A PATIENT AND FAMILY GUIDE TO TOTAL HIP TOTAL KNEE AND TOTAL SHOULDER SURGERY Total Joint Replacement Created by Dottie Megnia, BSN, RN, CNOR, ONC.

A PATIENT AND FAMILY GUIDETO

TOTAL HIPTOTAL KNEE

ANDTOTAL SHOULDER SURGERY

Total Joint Replacement

Created by Dottie Megnia, BSN, RN, CNOR, ONC

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

Target Audience

TJR patient

Ideally two-four weeks before surgery

Arthritis

Osteoarthritis OA

Rheumatoid Arthritis

RA

Gout Traumatic Arthritis

Avascular necrosis

What Causes Arthritis

Heredity-recessive gene discovered

Generalized wear and tearInjury or accident (torn rotator cuff or anterior cruciate ligament)

Chronic steroid useAutoimmune diseasePrevious surgery

Arthritis

Worn or degenerated cartilage

Bone spursBone rubbing on boneEffusions

Synovial changes

Goal of Surgery

Relieve painRestore function and mobilityImprove quality of life

In the 1960’s goal was to relieve pain only

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

Saw Bones Demonstration

Sawbones are passed around and questions are encouraged-someone always asks about the weight of the prosthesis

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

aidsLeave jewelry and money at homePack a separate bag if you think you

are going to a rehab center

Preparing for Surgery cont…

Television and phone may be purchased together and billed to your home

Do NOT need pajamas, bathrobes, slippersWill wear hospital johnnies and skid free

slippersKeep it simpleMay bring cell phone but AT&T does not get

service on the orthopedic floorThose wishing to bring laptops may do so

Airport Security

Your new prosthesis will set off airport security

Leave extra time so you won’t missyour flight

Dental Prophylaxis

Let your dentist know about your new prosthesis

Antibiotic prophylaxis may be used for minor dental procedures such as cleanings

Prevention of Complications-Infection

Screening

Normal flora versus dangerous MRSA flora

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.

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.

Prevention of Late Infections

Antibiotic prophylax

is

Anytime there is danger that bacteria may enter the bloodstream and travel to your prosthesis. The body treats the prosthesis as a foreign body.

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

Constipation

Anesthesia

Pain Meds

Iron therapy

Immobility

Change in diet

Increase dietary fiber and/or metamucil and water.

Early assisted mobilization

Stool softeners Mild laxative

Post-operative pneumonia

Post-operative Nausea

Nausea and vomiting protocol (N/V)Best to eat a light meal on evening of surgeryCall your nurse at the first sign of N/V

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 analgesiaPre-op oral cocktail of oxycontin and

celebrex IV tylenol q. six hours ARC for 36

hours

New Oral Pain Cocktail

Oxycodone 5-10 mg BIDCelebrex 200 mg BIDOxycontin 5-10 mg PRN

Pain is better controlled with new oral pain cocktail versus patient-controlled analgesia (PCA)

Less post-operative N/V

Post-operative Pain Control

Total Knee Patients Total Shoulder Patients

Nerve Blocks

Femoral nerve blockSciatic nerve block Intrascalene nerve block

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 daysSciatic and Intrascalene are one time

injections that usually wear off anywhere from 12-18 hours

Prepare Your Home

Arrange for a recovery station and a first floor set-up with access to a bathroom

Prepare simple meals and freeze themRemove scatter rugs or tape downClear commonly used pathwaysMeasure height of toilets and beds for the

occupational therapistsDepending on your height, hip patients will need

a good chair with armsArrange for someone to be with your for the first

24 hours after discharge

Physical and Occupational Therapy

Continuous passive motion machine-CPM

PT and OT continued

ContinuumDay 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

Simple Exercises

Quad set

Ankle pumps

Gluteal set

Hip Precautions

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

Total Shoulder Rehab

Plan on button down shirts (large)

Front closing undergarments

Rehab is less aggressive in the beginning

Pendulum swings

Case Management

A case manager will also visit with you on day one after surgery to begin planning for your discharge

Home is bestA 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 stoneBest to have two or three options for

discharge

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 dayDischarged home when safe to

perform activities of daily livingArrangements will be made for home

or out-patient therapy upon discharge

Discharge to home

Physical therapist will visit within 24 hours

Including weekendsBy carDurable medical equipment Detailed discharge instructionsFollow-up appointments Prescriptions for pain medicines

Returning to Activity

Consider pool therapy after your incision is healedTake it to the gymMake exercise a part of your lifeTake care of your new jointBiking, golfing, swimming, and walking are encouragedAvoid high impact exercises such as running marathonsand mogul skiing Avoid the pounding impact of a treadmill Instead use softer surfaces such as high school track

Don’t do anything crazy!

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