Medical and Nursing Admission Splenectomy Clinical Path MR 97

AFFIX IDENTIFICATION LABEL ROYAL CHILDREN'S HOSPITAL MELBOURNE, AUSTRALIA This path is 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 SPLENECTOMY CLINICAL PATH Medical and Nursing Admission Splenectomy Clinical Path MR 97 I On Admission Full medical assessment of child & document on pathway Notify haematology team of admission Ensure patient has had: • Pneumovax vaccine • Meningococcal vaccine • Hib vaccine Investigations pre operatively: Peripheral Bloods taken for FBE and XMATCH Post operatively: Ensure Intravenous Fluids reviewed and re written daily Ensure Intravenous Penicillin written Write request card for repeat FBE for day 1 post operative On Discharge Follow up appointment 1 – 2 weeks with General Surgical team Complete discharge script for prophylactic oral antibiotics (penicillin) The path has been developed with input from Consultants, Registrars, Residents, Nursing Staff and all Allied Health personnel involved and is based on best available evidence. Any queries please speak to the Clinical Analysis Development Unit. PLEASE NOTE All orders are to be documented on the MR56 -Treatment Order sheets All additional/ relevant information to be documented in the unit record. 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. spleenectomy2.doc Last updated Oct 2002 Page 1 Refer to instructions for use on variance tracking record last page of path MEDICAL ADMISSION NOTES Signature: spleenectomy2.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:………………….… 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 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: spleenectomy2.doc Last updated Oct 2002 Page 3 Refer to instructions for use on variance tracking record last page of path Splenectomy Clinical Path MR 97 I Date: Time: Consultations Assessment Medications Nutrition Family / Education On admission notify: • Surgical RMO/ Registrar/ Consultant • Haematology • Children’s Pain Management Service (CPMS) • Play therapy / Education Institute Baseline vital signs including BP Administer pre op sedation (check MR52 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 Patient Specific needs Outcomes 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 Additional notes written in UR • Date: Date: Date: Time: Time: Time: Print Name & Sign Additional notes written in UR • Print Name & Sign: Additional notes written in UR • Print Name & Sign: NURSE NURSE NURSE spleenectomy2.doc Last updated Oct 2002 Page 4 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 spleenectomy2.doc Last updated Oct 2002 DATE TIME 24 hr clock WHAT OCCURRED ? eg: Orientation not given to parents Page 5 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 spleenectomy2.doc Last updated Oct 2002 DATE TIME 24 hr clock WHAT OCCURRED ? eg: Orientation not given to parents Page 6 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