Enhanced recovery programme

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1 Enhanced recovery programme Colorectal surgery Information for patients Colorectal Surgery

2 Please bring this booklet with you to your Pre-operative Assessment appointment; when you are admitted to hospital to the Theatre Admissions Unit (TAU) and also to all future appointments. Introduction The Enhanced Recovery Programme is about improving patients' outcomes, and speeding up their recovery after surgery, by optimising their care throughout the surgical process. The programme also focuses on making sure that patients are active participants in their own recovery process. Our aim is for you and your family to understand as much as possible about your condition, your operation and the Enhanced Recovery Programme. This booklet will help to answer some of the questions that you may have about your treatment and the care that you will receive. However, it may not answer all of your questions. Please ask a member of the nursing or medical team who will be happy to answer any questions. There is a space in the back of this booklet to write any questions down. page 2 of 24

3 Contact details Theatre Admissions Unit Monday to Friday, 8.00am pm Pre-operative Assessment Clinic Monday to Friday, 8.00am pm When contacting us, you may be asked for the following information. Name Unit number Consultant Pre-operative assessment date and time We would like your time with us to be pleasant and we hope that you have a speedy recovery. If we can help, please let us know. page 3 of 24

4 Contents Enhanced recovery programme 5 Instructions regarding stopping medication 6 Before your operation 7 Preparations for coming into hospital 8 What should I bring with me? 8 Should I have surgery? 10 What are the benefits and risks involved? 10 How long will I stay in hospital? 11 Infection control 11 Where is Theatre Admissions Unit (TAU)? 13 What happens when I arrive? 14 Visiting times 15 What happens after my operation? 15 Advice about going home 20 What should I do if I think something is wrong? 23 page 4 of 24

5 The aim of this booklet is to try to help you understand the 'Enhanced Recovery Programme', and how you will play an important role in your recovery. This booklet explains what will happen from before your operation until you are ready to go home. This is usually 3 to 5 days after your operation. Date of pre-assessment appointment: / / Time: Date of Admission: / / Proposed length of stay: days. 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. Drink 1 Drink 2 Drink 3 Drink 4 Drink 5 Drink 6 Date Time 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 us on page 5 of 24

6 Specific instructions Medications 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 Central Pre-operative Assessment Clinic on If you develop a cough, cold, sore throat or another minor illness, please telephone for advice. (At least 48 hours before your operation is due). page 6 of 24

7 Before your operation What should I do before coming into the Theatre Admissions Unit (TAU)? Before you come into TAU there are certain preparations you need to make. Do not smoke for 24 hours or more before your operation. On the morning of your operation you will need to: Have a bath or shower Take off all your jewellery except your wedding ring if you have 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 ring us the day before your admission if you: Need advice Will be late Cannot keep your appointment Are unwell direct line until 5.00pm, Monday - Friday outside these hours page 7 of 24

8 Preparing to come into hospital Please refer to your admission letter, as your instructions for fasting will be clearly stated here. The following things are considered to be foods: Chewing gum Mints Sweets Please remember to have a glass of water, as advised in your letter, to help prevent post-operative complications related to dehydration. If you do not follow these instructions your operation may need to be cancelled. What should I bring with me? You will need to bring some things with you when you come to TAU. Most importantly you should remember to bring any medicines that you are taking. This might include: Tablets Medicines Inhalers Eye drops Creams All in their original packaging (if possible). Also, you should bring: Essential toiletries Nightwear (including slippers and dressing gown) Fresh cotton underwear to wear to theatre page 8 of 24

9 Any solutions and cases for contact lenses A denture pot for your dentures Glasses Mobility aids (frames, wheelchairs) Hearing aids Storage space is limited, so please only bring necessary things with you. You might also want to bring something to do while you wait to go to theatre. For example: A book Crosswords Knitting Before you go to theatre we will give you a bag or box to store your personal belongings. We advise you do not bring: Valuables Mobile phones Credit cards or large amounts of money (only loose change for the phone) 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 9 of 24

10 Should I have surgery? If you are unsure about the operation, or if you wish to discuss possible alternatives, you should ask your surgeon when he / she goes through the consent form with you. Although your doctor may have suggested that you have an operation, the final decision is yours. This must be made after you have thought about the benefits of the operation, the risks and any alternatives. You may wish to discuss the operation with your GP, family or carer before coming to a decision. All your questions should have been answered before you decide to have the operation. If you change your mind after you have been given a date for the operation, please contact the pre-operative assessment department on (We ask that you try and contact us at least 24 hours before you are due to come into hospital). What are the alternatives? All alternatives available should have been discussed in clinic with your consultant. What are the benefits? The benefits include: An improvement in symptoms A reduced risk of deterioration What are the risks involved? You will be asked to sign a consent form, which will explain all of the risks involved with your operation. page 10 of 24

11 The chance of problems occurring depends upon the operation and your general health. The surgeon will explain how these may affect you before your operation. If you require further information please ask. How long will I stay in hospital after my operation? Your pre-operative assessment nurse will discuss this with you at your appointment. At the Pre-operative Assessment Clinic the nurse will assess your state of health and will organise all the necessary tests. This may include blood tests, urine tests, an ECG (heart tracings) and x-rays. Our aim is to start discharge planning at this appointment. We 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 set in place as soon as possible. This will help to avoid any unnecessary delays in you going home. Your provisional length of stay is (Please note that this may change and depends on how you recover after your operation). Infection control At your pre-operative assessment appointment, the nurse will take swabs from your nose and groin. This is to check if you have any signs of Methicillin Resistant Staphylococcus Aureus (MRSA). If your swabs are found to be positive, you will still be able to have your operation. You will be given some treatments to use before your operation is due. On admission, you will be in a side room and will be 'barrier nursed.' This is to help prevent the spread of MRSA to other patients. The nursing staff will repeat the swabs to check if the treatment has been successful. page 11 of 24

12 Please remember to use the hand cleaning facilities available at the entrance to the ward and by the bedside. Please encourage your visitors to do so as well. Further information booklets are available if you would like them. page 12 of 24

13 Welcome to the Theatre Admissions Unit (TAU) TAU is used for both male and female patients who are admitted to hospital for an operation. The staff are here to help you. Please do not hesitate to ask any member of staff for help, information or support. On the day of your operation You will be admitted to the TAU on the day of your operation. After your operation, you will be transferred to one of the surgical wards as soon as a bed is available for you. On the day of your operation you will need to arrive on TAU at 7.00am, unless you have been told differently in your letter. There is limited pay and display parking at the Northern General Hospital. If you are coming into hospital by car, please allow yourself time to find a parking space. The reception desk is open from 7.00am. 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 entrance (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. page 13 of 24

14 5. Finally, go to TAU reception on the right hand side of the corridor and let us know that 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. What time will I go to theatre? This will depend on where you are on the operating list. It is the surgeon who decides the order of the operating list. The nurse will be able to give you, your relative or friend, more information about this when you arrive. What happens when I arrive at the unit? Once you have told us that you have arrived, the receptionist will check your personal details with you to make sure that all our 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, we will check your blood pressure, attach a wrist label and ask you questions about your health. We may have already asked you some of these questions, but it is necessary for these checks to be made. You will meet your anaesthetist and surgeon and have the chance to ask them any questions you have about your operation. The anaesthetist will talk to you about your general health and the surgeon may want to examine you. You may also be seen by the colorectal nurse specialist. page 14 of 24

15 If you haven't already done so, you will need to take off any jewellery, make up or nail varnish you are wearing. However, you do not have to remove any dentures, hearing aids or glasses until just before you are given the anaesthetic. Contact lenses must be removed if you are having a general anaesthetic. Finally, if we have prescribed you a pre-medication (tablet, medicine or injection) this will be given now. We will return any aids to you once you are awake on the recovery ward. Are people allowed to visit me? Yes, your relatives and friends can visit you. Visiting times are from 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 to TAU or to the ward. All our patients need as much rest as possible so that they can recover quickly. If your relatives or friends find it hard to visit at these times they should speak to the nurse in charge. Please note: Your visitors should not visit if they are unwell. What happens immediately after my operation? After your operation, we will take you to the recovery room where we will monitor your condition closely. If you have had a general anaesthetic, you may find that when you wake up you have an oxygen mask over your face. We will check your blood pressure, pulse, breathing rate and temperature frequently. You will have a catheter in place, which will be removed within 48 hours, and you will have a drip in your arm until you are able to drink without feeling sick. This is normal so please do not worry that something is wrong. We will also keep a check on your wound. page 15 of 24

16 You may be transferred to the Post Operative Surgical Unit (POSU) after your operation. This will have been explained to you at the Pre-operative Assessment Clinic. It depends on the type of operation and any medical problems that you may have. Otherwise, you will be taken back to one of the surgical wards, where the nursing staff will continue to monitor your condition. Will I be sore after my operation? You may have some discomfort, but if you are in pain or have any soreness, we will give you tablets or an injection to help this. If you have had a general anaesthetic you may feel sick but we can give you an injection called an 'anti-emetic' to ease this. Good pain control helps your recovery as you can walk about, breathe deeply, eat and drink, feel relaxed and sleep well. You may have a tiny tube in your back called an 'epidural' or you may have a pump containing morphine called a patient-controlled analgesia 'PCA' pump which will give you a constant supply of pain relieving medication. In addition, you may be given other pain killing tablets, which can help in different ways. When can I eat and drink? You will be given water to drink as soon as you feel able. You will be able to eat if you are managing to drink without feeling sick. You will also be expected to drink 2 high protein drinks / high energy drinks. page 16 of 24

17 Your recovery After your operation - day 0 You will be encouraged to do deep breathing exercises when you wake up as these help your lungs to work as normal. You should try to do this at least 5 times per hour. Coughing is also extremely important and should be done after the breathing exercises. In order to do this, you should sit upright, support your wound with a cough pillow or a towel, lean forwards slightly or bend your knees up, then cough strongly from your tummy, not your throat. The nursing staff will show you how to do this. You will be expected to sit upright in bed after your operation. The nursing staff will help you to do this. After your operation - day 1 The nursing staff will keep checking your blood pressure, pulse and weight and will observe your wound site(s) closely. The nursing staff will help you to sit out of bed, which should be for at least 8 hours, with rests on the bed in between as needed. You should try to walk along the corridor and back 4 times during the day. The physiotherapist or nursing staff will help you. Being out of bed in an upright position and taking regular walks will help to improve your breathing. It will also reduce the 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 more quickly. If you are drinking well, your drip will be taken down. We will expect you to drink 3 high protein / high energy drinks each day. These drinks will help your wound(s) to heal, reduce the risk of infection and will help your overall recovery. page 17 of 24

18 If you are able to walk around the ward, your catheter may be removed. If your operation involved having a 'stoma', a colorectal nurse specialist will visit you on the ward and will teach you how to care for your 'stoma'. (There are information books available about having a stoma and these will be given to you). After you have washed / bathed, you will be encouraged to wear your own clothes as this will help you to feel positive about your recovery. After your operation - day 2 You should try to walk along the corridor and back 4 times during the day. The physiotherapist or nursing staff will help you if needed. Being out of bed in an upright position and taking regular walks will help to improve your breathing. It will also reduce the 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 more quickly. You will be encouraged to eat and drink. You should aim to drink ten to fifteen drinks, this will include the high protein / high energy drinks. Your epidural or PCA will be removed and you will be given regular pain relieving tablets. The colorectal nurse specialist will visit you on the ward and will encourage you to assist in caring for your stoma (if applicable). The nursing staff will keep monitoring your blood pressure, pulse and weight and will observe your wound site(s) closely. page 18 of 24

19 After your operation - day 3 If you are eating and drinking well and you are able to walk around the ward without any problems, we will start preparing you to go home. The colorectal nurse specialist will visit you on the ward and will check that you are able to empty and change your stoma appliance independently (if applicable). After your operation - day 4 As long as you are feeling well enough and the medical staff are happy with your progress, you will be discharged home. The nursing staff will discuss your needs with your relative / carer / friend and make the appropriate arrangements for you. page 19 of 24

20 Going home after your operation Advice following your surgery Blood clot prevention - some patients having surgery are discharged from hospital and require injections for a specified period of time to reduce the risk of blood clots. The medical and nursing team looking after you will discuss this with you in more detail if necessary. Diet - we advise you to eat a healthy diet. You may find it easier to have lots of small meals throughout the day rather than having three large meals a day. Exercise - for the first few weeks it is wise for you to avoid excessive lifting or exercise such as carrying heavy shopping, vacuuming etc. You should aim to increase your activity level gradually after you go home, eg start with a short walk, for about 10 minutes, 2 or 3 times a day and then try to increase the distance as you feel able. It is important to continue to wear your support stockings for six weeks after discharge or until you are back to your usual level of mobility. These stockings and exercise are important in the prevention of deep vein thrombosis (DVT). Wound care - if your wound is clean and dry it can be left without a dressing. You can have a shallow bath or take a short shower. Try to avoid rubbing the wound; it is best to pat your wound dry. We advise that you do not use any strong soaps or creams around the wound area, at least until the wound has fully healed. If you require dressings, the ward nurses will arrange for the district nurse to visit you at home and you will be sent home with a supply of dressings. Do not go swimming until the wound is fully healed. page 20 of 24

21 The ward nurses will explain the type of stitches that you have and whether they will dissolve or will need removing by the district nurse or practice nurse. A stoma nurse may visit you at home to check on your progress. You will be given a contact number and you can telephone for advice or reassurance if you have any problems or worries. If you notice an increase in pain, redness or swelling around your wound you should contact your GP or district nurse. Rest and sleep - you may be surprised at how tired you feel when you first go home. Don't worry - this is normal and your strength and stamina will gradually come back. Try to plan a rest time each day, preferably on your bed. You may find sleeping difficult at first as your normal routine may have been disturbed. Try to avoid caffeine or heavy meals in the early evening. After a few weeks, you will find yourself gradually getting back to normal. If you find that pain is stopping you from sleeping, you could take a mild painkiller before you go to bed. Going to the toilet - after your operation you may find that your bowel habit has changed. This is common, as you have had part of you bowel removed. It can take up to several months to settle down into a usual pattern. How long will I be off work? This will depend on the type of work that you do. We normally advise people to take 2-3 months off work. People with jobs that involve a lot page 21 of 24

22 of heavy manual work may need to take more time than those with less active jobs. The staff on the ward can advise you on this. If you require a sick note please ask the nurse before going home. If you feel you need further time to recover, your GP will arrange further time off. Remember, it is common to feel tired and weak following an operation. Your body will take time to recover from having a major operation. When can I drive after my operation? You should not start to drive again until your strength and speed of movement are up to coping with an emergency stop. This can take over 4 weeks. We advise you to check with your doctor and your insurance company before starting to drive. You should also make sure that you do not feel drowsy from any tablets that you may be taking, particularly strong painkillers, before driving. What will I need when I go home? Any medication or medical supplies you may need come from the hospital pharmacy department. Sometimes there can be a delay, so please be patient with us. We will do all we can to prevent unnecessary delays. We will also: Give you a letter to give to your GP Make any follow-up appointments Give you a sick note, if required If you have a stoma you will be provided with supplies to take home Make a referral to a district nurse / practice nurse for stoma support or wound care, if required Give you the ward contact number for any concerns page 22 of 24

23 Once you are at home, you will be contacted by a nurse from the ward to check on your condition and progress. If you are staying with family/friends, it is important to let the ward staff know. Follow-up appointment You may need to come back to hospital for an outpatient appointment, although this is not always necessary. Your consultant will decide if a follow-up appointment is required and you will be told about this before you go home. This will allow us to check that you are progressing well, to help you if you need it and to discuss if you require further treatment. Your appointment may be given to you or may be posted to you at home. Please arrange for someone to bring you to this appointment. Is there anything to look out for when I go home? If you notice an increase in pain, redness or swelling around your wound, you should contact your GP or district nurse. You will have been given the leaflet 'Going home after bowel surgery' (PD5275 / PIL1730) which will give you more information about caring for yourself at home. What should I do if I have any concerns? If you have a problem or need advice after going home please contact the ward. The staff will try to answer your questions / concerns. If you consider it to be an emergency, please contact your GP or attend the nearest Accident and Emergency Department as soon as possible. Should you have any concerns regarding your care whilst you are in hospital, please speak to one of the nurses who will try to help. page 23 of 24

24 This space is for you to write down any questions you may have Produced with support from Sheffield Hospitals Charity Working together we can help local patients feel even better To donate visit Registered Charity No Alternative formats can be available on request. Please Sheffield Teaching Hospitals NHS Foundation Trust 2018 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. PD5770-PIL2096 v9 Issue Date: March Review Date: March 2020

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