Integrated Surgical Clinical Pathway for Patient for Appendectomy

INTEGRATED SURGICAL CLINICAL PATHWAY FOR

PATIENT FOR LapAROSCOPIC OR OPEN

APPENDECTOMYALNEIL ANTONIO RNLAURICE SARMIENTO

RN

AppendEcTOMY

ois the surgical removal of the appendix when an infection has made it inflamed and swollenoappendicitis, is considered an emergency because it can be life threatening if untreated

•most commonly performedemergency operation worldwide•Appendectomy is on the top 16 of the most common surgery in the Philippines according to Philhealth claims from January to September 2011•Top 12 with claims of 12, 847

HEADING

NAME: SEX:AGE: BIRTHDAY:ATTENDING PHYSICIAN: HOSPITAL

NUMBER:ADMITTING DIAGNOSIS: HEIGHT:

cmWEIGHT: Kg

ADMISSION DATE & TIME: ALLERGIES(if any):

DISCHARGE DATE & TIME:

FINAL DIAGNOSIS:

ACTUAL LENGTH OF STAY: days EXPECTED LENGTH OF STAY: days PATIENT TO INCLUDE IN PATHWAY: Patients with a diagnosis of probable appendicitisPATIENT TO EXCLUDE IN PATHWAY: (1) Incidental Appendectomy (2)Patient with symptoms that require ICU level of care (3) Patient with complicating chronic conditionREMOVE FROM THE PATHWAY IF THE FF. OCCURS: (1) change in Diagnosis (2) Transfer to a higher level of care (3) Significant post-operative complication such as:- Bowel obstruction requiring a second operation or prolonged TPN

ADULT HEALTH CARE HOSPITAL

PARTS OF THE PATHWAYPHASE OF CARE Phase i (emergency room/admission/ward)

ACTIVITY Specific Activities Health Care Team

Time & date

EVALUATIOn

ASsessment

ÿ Initial Vital Signs and Pain Assessment done

ÿ Observe Non verbal cues/ Pain behaviors

ÿ Verification of patient’s identity

ÿ Physical Examination

ÿ Medical History taken

ÿ Measure Height and Weight

RN:____

RN:____

MD:____

RN:____

MD:____

RN:____

MD:____

RN:____

ÿ Goal metÿ goal not met

Inclusion criteria

Patients with a diagnosis of probable appendicitis• The most common symptom of appendicitis is abdominal pain on the

right lower side of the abdomen§ Pain is a symptom described by a patient; tenderness is the response to

being touched. Certain specific signs will help to diagnose appendicitis.§ McBurney's sign -§ Rebound tenderness § Guarding § Rovsing's sign

Other less commonly elicited signs that may indicate appendicitis include:

§ Aaron's sign § Psoas sign § Obturator sign § Blumberg's sign

http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm

EXclusion criteria

(1) Incidental Appendectomy Surgical removal of the vermiform appendix, performed incidentally to another primary surgical procedure.

(2) Patient with symptoms that require ICU level of care

(3) Patient with complicating chronic condition


REMOVE FROM THE PATHWAY

(1) Change in Diagnosis (2) Transfer to a higher level of care (3) Significant post-operative complication such as:

Bowel obstruction requiring a second operation or prolonged TPN


PHASES OF CARE

q Phase i (emergency room/admission-ward)q PHASE II (FROM WARD-Perioperative)q PHASE III(POST ANESTHESIA CARE UNIT) q PHASE IV(DAY 1 WARD)q PHASE V (DAY 2 WARD-DISCHARGE)


Phase I (emergency room/admission-

ward)

Phase i (emergency room/admission-ward)

q Assessmentq LABORATORY & DIAGNOSTIC EXAMq COMFORT AND SAFETYq CONSULTq IV LINEq DIETq Medicationsq Ambulationq HEALTH TEACHINGq Discharge planningq ENDORSE


Assessment

•Initial Vital Signs and Pain Assessment done•Observe Non verbal cues/ Pain behaviors•Verification of patient’s identity•Physical Examination•Medical History taken•Measure Height and Weight


LABORATORY & DIAGNOSTIC EXAM

•CBC with differential•PT/PTT•Electrolytes•BUN, Creatinine•Blood sugar•Urinalysis•Pregnancy Test for female•Abdominal CT Scan•Abdominal Xray•ECG

•Other____


COMFORT AND SAFETY

•Always put the side rails up•Assisted the patient in knee-chest position to relieve pain•Provided instructions on pain relieving measures such as purse lip breathing and deep breathing exercises


CONSULT

Surgical Consult: Abdominal Pain, Ruled out Appendicitis


INTRAVENOUS LINE

•D5LRS1L x ____ gtts/min•PNSS1L x ____ gtts/min•Others:•_________


DIET

•NPO


ACTIVITIES

•Complete Bed Rest•Complete Bed Rest with BRP’s•Other______


HEALTH TEACHINGs

•Encouraged Deep Breathing Exercises and purse lip breathing•Instruct not to give any pain medication until the diagnosis is confirmed•Instruct the patient not to provide hot or cold compress•Instruct the patient not to eat anything•Encourage verbalization of feelings about pain•Others:__________________


Discharge planning

qAssess living conditions and Nature of workqLifestyle Modification


PHASE II (FROM WARD-PERIOPERATIVE)

PHASE II (FROM WARD-PERIOPERATIVE)

q Assessmentq COMFORT AND SAFETYq proceduresq IV LINEq DIETq SKIN PREPARATIONq Medicationsq HEALTH TEACHINGSq ENDORSE


Assessment

•Obtain Vital Signs Monitoring/ Pain Assessment Monitoring•Secure Surgical Consent/OR Schedule •OR Pre-Operative Evaluation/ Anesthesia Checklist Done•Ensure Cardio-Pulmonary Clearance Done


COMFORT AND SAFETY

•Ensure the safety from ward to Operating Room•Secure safety straps and arm boards•Ensure all instruments, sponges and sharps are counted complete


procedures

•Foley Catheter•Cardiac Monitor•Oxygen Therapy•O2 via NC@__LPM•O2 via FM@__LPM


INTRAVENOUS LINE

•D5LRS1L x ____ gtts/min•PNSS1L x ____ gtts/min•Others:•_________


DIET

•NPO


SKIN PREPARATION

•Skin Preparation and Removal of Hair at ward•Skin Prepping and Surgical Draping Done


Medications

Pain MedicationPre-Operative Medication given Anesthesia given: Spinal AnesthesiaGeneral AnesthesiaOthers:


Health TEACHINGS

•Explain the procedure to the patient•Instruct the client to void before the procedure•Instruct the client to remove dentures and accessories prior to transfer to OR


POST OPERATIVE CARE

•Surgical Dressings on incision site•Ensure patients care after the procedure•Assess the wound and drainage•Clean the surgical site•Ensure patients safety from OR to RR•Ensure that all records are accomplish


PHASE III(POST ANESTHESIA CARE

UNIT)

PHASE III(POST ANESTHESIA CARE UNIT)

q Assessmentq COMFORT AND SAFETYq PROCEDURESq IV LINEq DIETq SURGICAL INCISION and DRESSINGq Medicationsq ACTIVITIESq DRAINAGEq HEALTH TEACHINGq ENDORSE


Assessment

•Obtain Vital Signs Monitoring q 15 •Assess for Post-Op Pain and Complications•Assess the incision site, dressing and drainage•Assess for urine output


COMFORT AND SAFETY

•Ensure the safety in PACU and transfer from PACU to ward•Keep the siderails up at all times and keep the bed in low position•Provide thermoregulation via:•Thermal Blanket/ Warmer •Drop Light


PROCEDURES

•Hooked to Cardiac MonitorOxygen Therapy•O2 via NC@__LPM•O2 via FM@__LPM


DIET

•NPO


IV LINE

•D5LRS1L x ___gtts/min•PNSS1L x __gtts/min•Others:•_____________


SURGICAL INCISION and DRESSING

•Assess and change the surgical dressing if soaked with blood•Drain the drainage container(if any) before transfer to room


Medications

•Ketorolac ___/IV q__hrs x ___doses•Nubain __/SIVP PRN for severe pain•Demerol __mg/IV PRN for chills•Tramadol___mg/IV q___hrs x __doses•Ranitidine 60mg/IV q__ x __doses•Others:


ACTIVITIES

•Keep the patient flat on bed•Moderate to High Back Rest•Assisted patient on needs


DRAINAGE

•JP Drain•Penrose Drain•Hemovac


HEALTH TEACHING

•Inform the relative regarding the result of operation/complications, risk and stability of the patient• Inform the patient & relative after transfer to room diet, activities and


PHASE IV(DAY 1 WARD)

PHASE IV(DAY 1 POST OPERATIVE AT WARD)

q Assessmentq COMFORT AND SAFETYq Woundq IV LINEq DIETq ELIMINATIONq Medicationsq ACTIVITIESq DRAINAGEq HEALTH TEACHINGq ENDORSE


Assessment

•Monitor Vital Signs•Assess for Post-Op Pain and Complications•Assess the incision site and drainage•Assess for urine output, bowel sounds


COMFORT AND SAFETY

•Keep the side rails up at all times•Keep the bed at the possible lowest position•Assisted on needs


wound

•Assess and Record the amount of drainage •Assess the wound for any absess or sings of inlammation•Clean the wound with Normal Saline Solution and Hydrogen peroxide and Anti Septic


DIET

•NPO•Clear Liquid Diet•Soft Diet•Regular Diet


IV LINE



ELIMINATION

•Removes the indwelling urinary catheter. Record urinary output.•Check bowel sounds. Note stool consistency


Medications



ACTIVITIES

•Keep the patient flat on bed•Moderate to High Back Rest•Assisted patient on needs•May move from side to side but with assistance


HEALTH TEACHING

•Encouraged deep breathing and purselip exercises•Instruct not to lift heavy weights•Provided instructions on wound cleaning and change of dressings•


Discharge planning

•Stressed out the compliance in taking medications•Provided instructions on appropriate exercises and not to lift heavy objects•Instructed to follow the treatment regimen and health teachings given•Stressed out the importance of diet in patients condition•Instructed on follow up check up


PHASE V (DAY 2 WARD-DISCHARGE)

PHASE V (DAY 2 WARD-DISCHARGE)

q Assessmentq COMFORT AND SAFETYq Woundq IV LINEq DIETq ELIMINATIONq Medicationsq ACTIVITIESq DRAINAGEq HEALTH TEACHINGq ENDORSE


Assessment

•Monitor Vital Signs•Assess for Post-Op Pain and Complications•Assess the incision site and drainage•Assess for urine output, bowel sounds


COMFORT AND SAFETY

•Keep the side rails up at all times•Keep the bed at the possible lowest position•Assisted on needs


wound

•Assess and Record the amount of drainage •Assess the wound for any absess or sings of inlammation•Clean the wound with Normal Saline Solution and Hydrogen peroxide and Anti Septic•Remove the drainage


DIET

•NPO•Clear Liquid Diet•Soft Diet•Regular Diet


IV LINE



ELIMINATION

•Removes the indwelling urinary catheter. Record urinary output.•Check bowel sounds. Note stool consistency


Medications



ACTIVITIES

•Keep the patient flat on bed•Moderate to High Back Rest•Assisted patient on needs•May move from side to side but with assistance


HEALTH TEACHING

•Encouraged deep breathing and purselip exercises•Instruct not to lift heavy weights•Provided instructions on wound cleaning and change of dressings•


Discharge planning

•Stressed out the compliance in taking medications•Provided instructions on appropriate exercises and not to lift heavy objects•Instructed to follow the treatment regimen and health teachings given•Stressed out the importance of diet in patients condition•Instructed on follow up check up


DateTime

Type of VarianceDescription of Variance

Occurrence(Include what happened, why

it happened and what was done about it)

RN’s Name & Signature

Date Time Type of Variance Description of Variance Occurrence

(Include what happened, why it happened and what was done about it)

RN’s Name & Signature

VARIANCE RECORD SHEET

Variance code

A. PATIENT/ FAMILY

B. HEALTH CARE PROVIDER

C. HOSPITAL/ INSTITUTION

SYSTEM

D. OUTSIDE HOSPITAL/INSTI

TUTION

1.PATIENT’S MEDICAL CONDITION

1.MEDICAL ORDER 1. RESULTS/DATA UNAVAILABILITY

1. CONDITION/TRANSPORTATION

2.PATIENT’S/FAMILY DECISION

2. PROVIDER’S DECISION

2. SUPPLIES/EQUIPMENT RELATED

2.HOME CARE AVAILABILITY

3.PATIENT/FAMILY AVAILABILITY\

3.PROVIDER’S RESPONSE

3.APPOINTMENT/AVAILABILITY

3.OTHER REASONS

4.NO FUNDS 4.OTHER REASONS 4.WEEKEND/HOLIDAY

5.OTHERS 5.OTHER REASONS

Integrated Surgical Clinical Pathway for Patient for Appendectomy

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