Enhanced Recovery Programme Page 14 Contact details South Tyneside NHS Foundation Trust Harton Lane South Shields Tyne and Wear NE34 0PL For advice please contact ward 1 on 4041001 Or ward 3 on 0191 4041003. Ask to speak to the nurse in charge Enhanced Recovery Programme Planned date of admission Planned date of surgery Estimated day of discharge Direct line ward 1 0191 4041001 Direct line ward 3 0191 4041003 Visiting times 2pm 4pm, 7pm 8pm
Page 2 Telephone 0191 4041000 Page 13 Telephone 0191 4041000 What is Enhanced Recovery At South Tyneside NHS Foundation Trust we believe in ensuring you play an active part in both preparing for and recovering from surgery. The Enhanced Recovery Programme differs from traditional methods of surgery and can improve your recovery considerably. This booklet describes the steps in the journey of ERP, for this process to work you must be fully committed to the programme. What will happen at my pre operative assessment appointment You will be seen by a specialist nurse who will ensure that you are fit for an anaesthetic and an operation. A relative/carer may accompany you to the appointment if you wish. The nurse will ask questions about your past and present health, examine your heart and lungs and record your blood pressure, temperature, height and weight. You will have blood tests and a tracing of your heart ( ECG ) performed, nasal and underarm swabs to check for any infection, and then the nurse will see if any other tests are required. If you need to be seen by another healthcare professional she will arrange this for you. The nurse will discuss the preparation for your hospital admission and operation, give information about any medications that you are taking, answer any questions and may give additional information leaflets. Items to bring in to hospital on admission Night dress / pyjamas Book / magazine Toiletries Slippers Towel Medication Clothes Transport home You must inform staff if you require transport home, on the day of discharge staff will aim to discharge you as early in the day as possible. You will be referred to the district nursing service for on going monitoring of your wound, and stoma support if applicable. You will be followed up in the out patient department on... Staff will contact you the day after discharge to check how you are recovering, if you have any problems following discharge please contact staff on the ward. Discharge advice Abdominal pain it is not unusual to experience abdominal pain during the first week after surgery. Pain may last a few minutes and should go away. Severe pain that lasts for several hours may indicate some thing more serious and should be checked, please contact the ward for advice. Wound it is not unusual for a wound to be slightly red and uncomfortable the first few weeks after surgery. The district nurse will be able to advise you if you have any concerns. If the district nurse is not available then please contact the ward for advice. Your bowels your bowel habit is likely to change after removal of part of the bowel, initially you may experience constipation and or loose stools. Eat regular meals, drink plenty of fluids and exercise regularly. Exercise walking is encouraged and you should plan to take regular exercise several times a day for short periods, this should be gradually increased. Work you should be able to return to work within 4 weeks of your surgery if your job is not a heavy manual job, you may be required to take 6 weeks off if your job is of a heavy manual nature. Driving you should not drive until you feel comfortable to do so, you must be able to perform an emergency stop. Hobbies you may need to build up gradually, no heavy lifting.
Enhanced Recovery Programme Page 12 Day 2 Mobilisation you will continue to be seen by the physiotherapist, you will continue to sit out of bed for periods of time and mobilise up and down the ward with assistance of staff. Eating and drinking continue to eat and drink as you can tolerate, you must continue to drink the nutritional supplement, 3 per day. Pain Pain relief will continue via the chosen route, any extra pain relief will be administered as prescribed. The pain nurse specialist will assist in managing your pain if you feel this is not well controlled. Monitoring your blood pressure, pulse, oxygen saturations and temperature will be checked. Washing and dressing staff will assist you where necessary, you should dress in your own clothes if you feel up to it, staff will start to encourage your independence in this area. Stoma education this will continue daily for all patients for which it is necessary, the ward staff will fully support you in managing your stoma. The stoma nurse will give extra support Laxatives you will continue to take lactulose following surgery. Day 3 onwards Your Epidural or PCA will be taken down today, your pain will be monitored and managed with medication via mouth. Please let nursing staff know if this is not adequate so that they can address this as quickly as possible. You will continue to recover from your surgery, staff will discuss your discharge with you and your family, it is important to start planning going home. If you have been referred to social services staff will contact them and inform them that you are ready for discharge planning to commence. Information regarding nutritional drinks The pre assessment nurse will provide you with important nutritional drinks. You will receive 4 fortisip/fortijuice drinks and 6 carbohydrate drinks. 2 Days before operation drink 3 fortisip/fortijuce Day before operation drink 1 fortisip/fortijuice Night before operation drink 4 cartons of carbohydrate drink Day of operation drink remaining 2 carbohydrate drinks ( a time will be specified ) Following your operation you will continue to drink 3 nutritional drinks per day. Discharge after surgery It is very important that you consider how you will manage at home following your surgery. In order to ensure that you get the best support possible staff need to be informed as quickly as possible this will enable us to prevent any delays in getting you home. If you feel that you may require some assistance from adult services following discharge from hospital please inform the pre assessment nurse who will make a referral for you. This will enable social services to contact you prior to surgery and arrange with you and your family the appropriate package of care which will continue until you have recovered. Please consider how you will get home from hospital on the day of discharge, we would encourage where ever possible that you have your own transport arrangements, however if this is not possible this can be arranged for you.
What will happen when I see the colorectal nurse specialist The colorectal nurse will be a key worker in your treatment and care before, during and after your surgery. She will be able to answer any questions you may have relating to your surgery. If your surgery will result in you having a stoma formed the stoma nurse will show you a selection of pouches before surgery and will discuss what living with a stoma entails. She will be able to provide you with as much information as you feel you require regarding this. Prior to having surgery the stoma nurse will visit you on the ward and draw a circle on your abdomen at the desired site where the stoma will be, you should understand that occasionally this may change as a result of what the surgeon may have to do during your operation. Post operatively the stoma nurse will support you on the ward with on going education alongside the nursing staff. When you are discharged she will follow you up for as long as you feel is necessary. Will I need to take any bowel preparation before my surgery For some types of surgery bowel preparation is required, the consultant and/or the colorectal nurse will discuss whether this is necessary for your planned surgery. If you are required to take this medication you will be informed that this will cause you to have loose stools. You should ensure that you drink plenty of fluids to prevent dehydration. Page 11 Telephone 0191 4041000 occurring. You will be encouraged to walk to the fridge with staff to select your high energy drinks. Pain Pain relief will continue via the chosen route, any extra pain relief will be administered as prescribed. The pain nurse specialist will assist in managing your pain if you feel this is not well controlled. Feeling sick please inform the nursing staff so that medication can be administered. Tubes and drips the drip will be taken down as soon as you are able to tolerate an acceptable amount of oral fluids. the catheter will be removed when you are mobile and those patients with an epidural the catheter will be removed when the epidural comes down. Monitoring staff will continue to check your blood pressure, pulse, temperature, oxygen saturations and fluid balance during your stay in hospital. Washing and dressing staff will assist you in attending to your personal and oral hygiene needs, if you feel well enough you will be encouraged to dress in your own clothes as this will assist you to feel positive about your recovery. Stoma education this will continue daily for all patients for which it is necessary, the ward staff will fully support you in managing your stoma. The stoma nurse will give extra support. Laxatives you will be prescribed a laxative called lactulose to help your bowels move following surgery.
Preventing deep vein thrombosis you will have elasticated stockings in place unless contraindicated, you will also receive a daily injection into the fatty tissue of the abdomen which helps prevent blood clots forming. You should continue to wear your stockings up to 6 weeks after discharge as a preventative measure, enoxoparin injections will continue for 28 days post operatively. Monitoring following surgery staff will check your blood pressure, temperature, pulse, oxygen saturations, pain control, urine out put and fluid intake very regularly as part of monitoring your recovery. Wound care staff will monitor the dressing placed over your wound, this will be changed as appropriate. Your wound may be closed with dissolvable sutures or metal clips. Metal clips will be removed at approximately 8 10 days post operatively by the district nurse. Stoma education if you have a stoma the nursing staff will check this regularly to ensure that is healthy. The colorectal nurse will have already commenced your education with you prior to admission, she will continue this during your stay in hospital, the ward staff will also support you in stoma education. The day after your operation Day 1 Mobilisation it is advised that you sit in the chair, at intervals, for up to 6 hours. The physiotherapist will continue to work with you advising deep breathing and encouraging early mobility. You should aim to walk along the corridor and back 4 times during day 1. Being out of bed and in a more upright position and mobilising improves your breathing and helps prevent chest infections and blood clots. Eating and drinking it is important that you eat and drink following your operation. You should aim to drink approximately 1 glass per hour, high protein, high energy drinks are encouraged as these will help the body to repair and reduce the risk of infections Pain management after surgery There are 2 types of pain management currently used within the Trust following surgery within the Enhanced Recovery Programme, Epidural and Patient Controlled Analgesia. What is an Epidural The nerves from your spine run to your lower body and pass through an area in your back close to your spine, called the epidural space. The anaesthetist will inject a local anaesthetic into the epidural space, using a fine plastic tube called an epidural catheter, which will block the nerve messages. This causes numbness which can vary in extent according to the amount of anaesthetic administered. An epidural pump will be set up which will enable a continuous flow of anaesthetic to be administered. The pump has a facility to allow the patient to administer a top up of pain relief if necessary via a handset. Along with an epidural other pain relieving drugs can be administered, all amounts of drugs given are carefully monitored and controlled. When the epidural is stopped the feeling will return to your lower limbs. What is Patient Controlled Analgesia ( PCA) The medication used in a PCA is usually morphine, this is administered through a dedicated pump and is controlled by the patient. This allows you to be in control of the level of medication you administer in accordance with the level of pain you are experiencing. The pump has a 5 minute lock out system which ensures that you can administer to much medication. Other forms of pain relief are also administered along with the PCA.
Side effects of Epidural/PCA Sometimes you may feel sick, sleepy or may develop an itch, please inform the nursing staff who will be able to treat any of these side effects. Discontinuing the Epidural/PCA At around day 3 following your operation this form of analgesia will be discontinued. You will receive strong pain relief by mouth. You must inform the nursing staff if you feel your pain is not managed to a satisfactory level as this will have an impact on your ability to carry on with regular physiotherapy. The pain nurse specialist will review your pain management along with medical and ward nursing staff on a regular basis. Physiotherapy after surgery Following your operation the physiotherapist will teach you how to do some breathing exercises it is important that you start to do the breathing exercises as soon as you wake up. The simplest way to do this is to slowly breath in through your nose and out through your mouth, making sure you take as deep a breath as you can. Repeat this 3 times, and try to do the whole cycle at least twice every hour The physiotherapist will also teach you circulatory exercises. It is important to do these every hour whether you are sitting in a chair or are in bed You will be encouraged to build up your walking distance each day, back to your usual ability before surgery. It is very important that you mobilise with both the physiotherapist and the nursing staff regularly By doing these exercises research has shown that you are less likely to develop any problems after surgery. They can reduce the chance of any chest or circulatory problems and help your bowel function return to normal more quickly and so help you get home sooner. Day 0 Back on the ward Breathing exercises on return form theatre it is important that you perform deep breathing exercises. Breathe in through the nose and out through the mouth at least 5 times per hour ( family can remind you of this on visiting ) Getting out of bed for patients who have been to theatre in the morning, staff will assist you to get out of bed on the afternoon of surgery. You should try to sit up for 2 hours maximum. Eating and drinking if you do not feel nauseas you will be able to drink following surgery. You will be expected to continue taking nutritional supplements to enhance your recovery. Pain good pain control improves your recovery and will enable you to walk around, breathe deeply, eat, drink and feel relaxed post operatively. You may have a tiny tube in your back ( e pidural ) which provides a continuous supply of pain relieving medication. You will also be given other pain killers by mouth, which will help in different ways. Alternatively you may have patient controlled analgesia ( PCA ) which allows you to administer your own pain relief by pressing a button. There is a security device on the PCA which will ensure that you can not administer more medication than is prescribed. The anaesthetist will discuss pain relief options with you prior to surgery. Feeling sick after your operation you may feel sick or you may vomit. This is generally caused by the anaesthetic gases or drugs used during surgery. You may be given medication during your operation to reduce this, if you feel sick inform the nursing staff who will be able to administer further medication. Tubes and drips whilst in theatre a tube ( catheter ) will be inserted into your bladder so that your urine output can be monitored. You will have a drip in your arm and fluid will be administered to ensure you do not become dehydrated. You may also have an oxygen mask in place to help with your breathing. All of these devices will be removed as quickly as possible on review by the medical team and dependent on your recovery.
your legs. To prevent a DVT ( Deep Vein Thrombosis ), compression gators will be applied to your calves to aid the circulation in your legs. Strict monitoring of IV fluids is necessary so that you are not given too much or too little, and a urinary catheter will be present to monitor your urine output This will probably be reviewed on day one post-operatively. Once you are comfortable and your BP and resps are stable, you will be transferred to the ward for your ongoing care. Admission to hospital Day 0 You should attend ward. at for admission to hospital. On arrival to the ward you may be asked to wait in the day room until your bed is available. Some patients will require an enema pre operatively, the nurse will discuss this with you if necessary. Your details will be checked against the information collected at pre assessment, please inform staff of any changes. You will be seen by the consultant or a member of their team who will discuss your operation with you and ask you to sign a consent form. You will be seen by an anaesthetist who will discuss which anaesthetic would be most appropriate, again you will be asked to sign a consent form. For those patients who may require a stoma, the colorectal nurse will attend the ward and draw the site on the abdominal wall. You will be both escorted to and collected from theatre by a member of the ward team. On waking from surgery you will remain in the recovery area of theatre whilst staff make a thorough assessment of you. You will be able to drink fluids as soon as you feel able to on waking from your anaesthetic. What will happen when I wake up from my operation In recovery Before you go into the operating theatre staff will carry out several checks as part of the pre operative process. Following completion of your operation ( surgical procedure ), you will be transferred onto your bed, sat up to help with your breathing and oxygen applied via a mask. Oxygen helps you to recover from the anaesthetic and prevents headaches and dizziness. You will be met by a member of the recovery team who will escort you to recovery with the anaesthetist. On arrival in recovery, your blood pressure, pulse and respirations will be monitored every 5 minutes, to ensure your condition is stable. Your temperature will be recorded on arrival and every 15 minutes after this. If you do feel cold, warm blankets will be applied for your comfort. If your temperature has dropped, we will apply a device called a warm touch, this is similar to an electric blanket. You may need extra pain relief in recovery and this may be given intravenously ( IV ) via Patient controlled analgesia ( PCA ) or by an epidural catheter which you may have had inserted in the anaesthetic room. Any nausea or vomiting will be addressed immediately. To prevent a DVT ( Deep Vein Thrombosis ), compression gators will be applied to your calves to aid circulation in