post-op knee primary/revision patient … knee primary/revision replacement orders ... iv fluids:...

*POS* 81657013 02/11

*POS*

PATIENT LABEL

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POST-OP KNEE PRIMARY/REVISIONREPLACEMENT ORDERS

Rev 01/2011 Page 1 of 5

POST-OP: KNEE PRIMARY/REVISION Replacement Line through any order not to be used

Day of Surgery: Admit to floor as inpatient. Initiate total joint clinical pathway. Requests Primary Care Physician_____________________________ or Hospitalist __________________________ consult regarding advice on medical management. Call consulting hospitalist/PCP from PACU for further orders and medical management issues. Call orthopedic surgeon for pain management issues, unless on epidural.

If patient has continuous peripheral Nerve Catheter or Epidural catheter, follow anesthesia orders for monitoring. Call anesthesia for all orders related to pain management.

Review medication hx form and confer with hospitalist or primary care physician for continuation of home medications.

X-Ray AP & Lateral □ Rt Knee □ Lt Knee Diet: Clear liquids after bowel sounds auscultated. Advance as tolerated.

Diabetic: calorie ADA diet, chemstrips 30 minutes AC & HS. Other: _______________________

Labs: ▪ H&H 6 hours post op ▪ BMP at 5am (POD #1) ▪ CBC at 5am POD #1 (notify MD if Hgb less than 8) ▪ PT/INR daily at 5 am if Coumadin ordered (notify MD if INR less than 2 or greater than 2.5) ▪ H&H at 5am on POD #2 & POD #3(notify MD if Hgb less than 8) Antibiotics (Check one):

□ Ancef 1 gram IV Q 8 hours X 24hrs. □ Vancomycin 1 gram IVPB Q 12 hours X 24hrs (check the justification): □ MRSA + □ Inpt greater than 24 hrs prior to procedure □ Allergy to PCN □ High Risk: □ Inpt hospitalization in last yr □ Nursing home/extended care facility IV fluids: D5LR at 75 ml/hr x 24 hours, then decrease to KVO. If diabetic: 0.45% NS @ 75 ml/hr, then decrease to KVO.

DVT Prophylaxis (Check one): □ Lovenox 30 mg SQ Q 12hrs . (Teach Lovenox self injection) □ Coumadin 5mg po at 9pm evening of surgery and then 2.5mg po Q day. (Hold

Coumadin if INR greater than 2.5 and notify orthopedic MD.)

Rev 01/2011 Page 1 of 5

POST-OP: KNEE PRIMARY/REVISION Replacement Line through any order not to be used

Day of Surgery: Admit to floor as inpatient. Initiate total joint clinical pathway. Requests Primary Care Physician_____________________________ or Hospitalist __________________________ consult regarding advice on medical management. Call consulting hospitalist/PCP from PACU for further orders and medical management issues. Call orthopedic surgeon for pain management issues, unless on epidural.

If patient has continuous peripheral Nerve Catheter or Epidural catheter, follow anesthesia orders for monitoring. Call anesthesia for all orders related to pain management.

Review medication hx form and confer with hospitalist or primary care physician for continuation of home medications.

X-Ray AP & Lateral □ Rt Knee □ Lt Knee Diet: Clear liquids after bowel sounds auscultated. Advance as tolerated.

Diabetic: calorie ADA diet, chemstrips 30 minutes AC & HS. Other: _______________________

Labs: ▪ H&H 6 hours post op ▪ BMP at 5am (POD #1) ▪ CBC at 5am POD #1 (notify MD if Hgb less than 8) ▪ PT/INR daily at 5 am if Coumadin ordered (notify MD if INR less than 2 or greater than 2.5) ▪ H&H at 5am on POD #2 & POD #3(notify MD if Hgb less than 8) Antibiotics (Check one):

□ Ancef 1 gram IV Q 8 hours X 24hrs. □ Vancomycin 1 gram IVPB Q 12 hours X 24hrs (check the justification): □ MRSA + □ Inpt greater than 24 hrs prior to procedure □ Allergy to PCN □ High Risk: □ Inpt hospitalization in last yr □ Nursing home/extended care facility IV fluids: D5LR at 75 ml/hr x 24 hours, then decrease to KVO. If diabetic: 0.45% NS @ 75 ml/hr, then decrease to KVO.

DVT Prophylaxis (Check one): □ Lovenox 30 mg SQ Q 12hrs . (Teach Lovenox self injection) □ Coumadin 5mg po at 9pm evening of surgery and then 2.5mg po Q day. (Hold

Coumadin if INR greater than 2.5 and notify orthopedic MD.)

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PATIENT LABEL

Rev 01/2011 Page 2 of 5

Check boxes to indicate selection when option available Pain Management: □ PCA (See PCA physician order form). Discontinue POD #1 unless otherwise specified by MD to continue. Give PO pain med 30 mins prior to d/cing pump

□ EPIDURAL: Per Anesthesia. (Call Anesthesia for all orders related to pain management while patient has epidural.) Nurse to pull epidural catheter at 8PM POD #1.

□ Peripheral Nerve Block (See PNB order form) To be pulled on POD #2 per anesthesia. □ Celebrex 400 mg po day of surgery, then 200 mg BID (do not order if patient has hx of

peptic ulcer disease, heart disease, or sulfa allergy). OR

□ Toradol 30 mg IV Q 6 hours X 3 doses for pain if patient is 65yrs or younger, if older than 65yrs decrease dose to 15 mg every 6 hours. (Do not order if patient has hx of COPD, asthma, peptic ulcer disease, renal disease or creatinine clearance<50).

After PCA/Epidural discontinued (choose one): give pain meds 30mins prior to d/cing pain pump or epidural.

□ Percocet mg __tab(s) Q 4 hours prn pain. □ Lortab __mg ____tab(s) Q 4 hours prn pain. □ Demerol 75mg IM Q 3 hours prn pain. □ Morphine 5mg IM Q 3 hours prn pain

Routine Medications: ▪ Niferex 150 mg po bid ▪ Colace 100 mg po bid ▪ Dulcolax suppository at 9PM evening of surgery, repeat 9AM POD #1 if no BM

since admission, then again at 9AM POD #2 if no BM since admission. ▪ Fleets Enema at 9pm POD #2 if no BM since admission. ▪ Zofran 4 mg IV Q 6 hours prn nausea; Phenergan 25 mg IM Q 6 hours if Zofran

ineffective. ▪ Benadryl 25mg IV Q 6hrs prn nausea ▪ Tylenol 650 mg po Q4h prn temp greater than 101 ▪ Maalox 30 mls PO Q4h prn heartburn

▪ Zolpidem (Ambien) 5mg po HS prn sleep (May repeat X1) ▪ Other _________________________________________________

Monitoring: ▪Vital Signs: Q 1hr x4, Q 2hrs x12, then Q 4hrs ▪Notify MD if BP 30 points below baseline or systolic BP less than 100, urine output less than 30ml’s per hour, or O2 Sat less than 90%. Notify orthopedic surgeon if drain output greater than 300ml’s over 2hrs. ▪Monitor O2 Saturation Q 1hr x4, Q 2hrs x12, then Q 4hrs ▪Neurovascular checks both lower extremities: Q 1hr x4, then Q 8hrs ▪Strict I&O including drain output every 8hrs ▪Assess heels Q shift. If redness present, float heels off bed with pillows or apply heel protectors.

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PATIENT LABEL

*POS* 81657013 02/11

Rev 1/2011 Page 3 of 5

Check boxes to indicate selection when option available

Drains: Hemovac – empty & record Q 4 hours. Discontinue drain POD #1. Incentive Spirometry: Cardiopulmonary to instruct initial use; nursing will perform with patient Q 2hrs while awake. O2 per cardiopulmonary protocol

Dressing: Reinforce surgical dressing PRN, do not change unless saturated. Change dressing POD #2. Use antimicrobial dressing. Intermittent pneumatic compression device: □ Bilateral □ Non-operative side TED Hose: □ Bilateral □ Non-Operative side only Knee Immobilizer whenever out of bed & at HS. Remove Q shift and perform skin assessment. Other instructions: _______________________________ Physical Therapy & Occupational Therapy Evaluate Day of Surgery Start PT/OT morning of POD #1 treat per Total Hip Protocol. PT b.i.d OT begin education on hip precautions. OT bathing and dressing using hip kit to begin POD #1and continue until discharge. Discharge Planning consult for inpatient rehab, home health, or outpatient physical therapy. Begin discharge planning day of surgery. General Care ▪Ice to operative hip X 48 hours. ▪Turn back to non-operative side every 2hrs. Keep pillow between legs when turning. ▪Up in chair for meals starting morning of POD #1. (after PT evaluation & approval) ▪Overhead frame and trapeze. ▪Obtain walker and bedside commode on day of surgery. ▪Discontinue foley catheter on POD #1. (if unable to void within 8hrs of removal, re-insert foley for 24hrs then DC) ▪ If patient comes from surgery without a foley and if unable to void in 8 hours post-op, straight cath x2 then insert foley catheter x24 hours.

Date Time MD Signature

Contact # Print MD Name







Rev 01/2011 Page 3 of 5

Check boxes to indicate selection when option available Drains: Discontinue Hemovac/Stryker drain on POD #1 ▪ Hemovac – empty & record Q 4 hours x 3 then Q 8 hours. ▪ Reinfusion (Stryker) – record and reinfuse output within 6 hours post-op then

convert to drain. Incentive Spirometry: Cardiopulmonary to instruct initial use; nursing will perform with patient Q 2 hours while awake. O2 per cardiopulmonary protocol Dressing: Reinforce surgical dressing PRN, do not change unless saturated. Change dressing on POD #1. Use antimicrobial dressing. Intermittent compression device: □ Bilaterally □ Non-operative side only TED Hose: □ Bilaterally □ Non-operative side only Knee Immobilizer – when out of bed & apply at HS. Other instructions:______________ □ Apply CPM: ____________________________________________________ Physical therapy & Occupational Therapy Evaluate Day of Surgery Start PT morning of POD #1and treat per Total Knee Protocol . PT b.i.d Discharge Planning consult for inpatient rehab, home health, or outpatient physical therapy. Begin discharge planning day of surgery.

General Care ▪Elevate/Gatch foot of bed; keep leg extended; elevate leg when in chair. ▪Temptec to operative knee X 24 hours then d/c. Ice pack to knee between physical therapy sessions. ▪Turn back to side every 2 hours. ▪Up in chair for meals starting morning of POD #1. (after PT evaluation & approval) ▪Overhead frame and trapeze. ▪Obtain walker and bedside commode on day of surgery. ▪Discontinue foley catheter on POD #1. (if unable to void within 8hrs of removal, re- insert foley for 24hrs then DC) ▪ If patient comes from surgery without a foley and if unable to void in 8 hours post-op, straight cath x2 then insert foley catheter x24 hours.



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PATIENT LABEL

Rev 01/2011 Page 4 of 5

Check boxes to indicate selection when options available

Discharge Planning: □ Rehab □ Home Health □ Outpatient Rehab* (Case Mgr will arrange)* Rehab Admission:

Transport patient via facility van or ____________.

Follow up appointment with Ortho Physician in _________ weeks post op.

Follow up appointment: Date___________ Time_________

Follow up with PCP 10-14 days after discharge from rehab. Remove staples in _______ days and steristrip wound if needed. Lovenox __________________________________________ Coumadin Protocol: Coumadin _____mg po daily x_____ days. (INR Therapeutic Range 1.5-2.5) Check PT/INR weekly while patient on Coumadin. Fax results to Ortho Physician’s office for coumadin adjustment.









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PATIENT LABEL

*POS* 81657013 02/11

Rev 01/2011 Page 5 of 5

Check boxes to indicate selection when options available

Home Health:

Follow up with ortho surgeon in _______ weeks.

Follow up appointment: Date _________ Time __________

Follow up with PCP 10-14 days upon discharge from home health service.

Home Health Nurse and Physical Therapist will evaluate pt. at home the day after Discharge.

Physical Therapy will treat pt per physician orders – (Usual treatments 3-5 times per week for 4 weeks). Home Health Nurse will: ▪ Draw blood for PT/INR every Monday while patient on coumadin – fax to ortho physician office for coumadin adjustment. Follow Coumadin protocol below. ▪ Provide wound care, diabetes care, teach signs & symptoms of infection, and teach Lovenox self-injection if on Lovenox. ▪ Discontinue staples in _____ days post op, apply steristrips if needed (Keep incision dry until staples removed) Additional DME as indicated for home use as per OT/PT recommendations Coumadin Protocol: Coumadin ____ mg PO daily x ____ days. (INR Therapeutic Range 1.5-2.5)

Check PT/INR weekly while patient on Coumadin. Fax Ortho Physician office with INR results falling out of therapeutic range Fax:________________________________ Attention:____________________________ Call Ortho Physician office with INR >3 Phone:______________________________ Attention:____________________________









post-op knee primary/revision patient … knee primary/revision replacement orders ... iv fluids:...

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