Integrated Surgical Clinical Pathway For Patient For Appendectomy

INTEGRATED SURGICAL CLINICAL PATHWAY FOR PATIENT FOR LapAROSCOPIC OR OPEN ALNEIL ANTONIO RN APPENDECTOMY LAURICE SARMIENTO RN
AppendEcTOMY
is the surgical removal of the appendix when an infection has made it inflamed and swollen o appendicitis, is considered an emergency because it can be life threatening if untreated
o
most commonly performed emergency 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: AGE: ATTENDING PHYSICIAN: ADMITTING DIAGNOSIS: SEX: BIRTHDAY: HOSPITAL NUMBER: HEIGHT: cm WEIGHT: Kg ALLERGIES(if any):
ULT HEALTH CARE HOSPITAL

ADMISSION DATE & TIME: DISCHARGE DATE & FINAL DIAGNOSIS: TIME: ACTUAL LENGTH OF STAY: days EXPECTED LENGTH OF STAY: days
PATIENT TO INCLUDE IN PATHWAY: Patients with a diagnosis of probable appendicitis PATIENT TO EXCLUDE IN PATHWAY: (1) Incidental Appendectomy (2)Patient with symptoms that require ICU level of care (3) Patient with complicating chronic condition REMOVE 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
PARTS OF THE PATHWAY

PHASE OF CARE ACTIVITY Phase i (emergency room/admission/ward) Specific Activities Initial Vital Signs and Pain Assessment done Observe Non verbal cues/ Pain behaviors Verification of patients identity Physical Examination Medical History taken Measure Height and Weight Health Care Team RN:____ Time & date EVALUATIOn Goal met goal not met ASsessment
RN:____
MD:____ RN:____ MD:____ RN:____ MD:____ RN:____
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)
(3)
Patient with symptoms that require ICU level of care Patient with complicating chronic condition
REMOVE FROM THE PATHWAY
(1) (2) (3)
Change in Diagnosis Transfer to a higher level of care Significant post-operative complication such as: Bowel obstruction requiring a second operation or prolonged TPN
PHASES OF CARE
q q q q q
Phase i (emergency room/admission-ward) PHASE II (FROM WARD-Perioperative) PHASE III(POST ANESTHESIA CARE UNIT) PHASE IV(DAY 1 WARD) PHASE V (DAY 2 WARD-DISCHARGE)
Phase I (emergency room/admissionward)
q q q q q q q q q q q
Phase i (emergency room/admission-ward) Assessment

LABORATORY & DIAGNOSTIC EXAM COMFORT AND SAFETY CONSULT IV LINE DIET Medications Ambulation HEALTH TEACHING Discharge planning ENDORSE
Assessment
Initial Vital Signs and Pain Assessment done Observe Non verbal cues/ Pain behaviors Verification of patients 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 kneechest 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 BRPs 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
Assess living conditions and Nature of work q Lifestyle Modification

q
PHASE II (FROM WARD-PERIOPERATIVE)
PHASE II (FROM WARDPERIOPERATIVE)

q q q q q q q q q
Assessment COMFORT AND SAFETY procedures IV LINE DIET SKIN PREPARATION Medications HEALTH TEACHINGS 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
INTRAVENOUS LINE
DIET
NPO
SKIN PREPARATION
Skin Preparation and Removal of Hair at ward Skin Prepping and Surgical Draping Done
Medications
Pain Medication Pre-Operative Medication given Anesthesia given: Spinal Anesthesia General Anesthesia Others:
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)

Assessment COMFORT AND SAFETY PROCEDURES IV LINE DIET SURGICAL INCISION and DRESSING Medications ACTIVITIES DRAINAGE HEALTH TEACHING 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 Monitor Oxygen 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)

Assessment COMFORT AND SAFETY Wound IV LINE DIET ELIMINATION Medications ACTIVITIES DRAINAGE HEALTH TEACHING 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 WARDDISCHARGE)
PHASE V (DAY 2 WARD-DISCHARGE)

Assessment COMFORT AND SAFETY Wound IV LINE DIET ELIMINATION Medications ACTIVITIES DRAINAGE HEALTH TEACHING 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
VARIANCE RECORD SHEET Date

Date
Time Type of Variance Description of Variance Occurrence (Include what happened, why it happened and what was done about it) RNs Name & Signature
Time Type of Variance Description of Variance Occurrence (Include what happened, why it happened and what was done about it)
RNs Name & Signature
Variance code
A.
PATIENT/ FAMILY
B. HEALTH CARE PROVIDER
C. HOSPITAL/ INSTITUTION SYSTEM
D. OUTSIDE HOSPITAL/INSTI TUTION
1.PATIENTS MEDICAL CONDITION
1.MEDICAL ORDER
1. RESULTS/DATA UNAVAILABILITY 2. SUPPLIES/EQUIPME NT RELATED 3.APPOINTMENT/AV AILABILITY 4.WEEKEND/HOLIDA Y 5.OTHER REASONS
1. CONDITION/TRANSP ORTATION 2.HOME CARE AVAILABILITY 3.OTHER REASONS
2.PATIENTS/FAMILY 2. PROVIDERS DECISION DECISION 3.PATIENT/FAMILY AVAILABILITY\ 4.NO FUNDS 5.OTHERS 3.PROVIDERS RESPONSE 4.OTHER REASONS

Integrated Surgical Clinical Pathway For Patient For Appendectomy

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INTEGRATED SURGICAL CLINICAL PATHWAY FOR PATIENT FOR LapAROSCOPIC OR OPEN ALNEIL ANTONIO RN APPENDECTOMY LAURICE SARMIENTO RN

ULT HEALTH CARE HOSPITAL

PARTS OF THE PATHWAY

MD:____ RN:____ MD:____ RN:____ MD:____ RN:____

REMOVE FROM THE PATHWAY

(1) (2) (3)

Phase I (emergency room/admissionward)

Phase i (emergency room/admission-ward) Assessment

LABORATORY & DIAGNOSTIC EXAM CBC with differential

COMFORT AND SAFETY

Surgical Consult: Abdominal Pain, Ruled out Appendicitis

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

Complete Bed Rest Complete Bed Rest with BRPs Other______

Assess living conditions and Nature of work q Lifestyle Modification

PHASE II (FROM WARD-PERIOPERATIVE)

PHASE II (FROM WARDPERIOPERATIVE)

COMFORT AND SAFETY

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

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

POST OPERATIVE CARE

PHASE III (POST ANESTHESIA CARE UNIT)

PHASE III(POST ANESTHESIA CARE UNIT)

COMFORT AND SAFETY

Hooked to Cardiac Monitor Oxygen Therapy O2 via NC@__LPM O2 via FM@__LPM

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

SURGICAL INCISION and DRESSING

JP Drain Penrose Drain Hemovac

PHASE IV (DAY 1 WARD)

PHASE IV(DAY 1 POST OPERATIVE AT WARD)

COMFORT AND SAFETY

DIET NPO Clear Liquid Diet Soft Diet Regular Diet

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

PHASE V (DAY 2 WARDDISCHARGE)

PHASE V (DAY 2 WARD-DISCHARGE)

COMFORT AND SAFETY

DIET NPO Clear Liquid Diet Soft Diet Regular Diet

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

VARIANCE RECORD SHEET Date

RNs Name & Signature

B. HEALTH CARE PROVIDER

C. HOSPITAL/ INSTITUTION SYSTEM

D. OUTSIDE HOSPITAL/INSTI TUTION

1.PATIENTS MEDICAL CONDITION

1. RESULTS/DATA UNAVAILABILITY 2. SUPPLIES/EQUIPME NT RELATED 3.APPOINTMENT/AV AILABILITY 4.WEEKEND/HOLIDA Y 5.OTHER REASONS

1. CONDITION/TRANSP ORTATION 2.HOME CARE AVAILABILITY 3.OTHER REASONS

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MD: RN: MD: RN: MD: RN:

D5LRS1L x gtts/min PNSS1L x gtts/min Others: _____

D5LRS1L x gtts/min PNSS1L x gtts/min Others: _____

D5LRS1L x gtts/min PNSS1L x gtts/min Others: _____

Hooked to Cardiac Monitor Oxygen Therapy O2 via NC@LPM O2 via FM@LPM

D5LRS1L x _gtts/min PNSS1L x gtts/min Others: _____________

D5LRS1L x _gtts/min PNSS1L x gtts/min Others: _____________

D5LRS1L x _gtts/min PNSS1L x gtts/min Others: _____________