Post on 24-Feb-2018
OAI - 33800 R00 © 1998, 2003, 2009 Sunnybrook Health Sciences Centre, operating as the Holland Orthopaedic & Arthritic Centre. All rights reserved.
KNEE REPLACEMENT CARE PATHWAY
PATIENT IDENTIFICATION
OAI33800(2009/01/28)
Page 1 of 16
DISCHARGE CHECKLIST/GOALSDISCHARGE PLAN as per pre-admission: (specify)
Anticipated discharge date: Date cleared for discharge:
Pain control adequate
PAIN CONTROL & MEDICATIONS
Discharge medications reviewed with patient
Patient’s own medications returned at discharge Prescription for medications provided
Specify:
Satisfactory mobility to meet home requirements
PHYSICAL FUNCTION & SAFETY
Ambulation + gait aids (specify):
Understanding of any restrictions/precautions
Able to perform home ADL independently or has assistance arranged
Stairs:
Method of transportation
TRAVEL PLANS
Transportation booked and confi rmed Time: Date: Duration of trip:
Strategies to manage trip home discussed including pain management strategy Specify:
DISCHARGE INSTRUCTIONS
Holland Centre Guide discharge instructions completed, reviewed with patient
APPOINTMENT CARD(s) Cards completed and given to patient
CCAC: nursing / PT / OT / PSW / home safety assessment
APPROPRIATE REFERRALS COMPLETED
Out-patient physiotherapy
Rehabilitation Hospital
Other: specify
Application submitted on Transfer date: Time: confi rmed
YYYY/MM/DD YYYY/MM/DD
Reason(s) for delay (specify):
YYYY/MM/DDYYYY/MM/DD (h)
YYYY/MM/DD(h)
YYYY/MM/DDPrint Name Signature Designation Initial Date
OAI - 33800 R00 © 1998, 2003, 2009 All rights reserved.
Patient Name: HFN #:
PRE-ADMISSION
OAI33800(2009/01/28)
Fluid/Nutrition/Elimination
Medications
Activity
Page 2 of 16
Patient/family Perspective
Patient’s coach identifi ed; coach’s involvement discussed
Discuss patient/family perspective, needs & concerns
Identify patient’s coach
Systems Assessments/ Treatments
Assessment Intervention Evaluation. Teaching occurs with each patient contact during hospital stay
Complete/update interdisciplinary assessment form and pre-admission medication list
Complete Braden skin risk assessment record
Complete in-patient allergy record
Consultations:
Medical internist
Anaesthesiologist
Social Work
Physiotherapy
Complete education/tests
Measure height & weight
Screen/explain/recruit for clinical trials
Research consultation
Patient has received “A guide for patients having hip or knee replacement” and DVD
Patient instructed to review and sign partnership agreement
Complete admission information
Assessment completed
No S&S of pressure sores
Allergies & sensitivities identifi ed/ documented
Height cm Weight kg
Consultations completed
Understanding verbalized by patient/family
Patient understands need to review & sign partnership agreement
Patient verbalizes understanding
Pre-operative NPO routine
Understanding verbalized
Assess Rehab functional measures
*see Assessment Centre
Understanding verbalized
Understanding verbalizedMedications to take the morning of surgery documented/reviewed
Medications to be discontinued before surgery documented & reviewed
Demonstration and review of:
-deep breathing & coughing exercises
-foot & ankle pumping exercises
INTERVENTIONS OUTCOMES
Patient able to demonstrate
Initiate discharge planningDischarge Discharge Plan:
Home independent Home with out-patient physio
Home with CCAC FIT
External rehab Other
Patient/family perspective; needs and concerns documented in interdisciplinary progress notes
YYYY/MM/DD
D D
OAI - 33800 R00 © 1998, 2003, 2009 All rights reserved.
Patient Name: HFN #:
Print Name Signature Designation Initial Print Name Signature Designation Initial
OAI33800(2009/01/28)
Discuss patient perspective, needs and concerns
Page 3 of 16
Insertion well tolerated by patient; no diffi culty inserting
Catheter type:Size:Location:
No solid foods consumed
Date of last (BM)
Usual BM pattern
Insert IV catheter/saline lock as per physician order
Assess patient’s bowel routine
Provide oral fl uids as ordered
Type:
Amount: mL
Discuss patient/family perspective, needs and concerns
Identify patient’s coach Patient’s coach identifi ed;coach’s involvement discussed
Complete pre-operative checklist
Perform skin assessment: complete Braden skin risk assessment record
Assess baseline vital signs/SpO2/pain
Document neurovascular baseline status on neurovascular assessment form
Demonstration & review of deep breathing/coughing & foot/ankle pumping exercises
Review post-op pain management strategies
Glucose point of care testing (POCT)
Pre-op routine completed
No S&S of pressure sores
Assessment fi ndings normal for patient
Satisfactory neurovascular status
Patient able to demonstrate
Understanding verbalized by patient/family
Blood glucose within acceptable range for patient
Glucose POCT result (mmol/L)
Perform patient identifi cation actions and verify operative site
Surgical intervention uneventful; operative extremity warm with no reddened/broken skin when tourniquet removed
Document interventions on: Block area record; anaesthetic record;intraoperative electronic patient record; recovery room record
Administer prophylactic antibiotic(s)
Patient/family Perspective
SAME DAY ADMISSION - DAY 0 BLOCK/OR/PACU - DAY 0OUTCOMES OUTCOMESINTERVENTIONS INTERVENTIONS
Fluid/Nutrition/Elimination
Medications No negative effects
Antibiotic(s) administered on time; no negative effects
Administer anaesthesia and medications:
General anaesthesiaSpinal anaesthesiaSingle shot femoral nerve blockSingle shot sciatic nerve blockContinuous femoral nerve blockContinuous sciatic nerve blockEpidural analgesiaPosterior capsular infi ltration
BP (mmHg) HR (bpm)Temperature (ºC) SpO2 (%)Pain Score (0-10)
Systems Assessments/ Treatments
Patient/family perspec-tive; needs and concerns documented in interdisciplinary progress notes
Patient/family perspective; needs and concerns documented in interdisciplinary progress notes
Update medications
Administer pre-operative medications as ordered; document on pre-printed order form
Pharmacy care
Verify patients own medications
No negative effects
Pharmacy care provided
YYYY/MM/DD
YYYY/MM/DD
D D D D
Surgeon
OAI - 33800 R00 © 1998, 2003, 2009 All rights reserved.
Patient Name: HFN #:
INTERVENTIONS OUTCOMESYYYY/MM/DD
OAI33800(2009/01/28)
POST-OP DAY 0
Patient/family Perspective
Discuss patient/family perspective, needs and concerns
Identify patient’s coach Patient’s coach identifi ed; coach’s involvement discussed
Systems Assessment/Treatment
No excessive drainage/bleeding; no need to re-enforceMonitor dressing; assess for S & S of bleeding
Patient performs regular foot and ankle exercisesEncourage hourly foot/ankle exercises
Patient turned at least q4h
Discuss use of side rails with patient Patient agrees with plan; understanding verbalized
Review lab results; order blood work No critical lab results
Perform glucose point of care testing; document results on clinical fl ow sheet
Blood glucose within acceptable range for patient
Provide hygiene & skin care; complete Braden skin risk assessment record
No S & S of pressure sores; skin integrity maintained
Satisfactory neurovascular statusNeurovascular assessment; document on neurovascular assessment form
Level of spinal anaesthesia decreasing as expectedPerform spinal dermatome testing; document on pain fl ow sheet
No S & S of delirium/confusion; pt easy to arouse; no dizziness/drowsiness
Neurological assessment
Patient performs deep breathing and coughing as instructedEncourage patient to perform hourly deep breathing and coughing
No adventitious breath sounds; no S & S of respiratory distress/respiratory depression; Sp02 >90% maintained
Assess respiratory system; monitor SpO2/administer 02 as ordered; document on clinical fl ow sheet
BP and HR within acceptable limits for patient; Respiratory rate > 10, < 24 per min; Temperature < 38.0°C; pain score 3/10 or mild
Assess vital signs, pain score and pain location as per policy; document on clinical fl ow sheet
Help patient to turn in bed q2h q4h
Page 4 of 16
Assess for S & S of VTE No S & S of VTE
Patient/family perspective; needs and concerns documented in interdisciplinary progress notes
Fluid/Nutrition/Elimination
Administer IV fl uids as ordered; monitor IV insertion site; document on clinical fl ow sheet
Administer blood; document on clinical fl ow sheet
Monitor total fl uid input and output; complete fl uid shift balance; document on clinical fl ow sheet
Monitor BM
Ordered amount absorbed; IV infusing well; no S & S of complications at insertion site
No S & S of transfusion reaction
No S & S of hypovolemia/volume overload; clear odourless urine > 300mL over 12 hours
No abdominal discomfort/distension; no diarrhea
Assess food intake Increase diet as tolerated Assess nausea and vomiting; diet as per physician order
Light diet tolerated; minimized nausea and vomiting
Insert urinary catheter if indicated Urinary catheter inserted; no concerns
Assess abdomen No S & S of ileus; no S & S of urinary retention
Amount: small medium large
Consistency: hard formed loose liquid
Time of BM:(h)
ED ED
OAI - 33800 R00 © 1998, 2003, 2009 All rights reserved.
Patient Name: HFN #:
INTERVENTIONS OUTCOMESYYYY/MM/DD
Print Name Signature Designation Initial Print Name Signature Designation Initial
OAI33800(2009/01/28)
Page 5 of 16
Medications
POST-OP DAY 0
All ordered medications given/taken
Pharmacy care provided
Patient understands use of PCANo negative effectPatient satisfi ed with pain management
Administer medications; document on MAR
Pharmacy care
Monitor patient controlled analgesia (PCA); document on pain fl ow sheet
Verify patient’s own medications
No negative effect; patient satisfi ed with pain management
No negative effect; patient satisfi ed with pain management
Monitor continuous femoral nerve block; document on pain fl ow sheet
Monitor epidural analgesia; document on pain fl ow sheet
Perform MAR check against physician orders; initial last page of MAR in upper right corner
Perform 24-hour chart check; draw red line and initial/date after last order
All orders transcribed; MAR correct; yellow copies sent to pharmacy
Activity Unicompartmental
Total knee replacement
Patellar resurfacing
Bilateral
Activity restrictions
Assist sitting at edge of bed
Revision:
Tibia Femur Patella
Assist sitting to standing
WEIGHT BEARING (WB) STATUS
Non WB
Touch WB
Partial WB
WB as tolerated
Sat with assistance x /supervision
Stood with assistance x /supervision
Other restrictions Specify:
EDED
Left Right
OAI - 33800 R00 © 1998, 2003, 2009 All rights reserved.
Patient Name: HFN #:
INTERVENTIONS OUTCOMESYYYY/MM/DD
OAI33800(2009/01/28)
Patient/family Perspective
POST-OP DAY 1
N EDDiscuss patient/family perspective, needs and concerns
Identify patient’s coach Patient’s coach identifi ed; coach’s involvement discussed
Systems Assessment/Treatment
Assess vital signs, pain score and pain location as per policy; document on clinical fl ow sheet
Assess respiratory system; monitor SpO2/ administer 02 as ordered; document on clinical fl ow sheet
Encourage patient to perform hourly deep breathing and coughing while awake
Neurological assessment
Neurovascular assessment; document on neurovascular assessment form
BP and HR within acceptable limits for pt.; respiratory rate > 10, < 24 per min; Temp. < 38.0°C; pain score 3/10 or mild
No adventitious breath sounds; no S & S of respiratory distress Sp02 >90% maintained
Patient performs deep breathing and coughing as instructed
No S & S of delirium/confusion; patient easy to arouse; no dizziness/drowsiness Satisfactory neurovascular status
Fluid/Nutrition/Elimination
Page 6 of 16
N EDPatient/family perspective; needs and concerns documented in interdisciplinary progress notes
Encourage hourly foot/ankle exercises while awake
Check dressing every shift; assess for S & S of bleeding
Apply ice pack as needed for swelling and pain
Provide hygiene & skin care; complete Braden skin risk assessment record
Help patient to turn in bed q2h q4h
Discuss use of side rails with patient
Perform glucose point of care testing as ordered
Review lab results; order blood work
Hourly night checks
Medications Administer medications; document on MAR
Pharmacy care
Monitor patient controlled analgesia; document on pain fl ow sheet
Verify patient’s own medications
Administer IV fl uids as ordered; monitor IV insertion site; document on clinical fl ow sheet
Assess food and fl uid intake; diet as ordered; assess nausea and vomiting
Administer blood; document on clinical fl ow sheet
Monitor total fl uid input and output; complete fl uid shift balance; document on clinical fl ow sheet
Insert new peripheral IV catheter if indicated
Insert urinary catheter if indicated
Assess abdomen
Amount: small medium large
Consistency: hard formed loose liquid
Monitor BM Time of BM:(h)
Ordered amount absorbed; IV infusing well; no S & S of complications at insertion site
No S & S of hypovolemia/volume overload; clear odourless urine > 300mL over 12 hours
No signs and symptoms of transfusion reaction
IV catheter inserted; no concerns
Urinary catheter inserted; no concerns
No S & S of ileus; no S & S of urinary retention
No S & S of constipation; no diarrhea
Light diet tolerated; minimized nausea and vomiting
Patient performs regular foot and ankle exercises
Patient understands strategies to reduce swelling and pain
Dressing clean and intact; no excessive drainage/bleeding, no need to re-enforce
No S & S of pressure sores; skin integrity maintained
Patient turned at least q4h
Patient agrees with plan; understanding verbalized
Blood glucose within acceptable range for patient
No critical lab results
No concerns identifi ed
All ordered medications given/taken
Pharmacy care provided
Patient understands use of PCA; no negative effect;patient satisfi ed with pain management
OAI - 33800 R00 © 1998, 2003, 2009 All rights reserved.
Patient Name: HFN #:
INTERVENTIONS OUTCOMESYYYY/MM/DD
Print Name Signature Designation Initial Print Name Signature Designation Initial
OAI33800(2009/01/28)
POST-OP DAY 1
Page 7 of 16
Medications Monitor continuous femoral nerve block; document on pain fl ow sheet
Monitor epidural analgesia; document on pain fl ow sheet
Perform MAR to MAR check; initial last page of MAR in upper right corner
Perform 24-hour chart check; draw red line and initial/date after last order
No negative effect; patient satisfi ed with pain management
No negative effect; patient satisfi ed with pain management
Anticoagulant received; no S & S of excessive bleeding; no S & S of VTE
All orders transcribed; MAR correct; yellow copies sent to pharmacy
Activity Informed consent for Physiotherapy assessment and treatment
Consent for treatment by Physiotherapy Assistant
Elevate operative leg with knee extended. Follow guidelines re: positioning and splint use
Education: Exercise as per exercise book
Informed consent obtained
Consent obtained
Prevention of increased swelling and fl exion contractureSplint at night yes no discontinued
Exercise book providedExercise(s) demo as per list
Amb with assistance
Assess ROM
Assess Functional Measure(s)
Education: transfer techniques. Assist sitting at edge of bed.
Assist sitting to standing
Discharge Reassess progress and confi rm discharge plan Discharge as per POP plan
Other
FIT
Home Indep. exercisesOut-patient physiotherapy
CCAC
External Rehab
Anticoagulation
Expected discharge/transfer day 3 4 5 other specify reasons for delay
Referral completed, yes/no
PT / OT / PSW / home safety asessment / referral initiated / completed
FIT orders completed
Specify:
Application initiated/completed
N ED
Amb with assistance withAmb distance metersAmb with splint yes no discontinuedWB as tolerated Partial WB Touch WB Non WB (permitted)
Other
Transferred with assistance x /Supervision/Indep.
Transferred with assistance x /Supervision/Indep.
ROM p a/a a -degrees- - (Rt) -degrees- - (Lt)
ED
OAI - 33800 R00 © 1998, 2003, 2009 All rights reserved.
Patient Name: HFN #:
INTERVENTIONS OUTCOMESYYYY/MM/DD
OAI33800(2009/01/28)
POST-OP DAY 2
Patient’s coach identifi ed; coach’s involvement discussed
N EDPatient/family Perspective
N EDDiscuss patient/family perspective, needs and concerns
Identify patient’s coach
Systems Assessment/Treatment
Fluid/Nutrition/Elimination
Pharmacy care Verify patient’s own medications Pharmacy care provided
Page 8 of 16
Patient/family perspective; needs and concerns documented in interdisciplinary progress notes
Discontinue IV fl uids ; document on clinical fl ow sheet
Assess food intake; diet as ordered; assess nausea & vomiting
Saline lock left in situ; document on patient care plan
Monitor total fl uid input & output; complete fl uid shift balance until IV fl uids discontinued; document on clinical fl ow sheet
Assess abdomen
Discontinue peripheral IV access if drinking well; document on clinical fl ow sheet
Administer blood; document on clinical fl ow sheet
Provide education on stool softener
Amount: small medium large
Consistency: hard formed loose liquid
Monitor BM Time of BM:(h)
Assess vital signs, pain score and pain location as per policy; document on clinical fl ow sheet
Assess respiratory system; monitor SpO2; administer 02 as ordered; document on clinical fl ow sheet
Encourage patient to perform hourly deep breathing and coughing while awake
Neurological assessment
Neurovascular assessment; document on neurovascular assessment form
Encourage hourly foot/ankle exercises while awake
Perform dressing change using maximum barrier technique
Check dressing every shift
Apply ice pack as needed for swelling and pain
Provide hygiene & skin care; complete Braden skin risk assessment record
Help patient to turn in bed q2h q4h
Discuss use of side rails with patient
Perform glucose point of care testing as ordered
Review lab results; order blood work
Hourly night checks
BP and HR within acceptable limits for pt.; respiratory rate > 10, < 24 per min; Temp. < 38.0°C; pain score 3/10 or mild
No adventitious breath sounds; no S & S of respiratory distress; Sp02 >90% maintained
Patient performs deep breathing and coughing as instructed
No S & S of delirium/confusion; patient easy to arouse; no dizziness/drowsiness
Satisfactory neurovascular status
Patient performs regular foot and ankle exercises
Incision edges approximated/no open gaps; minimal amount of sanguineous or serous exudate; no purulent drainage
Patient understands strategies to reduce swelling and pain
Dressing clean and intact
No S & S of pressure sores; skin integrity maintained
Patient turned at least q4h
Patient agrees with plan; understanding verbalized
Blood glucose within acceptable range for patient
No critical lab results
No concerns identifi ed
Ordered amount absorbed; IV infusing well; no S & S of complications at insertion site
No S & S of hypovolemia/volume overload; clear odourless urine > 300mL over 12 hours
No S & S of ileus; no S & S of urinary retention
Saline lock fl ushed q8H
Removed catheter intact, site satisfactory
No S & S of constipation; no diarrhea
50% of meal consumed; no nausea and vomiting
No S & S of transfusion reaction
Patient understands the need for stool softener
Medications Administer medications; document on MAR All ordered medications given/taken
OAI - 33800 R00 © 1998, 2003, 2009 All rights reserved.
Patient Name: HFN #:
INTERVENTIONS OUTCOMESYYYY/MM/DD
Print Name Signature Designation Initial Print Name Signature Designation Initial
OAI33800(2009/01/28)
POST-OP DAY 2
Medications Monitor patient controlled analgesia; document on pain fl ow sheet
Perform MAR to MAR check; initial last page of MAR in upper right corner
Perform 24-hour chart check; draw red line and initial/date after last order
Discontinue patient controlled analgesia; document on pain fl ow sheet
Monitor continuous femoral nerve block; document on pain fl ow sheet
Discontinue continuous femoral nerve block
Monitor epidural analgesia; document on pain fl ow sheet
Remove epidural catheter
All orders transcribed; MAR correct; yellow copies sent to pharmacy
No negative effect; patient satisfi ed with pain management
Removed catheter intact; no signs and symptoms of site infection/bleeding
No negative effect; patient satisfi ed with pain management
Patient agrees to switch to oral pain management
Patient understands use of PCA; no negative effect; patient satisfi ed with pain management
Page 9 of 16
Activity Elevate operative leg with knee extended; follow guidelines re positioning and splint use
Education: exercise (s) as per exercise book
Reinforce transfer techniques; sitting at edge of bed
Assess ROM
Assess Functional Measure(s)
Sitting to standing
Encourage sitting as tolerated
Education: ambulation
OT assessment
Prevention of increased swelling and fl exion contractureSplint at night yes no
Exercise(s) reviewed/demo added as per list
Transferred with assistance x /Supervision / Indep.
Transferred with assistance x /Supervision / Indep.
Refer to OT ADL Assessment Form
Other
Amb with assistance / supervision / independent withAmb distance metersAmb with splint yes noWB as tolerated Partial WB Touch WB Non WB (permitted)
Anticoagulation Anticoagulant received; no S & S of excessive bleeding; no S & S of VTE
Discharge Reassess progress and confi rm discharge plan Discharge as per POP plan
Other
FIT
Home Indep. exercisesOut-patient physiotherapy
CCAC
Expected discharge/transfer day 3 4 5 other specify reasons for delay
Referral completed, yes/no
PT / OT / PSW / home safety asessment / referral initiated / completed
FIT orders completed
External Rehab
Specify:
Application initiated/completed
N ED
ROM p a/a a -degrees- - (Rt) -degrees- - (Lt)
N ED
OAI - 33800 R00 © 1998, 2003, 2009 All rights reserved.
Patient Name: HFN #:
INTERVENTIONS OUTCOMESYYYY/MM/DD
OAI33800(2009/01/28)
POST-OP DAY 3
Patient’s coach identifi ed; coach’s involvement discussed
N EDPatient/family Perspective
N EDDiscuss patient/family perspective, needs and concerns
Identify patient’s coach
BP and HR within acceptable limits for pt.; respiratory rate > 10, < 24 per min; Temp. < 38.0°C; pain score 3/10 or mild
No adventitious breath sounds; no S & S of respiratory distress; Sp02 >90% maintained
No S & S of delirium/confusion; patient easy to arouse; no dizziness/drowsiness
Satisfactory neurovascular status
Incision edges approximated/no gaps; no drainage/bleeding
Patient understands strategies to reduce swelling and pain
No S & S of pressure sores; skin integrity maintained
Blood glucose within acceptable range for patient
No critical lab results
No concerns identifi ed
Systems Assessment/Treatment
Assess vital signs, pain score and pain location; document on clinical fl ow sheet
Assess respiratory system; monitor SpO2; document on clinical fl ow sheet
Patient to continue deep breathing and coughing
Neurological assessment
Neurovascular assessment; document on neurovascular assessment form
Patient to continue foot/ankle exercises
Check surgical incision; reapply new dressing if incision not healed or if requested by patient
Apply ice pack as needed for swelling and pain
Assist patient with hygiene & skin care; complete Braden skin risk assessment record
Perform glucose point of care testing as ordered
Review lab results; order blood work
Regular night checks
Patient is drinking suffi cient amount/not vomiting; removed catheter intact; site satisfactory
No S & S of ileus
IV catheter inserted, no concerns
No S & S of constipation; no diarrhea
50% of meal consumed; no nausea and vomiting
No signs and symptoms of anaemia
BM as per usual pattern; patient understands the need for stool softener
Fluid/Nutrition/Elimination
Assess food intake; diet as ordered; assess nausea and vomiting
Discontinue saline lock; document on patient care plan
Assess abdomen
Insert new peripheral IV catheter if IV fl uids/medications continued; document on patient care plan
Administer blood; document on clinical fl ow sheet
Provide education on stool softener
Provide laxitive if no BM
Give suppositories if no BM; document on MAR
Patient accepts initiation of additional bowel routine strategies
No S & S of urinary retension. Adequate amount clear odourless urine voided
Page 10 of 16
Amount: small medium large
Consistency: hard formed loose liquid
Patient/family perspective; needs and concerns documented in interdisciplinary progress notes
Monitor BM Time of BM:(h)
OAI - 33800 R00 © 1998, 2003, 2009 All rights reserved.
Patient Name: HFN #:
INTERVENTIONS OUTCOMESYYYY/MM/DD
Print Name Signature Designation Initial Print Name Signature Designation Initial
OAI33800(2009/01/28)
POST-OP DAY 3
Activity Prevention of increased swelling and fl exion contractureSplint at night yes no discontinued
Exercise(s) reviewed/demo added as per list
Transferred with supervision / Indep.
Elevate operative leg with knee extended. Education: regarding fl exion contracture
Education: exercise(s) as per exercise book
Reinforce transfer techniques.
Page 11 of 16
Medications Administer medications
Pharmacy care
All ordered medications given/taken
Pharmacy care provided
Perform MAR to MAR check; initial last page of MAR in upper right corner
Perform 24-hour chart check; draw red line and initial/date after last order
Monitor effectiveness of oral analgesics and adverse effects: document on clinical fl ow sheet/progress notes
All orders transcribed; MAR correct; yellow copies sent to pharmacy
Patient satisfi ed with pain management
Anticoagulant received; no S & S of excessive bleeding; no S & S of VTE
Anticoagulation
Specify:
Discharge Reassess progress and confi rm discharge plan Discharge as per POP plan
Other
FIT
Home Indep. exercisesOut-patient physiotherapy
CCAC
Expected discharge/transfer day 3 4 5 other specify reasons for delay
Referral completed, yes/no
PT / OT / PSW / home safety asessment / referral initiated / completed
FIT orders completed
External Rehab Application initiated/completed
N ED
Sitting up in chair >45 min
Refer to OT ADL Assessment Form
Other
Assess ROM
Assess Functional Measure (s)
Encourage sitting as tolerated
Education: ambulation
OT assessment
Amb with supervision / independent with
Amb distance metersWB as tolerated Partial WB Touch WB Non WB (permitted)
If home education: stair technique Stairs managed assist / supervision / indep.
ROM p a/a a -degrees- - (Rt) -degrees- - (Lt)
N ED
OAI - 33800 R00 © 1998, 2003, 2009 All rights reserved.
Patient Name: HFN #:
INTERVENTIONS OUTCOMESYYYY/MM/DD
OAI33800(2009/01/28)
POST-OP DAY 4
Patient’s coach identifi ed; coach’s involvement discussed
N EDPatient/family Perspective
N EDDiscuss patient/family perspective, needs and concerns
Identify patient’s coach
BP and HR within acceptable limits for pt.; respiratory rate > 10, < 24 per min; temp. < 38.0°C; pain score 3/10 or mild
No adventitious breath sounds; no S & S of respiratory distress Sp02 >90% maintained
Satisfactory neurovascular status
Incision edges approximated/no gaps; no drainage/bleeding
Patient understands strategies to reduce swelling and pain
No signs and symptoms of pressure sores; skin integrity maintained
Blood glucose within acceptable range for patient
No critical lab results
No concerns identifi ed
Systems Assessment/Treatment
Assess vital signs; pain score and pain location, as per policy, document on clinical fl ow sheet
Assess respiratory system; monitor SpO2; document on clinical fl ow sheet; patient to continue deep breathing and coughing
Neurovascular assessment; document on neurovascular assessment form; patient to continue foot/ankle exercises
Check surgical incision; reapply new dressing if incision not healed or if requested by patient
Apply ice pack as needed for swelling and pain
Assist patient with hygiene & skin care; complete Braden skin risk assessment record
Perform glucose point of care testing as ordered
Review lab results; order blood work
Regular night checks
Assess food intake; diet as ordered; assess nausea and vomiting
Assess abdomen
Fluid/Nutrition/Elimination
Administer blood; document on clinical fl ow sheet
No S & S of ileus
No S & S of constipation; no diarrhea; BM as per usual pattern
50% of meal consumed; no nausea and vomiting
No signs and symptoms of anaemia
Patient accepts initiation of additional bowel routine strategies
No S & S of urinary retention; adequate amount clear odourless urine voided
Give suppositories/enema if no BM; document on MAR
Provide laxative if no BM
Medications Administer medications
Pharmacy care
All ordered medications given/taken
Pharmacy care provided
Monitor effectiveness of oral analgesics and adverse effects: document on clinical fl ow sheet
Patient satisfi ed with pain management
Page 12 of 16
Patient/family perspective; needs and concerns documented in interdisciplinary progress notes
Amount: small medium large
Consistency: hard formed loose liquid
Anticoagulation Anticoagulant received; no S & S of excessive bleeding; no S & S of VTE
Monitor BM Time of BM:(h)
OAI - 33800 R00 © 1998, 2003, 2009 All rights reserved.
Patient Name: HFN #:
INTERVENTIONS OUTCOMESYYYY/MM/DD
Print Name Signature Designation Initial Print Name Signature Designation Initial
OAI33800(2009/01/28)
POST-OP DAY 4
Perform MAR to MAR check; initial last page of MAR in upper right corner
Perform 24-hour chart check; draw red line and initial/date after last order
All orders transcribed; MAR correct; yellow copies sent to pharmacy
Medications
Activity Prevention of increased swelling and fl exion contractureSplint at night yes no discontinued
Exercise(s) reviewed/demo added as per list. Performing previously taught exercises correctly
Transfered independently
Other
Elevate operative leg with knee extended; Education: regarding fl exion contracture
Education: exercise(s) as per exercise book
Reinforce transfer techniques.
Assess ROM
Assess Functional Measure (s)
Encourage sitting as tolerated
Progress amb pattern, distance and gait aid as able
Address outstanding OT goals
Amb independent with
Amb distance metersWB as tolerated Partial WB Touch WB Non WB (permitted)
Education: stair technique Stairs managed assist / supervision / indep.
Assess gait aid needs for D/C Gait aid needs addressed
Page 13 of 16
Discharge Reassess progress and confi rm discharge plan Discharge as per POP plan
Other
FIT
Home Indep. exercisesOut-patient physiotherapy
CCAC
Expected discharge/transfer day 4 5 other specify reasons for delay
Referral completed, yes/no
PT / OT / PSW / home safety asessment / referral initiated / completed
FIT orders completed
External Rehab
Specify:
Application initiated/completed
N D
ROM p a/a a -degrees- - (Rt) -degrees- - (Lt)
N ED
OAI - 33800 R00 © 1998, 2003, 2009 All rights reserved.
Patient Name: HFN #:
INTERVENTIONS OUTCOMESYYYY/MM/DD
OAI33800(2009/01/28)
Patient’s coach identifi ed; coach’s involvement discussed
N DPatient/family Perspective
N DDiscuss patient/family perspective, needs and concerns
Identify patient’s coach
BP and HR within acceptable limits for pt.; respiratory rate > 10, < 24 per min; temp. < 38.0°C; pain score 3/10 or mild
No adventitious breath sounds; no S & S of respiratory distress; Sp02 >90% maintained
Incision edges approximated/no gaps; no drainage/bleeding
Patient understands strategies to reduce swelling and pain
No S & S of pressure sores; skin integrity maintained
Blood glucose within acceptable range for patient
No critical lab results
No concerns identifi ed
Systems Assessment/Treatment
Assess vital signs, pain score and pain location as per policy; document on clinical fl ow sheet
Assess respiratory system; monitor SpO2; document on clinical fl ow sheet; patient to continue deep breathing and coughing
Check surgical incision; reapply new dressing if incision not healed or if requested by patient; provide discharge education
Apply ice pack as needed for swelling and pain
Assist patient with hygiene & skin care; complete Braden skin risk assessment record
Perform glucose point of care testing as ordered
Review lab results; order blood work
Regular night checks
Assess abdomen No S & S of ileus; no S & S of urinary retention; adequate amount clear odourless urine voided
No S & S of constipation; no diarrhea; BM as per usual pattern
Patient/familiy’s questions/concerns addressedProvide laxative if no BM; provide education: regarding constipation and management technique
Medications Administer medications
Pharmacy care
All ordered medications given/taken
Pharmacy care provided
Monitor effectiveness of oral analgesics and adverse effects: document on clinical fl ow sheet/progress notes
Patient satisfi ed with pain management
Fluid/Nutrition/Elimination
Provide discharge teaching Patient/family’s questions/concerns addressed
POST-OP DAY 5
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Patient/family perspective; needs and concerns documented in interdisciplinary progress notes
Anticoagulation Anticoagulant received; no S & S of excessive bleeding; no S & S of VTE
Amount: small medium large
Consistency: hard formed loose liquid
Return patients own medication Patients medication returned
Monitor BM Time of BM:(h)
OAI - 33800 R00 © 1998, 2003, 2009 All rights reserved.
Patient Name: HFN #:
INTERVENTIONS OUTCOMESYYYY/MM/DD
Print Name Signature Designation Initial Print Name Signature Designation Initial
OAI33800(2009/01/28)
POST-OP DAY 5
Activity Prevention of increased swelling and fl exion contractureSplint at night yes no discontinued
Exercise(s) reviewed/demo added as per list. Performing previously taught exercises correctly, indep for home
Elevate operative leg with knee extended. Education: regarding fl exion contracture
Education: exercise(s) as per exercise book
If home, discuss indep exercise program and function at home.
Assess ROM
Assess Functional Measure (s)
Progress amb pattern, distance and aid as able
Address outstanding OT goals
Amb independent with
Amb distance metersWB as tolerated Partial WB Touch WB Non WB (permitted)
If home, Education stair technique Stairs managed assist / supervision / indep.
Other
Assess gait aid needs for discharge Gait aid needs addressed
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Discharge Reassess progress and confi rm discharge plan Discharge as per POP plan
Other
FIT
Home Indep. exercisesOut-patient physiotherapy
CCAC
Expected discharge/transfer day 5 other specify reasons for delay
Referral completed, yes/no
PT / OT / PSW / home safety asessment / referral initiated / completed
FIT orders completed
External Rehab
Specify:
Application initiated/completed
ROM p a/a a -degrees- - (Rt) -degrees- - (Lt)
DD
Surgeon
OAI - 33800 R00 © 1998, 2003, 2009 All rights reserved.
OAI33800(2009/01/28)
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a activea/a active assistedADL activities of daily livingamb ambulation/ambulateBlock a room to initiate regional anesthesiaBM bowel movementBPM beats per minuteCCAC Community Care Access CentreD daydemo demonstratesD/C discontinue/dischargeDVD digital video displayE eveningFIT Functional Independence TrainingIndep IndependenceMAR Medication Administraton Recordm/s meters per secondN nightN/A not applicableNPO nothing per oralOR operating roomOT occupational therapy/occupational therapistp passivePACU post anesthetic care unitPOP Patient Orientation ProgramPT physiotherapy/physiotherapistPSW personal support workerROM range of motions secondsSPW self-paced walkS & S signs and symptomsTUG timed up and goVTE venous thromboembolism> greater than< less than& and
LEGENDS