Conservative Treatment Spleen Trauma– Clinical Path MR80N

AFFIX IDENTIFICATION LABEL ROYAL CHILDREN'S HOSPITAL MELBOURNE, AUSTRALIA If patient requires surgery, complete Pre-op Checklist at end of path. It is then followed post operatively by either: Laparoscopic Splenectomy Path MR 97 I(I) or Open Splenectomy Path MR 97 I(II) (To be decided post-operatively) MEDICAL CHECKLIST CONSERVATIVE TREATMENT SPLEEN TRAUMA CLINICAL PATH Admission Criteria 1/ Patients who have a non penetrating splenic trauma 2/ Patients who are hemodynamically stable 3/ If there is no suspicion of a hollow viscus injury Full medical assessment of child & document on pathway Investigations: Abdominal CT performed q Or Abdominal Ultrasound q Or Abdominal Xray q Consider need to repeat radiological tests if clinical symptoms deteriorate or Hb decreases Peripheral Bloods taken for FBE, U & E, LFT’s and XMATCH Write request card for repeat Haemoglobin on day 2 (write request cards for other days or tests if applicable) Intravenous therapy ordered – Full maintenance whilst NBM Consider need for: • Nasogastric tube if abdomen distended or pt. vomiting (Document on MR 56) • Intravenous Antibiotics (Document on MR 52) • Indwelling Catheter (Document on MR 56) • Abdominal Girth Measurements required (Document on MR 56) Conservative Treatment Spleen Trauma– Clinical Path MR80N On Discharge Follow up appointment 1 – 2 weeks with surgical team Discuss home management with family Advise: No strenuous activities for 4 – 6 weeks No contact sport for 4 – 6 weeks Return if pain increases, febrile, vomiting or pale Complete discharge summary Complete discharge script (if applicable) Consider need for repeat radiological test prior to review The path has been developed with input from Consultants, Registrars, Residents, Nursing staff and all Allied Health personnel involved in patient’s care. We have attempted to base this path on best available evidence. Any queries please speak to Clinical Support Services ext 6956. PLEASE NOTE All orders are to be documented on the MR56 -Treatment Order Sheets All additional / relevant information to be documented in the Patient History. The Path is designed to assist clinicians by providing a framework of expected care. It is not intended to replace clinician judgement. If an individual patient does not fit the clinical care outlined, then the patient should be removed from the path. conserv tx spleen.doc Last updated Oct 2002 Refer to instructions for use on variance tracking record last page of path Page 1 MEDICAL ADMISSION NOTES Signature: conserv tx spleen.doc Last updated Oct 2002 Page 2 Refer to instructions for use on variance tracking record last page of path NURSING ADMISSION AFFIX IDENTIFICATION LABEL Date: …………..Time: …….………..Ward/Unit: ……………….……..…………..Consultant:………………….… ADMISSION CHECKLIST Bare weight documented on MR 29 Bloods taken IV court needle inserted WARD ADMISSION Interpreter required? qYes qNo Parents/guardians staying at: Contact numbers: Home circumstances: Primary caregivers / child to be discharged to Language: Details on ID label correct? qYes qNo Medical Certificate required? qYes qNo Yes / No Yes / No Yes / No Urinalysis result Nasogastric Tube - inserted - position checked Yes / No Yes / No Does anyone in the family smoke? Yes No Specify who: Are they interested in obtaining help stopping smoking? qNot interested qInterested qVery interested For those interested or very interested– Resources given? qYes qNo ALLERGIES: Recorded on medication q Red band attached q IMMUNISATIONS AND GP DETAILS: Record on Essential Particulars Record Infant feeding: Breast q Type of formula: Diet: Elimination: Nappies q number and size of nappies: Bottle q Both q Type of teat: Volume: Toilet Trained q Can a dummy be used to pacify the baby? qYes qNo Relevant Past History: Current Medications: Preferred time / method of administration Nursing Assessment: Signature & Designation: conserv tx spleen.doc Last updated Oct 2002 Page 3 Refer to instructions for use on variance tracking record last page of path Conservative Treatment Spleen Trauma Clinical Path STAGE 1 (Nil by mouth, rest in bed,1 – 2/24 vital signs) Consultations Date: Time: Assessment On admission notify: Surgical RMO/ registrar/ Consultant Physiotherapy Children’s Pain Management Service (CPMS) Social Work Play therapy / Education Institute Record HR, RR, BP & SaO2 1/24 (until review) Record Pain assessment hourly (until review, remain hourly if on opioids) If SaO2 < 92% commence O2 via mask (humidified min 4L/min) or Nasal Prongs (unhumidified max 2L/min). Arrange medical review Observe for signs of bleeding: increased abdominal distension & pain, pale, prolonged capillary refill, change in neurological status, tachycardia, tachypnoea, low or decreasing BP, referred shoulder pain Medications Treatment Nutrition Activity Skin / Hygiene Family / Education Patient Specific needs OUTCOMES Progress criteria Nurse Nurse Nurse Notify RMO ASAP if any of these signs are present Record Ng drainage & aspirates (as documented on MR56, if applicable) Record IDC output hourly (if applicable) Given as per MR 52 (ensure ranitidine ordered if Ng present) PCA / Opioid infusion & regular oral analgesia or Panadol / Codeine IVT Check IV site and initial MR 55 each shift Repeat bloods (if applicable) Maintain accurate FBC – (MR 75) Daily chest physiotherapy Daily urinalysis q NBM till review Rest in Bed Pressure area care if resting in bed Toilet privileges (if allowed) Maintain general hygiene (must be a sponge in bed) Orientate parent(s) to ward area Provide parent(s) with Conservative Spleen Trauma treatment information handout Explain plan of care using clinical path as a guide Explain & reinforce treatment, procedures and equipment to parents • • Reviewed by surgical team Pain assessment indicates pain control No signs of bleeding Ng drainage decreasing IDC draining adequate amounts urine output > 1ml / kg IV site checked and patent Parents understand unit layout, treatment plan & expected length of stay Immunisation status documented on Essential Particulars Record Progress to stage 2 when patient is allowed to: • Commence fluids or diet, start ambulating If this patient does not fit the care outlined, then remove from path Date: Time: Print name, sign, designation: Date: Time: Print name, sign, designation: Date: Time: Print name, sign, designation: Additional notes written in UR q Additional notes written in UR q Additional notes written in UR q If patient requires surgery, complete Pre-op Checklist at end of path. conserv tx spleen.doc Last updated Oct 2002 Page 4 Refer to instructions for use on variance tracking record last page of path Conservative treatment spleen trauma AFFIX IDENTIFICATION LABEL Consultations Assessment Date: STAGE 2 Ready for toilet privileges and commencing fluids/diet Time: Surgical RMO / Registrar / Consultant Physiotherapy Children’s Pain Management Service (CPMS) Record HR, RR & BP 2/24 (unless otherwise ordered, hrly if opioid infusion) Record oxygen saturation and temperature 4/24 (unless otherwise indicated) Record pain assessment 4 / 24 (hrly if opioid infusion present) Observe for signs of bleeding: increased abdominal distension & pain, pale, prolonged capillary refill, change in neurological status, tachycardia, tachypnoea, low or decreasing BP, referred shoulder pain Medications Treatment Nutrition Activity Skin / Hygiene Family Education Patient specific needs Outcomes Progress Criteria Notify RMO ASAP if any of these signs are present Record Ng drainage & aspirates (as documented on MR 56, if applicable) Consider removing Ng (post review) Record IDC output 4/24 (if applicable) Remove if toilet privileges allowed Given as per MR 52 (ensure ranitidine ordered if Ng present) PCA / Opioid infusion & regular oral analgesia or Panadol / Codeine Consider ceasing PCA / Opioid Infusion IVT Repeat haemoglobin Check IV site & initial MR55 each shift Daily Chest physiotherapy Daily urinalysis q Commence oral fluids Introduce light diet if fluids tolerated (check with registrar first) Reduce IVT as fluid intake increases Maintain strict FBC (MR 75) Rest in bed with toilet privileges Pressure area care Maintain general hygiene (can sit in bath / shower) Reinforce Conservative treatment spleen trauma information handout Reinforce plan of care with parents / caregivers using path as a guide • • Reviewed by surgical team, physiotherapy, CPMS Vital signs stable / improving No signs of bleeding Repeat haemoglobin taken Pain assessment indicates pain control Ng removed (if applicable) IDC removed (if applicable) IV site checked and patent Fluids tolerated Diet tolerated (if applicable) Parents understand plan of care Progress to Stage 3 when patient is allowed to: • Commence ambulation, diet & fluids & possible discharge Date: Time: Print name, sign, designation: Date: Time: Print name, sign, designation: Date: Time: Print name, sign, designation: Additional notes written in UR q Additional notes written in UR q Additional notes written in UR q Nurse Nurse Nurse If patient requires surgery, complete Pre-op Checklist at end of path. conserv tx spleen.doc Last updated Oct 2002 Page 5 Refer to instructions for use on variance tracking record last page of path Conservative treatment spleen trauma STAGE 3 Ready for ambulation, diet and fluids Consultations Date: Time: Assessment Surgical RMO / Registrar / Consultant Physiotherapy Children’s Pain Management Service (CPMS) Record HR, RR & BP 4/24 (unless otherwise ordered, hrly if opioid infusion)) Record oxygen saturation and temperature 4/24 (unless otherwise indicated) Record pain assessment 4 / 24 (hrly if opioid infusion present) Observe for signs of bleeding: increased abdominal distension & pain, pale, prolonged capillary refill, change in neurological status, tachycardia, tachypnoea, low or decreasing BP, referred shoulder pain Medications Treatment Nutrition Activity Skin / Hygiene Family Education Discharge Planning Patient specific needs Outcomes Progress Criteria Notify RMO ASAP if any of these signs are present Record NG drainage & aspirates (as documented on MR 56, if applicable) Remove NG if not already removed (post review) Record IDC output 4/24 if applicable Consider removing IDC (Post review) Time removed: Given as per MR 52 (ensure ranitidine ordered if Ng present) PCA / Opioid infusion & regular oral analgesia or Panadol / Codeine Consider ceasing PCA / Opioid Infusion IVT – Court IV if oral fluid intake adequate Check IV site & initial MR 55 each shift Daily chest physiotherapy Daily urinalysis Free fluids Commence light diet if fluids tolerated Maintain strict FBC (MR 75) Toilet Privileges and gentle ambulation with supervision Pressure area care whilst in bed Maintain general hygiene (can sit in bath / shower) Reinforce conservative treatment spleen trauma information handout Reinforce plan of care with parents / caregivers using path as a guide Seek review for discharge when: Vitals are stable, No abdominal pain, Haemaglobin stable, Tolerating diet and fluids, Tolerating gentle ambulation Discuss home care with patient and parent(s): § No strenuous activities 4 – 6 weeks § No contact sports 4 – 6 weeks § Seek medical help if pain returns, febrile, vomiting or pale § § Reviewed by:surgical team No signs of bleeding Vital signs stable / improving Pain assessment indicates pain control Opioid infusion ceased Ng removed (if applicable) IDC removed (if applicable) IV courted, site checked and patent Diet and fluids tolerated Parents state they understand plan of care Progress to Stage 4 when patient is allowed to: • ambulate, eat/drink as usual and discharge Date: Time: Print name, sign, designation: Date: Time: Print name, sign, designation: Date: Time: Print name, sign, designation: Additional notes written in UR q Additional notes written in UR q Additional notes written in UR q Nurse Nurse Nurse If patient requires surgery, complete Pre-op Checklist at end of path. conserv tx spleen.doc Last updated Oct 2002 Page 6 Refer to instructions for use on variance tracking record last page of path Conservative treatment spleen trauma AFFIX IDENTIFICATION LABEL STAGE 4 Ready for ambulation, diet and fluids and discharge Consultations Assessment Date: Time: Medications Treatment Nutrition Activity Skin / Hygiene Family Education Discharge Planning Patient specific needs Outcomes Discharge Outcomes Surgical RMO / Registrar / Consultant Physiotherapy Record HR, RR & BP 4/24 (unless otherwise ordered) Record pain assessment 4 / 24 (hrly if opioid infusion present) Observe for signs of bleeding: increased abdominal distension & pain, pale, prolonged capillary refill, change in neurological status, tachycardia, tachypnoea, low or decreasing BP, referred shoulder pain Notify RMO ASAP if any of these signs are present Given as per MR 52 (ensure ranitidine ordered if Ng present) Regular panadol / codeine IV Court needle insitu Check IV site and initial MR55 each shift Daily chest physiotherapy Usual diet and fluids Remove IV when oral intake adequate Maintain strict FBC (MR 75) Gentle ambulation with supervision Maintain general hygiene Reinforce conservative treatment spleen trauma information handout Reinforce plan of care with parents / caregivers using path as a guide Seek review for discharge when: Vitals are stable, No abdominal pain, Hb stable, Tolerating diet and fluids, Tolerating gentle ambulation Discuss home care with patient and parent(s): § No strenuous activities 4 – 6 weeks § No contact sports 4 – 6 weeks § Seek medical help if pain returns, febrile, vomiting or pale § § Reviewed by:surgical team No signs of bleeding Vital signs stable / improving Pain assessment indicates pain control IV removed Diet and fluids tolerated Parents state they understand plan of care Complete when ready for discharge; Patient and parents state they understand Home care plan Antibiotics ordered (if required) Parents understand follow up arrangements Date: Time: Print name, sign, designation: Date: Time: Print name, sign, designation: Date: Time: Print name, sign, designation: Additional notes written in UR q Additional notes written in UR q Additional notes written in UR q Nurse Nurse Nurse If patient requires surgery, complete Pre-op Checklist at end of path. conserv tx spleen.doc Last updated Oct 2002 Page 7 Refer to instructions for use on variance tracking record last page of path Pre Operative Checklist Complete only if patient requires surgery Pre Operative Checklist Ensure the following teams are involved: • Surgical RMO/ Registrar/ Consultant • Haematology • Children’s Pain Management Service (CPMS) pg. 5773 if applicable • Play therapy / Education Institute if applicable Baseline vital signs including BP Administer pre op sedation (check MR 52 if applicable) NBM as per fasting policy (unless otherwise ordered) Orientate parent(s) to ward area Provide parent(s) with Splenectomy information handout Explain plan of care using clinical path as a guide Explain & reinforce treatment, procedures and equipment to parents § § § Reviewed and admitted by surgical team Blood taken for FBE & X Match Patient fasted for theatre Patient prepared for theatre Parents understand unit layout, treatment plan & expected length of stay Immunisation status documented on Essential Particulars Record PROGRESS TO APPROPRIATE PATH POST SURGERY: Laparoscopic Splenectomy Path MR 97 I(I) or Open Splenectomy Path MR 97 I(II) Nurse Nurse Nurse Date: Time: Print name, sign, designation: Date: Time: Print name, sign, designation: Date: Time: Print name, sign, designation: Date: Time: Consultations Assessment Medications Nutrition Family / Education Patient Specific needs OUTCOMES Additional notes written in UR q Additional notes written in UR q Additional notes written in UR q conserv tx spleen.doc Last updated Oct 2002 Page 8 Refer to instructions for use on variance tracking record last page of path Variance Tracking Record WHY ? eg: Parents not in attendance WHAT DID YOU DO ABOUT IT ? eg: Handed over to next shift OUTCOME eg: Parents still require orientation SIGNED conserv tx spleen.doc Last updated Oct 2002 DATE TIME 24 hr clock WHAT OCCURRED ? eg: Orientation not given to parents Page 9 INSTRUCTIONS for USE Refer to instructions for use on variance tracking record last page of path • • • • • Record date and time as appropriate at the top of each column Each shift the nurse should complete the column & sign below in the space provided. TICK = item of care given as per path; “n/a” = care is not applicable to this patient at this time OR “VAR” = patient care or condition has varied from the path. The details are written on the Variance Tracking Record If you have any queries please contact the Care Coordination Manager in Clinical Support Servicesext / pager 6956 AFFIX IDENTIFICATION LABEL Variance Tracking Record WHY ? eg: Parents not in attendance WHAT DID YOU DO ABOUT IT ? eg: Handed over to next shift OUTCOME eg: Parents still require orientation SIGNED conserv tx spleen.doc Last updated Oct 2002 DATE TIME 24 hr clock WHAT OCCURRED ? eg: Orientation not given to parents Page 10 INSTRUCTIONS for USE Refer to instructions for use on variance tracking record last page of path • • • • Record date and time as appropriate at the top of each column Each shift the nurse should complete the column & sign below in the space provided. TICK = item of care given as per path; “n/a” = care is not applicable to this patient at this time OR “VAR” = patient care or condition has varied from the path. The details are written on the Variance Tracking Record above If you have any queries please contact the Care Coordination Manager in Clinical Support Servicesext / pager 6956