Orthopedic & Neurological Patient Population

1. Orthopedic & Neurological Patient Population Med Surg II

2. TOTAL JOINT ARTHROPLASTIES

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 • O2 @ 2L • Foley • Hemovac • Knee immobilizer • CPM

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

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

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 • O2 @ 2L • Foley • Hemovac

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?

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

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

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

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 • O2 @ 2L • Foley • Hemovac • Shoulder immobilizer or a sling • CPM usually for home or OP

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

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

14. SPINAL SURGERIES

15. Microdiscectomy • Meds • Analgesics: Opiods of morphine, fentanyl; epidurals; oral meds NSAIDS or opiods • Antibiotics • Labs/Diagnostics • Hb, Hct, WBC • Medical Equipment • Foley • O2@ 2L • Ted Hose • PAS stockings • IV

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

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

18. Laminectomy with DiscectomySpinal Internal FixatorsSpinal 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 • O2@ 2L • Ted Hose • PAS stockings • IV

19. Laminectomy with DiscectomySpinal Internal FixatorsSpinal 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”

20. Laminectomy with DiscectomySpinal Internal FixatorsSpinal 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

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 • O2@ 2L • Ted Hose • PAS stockings • IV • Soft or hard collar

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

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

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

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 • O2 @ 2L • Foley • Possible ace wrap for External and ace wrap/ace wrap with splint for internal • May have sling

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

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

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 • O2 @ 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

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

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

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 • O2 @ 2L • Foley

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)

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

34. OTHER ORTHOPEDIC CONDITIONS

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

36. Pelvis Fx, Rib Fx, Gout, Osteomyelitis, Bunionectomy, Halo • 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

37. Pelvis Fx, Rib Fx, Gout, Osteomyelitis, Bunionectomy, Halo • 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

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

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, O2 @ 2L, PAS stockings, TED hose • CVA bleed: May have ICP

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

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

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, O2 @ 2L, PAS stockings, TED hose • May have ICP or shunt

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 30-45 elevation at all times

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

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

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

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

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

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

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