1 Enhanced Recovery after Surgery Programme Trans - Hiatal and Ivor - Lewis Oesphagectomy Integrated Care Pathway Age: Consultant: Pre Operative Assessment Outcome: Suitable for Day of surgery admission (DOSA)? Y N Day before Surgery Admission (DBSA) Y N Admit .........days pre-op. Critical care bed required post-op? Booked Yes □ No □ Y N Level 2 or 3 Is the patient allergic to latex? Y N If Yes theatre informed: Date: Time: Is the patient’s BMI > 40? Y N If Yes theatre informed: Date: Time: Does the patient need to be first on list? Y N Is the patient suitable for carbohydrate loading Y N If No reason …………… Time of last : Time of last free fluids ………… Time of last clear fluids/’Pre-Op’ …………. Assessing Nurse: Signature: Date: Date of Admission: Operation: Date of surgery: Predicted date of discharge (PDD): Actual date of discharge: Length of stay Removed from pathway Date: Reason Addressograph Unit no.: DoB: Name: Address:
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1
Enhanced Recovery after Surgery Programme
Trans - Hiatal and Ivor - Lewis Oesphagectomy Integrated Care Pathway
Age:
Consultant:
Pre Operative Assessment Outcome:
Suitable for Day of surgery admission (DOSA)? Y N
Day before Surgery Admission (DBSA) Y N Admit .........days pre-op.
Critical care bed required post-op?
Booked Yes □ No □
Y N Level 2 or 3
Is the patient allergic to latex? Y N If Yes theatre informed:
Date: Time:
Is the patient’s BMI > 40? Y N If Yes theatre informed:
Date: Time:
Does the patient need to be first on list? Y N
Is the patient suitable for carbohydrate loading Y N If No reason ……………
Time of last :
Time of last free fluids …………
Time of last clear fluids/’Pre-Op’ ………….
Assessing Nurse: Signature: Date:
Date of Admission:
Operation:
Date of surgery:
Predicted date of discharge
(PDD):
Actual date of
discharge:
Length of stay
Removed from pathway
Date: Reason
Addressograph
Unit no.: DoB:
Name:
Address:
2
1. This Integrated Care Pathway (ICP) is a multidisciplinary document and replaces all other documentation to
form the patient’s sole record of care. It is intended as a guide to good practice and is evidence based. (NB
point
2. The ICP is not a rigid document and clinicians are free to use their own professional judgement as appropriate,
recording as a variance any alterations to the practice outlined, or any deviation from the expected plan of
treatment.
3. When using the pathway, sign yourself on below stating your discipline. Always use black ink
4. All sections should be fully completed. Please follow all instructions.
5. It is essential that all entries are signed and dated as indicated. Sign only for care that YOU have carried out or
outcomes that have been met.
6. When completing the pathway insert:
� Your initials if the outcome / plan has been met
� A X if it has not been met
� A 0 If the outcome / plan is not applicable to that patient
7. Any variation from the expected plan/ outcome of care: anything that happens that is not expected outcome /
plan is recorded as a VARIANCE.
8. In recording variances, please give as much information as possible
9. All variances must be recorded on the variance / multi-disciplinary notes sheet. Document the variance code
for the relevant action / outcome alongside the written detail of the variance
10. The Cardiff and Vale UHB generic risk assessment book must be used alongside this ICP to ensure that
patients undergo appropriate risk assessment during their stay
11. It may also be appropriate to use a nursing care plan as an adjunct to the pathway. Please make a record
below of the care plans in place and ensure each one is evaluated TDS in the multidisciplinary notes.
All patients Generic risk assessment book
Diabetic patients Diabetes core care plan
Relevant acute
pain team care
plans
Epidural care plan
PCA care plan
Intrathecal morphine care plan
12. If an outcome of care is not applicable to that patient write (0)
13. If the pathway is no longer suitable for a patient, discontinue the pathway, document why as a variance and
fill in the date in the table on page 1.
3
SIGNATURE PRINT NAME INITIALS JOB TITLE Bleep
/Extension
4
SOCIAL ASSESSMENT
Patient lives with:
Are they fit and well? Yes � No
Are they coping at home at present? Yes � No �
Are there stairs / steps in the home? Yes � No �
Does the patient care for anyone? Yes � No �
If Yes who?
Does the patient have a carer? Yes � No �
If Yes who?
Would patient or family like to see a Social
Worker Yes � No � If yes, reason:
Is OT assessment required Yes � No �
Does the patient have complex discharge needs?
Yes � No �
Are patient and family happy with social
circumstances and to organise own support
on discharge?
Yes � No �
Are there any adaptations / rails in the home?
Yes � No �
Date: Nurse signature:
Patient details Patient Known as:
Home telephone: Mobile telephone:
Email address Marital status:
Occupation Religion
1st Language Translator required Yes � No �
First contact Second contact
Name: Name:
Relationship to patient: Relationship to patient:
Address:
Address:
Home telephone: Home telephone:
Work telephone: Work telephone:
Mobile telephone: Mobile telephone:
To be contacted:
In an emergency: Yes � No �
At night: Yes � No �
To be contacted:
In an emergency: Yes � No �
At night: Yes � No �
GP details
Telephone number:
Practice address:
If social work referral required / discharge is complex complete Unified Assessment forms
Pre-op chemotherapy? yes ☐☐☐☐ no ☐☐☐☐ regime regime regime regime ☐☐☐☐ date completeddate completeddate completeddate completed ☐☐☐☐
Pre-op chemoradiotherapy? yes ☐☐☐☐ no ☐☐☐☐ date completeddate completeddate completeddate completed ☐☐☐☐
Previous
anaesthetic problems:
Family history of anaesthetic problems:
Previous motion sickness or post-operative nausea/vomiting: yes ☐☐☐☐ no ☐☐☐☐
Pre-operative clerking
6
Cardiovascular Y N Expand here:
MI □ □
Angina / Chest pain □ □
Hypertension □ □
AF / Arrhythmia □ □
Heart failure □ □
Stroke / TIA □ □
Previous cardiac surgery □ □
Coronary artery stents □ □
Pacemaker □ □
DVT / PE □ □
Palpitations / faints / syncope □ □
Rheumatic fever □ □
Peripheral vascular disease □ □
Respiratory
Asthma □ □
COPD / bronchitis / emphysema □ □
TB □ □
Sleep apnoea / snoring □ □
Cough □ □ Productive □ Haemoptysis □
Endocrine
Diabetes □ □ diet □ tablets □ insulin □
Thyroid disease □ □
Haematological
Excessive bleeding / bruising □ □
Anaemia / blood disorders □ □
Sickle cell disease □ □
GI/GU
Liver disease / jaundice / hepatitis □ □
Heartburn / acid reflux □ □
Hiatus hernia □ □
Stomach / duodenal ulcer □ □
Kidney / bladder problems □ □
Past medical history
7
CNS
Epilepsy / fits □ □
Neurological disorder □ □
Anxiety / Depression □ □
Psychiatric Illness □ □
Other
Arthritis/joint problems □ □
LMP …………….. Could you be pregnant? Yes No
Inoculation risk □ □
Other □ □ Maximum walking distance on flat …………… (yards / metres)
□ bed bound □ wheelchair bed to chair □ 5m end of room
□ 25m end of ward □ 100m length of football pitch □ 400m
□ 2km 30min walk □ >2km normal pace, no exercise limitation ��
Walking limited by □ joint pain □ breathing □ chest pain □ leg pain
□ balance □ fatigue □ other
Do you get SOB walking up a flight of 12 stairs? Y N Do you get chest pain walking up a flight of 12 stairs? Y N Orthopnoea Y N (State no. of pillows ……..) PND Y N Peripheral Oedema Y N
8
9
Abdomen
WEIGHT LOSS:
Weight pre illness:
Weight loss in KG:
Time frame of weight
loss:
Hand Signs:
10
Neurological
Investigations ordered (*=essential)
□ FBC* Hb: Plat: WCC: MCV:
□ U&E* Na: K: Ur: Creat:
□ G+S*
□ LFT*
□ Coagulation screen
□ Blood Glucose
□ HbA1c
□ TFT
□ Sickle cell
□ Arterial blood gases
□ MSU
□ MRSA swabs
□ ECG
□ CXR
□ Echocardiogram
□ Pulmonary function tests
□ CPX
□ Other
* NB: Please document FBC, U+E results and any other abnormal results above
Nutrition Carbohydrate loading: Refer to ward protocol Yes ☐ N/A ☐ document to be given 2-3 hours before surgery on drug chart � NB: Do not give within 4 hours of operation if previous gastric surgery or
severe reflux
Contra indications to NSAIDs Caution to NSAID use
Renal impairment Pregnancy / breast feeding
History of peptic ulceration Asthma
Hypersensitivity to NSAIDs CCF
Asthma hypersensitivity to aspirin Concurrent anti-coagulant therapy
Coagulopathy Hepatic impairment
Preoperative nursing assessment
Doctors name: Signature: Date:
12
Baseline assessment to be added in here
13
Baseline assessment to be added in here
14
Risk assessments completed and documented in generic risk assessment book
Initials
Waterlow Pressure ulcer risk assessment tool
Malnutrition risk assessment (WAASP) Weight……....Kgs (actual not estimated)
Pat-e-bac risk assessment
Falls and bedrails Risk assessment
Thromboprophylaxis risk assessment (doctor to complete)
Unified Assessment: Not to be completed for simple discharges
Patient education record:
Relative/carer present: Yes ☐ No ☐ Relationship to patient:
Teaching provided. Date: Yes N/A Initials
Understanding of Enhanced Recovery Programme & patient’s role
Fasting instructions
Bowel prep
Pain control
Mobilisation post-op
Carbohydrate loading
Pre and post operative dietary advice
Nutritional supplements
Thromboprophylaxis therapy
Deep breathing, leg exercises and preventing pressure ulcers
Smoking cessation advice
Written information provided:
Enhanced recovery programme
Surgery
Anaesthesia/analgesia
Discharge plans discussed
Family/social support plans for discharge discussed
Patient contract signed
Patient Diary given
15
Referrals
Y
Reason for
referral
Name/contact
referred to
Anaesthetist for notes review
Upper GI CNS
Dietician
Physiotherapist
Occupational Therapist
Acute pain team
Social services
Smoking cessation
Other
MRSA screen:
Full MRSA screen required if patient is being admitted from a nursing home or another hospital,
or if they are known to have had MRSA in the past:
MRSA screen sent: Yes ☐ No ☐ Not applicable ☐
Name of pre-assessment nurse:
Signature: Date
16
Physiotherapy – Preoperative Check List
Yes No Reason
Pain relief, in relation to Physiotherapy
Attachments, in relation Physiotherapy
Suitable clothing and footwear
Getting in and out of bed
Early mobilisation
Generic exercises
Breathing exercises taught and practiced
Supported cough
Return to normal activities
Driving
Booklet provided
Scholes Score: High Low
At risk of PPC?
Chest assessment : complete for all patients with a high Scholes score, chronic chest disease or cough
HABAM Score: Balance Transfers Mobility
At risk of mobility problems?
Taking into account complete assessment findings - is the Patient for routine post- operative Physiotherapy review?
Sign: Date: Print:
17
Nutrition and Dietetic - Preoperative Checklist
Yes No Reason
WAASP completed
MUST completed
SGA completed
Advised on carbohydrate loading
Food fortification advice
Advised on need for nutritional supplements x 3 day and explain different types available
Post operative dietary advice - early oral diet
Weight history and anthropometric assessment
Record of dietary intake
Diet sheet provided
Snacks and high protein options discussed
Any special dietary requirements?
Catering informed of special dietary requirement (as appropriate)
Anaesthetic /CPX Clinic Revised Cardiac Risk Index Score: Score 1 point for each variable:
High-risk surgery (includes any intraperitoneal, intrathoracic, or suprainguinal vascular procedures)
History of ischemic heart disease (history of MI or a positive exercise test, current complaint of chest pain considered to be secondary to myocardial ischemia, use
of nitrate therapy, or ECG with pathological Q waves; do not count prior coronary revascularization procedure unless one of the
other criteria for ischemic heart disease is present).
History of heart failure
History of cerebrovascular disease
Diabetes mellitus requiring treatment with insulin
Preoperative serum creatinine >177 µmol/L
TOTAL
CPX test Y N
ASA status 1 2 3 4 5
Peri-operative medicines instructions:
Continue all medicines on day of surgery ☐ or Continue all meds except list below ☐
Drug chart amended re: above instructions Yes ☐ No ☐
Anaesthetist name & signature: Date:
19
Variances/ Multidisciplinary Notes
Please record all variances or multidisciplinary notes below
Date, Time and
Variance code
Details, reason and action taken
Signature and
bleep number
20
Pre-operative Admission Day. Date:……………
Doctor: pm night Variance Code
Record changes in health status since POA in multidisciplinary notes PDr1
Record changes in medicines since POA in multidisciplinary notes PDr2
Check consent form has been signed and white copy has been given to patient PDr3
X-rays and ECG available PDr4
Investigations completed and results available PDr5
FBC/U&E/LFT performed within 14 days? Yes ☐ No ☐
If no then repeat on admission Yes ☐ N/A ☐
PDr6
If patient on warfarin INR check Yes ☐ Anaesthetist informed if INR > 1.4 Yes ☐ PDr7
G+S sample sent (2nd G+S sample for electronic blood issue) PDr8
Prescription chart written PDr9
On admission:
Patient fully aware of planned surgery PT1
Patient orientated to ward [NB: access to nutritional supplements] PT2
Repeat observations. (T, P, R, BP, SpO2 + weight) POb
Enoxaparin given at 1800 hours PM1
If prescribed patient measured for Anti-embolic stockings and stockings provided PAes
Identity band in place, patient details confirmed PN1
Bowel preparation: Discussed with consultant / Registrar and prescribed if required – please make a record on variance sheet if required
PM3
Referrals: Referred to pain control nurse PNr1
Inform physiotherapist of admission PNr2
Inform dietician of admission PNr3
Referred to Social worker, OT and Discharge liaison if required
Please document these referrals on variance sheet PNr4
Nutrition
Normal diet and fluids – stop diet 6 hours pre theatre: Time diet to stop:
(Unless undergoing bowel preparation) ………… PNU1
Bowel preparation: Administered if required and as prescribed
Record weight (kg) Insert weight………..(KG) PNW
Recalculate Malnutrition risk assessment and record changes (WAASP) PNA
Encourage Ensure Plus x2 supplement drinks are given 1 ☐ 2 ☐ PNS
Insert initials if achieved, a x if
not achieved and 0 if not
applicable
21
Carbohydrate loading: give 4 x 200ml ‘Pre-Op’ drinks evening before surgery
1 ☐ 2 ☐ 3 ☐ 4 ☐ NIGHT STAFF:NIGHT STAFF:NIGHT STAFF:NIGHT STAFF: please refer to operation day 0 re: administration of ‘Pre-Op’ drinks x 2 between 05.00 and 06.00. NB: Do not give if Diabetic or within 4 hours
of operation, previous gastric surgery or severe reflux PClam
pm night Variance Code
Patient Education
Importance of mobility post op and deep breathing and limb exercises PEm
Surgery / treatment plan PST
Importance of post op nutrition and early enteral feeding PN2
Patient’s and relatives’ roles in recovery process PER
Discharge arrangements PDis
Operation Day (day 0) Date:...................
Preoperative: Estimated time of surgery:
Yes Signature
Confirm G+S sample sent (2nd G+S sample for electronic blood issue) Doctor
No food for 6 hours prior to surgery
Carbohydrate loading (Pre-Op drinks) and clear fluids
(up to 2 hr pre-op) 1 ☐ 2 ☐ NB: Do not give within 4 hours of operation if previous gastric surgery or severe reflux
Theatre check list completed
Wearing AES (Anti-embolism stockings)
Patient’s usual medications given as prescribed
(omit ACE inhibitors or Angiotensin II Receptor blockers
on day of surgery)
22
Operation Notes Date: Consultant: Surgeon 1: Surgeon 2: Surgeon 3: Surgeon 4: Anaesthetist: Scrub Nurse: Anaesthetic time started: Time into theatre: Operation time started: Time finished: Site of cancer: Operation title: Cancer treatment intent:
Yes No Long-acting sedative premed avoided Seen in preop Anaesthetic Clinic CPX test performed DOSA Long-acting sedative pre-med avoided Carbohydrate loading taken 2-3hours preop Spinal Intrathecal Diamorphine Intrathecal Diamorphine with 0.5% heavy Bupivacaine TAP block Epidural Intraop Dexamethasone given as antiemetic Intraop Ondansetron given as antiemetic Bair Hugger Temp probe Warmed iv fluids Temp on leaving theatre Antibiotics prior to skin excision Cardiac Output Monitor used Volume (mls)
Total intraop crystalloid volume given Total intraop colloid volume given
Anaesthetic data (to be completed in theatre by anaesthetist
24
Post op: Day 0 (Day of operation) Date:....................
Plan: Pain well controlled, IV fluids, oxygen and catheter in situ, sterile water via jejunostomy
PM Night Variance
Code
Admitted to critical care 0ICU
Observations and EWS score completed ½ hrly for 2 hrs, 1 hrly for 2 hrs and then
2 hrly. Actions taken as per EWS chart: document actions on variance sheet 0Ob
Deep breathing promoted, patient able to deep breath and cough. 0Db
Sputum clear 0Sp
Oxygen in place as prescribed and oxygen saturations maintained above 97% 0O2
Fluid balance chart completed hourly 0Fb
Administer IV fluids (1.5L Hartmanns over 24 hrs = 62.5 mls/hr) Follow
GIFTASUP recommendations
0ivi
Central line care as per care bundle - site healthy 0Clb
Hourly catheter measurements (maintain 0.3 ml/kg/hour averaged over 4 hours)
NG tube insitu on free drainage only – no fresh blood noted
Do NOT aspirate or repass a NGtube without consultant direction
0Ng
Jejunostomy insitu - Administer sterile water at 10ml/hr for 12 hours using an enteral feeding pump
Sterile water should commence at 6pm post operative unless contra-indicated.
0Jejw
Pain assessed with each set of observations at rest and deep breathing and pain well controlled (0-1) ( If pain not well controlled actions taken as per protocol and relevant care plans (PCA / epidural) and documented on variance sheet)
0Pa
Epidural site: checked 8 hourly, no redness, oozing or swelling present ( If redness / oozing / swelling refer to per protocol and epidural care plan and document on variance sheet)
0Ep
Straight leg raises checked 4 hourly – patient able to raise leg (If patient unable to SLR refer to protocol and epidural care plan and document on variance sheet)
0Slr
VIP score completed for all venflons insitu 0Vip
Wound observed when observations recorded no bleeding / signs of infection 0W
Insert initials if achieved,
a x if not achieved and
0 if not applicable
25
Chest drain monitored and oscillation noted with each set of observations, note
colour and volume. Number of chest drains insitu …………………..
0Cd
Record output via Chest drain BD 0Cdor
PM Night Variance
Code
Abdominal drains checked, drainage measured and recorded before 12MN, blood
and haemoserous fluid draining volume is less than 200 mls
Number of drains insitu: …………………….
0Ad
Patient assisted to reposition 2 hourly by day / ………….. hourly by night 0Rep
Pressure areas checked all blanching with no discolouration / broken areas 0Pr
AES in situ (Legs, feet and heels checked all blanching and no discolouration / broken areas present) 0Aes
Waterlow, Pat-e-bac, falls and WAASP risk assessments recalculated post op 0Ra
Doctor: Blood tests (FBC, U & E) taken 0Dr1
Doctor: Blood tests (FBC, U & E) results reviewed and normal 0Dr2
Doctor: Review drug chart, change medications to IV whilst NBM 0Dr3
Please record all variances or multidisciplinary notes below
Date, Time and
Variance code
Details, reason and action taken
Signature and
bleep number
27
Post op: Day 1 (Day of operation) Date:....................
Plan: Lung re-inflated, observations stable, pain well controlled, sat out of bed, aim to achieve 40mls /hr of enteral feed by end of day 1.
am pm night Variance Code
Trans-hiatal oesophagectomy – transferred to ward C2
1C2
Ivor Lewis oesophagectomy – transferred to HDU
1HDU
Observations and EWS score recorded 2 hourly. Actions taken as
per EWS chart: document actions required on variance sheet
1Ob
Deep breathing promoted, patient able to deep breathe and cough. 1Db
Sputum clear 1Sp
Oxygen therapy maintained and oxygen sats > 97%) 1O2
Pain assessed 2 hourly at rest and deep breathing and pain well controlled (0-1) ( If pain not well controlled actions taken as per protocol and relevant care plans (PCA / epidural) and documented on variance sheet)
1Pa
Epidural site: checked 8 hourly, no redness, oozing or swelling present ( If redness / oozing / swelling refer to per protocol and epidural care plan and document on variance sheet)
1Ep
Straight leg raises checked 4 hourly – patient able to raise leg (If patient unable to SLR refer to protocol and epidural care plan and document on variance sheet)
1Slr
Flatus passed 1Fl
Faeces passed 1Bo
Strictly Nil By Mouth 1Nbm
Administer IV fluids (1.5L Hartmanns over 24 hrs = 62.5 mls/hr)
Follow GIFTISUP recommendations
1ivi
Jejunostomy insitu - If tolerating10ml/hr sterile water for 12 hours commence feed.
1Jejw
Commence Osmolite at 20ml/hr unless contra-indicated, increase
rate by 10mls per every 6 hours until a max of 80mls/h is reached.
Flush 6hrly with 30mls of sterile water.
1Jejf
Clean jejunostomy site daily with normal saline, check integrity of
sutures. (If suture not intact secure jejunostomy and inform team)
Physiotherapy – shoulder exercises for Ivor-Lewis procedure completed
1Ph5
29
Postoperative Morbidity Survey (POMS) Day 1 post-op
Morbidity type Criteria Tick if present*
Pulmonary Has the patient developed a new requirement for oxygen or respiratory support.
Infectious Currently on antibiotics and/or has had a temperature of >38°C
in the last 24hr.
Renal Presence of oliguria <500 ml/24 hr; Increased serum creatinine (>30% from preoperative level); Urinary catheter in situ.
Gastrointestinal Unable to tolerate an oral diet for any reason including nausea, vomiting, and abdominal distension.
Use of antiemetic.
Cardiovascular Diagnostic tests or therapy within the last 24 hr for any of the following:
• new myocardial infarction or ischemia,
• hypotension (requiring fluid therapy >200 mL/hr or pharmacological therapy),
• atrial or ventricular arrhythmias,
• cardiogenic pulmonary oedema,
• thrombotic event (requiring anticoagulation).
Neurological New focal neurological deficit, confusion, delirium, or coma.
Haematological Requirement for any of the following within the last 24 hr: packed erythrocytes, platelets, fresh-frozen plasma, or cryoprecipitate.
Wound Wound dehiscence requiring surgical exploration or drainage of pus from the operation wound with or without isolation of organisms.
Pain New postoperative pain significant enough to require IV or IM opioids or regional analgesia.
* If no scores above then please state reason why patient still in hospital:
Date: Doctor’s signature: Bleep no:
30
Variances/ Multidisciplinary Notes
Please record all variances or multidisciplinary notes below
Date, Time and
Variance code
Details, reason and action taken
Signature and
bleep number
31
Plan: Aim to achieve 80mls /hr of enteral feed by end of day 2, fluid
balanced achieved, pain well controlled, sitting out and mobilising with
assistance
AM PM Night Variance
code
Ivor Lewis Oesophagectomy transferred to ward C2 2C2
Observations and EWS chart score recorded 2hourly whilst PCA and
epidural insitu, Actions taken as per EWS chart: document all actions on
variance sheet
2Ob
Deep breathing promoted, patient able to deep breath and cough. 2Db
Sputum clear 2Sp
Oxygen saturations > 97% on prescribed oxygen 2O2
Fluid balance chart completed 1 hourly 2Fb
VIP score completed for all venflons in situ – Score 0 2Vip
Strictly Nil By Mouth 2Nbm
Administer IV fluids (1.5L Hartmanns over 24 hrs = 62.5 mls/hr)
Follow GIFTAISUP recommendations
2ivi
Continue Osmolite via jejunostomy unless contra-indicated, increase rate by 10mls per every 6 hours until a max of 80mls/h is reached. Flush 6hrly with 30mls of sterile water.
2Jejf
Clean jejunostomy site daily with normal saline, check integrity of
sutures. (If suture not intact secure jejunostomy and inform team)
2Jejc
Monitor urine output 1 hourly
(maintain minimum of 0.3 ml/kg/hour averaged over 4 hours)
2Uc
Weight recorded ………Kgs 2Wt
If weight gain>3kgs request surgical review 2Wtg
NG tube insitu and reviewed by consultant, haemoserous fluid / bile draining. Free Drainage Only
2Ng
Nausea assessed 2 hourly and actions taken as per protocol 2Na
Flatus passed 2Fl
Faeces passed. 2Bo
Patient checked for paralytic ileus - ie. Nausea/vomiting, increased
Pain assessed 2 hourly at rest and deep breathing and pain well controlled (0-1) ( If pain not well controlled actions taken as per protocol and relevant care plans (PCA / epidural) and documented on variance sheet)
2Pa
Epidural site: checked 8 hourly, no redness, oozing or swelling present ( If redness / oozing / swelling refer to per protocol and epidural care plan and document on variance sheet)
2Ep
Insert initials if achieved, a x if
unachieved and O if not
applicable
Post op day 2 Date:
32
AM PM Night Variance
code
Straight leg raises checked 4 hourly – patient able to raise leg (If patient unable to SLR refer to protocol and epidural care plan and document on variance sheet)
2Slr
Wound observed, no bleeding or signs of infection noted 2W
Abdominal drains monitored and reviewed by Registrar / Consultant 2Ad
Chest drain monitored and oscillation noted with each set of
observations, note colour and volume
2Cdos
Record output via Chest drain BD 2Cdor
Hygiene needs met. 2Hy Out of bed x 2 times in total and record length of time sat out
1 ☐ ……………… 2 ☐ ……………… 2Sc
Walks x 2 (Tick once each walk achieved and estimate distance)
1 ☐ …………………….. 2 ☐ ………………….. 2Wa
Foot exercises whilst in bed / whilst sat out in chair 2Fe
AES in situ (Legs, feet and heels checked all blanching and no discolouration / broken
areas present) 2Aes
AES completely removed once in 24hours for maximum of 30 mins for hygiene care and skin inspection 2Aesr
Pressure areas checked all blanching with no discolouration / broken areas
2Pr
Patient reminded to reposition 2 hourly by day and ……… by night 2Rep
Risk assessment scores reassessed if any change in condition 2Ra
Remind patient of ERAS programme requirements 2Pe
Doctor: Blood tests (FBC, U & E) taken 2Dr1
Doctor: (FBC, U & E) results reviewed and normal 2Dr2
Doctor: Review drug chart, change medications to IV whilst NBM 2Dr3
Doctor: If patient unwell consider possibility of an anastamotic leak and inform Consultant immediately
Pain assessed 2 hourly at rest and deep breathing and pain well controlled (0-1) ( If pain not well controlled actions taken as per protocol and relevant care plans (PCA / epidural) and documented on variance sheet)
3Pa
Epidural site: checked 8 hourly, no redness, oozing or swelling present ( If redness / oozing / swelling refer to per protocol and epidural care plan and document on variance sheet)
3Ep
Straight leg raises checked 4 hourly – patient able to raise leg (If patient unable to SLR refer to protocol and epidural care plan and document on variance sheet)
3Slr
Insert initials if achieved, a x if
unachieved and O if not
applicable
36
AM PM Night Variance
code
Wound observed, no bleeding or signs of infection noted 3W
Abdominal drains reviewed by team and removed if less than 50 mls
drained in previous 24 hours
3Ad
Chest drain monitored and oscillation noted with each set of
observations, note colour and volume
3Cdos
Record output via Chest drain BD, 3Cdor
Hygiene needs met. 3Hy
Out of bed x 3 times in total and record length of time sat out
1 ☐ ……………… 2 ☐ ……………… 3 ☐ ……………… 3Sc
Walks x 2 (Tick once each walk achieved and estimate distance)
1 ☐ …………………….. 2 ☐ ………………….. 3Wa
Foot exercises whilst in bed / whilst sat out in chair 3Fe
AES in situ (Legs, feet and heels checked all blanching and no discolouration / broken
areas present) 3Aes
AES completely removed once in 24hours for maximum of 30 mins for hygiene care and skin inspection 3Aesr
Pressure areas checked all blanching with no discolouration / broken areas
3Pr
Patient reminded to reposition 2 hourly by day and ……… by night 3Rep
Risk assessment scores reassessed if any change in condition 3Ra
Remind patient of ERAS programme requirements 3Pe
Doctor: Blood tests (FBC, U & E) taken 3Dr1
Doctor: (FBC, U & E) results reviewed and normal 3Dr2
Doctor: Review drug chart, change medications to IV whilst NBM 3Dr3
Doctor: If patient unwell consider possibility of an anastamotic leak and inform Consultant immediately
Pain assessed 2 hourly at rest and deep breathing and pain well controlled (0-1) ( If pain not well controlled actions taken as per protocol and relevant care plans (PCA / epidural) and documented on variance sheet)
4Pa
Epidural site: checked 8 hourly, no redness, oozing or swelling present ( If redness / oozing / swelling refer to per protocol and epidural care plan and document on variance sheet)
4Ep
Insert initials if achieved, a x if unachieved and O if not applicable
Post op day 4 Date:
40
AM PM Night
Straight leg raises checked 4 hourly – patient able to raise leg (If patient unable to SLR refer to protocol and epidural care plan and document on variance sheet)
4Slr
Wound observed, no bleeding or signs of infection noted 4W
Abdominal drains reviewed by team and removed if less than 50 mls
drained in previous 24 hours
4Ad
Remove abdominal drain if instructed and documented in patients
notes.
4Adr
Chest drain monitored and oscillation noted with each set of
observations, note colour and volume
4Cdos
Record output via Chest drain BD, 4Cdor
Hygiene needs met. 4Hy
Out of bed x 4 times in total and record length of time sat out
1 ☐ ………… 2 ☐ …………… 3 ☐ …………… 4 ☐ ……………
4Sc
Walks x 3 (Tick once each walk achieved and estimate distance)
1 ☐ ……………. 2 ☐ ………………… 3 ☐ ……………… 4Wa
Foot exercises whilst in bed / whilst sat out in chair 4Fe
AES in situ (Legs, feet and heels checked all blanching and no discolouration / broken
areas present) 4Aes
AES completely removed once in 24hours for maximum of 30 mins for hygiene care and skin inspection 4Aesr
Pressure areas checked all blanching with no discolouration / broken areas
4Pr
Patient reminded to reposition 2 hourly by day and ……… by night 4Rep
Risk assessment scores reassessed if any change in condition 4Ra
Remind patient of ERAS programme requirements 4Pe
Doctor: Blood tests (FBC, U & E) taken 4Dr1
Doctor: (FBC, U & E) results reviewed and normal 4Dr2
Doctor: Review drug chart, change medications to IV whilst NBM 4Dr3
Doctor: If patient unwell consider possibility of an anastamotic leak and inform Consultant immediately
Pain assessed 2 hourly at rest and deep breathing and pain well controlled (0-1) ( If pain not well controlled actions taken as per protocol and relevant care plans (PCA / epidural) and documented on variance sheet)
5Pa
Epidural site: checked 8 hourly, no redness, oozing or swelling present ( If redness / oozing / swelling refer to per protocol and epidural care plan and document on variance sheet)
5Ep
Straight leg raises checked 4 hourly – patient able to raise leg (If patient unable to SLR refer to protocol and epidural care plan and document on variance sheet)
5Slr
Wound observed, no bleeding or signs of infection noted 5W
Abdominal drains reviewed by team and removed if less than 50 mls
drained in previous 24 hours
5Ad
Post op day 5 Date: Insert initials if achieved, a x if
unachieved and O if not
applicable
44
AM PM Night Variance
code
Chest drain monitored and oscillation noted with each set of
observations, note colour and volume
Cdos
Record output via Chest drain BD, Cdor
Gastrograffin swallow to confirm integrity of anastamosis
(to be carried out on day 6 / 7 if day 5 is a weekend day)
5Gs5
Following successful swallow - Commence sips of water on
Consultant’s instruction and clearly documented in patients
notes.
5Of
Following successful swallow - Remove NG tube and chest drain on
Consultant’s instruction and clearly documented in patient’s
notes.
5Ngr
Hygiene needs met. 5Hy
Out of bed x 4 times in total and record length of time sat out
1 ☐ ………… 2 ☐ …………… 3 ☐ …………… 4 ☐ ……………
5Sc
Walks x 4 (Tick once each walk achieved and estimate distance)
1 ☐ ………… 2 ☐ ………………3☐ ……………… 4☐ ………………
5Wa
Foot exercises whilst in bed / whilst sat out in chair 5Fe
AES in situ (Legs, feet and heels checked all blanching and no discolouration / broken
areas present) 5Aes
AES completely removed once in 24hours for maximum of 30 mins for hygiene care and skin inspection 5Aesr
Pressure areas checked all blanching with no discolouration / broken areas
5Pr
Patient reminded to reposition 2 hourly by day and ……… by night 58Rep
Risk assessment scores reassessed if any change in condition 5Ra
Remind patient of ERAS programme requirements 5Pe
Doctor: Blood tests (FBC, U & E) taken 5Dr1
Doctor: (FBC, U & E) results reviewed and normal 5Dr2
Doctor: Review drug chart, change medications to appropriate route for administration
5Dr3
Doctor: If patient unwell consider possibility of an anastamotic leak and inform Consultant immediately
Consider discontinuing epidural /PCA and commencing IV / oral analgesia. (Document if epidural / PCA discontinued on variance sheet)
6Epr
Pain assessed 2 hourly at rest and deep breathing and pain well controlled (0-1) ( If pain not well controlled actions taken as per protocol and relevant care plans (PCA / epidural) and documented on variance sheet)
6Pa
Wound observed, no bleeding or signs of infection noted
6W
AM PM Night Variance
code
Insert initials if achieved, a x
if unachieved and O if not applicable
Post op day 6 Date:
48
Epidural site: checked 8 hourly, no redness, oozing or swelling present ( If redness / oozing / swelling refer to per protocol and epidural care plan and document on variance sheet)
6Ep
Straight leg raises checked 4 hourly for 24hrs post removal of epidural – patient able to raise leg (If patient unable to SLR refer to protocol and epidural care plan and document on variance sheet)
6Slr
Gastrograffin swallow to confirm integrity of anastamosis ( if not
carried out day 5, to be carried out on day 7 if day 6 is a weekend
day) Commence sips of water on Consultant’s instruction and
clearly documented in patients notes.
6Gs6
Remove NG tube on Consultant’s instruction and clearly
documented in patient’s notes.
6Ngr
Chest drain monitored and oscillation noted with each set of
observations, note colour and volume. Remove if instructed and
documented in patients notes
6Cdos
Record output via Chest drain BD, 6Cdor
Hygiene needs met. 6Hy
Out of bed x 5 times in total and record length of time sat out
1 ☐ ………… 2 ☐ ………… 3 ☐ …………… 4 ☐ …………… 5 ☐ …………
6Sc
Walks x 4 (Tick once each walk achieved and estimate distance)
1 ☐ ………… 2 ☐ ………………3☐ ……………… 4☐ ………………
6Wa
Foot exercises whilst in bed / whilst sat out in chair 6Fe
AES in situ (Legs, feet and heels checked all blanching and no discolouration / broken
areas present) 6Aes
AES completely removed once in 24hours for maximum of 30 mins for hygiene care and skin inspection 6Aesr
Pressure areas checked all blanching with no discolouration / broken areas
6Pr
Patient reminded to reposition 2 hourly by day and ……… by night 6Rep
Risk assessment scores reassessed if any change in condition 6Ra
Remind patient of ERAS programme requirements 6Pe
Doctor: Blood tests (FBC, U & E) taken 6Dr1
Doctor: (FBC, U & E) results reviewed and normal 6Dr2
Doctor: Review drug chart, change medications to appropriate route for administration
Dr3
Doctor: If patient unwell consider possibility of an anastamotic leak and inform Consultant immediately