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Golden Jubilee National Hospital
Total Hip Replacement – Side: __________
Patient label
Confidential
Pre assessment date _________________________________________
Consultant Pre assessment nurse
Provisional date of admission Actual date of admission
Provisional date of surgery Actual date of surgery
Expected date of discharge Occupational Therapist
Physiotherapist Attended pre-op talk Yes No
:
Alerts / allergies Comments
1. _________________________
2. _________________________
3. _________________________
4. _________________________
5. _________________________
6. _________________________
2
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
All staff
Please SIGN, PRINT and INITIAL below when you make your first written entry on the pathway
Print Sign Designation Initial
3
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Patient’s address: __________________________ Tel No:________________ Postcode: __________ Date of birth: _____/_____/_____ Age: ________ Marital status: ____________________________ Label details checked and correct Patient likes to be called: _________________ Occupation: ___________________________ Religion: _____________________________
GP name: _______________________________ GP address: _____________________________ Postcode: __________ Tel no:_______________
Next of Kin: ______________________________ Relationship: _____________________________ Address: ________________________________ _____________________ Postcode: __________ Telephone: ______________________________
Height: ______________ Weight: ___________ BMI: ____________ Oxford score : ____________
Blood pressure: ____________________________ Temperature: ______________________________ Pulse: ____________________________________ O2 saturation: _____________________________
Diabetic: Yes No If Yes BM: __________________
Date L.M.P. _____ / _____ / _____ Pregnancy test required? Yes No Result: __________________________________
Who will collect patient after surgery? Relative / friend May require transport
4
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Lives: Alone: Is patient independent? With healthy partner / family?: With elderly / infirm partner?: Does patient look after someone?: Yes No If yes, number of dependants: __________ Who is caring for dependant whilst patient is in hospital? ________________________________ If yes email discharge team
Does the patient have: Nursing home care: Residential care: Community nursing services: Home care services: Personal care: Meal preparation: If yes, which meals: Breakfast Lunch Dinner Shopping Housework Tuck in
Personal hygiene: Independent: Yes No If no, what assistance is required? Can dress independently: Yes No If no, what assistance is required?
Nutrition: No special requirements:
Therapeutic diet (state) ______________________
Cultural / ethnic diet (state) ___________________ Email dietician if celiac / peanut allergy or low BMI
Mobility: Independent Stick(s) Frame Wheelchair Hoist
Communication: Communicates effectively Impaired speech Visual aids Learning difficulties Cognitive issues (If appropriate, email clinical areas).
Primary language: Interpreter required Yes No Language: ________________________________ (If yes, document on outcome sheet).
Hearing; Normal Dull Hearing aid L R Bilateral Vision: Glasses Contact lenses Registered blind Eye disease
Emotional state: Alert / orientated Confused Mildly anxious Highly anxious History of depression History of anxiety
Falls questions How many falls have you had in the last six months? _________________________________ (If has had falls, email clinical areas).
5
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Medication on admission
Date of pre-admission clinic: ____________________ Date of admission: _______________ Allergy: NKDA Latex Yes No Metal: ________________ Reaction: ______________ Drug or other: ___________________________ Reaction: ______________________________________ Drug or other: ___________________________ Reaction: ______________________________________ Drug or other: ___________________________ Reaction: ______________________________________ Drug or other: ___________________________ Reaction: ______________________________________ Medication details to be filled by doctor, nurse or pharmacist Source of history (please circle) Patient / relative / GP referral letter / GP practice / old notes / Nursing home kardex / patient / list patients own drugs / Community Pharmacy _________________________________
Any Further Action required? Yes No E.g. ring GP in morning as medication unclear, check dose with relative
Comments
Medication history completed by: _____________________ Designation _____________ Date/time ___________
Doctors Signature _________________________________ Date/time _______________________
Admission medication Medication change (please tick)
Freq Name Dose 8am 12pm 6pm 10pm PRN
Hold Stop Comments (if medication held or stopped
Any herbal / over the counter medicines
6
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Pre-assessment details and medication confirmed
Investigations reviewed
General external Well / pale / cyanosed / clubbed / jaundiced / kachetic
CVS Pulse BP JVP
Apex Beat
Heart Sounds Oedema
RS Respiratory Rate
Trachea
Chest Expansion
BS (Breath Sounds)
SATS % R L
Abdomen
CNS / Locomotor Pulses Bruit
Assessing Doctor / Staff Nurse: Print Name:
Signature:
Date: Time: Designation:
·
7
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Past medical history Previous surgery / dates
Year
Year Surgery
Any recent hospital admit
Awaiting any tests / investigations
Any problems with anaesthetic Yes No Details:
Any family member with Yes No Details: anaesthetic problems?
Diagram of Mallampati’s score Class 1 – 4 Class ___________
Full range of neck movement Yes No Comments:
Joint / spinal problems Yes No Comments:
Dentition: Yes No Comments:
Any dental problems Yes No Details: Date last dental appointment:
8
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
All staff
Cardiac / respiratory Yes No Angina on exertion or rest? (use of GTN) Hypertension? Myocardial infarction? Year _______ Pacemaker (inform cardiology of details) Cardiac investigations? (ETT, Echo, Angiogram etc) Year _______ Heart murmur / rheumatic fever? Palpitations or arrhythmia? Ankle swelling or oedema? Left Right Bilateral *****Symptoms of breathlessness at Rest or Exertion (please circle)
Maximum equivalent activity (MET)
Eating/ Walk around Hill incline 2 flights of Jogging Dressing the house stairs 1 2 3 4 5 6 7 8 9 10
Take a Walk on Brisk walk Brisk swim shower level ground
Estimated METS score _______________ What prevents further activity?
Yes No Comments Angina
Arthritis or leg pain
Other (?weight) Yes No
*****Lie flat without getting breathless? No. of pillows required ____ *****Do you have sleep Apneoa (If concerned re new symptoms refer to Anaesthetist)
Asthma? / COPD? Peak flow 1 _______ 2 _______ 3 ________ Present or recent chest infection? Productive cough History of Tuberculosis? ******Deep Vein Thrombosis (DVT) or Pulmonary Embolus (PE)?
9
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Central nervous system Yes No
****Epilepsy / seizures
Cerebrovascular accident (CVA) or Transient Ischaemic Attack (TIA)?
Fainting / dizzy spells?
Gastrointestinal Yes No
*****Heartburn / indigestion / gastric reflux? / hiatus hernia
Nausea or vomiting? Recent weight loss?
*****Liver problems / jaundice / hepatitis
Bowel disorders?
Renal / genito-urinary / musculo-skeletal / other Yes No
Kidney disease?
Urinary problems?
Prostate problems / investigations? Specify: __________________________________________________
Muscle disease or progressive weakness?
*****Diabetes Type: ____________________________________
Thyroid problems? Hyperthyroidish Hypothyroidish
Skin conditions Specify: __________________________________________________
Any other serious illnesses (please list)
10
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Haematological Yes No
Anaemia
Haemophilia / blood disorders
Excessive bruising
Blood transfusion Year __________
Does patient smoke Yes No How many:
Does patient drink alcohol Yes No Number of units:
Does patient take recreational drugs Yes No Comments:
Investigations
Joint x-ray taken Yes No Chest x-ray required Yes No
If x-rays are less than 6 months old, do not repeat unless requested by Consultant. Blood samples taken (please circle)
Group and save / crossmatch Yes No Chemistry profile Yes No Full blood count Yes No Coagulation screen Yes No INR Yes No Blood glucose level Yes No Other? ___________________________________________________________________
12-lead ECG taken? Yes No All patients over 45 years of age should have a 12-lead taken. If “yes”, please give details below. Urinalysis / MSSU
Specimen sent? Yes No Attach printout
11
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
GJNH Risk Assessment for Thromboembolic Disease
Risk factors
• Previous DVT
• Previous PE
• Family history of VTE
• BMI >30
• Age >60
• Current malignancy
• Significant medical co morbidities
• HRT / contraception
Bleeding risk
• Existing anticoagulant / antiplatelet therapy
• Severe liver disease
• Haemophilia or other bleeding disorder
• Thrombocytopaenia
Type of surgery
• Hand or foot surgery
• Arthroscopic knee surgery
• Primary TKR / THR
• Bilateral TKR / THR
• Revision TKR / THR
Risk Assessment
VTE Bleeding risk
• Low • Low
• Medium • High
• High
• Very high
VTE prophylaxis recommended: (refer to current orthopaedic department guidelines)
Name Signature Date
12
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Infection Control admission assessment
Complete CJD risk assessment if not completed at pre assessment
Have you ever been notified that you are at increased risk of CJD or v CJD for public health purposes?
Annex 1 Brain High Spinal cord High Dura mater High Cranial nerves High Cranial ganglia High Posterior eye High Pituitary gland High
When taking a dry swab ensure it has been rubbed over area 10-20 times covering all surfaces of swab.
Infection assessment Admission MRSA screen taken? Yes No Does the patient have any wounds or invasive devices? Yes No
Nose Groin Perineum Wound Device Site ……………..….. Type …………..….……. If IV indicate location ____________________
Does the patient have any signs of infection? Yes No Take swab or urine sample if yes.
Wound Device Other Urine
Does the patient have an exfoliating skin condition? Yes No Take swab from one broken or inflamed area if yes and document skin condition.
Site
Has the patient been on antibiotics within the last 12 weeks? Yes No Not known
If yes, specify antibiotic name and reason for use. ________________________________________________________________________________
Has the patient had diarrhoea and / or vomiting within the last 48 hours? Yes No
If yes, please specify Obtain sample Isolate Inform Infection Control
Has the patient had any previous hospital admissions in the past 12 weeks? Yes No
If yes, please specify ________________________________________________________________________________
Response No
Surgery or endoscopy should proceed using normal infection control procedures unless the procedure is likely to lead to contact with high risk tissue. (see annex 1)
Yes Contact the Prevention and Control of infection team.
Unable to response Contact the Prevention and Control of infection team.
13
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Patient confirms all information obtained in ICP at pre assessment Yes No
Have you had a flu vaccination this season
Information on Anaesthetic given to patient DVD re exercises given to patient Discharge/ Arthroplasty follow up Information given to patient Patient Guide given to patient
YES NO
Patient assessment continued
Comments
Date completed: RN signature:
14
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Patient assessment continued
Comments
Date completed: RN signature:
15
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Doctors notes
Comments
16
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Doctors notes
Comments
17
Total Hip Replacement Integrated Care Pathway Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Doctors notes
Comments
18
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Doctors notes
Comments
19
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Occupational Therapy pre-operative assessment
O.T. introduced self Explained role of O.T.
Consent to treatment Consent to share information
Social History:
Roles: Working Retired Carer Other…………………………………
Living group: Alone Partner/ spouse Other…………………………………
Housing: Owner occupier Tenant of ………………………………………………
Accommodation House Number of levels ………………………………………………
Bungalow
Flat Position ………………………………………………
External access: …….. stairs, rail right side ascending left side ascending bilateral Nil
Internal access: …….. stairs, rail right side ascending left side ascending bilateral Nil
Internal stairs: …….. stairs, rail right side ascending left side ascending bilateral Nil
Room layout: Living area Level Up Down
Kitchen Level Up Down
Bedroom Level Up Down
Bathroom Level Up Down
Home situation prior to admission:
Seating …….. inches Bed …….. inches Toilet …….. inches
Bathing facilities: ……………………………………………………………………………………………………
Domestic ADL: Independent Family assist Home Help ………………… per week
Comments ……………………………………………………………………………………………………
Support available at home: ……………………………………………………………………………………………
20
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Occupational Therapy pre-operative assessment (cont’d)
Post discharge support required with:
TEDs Personal care Meal prep Domestic tasks N/A
Other ……………………………………………………………………………………………………
Joint replacement discussed in relation to function and activities of daily living
Recommended height ………………..inches
Ward equipment: R.T.S ………inches L.H.S.H H.H Other ……………… Equipment required for discharge: Not applicable
Equipment provider: ……………………………………………………………………………………………
Access arrangements: …………………………………………………………………………………………
Treatment Plan: Order equipment…………………………………………………………
Functional assessment…………………………………………………..
Other ……………………………………………………………………
Time: ………………… Signature:……………………………………(Occupational Therapist)
Date assessment completed: …………………
To be completed by Rehab Assistant
Patient admitted to ward Equipment insitu at home All above information remains accurate Signature: _________________________________
Equipment requested: please supply X
Helping Hand (H.H) Perch stool with arms (seat height)
Long Handled Shoe Horn. (L.H.S.H.) Trolley (handle height)
Sock Aid / Tights Aid Chair (seat height)
Raised Toilet Seat (size) (R.T.S) Chair raiser (size) (base) raised by: __________
Toilet frame (seat height) Cushion
Toilet frame (no seat)
Showerstool with arms (seat height) Bed raiser (size) (base)
Showerboard
To facilitate transfer ……….. leg leading Grab rails:
Other:
21
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Discharge checklist (commence on admission)
Expected Date of Discharge (EDD): ____/____/____ EDD discussed with patient: Yes No
Transport Signature
Own transport Approximate time for collection: ___________
GJNH Hospital transport Time for collection: ________________
Scottish Ambulance Service 1 man 2 man
Time for collection: ________________ Escort required: Yes No If Yes details:__________________________
Discharge medication (TTO)
TTO prescription complete and sent to pharmacy
Yes No
Medication explained and given to patient
Yes No
Referrals/ appointments made
Arthroplasty appt made Yes No
Social services aware Yes No N/A If Yes see next page
Practice Nurse letter complete Yes No N/A
(If required) District nurse contacted Yes No N/A
GP letter complete Yes No
Anticoagulation appt made if needed:
Yes No If Yes date of appt: ___________________
Other
Discharged from Physio Yes No
Discharged from OT Yes No
Valuables returned Yes No N/A
All invasive lines removed Yes No
Relatives aware of discharge Yes No
22
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Social Services requirements
Local Authority Contact Telephone Number Named Contact Direct Dial Number Home care requirements
Yes No Social Services
Family / friends
Signature
Assistance to get washed Assistance to get dressed Assistance with TED stockings Meal preparation Breakfast Lunch Evening Meal Drinks Meals on wheels Shopping Food train (Dumfries & Galloway)
Housework Laundry Emptying commode Tuck in service Prompt with medication Collection of medication Carers Assessment Community Care Assessment Community Alarm Key Safe Date and time care will start:
Morning Lunchtime Tea time Tuck in
Exact time cannot be given
Comments:
23
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Nutritional Assessment – admission day
Dietary requirements Yes No Comments Therapeutic diet e.g. food allergy, diabetes
Type of diet: Dietitian referral if appropriate
Diet preferences e.g. cultural, religion, ethnic
Type of diet:
Regular vitamin and/or mineral supplement
List:
Feeding aids required: Crockery Cutlery Drinking utensil
Contact Catering department
Food and Fluid Pattern Appetite Good Small Poor Comments: Drink Preferences eg tea, squash ………………………………. Cups/glasses per day ______
Eating and/or meal preferences Three meals/day Two meals + a snack One meal + two snacks snack meals only One meal/day Other please specify…………………... Comments:
MUST Score Body Mass Index (BMI) Greater than 20 - Score 0 18.5 – 20 - Score 1 Less than 18.5 - Score 2
Unplanned Weight Loss over past 3-6 months Less than 5% - Score 0 5 – 10% - Score 1 More than 10% - Score 2
Acute Illness Will patient have no/minimal diet for next 5 days? Yes Score 2 No, can eat normal/light diet – Score 0
Total MUST Score: _______________ If score 1 then monitor and record in care plan If score 2 or more, refer to dietitian and record in care plan
Signature and date: Dietician review: Signed: ______________________________________ Date: ______________
24
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Pharmacy admission day
Activity Comments
Medication history taken Yes No
Patients own medication assessed Yes No
Kardex reviewed Yes No
Pharmacy care plan completed Yes No
Time:
Pharmacist’s Signature:
25
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Admission day
Admission procedures checklist:
Consent Leg marked ECG XRAY Bloods MRSA TEDS Size: _____ Bilateral/Revision patients – Group & Save obtained
No. Nursing care plan Comments (please state time at any comment)
1 ID band correct and in situ Yes No
2 Red band insitu if patient has allergies Yes No N/A
3 Infection control issues, specify: Yes No
4 MUST score documented Yes No
5 Waterlow score documented Yes No
6 Skin intact Yes No
7 Falls risk assessment carried out Yes No
8 VTE risk assessment carried out Yes No
9 Seen by anaesthetist and premed prescribed
Yes No
10 Observations recorded on MEWS chart and within normal range. MEWS score recorded
Yes No
11 Patient fully understands all information provided including showering/fasting instructions
Yes No
12 Self caring Yes No
13 Mobile independently Yes No
14 Valuables given to security Yes No N/A
15 Discharge plan commenced (see pg 21) Yes No
16 Check mode of transport for discharge Yes No
17 If patient has social services pre-op they are aware of admission
Yes No
Registered Nurse Signature Day Shift: _____________________
Registered Nurse Signature Night Shift: _____________________
26
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Admission day
Time Activity number
Notes Signature
27
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Pre-op checklist
Description Yes No
1. ID Band correct
2. Patient has an allergy
3. Consent signed and in notes
4. Leg marked
5. Prosthesis removed
6. Artificial joint or implant
7. Jewellery removed/taped
8. Hairpins removed
9. Nail polish removed
10. Make-up removed
11. Dentures removed
12. Caps/crowns Top Front Bottom Front Top Right Bottom Right Top Left Bottom Left
13. Hearing aid in place
14. Pre-medication @ ___________ hours
15. Last food @ __________ hours Last drink @ _________ hours
16. If a diabetic, last blood glucose = _______ mmols/L @ ________ hours
17. Since date of LMP could you be pregnant Yes No N/A
18. Observations in patient’s normal range
19. Patient has had a hibiscrub shower using disposable cloths
20. Laboratory results available Yes No Not taken N/A 21. Comments:
Completed on ward by: Checked in pre op by:
28
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Anaesthetics perioperative record
Fluids Hartmans solution
mls
Gelofusine
mls
Estimated blood loss
mls
Other
mls
Other
mls
Comments:
Infiltration Yes No Volume ……………………………. Route of administration………………………………………………….. Skin closure Site 1. …………………………… Dressing…………………………………… Absorbable / Non absorbable / Staples Site 2. …………………………… Dressing……………………………………. Absorbable / Non absorbable / Staples / Sternal wires Other sites………………………………… Drain Yes No Number Type…………………. Secured with ………………… Opened in theatre Open in PACU Drain opening time ………………………………………………. Drainage on leaving theatre ………………………………………
29
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Implant labels and tracability labels
Specific post operative instructions for PACU/wards
Scrub Nurse Signature
Circulating Nurse Signature
30
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Theatre day
No. Nursing care plan
Comments (please state time at any comment)
1 ID band correct and in situ Yes No
2 Red band insitu if patient has allergies Yes No N/A
3 Infection control issues, specify: Yes No
4 Fluid balance commenced Yes No
5 TED stockings/ AV boots worn Yes No
6 Baseline observations recorded on return to ward then protocol followed according to analgesic regime. MEWS recorded
Yes No
7 Signs of shock Yes No
8 Has passed urine within 8 hours of theatre. If not fluid balance protocol followed
Yes No
9 Wound site satisfactory Yes No
10 C.S.M. satisfactory Yes No
11 Patient indicates adequate pain control Yes No
12 Nausea or vomiting Yes No
13 Tolerating diet and fluids Yes No
14 P.V.C bundle commenced and continued 8 hourly
Yes No
15 Waterlow score documented Yes No
16 P.A.C. carried out 2 – 4 hourly and documentation completed
Yes No
17 Skin intact Yes No
18 Up to sit once mobility assessment carried out by Physio or appropriately trained nurse
Yes No
19 Manual handling techniques adhered to when moving patient
Yes No
20 Patient hygiene needs met Yes No
21 Patient fully understands all information provided
Yes No
22 Nurse call buzzer within reach at all times Yes No
23 Discharge plan continued (see pg 21) Yes No
Registered Nurse Signature Day Shift ____________________
Registered Nurse Signature Night Shift ____________________
31
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Theatre day
Time Activity
Number Notes Signature
32
Manual handling risk assessment – Theatre day
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Manual handling category Low Medium High 1. Moving in bed
Self care Yes No If No comments:____________________________________ Repositioning chart in use Yes No Not required
2. Turning in bed Self care Yes No If No comments:____________________________________ Repositioning chart in use Yes No Not required
3.Transferring bed to chair / chair to bed
Self care Yes No If No comments:____________________________________
4.Standing/ mobilising in room
Self care Yes No If No comments:____________________________________
5. Personal hygiene Self care Yes No If No comments:____________________________________
6. Toileting Self care Yes No If No comments:____________________________________
7.Mobilising out with room Self care Yes No If No comments:____________________________________
Additional comments
Signature
Nursing – Day shift Time: ___________ Sign: ____________________
Nursing – Night shift Time:__________ Sign: ______________________
33
Physiotherapy post operative Day 0
AO1/AO2 = assistance of 1/2 person; SLR = straight leg raise, IRQ= inner range quadriceps, ROM = range of movement
On weekend list: Yes No N/A Mobilised with nursing staff
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
1. Physio Patient advised re deep breathing and circulatory exercises Yes No
2. Physio Pre mobility checks: Comments: Blood Pressure _________________________________________________________
Sensation _________________________________________________________
SLR Non operated side Yes No _________________________ IRQ Operated side Yes No _________________________ Reinforced hip precautions
3. Physio Weight bearing: FWB PWB Toe Touch NWB
4. Physio Bed transfers: assistance required: Supervision MIN MOD MAX AO1 / AO2
5. Physio Transferred bed to chair: Yes No
6. Physio treatment: Reason not mobilised: 1. Blocked 2. Hypotensive 3. Nausea & vomiting 4. Vasovagal 5. Pain 6. Not eaten 7. Late back ______________________8. Poor Proprioception 9. Other ______________________
7. Physio treatment plan: Physiotherapist signature: ______________________________________ Time: _____________
34
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Post operative Day 1
No. Nursing care plan Comment (please state time at any comment)
1 ID band correct and in situ Yes No
2 Red band insitu if patient has allergies Yes No N/A
3 Infection control issues, specify: Yes No
4 Fluid balance continues Yes No
5 TED stockings/ AV boots worn Yes No
6 Vital signs recorded 4 hourly and MEWS score completed
Yes No
7 Wound site satisfactory Yes No
8 C.S.M. satisfactory Yes No
9 Patient indicates adequate pain control. Pain score documented
Yes No
10 Wound / Epidural catheter removed Yes No N/A
11 Nausea or vomiting Yes No
12 Tolerating fluids and diet Yes No
13 P.V.C bundle continues Yes No
14 Waterlow score documented Yes No
15 P.A.C. carried out and skin intact Yes No
16 Up to sit and mobile as per Physio instructions
Yes No
17 Occupational therapy commenced Yes No
18 Patient hygiene needs met Yes No
19 Patient fully understands all information provided
Yes No
20 Nurse call buzzer within reach at all times Yes No
21 Discharge plan continues (see pg 21) Yes No
22 TTO ordered Yes No
Registered Nurse signature Day shift: ______________________________
Registered Nurse signature Night shift: _____________________________
35
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Post operative Day 1
Time Activity Number
Notes Signature
36
Manual handling risk assessment – Post operative Day 1
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Manual handling category Low Medium High 1. Moving in bed
Self care Yes No If No comments:____________________________________ Repositioning chart in use Yes No Not required
2. Turning in bed Self care Yes No If No comments:____________________________________ Repositioning chart in use Yes No Not required
3.Transferring bed to chair / chair to bed
Self care Yes No If No comments:____________________________________
4.Standing/ mobilising in room
Self care Yes No If No comments:____________________________________
5. Personal hygiene Self care Yes No If No comments:____________________________________
6. Toileting Self care Yes No If No comments:____________________________________
7.Mobilising out with room Self care Yes No If No comments:____________________________________
Additional comments
Signature
Nursing – Day shift Time: ___________ Sign: ____________________
Nursing – Night shift Time:__________ Sign: ______________________
37
Physiotherapy post operative Day 1
AO1/AO2 = assistance of 1/2 person; SLR = straight leg raise, IRQ= inner range quadriceps, ROM = range of movement
On weekend list: Yes No N/A
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
1. Physio Pre mobility checks: Comments: Up POD 0
Blood Pressure _________________________________________________________
Sensation _________________________________________________________
SLR Non operated side Yes No ________________________ IRQ Operated side Yes No ________________________ Reinforced hip precautions
2. Physio Weight bearing: FWB PWB Toe Touch NWB
3. Physio Bed transfers: assistance required:
Supervision MIN MOD MAX AO1 / AO2
4. Physio Transferred bed to chair: Yes No
5. Rehab Assistant: Comments:
SQ: _________________________________ Hip flexion with re-ed board ________________________________ IRQ: _________________________________ Hip abduction with re-ed board _____________________________
6. Physio treatment AM:
Treatment plan:
7. Physio treatment PM:
Treatment plan:
8. Physio Stair assessment commenced: Yes No Independent on stairs Yes No Further practice required Yes No Comments: ________________________________
9. Physio Discharged from Physio Yes No Out patient Physio required Yes No Comments: _____________________________
AM Physiotherapist signature: __________________________________Time: _______
PM Physiotherapist signature: __________________________________Time: _______
38
Occupational Therapy post operative Day 1
O.T. Intervention today: No intervention required Not appropriate ________________________ O.T. unable to see …………………… No O.T. service available i.e. non working day Occupational Therapy complete: Yes No
Time: ………………… Signature:……………………………………(Occupational Therapist)
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Personal care / dressing tasks: Not Applicable To be assessed Assessment completed Safe techniques explained Demonstrated by O.T. Demonstrated by patient Use of small aids explained Demonstrated by O.T. Demonstrated by patient N/A Level of ability: Dependent Assisted Supervised Independent Comment…………………………………………………………………….……………………………………………………….… ……………………………………………………………………………………………………………………………………………Practice sessions required Yes No
Functional mobility: Assisted Supervised Independent Using: Mobilator Crutches x…... Sticks x …...
Transfer ability: Not Applicable To be assessed Assessment completed Equipment Used Chair: Dependent Assisted Supervised Independent Bed: Dependent Assisted Supervised Independent Toilet: Dependent Assisted Supervised Independent Comment…………………………………………………………………….……………………………………………………….… ……………………………………………………………………………………………………………………………………………Practice sessions required Yes No
Kitchen assessment, basic tasks: Not Applicable To be assessed Assessment completed Level of ability: Dependent Assisted Supervised Independent Comment…………………………………………………………………….……………………………………………………….… ……………………………………………………………………………………………………………………………………………Practice sessions required Yes No
Bathing assessment Not Applicable, advised to strip wash To be assessed Assessment completed Safe techniques explained Demonstrated by O.T. Demonstrated by patient Use of bath aids explained Demonstrated by O.T. Demonstrated by patient N/A Level of ability: Dependent Assisted Supervised Independent Comment…………………………………………………………………….……………………………………………………….… ……………………………………………………………………………………………………………………………………………Practice sessions required Yes No Referral made for post discharge provision of equipment
Essential Equipment Insitu: Yes No N/A
Outstanding Issues: Comments:
39
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Occupational Therapy post operative Day 1
Activity:
Dressing Transfers Kitchen Bathing Other: …………………………
Level of ability: Dependent Assisted Supervised Independent
Equipment used:
Comment:
Further practice sessions required: Yes No
Completed by: Designation: Date:
Activity:
Dressing Transfers Kitchen Bathing Other: …………………………
Level of ability: Dependent Assisted Supervised Independent
Equipment used:
Comment:
Further practice sessions required: Yes No
Completed by: Designation: Date:
Activity:
Dressing Transfers Kitchen Bathing Other: …………………………
Level of ability: Dependent Assisted Supervised Independent
Equipment used:
Comment:
Further practice sessions required: Yes No
Completed by: Designation: Date:
Activity:
Dressing Transfers Kitchen Bathing Other: …………………………
Level of ability: Dependent Assisted Supervised Independent
Equipment used:
Comment:
Further practice sessions required: Yes No
Completed by: Designation: Date:
R.T.S, Raised toilet seat L.H.S.H, Long handled shoe horn H.H., helping hand
40
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Post operative Day 2
No. Nursing care plan Comment (please state time at any
comment)
1 ID band correct and in situ Yes No
2 Red band insitu if patient has allergies Yes No N/A
3 Infection control issues, specify: Yes No
4 Fluid balance discontinued Yes No
5 TED stockings/ AV boots worn Yes No
6 Vital signs recorded 6 hourly and MEWS score completed
Yes No
7 Wound site satisfactory Yes No
8 C.S.M. satisfactory Yes No
9 Patient indicates adequate pain control. Pain score documented
Yes No
10 Nausea or vomiting Yes No
11 Check x-ray carried out Yes No
12 FBC and U&E’s obtained Yes No
13 Venflon removed Yes No
14 Waterlow score documented Yes No
15 P.A.C. carried out and skin intact Yes No
16 Mobile as per Physio instructions Yes No
17 Occupational therapy continues Yes No
18 Patient hygiene needs met Yes No
19 Patient fully understands all information provided
Yes No
20 Nurse call buzzer within reach at all times Yes No
21 Discharge plan continues (see pg 21) Yes No
22 TTO ordered Yes No
Registered Nurse signature Day shift: _____________________
Registered Nurse signature Night shift: _____________________
41
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Post operative Day 2
Time Activity
Number Notes Signature
42
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Manual handling risk assessment – Post operative Day 2
Manual handling category Low Medium High 1. Moving in bed
Self care Yes No If No comments:____________________________________ Repositioning chart in use Yes No Not required
2. Turning in bed Self care Yes No If No comments:____________________________________ Repositioning chart in use Yes No Not required
3.Transferring bed to chair / chair to bed
Self care Yes No If No comments:____________________________________
4.Standing/ mobilising in room
Self care Yes No If No comments:____________________________________
5. Personal hygiene Self care Yes No If No comments:____________________________________
6. Toileting Self care Yes No If No comments:____________________________________
7.Mobilising out with room Self care Yes No If No comments:____________________________________
Additional comments
Signature
Nursing – day shift Time: ___________ Sign: ____________________
Nursing – night shift Time:__________ Sign: ______________________
43
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Physiotherapy post operative Day 2
AO1/AO2 = assistance of 1/2 person; SLR = straight leg raise, IRQ= inner range quadriceps, ROM = range of movement
On weekend list: Yes No N/A
1. Physio Mobility with walking aid: Commenced gait re-ed with sticks / crutches Yes No
Gait pattern or comments: ________________________________________________________________
_____________________________________________________________________________________
2. Physio Hip precautions reviewed Yes No
3. Rehab Assistant notes: Comments:
Completed bed exercises Yes No __________________________________________
Commenced standing exercises Yes No ______________________________________
4. Physio treatment AM:
Treatment plan:
5. Physio treatment AM:
Treatment plan:
6. Physio Stair assessment commenced: Yes No Independent on stairs Yes No Further practice required Yes No Comments: ________________________________
7. Physio Discharged from Physio Yes No Out patient Physio required Yes No Comments: _____________________________
AM Physiotherapist signature: __________________________________Time: _______
PM Physiotherapist signature: __________________________________Time: _______
44
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Occupational Therapy post operative Day 2
Personal care / dressing tasks: Not Applicable To be assessed Assessment completed Safe techniques explained Demonstrated by O.T. Demonstrated by patient Use of small aids explained Demonstrated by O.T. Demonstrated by patient N/A Level of ability: Dependent Assisted Supervised Independent Comment…………………………………………………………………….……………………………………………………….… …………………………………………………………………………………………………………………………………………... Practice sessions required Yes No
Functional mobility: Assisted Supervised Independent Using: Mobilator Crutches x…... Sticks x …...
Transfer ability: Not Applicable To be assessed Assessment completed Equipment Used Chair: Dependent Assisted Supervised Independent Bed: Dependent Assisted Supervised Independent Toilet: Dependent Assisted Supervised Independent Comment…………………………………………………………………….……………………………………………………….… …………………………………………………………………………………………………………………………………………... Practice sessions required Yes No
Kitchen assessment, basic tasks: Not Applicable To be assessed Assessment completed Level of ability: Dependent Assisted Supervised Independent Comment…………………………………………………………………….……………………………………………………….… ……………………………………………………………………………………………………………………………………………Practice sessions required Yes No
Bathing assessment Not Applicable, advised to strip wash To be assessed Assessment completed Safe techniques explained Demonstrated by O.T. Demonstrated by patient Use of bath aids explained Demonstrated by O.T. Demonstrated by patient N/A Level of ability: Dependent Assisted Supervised Independent Comment…………………………………………………………………….……………………………………………………….… …………………………………………………………………………………………………………………………………………... Practice sessions required Yes No Referral made for post discharge provision of equipment
Essential Equipment Insitu: Yes No N/A
Outstanding Issues:
O.T. Intervention today: No intervention required Not appropriate ________________________ O.T. unable to see …………………… No O.T. service available i.e. non working day Occupational Therapy complete: Yes No
Time: ………………… Signature:……………………………………(Occupational Therapist)
45
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Occupational Therapy post operative Day 2
Activity:
Dressing Transfers Kitchen Bathing Other: …………………………
Level of ability: Dependent Assisted Supervised Independent
Equipment used:
Comment:
Further practice sessions required: Yes No
Completed by: Designation: Date:
Activity:
Dressing Transfers Kitchen Bathing Other: …………………………
Level of ability: Dependent Assisted Supervised Independent
Equipment used:
Comment:
Further practice sessions required: Yes No
Completed by: Designation: Date:
Activity:
Dressing Transfers Kitchen Bathing Other: …………………………
Level of ability: Dependent Assisted Supervised Independent
Equipment used:
Comment:
Further practice sessions required: Yes No
Completed by: Designation: Date:
Activity:
Dressing Transfers Kitchen Bathing Other: …………………………
Level of ability: Dependent Assisted Supervised Independent
Equipment used:
Comment:
Further practice sessions required: Yes No
Completed by: Designation: Date:
R.T.S, Raised toilet seat L.H.S.H, Long handled shoe horn H.H., helping hand
46
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Post operative Day 3
No. Nursing care plan Comment (please state time at any comment)
1 ID band correct and in situ Yes No
2 Red band insitu if patient has allergies Yes No N/A
3 Infection control issues, specify: Yes No
4 TED stockings/ AV boots worn Yes No
5 Vital signs recorded 6 hourly and MEWS score completed
Yes No
6 Wound site satisfactory Yes No
7 C.S.M. satisfactory Yes No
8 Patient indicates adequate pain control. Pain score documented
Yes No
9 Waterlow score documented Yes No
10 P.A.C. carried out and skin intact Yes No
11 Mobile as per Physio instructions Yes No
12 Occupational therapy continues Yes No
13 Patient hygiene needs met Yes No
14 Patient fully understands all information provided
Yes No
15 Nurse call buzzer within reach at all times Yes No
16 Discharge plan continues (see pg 21) Yes No
17 TTO ordered Yes No
Registered Nurse signature Day shift: _____________________
Registered Nurse signature Night shift: _____________________
47
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Post operative Day 3
Time Activity Number
Notes Signature
48
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Manual handling risk assessment – Post operative Day 3
Manual handling category Low Medium High 1. Moving in bed
Self care Yes No If No comments:____________________________________ Repositioning chart in use Yes No Not required
2. Turning in bed Self care Yes No If No comments:____________________________________ Repositioning chart in use Yes No Not required
3.Transferring bed to chair / chair to bed
Self care Yes No If No comments:____________________________________
4.Standing/ mobilising in room
Self care Yes No If No comments:____________________________________
5. Personal hygiene Self care Yes No If No comments:____________________________________
6. Toileting Self care Yes No If No comments:____________________________________
7.Mobilising out with room Self care Yes No If No comments:____________________________________
Additional comments
Signature
Nursing – day shift Time: ___________ Sign: ____________________
Nursing – night shift Time:__________ Sign: ______________________
49
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Physiotherapy post operative Day 3
AO1/AO2 = assistance of 1/2 person; SLR = straight leg raise, IRQ= inner range quadriceps, ROM = range of movement
On weekend list: Yes No N/A
1. Physio Independent with all transfers: Yes No
2. Physio Independently mobile with elbow crutches / sticks Yes No
3. Rehab Assistant notes: Comments:
Completed bed exercises Yes No __________________________________________
Completed standing exercises Yes No ______________________________________
4. Physio treatment AM:
Treatment plan:
5. Physio treatment PM:
Treatment plan:
6. Physio Stair assessment commenced: Yes No Independent on stairs Yes No Further practice required Yes No
Comments: ________________________________
7. Physio Discharged from Physio Yes No Out patient Physio required Yes No
Comments: _____________________________
AM Physiotherapist signature: __________________________________Time: _______
PM Physiotherapist signature: __________________________________Time: _______
50
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Occupational Therapy post operative Day 3
Personal care / dressing tasks: Not Applicable To be assessed Assessment completed Safe techniques explained Demonstrated by O.T. Demonstrated by patient Use of small aids explained Demonstrated by O.T. Demonstrated by patient N/A Level of ability: Dependent Assisted Supervised Independent Comment…………………………………………………………………….……………………………………………………….… …………………………………………………………………………………………………………………………………………... Practice sessions required Yes No
Functional mobility: Assisted Supervised Independent Using: Mobilator Crutches x…... Sticks x …...
Transfer ability: Not Applicable To be assessed Assessment completed Equipment Used Chair: Dependent Assisted Supervised Independent Bed: Dependent Assisted Supervised Independent Toilet: Dependent Assisted Supervised Independent Comment…………………………………………………………………….……………………………………………………….… …………………………………………………………………………………………………………………………………………... Practice sessions required Yes No
Kitchen assessment, basic tasks: Not Applicable To be assessed Assessment completed Level of ability: Dependent Assisted Supervised Independent Comment…………………………………………………………………….……………………………………………………….… …………………………………………………………………………………………………………………………………………... Practice sessions required Yes No
Bathing assessment Not Applicable, advised to strip wash To be assessed Assessment completed Safe techniques explained Demonstrated by O.T. Demonstrated by patient Use of bath aids explained Demonstrated by O.T. Demonstrated by patient N/A Level of ability: Dependent Assisted Supervised Independent Comment…………………………………………………………………….……………………………………………………….… ……………………………………………………………………………………………………………………………………………Practice sessions required Yes No Referral made for post discharge provision of equipment
Essential Equipment Insitu: Yes No N/A
Outstanding Issues:
O.T. Intervention today: No intervention required Not appropriate ________________________ O.T. unable to see …………………… No O.T. service available i.e. non working day Occupational Therapy complete: Yes No
Time: ………………… Signature:……………………………………(Occupational Therapist)
51
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Occupational Therapy post operative Day 3
Activity:
Dressing Transfers Kitchen Bathing Other: …………………………
Level of ability: Dependent Assisted Supervised Independent
Equipment used:
Comment:
Further practice sessions required: Yes No
Completed by: Designation: Date:
Activity:
Dressing Transfers Kitchen Bathing Other: …………………………
Level of ability: Dependent Assisted Supervised Independent
Equipment used:
Comment:
Further practice sessions required: Yes No
Completed by: Designation: Date:
Activity:
Dressing Transfers Kitchen Bathing Other: …………………………
Level of ability: Dependent Assisted Supervised Independent
Equipment used:
Comment:
Further practice sessions required: Yes No
Completed by: Designation: Date:
Activity:
Dressing Transfers Kitchen Bathing Other: …………………………
Level of ability: Dependent Assisted Supervised Independent
Equipment used:
Comment:
Further practice sessions required: Yes No
Completed by: Designation: Date:
R.T.S, Raised toilet seat L.H.S.H, Long handled shoe horn H.H., helping hand
52
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Post operative Day 4
No. Nursing care plan Comment (please state time at any
comment)
1 ID band correct and in situ Yes No
2 Red band insitu if patient has allergies Yes No N/A
3 Infection control issues, specify: Yes No
4 TED stockings worn Yes No
5 Vital signs recorded 6 hourly and MEWS score completed
Yes No
6 Wound site satisfactory Yes No
7 C.S.M. satisfactory Yes No
8 Patient indicates adequate pain control. Pain score documented
Yes No
9 Waterlow score documented Yes No
10 P.A.C. carried out and skin intact Yes No
11 Mobile as per Physio instructions Yes No
12 Patient independent with hygiene Yes No
13 Patient fully understands all information provided
Yes No
14 Nurse call buzzer within reach at all times Yes No
15 Discharged from Physiotherapist Yes No
16 Discharged from Occupational Therapist Yes No
17 Discharge plan complete (see pg 21) Yes No
18 TTO ordered Yes No
Registered Nurse Signature Day Shift: _____________________
Registered Nurse Signature Night Shift: _____________________
53
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Post operative Day 4
Time Activity Number
Notes Signature
54
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Manual handling risk assessment – Post operative Day 4
Is patient independent in all activities of daily living: Yes No If no, continue to complete rest of risk assessment Manual handling category Low Medium High 1. Moving in bed
Self care Yes No If No comments:____________________________________ Repositioning chart in use Yes No Not required
2. Turning in bed Self care Yes No If No comments:____________________________________ Repositioning chart in use Yes No Not required
3.Transferring bed to chair / chair to bed
Self care Yes No If No comments:____________________________________
4.Standing/ mobilising in room Self care Yes No If No comments:____________________________________
5. Personal hygiene Self care Yes No If No comments:____________________________________
6. Toileting Self care Yes No If No comments:____________________________________
7.Mobilising out with room Self care Yes No If No comments:____________________________________
Additional comments
Signature
Nursing – day shift Time: ___________ Sign: ___________________
Nursing – night shift Time:__________ Sign: ______________________
55
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Physiotherapy post operative Day 4
AO1/AO2 = assistance of 1/2 person; SLR = straight leg raise, IRQ= inner range quadriceps, ROM = range of movement
On weekend list: Yes No N/A
1. Physio Independent with all transfers: Yes No
2. Physio Independently mobile with elbow crutches / sticks Yes No
3. Rehab Assistant notes: Comments:
Completed bed exercises Yes No __________________________________________ Completed standing exercises Yes No ______________________________________
4. Physio treatment AM:
Treatment plan:
5. Physio treatment PM:
Treatment plan:
6. Physio Stair assessment commenced: Yes No Independent on stairs Yes No Further practice required Yes No Comments: ________________________________
7. Physio Discharged from Physio Yes No Out patient Physio required Yes No Comments: _____________________________
AM Physiotherapist signature: __________________________________Time: _______
PM Physiotherapist signature: __________________________________Time: _______
56
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Occupational Therapy post operative Day 4
Personal care / dressing tasks: Not Applicable To be assessed Assessment completed Safe techniques explained Demonstrated by O.T. Demonstrated by patient Use of small aids explained Demonstrated by O.T. Demonstrated by patient N/A Level of ability: Dependent Assisted Supervised Independent Comment…………………………………………………………………….……………………………………………………….… …………………………………………………………………………………………………………………………………………... Practice sessions required Yes No
Functional mobility: Assisted Supervised Independent Using: Mobilator Crutches x…... Sticks x …...
Transfer ability: Not Applicable To be assessed Assessment completed Equipment Used Chair: Dependent Assisted Supervised Independent Bed: Dependent Assisted Supervised Independent Toilet: Dependent Assisted Supervised Independent Comment…………………………………………………………………….……………………………………………………….… …………………………………………………………………………………………………………………………………………... Practice sessions required Yes No
Kitchen assessment, basic tasks: Not Applicable To be assessed Assessment completed Level of ability: Dependent Assisted Supervised Independent Comment…………………………………………………………………….……………………………………………………….… …………………………………………………………………………………………………………………………………………... Practice sessions required Yes No
Bathing assessment Not Applicable, advised to strip wash To be assessed Assessment completed Safe techniques explained Demonstrated by O.T. Demonstrated by patient Use of bath aids explained Demonstrated by O.T. Demonstrated by patient N/A Level of ability: Dependent Assisted Supervised Independent Comment…………………………………………………………………….……………………………………………………….… …………………………………………………………………………………………………………………………………………... Practice sessions required Yes No Referral made for post discharge provision of equipment
Essential Equipment Insitu: Yes No N/A
Outstanding Issues:
O.T. Intervention today: No intervention required Not appropriate ________________________ O.T. unable to see …………………… No O.T. service available i.e. non working day Occupational Therapy complete: Yes No
Time: ………………… Signature:……………………………………(Occupational Therapist)
57
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Occupational Therapy post operative Day 4
Activity:
Dressing Transfers Kitchen Bathing Other: …………………………
Level of ability: Dependent Assisted Supervised Independent
Equipment used:
Comment:
Further practice sessions required: Yes No
Completed by: Designation: Date:
Activity:
Dressing Transfers Kitchen Bathing Other: …………………………
Level of ability: Dependent Assisted Supervised Independent
Equipment used:
Comment:
Further practice sessions required: Yes No
Completed by: Designation: Date:
Activity:
Dressing Transfers Kitchen Bathing Other: …………………………
Level of ability: Dependent Assisted Supervised Independent
Equipment used:
Comment:
Further practice sessions required: Yes No
Completed by: Designation: Date:
Activity:
Dressing Transfers Kitchen Bathing Other: …………………………
Level of ability: Dependent Assisted Supervised Independent
Equipment used:
Comment:
Further practice sessions required: Yes No
Completed by: Designation: Date:
R.T.S, Raised toilet seat L.H.S.H, Long handled shoe horn H.H., helping hand
58
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Post operative Day 5
No. Nursing care plan Comment (please state time at any comment)
1 ID band correct and in situ Yes No
2 Red band insitu if patient has allergies Yes No N/A
3 Infection control issues, specify: Yes No
4 TED stockings worn Yes No
5 Vital signs recorded 6 hourly and MEWS score completed
Yes No
6 Wound site satisfactory Yes No
7 C.S.M. satisfactory Yes No
8 Patient indicates adequate pain control. Pain score documented
Yes No
9 Waterlow score documented Yes No
10 MUST score documented Yes No
11 P.A.C. carried out and skin intact Yes No
12 Mobile as per Physio instructions Yes No
13 Patient independent with hygiene Yes No
14 Patient fully understands all information provided
Yes No
15 Nurse call buzzer within reach at all times Yes No
16 Discharged from Physiotherapist Yes No
17 Discharged from Occupational Therapist Yes No
18 Discharge plan complete (see pg 21) Yes No
19 TTO ordered Yes No
Registered Nurse signature Day shift: _____________________
Registered Nurse signature Night shift: _____________________
59
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Post operative Day 5
Nutritional Re-assessment:
Diet/Fluid requirements Comments Oral Fluid Intake Good, 2 litres/day or more ٱNormal, 1.5 –2 litres/day ٱPoor, 1 litre/day or less ٱ
Include action if poor intake.
Vitamin/ mineral Supplement Prescribed.
Yes No List:
Feeding aids required: Crockery Cutlery Drinking Utensil
Yes No Catering department aware
Food Pattern Appetite Normal (i.e. same/better than at home) Reduced but improving Poor Comments:
Dietary supplements prescribed Milk Shake Style Fruit Juice Style Other Name………………...…………… Supply required for home – Yes No
Updated MUST score Body Mass Index (BMI) Greater than 20 - Score 0 18.5 – 20 - Score 1 Less than 18.5 - Score 2
Unplanned weight loss Less than 5% - Score 0 5 – 10%% - Score 1 More than 10% - Score 2
Acute illness Has the patient had minimal/poor diet for last 5 days? Yes – Score 2 No, eating normally – Score 0
Total MUST score: _______________ If score 1 then monitor & record in care plan If score 2 or more, refer to dietitian
Signed: Date: Dietitian’s review: Diet advice for home GP Letter
Signed: Date:
60
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Post operative Day 5
Time Activity
Number Notes Signature
61
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Manual handling risk assessment – Post operative Day 5
Is patient independent in all activities of daily living: Yes No If no, continue to complete rest of risk assessment Manual handling category Low Medium High 1. Moving in bed
Self care Yes No If No comments:____________________________________ Repositioning chart in use Yes No Not required
2. Turning in bed Self care Yes No If No comments:____________________________________ Repositioning chart in use Yes No Not required
3.Transferring bed to chair / chair to bed
Self care Yes No If No comments:____________________________________
4.Standing/ mobilising in room Self care Yes No If No comments:____________________________________
5. Personal hygiene Self care Yes No If No comments:____________________________________
6. Toileting Self care Yes No If No comments:____________________________________
7.Mobilising out with room Self care Yes No If No comments:____________________________________
Additional comments
Signature
Nursing – day shift Time: ___________ Sign: ___________________
Nursing – night shift Time:__________ Sign: ______________________
62
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Physiotherapy post operative Day 5
AO1/AO2 = assistance of 1/2 person; SLR = straight leg raise, IRQ= inner range quadriceps, ROM = range of movement
On weekend list: Yes No N/A
1. Physio Independent with all transfers: Yes No
2. Physio Independently mobile with elbow crutches / sticks Yes No
3. Rehab Assistant notes:
4. Physio treatment AM:
Treatment plan:
5. Physio treatment PM:
Treatment plan:
6. Physio Stair assessment commenced: Yes No Independent on stairs Yes No Further practice required Yes No Comments: ________________________________
7. Physio Discharged from Physio Yes No Out patient Physio required Yes No Comments: _____________________________
AM Physiotherapist signature: __________________________________Time: _______
PM Physiotherapist signature: __________________________________Time: _______
63
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Occupational Therapy post operative Day 5
Personal care / dressing tasks: Not Applicable To be assessed Assessment completed Safe techniques explained Demonstrated by O.T. Demonstrated by patient Use of small aids explained Demonstrated by O.T. Demonstrated by patient N/A Level of ability: Dependent Assisted Supervised Independent Comment…………………………………………………………………….……………………………………………………….… ………………………………………………………………………………………………………………………………………….. Practice sessions required Yes No
Functional mobility: Assisted Supervised Independent Using: Mobilator Crutches x…... Sticks x …...
Transfer ability: Not Applicable To be assessed Assessment completed Equipment Used Chair: Dependent Assisted Supervised Independent Bed: Dependent Assisted Supervised Independent Toilet: Dependent Assisted Supervised Independent Comment…………………………………………………………………….……………………………………………………….… …………………………………………………………………………………………………………………………………………... Practice sessions required Yes No
Kitchen assessment, basic tasks: Not Applicable To be assessed Assessment completed Level of ability: Dependent Assisted Supervised Independent Comment…………………………………………………………………….……………………………………………………….… …………………………………………………………………………………………………………………………………………... Practice sessions required Yes No
Bathing assessment Not Applicable, advised to strip wash To be assessed Assessment completed Safe techniques explained Demonstrated by O.T. Demonstrated by patient Use of bath aids explained Demonstrated by O.T. Demonstrated by patient N/A Level of ability: Dependent Assisted Supervised Independent Comment…………………………………………………………………….……………………………………………………….… …………………………………………………………………………………………………………………………………………... Practice sessions required Yes No Referral made for post discharge provision of equipment
Essential Equipment Insitu: Yes No N/A
Outstanding Issues:
O.T. Intervention today: No intervention required Not appropriate ________________________ O.T. unable to see …………………… No O.T. service available i.e. non working day Occupational Therapy complete: Yes No
Time: ………………… Signature:……………………………………(Occupational Therapist)
64
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Occupational Therapy post operative Day 5
Activity:
Dressing Transfers Kitchen Bathing Other: …………………………
Level of ability: Dependent Assisted Supervised Independent
Equipment used:
Comment:
Further practice sessions required: Yes No
Completed by: Designation: Date:
Activity:
Dressing Transfers Kitchen Bathing Other: …………………………
Level of ability: Dependent Assisted Supervised Independent
Equipment used:
Comment:
Further practice sessions required: Yes No
Completed by: Designation: Date:
Activity:
Dressing Transfers Kitchen Bathing Other: …………………………
Level of ability: Dependent Assisted Supervised Independent
Equipment used:
Comment:
Further practice sessions required: Yes No
Completed by: Designation: Date:
Activity:
Dressing Transfers Kitchen Bathing Other: …………………………
Level of ability: Dependent Assisted Supervised Independent
Equipment used:
Comment:
Further practice sessions required: Yes No
Completed by: Designation: Date:
R.T.S, Raised toilet seat L.H.S.H, Long handled shoe horn H.H., helping hand
65
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Post operative Day 6
No. Nursing care plan Comment (please state time at any
comment)
1 ID band correct and in situ Yes No
2 Red band in situ if patient has allergies Yes No N/A
3 Infection control issues, specify: Yes No
4 TED stockings worn Yes No
5 Vital signs recorded 6 hourly and MEWS score completed
Yes No
6 Wound site satisfactory Yes No
7 C.S.M. satisfactory Yes No
8 Patient indicates adequate pain control. Pain score documented
Yes No
9 Waterlow score documented Yes No
10 MUST score documented Yes No
11 P.A.C. carried out and skin intact Yes No
12 Mobile as per Physio instructions Yes No
13 Patient independent with hygiene Yes No
14 Patient fully understands all information provided
Yes No
15 Nurse call buzzer within reach at all times Yes No
16 Discharged from Physiotherapist Yes No
17 Discharged from Occupational Therapist Yes No
18 Discharge plan complete (see pg 21) Yes No
19 TTO ordered Yes No
Registered Nurse signature Day shift: _____________________
Registered Nurse signature Night shift: _____________________
66
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Post operative Day 6
Time Activity Number
Notes Signature
67
Manual handling risk assessment – Post operative Day 6
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Is patient independent in all activities of daily living: Yes No If no, continue to complete rest of risk assessment Manual handling category Low Medium High 1. Moving in bed
Self care Yes No If No comments:____________________________________ Repositioning chart in use Yes No Not required
2. Turning in bed Self care Yes No If No comments:____________________________________ Repositioning chart in use Yes No Not required
3.Transferring bed to chair / chair to bed
Self care Yes No If No comments:____________________________________
4.Standing/ mobilising in room Self care Yes No If No comments:____________________________________
5. Personal hygiene Self care Yes No If No comments:____________________________________
6. Toileting Self care Yes No If No comments:____________________________________
7.Mobilising out with room Self care Yes No If No comments:____________________________________
Additional comments
Signature
Nursing – day shift Time: ___________ Sign: ___________________
Nursing – night shift Time:__________ Sign: ______________________
68
Physiotherapy post operative Day 6
AO1/AO2 = assistance of 1/2 person; SLR = straight leg raise, IRQ= inner range quadriceps, ROM = range of movement
On weekend list: Yes No N/A
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
1. Physio Independent with all transfers: Yes No
2. Physio Independently mobile with elbow crutches / sticks Yes No
3. Rehab Assistant notes:
4. Physio treatment AM:
Treatment plan:
5. Physio treatment PM:
Treatment plan:
6. Physio Stair assessment commenced: Yes No Independent on stairs Yes No Further practice required Yes No Comments: ________________________________
7. Physio Discharged from Physio Yes No Out patient Physio required Yes No Comments: _____________________________
AM Physiotherapist signature: __________________________________Time: _______
PM Physiotherapist signature: __________________________________Time: _______
69
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Occupational Therapy post operative Day 6
Personal care / dressing tasks: Not Applicable To be assessed Assessment completed Safe techniques explained Demonstrated by O.T. Demonstrated by patient Use of small aids explained Demonstrated by O.T. Demonstrated by patient N/A Level of ability: Dependent Assisted Supervised Independent Comment…………………………………………………………………….……………………………………………………….… ………………………………………………………………………………………………………………………………………….. Practice sessions required Yes No
Functional mobility: Assisted Supervised Independent Using: Mobilator Crutches x…... Sticks x …...
Transfer ability: Not Applicable To be assessed Assessment completed Equipment Used Chair: Dependent Assisted Supervised Independent Bed: Dependent Assisted Supervised Independent Toilet: Dependent Assisted Supervised Independent Comment…………………………………………………………………….……………………………………………………….… …………………………………………………………………………………………………………………………………………... Practice sessions required Yes No
Kitchen assessment, basic tasks: Not Applicable To be assessed Assessment completed Level of ability: Dependent Assisted Supervised Independent Comment…………………………………………………………………….……………………………………………………….… …………………………………………………………………………………………………………………………………………... Practice sessions required Yes No
Bathing assessment Not Applicable, advised to strip wash To be assessed Assessment completed Safe techniques explained Demonstrated by O.T. Demonstrated by patient Use of bath aids explained Demonstrated by O.T. Demonstrated by patient N/A Level of ability: Dependent Assisted Supervised Independent Comment…………………………………………………………………….……………………………………………………….… …………………………………………………………………………………………………………………………………………... Practice sessions required Yes No Referral made for post discharge provision of equipment
Essential Equipment Insitu: Yes No N/A
Outstanding Issues:
O.T. Intervention today: No intervention required Not appropriate ________________________ O.T. unable to see …………………… No O.T. service available i.e. non working day Occupational Therapy complete: Yes No
Time: ………………… Signature:……………………………………(Occupational Therapist)
70
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Occupational Therapy post operative Day 6
Activity:
Dressing Transfers Kitchen Bathing Other: …………………………
Level of ability: Dependent Assisted Supervised Independent
Equipment used:
Comment:
Further practice sessions required: Yes No
Completed by: Designation: Date:
Activity:
Dressing Transfers Kitchen Bathing Other: …………………………
Level of ability: Dependent Assisted Supervised Independent
Equipment used:
Comment:
Further practice sessions required: Yes No
Completed by: Designation: Date:
Activity:
Dressing Transfers Kitchen Bathing Other: …………………………
Level of ability: Dependent Assisted Supervised Independent
Equipment used:
Comment:
Further practice sessions required: Yes No
Completed by: Designation: Date:
Activity:
Dressing Transfers Kitchen Bathing Other: …………………………
Level of ability: Dependent Assisted Supervised Independent
Equipment used:
Comment:
Further practice sessions required: Yes No
Completed by: Designation: Date:
R.T.S, Raised toilet seat L.H.S.H, Long handled shoe horn H.H., helping hand
71
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Wound assessment chart
Site Date
Time
Score
Time
Score
Time
Score
Time
Score
0 = Dressing dry & intact; 1 = Small strike through; 2 = Moderate strike through; 3 = Large strike through; 4 = Dressing r renewed
Urinary catheterisation Inserted Enter date
Removed Enter date
Catheter type: __________________ Size: ____________ Balloon volume: ________mls Lot No: _______________
72
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Continuation sheet
Date Time Notes Signature
73
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Continuation sheet
Date Time Notes Signature
74
Total Hip Replacement Integrated Care Pathway
Date: ______/______/______
Affix addressograph label or complete:
Patient name:
Hospital number:
DOB: _____/_____/_____ Age:
Continuation sheet
Date Time Notes Signature
Recommended