Nursing assessment Pain q 2 hours Nursing assessment Nursing assessment No signs and/or per protocol Oral pain management per unit protocol per unit protocol symptoms of infection NV check q 4 hours IV meds for TEDs/SCDs TEDs/SCDs Absence DVT continous pulse ox breakthrough I/Os I/Os UOP monitoring D/C PCA IS education Change dressing functioning WNL Assess dressings D/C IV fluids De bulk dressing Shower Monitor and record Nursing assessment NV checks q 4 hours Oral pain management Demonstrates drains per unit protocol Oral pain management IV meds for anticoagulation TEDS/SCDs NV q 4 hours IV meds for breakthrough administration I/Os Foley IS education breakthrough CPM application & Clear diet (ADAT) TEDs/SCDs CPM application & teaching Demonstrates CPM IS education I/Os teaching Ambulate with nurse application Post op abx DC Ambulate with nurse in afternoon if PT not check HCT - may in afternoon if PT not available Hct 1800 transfuse available Anticoagulation Debulk/decast Anticoagulation teaching CPM application & teaching teaching Ambulate with in afternoon if PT not available Anticoagulation teaching Patient/Family Joint Class will Knee Precautions - PT Knee Precautions - PT Discuss car transfers - Review D/C Patient and Family Education review what to expect Bed Mobility - PT No pillow under knee - PT instructions - RN verbalize with surgery, pain No pillow under knee - PT/RN Anticoagulation Review prescriptions - understanding of management, PT/RN weight bearing status - education - RN RN discharge instructions anticoagulation, Incentive Spirometer - PT Educate use of CPM - Provide dressing RN Post op exercises - PT PT/RN changes - Ortho team Pain Management - Anticoagulation ADL equipment - OT Anticoagulation RN education - RN Assistive Device - OT teaching - RN Orient to Room - RN TEDs teaching - PT/RN Outcomes Pain level 1 - 3 Pain level 1 - 3 Pain level 1 - 3 Pain level 1 - 3 Discharge VS WNL VS WNL VS WNL Progress activity Pulse ox > 90 % I/Os WNL Progress activity Bowel Movement lungs CTAB Ambulate Progress ambulation Progress ambulating
Nursing assessment per protocol NV check q 4 hours continous pulse ox monitoring Assess dressings Monitor and record drains TEDS/SCDs I/Os Foley Clear diet (ADAT) IS education Post op abx Hct 1800 Pain q 2 hours Oral pain management IV meds for breakthrough D/C PCA D/C IV fluids Nursing assessment per unit protocol NV q 4 hours IS education TEDs/SCDs I/Os DC check HCT - may transfuse Debulk/decast CPM application & teaching Ambulate with in afternoon if PT not available Anticoagulation teaching Nursing assessment per unit protocol TEDs/SCDs I/Os IS education De bulk dressing NV checks q 4 hours Oral pain management IV meds for breakthrough CPM application & teaching Ambulate with nurse in afternoon if PT not available Anticoagulation teaching Nursing assessment per unit protocol TEDs/SCDs I/Os Change dressing Shower Oral pain management IV meds for breakthrough CPM application & teaching Ambulate with nurse in afternoon if PT not available Anticoagulation teaching No signs and/or symptoms of infection Absence DVT UOP functioning WNL Demonstrates anticoagulation administration Demonstrates CPM application Patient/Family Education Joint Class will review what to expect with surgery, pain management, anticoagulation, Knee Precautions - PT Bed Mobility - PT No pillow under knee - PT/RN Incentive Spirometer - RN Pain Management - RN Orient to Room - RN Knee Precautions - PT No pillow under knee - PT/RN weight bearing status - PT Post op exercises - PT Anticoagulation education - RN Discuss car transfers - PT Anticoagulation education - RN Educate use of CPM - PT/RN ADL equipment - OT Assistive Device - OT Review D/C instructions - RN Review prescriptions - RN Provide dressing changes - Ortho team Anticoagulation teaching - RN TEDs teaching - PT/RN Patient and Family verbalize understanding of discharge instructions Outcomes Pain level 1 - 3 VS WNL Pulse ox > 90 % lungs CTAB Pain level 1 - 3 VS WNL I/Os WNL Ambulate Pain level 1 - 3 VS WNL Progress activity Progress ambulation Pain level 1 - 3 Progress activity Bowel Movement Progress ambulating Discharge
care-map-knee.docx