SPINE SURGERY (FUSION/INSTRUMENTATION) - CLINICAL PATHWAY · •Teach back: post-discharge pain management plan •Pain medication listed on home medication sheet Wean off IV pain

SPINE POD 0 POD 1 POD 2

Standard of Care

Spine Precautions: No Bending No Lifting No Twisting No Pushing No PullingFollow all spine precautions w/all ADL’s • Log roll • Sitting for 30mins, as tolerated • Out of bed w/brace • Ankle pump exercise 10x’s Q1H • Encourage C&D • Fall precautions • IS 10x’s Q1H • Reposition Q2H • Ice to site for 20 mins TID & PRN • Knee high anti-embolism stockings • SCD sleeves

NursingIntervention

Per Unit Standard: Vital signs • Neuro checks • Pain assessment • I&O • Initiate/Review/Update care plans & outcomesDiscontinue foley POD#1 if ambulating to bathroom or no later than POD 2 by 0600 • Apply bulb suction 8 hr post-op • Saline flush qshiftMEPILEX dsg ONLY: Leave dsg intact for 5 days, DO NOT remove dsg to observe, change dsg if it comes off/excessive drainage • All dsg: Observe qshift

Notify

Diet NPO except ice chips, advance once GI parameters are WNL (disease specific per physician order)

Advance diet to regular when GI parameters are WNL (disease specific per physician order)

Patients regular diet (disease specific per physician order)

Nursing Standard

• Teach: Standards of Care (see above)• Print: Spine Surgery (lumbar/thoracic)• Teach: Spine Precautions• Activity: Dangle at bedside-RN w/ CNA

- When awake, able to follow commands- Goal before midnight w/in clinical parameters

• Safe patient handling equip on bed

• Reinforce/Teach back: Standards of Care (see above)• Reinforce/Teach back: Spine Precautions• Teach: D/C Spine Surgery• Activity: Up in chair w/all meals w/brace • Ambulate TID w/assist w/appropriate assistive device/

& brace• Bed bath w/assist• D/C foley POD 1 when ambulating to bathroom• Toilet hat specimen collection in bathroom

• Teach back: Standards of Care (see above)• Teach back: Spine Precautions• Teach back: D/C Spine Surgery• Activity: Up in chair w/all meals w/brace • Ambulate TID w/supervision w/appropriate

assistive device/& brace• Independent w/bed mobility w/spine precautions• D/C foley no later than 6am• Toilet hat specimen collection in bathroom• Urinating w/out difficulty

Meds

• IV Fluids• Colace 200mg PO BID &/or bowel regimen• Analgesic: IV & PO available• Prophylactic antibiotic • Teach: Medications w/patient education

handout

• Saline lock when tolerating PO• Anticoagulation med or documentation of

contraindication• Colace 200mg PO BID &/or bowel regimen• Analgesic: IV & PO available• Reinforce/Teach back: Medications (reason for

taking, side effects etc)

• Saline lock • Anticoagulation med & listed on home med

sheet• Colace 200mg PO BID &/or bowel regimen• Analgesic: IV & PO available• Teach, reinforce w/teach back: Home medications

(reason for taking, side effects etc)

Pain*Intensity

&*Quality

CharacterLocation

FrequencyDuration

• Assess/reassess pain level per policy-offer analgesic consistent w/order

• Offer IV/PO analgesics-ensure both are avail-able (Use PO when tolerating a diet)

• White board update w/medication times• Educate pt/family about pain (risk, pain pro-

cess, pain mng techniques, potential limita-tions, side effects)

• Use non-pharmacological interventions (cold, guided imagery, relaxation, distraction, prayer/meditation, humor, massage)


• Teach: Current & post-discharge pain manage-ment plan

• Use oral analgesic first, limit IV PRN• Be proactive in D/C of PCAs• Use non-pharmacological interventions• White board update w/medication times• Best practice no IV analgesic w/in 24 hours of

discharge


• Teach back: post-discharge pain management plan• Pain medication listed on home medication sheet• Wean off IV pain medication• Use oral analgesics• Use non-pharmacological interventions• White board update w/medication times• Educate about the post-discharge pain mng plan • Best practice no IV analgesic w/in 24 hours of

discharge

PT

• PT inpatient initial evaluation• Initiate care plan• Recommendations: Home/ SNF/DME• Education: (teach)

- Spine precautions- Don/doff/fitting of brace - Proper body mechanics

• Activity:- Perform bil LE exercises: Ankle pumps, knee bends, quad sets, glut sets- Transfer bed<->chair- Ambulate w/assist, at least 50 ft w/appropriate assistive device & brace

• Handouts:- Spine precautions

• White board update: Transfer & gait

• PT BID• Review care plan• Education:

- Teach back: Spine precautions & proper body mechanics- Teach back/return demonstration: Don/doff/fitting of brace

• Activity:- Ambulate w/assist, at least 150ft, w/assistive device (PRN)/ & brace - Stair training (PRN)- Car transfers training (PRN)

• White board update: Transfer & gait• When all PT goals met: D/C PT

• PT PRN per plan of care• Ambulate w/supervision w/appropriate assis-

tive device (PRN)/& brace

OT

• OT initial evaluation• Initiate care plan• Recommendations: Home/SNF/DME• Education (teach):

- Body mechanics & posture education for ADLs w/spine precautions- Activity modification to minimize stress on tissues- ADL training w/adaptive equipment, DME w/ spine precautions

• Activity (teach):- Don/doff/fitting of brace- Toilet transfer w/DME

• Handouts (teach):- ADLs: After Spine Surgery- Vendor information for adaptive equip/DME

• Education (teach back/return demonstration):- Body mechanics & posture education for ADLs w/spine precautions- Activity modification to minimize stress on tissues

• Activity (teach back/return demonstration):- Don/doff/fitting of brace- Perform upper and lower body dressing w/ adaptive aids w/spine precautions- Toilet transfer w/DME

• Handout (teach back):- ALDs: After Spine Surgery

Discharge Plan

*If pt is HMO, HMO CM will work on D/C[Facey, Lake-side, Health

Care Partners]

• Anticipate D/C POD #2• Physical therapy & occupational notes reviewed• CM D/C planning initial completed (discharge

location established)- Anticipated D/C needs: ° PT/OT/HH □ Arrange PT/OT/HH PRN w/order ° SNF list given PRN ° SNF choices given to CM- Anticipated DME Needs: □ Order DME (walker, BSC, CPM etc-per order)- Teach: Anticipated D/C date

• Fax pre-auth medications to patient’s pharmacy: Lovenox, Xarelto etc.

• Anticipated D/C today, POD#2, D/C should be no later than POD#3

• CM or D/C planner daily visits PRN• CM D/C planning final completed• Teach back: Established D/C location • Teach back: Anticipated D/C date• Home D/C: Refer to CM follow up note:

- DME delivered with # listed on D/C instruc-tions- MD signed DME order- PT/OT/HH #’s listed on D/C instructions

• SNF D/C referral sent/faxed/authorized: • Refer to: Care provider contact interaction note

- POD #3 transportation arranged to SNF*At discharge: Nurse to evaluate and confirm patient has all necessary discharge resources (DME, HH, etc.)

Discharge*Teach back and return

demonstration

Call Surgeon when D/C criteria met: 1. Ambulating 2. Tolerating PO well 3. No Nausea/vomiting 4. Tolerating diet 5. Afebrile for 24 hours 6. Pain controlled w/PO meds Blue manila envelope include: 1. Nursing discharge instructions 2. Patient belonging’s record 3. Case Mng discharge planning final 4. Discharge Instructions Spine Surgery • Spine Precautions • Activities of Daily Living: After Spine Surgery

References: Core Curriculum for Orthopaedic Nursing 7th Edition, Lippincott Procedures, National Association of Orthopaedic Nurses (NAON) • Green, U. R., Dearmon, V., Taggart, H. (2015). Improving transition of care for veterans after total joint replacement. Orthopaedic Nursing, 34(2), 79-86. • Polster, D. (2015). Patient discharge information. Nursing 2015, 45(5), 42-49 • The Joint Commission • Veesart, Amand, Ashcraft, Alyce. (2015, May). Get your patients moving now. The American Nurse Today, 11-13.

Revised 11/2015SPINE SURGERY (FUSION/INSTRUMENTATION) - CLINICAL PATHWAY

23845 McBean Parkway, Valencia, CA 91355 | 661.253.8000 | henrymayo.com

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*Clinical judgment may supersede the clinical pathway.

Temp > 101.4

HR >110 or <50

RR >20 or <8

SBP >180 or <90

DBP >100, or <40

O2Sat <90%

UO <30ml/hr x 4hrs

No BM x3 days

Hgb <8

BS <70 or >100

Bulb Drainage>300 ml/shift

Day of Surgery: # 0

After Surgery Day:# 1

After Surgery Day:# 2

Precautions • No Bending • No Lifting • No Twisting • No Pushing • No Pulling

Activity Out of bed with brace,with help

Walk 3 times with helpGoal: Walk 150 feet

Practice stairs & car transfers

Walk 3 times with helpGoal: Ready for home

Diet Ice Chips Food & Liquids Food & Liquids: Home

PainTell nurse if you are having pain

Pills or IV Pills only Pills only, prescription given

Discharge PlanWith patient and family

Discuss and confirmdischarge plan

Home with plan

Important Reminders• Follow-up with your surgeon within 1-2 weeks• Start walking daily•Monitor your wound for infection• Back brace is worn at the discretion of the surgeon • Use long handled equipment to keep your precautions•Driving precaution and restrictions apply

Before leaving hospital- Make sure you have blue envelop with:• Patient Visit Summary Discharge Instructions• Patient Belonging’s Record• Case Management Discharge Planning Final•Discharge Instructions Spine Surgery (Lumbar/Thoracic)• Physical therapy home exercise program•Occupational therapy home exercise program

SUDDEN LOSS OF BOWEL OR BLADDER FUNCTION, LOSS OF FEELING IN LEGS OR IN GENITAL AREA, CHEST PAIN, SHORTNESS OF BREATH


YOUR PATH TO RECOVERY AFTERSPINE FUSION SURGERY

Revised 11/2015

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You will need to follow the below precautions.Good body mechanics will be needed overall for the rest of your life.


NO BENDING

NO LIFTING

NO TWISTING

Revised 11/2015

SPINE PRECAUTIONS

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NO PUSHING / NO PULLING

RIGHT WRONG

RIGHT WRONG

RIGHT WRONG

RIGHT WRONG

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DISCHARGE INSTRUCTIONSSPINE SURGERY

(FUSION, INSTRUMENTATION, AND NO HARDWARE)

*The information below does not replace instructions your doctor may give you.


SPINE PRECAUTIONS (Remember a complete fusion can take 6 months to 1 year) _____________________________________________________________________________________________You will need to follow the below precautions. Good body mechanics will be needed overall for the rest of your life.• NO Bending • NO Lifting 5-10 pounds • NO Twisting • NO pushing & pulling items*Remember Spine Precautions with All Activities

FOLLOW UP _____________________________________________________________________________________________• Follow-up with your surgeon within 1-2 weeks after your surgery

NOTIFY YOUR DOCTOR IMMEDIATELY WITH_____________________________________________________________________________________________• Sudden loss of urine/stool (bowel/bladder) control• Loss of feeling (numbness) or weakness in both legs• Loss of feeling (numbness) in the genital/crotch area (perineum)• An increase in pain not relieved by pain medication or rest• Fever above 100.4 degrees Fahrenheit• Pain, swelling, tenderness in your calf• Any signs of infection to the incision or the surrounding skin : increased swelling, redness, pain, very

warm to touch, painful to touch, increase in drainage or the presence of pus-like drainage, the incision is pulling apart, foul smell, shaking, chills

CALL 911 RIGHT AWAY IF YOU HAVE ANY OF THE FOLLOWING _____________________________________________________________________________________________• Chest pain• Shortnessofbreathandordifficultybreathing

HOME EXERCISE PROGRAM - PHYSICAL THERAPY & OCCUPATIONAL THERAPY_____________________________________________________________________________________________• Start walking daily. This is very important for your recovery• Walkonaflat/levelsurface.Trytoincreasethedistanceyouwalkeachday• Daily activates are crucial to returning to your life after surgery

Revised 11/2015

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IMPORTANT REMINDERS_____________________________________________________________________________________________• You may still experience the same symptoms you did prior to surgery• Healing can take time, even months

INCISIONAL CARE_____________________________________________________________________________________________• Mepilex dressing ONLY: Leave the dressing on for a total of 5 days from the date of your surgery. After 5

days take off dressing and leave open to air• Any other dressing: remove dressing, look at site daily and follow your doctors instructions on how to care

for the incision-If dressing is open to air after your surgery, leave open to air• Keep your dressing clean and dry• If dressing comes off, seems wet or is soaked with drainage replace with new dressing • DONOTuse:Soap,lotion,antibiotics(tripleantibiotic,firstaidcreametc)ontheincision• DO NOT remove or pick at staples, sutures, steri-strips, skin glue

PAIN_____________________________________________________________________________________________• You can expect to have pain after your surgery• Take your pain medication as directed — Many doctors advise not to take NSAIDS after a fusion because it may interfere with bones fusing together-Please speak with your doctor prior to taking an NSAID (Advil, Motrin, Aleve, Ascriptin, Bayer, Ecotrin, Ibuprofen, Naproxen Sodium, Aspirin) — You should NOT drink alcohol or drive when taking pain medication• Ice the surgery area, 20 Minutes On, 20 Minutes Off — Ensure you have a barrier between the ice and the surgery area — DO NOT use heat• Change positions frequently to decrease pain and stiffness• Use Non-Pharmacologic Interventions (No medication) such as: Guided imagery, relaxation, distraction,

prayer/meditation, humor, massage

BACK BRACE _____________________________________________________________________________________________A back brace is used to provide support and limit movement in the spine. Your doctor may or may not order a brace.• Wear a shirt under the brace. The brace shoulder not contact the skin directly• Typically the brace should be worn only when out of bed. You do not need to have the brace on in bed• Typically the brace does not need to be worn when showering• Assess skin under brace daily. Look for any skin irritations (redness, blisters, hives)*Back brace is worn at the discretion of the surgeon

MANAGING CONSTIPATION_____________________________________________________________________________________________• Pain medication most likely will cause constipation• Increase your water, try drinking at least 8 glasses of water a day• Slowlyincreasefiberintoyourdiet• Over the counter stool softeners or laxatives can be helpful


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NUTRITION_____________________________________________________________________________________________• Eat healthy, well-balanced meals • Drink at least 8 glasses of water per day• DO NOT diet while you are healing

SUPPORT HOSE_____________________________________________________________________________________________• Keep the support hose on for at least 2 weeks, removing stockings at least 1-2 times a day or at night to

allow air to reach your legs• Monitor skin for breakdown (blisters, deep redness, creases in skin)• Wash with soap and water and hang to dry

SITTING AND SLEEPING_____________________________________________________________________________________________• Remember to use a log roll when getting into and out of the bed• Sit for 20 to 30 minutes at a time to let the back muscles rest• Sometimes sitting can cause leg pain, if this is the case limit sitting • Sleeping with a body pillow in between your legs can be helpful to keep your spine in proper alignment if

you are a side sleeper

DRIVING_____________________________________________________________________________________________• Nodrivingundertheinfluenceofpainmedication(narcotic/opioidtypeofpainmedications)• Must be able to make an emergency stop• Must be able to operate machinery safely• Driving will depend on leg positioning, strength, coordination• Most can drive within a couple of weeks and may take up to six weeks

SHOWERING_____________________________________________________________________________________________• Usually ok to shower within 48-72 hours after your surgery• Please have a family member or friend help you in the beginning• DO NOT swim, take baths or go in hot tubs for a few weeks

SEXUAL INTERCOURSE_____________________________________________________________________________________________• Typically can be resumed when you can walk a mile without pain• Communication is important especially to ensure your comfort and your precautions. It is important to

communicate force, speed, and amount of weight you can tolerate • Stop immediately should you experience pain


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RETURNING TO WORK_____________________________________________________________________________________________• You will be recovering for a period of 4-6 weeks• Speed of recovery depends on your condition before surgery, after surgery, how well you follow your

doctor’s orders and your participation• Depends on what type of work you do

NURSE NAVIGATOR_____________________________________________________________________________________________• The navigator is your liaison between all the members of your team. They will work with you and your

family as much as you need• Do not hesitate to call the Nurse Navigator at 661.200.2225, at any time


Applies to Mepilex Dressing

Revised 11/2015

THE CARE OF YOUR INCISION


Any signs of infection are present to the incision or the surrounding skin:• Increased swelling, redness or pain• Very warm to touch• Painful to touch• Increase in drainage or the presence of pus-like drainage• The incision is pulling apart• A very foul smell• Shaking chills or fever above 100.4 °F (38°C)

• Keep your dressing clean and dry• After 5 days take off dressing and leave open to air. Observe wound and report any signs and

symptoms of infection.• DO NOT apply anything to your incision (unless directed by your physician) especially: Soap, lotion,

antibiotics (triple antibiotic, first aid cream etc)• DO NOT remove or pick at staples, sutures, steri-strips, skin glue or a scab

CALL YOUR DOCTOR RIGHT AWAY IF:

KEEP YOUR INCISION CLEAN, DRY AND INTACT

APPLYING A NEW DRESSING

Step 1 - Preparing to care for your incision• Clean your work area before changing your dressing• Grab your new dressing, and a plastic bag• Thoroughly wash and dry your hands

Step 2 - Remove soiled dressing• Discard in the plastic bag• Wash and dry your hands

Step 3 - Clean your incision• Gently pour warm water or saline over the incision to rinse the area• DO NOT scrub• DO NOT use soap

Step 4 - Apply new dressing• Removethereleasepaper(seefigureA)• Center the dressing over the incision; place the tacky side down on

topofthewound.Donotstretch(seefigureB)• GentlyPressthedressingontoyourskin.Ensurealledgesareflat

topreventmoisturefromgoingunderthedressing(seefigureC)

A.

B.

C.

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Don’t rush! Give yourself extra time to set up proper work conditions and carry out good body mechanics.

• At the sink, bend your knees and hips • Place one hand on the counter to brace yourself• Do not bend over• Bring a cup to your mouth to rinse rather than

bending forward into the sink

GETTING IN AND OUT OF BED - LOG ROLL

GROOMING: SHAVE, BRUSH TEETH, WASH YOUR FACE

HOUSEHOLD ACTIVITIES

A. Sitonedgeofbed,feetonfloorB. Lower self to lie down on one side by raising

legs & lowering head at the same timeC. Roll over onto back keeping shoulders, hips

and knees moving together (Like a log)***To get out of bed, reverse steps

• Useareachertograbobjectsonthefloor• Avoid reaching as much as possible• Carry objects close to your body• Keep items in easy reach

ACTIVITIES OF DAILY LIVINGAFTER SPINE SURGERY

Revised 11/2015


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LOWER BODY DRESSING• Sit on side of your bed or in chair• Cross leg and start clothing over foot • Keep back in neutral spine. Avoid arching back, twisting

or bending• As needed use: Reacher (to grab clothing) Sock aid (to put on sock) Long shoe horn (to put on shoe)

A raised toilet seat with armrests may be helpful • Back up to the toilet until you feel the back of

your legs touching the toilet seat.• Reach back for the armrests and slowly lower

yourself down• Reverse the procedure to get up, pushing up

from the armrests• Be careful not to twist


HELPFUL SHOWER ITEMS

USING THE BATHROOM

SAFETY

• Ahand-heldshowerdevicetodirectflowofwater• Long-handled sponge to clean your lower legs & feet• Shower chair or tub bench to help with conserving energy• Non-skid bath mat to prevent slipping • A rack to hold toiletries to prevent stooping & twisting • Grab bar to promote balance & prevent falling

• Pick up clutter, remove throw rugs, and tape down electrical cords

• Arrange a driver to help you with errands during thefirstfewdayshome

• Avoid long car rides• Have a secure handrail on stairs• Useastablechairwithafirmseatcushionand

armrests

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CAR TRANSFER

• Avoid long car rides. Get up and walk around every 2 hours

• Back up to the seat, steady yourself, reach back for the seat and slowly lower yourself down

• Bring one leg in at a time• Keep shoulders, hips and knees facing the same

direction as you turn to face forward in the seat• Reverse steps to get out

Documents

SPINE SURGERY (FUSION/INSTRUMENTATION) - CLINICAL PATHWAY · •Teach back: post-discharge pain management plan •Pain medication listed on home medication sheet Wean off IV pain