TOTAL KNEE REPLACEMENT (TKR) HOME HEALTH CARE PROTOCOL

My Home Nurses || NM
Clinical Intervention & Patient Teaching Template

Reviewed and approved 06/30/2026
Annie Tchinjo RN, MSN  |  Terri Lorenz, RN  |  Felix Leshey MRes

CONFIRMING ATTENDING SURGEON DIRECTION PRIOR TO INITIATION: This standardized documentation template applies to standard TKR clinical pathways under Dr. Edelstein, Dr. Manning, Dr. Hardt, and Dr. Thomas. Always cross-reference the patient’s individual discharge paperwork and/or specialized home health care orders for patient-specific modifications.

1. MANDATORY CLINICAL VISITING SEQUENCE

• Weekday Discharges (Monday – Thursday): The initial RN evaluation and the initial Physical Therapy (PT) visit must both occur the next calendar day following patient discharge.
• Weekend Discharges (Friday – Saturday): Allow a strict 24–48 hour window for initial evaluations. Specifically: Discharged Friday: Initial RN/PT visits must be scheduled on Saturday or Sunday. Discharged Saturday: Initial RN/PT visits must be scheduled on Monday.
• First Post-Operative Office Visit (POV): Confirm that the patient’s first clinic follow-up appointment is verified and scheduled at the 3-week post-op mark.

2. CUSTOMIZED ADVANCED WOUND & DRESSING CARE

• MEPILEX DRESSING (Typically Dr. Edelstein standard): The primary dressing should remain completely sealed and intact until the 3-week post-op office visit. Do not remove unless specialized criteria are met. If the border becomes loose, saturated, or wet, remove it immediately, replace with dry gauze and a water-resistant cover (Tegaderm), and notify the surgical office right away (the patient will likely require an urgent clinic wound check). If mild localized drainage occurs, cover with a dry island dressing (Telfa) or gauze/tape to be changed by the patient every 1-2 days under clinical supervision. For showering, completely cover the Mepilex dressing with plastic wrap and protect it from the direct stream of water.
• AQUACEL OR SILVERLON DRESSING (Typically Drs. Manning / Hardt / Thomas standard): The primary dressing must remain perfectly sealed and in place until precisely 7 days post-op. On Post-Op Day 7, the nurse or instructed patient should completely remove the dressing and leave the incision open to air. If any minor drainage persists after removal, cover with a dry island dressing (Telfa) or gauze/tape changed daily by the patient. Dressings can be stopped entirely once drainage ceases. If excessive drainage is identified, cover and notify the surgical office. If the incision is fully dry on day 7, the patient may shower normally over the bare incision (strictly no scrubbing, pat dry with a clean towel).
• PREVENA WOUND VAC SYSTEM: Keep the localized vacuum system clean, continuously powered, and sealed in place for 7 full days from the surgery date. The dressing must be removed by day 6 or 7, or immediately when the portable battery expires and negative pressure suction ceases. The RN or PT should carefully peel away the Prevena dressing and safely discard all electrical and single-use elements. Immediately apply a clean Telfa island dressing and leave it in place for 3 days (remove immediately if it becomes wet). Once that secondary dressing is removed, leave the fully dry incision open to air. Enforce strict showering protocols: Patient may shower with the Prevena dressing on but it must be kept entirely out of the direct stream of water. Prior to entering the shower, power the device box off, disconnect it from the line, and wrap the entire remaining site tightly in plastic wrap. After showering, remove the plastic wrap completely, reconnect the line, and power the device back on. The secondary Telfa island dressing is NOT waterproof and must also be wrapped in plastic wrap during showering (remove immediately and replace if it gets damp). Once removed entirely, you may shower normally and let soapy water run over the incision (no scrubbing, rinse well, and pat completely dry).
• WATER SUBMERSION BAN & STAPLE REMOVAL: The surgical incision must NEVER be submerged in water (no baths, hot tubs, or pools) until explicitly cleared by the provider, typically 6 weeks from discharge. If applicable, surgical skin staples will be formally removed by clinical staff during the first follow-up clinic appointment 2 to 3 weeks following surgery.

3. PHARMACOLOGICAL THROMBOPROPHYLAXIS & ANTICOAGULATION

• Aspirin Only Regiment: Aspirin 81mg PO twice daily (BID) for a total duration of 28 days. Instruct the patient to take Aspirin with meals to reduce gastric upset.
• Lovenox Only Regiment: Lovenox daily subcutaneous injection (initiated on POD #1) for 21 days. Reinforce injection teaching with the patient and family members.
• Lovenox to Home Anticoagulation Bridge: Lovenox daily injections starting POD #1 for 5 days, followed by the immediate resumption of the patient’s pre-operative home Direct Oral Anticoagulant (DOAC) regimen.
• Coumadin Regiment: Coumadin dosing as ordered. Perform mandatory home phlebotomy blood draws for PT/INR tracking every single Monday and Thursday without fail.

4. MULTIMODAL ACUTE PAIN CONTINUUM

• Long-Acting Opioids: MS Contin 10mg PO nightly PRN may occasionally be prescribed for severe breakthrough pain during the first 2-3 nights only.
• Short-Acting Opioids: Administered strictly PRN for severe activity-limiting pain. Prescribed regimens include Roxicodone 5-10mg every 3 hours PRN, Norco 10/325mg every 4 hours PRN, or Dilaudid 2mg every 2 hours PRN.
• Transition Goal: The clinical goal is to transition from all narcotics to standard Tylenol 1000mg every 8 hours PRN. (Note: Tylenol will not be co-administered if the patient is actively taking Norco due to high risks of acetaminophen toxicity).
• Scheduled Post-Op NSAIDs: To control localized surgical inflammation, administer Celebrex 200mg PO twice daily for 21 days OR Naproxen 375mg PO twice daily for 21 days. Educate that no other over-the-counter NSAIDs are safe to take for a minimum of 2 months after surgery. Take with meals to reduce GI upset.
• Gastric Protection & Bowel Management: If Naproxen is prescribed, the patient must take Pantoprazole daily before breakfast. Discontinue if acid reflux or stomach pain develops. For opioid-induced constipation, administer Senokot daily. Patients must have a bowel movement every 3 days at a minimum; increase water and fiber intake.
• Surgical Antibiotic Prophylaxis: Oral prophylactic antibiotics are prescribed ONLY for outpatient surgeries or high infection risks. Ensure full completion of Cefadroxil 500mg BID for 7 days OR Bactrim DS 800mg-160mg BID for 7 days.

5. THERAPEUTIC REHABILITATION & CIRCULATORY PATHWAY

• Physical Therapy Frequency: In-home Physical Therapy must occur 3 times per week for a 2-week duration, or based on specific patient need, before transitioning to outpatient physical therapy.
• Weight Bearing Restrictions: Assume the patient is Weight Bearing As Tolerated (WBAT) and gait train to baseline (may advance assistive device) unless a specific restriction is explicitly documented on the referral or AVS. Protected WBAT: Must remain on crutches or a rolling walker at all times until the first post-op office visit. 50% Weight Bearing: Body weight supported evenly by both feet only when standing; when walking, the operative leg absorbs only 50% of stride weight (typically enforced for 3-6 weeks). Flat Foot Weight Bearing: Operative foot rests on the ground for balance, but zero weight transfer occurs during strides.
• Range of Motion & Strengthening: There are no range of motion (ROM) structural limits unless explicitly specified on the referral. Progress strengthening and activity as tolerated within reason.
• Edema and Swelling Control: Actively encourage elevating the operative leg above the level of the heart to decrease localized swelling and optimize venous circulation (Dr. Manning standard recommends at least 5 distinct times per day). Encourage continuous localized icing 3 to 4 times per day for 20 to 30 minutes per session to decrease swelling (utilizing the Polar Care Ice unit if provided).

6. RN VISIT NOTE INSERT & DOCUMENTATION CHECKLIST

========================================================================         
NORTHWESTERN MEDICINE HOME HEALTH - DAILY TKR VISIT NOTE
========================================================================
[ ] VERIFIED VISITING PATHWAY SEQUENCE COMPLIANCE:    
    - Initial RN and PT visits both scheduled next day (Mon-Thu discharge)      
      or within a 24-48h window (Weekend discharge).    
    - Confirmed 3-week clinic follow-up appointment is verified.
[ ] AUDITED CHOSEN SURGICAL DRESSING PROTOCOL:    
    [ ] MEPILEX: Inspected border seal. Intact [ ] Saturated >=50% [ ] Loose [ ]        
        *Action: If wet/loose, replaced with gauze/Tegaderm and notified office.*    
    [ ] AQUACEL/SILVERLON: Verified POD #7 removal timeline. Left open to air [ ]    
    [ ] PREVENA VAC: System active and pressurized. Dressing removed at Day 6-7 [ ]        
        - Telfa secondary dressing applied for 3 days [ ] Re-verified open to air at Day 10 [ ]    
    *Audit Point: Reinforced strict zero water submersion ban for 6 weeks from discharge.*
[ ] MANAGED PHARMACOLOGICAL & DVT PROPHYLAXIS COMPLIANCE:    
    - Current Anticoagulant: [ ] Aspirin 81mg BID | [ ] Lovenox Injections | [ ] Coumadin    
    - Injection technique audited / Coumadin home blood draws completed (Mon/Thu) [ ]    
    - Confirmed scheduled NSAID taken with meals; Pantoprazole taken before breakfast [ ]    
    - Evaluated bowel movements: Senokot compliance checked. Minimum BM q3 days met [ ]
[ ] AUDITED HOME REHABILITATION INTERVENTIONS:    
    - Frequency verified at 3 times per week for 2 weeks.    
    - Enforced weight-bearing limits (WBAT / Protected Walker / 50% Restricted).    
    - Verified leg elevated above heart level (at least 5x/day) and ice applied 3-4x/day      
      using Polar Care Ice unit as tolerated.
[ ] ASSESSED RED FLAGS & RECOVERY DEVIATIONS (NOTIFIED OFFICE FOR ANY MATCH):    
    - Localized incisional drainage/open borders, redness, excessive warmth, or fever.    
    - Calf pain, sudden asymmetrical lower extremity swelling, or respiratory distress.    
    - Uncontrolled pain or complete drug intolerance (acid reflux, severe stomach pain).
========================================================================

7. CLINICAL CONTACT & ESCALATION ROUTING

• Assigned Orthopedic Support Staff: Lizzie Bazzetta, PA-C; Jessica Sperling, PA-C; Becke Schmidt, PA-C; Alicia Lew, PA-C; Teri Heywood, RN; Meg Van Dyke, RN; Rachel Doyle, RN.
• Primary Contact Phone: 312-695-6800.
• Primary Secure Fax Lines: 312-472-4871 / 312-695-2772.