Download Patient Expected Flow Sheet

Treatment Timetable
Discharge Recommendations
Pre-operative
Day
Day of surgery
Post-op Day 1-2
Post-op Day 3-6
The patient & family
will meet with program
coordinator for
education/information
concerning hospital
services & treatment
process
The patient arrives in admitting for
completion of paperwork.
The amount of swelling and bruising varies
from patient to patient and is dependant
on the surgical approach. Patients
undergoing an endoscopic procedure have
very little swelling and generally no
bruising. Patients having a transcallosal
approach have minimal swelling. It is
common for patient’s undergoing an
orbito-zygomatic procedure to have
significant bruising and swelling for several
days.
An EEG may be completed at
this point if seizures are present.
Frequently they are inconclusive
for several weeks to months.
VNS devices will be turned on at
the discretion of the neurologist.
The patient will be able to eat and drink
fluids as tolerated and will be encouraged
to do so. The nursing staff will keep track
of the patient’s oral intake therefore they
will need to know what fluids the family
has given the patient. Extreme hunger
and/or thirst or lack of thirst should be
reported to the nurse as these are
indicators of Diabetes Insipidus (DI).
Transfer to regular nursing floors
is expected during this time.
General discharge recommendations include
the following:
Patients are expected to be
ambulating (walking) on a regular
basis with supervision at this
time. This may be completed with
the nursing staff or physical
therapist.
Activity will be encouraged when the
patient is alert and oriented. The patient
should be walking with assistance by the
end of the first or second day following
surgery unless sedation is altering his/her
The patient should be eating
frequent meals with protein &
drinking plenty of fluids.
Neurology
 Follow up with local neurologist for
seizure management within 30 days of
returning home
 Obtain an EEG in six to twelve weeks,
and another one at twelve months
following surgery. Please send a copy of
the EEG report to Maggie
 Complete a MRI without contrast six to
twelve weeks post-operatively. Please
send the report and a copy of the MRI to
Tracy @
Consultations with the
team physicians will
be provided
separately. If the
patient has a VNS it
will be turned off prior
to surgery by our
neurologist. The
patient should advice
the team of a VNS
during this visit.
The patient proceeds to the Preoperative Service department for
lab tests, brief assessment,
placement of IV lines, and
introduction of the surgical team.
Pre-op labs include the following
tests:

Coag's - PT, PTT, INR

CBC (includes H & H)

CMP (includes liver
function tests - SGOT &
SGPT)

UA (without C & S)

T & C (2 PRBC's)

FSH & LH, Prolactin

TSH, T3, Free T4, IGF-1

Cortisol

ACTH, Vasopressin
An MRI will be completed prior to
surgery with the appropriate
sedation necessary for each
patient. A Stealth Navigational
System will be incorporated into
MRI study to be utilized during
surgery. If patient is old enough to
undergo MRI without sedation,
he/she will proceed to radiology at
this time. If patient requires
sedation he/she will be
anesthetized first and then taken
to the radiology department.
Maggie Varland, RN, MBA
Barrow Hypothalamic Hamartoma
Neuroscience Program Coordinator
Revised 1/15/2010
A copy of the discharge and follow up
recommendations will be provided to the
patient/family and all local physicians who
were documented with the program
coordinator. All other pertinent documents
including labs, MRI scans, consultations and
operative reports will be given to the patient
who will be free to make copies for their local
physicians.
The patient will be given an appointment for a
follow-up visit with the neurosurgeon a few
days after discharge from the hospital. Labs
may or may not be drawn at this time
depending on the patient’s condition.
Generally patients are released to travel home
at this time.
Less edema to face and
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Treatment Timetable
The patient will have multiple IV
lines including one in the neck or
chest. The A-line is an invasive
line that monitors blood pressure.
A Foley catheter is placed to drain
the urine & accurately monitor
urine output. Pneumatic stocking
may be applied to assist with
circulation. The patient may have
an EVD, which is a catheter that
drains fluid from the brain in order
to relieve pressure. Several
monitors will be utilized including
EKG, blood oxygen saturation,
intracranial pressure (ICP), blood
pressure & heart rate.
Family members will be escorted
to the surgical waiting room and
will be updated about the condition
of the patient frequently.
A small sample of tissue from the
lesion will be sent to the pathology
& research departments for
molecular & genetic testing.
level of consciousness.
The nurse should be notified when the
patient has his/her first bowel movement.
The Foley catheter may be removed on
this day if no signs of DI are present as
determined by the lead physician. Sodium
and potassium is checked every six hours
for the first two days and then once a day
until discharge.
The patient’s vital signs will be monitored
closely for the first couple of days.
Temperature will also be closely watched.
Some patients have an elevated
temperature after surgery, which will
subside over a couple of days. A
substantial elevation could indicate a postoperative infection or hormonal
interference.
Although some patients are seizure free
immediately after surgery, many patients
experience a trickling down of activity over
several months. .Anti-convulsants are
given though the IV lines until patients are
taking food, liquids, and medications orally
at which point they will be placed back on
their pre-operative seizure medications. It
is recommended that patients remain on
their pre-operative seizure medications for
up to one year even if the patient is
seizure free. Tapering off of medications
will be at the direction of their local
neurologist.
Maggie Varland, RN, MBA
Barrow Hypothalamic Hamartoma
Neuroscience Program Coordinator
Revised 1/15/2010
surrounding structures should be
apparent. The patient may begin
to notice fluid buildup underneath
the incision line. This is common
and will be absorbed within 4-6
weeks. Unless there is an
odorous, thick colored drainage,
indicating an infection, there is no
need to become alarmed.
Office of Dr. Harold L. Rekate
Attention: Tracy Slack
500 W. Thomas Road, Suite 400
Phoenix, AZ 85013
Neuropsychology/Developmental
Pediatrician
 Evaluation is recommended at one year
after surgery at Barrow (preferred) or in
local area
 Asses for:
o
Short term memory loss
o
Word finding difficulty
o
Behavior difficulties
Endocrinology
 Follow up with local endocrinologist
within 60 days after returning home
 Request sodium check from primary
care physician or neurologist soon after
arriving home. If abnormal results are
shown see endocrinologist sooner.
 Observe thirst and urination patterns
 Obtain labs including electrolytes, CBC,
thyroid levels
o
Monitor for:
o
Diabetes Insipidus
o
Anemia
o
Thyroid disturbances
(wait approximately 2
months to assess thyroid
function in labs)
o
Weight gain secondary to
insatiable appetite
Therapies
 OT, ST, PT- as directed by specialty
Nutrition
 Small, frequent, balanced meals
 Protein in each meal
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Treatment Timetable
Members of surgical team will
discuss the surgical outcome with
the family. The patient will undergo
an MRI scan immediately after
surgery and then recover in the
Post Anesthesia Care Unit (PACU)
for about one hour. The family will
be notified at the time of arrival to
the PACU and will be able to visit
with patient when stable.
The lead physician changes during the
recovery process. The ICU provides
Hospitalists that manage the overall care
of the patient and communicate with each
specialist as needed. Once the patients
are on the regular nursing floor only the
pertinent specialist will follow the patients.
The neurosurgeon is responsible for
determining transfers out of the ICU as
well as discharge from the hospital.
The patient should expect to be
sedated after surgery. Recovery is
subjective and varies patient to
patient.
One parent of a pediatric patient is
permitted to stay overnight in the
ICU. Visitors are generally limited
to two at a time in most of the
ICUs.
Team rounds are completed daily
at different times of the day. Each
pertinent physician will see the
patient as needed.
Maggie Varland, RN, MBA
Barrow Hypothalamic Hamartoma
Neuroscience Program Coordinator
Revised 1/15/2010
Patients will have three to six miniature
titanium plates with screws in his/her head
placed to secure the bone that had been
removed during surgery. The only
exceptions are those patients that have an
endoscopic procedure. These implants
will not interfere with future MRI tests or
metal detectors; although MRI facilities
should be informed of their presence as
they may cause distortion on the studies.
Short-term memory (STM) loss is
expected in most patients and may
improve while in the hospital. Some
patients experience STM loss for several
weeks, months, or longer. It is not possible
to predict the length or severity of STM
problems in advance.
Patients may feel some discomfort from
the pin site where the surgical fixation
device was applied to their head in
surgery. This should subside quickly.
Overall incisional pain varies from patient
to patient and should be adequately
managed while in the hospital and upon
discharge.
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