CLINICAL PATHWAY Total Knee Replacement - …

1 Diagnosis: Bed rest Bed rest OOB in Chair (BID) OOB in Chair (BID) OOB in Chair (BID) OOB in Chair (BID) Ambulation / Transfer Demonstration of ADL's Demonstration of ADL'swith assistive devices as Ambulation in room w/ Ambulation in room w/toleratedassistive devicesassistive devices SMA7 CBC (Post-Op Review results of CBC CBC [Call if H&H CBC [Call if H&H CBC [Call if H&H PT / INR (1-2 normal CBC in PACU) [Call [Call if H&H < 8&26]< 8&26]< 8&26]< 8&26]INR) if on Coumadin PT if H&H < 8&26] PT / INR (1-2 goal INR) PT / INR (1-2 goal INR) PT / INR (1-2 goal INR) Stool for guaiac if on PTT Radiographsif on Coumadinif on Coumadinif on CoumadinLovenex U/A of knee Stool for guaiac if on Stool for guaiac if on CXRL ovenexLovenex EKG PREAL-BUMIN NPO NPO Advance Diet as Advance Diet as Advance Diet as Diet as tolerated Diet as tolerated toleratedtoleratedtolerated Maintenance As per Coumadin at 18:00 Hours Coumadin at 18:00 Hours Coumadin at 18:00 Hours Coumadin at 18:00 Hours Coumadin at 18:00 Hours meds as per Anesthesia if prescribed.

2 (Notifyif prescribed. (Notifyif prescribed. (Notifyif prescribed. (Notifyif prescribed. anesthesiol- Anesthesia before givingAnesthesia before givingAnesthesia before givingAnesthesia before giving Lovenox BID if prescribed ogist and/or Coumadin).Coumadin).Coumadin).Coumadin). Maintenance drugs as physician. Maintenance drugs as Lovenox BID if prescribed Lovenox BID if prescribed Lovenox BID if prescribedprescribed. Prophylactic no Epiduraland no Epidural Maintenance drugs as Antiemetic prn antibiotics as Antiemetric prn Maintenance drugs as Maintenance drugs asprescribed. Laxative/Stool softener prescribed Laxative/Stool Antiemetic prn Antiemetic prn Antiemetic prn Laxative/Stool softener Laxative/Stool softener Laxative/Stool softener PAIN MANAGEMENT:PAIN MANAGEMENT:PAIN MANAGEMENT:PAIN MANAGEMENT:PAIN MANAGEMENT: As per Anesthesia if As per Anesthesia if Consider d/c epidural D/C epidural catheter + PO pain management epidural catheter -OR-epidural catheter -OR-catheter and initiate PO pain initiate PO pain management As per MD order As per MD order -OR-management (Notify Consider d/c epiduralsurgeon if epidural not D/C)catheter and initiate PO painmanagement (Notify surgeonif epidural not D/C)8850058 Rev.

3 05/05 PAGE 1 of 4 DAY 2 PATIENT IDENTIFICATIONDRG NO: 209 POD #4 LENGTH OF STAY: 4 POD #3 DAY 5 CLINICAL PATHWAY Total knee Replacement CLINICAL pathways are tools to facilitate and guide multi-disciplinary patient care. They do not represent a standard of care or replace physician orders orclinical judgment. Modifications are made based on documented individual patient needs. TEST SPECIMENSDAY 1 Post-Op MEDS DIETPOD #1 DAY 1 Pre-Op ACTIVITYT otal knee Replacement CLINICAL Pathway_CLINICAL PATHWAYS_MEDICAL AFFAIRSDAY 3 POD #2 DAY 1or / PACUPART OF THE MEDICAL RECORDon UNIT: _____InitiatingDATE:InitiatingTIME:Initi atingUNIT:DRG NO 209 I & O I & O I & O I & O Cough & deep breath Cough & deep breath Cough & deep Cough & deep breath Cough & deep breath Cough & deep breath Place foot of bed and Place foot of bed and breathe Turn + reposition q 2 hr Turn + reposition q 2 hr Turn + reposition q 2 hrknee gatchedknee gatched Turn + reposition Place foot of bed and Place foot of bed and Place foot of bed and Pneumatic compression Pneumatic compression q 2 hr knee gatchedknee gatchedknee gatcheddevicedevice Place foot of bed Ice to operative site Ice to operative site Ice to operative site TEDS TEDS and knee gatched Drsg to operative site Drsg to operative site Pneumatic compression knee immobilizer knee immobilizer Ice to operative Pneumatic compression Pneumatic

4 Compressiondevice CPM as per order CPM as per order site devicedevice TEDS Evaluate need for Evaluate need for Drsg to operative TEDS TEDS knee immobilizerlaxativelaxative site knee immobilizer Hemovac Dressing change Call MD for Temp > 101F Call MD for Temp > 101F Pneumatic Auto transfusion as per knee immobilizer CPM as per order compression order and convert to Incentive Spirometry q 1 D/C Hemovac device Hemovac post transfusionhour while awake D/C Foley TEDS Incentive Spirometry q 1 CPM as per order Evaluate need for knee immobilizer hour while awake Consider discontinue oflaxative Auto transfusion Foley (indwelling) ifFoley if appropriate Call MD for Temp > 101F as per order unable to void within 8 hrs Call MD for Temp > 101F Call MD for Post-Op Temp > 101 F CPM as per order Call MD for Temp > 101F As per IV as per order IV as per order & convert IV as per order & convert DC saline lock if Anesthesia to saline lock once toleratingto saline lock once toleratingappropriate POPO Per Per protocol As ordered As ordered As ordered As ordered As ordered protocol8850058 Rev.

5 05/05 PAGE 2 of 4 PART OF THE MEDICAL RECORDor / PACU TREATMENTS IVS VITALon UNIT: _____Total knee Replacement CLINICAL Pathway_CLINICAL PATHWAYS_MEDICAL AFFAIRSCLINICAL PATHWAY Total knee Replacement CLINICAL pathways are tools to facilitate and guide multi-disciplinary patient care. They do not represent a standard of care or replace physician orders orclinical judgment. Modifications are made based on documented individual patient 1 Post-OpDAY 1 Pre-OpDAY 1 SIGNSDAY 2 POD #1 DAY 3 POD #2 DAY 4 POD #3 DAY 5 PATIENT IDENTIFICATIONPOD #4 DRG NO 209 Physical & Occupational PT - Initiate bedside PT - initiate gait training, PT - Gait training, PT - Gait training, Therapy consult requestedexercises (quadriceps,transfer training, andtransfer training, andtransfer training, andsets, gluteal sets, ankleexercises (quadriceps,exercises (quadriceps,exercises (quadriceps,pumps and SLR)sets, gluteal sets, anklesets, gluteal sets, anklesets, gluteal sets, ankle OT - ADL Training, pumps and SLR, AROM pumps and SLR, AROM pumps and SLR, AROM progress to highest/AAROM, knee flexion +/AAROM, knee flexion +/AAROM, knee flexion +functional levelterminal knee extension)terminal knee extension))

6 Terminal knee extension, OT - ADL Training, OT - ADL Training, stairs).progress to highestprogress to highest OT - ADL Training, functional levelfunctional levelprogress to highest Ambulation with Ambulation withfunctional levelstandard walker withstandard walker with Ambulation withappropriate level ofappropriate level ofstandard walker withassistance. Progressassistance. Progressappropriate level oflevel of assistance andlevel of assistance andassistance. Progressdistance as as of assistance anddistance as will demonstratethe following: AROM/AAROM kneeflexion (60-80 degrees oraccording to MD) Independence infunctional transfer andactivities Independence inambulation and std walkeron level surfaces (100ft)and stairs Encourage Discuss pain Discuss pain mgmnt Reinforce education Continue to reinforce Reinforce education Reinforce education Pre-Op TJA management (pain scale) & side effectsfrom DAY 1education from DAY 1 +from DAYs 1, 2 & DAYs 1, 2, 3 & 4.

7 Class (pain scale) & Teach ankle pumps Explain rationale forDAY 2. Teach methods to Discharge instructions attendance side effects Explain treatmentsphysical therapy + need Teach signs + symptomsprevent infection of Did Pt Teach anklefor patient participationto report (signs of woundprosthesis (prophylactic attend Pre- pumps Teach fall preventioninfection, DVT, Temp>101F,antibiotics prior to dental op TJA class? Explain(Hospital based + homeunrelieved knee pain,work or out patient treatmentsbased precautions).neurovascular changes).surgery, and prompt Pre-Op & Teach PO pain mgmnttreatment of systemic Post-Op careinfections)8850058 Rev. 05/05 PAGE 3 of 4 PART OF THE MEDICAL RECORDDAY 4 POD #3 DAY 5or / PACU PHYSICAL & TEACHING OCCUPA- TIONAL THERAPYPATIENT IDENTIFICATIONPOD #4on UNIT: _____DAY 2 POD #1 DAY 3 POD #2 Total knee Replacement CLINICAL Pathway_CLINICAL PATHWAYS_MEDICAL AFFAIRSCLINICAL PATHWAY Total knee Replacement CLINICAL pathways are tools to facilitate and guide multi-disciplinary patient care.

8 They do not represent a standard of care or replace physician orders orclinical judgment. Modifications are made based on documented individual patient 1 Post-OpDAY 1 Pre-OpDAY 1 ___Y ___NDRG NO 209 Assess Assess Living Assess Living Assess Living Assess the following: Assess the following: Living SituationSituationSituation1. Review / Rehab Clinical1. Review / Rehab CLINICAL Situation 1. Functional & Clinical1. Functional & Clinical1. Functional & ClinicalProgressProgress 1. Functional StatusStatusStatus2. Adjust / Update Plans as2. Adjust / Update Plans as & CLINICAL 2. Supportive Systems2. Supportive Systems2. Supportive Systemsappropriateappropriate Status 3. Community Services3. Community Services3. Community Services3. Finalize Discharge3. Finalize Discharge 2. SupportiveDISCHARGE DISPOSITIONDISCHARGE DISPOSITIONA rrangementsArrangements SystemsDISCHARGE DISPOSITIONDISCHARGE DISPOSITION 3.

9 Community1. Assisted Living or1. Assisted Living or ServicesOTHER REHAB FACILITYOTHER REHAB FACILITY1. Assisted Living or1. Assisted Living or Input Rehab Benefits Input Rehab BenefitsOTHER REHAB FACILITYOTHER REHAB FACILITY Initiate Medicaid Initiate Medicaid Assisted Living Assisted LivingApplication (if appropriate)Application (if appropriate)forms on on chart. Complete Referral Complete Referral Nursing Transfer Form Nursing Transfer Form Target D/C date Target D/C dateCompletedCompletedcompletedcompleted MIMR Screen MIMR Screen Rehab assessment Rehab assessment Medical Record copied Medical Record copiedcompletedcompleted or: Medical Record dictated Assisted Living decision Assisted Living decision2. HOME: DC summary completedcompleted, or:completed, or: Home Care Form(before 3pm)2. HOME:2. HOME:completed (MD,CN,CM) Discharge order obtained Input Home Care Benefits Input Home Care Benefits Equipment Transportation arranged Initiate Referrals Initiate Referrals Supplies Report to CM by CLINICAL Confirm target D/C date Confirm target D/C date ServicesNurse, or Coordinate Discharge Coordinate Discharge Agencies2.

10 HOME:ArrangementsArrangements Medications Home Care Form Transportation arrangedcompleted (MD,CN,CM) Discharge order obtained Equipment Discharge Instruction SuppliesForm completed (MD, CN, CM) Services Agencies Medications Transportation arranged Discharge order obtained Discharge InstructionForm completed (MD, CN, CM)8850058 Rev. 05/05 PAGE 4 of 4 DAY 4 POD #3 DAY 5 PATIENT IDENTIFICATIONPOD #4on UNIT: _____DAY 2 POD #1 DAY 3 POD #2 Total knee Replacement CLINICAL Pathway_CLINICAL PATHWAYS_MEDICAL AFFAIRSCLINICAL PATHWAY Total knee Replacement CLINICAL pathways are tools to facilitate and guide multi-disciplinary patient care. They do not represent a standard of care or replace physician orders orclinical judgment. Modifications are made based on documented individual patient 1 Post-OpDAY 1 Pre-OpDAY 1or / PACU DISCHARGE PLANNING EVALUATION_____Init'ls_____Unit_____Init 'ls_____Unit_____ Initials_____ UnitPART OF THE MEDICAL RECORD_____ Initials_____ Unit_____ Initials_____ Unit_____ Initials_____ Unit_____ Initials_____ UnitDRG NO 209