Enhanced recovery programme

Transcription

1 Enhanced recovery programme Liver surgery Information for patients Hepatobiliary

2 Please bring this booklet with you to your Pre-operative Assessment appointment and when you are admitted to hospital to the Theatre Admissions Unit (TAU) and to all future appointments. Introduction Our aim is for you and your family to understand as much as possible about your condition, your operation and the Enhanced Recovery Programme for liver surgery. This booklet will give you and your family an outline of what to expect in the days leading up to and following your operation, and some of the health professionals who will be part of your care. By knowing what to expect, we hope it will assist you in reducing any anxiety you and your family may have. However, it may not answer all your questions, so please ask your consultant, clinical nurse specialist, or any member of the nursing or medical team if you have any further questions. There is space at the back of the booklet for you to write down any questions and monitor your own progress each day, and we would encourage you to do this. page 2 of 44

3 Contents 1. What is enhanced recovery? 4 Who will provide my care? 6 What does the procedure involve? 7 What are the risks related to liver surgery? 8 2. Pre-operative assessment 9 Nutricia Pre-op drink 10 Special instructions relating to medication Preparing for your operation 12 The week before your operation 12 The day before your operation 12 On the day of surgery 13 What should I bring to hospital with me? Arrival at the Theatre Admission Unit (TAU) 16 Where is TAU? 16 At what time will I go to theatre? What should I expect 18 Day 0 to Day After discharge 31 Is there anything I should look out for when I go home?31 Who should I contact if I have any questions or 31 concerns? 7. Patient diary Frequently asked questions Increasing activity and exercising Other contacts you may find helpful 43 page 3 of 44

4 1. What is enhanced recovery? The aim of enhanced recovery is to improve your recovery from surgery and enable you to return to normal activities at an earlier stage than you would otherwise be able to. There is less chance of developing complications like blood clots in the legs and lungs or chest infections with enhanced recovery and it also means that you will be able to get home earlier. The enhanced recovery process needs to be planned out very carefully. The different stages of enhanced recovery will be discussed by the team looking after you before your admission to hospital. The key principles of enhanced recovery are: Improving your nutrition before surgery. To help to enhance your recovery, you will be given six nutrition drinks called Nutricia Pre-op. These drinks will be given to you at your Pre-operative Assessment appointment and should be taken before surgery. Nutricia Pre-op is a pleasant lemon flavoured drink that is specially formulated to help your body cope with the stress of surgery. This helps to make you feel more comfortable and less anxious before your operation. It can also make you feel a lot better after your surgery and help you recover more quickly. We aim to allow you to eat and drink within 1 to 2 days of your operation. We hope to get you out of bed and start walking as soon as possible. We aim for you to be able to return home on days 5-6 following your operation, as long as you are well enough to do so. page 4 of 44

5 Providing you don't need on-hand medical care we believe your recovery is improved when you are in the comfort of your own home. If however you develop any complications after your operation it may be necessary for you to stay in hospital a little longer. However, forward planning for an early discharge does need to be considered in advance of coming into hospital. Please read this booklet as it will tell you what to expect throughout the enhanced recovery process. page 5 of 44

6 Who will provide my care? You will be cared for by a number of professionals within the Hepato-Pancreatico-Biliary team. These professionals specialise in different areas of your care and are collectively named the multidisciplinary team (MDT). The team consists of professionals who are involved at different stages of your care. Should you wish to make contact with members of your care team please use the following numbers: Consultant Surgeon:... Secretary to Consultant Surgeon:... Clinical Nurse Specialist (Key Worker)... Hospital Ward:... Outpatients Department:... Other members of the multidisciplinary team: page 6 of 44

7 What does the procedure involve? A liver resection is an operation to remove part of your liver. The amount of liver removed determines how big your operation will be and will determine the risks associated with it. An open liver resection means that the operation is performed through an incision across the top of your abdomen. We choose this incision because it gives us the best access to your liver and allows us to perform the operation safely. Please note that the gallbladder is sometimes removed as part of the procedure (since it is attached to the liver). Left hepatic duct Inferior vena cava Right hepatic duct Cystic duct Portal vein Liver Spleen Gallbladder Pancreatic ducts emptying into duodenum Pancreas Pancreatic duct Common bile duct page 7 of 44

8 What are the risks related to liver surgery? Bleeding during and after surgery: The liver is very well supplied with blood and 1.5 litres of blood passes through it every minute. This makes operating on the liver hazardous. However, with newer techniques and equipment, this risk is kept low but you need to be aware of it. If it occurs a few days after surgery, we may need to return you to theatre and re-operate to stop the bleeding. Bile and fluid collection: Occasionally bile or fluid can collect around the operation site which might require drainage. Bile or fluid is drained off using a needle; this is usually done in the X-ray department. Wound infections: Occasionally wounds from surgery can become infected. We treat infection by opening up part of the wound. This involves removing the staples that were used to close the wound. The infection is then drained away through the opening. We will sometimes use antibiotic treatment as well. The vast majority of wound infections will settle down with this treatment and if necessary, the District Nurses will help with wound dressing once you go home. Chest infections: Some people may get a chest infection after surgery, which may delay your discharge. Usually this is because of smoking, or not being able to breathe deeply after the operation. Chest infections are treated with chest physiotherapy and antibiotics. Difficulty in sleeping, nightmares and hallucinations: These sometimes happen after the operation but they will subside over time. Consent As with any procedure we must ask for your consent beforehand. The risks and benefits of surgery will be discussed with you by your medical team, including any alternative options. If you feel you need more information or have any questions about the procedure before giving consent please don't hesitate to ask. page 8 of 44

9 2. Pre-operative assessment Date of Pre-Operative Assessment appointment: Time: Date of Admission: Proposed length of stay (days): At your Pre-operative Assessment appointment the nurses will assess your fitness for surgery. They will ask questions about your past medical history, home circumstances and complete any tests you may need to assess your fitness. You may also require additional tests to assess your fitness for liver surgery. These may include cardiopulmonary exercise test (CPX) or shuttle test at the Pulmonary Function Unit (next to the Chest Clinic). Your Consultant Surgeon or Specialist Nurse (Key Worker) will have already discussed this with you. If these tests are necessary, they will be booked by your Specialist Nurse (Key Worker). As your length of stay is planned to be 5-6 days, the Pre-operative Assessment Nurse will discuss discharge planning with you. They will ask you questions about your home situation. It is important for you to ask for any extra help that you feel you may need when you go home, so that plans can be put in place as soon as possible. If you already have carers, please inform your care provider that your estimated stay in hospital is 5-6 days. We hope that this will avoid any unnecessary delays in you going home. page 9 of 44

10 Nutricia Pre-op drink At your pre-operative assessment appointment you will be given six cartons of glucose drink that you will need to take before having your operation. 4 drinks to be taken in the evening before your operation. 2 cartons to be taken at least 2 hours before your operation. These drinks are very important as they will help you to recover from your operation. If you are unsure about anything, please ask the nurse at your appointment or telephone the Pre-operative Assessment Clinic on page 10 of 44

11 Specific instructions relating to medication You have been advised to stop taking the following medications Date Name of medicine Time of last dose All other medications should be taken as normal. Signed... Print name... Date... If you have any questions please contact the Pre-operative Assessment Clinic on If you develop a cough, cold, sore throat or another minor illness, please call us on for advice (at least 48 hours before your operation is due). page 11 of 44

12 3. Preparing for your operation Before you are admitted to hospital there are certain preparations you need to make. If you have any concerns regarding your admission that are not stated within this booklet or your admission letter, please contact the Waiting List Co-ordinator on the number on The week before your operation Please make any necessary transport arrangements. Your admission time is likely to be 7.00am on the day of the operation unless specified otherwise in your admission letter. If you have carers, please contact your care provider to ensure they are aware of your hospital admission and likely discharge date. If you develop a cough, cold, sore throat or another minor illness, please contact Pre-operative Assessment on for advice (at least 48 hours before your operation is due). Please also let us know if you cannot keep your appointment. The day before your operation Do not smoke for 24 hours or more before your operation. Try to drink four Nutricia Pre-op drinks on the evening before surgery. Please remember these drinks will help you to recover from your operation more quickly. Drink 1: Time taken... Drink 2: Time taken... Drink 3: Time taken... Drink 4: Time taken... Do not eat anything from midnight. page 12 of 44

13 On the day of surgery Please follow the instructions given by Pre-operative Assessment on which medication you can take. Carefully follow the fasting instructions contained in your admission letter. Remember, the following things are considered to be foods: Chewing gum, mints and sweets Please try to drink the 5th and 6th Nutricia Pre-op drinks before 6.30am. This is to help prevent post-operative complications related to dehydration. Drink 5: Time taken... Drink 6: Time taken... Have a bath or shower Take off all your jewellery except your wedding ring if you wear one Take off any nail varnish or false nails on your fingers and toes Bring make-up remover with you to use before your surgery Please note if you do not follow these instructions your operation may need to be cancelled. page 13 of 44

14 What should I bring to hospital with me? You will need to bring some things with you when you come to the Theatre Admissions Unit (TAU). Most importantly you should remember to bring any medicines that you are taking. This might include: Tablets Inhalers Eye drops Creams Medicines should be in their original packaging (if possible) and you should try to bring enough to last 28 days. Bringing your medicines to hospital with you can help to make sure you do not miss any doses and may speed up your discharge. Please bring the form you use to order medicines from your GP or if you have a green card please bring this. You should also bring: Essential toiletries Loose fitting nightwear (including slippers and dressing gown) Fresh cotton underwear to wear to theatre Glasses Any solutions and cases for contact lenses A denture pot for your dentures Mobility aids (frames, wheelchairs) Hearing aids page 14 of 44

15 Storage space is limited, so please only bring necessary items. You might want to bring something to do while you wait to go to theatre. For example: A book Magazine / newspaper Crossword Before you go to theatre we will give you a bag or box to store your personal belongings. We advise you not to bring: Valuables Mobile phones Credit cards or large amounts of money (small amounts only for the telephone) We are sorry but we cannot take responsibility for the safety of your property. You will be asked to sign a disclaimer as part of your admission. page 15 of 44

16 4. Arrival at the Theatre Admission Unit (TAU) Your admission letter from the Waiting List Co-ordinator will confirm the day and time of your admission to TAU for liver surgery. Please remember it is likely to be 7.00am, unless specified differently in your admission letter. Where is TAU? The Unit is on E Floor of the Huntsman Wing of the Northern General Hospital. You can come into the hospital grounds through either the Barnsley Road or Herries Road entrances (see site plan enclosed). Once you are in the hospital grounds: 1. Follow the red signs for the main Huntsman building. 2. Enter through the main entrance on C floor. 3. Go through the Reception area to the first set of lifts and go up to E floor. 4. The entrance to TAU is straight ahead of you. 5. Finally, go to TAU reception on your right hand side of the corridor and let us know you have arrived TAU has limited waiting facilities, so, once you have been shown to your bed / trolley, your relative / friend will be asked to leave. The staff will give your relative / friend a contact telephone number and advice on when to return. TAU is used for both male and female patients who are admitted to hospital for an operation. The staff are here to help you, so please do not hesitate to ask any member of staff for help, information or support. page 16 of 44

17 At what time will I go to theatre? This will depend on where you are on the operating list, usually 8.15am for morning operations, or 12.30pm for afternoon operations. It is your Consultant Surgeon who decides the order of the list. The nurse in TAU will be able to give you, your relative or friend more information about this when you arrive. Please note that if there is no High Dependency Unit (HDU) or Post-Operative Surgical Unit (POSU) bed, your operation will be cancelled on the day of admission, for your own safety. page 17 of 44

18 5. What should I expect? Day 0: Day of admission / surgery When you arrive the receptionist will check your personal details with you to make sure all the information is correct. If you have any queries, please let one of the nursing staff know, and they will arrange for you to talk these over in private. Once you have settled in, the nurses will check your blood pressure, attach a wrist label and ask you questions about your health which will include your medical history and home circumstances. You will have been asked some of these questions already, but it is necessary for these checks to be made. Today, you will also see the following people: The Anaesthetist who will be putting you to sleep; they may want to discuss your medical history and general health. Before your operation your nurse or anaesthetist will be able to tell you which form of pain relief is recommended for you. However, it is your decision on what forms of pain relief to be used. If you have any questions you should ask your anaesthetist or any member of the healthcare team. Your Consultant Surgeon will discuss the surgery again and you will need to complete your consent form if this has not already been done. You will have the opportunity to ask any questions you or your family may have. If you have not done so already, you will need to take off any jewellery, make up or nail varnish you are wearing, and remove your contact lenses. However, you do not need to remove any dentures, hearing aids or glasses until just before you are given the anaesthetic. page 18 of 44

19 The nurses will provide a theatre gown and measure your legs for surgical stockings (these help to prevent blood clots forming in your legs). Finally, if you have been prescribed a pre-medication (tablet, medicine, or injection) this will be given now. A pre-operative checklist will be talked through with you, and then you will walk to theatre (if it is safe to do so). On arrival at theatre In the Anaesthetic Room, before you are put to sleep, the anaesthetist will insert an epidural. This is a small tube inserted into the space around your spine. After surgery it will be used to deliver painkilling medication to numb the area around your wound. It is important that your pain is controlled after the operation so that you can walk about, breathe and cough effectively, eat and drink, feel relaxed and sleep. During your operation During the operation a catheter may be placed in your bladder so that we can check your kidneys are working properly. Fluid drips will also be placed in your neck and arm to give drugs and keep you hydrated during the operation. You will also have a line in your wrist to enable us to monitor your blood pressure. You will have a catheter in your bladder to drain your urine away. This is normal; please do not worry that something is wrong. When you wake there may also be a tube(s) coming from your abdomen, this is called a wound drain. This is to drain fluid from the site of surgery and will usually be removed 3 days after your operation. Removing this drain is not painful. page 19 of 44

20 What happens immediately after my operation? After your operation, you will be taken to the Theatre Recovery Ward, where they will monitor your condition closely. You will wake up with an oxygen mask over your face. The nursing staff will check your blood pressure, pulse, breathing rate, temperature, wound and wound drains frequently. Your pain will be monitored regularly, to ensure the epidural is set at the correct level. You will also be given regular intravenous analgesia if necessary. Transfer from the Operating Theatre following surgery When the Anaesthetist and Theatre recovery nurse are happy you have recovered from the anaesthetic, you will be transferred to either the High Dependency Unit (HDU) or the Post-Operative Surgical Unit (POSU). All patients are transferred to either ward for the first night following their operation. You will continue to be closely monitored by nurses who will check your observations which include: oxygen levels, blood pressure, temperature, heart rate, breathing rate, pain scores, sickness level, wound, leg mobility, skin condition and blood sugars particularly if you are diabetic. As part of the enhanced recovery programme you will: Be offered 1 Fortisip / Fortijuce twice a day, as soon as it is safe to do so. These are protein drinks to help with your recovery. Have epidural as pain relief. Have anti-emetics to stop you feeling sick, (or acupuncture, if staff are trained). Sit up in bed (cardiac chair position) or out of bed depending upon your return from theatre, and if it is safe for you to do so. You will return to the ward tomorrow, if the Consultant, Anaesthetist and Nurses feel it is safe for you to do so. page 20 of 44

21 Visiting Visiting times are 2.00pm to 3.30pm and 6.00pm to 8.00pm. We only allow two visitors per patient. We also ask that your visitors do not bring children under the age of 12 years. All our patients need as much rest as possible so they can recover quickly. Please speak to the Ward Manager if your family have any concerns about visiting. Please note: Your visitors are encouraged to use the hand gel provided to help with infection control. They should not visit if they are unwell. Contact details for visitors Please ask your family and friends to call after 10.00am if they are calling for an update on your condition. Please try to nominate one relative who can ring and ask about your condition then communicate this to the rest of your family/friends. This enables the nurses to spend more time on direct patient care. page 21 of 44

22 Day 1: First post-operative day You will be reviewed by the Consultant Surgeon, Anaesthetist and Nurses. If they feel it is safe for you to be transferred to the ward (Firth 9), this will be arranged. The team will continue to monitor you in a similar way as yesterday. Other members of the multidisciplinary team visiting today: Your surgical team of doctors will visit and review your progress so far. You may need to have some blood tests repeated, or if necessary other tests. The physiotherapist will visit to assess your chest and give you advice on chest exercises to prevent chest infections and assist with mobilising. The acute pain team to assess your pain relief via the epidural is adequate. They will ensure that you are getting adequate pain control in the most appropriate way. This will help to prepare you for taking walks around the ward, being able to breathe deeply and cough, and feel well enough to eat properly. The nurses will monitor your food intake when you start to eat and can refer you to the Dietitian if your appetite is poor. Choosing high protein meals and snacks, along with the Fortisip / Fortijuce will improve your nutrition and this can speed up your recovery and reduce the risk of serious complications. Please ask the ward staff to contact your Clinical Nurse Specialist if they have not already visited, and if you would like their support or advice. page 22 of 44

23 As part of the enhanced recovery programme today we expect you to: With the help of nursing staff sit out of bed, with rests in your bed in between as needed. By discharge this should be slowly increased to at least 8 hours. With encouragement from physiotherapists and nursing staff, you should aim to walk up to 4 times a day, increasing your distance slowly. The aim prior to discharge will be to walk 60m (to the lift area outside of the ward). Being out of bed in an upright position and taking regular walks will improve your breathing and there is less chance that you will get a chest infection or a clot in your leg. This will also encourage your bowel function to return to normal faster. If you are able to mobilise well, we will discontinue oxygen therapy. Drink clear fluids (if not started yesterday), we will discontinue IV fluids if you are tolerating oral fluids. Drink 1 Fortisip / Fortijuce twice a day. Begin to return to your normal activity and independence levels. page 23 of 44

24 Day 2: Second post-operative day Today ward staff and other members of the multidisciplinary team will: Continue to monitor you closely, and your doctor/team will see you again today. The nurses will continue with your observations, at least every four hours, and they will talk with you again about your discharge circumstances. The Acute Pain Team will talk with you about reducing the amount of pain relief you are getting from the epidural. You may have pain killers for pain relieving in the form of either oral analgesia or a fentanyl patch; the team will discuss this with you. If a pain relieving patch is chosen it will be applied at 10.00pm in order to assist pain management and in preparation for removal of your epidural the next day. As part of the enhanced recovery programme today we expect you to: With encouragement from physiotherapists and nursing staff, you should aim to walk up to 4 times a day, increasing your distance slowly. The aim prior to discharge will be to walk 60m (to the lift area outside of the ward). If appropriate, commence diet and continue with oral fluids. Aim to drink 1 Fortisip / Fortijuce twice a day. Continue with your return to your normal activity and independence levels. The nurses will speak with you about arrangements for discharge and refer you to the Occupational Therapist (discharge planning team) if required. You will have already indicated prior to surgery that you need help to care for yourself on discharge. page 24 of 44

25 Day 3: Third post-operative day Today ward staff and other members of the multidisciplinary team will: Continue monitoring your progress in a similar way to the last two days, your observations will continue at least every four hours. We will turn the epidural off. The doctors will check your blood tests today, in particular your blood clotting level. If your blood clotting is within normal range, we will remove the epidural. Your urinary catheter will be removed after the epidural. The nursing and medical staff will discuss your estimated day of discharge and start planning for your discharge. As part of the enhanced recovery programme today we expect you to: Continue with diet and oral fluids. Drink 1 Fortisip / Fortijuce twice a day. Either oral analgesia or fentanyl patch for pain relief. Continue with your return to your normal activity and independence levels. Please ask the ward staff to contact your Clinical Nurse Specialist if they have not already visited, and if you would like their support or advice. page 25 of 44

26 Day 4: Fourth post-operative day Today ward staff and other members of the multidisciplinary team will: Continue monitoring you in a similar way to the past three days. Your observations will be recorded at least three times a day. Your doctors will assess if any of your drains can come out if there is no bile in the drain. Discuss whether you have passed flatus (wind). You will be assessed to see whether you are fit for discharge. The nurses will again discuss discharge arrangements and transport home with you, and organise take home medicines in preparation for your discharge. As part of the enhanced recovery programme today we expect you to: Continue to walk up to 4 times a day, as directed by the physiotherapist; to the end of the ward corridor (40m walks). The aim will be to walk 60m (to the lift area outside of the ward) by discharge. Continue with diet and oral fluids. Drink 1 Fortisip / Fortijuce twice a day. Either oral analgesia or fentanyl patch for pain relief. page 26 of 44

27 Day 5: Fifth post-operative day Today ward staff and other members of the multidisciplinary team will: Plan for your discharge either today or tomorrow, providing you have had no post-operative problems, your pain is well controlled, and everything is in place for a safe discharge. You also need to feel confident and well enough to be discharged. Any remaining drains will be removed. However, occasionally people go home with a drain in, and have District Nurses visit. The Physiotherapist will do a stair assessment if you are being discharged today. Any other discharge arrangements will be confirmed with you. If you will be having additional care at home, the Occupational Therapist or discharge planning team will visit. You will be given advice on dressings and medication for taking home. Information will also be given about any district nurse visits or if you need to attend your GP surgery or community clinic for removal of drains, stitches or skin clips or for wound care. As part of the enhanced recovery programme today we expect you to: With encouragement from physiotherapists and nursing staff, continue to aim to walk up to 4 times a day, increasing your distance slowly. The aim prior to discharge will be to walk 60m (to the lift area outside of the ward). Continue with diet and oral fluids. Drink 1 Fortisip / Fortijuce twice a day. Painkillers - oral analgesia. If a fentanyl patch was used for pain relief it will be changed or removed today, as it expires after 3 days. You can continue to take oral painkillers as prescribed. Continue with your return to your normal activity and independence levels. page 27 of 44

28 Day 6: Discharge from hospital Today ward staff and other members of the multidisciplinary team will: Recheck your blood clotting level, to ensure it is safe for your discharge. Your ward nurse will let you know your proposed discharge date and the approximate time that everything will be ready for you. We will ask about your transport arrangements; ideally we'd like you to be able to go home before 12 noon. If there are any problems we can easily transfer you to the Discharge Lounge (see information below). The Physiotherapist will do a stair assessment if you are being discharged today. We will explain any equipment or services you may need at home, this will involve being visited by the district nurses or attending your GP surgery to see the GP or practice nurse. We will give you written information for yourself, your GP, the district nurse or practice nurse. We will also give you your medication and explain how to take it. (Please note it may take Pharmacy up to four hours to dispense your medication). Please ask the ward staff to contact your Clinical Nurse Specialist if they have not already visited and if you would like their support or advice. page 28 of 44

29 As part of the enhanced recovery programme today we expect you to: Continue to walk up to 4 times a day, to the lift area (60m) if you are to be discharged today. Continue with your return to your normal activity and independence levels. Continue with diet and oral fluids. Drink 1 Fortisip / Fortijuce twice a day. If a fentanyl patch was used for pain relief it will be removed today prior to your discharge. Otherwise, you can continue to take your oral painkillers as prescribed. On discharge you will be given: 1. A sharps bin and the 28 days of prophylactic Daltaparin you started from theatre. 2. The date you need to have a blood test with your GP to check your clotting; medical staff (Ward Doctors) will organise this with your GP. 3. Your medications to take home and GP letter days' worth of Fortisip or Fortijuce. 5. Your follow-up appointment (approximately 2/3 weeks) with the Consultant and Clinical Nurse Specialist. 6. A District Nurse letter. page 29 of 44

30 The Discharge Lounge This is an area where patients can wait until their transport is ready. The Discharge Lounge is situated on the Vickers Corridor, Floor D, near the main entrance to the Renal Unit. If you have concerns about going to the Discharge Lounge please speak to the nurse looking after you. The Discharge Lounge is open Monday to Friday 9.00am to 8.00pm and Saturday 9.00am to 5.00pm. You can contact the Discharge Lounge through the Hospital Switchboard on Transport home Where possible before your admission day, please try and arrange for someone to collect you after your operation on discharge day. Your ward nurse will let you know approximately what time you will be ready for discharge. If you have a friend or relative coming to collect you, ask them to bring a wheelchair to the ward. Wheelchairs are available in the main Huntsman or Chesterman entrances. Please Note: Ambulance transport will only be provided for patients with specific needs. page 30 of 44

31 6. After discharge Is there anything I should look out for when I go home? If your wound becomes increasingly sore or leaks, contact your District Nurse, Practice Nurse or GP in the first instance. If necessary they may advise you to contact your Clinical Nurse Specialist so an appointment can be arranged. If you are discharged with a drain in situ and are concerned about the amount of leakage, increase in pain, redness/inflammation around the drain site, please contact your Clinical Nurse Specialist, who may advise you to come to the clinic or contact your GP. For any other concerns please refer to the 'Frequently asked questions' section of this booklet or contact your Clinical Nurse Specialist. Who should I contact if I have any questions or concerns? If you have any concerns about your progress, need advice or are worried please contact: Clinical Nurse Specialist (Key Worker) (Heather Allen) (Jo Bickerstaff) (Maria Bellamy) Monday - Friday, 9.00am pm Firth Monday - Sunday, 5.00pm am Weekends / Bank Holidays page 31 of 44

32 Or in an emergency please contact either your GP or attend Accident and Emergency. In the unlikely event that you are re-admitted to hospital please tell the nurse in charge that you are an enhanced recovery patient and that they should inform Karen Smith (Ward Manager, Firth 9) of your re-admission. Your Consultant and Clinical Nurse Specialist (Key Worker) will then be informed of your admission. page 32 of 44

33 7. Patient diary Please use this space to record any concerns you have: Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 You may find it helpful to continue your diary at home to note any concerns or questions you may have for the specialist nurse, district nurse, or consultant clinic. page 33 of 44

34 Day 7 Day 8 Day 9 Day 10 Day 11 Day 12 Day 13 Day 14 page 34 of 44

35 Any concerns you wish to discuss in clinic page 35 of 44

36 8. Frequently asked questions It is important to remember recovery from this kind of surgery varies from individual to individual and overall takes around 3 months. Why do I feel so tired? You have undergone a major operation and your liver is re-growing, using up a lot of your energy. It is therefore normal to feel weak and washed out. You may find even the simplest task tiring. This fatigue usually lasts between 6 to12 weeks. A short nap may help but do not sleep for too long during the day as this may disturb your normal sleep pattern. Make sure you get a good balance between rest and exercise. Try to get up, get dressed and walk every day, gradually increasing your activity level. You should find that week-by-week you slowly regain your strength and feel yourself getting back to normal. It is common to have poor concentration and feel low and depressed after major surgery. This can last for a number of weeks and may affect your appetite and sleeping. When should I return to normal activities? You should aim to get back to the activities of daily life gently and gradually. In activities such as walking, light shopping, household chores you should find yourself becoming stronger and more active each week. Do I need painkillers? You may have some pain or discomfort for several weeks after your operation. This is quite normal. You will be prescribed painkillers to take home with you from the hospital according to your particular needs. You may be prescribed one or a combination of painkillers to take. Each painkiller will have a label clearly explaining how to take it. If you find that your painkillers are not working please see your GP for advice. As your pain gets less, you can start to reduce the amount of painkillers you page 36 of 44

37 are taking. This can take several weeks or months. If you require advice about reducing your painkillers please contact your Clinical Nurse Specialist (Key Worker) or your GP. Will I be able to eat and drink normally? It is normal to have a lack of appetite after your operation. You may find in the first few weeks of your recovery that eating small amounts of food regularly (4-6 times a day) is better for you than trying to eat three large meals a day. Whilst in hospital catering provides 3 meals a day, but if you aren't able to eat full portions you can request extra snacks such as cereal, toast or sandwiches in between meals. You can also request milk to drink, which is beneficial as it is high in protein. Aim to keep your weight stable after your operation, because this shows that you are getting enough nutrition to support your recovery. It is important that you eat a healthy balanced diet; there are no specific foods to avoid. Try to eat 3 meals a day, and if you can't manage your normal portion sizes, add in some extra snacks in between your meals. Have starchy carbohydrates at each meal, for example bread, cereals, rice, potatoes or pasta. Have high protein foods at least twice a day, such as meat, chicken, fish, eggs, cheese, beans or lentils. Have 3 servings of dairy products a day, such as a glass of milk, a pot of yoghurt, or a small piece of cheese. Aim for 5 portions of fruits and vegetables each day. If you have been told that you have a fatty liver, you still require a high protein diet. However, try to choose low fat options, such as lean meat or chicken without the skin, and low fat dairy products, and avoid high fat, processed or fried food. page 37 of 44

38 If you have been referred to a dietitian during your hospital stay please continue to follow their advice. If you were not referred to a dietitian during your stay, but have concerns about your diet or weight please discuss this with your Clinical Nurse Specialist, who will be able to advise you or arrange for you to see the dietitian when you come back to the Outpatient Clinic. It is advisable for the first three months after your operation to avoid or take only small quantities of alcohol. After this time, when the liver has re-grown, you may drink alcohol within the normal limits (2-3 units per day for women and 3-4 units per day for men). How should I care for my wound? The staples holding your wound edges together will be removed around days after your operation by the district nurse or practice nurse. The ward staff will arrange for a District Nurse to call at your home. You may have a bath or a shower as normal when you get home but avoid using any creams or powders directly on the wound until it has healed fully. You can expect some soreness around the wound for several weeks after your operation. You should keep taking your painkillers regularly to ease any discomfort. However, if your wound becomes increasingly sore or red or it begins to leak, contact your District Nurse, Practice Nurse or GP. It is normal to feel a ridge along your wound and this will go away over time. You may also notice numb or over sensitive areas along the wound and may experience tingling sensations and itching where small nerves in the skin have been cut at the time of the operation. These sensations will disappear over time but you may be left with a permanent area of numbness in the centre of your wound. The incision itself will fade and become less prominent over the next few months. page 38 of 44

39 When can I go on holiday following my discharge from hospital? The time at which patients are safe to travel varies according to each individual and it is therefore important you discuss it with your Consultant or Clinical Nurse Specialist (Key Worker). Travel insurance can be very expensive following medical treatment; please ask your Clinical Nurse Specialist for more information and an update on which companies are providing a reasonable price. Can I claim benefits? It is difficult to predict which patients will be eligible for benefits since they are mainly aimed at helping people with permanent disabilities. If you need advice on this matter please contact one of the following (see contact details at the back of this booklet): Clinical Nurse Specialist (Key Worker) Cancer Support Centre Macmillan Cancer Support page 39 of 44

40 9. Increasing activity and exercising Should I do any exercise? Exercising can be thought of as anything from a short walk to a round of golf or game of tennis. The type of activity/exercise you are able to do after your operation will depend on your general health and previous level of fitness. Gentle exercise/activity will benefit you in the following ways: Help to speed your recovery and get back to the activities you enjoyed before the operation. Improve your confidence and reduce stress. What exercise should I do? Walking is the best form of exercise. When you go home it is safe to walk outside, gradually increasing the distance and speed that you walk. On wet days, walking up and down the stairs is a good alternative. Continue with the breathing exercises (deep breathing, huffing and coughing) that your hospital physiotherapist taught you. Keep an upright posture, resisting the tendency to lean to the side of your operation. How hard should I work? Remember to listen to your body. Exercise as hard as you feel comfortable with each day. It is normal to become short of breath, to feel warm or for your heart to beat faster. This shows you are working. However, you should not be so short of breath that you cannot talk, feel sick or faint, or feel so tired that you have to sleep after exercising. page 40 of 44

41 How can I increase my exercise? It is important that you increase your fitness gradually, starting from the level you were at in hospital. You can build from there. Increase the time you exercise for.* Increase the distance you walk or number of repetitions of each exercise.* Increase the pace (speed) you work at.* Increase the number of exercise sessions you do each week.* *Only change one of these at a time Start slowly and finish slowly, allowing your body to warm up and cool down. Wear loose clothing and sensible footwear. Take notice of the weather. If it is very wet, cold or windy, you may have to lessen what you do or exercise indoors. Do not exercise if you feel unwell. Avoid swimming until your wound is fully healed. Avoid strenuous activities such as heavy lifting, straining or any activity that makes you breathless, such as digging in the garden or vacuuming. When can I drive again? Because the surgery has involved cutting into the large abdominal muscles you must not drive a car until you have had a chance to fully heal. This will not be until at least 6 weeks. Please do not drive until you are confident about controlling your vehicle in an emergency and always check with your insurance company first. Some companies may extend this period until either your consultant or GP have given you permission. page 41 of 44

42 When should I return to work? Recovery takes time. If you were working prior to your treatment you are going to be off sick for some time; at least 2-3 months. It could be up to 12 months or so before you are back to your best, although you will feel well long before this. It may help to discuss this with your Clinical Nurse Specialist, Consultant, GP and returning to work may depend upon the job you do. Please talk to your employer about their return to work and capability policies. page 42 of 44

43 10. Other contacts you may find helpful Cavendish Centre for Cancer Care Offer support, assessment and a range of complementary therapies for patients and their carers. All services are provided free of charge and referrals are taken directly from patients Cancer Support Centre Provide support and information on an informal basis Macmillan Cancer Support Cancer Research UK page 43 of 44

44 Produced with support from Sheffield Hospitals Charity Working hard to fund improvements that make life better for patients and their families Please donate to help us do more Registered Charity No Alternative formats can be available on request. Please Sheffield Teaching Hospitals NHS Foundation Trust 2017 Re-use of all or any part of this document is governed by copyright and the Re-use of Public Sector Information Regulations 2005 SI 2005 No Information on re-use can be obtained from the Information Governance Department, Sheffield Teaching Hospitals. PD6796-PIL2636 v3 Issue Date: January Review Date: January 2019