Sample Care Path:
 MASTECTOMY

The Program in Evidence-Based Care gratefully acknowledges Lakeridge Health Oshawa for permitting the use of the Mastectomy Patient Case Path.

Path Developers and Full Title
 How to Use the Patient Case Path
 Mastectomy Patient Case Path

Associated Documents:
    Key Indicators and Discharge Criteria
    Routine Orders
    What Is a Care Path?
    Variances
    Mastectomy - Background Information

UPPath Developed By:
  Judy McCarten, Susan Blacker, Carolyn Farquharson, Carolyn Erwin, Medical Input: Dr. Wherrett


 

 

Lakeridge Health Oshawa
Patient Case Path

 
MASTECTOMY

 

Includes Modified Radical Mastectomy
Axillary Lymph Node Dissection
Partial Mastectomy & Axillary Lymph Node Dissection

 
ŠLakeridge Health Oshawa Patient Process Management 1998

 

 

UPHow to Use the Patient Case Path
 

HOW TO USE THE PATIENT CASE PATH (PCP)

  1. This is a proactive planning tool to avoid delays in treatment and discharge. THESE ARE NOT ORDERS, only a guide to usual orders.

KEY INDICATORS show PROGRESS and DISCHARGE CRITERIA.

  1. Select appropriate PCP in clear plastic cover, and place where it will best support patient care planning on your PCU. Do not document or mark on the PCP.
  2. Enter PCP in computer, & it will automatically generate a Key Indicator List & Patient Problem Record (hard copy) to be kept in the chart.
  3. Inital key indicator when met at target. If not met, consider use of the problem record if the treatment plan is affected.
  4. When the patient is discharged, the PCP can be recycled for another patient. The Key indicator and discharge criteria list remains part of the legal chart.

 


 

UPMastectomy Patient Case Path

MASTECTOMY

PRE-ADMISSION CLINIC

DAY OF SURGERY (POST OP)

POST OP DAY 1 IN-PATIENT)

DISCHARGE CRITERIA<BR< DAY or>

Clinical Observations

Assessment of coping with cancer diagnosis

Pain control
Nausea control
Assessment of coping skills

Pain Control
Nausea control
Beginning self care

Pain & Nausea
Controlled (with or without medication)

Afebrile

Potential Complications

Problems with concentration & remembering information
Stress reaction re: diagnosis

--->
Bleeding
Seroma

--->
--->

Teaching re: s/s
Infection, Seroma, Bleeding, Impaired function (shoulder), Lymphedema, Coping problems

Medications

Have Rx filled if same day surgery

Analgesia
Antiemetic

--->

---> at home or has Rx

Treatments

 

Hemovac
Drsg

Hemovac draining
Drsg/Tensor

--->
Home with hemovac
Printed Instructions
Given, Taught & Reinforced Re Wound & Drain Care

Nutrition / Hydration

 

Fluids po - DAT

DAT

--->

Elimination

  

 

 

 

Voiding

Voiding
Passing flatus

--->

 

 

Activity/
Positioning

  DAY SURGERY
Printed instructions given & explained re: Exercises

 
(Day surgery) Axillary Node Dissection &/or Modified Rad. Mastectomy
seen by Physio Pre-op

Physiotherapist prn

Patient does Stage 1 Exercises

Affected arm supported by pillow.
ACTIVITY LEVEL 3-4

Physiotherapist

 
--->
Stage 2 Exercises

 

 
ACTIVITY LEVEL 5

Printed Instructions Given, Taught & Reinforced Re: Exercises
Teaching/
Psychosocial

All patients:
seen by Nurse Clinician

 

 

Social worker prn --->
If diagnosis of Cancer is confirmed, check that
Breast Cancer Package & Community Resources info given

Reassurance that responses (anxiety, fear) are normal.
Explore threats to self-esteem.
Social work referral prn

Encourage to view operative site
Taught to empty drain
--->

--->--->

Printed Instructions
Given, Taught & Reinforced Re: Post-op care.

Breast Cancer Pkg.
Has been given (pre-op, or while in hospital)

Patient Process

DATC referral made by physician's office
Confirm DATC referral

CONFIRM DATC REFERRAL

--->--->

DATC arranged
F/U app't for surgeon

Note:
PCU =   Patient Care Unit
DAT =   Diet As Tolerated
DATC =  Durham (Region) Access To Care

ASSOCIATED DOCUMENTS

UPKey Indicators and Discharge Criteria
 

LAKERIDGE HEALTH CORPORATION

MASTECTOMY:  KEY INDICATORS & DISCHARGE CRITERIA

TARGET LOS  =  0-2 DAYS

Please delete and/or add indicators according to PHYSICIAN TREATMENT PLAN

Consider use of PATIENT PROBLEM LIST if Target date not met.

DATE

GOAL # / PATH GOAL
           (Key Indicator)

DOCUMENT GOAL
(Date Met/Initial)

 

 

 

______

POST OP DAY 0
MAS0001 Stage 1 exercises

__________/___

 

MAS0002 DATC referral

__________/___

______

POST OP DAY 1
MASOOO3 Stage 2 exercises

__________/___

______

DISCHARGE CRITERIA (In-pt. or Day Surgery)
MAS0004 Pain & Nausea controlled

__________/___

 

 
MAS0005 Afebrile

__________/___

 

Instruction package give, taught and reinforced re:
MAS0008 Wound/drain care Physio exercise book

__________/___

 

 
MAS0009 Post op care

__________/___

 

 
MAS0010 DATC arranged

__________/___

SEPT/99     Version # 4     TO BE RETAINED WITH THE HEALTH RECORD


 

UPRoutine Orders

ROUTINE ORDERS    Lakeridge Health Oshawa/ Durham Access to Care

POST-OP MASTECTOMY/AXILLARY NODE DISSECTION

D R A F T

  1. Delete orders not required.
  2. Select ONE where optional orders occur.
  3. Write additional orders on standard order sheets.
  4. Sign all orders.

Date:  ______

DRUG SENSITIVITIES: None Known ______ or If yes, please list: _______________________________________________________ _______________________________________________________ _______________________________________________________

  1. Notify DATC.
  2. Activity and Diet as tolerated.
  3. IV RL ____________ml @ __________________cc/hr (in hospital setting only)
  4. Discontinue IV when drinking well.

** I.V. push medications are NOT to be given in community setting **

  1. Demerol ______________mg IM/IV q_________h prn (Not to exceed_______mg in _______h)
  2. Demerol ______________mg po q _________ h prn.
  3. Morphine ______________mg IM/IV q_________h prn (Not to exceed_______mg in _______h)
  4. Gravol _______________mg po/IM/IV q _________ prn.
  5. Stemetil ______________mg IM/IV q _________ prn.
  6. Ondansetron ___________mg IV q __________ prn.
  7. Tylenol #3________ tabs po q_________prn OR Percocet ________tabs po q________ prn
  8. Consult: Physiotherapist_____Social Worker_____CNS Oncology______
  9. Empty reservoir (drain) & record volume _________________________________
  10. Change dressing __________________________________________________________
  11. Remove reservoir _______________________________________________________
  12. Discharge from hospital when ____________________________ or EDD _________
  13. Followup to my office ___________________________________________________

PHYSICIAN'S SIGNATURE ________________________ TIME ________________

NURSE'S SIGNATURE ____________________________ TIME ________________

UNIT CLERK'S SIGNATURE ____________________________ TIME ________

Originating Source: Surgical Council Sept 1999
Nursing Professional Practice:
Pharmacy andTherapeutics:
Clinical Committee:
Stores # _________

UPWhat Is a Care Path?
Care paths are designed by all disciplines to meet the needs of 70-80% of an identified patient population. They provide opportunity for consistent, patient-centered, quality care. Not every patient is expected to follow the care path without variance. Care paths reflect good clinical practice but NEVER replace sound clinical judgement.

UPVariances
Variances are the reason(s) a patient does not progress on a path. Select appropriate variance(s) from list below and record in space provided. A highly complex patient may require an individual treatment plan rather than a path.

Categories, Variance #, & Descriptions:

1. Patient Condition (specify)

  1.1 Clinical condition

  1.2 Change path (specify)

2. Professional Practice Issue

  2.1 Communication Issues (specify)

  2.2.1 DATC

  2.2.2 Dietitian

  2.2.3 Discharge Planning

  2.2.4 Physician

  2.2.5 Consulting Nurses

  2.2.6 Nursing

  2.2.7 OT

  2.2.8 Other

  2.2.9 Palliative Care

  2.2.10 Pharmacy

  2.2.11 Psychology

  2.2.12 Respiratory Therapist

  2.2.13 Speech LP

  2.2.14 Social Work

  2.2.15 Physiotherapy

3. Test Issues (specify test)

  3.1 Not done

  3.2 Not reported

  3.3 Other

4. Miscellaneous System Issues

  4.1 Equipment not available

  4.2 Test/procedure could be done as an outpatient

  4.3 Pre-op or pre-procedure day

  4.4 Pass

5. Patient/Family Issue

  5.1 Unable to contact family

  5.2 Pt/family delay in decision making

  5.3 Pt/family refuse test/treatment

6. Discharge Issue

  6.1 Family not prepared/able to take patient

  6.2 Bed/facility not available

  6.3 Meets discharge criteria/ not D/C

7. Other (be very specific)

 

Date

 

Path Goal #

 

Variance #

 

Comment

 

Initial

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

UPMastectomy - Background Information

Resource Materials:

Alterations in Reproduction and Sexuality, Unit IX, Management of Persons with Problems of the Breast, p 1844-1846.

Assessing Postmastectomy Care in a Community Hospital, QA Clearinghouse, QRB / April 1983, p 116-119.

Cancer of the Breast / Surgical Intervention, Patient Care Standards: Collaborative Practice Planning Guides, 6th Edition, p 867-871.

De Grasse, Catherine E. RN, BScN, MScN, OCN, Hugo, Kylie, MEd, and Plotnikoff, Ronald C., PhD. Supporting Women During Breast Diagnostics. The Canadian Nurse, October 1997, p 24-30, 49-50.

Forkner, D. June, MSN, RN (1996). Clinical Pathways - Benefits and Liabilities, Nursing Management / November 1996, p 35-37.

Hoehn, James L. MD (1996). Definitive Breast Cancer Surgery As an Outpatient: A Rational Basis for the Transition, Seminars in Surgical Oncology 12:53 - 58, Wiley-Liss, Inc.

Johnson, Janet Re, RN, BSN (1994). Caring for the Woman Who's Had a Mastectomy, American Journal Nursing / May 1994, p 25-32.

The Program in Evidence-Based Care gratefully acknowledges Lakeridge Health Oshawa for permitting the use of the Mastectomy Patient Case Path.

 

 

Page Created: August 19, 1999  by Program in Evidence-Based Care Cancer Care Ontario. Page Reviewed: June 4, 2002.     Page removed from CCO site  February 2003                   

Page re-posted by The Brondesbury Group April 2003                                                                                                                    Web Queries:  webmaster@brondesbury.ca