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Orthopedic & Neurological Patient Population Med Surg II 1.

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Presentation on theme: "Orthopedic & Neurological Patient Population Med Surg II 1."— Presentation transcript:

1 Orthopedic & Neurological Patient Population Med Surg II 1

2 TOTAL JOINT ARTHROPLASTIES 2

3 Total Knee Arthroplasty (TKA) Meds Analgesics for Pain: Ocycodone, Percocet, Vicoden, Lortab OR Epidural Anticonstipation: Colace Antibiotics: Cefadroxil, Levafloxacine Antinausea: Zofran Blood thinner: Coumadin Labs/Diagnostics Hb, Hct, WBC, PT, PTT, INR Post Xray for component placement Medical Equipment PAS stockings or foot pumps 2L Foley Hemovac Knee immobilizer CPM 3

4 Total Knee Arthroplasty (TKA) Precautions/Contraindications WBAT No shower if drainage Physician changes the first bandage Hold the Post OP leg during bed mobility for comfort When sitting, bring surgical leg forward for comfort B TKA place walker farther out b/c decreased knee ROM will place feet in front of knees 4

5 Total Knee Arthroplasty (TKA) PT Eval – Unilateral, Bilateral, Unicompartment Goniometric measurement of knee extension - flexion Screen incision Screen Sensory Screen Muscle Strength General mobility of bed, transfers, gait PT POC – 3 Days BID for exercise and gait Stairs, car, tub/shower Tf Cold Pack Change in position elevation (edema management) to sitting with knee flexed (prolonged stretch for knee flexion) Pt Ed: DVT prevention, swelling, ROM 5

6 Total Hip Arthroplasty (THA) Meds Analgesics for Pain: Ocycodone, Percocet, Vicoden, Lortab OR Epidural Anticonstipation: Colace Antibiotics: Cefadroxil, Levafloxacine Antinausea: Zofran Blood thinner: Coumadin Labs/Diagnostics Hb, Hct, WBC, PT, PTT, INR Post Xray for component placement Medical Equipment PAS stockings or foot pumps 2L Foley Hemovac 6

7 Total Hip Arthroplasty (THA) Precautions/Contraindications WBAT (unless surgery due to osteoporosis or fracture then may have TTWB or PWB) No showering if drainage Hip Precautions – No excessive hip Anterior: Flex or Ext, ADD, IR Lateral: Flex, ADD, ER Posterior: Flex, ADD, ER **Make them meaningful with functional activity examples Should a pt roll onto or away from the surgical side? 7

8 Total Hip Arthroplasty (THA) PT Eval – Ball & Socket, Endoprosthesis, Hip Resurfacing Screen ROM primarily at the knee due to precautions Screen incision Screen Sensory Screen Muscle Strength General mobility of bed, transfers, gait PT POC – 3 Days BID for exercise and gait Stairs, car, tub/shower Tf Cold Pack Change in position so no prolonged sitting Pt Ed: DVT prevention, swelling, precautions during fxnal activities 8

9 Joint Programs – Seen BID Day of Surgery Sit EOB Day 1 Exercises as a group Gait Training Day 2 OT Evaluation Exercises as a group Gait Training Tub/Shower Tf, Stairs, Car Tf Day 3 Exercises as a group Gait Training 9

10 Joint Programs – Seen BID Gait Training Normalize gt pattern ASAP Step to – Step through – Step through heel strike Exercises AP Quad and Glut Sets SAQ Heel slides SLR for TKA and SLR modified for THA Seated LAQ Seated ROM prolonged stretch for TKA and moderate stretch for THA 10

11 Total Shoulder Arthroplasty (TSA) Meds Analgesics for Pain: Ocycodone, Percocet, Vicoden, Lortab OR Epidural Anticonstipation: Colace Antibiotics: Cefadroxil, Levafloxacine Antinausea: Zofran Labs/Diagnostics Hb, Hct, WBC, PT, PTT, INR Post Xray for component placement Medical Equipment PAS stockings or foot pumps 2L Foley Hemovac Shoulder immobilizer or a sling CPM usually for home or OP 11

12 Total Shoulder Arthroplasty (TSA) Precautions/Contraindications No active elevation: flexion, abd, scaption No Shoulder ER active or passive x 6 weeks NWB Immobilizer or sling 12

13 Total Shoulder Arthroplasty (TSA) PT Eval ROM elbow to wrist on affected side Screen sensory Screen bed mobility, Tfs PT POC 1-2 Days AROM elbow to wrist on affected side by unfastening different areas of immobilizer or sling Codman’s or Pendulum – keep it PROM How to don/doff immobilizer or sling, change shirt, put on deodorant 13

14 SPINAL SURGERIES 14

15 Microdiscectomy Meds Analgesics: Opiods of morphine, fentanyl; epidurals; oral meds NSAIDS or opiods Antibiotics Labs/Diagnostics Hb, Hct, WBC Medical Equipment Foley 2L Ted Hose PAS stockings IV 15

16 Microdiscectomy Precautions/Contraindications No prolonged sitting more than 30, 45, 60 min Need to change position even if just stand or walk No lifting >10# No excessive bending or twisting 16

17 Microdiscectomy PT Eval Screen myotomes Screen dermatomes Screen for edema, incision PT POC 1 day General mobility – usually no assistive device needed LE strength exercises pending screens Initiate core stability with abdominal sets, abdominal set with UE then LE movement and progress to UE & LE movements Log roll supine to sit and sit to supine 17

18 Laminectomy with Discectomy Spinal Internal Fixators Spinal Fusions, Vertebroplasty Meds Analgesics: Opiods of morphine, fentanyl; epidurals; oral meds NSAIDS or opiods Antibiotics Labs/Diagnostics Hb, Hct, WBC Xray to check the components Medical Equipment Foley 2L Ted Hose PAS stockings IV 18

19 Laminectomy with Discectomy Spinal Internal Fixators Spinal Fusions, Vertebroplasty Precautions/Contraindications No prolonged sitting more than 30, 45, 60 min Need to change position even if just stand or walk No lifting >10# No excessive bending or twisting Allograph site per pt tolerance Corset or Brace pending level of the surgery May don in supine, sit or standing Some orders may state “brace on when up” Some orders may state “no brace if bed to bathroom” 19

20 Laminectomy with Discectomy Spinal Internal Fixators Spinal Fusions, Vertebroplasty PT Eval Screens of muscle strength for myotomes Screens of sensory for dermatomes Screen of integument for edema, incision PT POC 1-3 days General mobility – may need assistive device Higher than norm so no flexion and RW so no activation of back extensors LE strength exercises pending screens Initiate core stability with abdominal sets, abdominal set with UE then LE movement and progress to UE & LE movements Log roll supine to sit and sit to supine 20

21 Anterior Cervical Discectomy, C/S Fusion Meds Analgesics: Opiods of morphine, fentanyl; epidurals; oral meds NSAIDS or opiods Antibiotics Labs/Diagnostics Hb, Hct, WBC Xray to check the components Medical Equipment Foley 2L Ted Hose PAS stockings IV Soft or hard collar 21

22 Anterior Cervical Discectomy, C/S Fusion Precautions/Contraindications No forced C/S ROM – ROM for daily activity Brace on when up and supine Swallow in upright position 22

23 Anterior Cervical Discectomy, C/S Fusion PT Eval Screen ROM and strength of UE (sometimes LE if tumor or cord involvement) Screen swallow and recommend SLP if unable to swallow by lunch time PT POC – 1-2 days Gentle C/C isometrics No excessive AROM or no PROM of C/S Log roll for supine to sit and sit to supine Scapular motion to pt tolerance Gait – focus on relaxed shoulders and arm swing Exercise for strength pending strength screen Usually no assistive device unless LE impacted 23

24 INTERNAL & EXTERNAL FIXATORS Most patients are sent home from ER in a cast for elbow to wrist, ankle fractures and return for surgery in approx 1 week with a LOS of 1 day in the hospital. PT to reassess gait but pt has been mobile at home prior to surgery 24

25 Wrist or Elbow Meds Analgesics for Pain: Ocycodone, Percocet, Vicoden, Lortab OR Epidural Anticonstipation: Colace Antibiotics: Cefadroxil, Levafloxacine Antinausea: Zofran Labs/Diagnostics Hb, Hct, WBC, PT, PTT, INR Post Xray for component placement Medical Equipment PAS stockings or foot pumps 2L Foley Possible ace wrap for External and ace wrap/ace wrap with splint for internal May have sling 25

26 Wrist or Elbow Precautions/Contraindications NWB 4-6 weeks External fixator keep pins clean Some internal fixators will be removed in future 26

27 Wrist or Elbow PT Eval Assess ROM and Strength above or below site Assess sensory Assess edema PT POC – 1 day Mobility Pt Ed: ROM above or below site, precautions 27

28 Ankle, Femur or Pelvis Meds Analgesics for Pain: Ocycodone, Percocet, Vicoden, Lortab OR Epidural Anticonstipation: Colace Antibiotics: Cefadroxil, Levafloxacine Antinausea: Zofran Labs/Diagnostics Hb, Hct, WBC, PT, PTT, INR Post Xray for component placement Medical Equipment PAS stockings or foot pumps 2L Foley Possible ace wrap for External and ace wrap/ace wrap or short cast with splint for internal ankle; ace wrap/ace wrap or long cast with splint for internal femur 28

29 Ankle, Femur or Pelvis Precautions/Contraindications NWB 4-6 weeks External fixator keep pins clean Some internal fixators will be removed in future 29

30 Ankle, Femur or Pelvis PT Eval Assess ROM and Strength above and below site Assess sensory Assess for edema PT POC – Ankle 1 day, femur/pelvis 3 days General mobility Stairs Assistive device Pt Ed: ROM above and below site, assistive device 30

31 ORIF Hip Meds Analgesics for Pain: Ocycodone, Percocet, Vicoden, Lortab OR Epidural Anticonstipation: Colace Antibiotics: Cefadroxil, Levafloxacine Antinausea: Zofran Labs/Diagnostics Hb, Hct, WBC, PT, PTT, INR Post Xray for component placement Medical Equipment PAS stockings or foot pumps 2L Foley 31

32 ORIF Hip Precautions/Contraindications Usually NWB, but sometimes TTWB, rarely PWB No hip precautions (fixators past the joint, however, following the hip precautions will be more comfortable for the patient) 32

33 ORIF Hip PT Eval – Screen ROM primarily at the knee due to hip pain Screen incision Screen Sensory Screen Muscle Strength General mobility of bed, transfers, gait For pt’s in traction waiting for surgery When is the surgery scheduled What is the pt’s cognition or pain level for pre-surgical education or exercise on non-fractured side, breathing exercises, relaxation for pain relief PT POC – 3 Days Similar to THA but usually less aggressive Exercise and Mobility If from a fall, many times pt is afraid of mobility Pt Ed: DVT prevention, swelling, precautions during fxnal activities 33

34 OTHER ORTHOPEDIC CONDITIONS 34

35 Pelvis Fx, Rib Fx, Gout, Osteomyelitis, Bunionectomy, Halo Meds Analgesics Antibiotics for osteomyolitis, halo Labs/Diagnostics Gout: uric acid Medical Equipment PAS stockings Possible O2 if needed Bedpan/urinal 35

36 Precautions/Contraindications All usually NWB weight bear status (except Halo) Bunionectomy surg boot with wt through heel Pelvic fx avoid prolonged sitting Rib fx Difficult if need of assistive device Guard/Splint for cough/sneeze Deep breathing per pt tolerance Watch placement of gait belt Halo Cleanliness of pins for Halo Eat in upright position for Halo May use wedge for supine for comfort Pelvis Fx, Rib Fx, Gout, Osteomyelitis, Bunionectomy, Halo 36

37 PT Eval Screen ROM and Strength Pain levels Bed mobility PT POC – Pending pain, lab results Breathing exercises Needed ROM Needed Strength bedside Tf NWB to sit in chair Use of assistive device Pelvis Fx, Rib Fx, Gout, Osteomyelitis, Bunionectomy, Halo 37

38 Orthopedic Considerations Weight Bearing Status WBAT/WBTT: wt bear as tolerated PWB: partial wt bear, usually 50% of body wt TTWB: toe touch wt bear, usually 10% of body wt or 10# of wt NWB: non wt bear, must hike hip or bend knee or both, may rest on floor but NWB once transferring Gait Training Focus on step length with step to and progress step through Focus on heel strike Focus on midstance to push off NWB focus on hip hike and knee flexion 38

39 TIA, CVA Occlusion, CVA Bleed Meds TIA/CVA Occlusion: anticoagulants heparin, coumadin, antiplatelet, aspirin, plavix CVA occlusion: TPA if within 24 hours CVA bleed: antihypertensives Labs/Diagnostics MRI/CT Scan (TEE, angiography, echo of heart, SPECT, chest xray for enlarged heart) TIA, CVA Occlusion: carotid doppler TIA: CBC, PT, PTT, INR, Immunoglobins, electrolytes, sediment rates, lipid profile Medical Equipment TIA/CVA IV, foley, 2L, PAS stockings, TED hose CVA bleed: May have ICP 39

40 TIA, CVA Occlusion, CVA Bleed Precautions/Contraindications Usually 24 hr bedrest BP usually still on the high side so not to drop BP too quickly Dependent position of the hemiparetic side Injury to the hemiparetic side 40

41 TIA, CVA Occlusion, CVA Bleed PT Eval Mental status/Cognition Screen ROM, strength Screen sensory Screen Reflexes, Tone Screen Coordination PT POC TIA 1 -2 days for general mobility CVA 3-5 days for general mobility, upright and sitting, standing gait, focus on above areas of need Think neuro, musculoskeletal, Cardiopulm, Integument 41

42 Aneurysm, Hydrocephalus, Brain Tumor, Craniotomy, Encepholopathy, TBI Meds Anticoagulants heparin, coumadin Antiplatelet, aspirin, plavix Antihypertensives Antiseizure Antispastic Antibiotics Meds for other systems impacted Labs/Diagnostics MRI/CT Scan CBC, PT, PTT, INR, Immunoglobins, electrolytes, sediment rates, lipid profile Medical Equipment IV, foley, 2L, PAS stockings, TED hose May have ICP or shunt 42

43 Aneurysm, Hydrocephalus, Brain Tumor, Craniotomy, Encepholopathy, TBI Precautions/Contraindications Shunt guided by symptoms of headache Seizure Precautions Helmet if open skull (sometimes skull in place in abdomen for later reattachment) Most will have head of bed at least elevation at all times 43

44 Aneurysm, Hydrocephalus, Brain Tumor, Craniotomy, Encepholopathy, TBI PT Eval Mental status/Cognition Screen ROM, strength Screen sensory Screen Reflexes, Tone Screen Coordination PT POC General mobility Upright and sitting, standing gait, focus on above areas of need Think neuro, musculoskeletal, Cardiopulm, Integument 44

45 Parkinsons, MS, GB Meds Parkinsons – Sinemet, deep brain stimulation, reason for admit MS – Interferons, muscle relaxants, antianalgesics, antidepressants GB – Respiratory, Cardiac, IgG, possible plasmapheresis Labs/Diagnostics Parkinsons – respiratory, cardiac, urinary so general blood tests and diagnostics, if for dx of parkinson perform neuro exam and may perform CT or MRI; any reason for admit MS – CSF, MRI, any reason in admit GB – CSF, CBC, EMG Medical Equipment Parkinsons – IV, O2 MS – IV, O2 GB – Vent, PAS stocking, TED hose, foley, O2, IV 45

46 Parkinsons, MS, GB Precautions/Contraindications Parkinsons Bradykinesia Swallow Respiratory Multiple Sclerosis Respiratory See in am Avoid overheating Guillian-Barre Respiratory Pain when recovering 46

47 Parkinsons, MS, GB PT Eval Mental status/Cognition Screen ROM, strength Screen sensory Screen Reflexes, Tone Screen Coordination PT POC General mobility Upright and sitting, standing gait, focus on above areas of need Think neuro, musculoskeletal, Cardiopulm, Integument 47

48 Spinal Cord Injury Meds Methylprenisone to reduce inflammation Labs/Diagnostics Xray, CT scan Non surgical: systems impacted Post surgical labs: Hb, Hct, PT, PTT, INR, WBC Medical Equipment IV Foley Possible vent for C3 or higher 48

49 Spinal Cord Injury Precautions/Contraindications Levels T6 or higher – autonomic dysreflexia Levels C6, C7 – watch stretch of finger extensors for tenodesis, and stretch of hamstrings for long sit stability Hypotension Use of belly binder, TED hose 49

50 Spinal Cord Injury PT Eval Mental status/Cognition Screen ROM, strength pending level of injury Screen sensory pending level of injury Screen Reflexes, Tone PT POC General bed mobility Sitting balance Slideboard transfers W/C skills Respiratory ROM and stretching Strength of levels above SCI 50


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