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Total Joint Replacement

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Presentation on theme: "Total Joint Replacement"— Presentation transcript:

1 Total Joint Replacement
A patient and family guide To Total hip Total knee And Total shoulder surgery This presentation is about the education we provide to our total joint replacement surgery patients every Monday from 8 am to 10 am. As you all know, TJR surgery is one of the most common elective surgical procedures performed in the US Created by Dottie Megnia, BSN, RN, CNOR, ONC

2 Objectives Understand what is expected of them and what to expect from the health care team Will be able to recall three reasons for early mobilization after a joint replacement surgery Describe four preventable complications and the measures used to prevent them Together with their care plan partner, will be able to choose a discharge plan After attending a two-hour presentation on total joint replacement surgery, the patients will be able to;

3 Target Audience Ideally two-four weeks before surgery TJR patient
Care plan partner spouse friend family member Ideally two-four weeks before surgery

4 Arthritis Osteoarthritis OA Rheumatoid Arthritis RA Gout Traumatic Arthritis Avascular necrosis TJR surgery is usually performed for patients who have OA. Show of hands

5 Heredity-recessive gene discovered Generalized wear and tear
What Causes Arthritis Heredity-recessive gene discovered Generalized wear and tear Injury or accident (torn rotator cuff or anterior cruciate ligament) Chronic steroid use Autoimmune disease Previous surgery

6 Arthritis Worn or degenerated cartilage Synovial changes Effusions
This slide shows the destruction OA causes to the joint. Here we see………… OA occurs when the cartilage cracks and wears away causing exposed bones to rub together. RA and gout cause inflammation that causes heat and swelling and eventually joint stiffness. Traumatic arthritis occurs when an injury does not heal properly (Conrad, nd). Effusions Bone rubbing on bone Bone spurs

7 Goal of Surgery Relieve pain Restore function and mobility
Improve quality of life Goal when first performed in the 1960’s was to relieve pain only. In the 1960’s goal was to relieve pain only

8 Surgical Procedure Remove diseased bone, including bone spurs (osteophytes) and fluid (effusions) Damaged or diseased ligaments and cartilage Bone edges are resurfaced and fitted with metal and plastic prosthetic components Surgery takes between two and four hours

9 Saw Bones Demonstration
Give brief description of each operation using sawbones being sure to go through range of motion. Pass sawbones around and encourage questions. Sawbones are passed around and questions are encouraged-someone always asks about the weight of the prosthesis

10 Preparing for Surgery Prepare a list of medications including herbal preparations for anesthesia consult Pack light-wear in what you will wear home Good walking shoes (mile) Bring dentures, glasses, and hearing aids Leave jewelry and money at home Pack a separate bag if you think you are going to a rehab center You will need an updated history and physical and in some cases clearance from any specialists involved in your care.

11 Preparing for Surgery cont…
Television and phone may be purchased together and billed to your home Do NOT need pajamas, bathrobes, slippers Will wear hospital johnnies and skid free slippers Keep it simple May bring cell phone but AT&T does not get service on the orthopedic floor Those wishing to bring laptops may do so Those wishing daily newspapers and small items from the gift shop will be accommodated.

12 Airport Security Your new prosthesis will set off airport security
Women will require a female attendant Leave extra time so you won’t miss your flight

13 Dental Prophylaxis Let your dentist know about your new prosthesis
Antibiotic prophylaxis requirements are changing so it is best to have your orthopedic surgeon consult with your dentist for the best regime for you. In some cases, antibiotic prophylaxis is not indicated unless the patient is at increased risk for experiencing hematogenous total joint infection. Presently, no scientific evidence supports the position that antibiotic prophylaxis is necessary for patients with total joint prosthesis (“Antibiotic prophylaxis”, 2003, para 7). Antibiotic prophylaxis may be used for minor dental procedures such as cleanings

14 Prevention of Complications-Infection
Screening The purpose of this test is to screen patients for Methacylin-Sensitive Staph Aureas (MSSA), a natural bacteria that lives on the skin, and Methacylin-Resistant Staph Aureus (MRSA), which is a an antibiotic –resistant form of Staph that may cause serious infections in people who are having joint replacement surgery. If your test is positive, someone will contact you to begin treatment with an antibiotic nasal ointment prior to surgery. Screening takes place two weeks before surgery and if you are positive, you will be contacted by a nurse and a prescription will be faxed to your pharmacy. Normal flora versus dangerous MRSA flora

15 Surgical Site Infection (SSI)
Antibiotics will be given through your intravenous within one hour of your incision. Antibiotics are used to prevent a surgical site infection and these guidelines are the latest evidence-based practice shown to prevent a surgical-site infection. SSH just recently started using Vancomycin 2 hours before the incision combined w/ ancef within one hour of the incision. Vancomycin is used alone for pen allergic patients. You will be given two more doses through your intravenous over a 24 hour period and this is the latest evidence based practice shown to prevent a SSI.

16 Infection cont. Hibiclens is an antiseptic liquid skin cleanser that removes dangerous bacteria from skin that could enter the surgical incision Shower with Hibiclens up to two days before surgery Available from your orthopedic surgeon Avoid contact with eyes and ears Two tablespoons of Hibiclens- full body shower. Side effects include the following; shortness of breath, rash, hives, itching, swelling of throat, cough, and skin irritation. Stop using and report any of these side effects to your physician.

17 Prevention of Late Infections
Antibiotic prophylaxis Dog or cat bite Wound not healing well Minor surgical procedures Chronic athletes foot You may need to go on antibiotics when there is the danger that bacteria may enter the blood stream and travel to your prosthesis which your body treats as a foreign body. Anytime there is danger that bacteria may enter the bloodstream and travel to your prosthesis. The body treats the prosthesis as a foreign body.

18 Prevention of Blood clots
Early assisted mobilization Blood-thinning medication such as Coumadin, Aspirin, or Lovenox for four weeks Sequential sleeves on calves Compression stockings Anytime you have surgery on a bone, whether it be a fracture or a total joint replacement surgery, you are at increased risk for blood clots. You will be given a blood-thinning medication such as aspirin, coumadin, or lovanox and your blood viscosity will be kept at a therapeutic range usually for a period of six weeks. Early mobilization and the use of a combination of compression stockings and sequential sleeves greatly reduces this rarely seen complication.

19 Constipation Change in diet Early assisted mobilization
Anesthesia Pain Meds Iron therapy Immobility Stool softeners Mild laxative One of the systems that gets slowed down from surgery is the GI system. Try to get regular before you come in for surgery. We recommend increasing dietary fiber and/or metamucil. You will have orders for a stool softener and a mild laxative in the hospital. Increased fluid intake and early-assisted ambulation will help prevent constipation. Increase dietary fiber and/or metamucil and water.

20 Post-operative pneumonia
Another system that gets slowed down by the medications used for surgery is the respiratory system. Think about stagnant water in a birdbath and the bacteria and mold that grows there. The combination of surgery, anesthesia, and pain meds may prevent you from taking deep breaths which could lead to stagnant air in the bases of your lungs that could cause post-operative pneumonia. Using the incentive spirometer as directed by your nurse can prevent this rarely seen post-operative complication. Demonstrate the use of the incentive spirometer. Think of the hose as a straw and the device as a milk shake. Keep it on your bedside table and use every two hours while in the hospital times remembering not to do it too quickly as this could cause dizziness. If this should happen, call the nurse. Coughing also helps to remove excess secretions from your lungs. Use at home until you get your strength back and resume normal breathing patterns.

21 Post-operative Nausea
On the day of surgery, you will be given medicine to prevent post-op N/V but occasionally patients experience N/V the day after surgery due to the anesthesia and the pain medicines. All TJR patients are put on a N/V protocol and it is important for you to tell the nurse if you are experiencing N/V. The protocol allows the nurse to administer N/V medications without the need to call the surgeon. As with pain, N/V is best controlled if you stay ahead of it. out. Nausea and vomiting protocol (N/V) Best to eat a light meal on evening of surgery Call your nurse at the first sign of N/V

22 Pain Management THR patients wish they have had their surgery sooner-post-operative pain is easily managed by oral medications and the use of …….. Pre-emptive analgesia Pre-op oral cocktail of oxycontin and celebrex IV tylenol q. six hours ARC for 36 hours

23 New Oral Pain Cocktail Oxycodone 5-10 mg BID Celebrex 200 mg BID
Oxycontin 5-10 mg PRN Pain is better controlled with new oral pain cocktail versus patient-controlled analgesia (PCA) Less post-operative N/V

24 Post-operative Pain Control
Our goal for you is to be between a 4 and a 6 so that you may participate in your rehabilitation early and often. We suggest not letting the pain get ahead of you by using your pain medications as directed by your nurse and physician.

25 Nerve Blocks Femoral nerve block Sciatic nerve block
Total Knee Patients Total Shoulder Patients TKR & TSR patients experience more pain post-operatively compared to THR and will require nerve blocks. Explain that the hair-like catheter is inserted by an Anesthesiologist w/ sedation. Femoral nerve block Sciatic nerve block Intrascalene nerve block

26 Nerve Blocks cont…… Adjunct to anesthesia-helps to control post-operative pain Less sedation w/ resultant decreased anesthesia risk Less narcotic w/ decreased incidence of constipation, pneumonia, n/v & drowsiness Femoral nerve block is left in for two days Sciatic and Intrascalene are one time injections that usually wear off anywhere from hours

27 Prepare Your Home Arrange for a recovery station and a first floor set-up with access to a bathroom Prepare simple meals and freeze them Remove scatter rugs or tape down Clear commonly used pathways Measure height of toilets and beds for the occupational therapists Depending on your height, hip patients will need a good chair with arms Arrange for someone to be with your for the first 24 hours after discharge

28 Physical and Occupational Therapy
TKR patients will be put into the CPM in the recovery room on the day of surgery. Evidence has shown that the use of the CPM in the first 48 hours reduces the incidence of joint stiffness. Continuous passive motion machine-CPM

29 PT and OT continued Continuum
Day One-The physical and occupational therapists (PT & OT) will come together on day one to get you up to the commode or the bedside chair. You should get up with assistance three times a day for meals. Day Two-You should be walking to the bathroom with assistance Day Three- You should be walking in the hallway with assistance Day Three-Day of discharge Plan for three overnights. Day one is considered the first day after surgery.

30 Simple Exercises Gluteal set Ankle pumps Quad set
These simple exercises can be performed before surgery as long as they do not cause you any discomfort. Therapist and nurse demonstrate the proper technique for performing the exercises. Gluteal set

31 No bending more than 90 degrees at the waist No crossing your legs
Hip Precautions No bending more than 90 degrees at the waist No crossing your legs No turning your toes in

32 Plan on button down shirts (large) Front closing undergarments
Total Shoulder Rehab Plan on button down shirts (large) Front closing undergarments Rehab is less aggressive in the beginning Pendulum swings

33 Case Management A case manager will also visit with you on day one after surgery to begin planning for your discharge Home is best A short stay (anywhere from a few days to two weeks) at a skilled nursing facility may be needed The case managers meet with your healthcare team daily Nothing is ever set in stone Best to have two or three options for discharge The Case Manager is familiar with insurance contracts and Medicare and Medicaid requirements. They also arrange for durable medical equipment, such as walkers, crutches, shower chairs, and commodes or raised toilet seats. If you go to a SNF, it will be by ambulance. All co-payments and uncovered charges will be explained to you and your care-plan partner. It is advisable for your care-plan partner to be with you when the case manager visits.

34 Skilled Nursing Facility
If you think you are going to a SNF, pack a separate suitcase with personal items and comfortable clothing as you will be expected to dress each day Two hours of therapy per day Discharged home when safe to perform activities of daily living Arrangements will be made for home or out-patient therapy upon discharge Depending on level of function, some patients may be discharged to out-patient therapy for a period of two to six weeks depending on the individual.

35 Discharge to home Physical therapist will visit within 24 hours
Including weekends By car Durable medical equipment Detailed discharge instructions Follow-up appointments Prescriptions for pain medicines Insurance and Medicare only pay for one assistive device so we recommend the walker as it is more expensive than crutches and most people find it easier to do things (laundry, cooking) with a walker as opposed to crutches that have a tendency to fall. No more cleaning for the women for the rest of their lives.

36 Returning to Activity Don’t do anything crazy!
Consider pool therapy after your incision is healed Take it to the gym Make exercise a part of your life Take care of your new joint Biking, golfing, swimming, and walking are encouraged Avoid high impact exercises such as running marathons and mogul skiing Avoid the pounding impact of a treadmill Instead use softer surfaces such as high school track These recommendations are intended for those of you that want your new joint to last. Don’t do anything crazy!

37 References Antibiotic prophylaxis for dental patients with total joint replacements (2003). Retrieved August 15, 2011 from Conrad, S. (nd) Knee replacement. Krames patient education. Hockenbury, M.J. (2005). Essentials of pediatric nursing, (Ed. 7). St. Louis, MI: Mosby, Inc. Incentive spirometry. Retrieved August 16, 2011 from

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