Total Joint Replacement

1. Total Joint Replacement A patient and family guide To Total hip Total knee And Total shoulder surgery 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

3. Target Audience Ideally two-four weeks before surgery

4. Arthritis

5. 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 Bone rubbing on bone Bone spurs

7. Goal of Surgery • Relieve pain • Restore function and mobility • Improve quality of life 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 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

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

12. Airport Security Your new prosthesis will set off airport security Leave extra time so you won’t miss your flight

13. Dental Prophylaxis Let your dentist know about your new prosthesis Antibiotic prophylaxis may be used for minor dental procedures such as cleanings

14. Prevention of Complications-Infection Screening Normal flora versus dangerous MRSA flora

15. Surgical Site Infection (SSI) Antibiotics will be given through your intravenous within one hour of your incision. 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.

17. Prevention of Late Infections 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

19. Constipation Change in diet Early assisted mobilization Stool softeners Mild laxative Increase dietary fiber and/or metamucil and water.

20. Post-operative pneumonia

21. Post-operative Nausea 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

25. Nerve Blocks Total Knee Patients Total Shoulder Patients 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 12-18 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 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

30. Simple Exercises Ankle pumps Quad set Gluteal set

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

32. 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

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

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

36. Returning to Activity 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 Don’t do anything crazy!

37. References • Antibiotic prophylaxis for dental patients with total joint replacements (2003). Retrieved August 15, 2011 from http://jada.ada.org/content/134/7/895.full • 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 shutterstock.com