KNEE REPLACEMENT CARE PATHWAY - Sunnybrook · PDF fileKNEE REPLACEMENT CARE PATHWAY PATIENT...

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)

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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

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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



Print Name Signature Designation Initial Print Name Signature Designation Initial

OAI33800(2009/01/28)

Discuss patient perspective, needs and concerns

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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)


SAME DAY ADMISSION - DAY 0 BLOCK/OR/PACU - DAY 0OUTCOMES OUTCOMESINTERVENTIONS INTERVENTIONS


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


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



INTERVENTIONS OUTCOMESYYYY/MM/DD

OAI33800(2009/01/28)

POST-OP DAY 0


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


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

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Assess for S & S of VTE No S & S of VTE



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





OAI33800(2009/01/28)

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Medications

POST-OP DAY 0

All ordered medications given/taken


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


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




OAI33800(2009/01/28)


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



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


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


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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



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


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



Monitor BM Time of BM:(h)



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



Patient agrees with plan; understanding verbalized


No critical lab results

No concerns identifi ed



Patient understands use of PCA; no negative effect;patient satisfi ed with pain management





OAI33800(2009/01/28)

POST-OP DAY 1

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Medications Monitor continuous femoral nerve block; document on pain fl ow sheet


Perform MAR to MAR check; initial last page of MAR in upper right corner




Anticoagulant received; no S & S of excessive bleeding; no S & S of VTE


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




OAI33800(2009/01/28)

POST-OP DAY 2


N EDPatient/family Perspective





Pharmacy care Verify patient’s own medications Pharmacy care provided

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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


Provide education on stool softener





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



Encourage hourly foot/ankle exercises while awake

Perform dressing change using maximum barrier technique

Check dressing every shift




Discuss use of side rails with patient



Hourly night checks


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


Patient performs regular foot and ankle exercises

Incision edges approximated/no open gaps; minimal amount of sanguineous or serous exudate; no purulent drainage


Dressing clean and intact



Patient agrees with plan; understanding verbalized






No S & S of ileus; no S & S of urinary retention

Saline lock fl ushed q8H

Removed catheter intact, site satisfactory


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





OAI33800(2009/01/28)

POST-OP DAY 2

Medications Monitor patient controlled analgesia; document on pain fl ow sheet



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


Remove epidural catheter



Removed catheter intact; no signs and symptoms of site infection/bleeding


Patient agrees to switch to oral pain management

Patient understands use of PCA; no negative effect; patient satisfi ed with pain management

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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


Other

FIT


CCAC





External Rehab

Specify:


N ED


N ED




OAI33800(2009/01/28)

POST-OP DAY 3







No S & S of delirium/confusion; patient easy to arouse; no dizziness/drowsiness


Incision edges approximated/no gaps; no drainage/bleeding







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



Patient to continue foot/ankle exercises

Check surgical incision; reapply new dressing if incision not healed or if requested by patient


Assist patient with hygiene & skin care; complete Braden skin risk assessment record



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 signs and symptoms of anaemia

BM as per usual pattern; patient understands the need for stool softener


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


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

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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.

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Medications Administer medications

Pharmacy care





Monitor effectiveness of oral analgesics and adverse effects: document on clinical fl ow sheet/progress notes


Patient satisfi ed with pain management

Anticoagulant received; no S & S of excessive bleeding; no S & S of VTE

Anticoagulation

Specify:


Other

FIT


CCAC





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)


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.


N ED




OAI33800(2009/01/28)

POST-OP DAY 4





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 signs and symptoms of pressure sores; skin integrity maintained





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






Assess food intake; diet as ordered; assess nausea and vomiting

Assess abdomen



No S & S of ileus

No S & S of constipation; no diarrhea; BM as per usual pattern


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


Pharmacy care



Monitor effectiveness of oral analgesics and adverse effects: document on clinical fl ow sheet


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OAI33800(2009/01/28)

POST-OP DAY 4




Medications


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


Reinforce transfer techniques.

Assess ROM



Progress amb pattern, distance and gait aid as able

Address outstanding OT goals

Amb independent with


Education: stair technique Stairs managed assist / supervision / indep.

Assess gait aid needs for D/C Gait aid needs addressed

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Other

FIT


CCAC

Expected discharge/transfer day 4 5 other specify reasons for delay




External Rehab

Specify:


N D


N ED




OAI33800(2009/01/28)


N DPatient/family Perspective

N DDiscuss patient/family perspective, needs and concerns


BP and HR within acceptable limits for pt.; respiratory rate > 10, < 24 per min; temp. < 38.0°C; pain score 3/10 or mild










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






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


Pharmacy care



Monitor effectiveness of oral analgesics and adverse effects: document on clinical fl ow sheet/progress notes



Provide discharge teaching Patient/family’s questions/concerns addressed

POST-OP DAY 5

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Return patients own medication Patients medication returned






OAI33800(2009/01/28)

POST-OP DAY 5


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


If home, discuss indep exercise program and function at home.

Assess ROM


Progress amb pattern, distance and aid as able

Address outstanding OT goals

Amb independent with


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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Other

FIT


CCAC

Expected discharge/transfer day 5 other specify reasons for delay




External Rehab

Specify:



DD

Surgeon


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

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KNEE REPLACEMENT CARE PATHWAY - Sunnybrook · PDF fileKNEE REPLACEMENT CARE PATHWAY PATIENT...

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