Colorectal Enhanced Recovery After Surgery Patient Diary | Hull University Teaching Hospitals NHS Trust

This booklet has been produced to give you general information about your surgery, maximise your recovery, minimise any complications and assist you to be well prepared for your stay on the colorectal surgical unit.

Most of your questions should be answered by this booklet. It is not intended to replace the discussion between you and your doctor but may act as a starting point for discussion. If, after reading it, you have any concerns or require further explanation, please discuss this with a member of the team who are caring for you.

Enhanced Recovery After Surgery (ERAS)

As part of our ongoing commitment to the delivery of quality care we have developed a programme designed to enhance your recovery after surgery and to ensure that your stay is as short as possible. As part of this programme, it is necessary to involve you in all aspects of your care from the moment we see you in our clinics through to your discharge from hospital.

We will aim to:

Ensure you are provided with appropriate nutritional support prior to and following your surgery. This is important in order to maintain adequate fluid intake, assist wound healing and promote your recovery. You will therefore be encouraged to eat and drink as soon as possible after your operation.
Ensure you have adequate pain relief throughout your stay and following discharge home.
Support you through a programme of mobilisation as soon as possible after your operation. This is important in order to prevent you from developing blood clots in your legs and to stop muscle wastage. Early mobilisation will also help to prevent you developing pressure sores to your skin. We will also teach you how to breathe more effectively which reduces the risk of developing a chest infection.

The anticipated length of your stay is days.

PLEASE NOTE this does not always mean that you will be in hospital for this amount of time. You may need to stay longer, or you may recover more quickly and require less time in hospital. We will assess your progress every day to make sure that you are safe when you go home.

Preparing for your hospital admission

Before You Come into Hospital

We encourage you to be involved with the planning of your care and recovery from the time you are seen in clinic until your discharge from hospital. You will have the opportunity to inform us about your individual needs and home circumstances.

It is important that you inform us if you feel that your circumstances have changed, or if you feel you may be unable to manage your daily activities when you are discharged from hospital, following your operation.

Medication

You will need to bring with you all the medication that you are currently taking. You will also need to have a supply of paracetamol (unless you are allergic to it), at home ready for your discharge. The hospital will arrange for you to have a supply of any additional medications prescribed whilst in hospital if you need to continue taking them after your discharge.

If you are taking warfarin, clopidogrel or any other medication that thins your blood it is important that you inform the pre-assessment nurse in case you need to stop taking this prior to your operation; this is to prevent you having problems with bleeding.

To help prevent the formation of blood clots you will be expected to give yourself an injection each evening called Fragmin. The nursing staff will do this for you for the first few days, but they will teach you how to give your own injection. This is important as Fragmin needs to be administered for 28 days following your surgery. If you are physically unable to do this, it may be possible to teach a family member or carer how to do this for you.

Available support

We have a large team of dedicated medical and nursing staff and other professionals who can help organise whatever support you might need. Please do not hesitate to ask for assistance or advice.

Admission checklist

Before you leave home, please look at the list below to make sure you have not forgotten any essential items you will require for your admission. Please be aware that the ward cannot accept responsibility for items left on the ward. The Trust will only accept responsibility for items that are recorded in the valuables book and stored in the general office. You are advised to only bring a small amount of change with you to purchase newspapers or snacks from the WRVS trolley. Please leave your valuables at home.

Bring all medications in their original packaging (the name label that the pharmacy placed on the box with dose and any cautions)
Bring suitable comfortable day clothes (loose fitting around the waist), and if you bring slippers, please try to bring the ones that go all around your feet (not slip on/mules). The anti-embolic stockings you need to wear throughout your stay can make your feet more slippery and can cause a falls risk with ill-fitting slippers.
Please can you nominate one person to contact the ward each day and ensure that they have the ward telephone number? We ask that your nominated contact provides updates to other members of your family and friends. This is so we can concentrate on looking after you rather than answering telephone calls.

Ward 10 (male) tel: 01482 623010

Ward 11 (female) tel: 01482 623011

The visiting hours for both wards are 11:00 to 19:00. Maximum of two visitors at any one time.

If you need to visit out of these hours, please contact the ward and we will try to make arrangements for you.

Please identify who would be available to collect you on discharge and make a note of their contact details.
If you have carers to help you at home, please bring their contact details in with you so the nursing staff can liaise with them for your discharge.

Nutrition has an important role in your recovery. After bowel surgery it is normal to have a reduced appetite. We encourage our patients to snack on a variety of foods some of which are listed below. Your friends and family can bring snacks into hospital for you but please remember that we are unable to reheat any food. We do however have a fridge and a freezer. Please ask the staff for any further advice. If we become worried that you are losing weight or not eating enough to heal your body you will be referred to a Dietician, who will provide a plan of care to meet your nutritional needs.

The Day Before your Operation

The majority of patients do not require admission to hospital until the day of surgery. However, depending upon your personal circumstances and the type of surgery planned, it may be necessary for you to be admitted to the ward the afternoon before your surgery.

If this is the case, you will be shown to your bed, shown around the ward and a member of the nursing team will check the details given at your pre-assessment appointment. A member of staff will weigh you and check your observations. You will also be assessed by a doctor.

Most patients are able to eat and drink normally the day before surgery either in hospital or at home until midnight. After midnight it is important that you only drink clear fluids. You will be provided with six carbohydrate drinks in cartons called “Pre-op”. You should drink four of the cartons throughout the evening and two in the early morning. The drinks are NOT bowel prep and will not clear your bowels, they are purely to build up your energy reserves. They are not suitable for diabetic patients taking medication to control their diabetes so they will only be provided if appropriate for you.

If you are being admitted the day before your surgery, you will also be given an injection called Fragmin to reduce the chance of developing bloods clots.

For certain surgeries it may be necessary for you to have two enemas. The nurse will administer one at bedtime, the evening before your surgery and another early in the morning. Some patients may be required to have oral bowel prep called “Moviprep”. This is usually arranged prior to your admission and a separate information sheet provided, with instructions for its use.

Day of Surgery

If you are already in hospital, you will be woken by a member of the nursing team at 6am and provided with the final two carton pre-op drinks and asked to take a shower.

If at home, you will need to wake up early to take the two pre op drinks at 6am. We recommend you also take a shower before coming into hospital.

If you are coming into hospital that morning, you will be shown to the Day Room where you will wait until your bed becomes available. This can sometimes take a few hours but please be assured the teams are doing everything possible to make your bed available as quickly as possible. We will keep you updated regularly on this.

A member of the nursing team will check the details given at your pre-assessment appointment. A member of staff will weigh you and check your observations. You will also be assessed by a doctor.

All patients will:

Have their legs measured and antiembolic stockings fitted.
See the Anaesthetist to assess and discuss the best anaesthetic for you.
See either your consultant or one of their Registrars who will explain to you what is planned to happen in theatre that day. This will include the possible complications that can occur. It is a legal requirement for them to explain this to you prior to you signing your consent form.
See a Stoma Nurse if the consultant has requested it. The Stoma Nurse will come and talk to you about stomas and place a mark at the site of the best place for you to have one. The Stoma Nurse will answer any last-minute questions you may have.
Be asked a series of questions as part of the Theatre Checklist, multiple times prior to your surgery by different members of staff.

Once you have had your surgery you will transfer to the recovery area where the Theatre team will make sure that you are awake from the anaesthetic, your observations will be recorded frequently, and the team will ask if your pain is controlled. Once the team are satisfied that your condition is stable, you will return to the ward where you will be cared for in the High Observation Bay (HOB). The HOB is an area of the ward where we monitor you more closely following your surgery. Please note there may be patients of the opposite gender in the HOB. This will only happen by exception and is always based on clinical needs of patients. All staff will take extra care to ensure that your privacy and dignity is maintained.

HOB

On return to the HOB you will be attached to a heart monitor, this will take your blood pressure, respirations, oxygen levels, pulse and show the rhythm of your heart on the screen. The nursing staff will also monitor your temperature. You will have some oxygen delivered either via a mask (if you are sleepy) or via some nasal prongs (if you are awake).

You will have some form of analgesia, either an Epidural, which is a small tube into your back which delivers a continuous amount of pain relief and a small dose on request, or an IV PCA, which delivers a small dose of morphine on request. Your Anesthetist will discuss this with you prior to your surgery. It is very important that your pain is controlled enough so that you can move around the bed and practice your breathing and leg exercises as these can prevent complications and support your recovery. If you have pain, please inform your Nurse.

Your Nurse will monitor your wound for oozing and if you have a stoma will check it is healthy. You will also have a urinary catheter into your bladder to monitor your urine output; this is the best way to ensure you are not dehydrated.

If you are awake and feel up to it you will be offered some water, and if you would like a hot drink a bit later this may also be possible. However, if you are sleepy and your Nurse is concerned that you will fall asleep whilst drinking then you will only be allowed to take sips.

You will have an intravenous infusion or drip to ensure you do not become dehydrated so you will not need to drink. Please inform your Nurse if you feel nauseous.

Post-operative recovery

Everyone is different and will recover at different rates, so we will tailor your care to you. As soon as you feel able to eat you will be offered food and when you begin to drink sufficiently your intravenous infusion will be stopped. You will be given tablet pain relief in addition to the Epidural or IV PCA, and once your pain is managed with oral pain relief, your epidural or IV PCA will be reduced and then removed. Your catheter will need to stay in place whilst you have an epidural.

We will give you assistance to meet your hygiene needs. If you have a stoma, we will help you to look after it until you feel confident with it. The Stoma nurses and ward staff will teach and support you this.

Every day you will be encouraged to sit in your chair and mobilise around the ward, this is better for your chest as it prevents infection, but it can also encourage the gut to work.

Chewing gum has been proven to help the gut to work and is available if you ask your Nurse, however if you feel nauseated or bloated it is not recommended.

The nursing staff will administer your routine medication. They will also administer your Fragmin injection until they feel you are well enough to attempt it yourself. Then they will teach you how to safely administer it to yourself once you are discharged home.

Daily Diary

The following sections will give you some goals to try and achieve and provide you with an understanding of what is likely to be happening each day. Please discuss any queries with your nurse as not every patient will have the same treatments.

Try not to worry if you are not progressing as quickly as is planned in this diary, some patients will have a slower recovery. Your Doctor and Nurse will be able to discuss this further.

Day 1

Please aim to complete the following activities which will aid your recovery.

Sit out in the chair twice (aim for an hour each time).
Walk once with assistance.
Drink 2 supplement drinks (Fortisip or Fortijuice).
Eat and Drink as you feel able (the nurses can help you to choose foods that are suitable).
If you have brought a supply into hospital, you can start to use chewing gum if you feel able and not feeling sick / nauseous.
Take pain relief that is offered and inform the nurses if you are in pain or are feeling sick.
Complete your deep breathing and calf exercises every hour

Day 2

Please aim to complete the following activities which will aid your recovery

Eat and Drink as you feel able.
If you are drinking sufficiently your IV fluids (drip) may be reduced or stopped.
Be out of bed for at least 4 hours.
Walk twice or more with assistance.
Drink 2 supplement drinks (Fortisip or Fortijuice).
Continue to use chewing gum.
Take pain relief that is offered and inform the nurses if you are in pain or are feeling sick.
Complete your deep breathing and calf exercises every hour.
Watch the Nurse administer the Fragmin injection.
Observe Stoma care

From now on you must continue to eat and drink, take the supplement drinks and mobilise unless told otherwise. You also need to continue to do your deep breathing and leg exercises. Try to get dressed into comfy clothing that you can walk around in.

Day 3

Please aim to complete the following activities which will aid your recovery.

Try to be out of bed for 8 hours.
Go for a walk 4 to 6 times.
Your catheter may be removed.
Your Epidural / IV PCA will be removed.
Begin to empty your Stoma pouch.
Try to give your own Fragmin injection with guidance from your Nurse

Day 4 onwards

Continue as you did on Day 3.
If your recovery is going as expected the next few days are about increasing your activity until you are well enough to go home.
The Nurses and Discharge Assistants will talk to you about discharge plans.
Your Doctor will prepare your Immediate Discharge Summary (IDS).
Your Nurse will obtain any medications you will need from the pharmacy.

Discharge Plans

The nursing staff and Discharge Assistants will try and get everything in place the night prior to your discharge so that you can go home the following morning. However, in some cases it may be the same day. Please be aware that if you require discharge medication on the same day, Pharmacy will take some time to prepare these.

It is important when you go home that all the medications you brought in with you, which you still need for discharge are returned to you. If anything has been stopped then this will be written on your Discharge Summary as your G.P will need to know about it. The nursing staff will also go through all your new medications and make sure you know when you need to take them and what they are for.

The nurses will have check your wound, redress if required and give you some dressings to go home with. If they have any concerns, they will make arrangements either for a District or Practice Nurse to observe your wound and they will supply you with a small number of dressings for them to do this. You will also be told the date that your sutures or clips can come out. The team will make arrangements for them to be removed either by your District or Practice Nurse as well. We will also provide you with the equipment to have them removed.

You should be given a second pair of anti-embolic stockings. You will need to continue to wear your stockings for at least 28 days.

The nursing staff should check whether you have any cannulas left in you (the little needles that give you drugs or fluids), these need to be taken out before you go home.

If you have a stoma, a Stoma Nurse will come and see you and make sure you are confident with your stoma care. The Stoma Nurse will check you have all the equipment you need and know how to order equipment/ supplies. He or she will also make arrangements to come on a home visit to you.

Day of Discharge

You will receive a copy of your Immediate Discharge Summary (IDS) and your GP will be sent an electronic copy.
Your own medications will be returned.
You will be given Fragmin instructions and a sharps disposal pack.
You will be given a second pair of stockings to wear at home.
Your Nurse will provide wound care advice and arrange any wound care appointments. You will be provided with any dressings required and arrangements will be made for suture or clip removal. If you are discharged at the weekend or Bank Holiday then we will ask you to make your own arrangements with Practice nurse for removal of clips.
Follow-up arrangements will be made for you to be seen in clinic (usually 6 to 8 weeks after surgery).
Where possible you will be discharged home at 10am

Discharge Information After Your Bowel Resection

ABDOMINAL PAIN

It is not unusual to suffer some colicky type pain during the first few weeks following surgery. The pain will only last a few minutes.

However, severe pain that lasts for several hours may indicate a leakage of fluid from the area where the bowel has been joined together. This may be, but not always, accompanied by feeling hot and sweaty, feeling sick and/or vomiting, a bloated tummy and the absence of passing wind or stool. This is a rare complication and is very serious. If you have severe pain with or without a high temperature and feel generally unwell you need to contact either the ward from which you were discharged for advice or your GP.

WOUNDS

If your wound(s) require dressings on discharge the ward nurses will have arranged for the district nurse/ practice nurse/ wound clinic to attend to your dressing at home or have arranged for you to attend one of our ward clinics.

It is not unusual for your wound(s) to be uncomfortable for the first 2 or 3 weeks after surgery. However please contact your GP if your wound becomes red, swollen, and painful and/or starts to discharge fluid.

DAY TO DAY ACTIVITIES

Do not worry if you still haven’t fully recovered from your operation after many weeks. It can take 12 weeks or more and it may take longer if you require chemotherapy or radiotherapy. Feeling physically tired is only natural after major surgery. However, this does not mean you should go home and do nothing. You are advised not to lift heavy objects or perform heavy manual work for at least 6 weeks after your operation e.g. heavy shopping, housework, cleaning windows and gardening. After 6 weeks you can begin to build up your level of activity and exercise. Your body will tell you when you are tired, so you do not overdo it. You may find that during the first 4 to 6 weeks you need to sleep/rest 2-3 times a day, getting gentle exercise and fresh air will help your recovery in the first few weeks. Continue to take short walks, this will help to strengthen your abdominal muscles and prevent blood clots.

BATHS AND SHOWERS

If you are less than 5 days since your surgery it is advisable that you do not immerse yourself in a bath, this is because your tummy wound will still be healing. After this you may bathe and shower as normal, the water will not harm your wound.

STOCKINGS

We advise that you wear your surgical stockings for 28 days or until you are back to your normal level of mobility. You may take them off whilst having a bath or shower. You can wash your stockings at 40 degrees centigrade in your washing machine. PLEASE DO NOT TUMBLE DRY.

Please make sure that you complete your course of Fragmin injections and dispose of your sharps bin when finished by contacting:

Hull City Council: tel: 01482 300300 (choose waste disposal option)

East Riding Council: tel: 01482 393939

This is a free service, and the council will come and collect your sharps bin from you.

DIET

Please read the dietary information leaflet provided for you. Share the information it contains with your partner and family (if you wish) so that they can be of help and support. There may be information they need to know, especially if they are taking care of you following your surgery. After having an operation on your bowels there may be some long-term dietary restrictions depending on the surgery you have just had. If you have a stoma, please follow the advice given to you by the stoma care nurses. You made find it takes a few weeks before your appetite returns to normal. Try eating little and often rather than 1 or 2 big meals per day.

DIARRHOEA AND CONSTIPATION

Depending on the type and extent of your surgery to your bowels it may take a few months to get back to what was your normal routine. You may experience diarrhoea and/or constipation. Some surgery will result in permanently looser stools as there is less bowel to reabsorb water back into your body. However, the bowel does tend to adapt with time. Your surgeon and colorectal nurse will explain this to you. It is important to keep yourself hydrated, that is to say you need to drink enough water to balance what you are losing. Try and drink one glass of fluid an hour if possible.

Dioralyte is a rehydration drink, 1 to 2 sachets daily may help to prevent you becoming dehydrated. Your consultant may also want to start you on some medication to firm up your stool. Try and avoid dairy products, rich and spicy foods whilst the diarrhoea persists.

Eating toast, crackers or white rice may help as they are easily digested and will not cause any more irritation to the bowel.

To prevent constipation, it is important to eat a high fibre diet and drink at least 2 litres of fluids a day. Fluid can include soup, squash or juice. Pureed fruit may also help, for example prunes, kiwi fruit and apricots. If your symptoms persist, please consult your GP.

STOMA CARE

Your Stoma Care Specialist Nurse will have seen you in hospital and arrange a telephone review within 2 to 3 days of your discharge. A home visit will also be arranged within the first week after discharge. They can be contacted if necessary for help and advice

Monday to Friday 8am to 4pm

Sat 8.30am to 12.30pm

Tel: 01482 624026

DRIVING

We advise that you do not drive for at least 6 weeks following your surgery. If your car does not have power steering and is heavy to steer, then you should not drive for at least 8 weeks. Before you drive you should sit in the car with your seatbelt fastened and your foot pressed hard on the brake as if doing an emergency stop. If there is any discomfort at all you must not drive as you may cause an accident. It is advisable to check with your insurance company, that they will cover you to drive form this time.

WORK

Depending on your type of work, you may be able to return 8 weeks following your surgery. You should discuss this with your consultant. Check with your Consultant if your work involves heavy manual labour.

INTIMACY

You probably won’t feel like being intimate for about 6 to 8 weeks. It is natural to feel nervous so only do what feels comfortable, take your time and talk to your partner. Having any bowel surgery can affect how you look and feel about your body. Try and accept that it will take time to adjust as there is often bruising and damage to the tissues which need time to heal before normal sexual function can take place. If however, everything is not normal after 6 months ask your GP or Stoma Nurse for advice.

FURTHER DISCHARGE ADVICE

You will receive an appointment through the post for 6 to 8 weeks post op to be seen in one of our follow up clinics. If you have not received a letter within 4 weeks of discharge, please contact the ward clerk on the ward that you were discharged from.

Ward 10: tel: 01482 623010

Ward 11: tel: 01482 623011

We are continually trying to improve the service we provide and therefore would appreciate any feedback or suggestions you may have regarding this patient diary, or the ERAS service (Enhanced Recovery After Surgery) provided pre and post operatively.

This can be done anonymously via

the ward feedback form given to you on discharge
by posting any suggestions into the ERAS post-box at the nurses station
by speaking with the nursing staff or Sister on the ward
by email to: colorectal@nhs.net