Name.................

DOB.HN...AN.

Clinical Pathway : Appendectomy

Unit
Time line
Date
1.Assessment/
Consult

Age.Gender..Visit Date...

OPD Sur / ER
ICU /Ward
OR
PACU
Ward
Pre-admission
Pre-operative
Peri - operative

Ward
D1
D2-3
Date. Date............... Date. Date. Date. Date............ Date............

[ ]


CPG Guideline
[ ] complicated
appendicitis
1. [ ] appendiceal
phlegmon
2. [ ] appendiceal
abcess
3. [ ] ruptured
appendicitis
[ ] consult med for
underlying disease and
preoperative evaluation
(if need)

[ ]
[ ] Consciousness
[ ] Vital signs
[ ] Physical
examination

F/M-02.1-SUR-008 Rev.0 (21/11/2011)

[ ]
[ ] Consciousness
[ ] Vital signs
[ ] Physical examination
[ ] Pain assessment
[ ] complicated
appendicitis
1. [ ] appendiceal
phlegmon
2. [ ] appendiceal
abcess
3. [ ] ruptured
appendicitis
[ ] underlying disease
[ ] Past history, Drug &
Food allergy
[ ] family history
[ ] intake/ output
[ ]
[ ] Fall assessment
[ ] Psychosocial
[ ] ADL / Function
[ ]

[ ]

[ ] Level of conscious
[ ] Preoperative
verification
[ ] Vital sings
[ ] Pain assessment
[ ] complicated
appendicitis
1. [ ] appendiceal
phlegmon
2. [ ] appendiceal
abcess
3. [ ] ruptured
appendicitis
[ ] Past history, Drug &
Food allergy
[ ] intake/ output
[ ] Fall
[ ] Psychosocial
[ ]
consent form

[ ]

[ ] Level of conscious
[ ] Vital signs 5-10

[ ] Respiration and
respiratory movement
[ ]

[ ]

1. [ ] Intraabdominal
abscess
2. [ ] Fecal fistula
3. [ ] Intestinal
obstruction
[ ] Pain assessment
[ ] wound at surgical
site
[ ] urinary retention
[ ] intake/ output
[ ] Fall
[ ] Psychosocial

[ ] Consciousness
[ ] Vital signs
q 15 x 4
q 30 x 2
q 60 then q 4 hr
[ ] Respiration
[ ] Pain assessment
[ ] wound at surgical
site
[ ]

1. [ ] Intraabdominal
abscess
2. [ ] Fecal fistula
3. [ ] Intestinal
obstruction
4. [ ] Lung atelectasis
[ ] bowel movement
[ ] urinary retention
[ ] intake/ output
[ ]
[ ] Fall assessment
[ ] Psychosocial

[ ] Consciousness
[ ] Vital signs q 4 hr
[ ] Pain assessment
[ ] wound at surgical
site
[ ]

1. [ ] Intraabdominal
abscess
2. [ ] Fecal fistula
3. [ ] Intestinal
obstruction
4. [ ] Lung atelectasis
[ ] signs of infection
[ ] bowel movement
[ ] intake/ output
[ ]
[ ] Fall assessment
[ ] Psychosocial
[ ] ADL / Function

[ ] Consciousness
[ ] Vital signs q 4 hr
[ ] Pain assessment
[ ] wound at surgical
site
[ ] signs of infection
[ ] bowel movement
[ ] intake/ output
[ ]
[ ] Fall assessment
[ ] Psychosocial
[ ] ADL / Function
[ ]

Page 1/6

Name.................
DOB.HN...AN.

Clinical Pathway : Appendectomy

Unit
Time line
Date
1.Assessment/
Consult ()

2. Investigation

Age.Gender..Visit Date...

OPD Sur / ER
ICU /Ward
OR
PACU
Ward
Pre-admission
Pre-operative
Peri - operative

Ward
D1
D2-3
Date. Date............... Date. Date. Date. Date............ Date............
[ ] Pain assessment q 1
hr.
[ ] underlying disease
[ ] Past history, Drug &
Food allergy
[ ] Family history
[ ]

[ ]

[ ] CBC
[ ] UA
[ ] Coagulogram
[ ] anti HIV
[ ] Cross match Blood
group
[ ] Ultrasound
[ ] CT if indicated
[ ] EKG as ordered
[ ] Other investigation
as needed..
..

F/M-02.1-SUR-008 Rev.0 (21/11/2011)

[ ]

[ ]

[ ]

OR
[ ] U /S

[ ]

[ ]

[ ] Lab as
needed

[ ] ADL / Function
[ ] Team meeting
[ ]

[ ] Hct
[ ] Repeat lab as
needed
[ ] Other lab as
needed.
..

[ ] Hct
[ ] Repeat lab as
needed
[ ] Other lab as
needed.
..

[ ] Hct
[ ] Repeat lab as
needed
[ ] Other lab as
needed.
..

[ ] Other lab as
needed.
..

Page 2/6

Name.................
DOB.HN...AN.

Clinical Pathway : Appendectomy

Unit
Time line
Date

Age.Gender..Visit Date...

OPD Sur / ER
ICU /Ward
OR
PACU
Ward
Pre-admission
Pre-operative
Peri - operative

Ward
D1
D2-3
Date. Date............... Date. Date. Date. Date............ Date............

3. Medication /
Fluid

[ ] IV Fluids
[ ] Preoperative
medication
[ ] Others...
.....................................

[ ] Preoperative
medication
[ ] IV Fluids as ordered
[ ] Antibiotics as
ordered
[ ] Others
.........................................

4. Treatment &
Intervention

[ ]

[ ]
Preoperative medication

5. Nutrition

[ ] NPO

[ ]
[ ] Skin preparation as
order
[ ]

[ ] foleys cath
OR
[ ] NPO

F/M-02.1-SUR-008 Rev.0 (21/11/2011)

[ ] IV Fluids
[ ] Volatile anesthesia
[ ] Narcotic
[ ] Sedative
[ ] Reverse drug
[ ] Blood component if
necessary
[ ] Others..
..........................................
[ ]

(General anesthesia)
[ ]

[ ] NPO
[ ] IV fluid

[ ] IV Fluids
[ ] Narcotic as order
[ ] Anti-emetic as
order
[ ] Others
.....................................

[ ] IV Fluids
[ ] Antibiotics
Ruptured
Appendicitis
[ ] Others
......................................

[ ] Off IV Fluids
[ ] Antibiotics
Ruptured
Appendicitis
[ ] Others...
......................................

[ ] Others.....
........................................

[ ]

[ ]

[ ] oxygen support if
necessary

[ ]

[ ] Pain management
[ ] Wound care
[ ] Breathing exercise

[ ] Pain management
[ ] Wound care
[ ] Dressing

[ ] Pain management
[ ] Wound care
[ ] Dressing

[ ] NPO
[ ] IV fluid

[ ] Liquid diet / Soft

diet
[ ] IV fluid

[ ] Soft diet / Regular

diet

[ ] Soft diet / Regular

diet

Page 3/6

Name.................
DOB.HN...AN.

Clinical Pathway : Appendectomy

Unit
Time line
Date
6. Activity &
Safety

7. Rehabilitation

8. Health
Education

Age.Gender..Visit Date...

OPD Sur / ER
ICU /Ward
OR
PACU
Ward
Pre-admission
Pre-operative
Peri - operative

Ward
D1
D2-3
Date. Date............... Date. Date. Date. Date............ Date............
[ ] Bed rest
[ ] Semis
Fowler or Fowlers
Position

[ ]

Inform
consent
[ ]

F/M-02.1-SUR-008 Rev.0 (21/11/2011)

[ ] As tolerated
[ ] exercise
breathing
[ ] Fall prevention
[ ] Pressure Sore
Prevention

[ ] Bed rest
[ ] Aseptic technique
[ ] Fall prevention

[ ]
[ ]

[ ]

[ ]

[ ]
General
Anesthesia
[ ]
General
Anesthesia

[ ] Bed rest
[ ] Fall prevention

[ ]
[ ]

[ ]
General Anesthesia

[ ]

[ ] Ambulation
[ ] Encourage deep
breathing
[ ] Aspiration precaution
[ ] Fall prevention
[ ] Pressure Sore
Prevention
[ ]
[ ]

[ ] pain management
[ ]

[ ]

[ ] /

[ ] Exercise breathing
[ ] Effective cough
[ ] Turning 2 hr
[ ] Leg exercise

[ ] As tolerate
[ ] Encourage deep
breathing
[ ] Aspiration precaution
[ ] Fall prevention

[ ] As tolerate
[ ] Fall prevention

[ ]
[ ]

[ ]

Caregiver
1. position
position
2. Wound care
3. Pain management
4. Home medication
5. Rehabilitation
6.
ADL

[ ]
[ ]

[ ]

[ ]

Caregiver
[ ]

Page 4/6

Name.................
DOB.HN...AN.

Clinical Pathway : Appendectomy

Unit
Time line
Date

Age.Gender..Visit Date...

OPD Sur / ER
ICU /Ward
OR
PACU
Ward
Pre-admission
Pre-operative
Peri - operative

Ward
D1
D2-3
Date. Date............... Date. Date. Date. Date............ Date............

8. Health
Education ()

9. Patient / Family
support/
Psychosocial
support

[ ]

10. Expected
Outcome

[ ]


[ ]
appendicitis
[ ]

F/M-02.1-SUR-008 Rev.0 (21/11/2011)

1. Lung atelectasis
2. Wound infection
[ ] Bed exercise
[ ] Exercise breathing
[ ] Effective cough
[ ] Turning
[ ] Leg exercise
[ ]

[ ]
[ ]

[ ]
aspiration

[ ]

[ ]
[ ]

[ ]

[ ]
[ ]

[ ]

[ ]
[ ]

[ ]
[ ]

[ ]
[ ]

[ ]

[ ]

[ ]

[ ]

[ ]

[ ]

[ ] gain consciousness
[ ] Vital signs
[ ]

[ ]

[ ]
discharge

[ ] full consciousness
[ ] Vital signs
[ ]

[ ]

[ ] Early
ambulate 24 hr

[ ] full consciousness
[ ] Vital signs
[ ]

[ ]
discharge

[ ] no accident

[ ] full consciousness
[ ] Vital signs
[ ]

[ ]
discharge

[ ] no accident

Page 5/6

Name.................
DOB.HN...AN.

Clinical Pathway : Appendectomy

Unit
Time line
Date
10. Expected
Outcome ()

Age.Gender..Visit Date...

OPD Sur / ER
ICU /Ward
OR
PACU
Ward
Pre-admission
Pre-operative
Peri - operative

Ward
D1
D2-3
Date. Date............... Date. Date. Date. Date............ Date............
[ ]

[ ] no accident
[ ]

[ ] Hct > 30 %
[ ]

[ ]
discharge
[ ] lab
[ ]

[ ]
[ ]

[ ]

[ ] urine
retention
[ ] no accident
[ ] no pressure sore
[ ]

[ ]
ADL

[ ] ADL

[ ]

[ ]

[ ]

[ ]

RN signature

F/M-02.1-SUR-008 Rev.0 (21/11/2011)

Page 6/6