integrated surgical clinical pathway for patient for appendectomy
TRANSCRIPT
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
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
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
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
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)
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
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
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
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
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
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____
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
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
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
CONSULT
Surgical Consult: Abdominal Pain, Ruled out Appendicitis
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
INTRAVENOUS LINE
•D5LRS1L x ____ gtts/min•PNSS1L x ____ gtts/min•Others:•_________
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
DIET
•NPO
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
ACTIVITIES
•Complete Bed Rest•Complete Bed Rest with BRP’s•Other______
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
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:__________________
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
Discharge planning
qAssess living conditions and Nature of workqLifestyle Modification
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
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
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
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
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
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
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
procedures
•Foley Catheter•Cardiac Monitor•Oxygen Therapy•O2 via NC@__LPM•O2 via FM@__LPM
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
INTRAVENOUS LINE
•D5LRS1L x ____ gtts/min•PNSS1L x ____ gtts/min•Others:•_________
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
INTRAVENOUS LINE
•D5LRS1L x ____ gtts/min•PNSS1L x ____ gtts/min•Others:•_________
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
DIET
•NPO
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
SKIN PREPARATION
•Skin Preparation and Removal of Hair at ward•Skin Prepping and Surgical Draping Done
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
Medications
Pain MedicationPre-Operative Medication given Anesthesia given: Spinal AnesthesiaGeneral AnesthesiaOthers:
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
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
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
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
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
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
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
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
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
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
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
PROCEDURES
•Hooked to Cardiac MonitorOxygen Therapy•O2 via NC@__LPM•O2 via FM@__LPM
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
DIET
•NPO
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
IV LINE
•D5LRS1L x ___gtts/min•PNSS1L x __gtts/min•Others:•_____________
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
SURGICAL INCISION and DRESSING
•Assess and change the surgical dressing if soaked with blood•Drain the drainage container(if any) before transfer to room
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
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:
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
ACTIVITIES
•Keep the patient flat on bed•Moderate to High Back Rest•Assisted patient on needs
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
DRAINAGE
•JP Drain•Penrose Drain•Hemovac
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
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
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
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
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
Assessment
•Monitor Vital Signs•Assess for Post-Op Pain and Complications•Assess the incision site and drainage•Assess for urine output, bowel sounds
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
COMFORT AND SAFETY
•Keep the side rails up at all times•Keep the bed at the possible lowest position•Assisted on needs
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
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
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
DIET
•NPO•Clear Liquid Diet•Soft Diet•Regular Diet
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
IV LINE
•D5LRS1L x ___gtts/min•PNSS1L x __gtts/min•Others:•_____________
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
ELIMINATION
•Removes the indwelling urinary catheter. Record urinary output.•Check bowel sounds. Note stool consistency
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
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:
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
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
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
HEALTH TEACHING
•Encouraged deep breathing and purselip exercises•Instruct not to lift heavy weights•Provided instructions on wound cleaning and change of dressings•
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
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
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
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
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
Assessment
•Monitor Vital Signs•Assess for Post-Op Pain and Complications•Assess the incision site and drainage•Assess for urine output, bowel sounds
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
COMFORT AND SAFETY
•Keep the side rails up at all times•Keep the bed at the possible lowest position•Assisted on needs
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
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
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
DIET
•NPO•Clear Liquid Diet•Soft Diet•Regular Diet
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
IV LINE
•D5LRS1L x ___gtts/min•PNSS1L x __gtts/min•Others:•_____________
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
ELIMINATION
•Removes the indwelling urinary catheter. Record urinary output.•Check bowel sounds. Note stool consistency
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
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:
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
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
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
HEALTH TEACHING
•Encouraged deep breathing and purselip exercises•Instruct not to lift heavy weights•Provided instructions on wound cleaning and change of dressings•
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
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
http://www.medindia.net/patients/patientinfo/Appendicitis_symptoms.htm
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