yes Stoma nurse input required Yes Referred Yes Day of Admission to Surgical Admissions Routine admission procedure completed Bowel preparation completed or administered if required Clear oral fluids up to 2 hours pre-op Time documented Nutricia preop drink was taken and finished Medication charted and given as per ERAS Anaesthetic Protocol TED stockings in situ unless contraindicated Patient prepared for theatre as per pre-op checklist Completed Yes Yes Yes Yes Yes Yes Yes Print Name Signature Initial Print Name Signature Initial Page 5 of 11

6 All columns must be completed with Yes or not applicable Observations Vital signs recorded as per post-op protocol EWS recorded and acted on as per protocol Oxygen therapy as charted Input IV Plasmalyte 148 no more than 80 ml/hr Replacement as per protocol Free oral fluids commenced after surgery D37 diet started Two fortisip drinks: 1 2 Oral fluid target met: >600ml Elimination Fluid Balance Chart maintained Urinary output target met: ml/kg/hr Bowel function recorded If unexpected stoma refer to stoma CNS Stoma cares Colour and size of stoma documented Flatus, volume and consistency of stoma output documented Clear and drainable stoma bag in situ Pain management Epidural: PCA RSC Other Medication charted as per Anaesthetic Protocol Analgesia administered as per Anaesthetic Protocol Pain score recorded Physio & mobility Deep breathing and coughing exercises educated At minimum patient mobilised to bedside Out of bed for 2 hours: 1hr 2hrs Physio seen patient Post-op requirements Post-op wash and mouth cares attended to Wound checked each shift Drain output recorded on drain chart Patient diary completed each shift Risks Complete and action Braden Scale Assessment Complete and action Falls Risk Assessment TEDs in situ unless contraindicated Appropriate referrals initiated DAY OF SURGERY AM V PM V N V Page 6 of 11

7 All columns must be completed with Yes or not applicable Observations Vital signs recorded as per post-op protocol EWS recorded and acted on as per protocol Oxygen therapy as charted Daily morning weight before 1000hr Input Oral intake goals explained to patient Discontinue IVF at 0800hr Oral fluid target met:1500ml/24hr 500ml 1l 150ml Three fortisip drinks: Rechart IVF if fluid intake <1L at 2000hrs D37 diet tolerated Dietician assessment required: yes no referred Antiemetics administered as charted Elimination Fluid Balance Chart maintained IDC removed by 0600 Urine output target met: ml/kg/hr Bowel function recorded Stoma cares Colour and size of stoma documented Flatus and volume, colour and consistency of stoma output documented Patient watched stoma bag empty and bag change Pain management Epidural: PCA RSC Other PCA stopped if pain managed Analgesia administered as per Anaesthetic Protocol Pain score recorded Physio & mobility Deep breathing and coughing exercises encouraged Out of bed for 2 hours AM: 1 hr 2 hr Out of bed for 4 hours PM: 1 hr 2 hr 3 hr 4 hr Walk 4x 10mins: Mobility aid required: yes no specify: Physio seen patient Post-op requirements Wound checked each shift Check patient diary completed each shift Patient assisted with shower/wash Discharge Planning Social Work required: yes no referred: OT required: yes no referred: Patient and support person informed of planned discharge date Risks and barriers to discharge identified Risks Pressure areas assessed TEDs unless contraindicated POST OPERATIVE DAY 1 AM V PM V N V Page 7 of 11

8 All columns must be completed with Yes or not applicable Observations Vital signs recorded as per post-op protocol EWS recorded and acted on as per protocol Oxygen therapy as charted Daily morning weight before 1000hr Input Oral intake goals explained to patient Discontinue IVF at 0800hr if restarted yesterday Replacement as per protocol required Oral fluid target met:1500ml/24hr 500ml 1l 150ml Three fortisip drinks: D37 diet tolerated Antiemetics administered as charted Elimination Fluid Balance Chart maintained IDC removed by 0600 Urine output target met: ml/kg/hr Bowel function recorded Stoma cares Colour and size of stoma documented Flatus and volume, colour and consistency of stoma output documented Patient assisted to empty stoma bag Patient assisted to change stoma bag Patient educated in skin & hygiene cares Pain management Epidural: PCA RSC Other Epidural / PCA / RSC stopped & removed Analgesia administered as per Anaesthetic Protocol Pain score recorded Physio & mobility Deep breathing and coughing exercises encouraged Out of bed for 3 hours AM: 1 hr 2 hr 3 hr Out of bed for 4 hours PM: 1 hr 2 hr 3 hr 4 hr Walk 4x 10mins: Mobility aid required: yes no specify: Physio input required: yes no specify: Post-op requirements Wound checked each shift Check patient diary completed each shift Patient showered / washed with minimal assistance Risks Pressure areas assessed TEDs unless contraindicated Social work required: yes no seen OT required: yes no seen Patient & support person informed of planned discharge date Risks & barriers to discharge identified POST OPERATIVE DAY 2 AM V PM V N V Page 8 of 11

9 All columns must be completed with Yes or not applicable Observations Vital signs recorded as per post-op protocol EWS recorded and acted on as per protocol Daily morning weight before 1000hr Input Oral intake goals explained to patient Replacement as per protocol required Oral fluid target met:1500ml/24hr 500ml 1l 150ml Three fortisip drinks: D37 diet tolerated Antiemetics administered as charted Elimination Fluid Balance Chart maintained Bowel function recorded Stoma cares Colour and size of stoma documented Flatus and volume, colour and consistency of stoma output documented Patient assisted to empty stoma bag Patient assisted to change stoma bag Patient demonstrates skin & hygiene cares Pain management Analgesia administered as per Anaesthetic Protocol Pain score recorded Physio & mobility Deep breathing and coughing exercises encouraged Out of bed for 3 hours AM: 1 hr 2 hr 3 hr Out of bed for 4 hours PM: 1 hr 2 hr 3 hr 4 hr Walk 4x 10mins: Mobility aid required: yes no specify: Physio input required: yes no specify: Post-op requirements Wound checked each shift Check patient diary completed each shift Patient showered / washed with minimal assistance Patient & support person informed of planned discharge date Risks & barriers to discharge being addressed Discharge criteria IVF required and patient tolerating diet and oral fluids Pain is managed with oral analgesia Patient has passed flatus not necessary to have a bowel motion Returning to normal level of function Satisfactory home support Vitals signs within normal range POST OPERATIVE DAY 3 AM V PM V N V Page 9 of 11

10 All columns must be completed with Yes or not applicable Observations Vital signs recorded as per post-op protocol EWS recorded and acted on as per protocol Daily morning weight before 1000hr Input Oral fluid target met:1500ml/24hr 500ml 1l 150ml Three fortisip drinks: D37 diet tolerated Antiemetics administered as charted Elimination Fluid Balance Chart maintained Bowel function recorded Stoma cares Colour and size of stoma documented Patient independently empties stoma appliance Patient independently changes stoma appliance Patient demonstrates skin & hygiene cares Pain management Analgesia administered as per Anaesthetic Protocol Pain score recorded Physio & mobility Deep breathing and coughing exercises encouraged Out of bed for 3 hours AM: 1 hr 2 hr 3 hr Out of bed for 4 hours PM: 1 hr 2 hr 3 hr 4 hr Walk 4x 10mins: Mobility aid required: yes no specify: Post-op requirements Wound checked each shift Check patient diary completed each shift Patient showered / washed with minimal assistance Discharge issues addressed Discharge criteria IVF required and patient tolerating diet and oral fluids Pain is managed with oral analgesia Patient has passed flatus and/or bowels opened Returning to normal level of function Satisfactory home support Vitals signs within normal range Stoma CNS seen and discharged patient POST OPERATIVE DAY 4 AM V PM V N V Page 10 of 11

11 All columns must be completed with Yes or not applicable Observations Vital signs recorded as per post-op protocol EWS recorded and acted on as per protocol Daily morning weight before 1000hr Input Oral fluid target met:1500ml/24hr 500ml 1l 150ml Three fortisip drinks: D37 diet tolerated Antiemetics administered as charted Elimination Fluid Balance Chart maintained Bowel function recorded Stoma cares Colour and size of stoma documented Patient independently empties stoma appliance Patient independently changes stoma appliance Patient demonstrates skin & hygiene cares Pain management Analgesia administered as per Anaesthetic Protocol Pain score recorded Physio & mobility Deep breathing and coughing exercises encouraged Out of bed for 3 hours AM: 1 hr 2 hr 3 hr Out of bed for 4 hours PM: 1 hr 2 hr 3 hr 4 hr Walk 4x 10mins: Mobility aid required: yes no specify: Post-op requirements Wound checked each shift Check patient diary completed each shift Patient showered / washed with minimal assistance Discharge issues addressed Discharge criteria IVF required and patient tolerating diet and oral fluids Pain is managed with oral analgesia Patient has passed flatus and/or bowels opened Returning to normal level of function Satisfactory home support Vitals signs within normal range Stoma CNS seen and discharged patient POST OPERATIVE DAY 5 AM V PM V N V CapitalDocs ID: SUR NMP-01 Issue date: January 2016 Review date: January 2019 Page 11 of 11

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