Post on 10-Apr-2018
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TOTAL HIP REPLACEMENT
CLINICAL PATHWAY
SITE: GBHS - Owen Sound PATIENT ID
INCLUSION CRITERIA:
All patients admitted for an ELECTIVE total hip replacement procedure.
HOW TO USE THE CLINICAL PATHWAY
This is a proactive tool to avoid delays in treatment and discharge. These are not orders, only a guide to usual orders.
Place the Clinical Pathway in the nurses clinical area of the chart. All health care professionals should fill in the master signature sheet at the front of the Pathway. Addressograph/sticker each page of the Pathway, except for the Variance Record.
PHYSICIANS: Add or delete tasks according to individual patient complexity, and initial all changes.
HEALTH CARE PROFESSIONALS: Initial tasks as completed. Place N/A and initial any box where the task is not applicable to the patient. Additional tasks due to patient individuality can be added to the pathway in “OTHER” boxes and/or Progress Notes.
Please indicate any variances to Indicators on the Variance Record.
NAME (Please Print)
INITIAL SIGNATURE
POSITION
NU
RS
ING
CL
INIC
AL
NU
TR
ITIO
N
OT
PT
DIS
CH
AR
GE
P
LA
NN
ING
CC
AC
Grey Bruce Health Network
CP-THR-117©2003-2006 Grey Bruce Health Network
Approved (May, 2006)1
Annual Review (May, 2007)
OTHER (SPECIFY)
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NAME (Please Print)
INITIAL SIGNATURE
POSITION
NU
RS
ING
CL
INIC
AL
NU
TR
ITIO
N
OT
PT
DIS
CH
AR
GE
P
LA
NN
ING
CC
AC
All rights reserved. No part of this document may be reproduced or transmitted, in any form or by any means, without the prior permission of the copyright owner.
CP-THR-117©2003-2006 Grey Bruce Health Network
Approved (May, 2006)2
Annual Review (May, 2007)
DATE ___________
PERFORMANCE INDICATOR 1
Record as "Met"or "Not Met" on
Variance Record
HEIGHT AND WEIGHT
REVIEW PRE-ANAESTHETIC QUESTIONNAIRE
ALL NON-SHADED BOXES TO BE INITIALLED UPON COMPLETION OR MARKED N/A AND INITIALLED
OTHER:
INTERNAL MEDICINE
ANESTHESIOLOGIST
PATIENT ON ANTI-COAGULANT THERAPY
PHYSIO CLINIC
CCAC IF REQUIRED (SEE BLAYLOCK DISCHARGE PLANNING RISK ASSESSMENT SCREEN)
SITE: GBHS - Owen Sound PATIENT ID
COMORBID CONDITIONS:
PHYSIO VISIT
VITAL SIGNS WITH O2 SATS: BP
REVIEW PCA VIDEO AND PAMPHLET
OTHER:
MEDICATIONS
OTHER:
INSTRUCT PATIENT TO REVIEW MED NEEDS WITH PHYSICIAN
CHEST X-RAY
OTHER:
TOTAL HIP REPLACEMENT
CLINICAL PATHWAY
PRE-ADMISSIONPROCESS
CONSULTS
ECG
ASSESSMENT (OBSERVATIONS/ MEASUREMENTS/
ELIMINATION)
DIAGNOSTICS/ LABORATORY
OTHER:
COMPLETE NURSING HISTORY
CONSENT SIGNED BY PATIENT
START PRE-OP CHECKLIST
CBC, Na, Cl, K, CROSSMATCH G&S, URINE C&S
Grey Bruce Health Network
CP-THR-117©2003-2006 Grey Bruce Health Network
Approved (May, 2006)3
Annual Review (May, 2007)
DATE ___________
ATTEND PHYSIO CLASS
ALL NON-SHADED BOXES TO BE INITIALLED UPON COMPLETION OR MARKED N/A AND INITIALLED
PSYCHOSOCIAL SUPPORT/
EDUCATION
DISCHARGE PLANNING
COMPLETE LOWER EXTREMITY FUNCTIONAL SCALE (LEFS) AND PUT SCORE ON VARIANCE RECORD DISCHARGE SUMMARY
COMPLETE BLAYLOCK DISCHARGE PLANNING RISK ASSESSMENT SCREEN
REVIEW HOME SUPPORT
SHOWER PRIOR TO COMING TO HOSPITAL
DISCHARGE PLANS DISCUSSED WITH PATIENT
REVIEW SURGICAL INFORMATION BOOKLET AND VIDEO: DEEP BREATHING AND COUGHING, CALF PUMPING, ETC.
HOSPITAL POLICY RE: DISCHARGE TIME
MOBILITY/ACTIVITY REVIEW TOTAL HIP REPLACEMENT INFORMATION PACKAGE
TREATMENTS/ INTERVENTIONS
REVIEW CLOTHING REQUIREMENTS
REVIEW USE OF BEDPAN, URINAL, CATHETER
OTHER:
ATTEND OT CLASS
SPECIFIC INSTRUCTIONS BY SURGEON OR INTERNIST
REVIEW PRE-OP INSTRUCTIONS RE: DIET, NPO
PRE-ADMISSIONPROCESS
OTHER:
NUTRITION
CP-THR-117©2003-2006 Grey Bruce Health Network
Approved (May, 2006)4
Annual Review (May, 2007)
Today, do you, or would you have any difficulty at all with:Extreme
Difficulty/ Unable to Perform Activity
Quite a bit of Difficulty
Moderate Difficulty
A little bit of Difficulty
No Difficulty
1 0 1 2 3 4
2 0 1 2 3 4
3 0 1 2 3 44 0 1 2 3 45 0 1 2 3 46 0 1 2 3 4
7 0 1 2 3 4
8 0 1 2 3 4
9 0 1 2 3 4
10 0 1 2 3 411 0 1 2 3 412 0 1 2 3 4
13 0 1 2 3 4
14 0 1 2 3 415 0 1 2 3 416 0 1 2 3 417 0 1 2 3 4
18 0 1 2 3 4
19 0 1 2 3 420 0 1 2 3 4
Total Score /80
TOTAL HIP REPLACEMENTCLINICAL PATHWAY
Lower Extremity Functional Scale
SITE: GBHS - Owen Sound PATIENT ID
We are interested in knowing whether you are having any difficulty at all with the activities listed below because of your lower limb problem for which you are currently seeking attention. Please provide an answer for EACH activity.
(Circle one number on each line)
ActivitiesAny of your usual work, housework or school activitiesYour usual hobbies, recreational or sporting activitiesGetting into or out of the bathWalking between roomsPutting on your shoes or socksSquattingLifting an object, like a bag of groceries from the floorPerforming light activities around your homePerforming heavy activities around your homeGetting into or out of a carWalking 2 blocksWalking a mileGoing up or down 10 stairs (about 1 flight of stairs)Standing for 1 hourSitting for 1 hour
Rolling over in bedColumn Totals
Goal - score of 50 by discharge from services
Running on even groundRunning on uneven groundMaking sharp turns while running fastHopping
Grey Bruce Health Network
CP-THR-117©2003-2006 Grey Bruce Health Network
Approved (May, 2006)5
Annual Review (May, 2007)
0 0
1
2 1
3 1
0 11 12 13 14 1
5 1
None in the last 3 months 0 1One in the last 3 months 1 1Two in the last 3 months 2 1
More than two in the last 3 months 3 0
Up to three medical problems 0 1
Three to five medical problems 1 1
More than five medical problems 2 1
Fewer than three drugs 0 1
Three to five drugs 1 0
More than five drugs 2 1
0 2
1 3
2 0
3 1
4 2
5
0-10
11-19
>20
TOTAL HIP REPLACEMENTCLINICAL PATHWAY
Blaylock Discharge Planning Risk Assessment Screen
SITE: GBHS - Owen Sound PATIENT ID
Circle all that apply and total. Refer to scoring index for recommendations regarding discharge planning.
Age
55 years or less
Functional Status
Independent in activities of daily living and instrumental activities of daily living
56-64 years Dependent in:
65-79 years Eating/Feeding
80+ years Bathing/Grooming
Living Situation/Social
Support
Lives only with spouse Toileting
Lives with family Transferring
Lives alone with family support Incontinent of bowel function
Lives alone with friend's support Incontinent of bladder function
Lives alone with no support Meal Preparation
Nursing home/residential careResponsible for own medication administration
Number of Previous
Admissions/ Emergency Room
Visits
Handling own finances
Grocery Shopping
Transportation
Behaviour Pattern
Appropriate
Number of Active Medical Problems
Wandering
Agitated
Confused
Number of Drugs
Other
Mobility
Ambulatory
Ambulatory with mechanical assistance
Cognition
Oriented Ambulatory with human assistance
Disoriented to some spheres (person, place, self, time) some of the time
Nonambulatory
Disoriented to some spheres (person, place, self, time) all of the time
Sensory Deficits
None
Disoriented to all spheres (person, place, self, time) and some of the time
Visual or hearing deficits
Disoriented to all spheres (person, place, self, time) all of the time
Visual and hearing deficits
Comatose
Total Score: ____________ Signature: _____________________ Date: ____________________
Scoring Index
Probable outpatient physiotherapy or occupational therapy follow up, refer to Discharge Planner
May require CCAC services, refer to Case ManagerMay require alternative level of care, refer to Discharge Planner
Grey Bruce Health Network
CP-THR-117©2003-2006 Grey Bruce Health Network
Approved (May, 2006)7
Annual Review (May, 2007)
CERNER ORDER
CONSULTS
MOBILITY/ACTIVITY
TOTAL HIP REPLACEMENT
CLINICAL PATHWAY
SITE: GBHS - Owen Sound PATIENT ID
PROCESS PRE-OP ADMISSION/DAY OF SURGERY
DATE _____________
ASSESSMENT (OBSERVATIONS/ MEASUREMENTS/
ELIMINATION)
VITAL SIGNS WITH O2 SATS: TPR & BP
COMPLETE PRE-OP ORDERS (I.E. SCRUBS, SHAVES)
MEASURE FOR TED STOCKINGS AND SEND TO PACU
DIAGNOSTICS/ LABORATORY
REVIEW CHART FOR LAB WORK, ECG & X-RAY ORDERS
COMPLETE PRE-OP CHECKLIST
COMPLETE ANY PRE-OP BLOOD WORK OR TESTS ORDERED (I.E. FBS)
OTHER:
OTHER:
REVIEW MEDS TAKEN USING NURSING HISTORY
PRE-OP MEDS
OTHER:
OTHER:
ALL NON-SHADED BOXES TO BE INITIALLED UPON COMPLETION OR MARKED N/A AND INITIALLED
TO OR: WALK q STRETCHER q
PSYCHOSOCIAL SUPPORT/
EDUCATION
MONITOR ANXIETY LEVEL
FAMILY INSTRUCTED RE: SURGICAL WAITING AREA
DISCHARGE PLANNING
PLANS FOR DISCHARGE DISCUSSED WITH FAMILY
OTHER:
TOTAL HIP REPLACEMENT PATHWAY
NUTRITIONNPO AS ORDERED
CLEAR FLUIDS UNTIL 0800 (IF SURGERY IN PM)
TREATMENTS/ INTERVENTIONS
MRSA & VRE SWAB (NARES AND RECTUM)
OTHER:
OTHER:
OTHER:
MEDICATIONS
Grey Bruce Health Network
Grey Bruce Health Network
CP-THR-117©2003-2006 Grey Bruce Health Network
Approved (May, 2006)9
Annual Review (May, 2007)
NUTRITION
TOTAL HIP REPLACEMENT
CLINICAL PATHWAY
SITE: GBHS - Owen Sound PATIENT ID
PROCESS POST-OP DAY OF SURGERY
DATE _____________
ASSESSMENT (OBSERVATIONS/ MEASUREMENTS/
ELIMINATION)
VITAL SIGNS WITH O2 SATS: Q4H
ASSESS DRESSING
MONITOR INTAKE / OUTPUT
FOLEY CATHETER PRN
OTHER:
CONSULTSINTERNAL MEDICINE IF REQUIRED
PHYSIO
DIAGNOSTICS/ LABORATORY
BLOOD WORK AS ORDERED
OTHER:
OTHER:
MEDICATIONS
PCA AS ORDERED
SEE MAR SHEET
OTHER:
ANCEF GIVEN IN OR
OTHER:
TREATMENTS/ INTERVENTIONS
IV AS ORDERED
SUPPLEMENTARY O2 AS PER PROTOCOL
EMPTY DRAIN Q SHIFT AND PRN
CIRCULATION / SENSATION / MOTION Q4H
APPLY TED STOCKINGS IN PACU
BED BATH
OTHER:
OTHER:
ALL NON-SHADED BOXES TO BE INITIALLED UPON COMPLETION OR MARKED N/A AND INITIALLED
q SIPS - REGULAR DIETq SIPS - SPECIAL DIET: _________________________________________
MOBILITY/ACTIVITY
BED REST
POSITIONING Q2-4H WITH PILLOW BETWEEN LEGS
OVERHEAD TRAPEZE
Grey Bruce Health Network
CP-THR-117©2003-2006 Grey Bruce Health Network
Approved (May, 2006)11
Annual Review (May, 2007)
PROCESS POST-OP DAY OF SURGERY
DATE _____________
PSYCHOSOCIAL SUPPORT/
EDUCATION
REVIEW PCA
ORIENTATION TO UNIT
COMPLETE NURSING HISTORY WITH BRADEN RISK ASSESSMENT TOOL IF NECESSARY
POST-OP NEEDS—DEEP BREATHING & COUGHING, CALF PUMPING
REVIEW HIP PRECAUTIONS
ALL NON-SHADED BOXES TO BE INITIALLED UPON COMPLETION OR MARKED N/A AND INITIALLED
DISCHARGE PLANNING
ESTIMATED DATE OF DISCHARGE AND DESTINATION KNOWN AND DOCUMENTED ON PROGRESS NOTES
OTHER:
CP-THR-117©2003-2006 Grey Bruce Health Network
Approved (May, 2006)12
Annual Review (May, 2007)
DATE_______
DATE_______
DATE_______
RISK FACTOR 1 2 3 4
Sensory Perception: Ability to respond meaningfully to pressure—related discomfort
Completely Limited
Very LimitedSlightly Limited
No Impairment
Moisture: Degree to which skin is exposed to moisture
Constantly Moist
Often MoistOccasionally Moist
Rarely Moist
Activity: Degree of Physical Activity
Bedfast Chair FastWalks Occasionally
Walks Frequently
Mobility: Ability to change and control body position
Completely Immobile
Very LimitedSlightly Limited
No Limitations
Nutrition: Usual food intake pattern
Very PoorProbably Inadequate
Adequate Excellent
Friction and Sheer ProblemPotential Problem
No Apparent Problem
LOW RISK(SCORE > 15)
Ongoing assessment for change in status related to any of the six risk areas
TOTAL HIP REPLACEMENTCLINICAL PATHWAY
Braden Risk Assessment
SITE: GBHS - Owen Sound PATIENT ID
SCORING (Key on Reverse)
SCORE
TOTAL SCORE
NURSE’S INITIALS
Nursing Intervention: Once you have assessed the patient and identified a risk category (high, moderate, or low), carry out the following interventions for the patient's risk category.
MODERATE RISK (SCORE 13-14)
HIGH RISK (SCORE < 12)
Initiate and document plan of care on Kardex and Unit specific Progress Notes including:
Includes “Moderate Risk Intervention” plus requested referral to:
Document reassessment weekly on Kardex
-Activity level (i.e. turning, positioning) -Physiotherapy-Continence management -Occupational Therapy-Monitoring of pressure point areas -Dietitian
-Patient education re: prevention
-Monitor nutritional status-Skin care tools used: prevention mattresses or treatment (i.e. air mattresses), creams, bed hoop, trapeze, dressings
Grey Bruce Health Network
CP-THR-117©2003-2006 Grey Bruce Health Network
Approved (May, 2006)13
Annual Review (May, 2007)
RISK FACTOR
Moisture
Degree to which skin is exposed to moisture
1. Constantly MoistSkin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned.
2. Often MoistSkin is often, but not always moist. Linen must be changed at least once a shift.
3. Occasionally MoistSkin is occasionally moist, requiring an extra linen change approximately once a day.
4. Rarely MoistSkin is usually dry, linen only requires changing at routine intervals.
Activity
Degree of physical activity
1. BedfastConfined to a bed.
2. Chair FastAbility to walk severelylimited or nonexistent. Cannot bear own weight and/or must be assisted into chair or wheelchair.
3. Walks OccasionallyWalks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair.
4. Walks FrequentlyWalks outside the room at least twice a day and inside room at least once every two hours during waking hours.
Mobility
Ability to change and control body position
1. Completely ImmobileDoes not make even slight changes in body or extremity position without assistance.
2. Very LimitedMakes occasional slight changes in body or extremity position, but unable to make frequent or significant changesindependently.
3. Slightly LimitedMakes frequent, though slight changes in body or extremity position independently.
4. No LimitationsMakes major and frequent changes in position without assistance.
Nutrition 1. Very PoorNever eats a complete meal. Rarely eats more than 1/3 of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement.ORIs on NPO and/or maintained on clear fluids or IV for more than 5 days.
2. Probably InadequateRarely eats a complete meal and generally eats only about 1/2 of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement.ORReceives less than optimum amount of liquid diet or tube feeding.
3. AdequateEats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products) each day. Occasionally, will refuse a meal, but will usually take a supplement if offered.ORIs on a tube feeding or TPN (Total Parenteral Nutrition) regimen, which probably meets most of nutritional needs.
4. ExcellentEats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eatsbetween meals. Does not require supplementation.
Friction and Shear
1. ProblemRequires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures or agitation leads to almost constant friction.
2. Potential ProblemMoves feebly or requires minimum assistance. During a move, skin probably slides to some extent against sheets, chair, restraints or other devices. Maintains relatively good position in chair or bed most of the time, but occasionally slides down.
3. No Apparent ProblemMoves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair at all times.
SCORE/DESCRIPTION
Sensory Perception
Ability to respond meaningfullyto pressure related discomfort
1. Completely LimitedUnresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level or consciousness or sedation.OR Limited ability to feel pain over most of body surface.
2. Very LimitedResponds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness.ORHas a sensory impairment, which limits the ability to feel pain or discomfort over 1/2 of body.
3. Slightly LimitedResponds to verbal commands but cannot always communicate discomfort or need to be turned.ORHas some sensory Impairment, which limits ability to feel pain or discomfort in 1 or 2 extremities.
4. No ImpairmentResponds to verbal commands. Has no sensory deficit, which would limit ability to feel or voice pain or discomfort.
CP-THR-117©2003-2006 Grey Bruce Health Network
Approved (May, 2006)14
Annual Review (May, 2007)
PERFORMANCE INDICATORS 2
CONSULTS
NUTRITION
DIAGNOSTICS/ LABORATORY
MEDICATIONS
ALL NON-SHADED BOXES TO BE INITIALLED UPON COMPLETION OR MARKED N/A AND INITIALLED
q SIPS - REGULAR DIETq SIPS - SPECIAL DIET: _________________________________________
OTHER:
SEE MAR SHEET
OTHER:
OTHER:
REMOVE DRAIN ORDERED
TREATMENTS/ INTERVENTIONS
HIP X-RAY
BED BATH WITH ASSIST
TOTAL HIP REPLACEMENT
SITE: GBHS - Owen Sound
VITAL SIGNS WITH O2 SATS: Q4H
IV AS ORDERED
REMOVE CATHETER (24 HOURS POST-OP)
CLINICAL PATHWAY
OTHER:
ASSESSMENT (OBSERVATIONS/ MEASUREMENTS/
ELIMINATION)
OTHER:
Record as "Met"or "Not Met" on
Variance Record
POST-OP DAY 1
PATIENT ID
DATE _____________
TED STOCKINGS REMOVED FOR SKIN CARE
OTHER:
OTHER:
EMPTY DRAIN Q SHIFT AND PRN
CBC & LYTES
ANTIBIOTIC DISCONTINUED 24 HOURS POST SURGERY
CATHETER
CHEST ASSESSMENT
CIRCULATION / SENSATION / MOTION Q4H
ASSESS DRESSING
MONITOR INTAKE / OUTPUT
PROCESS
Grey Bruce Health Network
CP-THR-117©2003-2006 Grey Bruce Health Network
Approved (May, 2006)15
Annual Review (May, 2007)
PSYCHOSOCIAL SUPPORT/
EDUCATION
DISCHARGE PLANNING
DATE _____________
UP IN CHAIR
ALL NON-SHADED BOXES TO BE INITIALLED UPON COMPLETION OR MARKED N/A AND INITIALLED
MOBILITY/ACTIVITY
UP WITH WALKER IN ROOM
PROCESS POST-OP DAY 1
REVIEW HIP PRECAUTIONS
PLANS FOR DISCHARGE DISCUSSED WITH PATIENT/FAMILY AND DOCUMENTED ON PROGRESS NOTES
ESTIMATED DATE OF DISCHARGE DISCUSSED WITH PATIENT/FAMILY
OTHER:
REVIEW PATIENT PATHWAY
FOOT AND ANKLE EXERCISES
ISOMETRIC QUADS AND GLUTS
ROUTINE POST-OP TEACHING
POST-OP NEEDS—DEEP BREATHING & COUGHING, CALF PUMPING
PHYSIO DATABASE INITIATED
ASSESS DISCHARGE CRITERIA DAILY
WEIGHT BEARING STATUS ORDERED
POSITIONING IN BED WITH PILLOW BETWEEN LEGS
LIE TO SIT WITH USE OF RAIL
CP-THR-117©2003-2006 Grey Bruce Health Network
Approved (May, 2006)16
Annual Review (May, 2007)
NUTRITION
TOTAL HIP REPLACEMENT
CLINICAL PATHWAY
VITAL SIGNS WITH O2 SATS: QID
CHEST ASSESSMENT
SEE MAR SHEET
TED STOCKINGS REMOVED FOR SKIN CARE
OTHER:
CIRCULATION / SENSATION / MOTION Q4H
PHYSIO DATABASE COMPLETED
AMBULATE 3 METRES WITH WALKER AND ASSISTANCE
ACTIVE ASSISTED HIP ROM EXERCISES
PATIENT ID
DATE _____________
POST-OP DAY 2
SITE: GBHS - Owen Sound
PROCESS
TRANSFER TECHNIQUE REVIEWED WITH PATIENT
DIAGNOSTICS/ LABORATORY
CONSULTS
CBC & LYTES
OTHER:
OTHER:
MEDICATIONS OTHER:
q REGULAR DIETq SPECIAL DIET: ______________________________________________
MOBILITY/ACTIVITY
MONITOR BOWEL MOVEMENT
OTHER:
CCAC IF NECESSARY
OT - DRESSING IN STREET CLOTHES
MONITOR INTAKE / OUTPUT
DISCONTINUE IV FLUID AND ASSESS NEED FOR INTERMITTENT SET
ASSESS DRESSING
REDUCE DRESSING TO ISLAND DRESSING
ALL NON-SHADED BOXES TO BE INITIALLED UPON COMPLETION OR MARKED N/A AND INITIALLED
TREATMENTS/ INTERVENTIONS
OTHER:
OTHER:
ASSESSMENT (OBSERVATIONS/ MEASUREMENTS/
ELIMINATION)
Grey Bruce Health Network
CP-THR-117©2003-2006 Grey Bruce Health Network
Approved (May, 2006)17
Annual Review (May, 2007)
PSYCHOSOCIAL SUPPORT/
EDUCATION
REVIEW PATIENT PATHWAY
REVIEW HIP PRECAUTIONS
VERBALIZES UNDERSTANDING OF PLAN OF CARE
PATIENT TAUGHT USE OF MOLECULAR WEIGHT HEPARIN POST DISCHARGE IF APPLICABLE
REVIEW WITH SURGEON, NOTIFY APPROPRIATE RECEIVING HOSPITAL OR UNIT OF POTENTIAL TRANSFER IF APPLICABLE
DISCHARGE NEEDS ASSESSED BY PHYSIO
DISCHARGE PLANNING
OTHER:
BLAYLOCK DISCHARGE PLANNING RISK ASSESSMENT SCREEN REVIEWED, INFORM CCAC OF CHANGES IF APPLICABLE
ALL NON-SHADED BOXES TO BE INITIALLED UPON COMPLETION OR MARKED N/A AND INITIALLED
ASSESS DISCHARGE CRITERIA DAILY
PLANS FOR DISCHARGE DISCUSSED WITH PATIENT/FAMILY AND DOCUMENTED ON PROGRESS NOTES
DATE _____________
PROCESS POST-OP DAY 2
CP-THR-117©2003-2006 Grey Bruce Health Network
Approved (May, 2006)18
Annual Review (May, 2007)
NUTRITION
TOTAL HIP REPLACEMENT
OTHER:
OTHER:
CHEST ASSESSMENT
CIRCULATION / SENSATION / MOTION Q4H
q REGULAR DIETq SPECIAL DIET: ______________________________________________
OTHER:
MONITOR INTAKE / OUTPUT
CBC & LYTES
OTHER:
VITAL SIGNS WITH O2 SATS: TID
ASSESSMENT (OBSERVATIONS/ MEASUREMENTS/
ELIMINATION)
SEE MAR SHEET
DIAGNOSTICS/ LABORATORY
OTHER:
MEDICATIONS
IV DISCONTINUED AS PER ORDERS
ALL NON-SHADED BOXES TO BE INITIALLED UPON COMPLETION OR MARKED N/A AND INITIALLED
TREATMENTS/ INTERVENTIONS TED STOCKINGS REMOVED FOR SKIN CARE
OT - IF PATIENT GOING HOME AND DESIRE FOR TUB BATH
OT - TEDS DRESSING TRAINING IF APPROPRIATE
PROCESS
MONITOR BOWEL MOVEMENT
CONSULTS
DATE _____________
PATIENT ID
OTHER:
OTHER:
VOIDING QS
POST-OP DAY 3
CLINICAL PATHWAY
SITE: GBHS - Owen Sound
ASSESS DRESSING
DRESSING CHANGE
Grey Bruce Health Network
CP-THR-117©2003-2006 Grey Bruce Health Network
Approved (May, 2006)19
Annual Review (May, 2007)
MOBILITY/ACTIVITY
UP WITH WALKER IN HALL INDEPENDENTLY
PHYSIO FOLLOW UP ARRANGED
TAUGHT LIE TO SIT UNDER HOME CONDITIONS
ASSISTED WITH EXERCISES
TRAINING TO DRESS IN STREET CLOTHES
DRESSED IN STREET CLOTHES
EQUIPMENT FOR HOME ARRANGED IF NECESSARY
REVIEW TRANSFER TECHNIQUE WITH PATIENT
Date: ______________________________________________
DISCHARGE DISCUSSED WITH PATIENT/FAMILY
DESTINATION AND DATE FOR DISCHARGE KNOWN
Destination: _________________________________________
ALL NON-SHADED BOXES TO BE INITIALLED UPON COMPLETION OR MARKED N/A AND INITIALLED
DISCHARGE PLANNING
ASSESS DISCHARGE CRITERIA DAILY
DATE _____________
PROCESS
PSYCHOSOCIAL SUPPORT/
EDUCATION
REVIEW PATIENT PATHWAY
POST-OP DAY 3
REVIEW TOTAL HIP REPLACEMENT TEACHING BOOKLET
PATIENT TAUGHT USE OF MOLECULAR WEIGHT HEPARIN POSTDISCHARGE IF APPLICABLE
OTHER:
DISCHARGE NEEDS ASSESSED
REVIEW HIP PRECAUTIONS
PATIENT PREPARED FOR DISCHARGE (E.G. CLOTHING)
REHAB ASSESSMENT COMPLETED AS NEEDED
CP-THR-117©2003-2006 Grey Bruce Health Network
Approved (May, 2006)20
Annual Review (May, 2007)
ASSESS DURATION OF DVT PROPHYLAXIS ACCORDING TO RISK FACTORS
CONSULTS
NUTRITION
SITE: GBHS - Owen Sound
DRESSING CHANGE
ASSESSMENT (OBSERVATIONS/ MEASUREMENTS/
ELIMINATION)
DIAGNOSTICS/ LABORATORY
MONITOR INTAKE / OUTPUT
CIRCULATION / SENSATION / MOTION Q4H
MONITOR BOWEL MOVEMENT
TOTAL HIP REPLACEMENT
CLINICAL PATHWAY
OTHER:
ASSIST WITH AM CARE
DATE _____________
INDEPENDENT EXERCISES
TEDS DRESSING TRAINING IF APPLICABLE
TUB TRANSFER TRAINING IF APPLICABLE
ASSESS STAIRS IF REQUIRED
MOBILITY/ACTIVITY
PROGRESS TO CRUTCHES IF REQUIRED
MEDICATIONS
TREATMENTS/ INTERVENTIONS
q REGULAR DIETq SPECIAL DIET: ______________________________________________
SEE MAR SHEET
OTHER:
OTHER:
ASSESS DRESSING
ALL NON-SHADED BOXES TO BE INITIALLED UPON COMPLETION OR MARKED N/A AND INITIALLED
INDEPENDENT TRANSFERS IN AND OUT OF BED
OTHER:
INDEPENDENT LIE TO SIT UNDER HOME CONDITIONS
TED STOCKINGS REMOVED FOR SKIN CARE
OTHER:
OTHER:
PROCESS POST-OP DAY 4
DISCHARGE PLANNING REFERRAL FOR ALC IF REQUIRED
OTHER:
CHEST ASSESSMENT
VITAL SIGNS WITH O2 SATS: BID
Grey Bruce Health Network
CP-THR-117©2003-2006 Grey Bruce Health Network
Approved (May, 2006)21
Annual Review (May, 2007)
REVIEW HIP PRECAUTIONS
DISCHARGE HOME q
ALL NON-SHADED BOXES TO BE INITIALLED UPON COMPLETION OR MARKED N/A AND INITIALLED
ONE OF:
DISCHARGE PLANNING
TRANSFER TO HOME HOSPITAL q
OTHER:
ASSESS DISCHARGE CRITERIA DAILY
VERBALIZES UNDERSTANDING OF PLAN OF CARE
TRANSFER TO REHAB q
PSYCHOSOCIAL SUPPORT/
EDUCATIONPATIENT TAUGHT USE OF MOLECULAR WEIGHT HEPARIN POST DISCHARGE IF APPLICABLE
REVIEW PATIENT PATHWAY
PROCESS POST-OP DAY 4
DATE _____________
CP-THR-117©2003-2006 Grey Bruce Health Network
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Annual Review (May, 2007)
ARRANGED: ___________________________
NUTRITION
ASSIST/TEACH DRESSING IN STREET CLOTHES
OTHER:
ASSESS DRESSING / CHANGE PRN
REMOVAL OF SUTURES / STAPLES:
ASSESS WOUND PRN
REMOVE DRESSING IF WOUND CLEAN & DRY
MONITOR BOWEL MOVEMENT
OTHER:
CCAC AND/OR OUTPATIENT PHYSIO
DISCHARGE PLANNING IF REQUIRED
FOLLOW UP APPOINTMENT
TREATMENTS/ INTERVENTIONS
q REGULAR DIETq SPECIAL DIET ________________________
ALL NON-SHADED BOXES TO BE INITIALLED UPON COMPLETION OR MARKED N/A AND INITIALLED
MEDICATIONS
SEE MAR SHEET
SELF-MED PROGRAM IF APPROPRIATE
OTHER:
OTHER:
OTHER:
DATE: _________________________________
TEDS REMOVED FOR SKIN CARE
ASSESSMENT (OBSERVATIONS/ MEASUREMENTS/
ELIMINATION)
CONSULTS
DIAGNOSTICS/ LABORATORY
OTHER:
OTHER:
SKIN ASSESSMENT
VITAL SIGNS WITH O2 SATS: Q SHIFT
CIRCULATION / SENSATION / MOTION
CALF PUMPING
VOIDING QS
ONGOING POST-OP CARE
SIGNS/SYMPTOMS OF THROMBUS/PHLEBITIS
SITE: GBHS - Owen Sound PATIENT ID
PROCESS
DATE ___________
DATE ___________
DATE ___________
TOTAL HIP REPLACEMENT
CLINICAL PATHWAY
Grey Bruce Health Network
CP-THR-117©2003-2006 Grey Bruce Health Network
Approved (May, 2006)23
Annual Review (May, 2007)
REVIEW/DISCUSS SURGICAL COMPLICATIONS
ASSESS DISCHARGE CRITERIA DAILY
EQUIPMENT IN PLACE FOR DISCHARGE
EXERCISES:
INDEPENDENTLY q
WITH ASSISTANCE q
TRANSFERS:
AMBULATION: INDEPENDENTLY
DISCHARGE PLANNING
DISCHARGE PLANS REVIEWED WEEKLY
HYGIENE NEEDS ASSESSED AND TAUGHT(E.G. TEDS, SHOWER/TUB TRANSFERS)
TOTAL HIP ROUTINE REVIEWED
TEACHING THE USE OF AIDS
DATE DUE: _____________________________
DESTINATION: __________________________
DATE: _________________________________
OTHER:
MOBILITY/ACTIVITY
ALL NON-SHADED BOXES TO BE INITIALLED UPON COMPLETION OR MARKED N/A AND INITIALLED
HOME SUPPORTS REVIEWED
DISCHARGE PLANS DISCUSSED WITH PATIENT AND FAMILY:
INDEPENDENTLY q
WITH ASSISTANCE q
PSYCHOSOCIAL SUPPORT/
EDUCATION PATIENT TAUGHT USE OF MOLECULARWEIGHT HEPARIN POST DISCHARGEIF APPLICABLE
BED MOBILITY
AWARE OF PRECAUTIONS
PROCESSONGOING
POST-OP CARE
DATE ___________
DATE ___________
DATE ___________
STAIRS:
INDEPENDENTLY q
WITH ASSISTANCE q
INDEPENDENTLY q
WITH ASSISTANCE q
CP-THR-117©2003-2006 Grey Bruce Health Network
Approved (May, 2006)24
Annual Review (May, 2007)
CONSULTS
DIAGNOSTICS/ LABORATORY
NUTRITION
ASSESS DRESSING
DRESSING CHANGE
INDEPENDENT EXERCISES
UNDERSTANDS SIGNS AND SYMPTOMS OF WOUND INFECTION
AWARE OF PRECAUTIONS
SAFE AMBULATION WITH AID ON LEVEL AND STAIRS
EQUIPMENT IN PLACE
TOTAL HIP REPLACEMENT
CLINICAL PATHWAY
ALL NON-SHADED BOXES TO BE INITIALLED UPON COMPLETION OR MARKED N/A AND INITIALLED
FREE OF SIGNS/SYMPTOMS OF THROMBUS/PHLEBITIS
VOIDING QS
RETURN TO NORMAL BOWEL ROUTINE
PATIENT TAUGHT USE OF MOLECULAR WEIGHT HEPARIN POST DISCHARGE IF APPLICABLE
CCAC AND/OR OUTPATIENT PHYSIO ARRANGED
DISCHARGE SUMMARY COMPLETED ON VARIANCE RECORD
PATIENT IDSITE: GBHS - Owen Sound
DISCHARGE CRITERIA DATE MET INITIAL
MOBILITY/ACTIVITY
ASSESSMENT (OBSERVATIONS/ MEASUREMENTS/
ELIMINATION)
AFEBRILE
VITAL SIGNS STABLE
WOUND INTACT
NIL DRAINAGE
PRESCRIPTION FOR ANALGESIC AND/OR ANTI-COAGULANT AS ORDERED
PROCESS
ARRANGE FOR INR AT HOME IF PATIENT ON ANTI-COAGULANT
FOLLOW UP APPOINTMENT ARRANGED
DISCHARGE PLANNING
MEDICATIONS
REGULAR DIET
SAFE, INDEPENDENT TRANSFERS
TREATMENTS/ INTERVENTIONS
PSYCHOSOCIAL SUPPORT/
EDUCATION
HEALTH TEACHING RELATED TO MEDS
PLANS FOR ANTI-COAGULATION KNOWN & DOCUMENTED ON TRANSFER SHEET
Grey Bruce Health Network
CP-THR-117©2003-2006 Grey Bruce Health Network
Approved (May, 2006)25
Annual Review (May, 2007)
METNOT MET
DATE/TIME INITIAL CODEDATE
RESOLVED(or N/A)
INITIAL
1 q q
2 q q
PRE-ADMIT PHYSIO VISIT
THIS VARIANCE RECORD IS USED FOR EVALUATIVE PURPOSES ONLY. DO NOT PUT PATIENT INFORMATION ON THIS FORM. REMOVE AND SEND TO SITE CHAMPION AT PATIENT DISCHARGE.
Patient Age: _____ Gender: _____ Admission Date: ____________________ LEFS Score: ________ Targeted LOS: 5 Days
TIME FRAME
INDICATOR DESCRIBE CORRECTIVE ACTION
(or N/A if not applicable)
Patient transferred from another hospital? Yes (specify) q ______________________________ Pathway Day: ________ No q
TOTAL HIP REPLACEMENTVARIANCE RECORD
SITE: GBHS - Owen SoundGREY BRUCE HEALTH NETWORK
Total Hip Replacement Post-Op Pre-Printed Orders used: Yes q No q
Discharge Destination: Home q Home with CCAC q Rehab q Hospital q (specify) ____________________________
DAY 1ANTIBIOTIC DISCONTINUED 24 HOURS POST SURGERY
Other q (specify) _____________________________
DISCHARGE SUMMARY: (To be completed upon discharge off pathway or unit)
See back of page for instructions re: Transfer Patients or CCAC Clients
Signature: Date:
Date Pathway Completed: __________________________ Days on Pathway: ___________________________________
Weight Bearing Status: ____________________________
Patient education materials given to Patient: Yes q No q If no, reason: ________________________________________
Patient removed from Pathway before discharge: Yes q Reason: ______________________________________________
Patient teaching completed: Yes q No q If no, reason: ____________________________________________________
CP-THR-117©2003-2006 Grey Bruce Health Network
Approved (May, 2006)27
Annual Review (May, 2007)
1. On Admission:l
l Place the Variance Record behind the clinical pathway on the chart.
2. Documenting the Variance:l For each indicator, tick whether met or not met, indicate the date, time and initial.l If not met, the indicator becomes a variance. State variance code as either A, B or C, and
l Indicate your action plan to correct the variance, or indicate N/A if not applicable.l Indicate the date variance was resolved and initial, or indicate N/A if not applicable.
3. On Discharge:l
l If patient is being discharged home, send Variance Record to Site Champion to be
l
m m
m m
4. Transfer Patients:l
m
m
m
m
m
m
l
l
A1) B1) C1) B2) C2)
A2) B3) C3) B4) C4)
A3) B5) C5) A4) C6) A5) C7)
C8) A6) C9) A7) C10)
C11)
A8)
- original to stay on patient chart
VARIANCE DOCUMENTATION GUIDELINESVariances to clinical pathway activities will be documented on a Variance Record. Upon completion, this form is to be sent to the Evidence-Based Care Program Coordinator for evaluation purposes.
Complete the demographic section: patient age, gender, admission date.
Complete the Discharge Summary.
the number within the category.
forwarded to Evidence-Based Care Program Coordinator.If appropriate, send a copy of the following to the receiving service provider:
Variance RecordBlaylock Discharging Planning ToolSmiley Face Tool
Discharge Criteria
If patient is transferred to another hospital in Grey-Bruce, send the following:Variance Record - copy with patient to receiving hospital
- original to Evidence-Based Care Program Coordinator Discharge Criteria - copy with patient to receiving hospital
- original to stay on patient chart
Smiley Face Tool - original with patient to receiving hospital
MAR Sheet - copy with patient to receiving hospital - original to stay on patient chart
Anticoagulant Record - copy with patient to receiving hospital
Blaylock Discharge Tool - copy with patient to receiving hospital - original to stay on patient chart
A new Variance Record should be started in the new facility for the remainder of thepatient’s stay.When the patient is discharged from the transfer facility, fill out Discharge Summary,staple both Variance Records together and send to Site Champion to be forwarded to Evidence-Based Care Program Coordinator.
VARIANCE CODESPATIENT OUTCOME VARIANCES PERFORMANCE VARIANCES
A) PATIENT/FAMILY B) CARE PROVIDER C) SYSTEM
Inability to learn skill needed for Lack of or inadequate documentation Bed availabilityself-care Physician/provider response time Schedule conflictInadequate social support or systems Physician preference Consultant unavailableat home Pre-Printed Orders not used OR time unavailableFailure to respond to treatment Orders outside clinical pathway Results/data unavailablePatient/caregiver unavailability parameters Supply/equipment unavailableUnable to return to pre-admission B6) Treatment or intervention omitted Department closedenvironment B7) Other (please specify) Placement unavailablePatient/caregiver decision Home health care unavailableComplication of condition Transportation unavailable(physiological/psychological) Other (please specify)
Other (please specify)
CP-THR-117©2003-2006 Grey Bruce Health Network
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Annual Review (May, 2007)