Diary for Enhanced Recovery after Colorectal Surgery

This is a general booklet that covers all surgeries within a speciality.
For more specific information about your surgery you may want to
contact the specialist nurses who are involved with your care.
Completing your Daily Progress Record is really helpful, not only
to achieve your goals and monitor your progress, but to help us
collect important information so we can provide feedback to staff and
continually improve our Enhanced Recovery Programme.

Enhanced Recovery Programme

What is the Enhanced Recovery Programme (ERAS).
At Blackpool Teaching Hospitals NHS Foundation Trust we aim to
provide high standards of care based on current recommendations
and protocols. The enhanced recovery programme is part of this and
ensures that all members of the hospital and primary care staff work
together to ensure patients;

• Are kept fully informed of what is happening at all times to enable
you to make informed choices.
• Are as healthy / fit as possible before receiving treatment.
• Receive the best possible care during their operation.
• Receive the best possible care whilst recovering.
• Play an active role in your own recovery.

What the Enhanced Recovery Programme means to you
You will follow an ERAS programme which will provide you with daily
goals to strive to achieve. Please remember that these goals are set
to be worked towards, but everyone is an individual and will achieve
these goals at different times. Please do not be disheartened if you
don’t always meet your goals each day. This programme has input
from all members of the team that will treat you and includes:

• Pre-admission screening and information
• Good pain relief
• Improved sickness plan
• Early walking after surgery
• Early removal of catheters
• Less drips and drains
• Smaller wounds or keyhole surgery
• Early eating and drinking
• Reduced infection rates
• Shorter and more comfortable stay in hospital
• You feel involved in your care

This booklet will give you some information about the programme
and how you can play an active part in your recovery.

Pre-habilitation – Your role in preparing for surgery

Improve your fitness before your surgery
Moderate exercise before your operation will help strengthen your muscles and
build up stamina which will benefit your recovery after surgery. This will allow
you to mobilise earlier and reduce your risk of breathing problems such as
chest infections which are common after major surgery. Depending upon your
general fitness levels and the effects of any treatments you have already
undergone, you may have a reduced ability, try going for a walk twice a day and
increasing the distance over a period of time, to aid your personal fitness levels.

Walking, swimming, cycling and climbing stairs are all good ways of
improving your fitness and strengthen your core muscles. You should choose
an activity and an intensity that is appropriate for your current level of fitness.
Ideally the exercise should raise your heart rate and make you feel
breathless; however you should not be so breathless that you cannot hold a
conversation. Please document on the next page the exercise that you do in
the weeks leading up to your surgery – the more weeks you do the better!

Encouraging deep breathing and oral hygiene
Our aim both before and after your admission is to reduce the risk of you
developing any complications such as a chest infection. As well as your
increased activity level prior to surgery we would also like you to complete
regular deep breathing exercises both before and after your operation. These
are very important to reduce the risk of complications, we will be encouraging
you to carry them out as soon as you return from the operating theatre.

In order to perform the breathing exercises firstly sit upright, as your lungs will
expand better in this position. Place your hands on your tummy and breathe in
deeply through your nose, pushing your tummy out into your hands as you do
so. Try to hold your breath at the top for a count of 3 seconds and then slowly
breathe out through your mouth. Repeat this for a maximum of 5 times at
once, any more may cause you to experience dizziness or light headedness.
Try to perform these exercises 3-4 times a day at home in preparation for
your surgery which will help to improve your lung function. Good oral hygiene
is also important to reduces the risk of lung complications after major surgery
and improves your overall general health. Therefore brush your teeth for two
minutes and use an antiseptic or chlorhexidine mouthwash twice.

Exercise diary pre admission

7 days prior to surgery, walk or activity twice a day
Deep breathing exercises...............Oral hygiene twice a day..............
6 days prior to surgery, walk or activity twice a day
Deep breathing exercises...............Oral hygiene twice a day..............
5 days prior to surgery, walk or activity twice a day
Deep breathing exercises...............Oral hygiene twice a day..............
4 days prior to surgery, walk or activity twice a day
Deep breathing exercises...............Oral hygiene twice a day..............
3 days prior to surgery, walk or activity twice a day
Deep breathing exercises...............Oral hygiene twice a day..............
2 days prior to surgery, walk or activity twice a day
Deep breathing exercises...............Oral hygiene twice a day..............
The day before your surgery, walk or activity twice a day
............................................................................................................
Deep breathing exercises...............Oral hygiene twice a day..............

Its important to remember moderate exercise before surgery
will help strengthen your muscles and build up stamina which
will benefit your recovery, the longer you give your body to
build up stamina the better.

Your Role in Preparing for Surgery continued

Eating Well
Good nutrition is always important but it becomes even more vital
before and after surgery. After surgery you will have wounds that will
heal better if you have been eating a healthy balanced diet before
surgery.
Try and eat your recommended 5 portions of fruit and vegetables in
the days / weeks leading up to your admission, and include some
sort of protein in your meals (meat, chicken, fish, eggs, pulses).
Continue to eat and drink as normal the day before surgery. After
surgery we will give you supplement drinks to boost your vitamins,
mineral and protein intake. These are all essential elements needed
for wound healing and your post operative recovery.
Preload Drink
At the preadmission clinic you will be given a Preload drink that
you should take before surgery. This drink provides you with extra
carbohydrates that will help prepare your body for surgery. How
and when you should take this drink will be explained to you at
preadmission. This drink is an important part of your pre operative
build-up and it is essential that you take it as requested.
Sachet one, mix with 400mls of water and drink at _____________
Sachet two, mix with 400mls of water and drink at _____________

If you are a diabetic who takes insulin you will not be given
the pre-load drink. It is important that you continue to eat and
drink normally the day before surgery. Please have supper
before 10pm and follow the instructions given to you at
pre-admission clinic.

Smoking and Alcohol
In order for you to be in the best possible health for your surgery we
recommend that you ideally stop (or at least reduce) your alcohol
and cigarette intake. Smoking significantly increases your risk of
developing a chest infection and also slows down the healing process
causing problems with your wounds. Alcohol can also suppress the
immune system meaning a much higher risk of complications following
surgery. If you do smoke or drink please use this as an opportunity
to stop or cut down as smoking increases your risk of developing
complications. Cutting back or stopping completely will help speed up
the healing process, speed up your recovery and reduce the risk of
complications occurring, reducing your stay in hospital.
For smoking cessation advice or drop in clinic times please call
Stop Smoking Services on:
• Blackpool - 01253 957457
• North Lancashire - 08081964324
Likewise If you require support with reducing your alcohol
consumption please contact your GP or ask the nurses to contact
our Hospital Alcohol Liaison Team (HALS) – 01253 953943.
Planning Your Discharge
We will talk to you about your discharge before you come into
hospital. Most people want to leave hospital as soon as possible and
in order to make your discharge a smooth process we start to plan
for this before you are admitted. It is helpful for you to talk to your
relatives, carers or friends about what help and support you will need
following your discharge home.
If you live alone it is essential that you consider what help you may
need when you go home. It is unlikely that you will be able to do
many everyday jobs such as lift shopping bags, push hoovers or
mop floors when you first go home. You may need a relative to stay
with you for a short time after your operation. Please tell us as early
as possible if you have concerns about managing at home after
your discharge from hospital. We can discuss support and the other
options available to you and begin to organise your discharge.
Your estimated length of stay will vary according to your pre op
fitness level.

Planning your stay

We recognise that coming into hospital can be very daunting.
Planning ahead for when you get home can help reduce stress.
Below are some practical points to remember.
Check list
• I know my expected date for discharge (going home).
• I have informed the relevant people where I will be.
• I have all my medication ready to take with me.
• I have packed a small bag (e.g. loose day clothes, night clothes,
non-paraffin based lip balm, toiletries, reading material, good
fitting shoes and slippers).
• I have arranged my transport to and from hospital.
• I have checked I have the right equipment and support in place
when I get home.
• I have taken any pre-operative bowel prep discussed at
preadmission.
• Write a list of questions I want to ask so I do not forget.
Some of these questions may be:
• When can I have a shower or bath?
• When can I drive again? When can I go back to work?
• Who can I contact if I have any concerns or questions when
I get home?
• I know where to go on my day of admission?
• I have the following details?
I am expecting to stay in hospital for__________________nights
I can eat and drink normally until:_ _______________________
I can have clear fluids until:_____________________________
I must be nil by mouth from:____________________________
Medication instructions:________________________________

Working Together to Achieve your Postoperative Goals

We aim to manage your care for your individual needs after your
operation. Your daily goals are designed to help get you back to your
normal level of activity as soon as possible. Getting fitter quicker
and home sooner means returning to normal life sooner. This will be
done by incorporating the following;
Performing Lower Risk Surgery
Wherever possible we aim to perform surgical techniques with
smaller wounds or keyhole surgery. We aim to remove tubes, drains
and drips as soon as it is safe to do so, this helps reduce the risk of
infection and helps you to mobilise more freely and easily.
Reducing Your Pain
Good effective pain control is an essential part of your recovery, if your
pain is well controlled you will be able to breathe easily, walk about,
eat, drink, sleep well and participate effectively in your physiotherapy
regime. It may also reduce the chance of complications occurring.
• If you can breathe deeply and cough easily after your operation,
you are less likely to develop a chest infection
• If you can move around freely, you are less likely to develop
a blood clot (venous thromboembolism or VTE) in the legs or
elsewhere.
After your surgery you may be given a number of different pain
relieving therapies, in either tablet or liquid form, via a fentanyl patch
stuck to your arm or directly into a cannula in your arm or the back of
your hand. It may be appropriate for you to have more than one form
of pain relief.
It is therefore essential that you let us know if your pain relief is
not effective or starts to be less effective than it was. Staff will
encourage you to play an active role by regularly asking you to
record your pain out of 10 (you will see this scoring system in your
daily progress record later on in this book).
Additional painkillers are available and the specialist pain team can
see you if needed to help you achieve your daily targets and help
make you more comfortable.

Encouraging early movement and activity
Regular deep breathing exercises after your operation, carried out as
soon as you return from the operating theatre, will reduce the risk of
developing a chest infection.
Performing leg and ankle movements every hour can reduce your
chances of developing a blood clot (VTE). Depending on your reasons
for surgery you may be commenced on blood thinners such as
Deltaparin via an injection to avoid VTE. If it is deemed appropriate
this will be commenced in hospital and discussed along with your other
medications prior to discharge.
Following your surgery if safe to do so you will be encouraged to get
out of bed on the day of your operation and to sit out in a chair for at
least two hours. You will then be seen by a Physiotherapist the day
after your operation when all patients, if clinically fit, will get out of bed
and aim to be out of bed for at least eight hours throughout the day.
Short rests on the bed through out the day are allowed.
Early mobility will be encouraged by the staff and Physiotherapists,
however it is important that you understand the importance of taking
an active role in your own mobility. Mobilising around your bedspace
or walking around the ward area 3-5 times a day starting on the day
after your surgery is a vital part of your recovery plan.
Completing your Daily Progress Record will help you achieve
these goals
Encouraging Early Eating and Drinking
Most of our patients are encouraged to eat and drink normally and
as soon as they want after their operation. The nutrition helps your
body to recover more quickly. Sometimes surgery and medication can
make you feel nauseated (sick), please let us know if you feel sick as
we can give you medication to settle this feeling. Staff will encourage
you to play an active role by regularly asking you to record your score
for nausea, in order for us to be able to treat your nausea with the
appropriate medication. When you are allowed to drink we want you
to aim for 2 litres of oral fluid a day.
We will also supplement your diet with high protein and calorie drinks
for a few days after surgery. We also advise a low fibre diet for the
first six weeks to avoid complications, opt for low fibre cereals when choosing your meals such as cornflakes or rice crispies, trying to
avoid branflakes or Weetabix. Choose white bread, pasta or rice
instead of brown or whole- meal and avoid leafy green vegetables.
Staff will be happy to advise you.

Recovery goals and targets

Its important you mobilise as much as possible. Before your ‘drips’
and ‘drains’ are removed you will be able to carry or push them
around with you. Mobilisation is the key to your recovery. Below
is a list of goals / targets you should be able to achieve prior to
discharge, we acknowledge that every patient is an individual and
everyone will achieve these goals at their own pace, so please
document the post operative day on which the goal was achieved,
for your own reference and to keep you motivated with the Enhanced
Recovery Programme.

Your Daily Progress Record

Prior to coming into hospital please have a look at the next section of
your booklet. This is your ‘Daily Progress Record.’ Please familiarise
yourself with this before your admission. Please remember to bring
your booklet with you on your admission day so you can complete
your daily progress record.
Why we would like you to fill in a Daily Progress Record
We ask all our Enhanced Recovery patients to complete a patient
diary. Using the diary will help you:
• Achieve your goals and track your progress
• Help you recover more quickly, with fewer complications
• Help staff in helping you to recover
How to Use the Daily Progress Record
The diary covers all types of surgery and therefore covers 6 days.
Once you are ready to go home there is no need to continue the
diary. The nursing staff will explain the purpose of the diary to you
but if you need further help with completing it please ask.
Please cross the box each time you do the task mentioned. For
example, if you sat out in the chair twice.
Sat in the chair twice X X
If you didn’t then put the reason why (for example)
If not, why? I felt dizzy
At the end of each day you are asked to mark on the line your overall
pain score in the last 24hrs. The smiley face is no pain and the sad
face is the worst pain. Below is an example

  1      2       3        4         5         6          7          8        9       10 

no pain                                                                        severe pain

Surgery Diary to be completed (please upload the Leaflet PDF above to see this )

Planning your Discharge

Who to Contact
We recognise that coming in for any surgery can be a very stressful and
emotional time and you may be apprehensive about it but these feelings
are normal. The staff will be able to help answer any questions you may
have before, during or after your stay in hospital. Please ensure you
have the relevant contact numbers you may need. The contact names
and numbers will vary depending upon the type of surgery you have.
Contact details
Switchboard: 01253 300000
Enhanced Recovery Nurses: 01253 956549
Colorectal Nurse Specialists: 01253 956620
Clinical Area of discharge: ..................................................................
Ward Number: ....................................................................................
When You Leave Hospital
We expect your recovery to progress well following your discharge
but occasionally complications may occur following major surgery. It
is important you know what to look out for. If you are worried about
any of the following please contact us on the numbers above. If you
are unable to contact any of the numbers above please contact your
GP or phone 111 for out of hours emergency care.
Your Wound
It is not unusual for the wound to be uncomfortable for the first
2 weeks. Please let us or your GP know if your wound becomes
progressively inflamed(very red), painful or swollen, or starts to
discharge fluid or begins to open.
Blood Clots
Surgery increases the risk of blood clots, which is why it is important
to maintain your mobility after surgery. You will need urgent medical
attention if your calf becomes progressively painful or swollen or if
you develop shortness of breath.

Sexual activity
Resume sexual intercourse once you feel confident to do so. If you
remain relaxed and possibly adopt a more passive role, you may
return more easily to your normal routine. After some operations
however this time may be extended. Please talk to your consultant or
nurse specialist about this further.
Bowels
Following surgery on your bowel you may find your stools are looser
and you may get increased wind or bloating. This is normal whilst the
bowel recovers from surgery, make sure you eat regularly and drink
plenty of fluids. For the first six weeks after surgery we advise a low
fibre diet. This will be discussed with you prior to discharge and you
will be given a diet information sheet. If you are constipated for more
than 3 days please contact us or your GP for advice.
Exercise
You should take regular gentle exercise several times a day.
Gradually increase your exercise during the 4 weeks following your
operation until you are back to your normal level of activity. Do not
attempt to lift anything heavy for 6-8 weeks after surgery.
Driving
There is no exact specified time or law that determines when it is
safe to drive after surgery. Do not drive until you are confident you
can drive safely and perform an emergency stop. This is usually at
least 6 weeks after surgery. If you are still taking strong pain killers,
which is unlikely, they will affect your ability to drive.
It is recommended that you check with your car insurance company
before you start driving again.
Follow-up
You will receive a follow-up appointment via the post. The date will
depend on your surgeon and the type of surgery you have had. The
ward staff and surgical team will be able to advise you when it is
likely to happen.

I am fit enough to go home today
Date of discharge …………………………………

We are aware this PDF are might not be accessible to all users. If you would like to request an accessible version, please contact bfwh.trustpolicyteam@nhs.net 

Read our accessibility statement to learn more. 

Author Enhanced Recovery after Colorectal Surgery 

Approved by SACCT Clinical Quality Safety and Governance Committee Meeting 

Date of Publication 12/03/2024 

Review Date 01/03/2027 

Reference No PL/982 (v3)