H&N Laryngectomy ERAS pathway - Bedside Notes Version 2

Head & Neck Surgery – Laryngectomy

Enhanced Recovery Programme

Bed End Chart for Staff use

This chart is to be used as a prompt for compliance with the patient pathway and an audit tool – it does not replace medical notes

Please ensure this document accompanies the patient at all times, and is used during nursing handover and ward rounds.

October 2015 (version 2:0)

Admission Date: ______________

PATIENT DETAILS

NOK CONTACT INFORMATION

Head & Neck Surgery – Laryngectomy Enhanced Recovery Programme Bed End Chart V1.0

1

Neck dissection (ND) Yes No

ND Type (details) Lt Rt

Flap Reconstruction Yes No

Donor Site

Thyroidectomy Yes No

Thyroidectomy procedure Hemi Total

Primary Tracheoesophageal Puncture Yes No

Salivary Fistula Tube Yes No

Enteral feeding Yes No

Carbohydrate loading Yes No

Tracheostomy Yes No

Type of tube Make: Size:

Head and Neck Consultant Name

Clinical Nurse Specialist Name

Admission Date

Planned Discharge Date

Actual Discharge Date

Delayed discharge cause

� airway � wound � Medical � Equipment

� Other


2

Clinic: Pre-admission Assessment Information:

0 Surgical plan confirmed ____________________________________

0 Operation discussed

0 Enhanced recovery concept explained

0 Patient encouraged to increase activity levels

0 Patient information leaflet provided

Dietician:

0 Dietician review

0 Nutritional status assessed

0 Feeding plan confirmed with consultant (e.g. NG feed or if PEG to be placed)

0 Discuss nutritional supplements, if indicated

0 Preload feeding discussed

0 Post-op nutrition discussed

SALT: 0 SALT review

PHYSIOTHERAPIST: 0 Physiotherapy review

ANAESTHETIST: Contact Dr B Patel or scheduled anaesthetist via Hazel Still (Ext 4116)

0 Reviewed in MDT or 0 Anaesthetic pre-assessment clinic

CLINICAL NURSE SPECIALIST:

0 Reviewed by CNS

0 Patient assessed for risk of ETOH withdrawal - Detox regimen if appropriate

- Alert ENT team

0 If smoker consider smoking cessation & refer Smoking Cessation Team

0 Consider risk of delayed discharge At risk? YES 0 NO 0

If yes, refer to Discharge Co-ordinator (below). Date: _____________________

[email protected] and leave message on extension 4519 0


3

Pre-operative surgical checklist

0 Clerking

0 Imaging available (MRI / CT / PET)

0 Pre-op blood results available (FBC / U&E / Coag)

0 G&S: 2 samples required, one of which must be within 7 days.

(Cross match 2 units only if Hb <10 or antibodies or significant blood loss anticipated)

0 ECG

0 Drug chart – Cross off ACE Inhibitor (if applicable) night before surgery

0 Mark surgical site

0 Consent

0 TEDS

0 Ensure preload prescribed:

2 sachets in 800mls water at 21.00 - evening prior to surgery

1 sachet in 400mls water at 05.30 - morning of surgery

0 If diabetic, follow standard DM pre-op guidance as per trust protocol (red book)

0 Confirm ICU bed booked

Morning of surgery:

0 Patient to be ready for theatre 07.30 on morning of surgery

Deviation:


4

Anaesthesia

0 Lines: Arterial line, consider Femoral CVC if required

0 Standard anaesthetic technique with remifentanil infusion

0 LiDCO: Optimise cardiac output - goal directed fluid management, as per protocol for

duration of operation

0 Aim lactate <2mmol/l

0 Give first dose of antibiotics (augmentin or ciprofloxacin & metronidazole if pen. allergic)

0 Give first dose of Dexamethasone 8mg

0 Prescribe/sign for regular Paracetamol 1g iv/po 8 hrly

0 Write up prn Tramadol 50-100mg 6 hrly iv/po (if not given, document why)

0 Write up prn Cyclizine and Ondansetron

0 VTE prophylaxis (LMWH - commence evening of surgery if surgeon in agreement)

Deviation:


5


6

Post Operative – Recovery & ICU/Clandon admission Post-op Day Zero Date & Time: _____________

Notes: __________________________________________________________________________

________________________________________________________________________________

Airway

Patient will come to ICU with ETT/tracheostomy/laryngectomy tube - confirm and label spare

tracheostomy inner tube on admission

0 Chest XR – check NG position if present

0 Check tube secured, humidified oxygen and secretions suctioned

Circulation

0 Continue GDFT with LiDCO overnight if on ICU

0 Maintain:

MAP 70 - 80mmHg

lactate <2mmol/l

Hb >80g/l (>100g/l if CVS co-morbidity)

If MAP low, consider Outreach / ICU referral

Post-operative care

0 Nurse slightly head up at 45°

0 Laryngectomy – heated, humidified oxygen, site checked at least once/shift, suction

once/shift or as necessary, TOP observation

0 VTE prophylaxsis/anticoagulation as prescribed

0 Monitor drains, ensure vacuum present (revac as appropriate)

0 Ensure saliva fistula tube in situ (contact ENT on bleep 0500 if concerned)

0 Check topical lidocaine spray prescribed to aid tolerance of salivary fistula tube

0 Check antibiotics prescribed (total 7 day course)

Deviation:


7

ITU / ADU / Ward Post-op Day One Date & Time ______________ Nursing:

0 Transfer to Clandon Ward as able

0 Remove arterial and (femoral) central venous lines before ward transfer

0 Laryngectomy (care as per day zero)

0 Monitor drain & urine output

Doctors:

0 Consider change to laryngectomy tube after discussion with surgeon

0 Ensure antibiotics prescribed and given and consider steroids if appropriate

0 Analgesia as prescribed. Consider uptitrating if required

0 Ensure antiemetics and anti reflux medication prescribed

0 LMWH until discharge

0 Confirm presence and tolerance of salivary fistula tube

0 Monitor drain output and presence of vacuum

0 Discuss with surgeon re: water soluble contrast swallow assessment for day 7

Feeding:

0 Commence standard feeding regimen following surgical review: Increase rate (and

reduce IVI) as per protocol

0 Record blood sugars, bowel movement

Mobilisation/Physio:

0 Chest physio

0 Transfer out of bed/mobilise as able : morning 0 afternoon 0


SALT:

0 Review, airway assessment, laryngectomy tube removal plus stoma obs if appropriate 0 Education


8

ITU / ADU / Ward Post-op Day Two Date & Time: _____________ Nursing:

0 Transfer out of bed & encourage to sit out in chair

0 TWOC



Doctors:

0 Consider neck drain(s) removal if <30ml + surgeon approval

0 Ensure antibiotics prescribed and given


0 Ensure antiemetics anti reflux medication prescribed


Feeding:

0 Continue feeding regime via NG tube

0 Record BMs and bowel movement

Physio/Mobilisation:

0 Chest physio

0 Neck / Shoulder physio as appropriate (if drains out)

0 Mobilise as able with physio: Morning 0 Afternoon 0

0 Laryngectomy (care as per day 0)

SALT:

0 Education, support and manage stoma care

Social:

0 Review by discharge coordinator to identify problems and target discharge date 0 Family update as necessary


9

ITU / HDU / Ward Post-op Day Three Date & Time _____________ Nursing:




Doctors:

0 Consider neck drain removal if <30ml & still in situ





Feeding:

0 Aim to meet full nutritional requirements via NG

0 Record BMs and bowels


0 Chest physio


0 Mobilise independently

or as able with physio: Morning 0 Afternoon 0

0 Laryngectomy (care as per day 0)

SALT:


Social:

0 Ensure review by discharge coordinator to identify problems

0 Family update as necessary


10

ITU / HDU / Ward Post-op Day Four Date & Time _____________ Nursing:




Doctors:






Feeding:

0 Full nutritional requirements via NG



0 Chest physio


0 Mobilise independently

or as able with physio: Morning 0 Afternoon 0

0 Rehabilitation will be continued until the patient is mobilising independently.

SALT:


Social:

0 Review target discharge date



11

ITU / HDU / Ward Post-op Day Five Date & Time: _____________

Nursing:

0 Encourage independence



Doctors:

0 General reassurance

0 Consider removal of sutures if surgeon in agreement






Feeding:

0 NG feed



0 Chest physio continued until the patient is independent maintaining own chest

0 Rehabilitation to be continued until patient mobilising independently.

SALT:


Social:




12

ITU / HDU / Ward Post-op Day Six Date & Time: _____________

Nursing:




Doctors:

0 General reassurance





Feeding:

0 NG feed



0 Continue until independent

SALT:


Social:




13

ITU / HDU / Ward Post-op Day Seven Date & Time: _____________

Nursing:



Doctors:

0 Ensure water soluble contrast swallow assessment completed today

0 Stop antibiotics – completion of 7 days

0 Consider removal of clips (alternate)

0 Examine stoma

Feeding:

0 Eating and drinking if swallow test passed




SALT:

0 Education, support and manage stoma care 0 Eating and drinking if swallow test passed - monitor

Social:

0 Consider fitness for discharge

0 Home help/social service referrals as appropriate



14

ITU / HDU / Ward Post-op Day Eight Date & Time: _____________

Nursing:



Doctors:

0 Check oral intake

0 Consider removal of remaining clips

0 Examine stoma

Feeding:

0 Oral feed (NGT removal as able)




0 Shoulder and neck function assessed

SALT:

0 Education, support and manage stoma care 0 Monitor eating and drinking 0 Change TOP if indicated 0 Voice prosthesis management

Social:




15

ITU / HDU / Ward Post-op Day Nine Date & Time: _____________

Nursing:



Doctors:

0 Check oral intake

0 Examine stoma

Feeding:

0 Oral feed




SALT:

0 Education, support and manage stoma care 0 Airway and voice prosthesis management 0 Encourage independence and laryngectomy self care

Social:


0 Chase home help/social service referrals



16

ITU / HDU / Ward Post-op Day Ten Date & Time: _____________

Nursing:

0 Encourage independence 0 Laryngectomy (care as per day zero)

Doctors:

0 Discharge care information to patient

0 Confirm follow-up plans

0 Check stoma

Feeding:

0 Oral feed



SALT:


Social:

0 Discharge planning 0 Family update as necessary


17

ITU / HDU / Ward Post-op Day Eleven Date & Time: _____________

Nursing:


Doctors:



Feeding:

0 Oral feed



SALT:


Social:

0 Discharge planning 0 Family update as necessary


18

ITU / HDU / Ward Post-op Day Twelve Date & Time: _____________

Nursing:


Doctors:



Feeding:

0 Oral feed



SALT:



19

ITU / HDU / Ward Post-op Day Thirteen Date & Time: _____________

Nursing:


Doctors:



Feeding:

0 Oral feed



SALT:

0 Education, support and manage stoma care 0 Airway and voice prosthesis management 0 Encourage independence and laryngectomy self caring


20

ITU / HDU / Ward Post-op Day Fourteen Date & Time: _____________

DISCHARGE CHECKLIST

0 Ensure self caring in context of laryngectomy

0 Home suction and laryngectomy equipment in place

0 Discharge medication: Analgesia/regular medications

0 Follow up appointment and out patient plan

0 Ward and emergency contact details

H&N Laryngectomy ERAS pathway - Bedside Notes Version 2

Documents

Transcript of H&N Laryngectomy ERAS pathway - Bedside Notes Version 2