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JOINT REPLACEMENT PREOPERATIVE TEACHING

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Title: JOINT REPLACEMENT PREOPERATIVE TEACHING


1
JOINT REPLACEMENTPRE-OPERATIVE TEACHING
  • FOR THE
  • WHITE PLAINS HOSPITAL CENTER ORTHOPEDIC INSTITUTE
    PATIENTS

2
WELCOME
  • We have prepared the following to provide you
    with information to make your stay in our
    Orthopedic Institute more comfortable and to let
    you know beforehand, what you can expect during
    your stay.
  • Our goal is that all patients should have a very
    good experience while they are here.

3
  • Be sure your surgeon has fully explained the
    joint replacement procedure to you and has
    outlined all of the risks and alternatives. Make
    sure you know restrictions/precautions related to
    your procedure and the approximate duration of
    your recovery. Our presentation should help you
    with this.

4
  • Within 5 days of your surgery a blood testing
    procedure called a Type and Cross will need to
    be completed at White Plains Hospital. This is
    done in the Admissions Testing Department next to
    Admitting. No appointment is necessary. Just go
    to the Admitting Department and tell the
    receptionist what you are there to have done.

5
  • Also, your doctor should have had you stop taking
    blood thinners, anti-inflammatory, and aspirin
    products generally 7 days prior to surgery. Be
    sure to discuss this with your doctor.

6
Preparing to leave for the hospital
  • Discuss with your medical doctor which, if any,
    of your regular medications you should take
    before leaving for the hospital on the day of
    your surgery. Once taken, leave all medications
    at home. You will be given medications from the
    hospital while you are an in-patient here. Do
    not bring your own.
  • Remember to bring your medical history packet and
    your Medication Reconciliation pamphlet with you
    when you come to WPHC. Be sure youve put your
    name on it.

7
Pre-operative procedures
  • Pre-operatively, you will be given a surgical
    scrub. Use it as directed the night before and
    the morning of the surgery. This will help
    control bacteria prior to the surgery. This
    scrub will be given to you when you come for your
    pre-operative teaching class prior to surgery.
    (The instruction sheet for use can be found at
    the end of this presentation.)

8
  • To prevent infection, DO NOT shave or use
    depilatories on the surgical area. The surgical
    team will use clippers to remove hair just prior
    to surgery.
  • Remember you cannot drink or eat after midnight
    before surgery.

9
Understanding your admitting procedure
  • When you arrive at White Plains Hospital on the
    day of your surgery, GO DIRECTLY to the
    third-floor Ambulatory Surgery Department. The
    admissions process has been streamlined so you
    can by-pass the Admitting Department.

10
  • Once in this department, your nurse will escort
    you to the pre-operative holding area where you
    will change into a gown in preparation for your
    surgery.
  • Your nurse will provide and reinforce
    pre-operative teaching and you will be given the
    opportunity to have any questions answered.
  • As an added measure to prevent infection, the
    nurse will use a pre-treated wipe to cleanse the
    surgical area once again.

11
  • At this time, you should give your valuables to a
    family member/ accompanying friend for
    safekeeping.

12
  • From the holding area, you will be wheeled on a
    stretcher to the operating area.
  • Once you are wheeled to the operating room area,
    your family/significant others who have
    accompanied you for the surgery can wait in the
    3rd floor family waiting area. The doctor will
    come out to them once the surgery is completed to
    let them know your status. Generally, the
    surgery can be expected to last 1 to 2 hours.

13
  • Prior to your surgery, you will meet with the
    anesthesiologist, your surgeon, and the nurses
    involved in your surgery.
  • You will have an IV started for the
    administration of fluids and necessary
    intravenous medications.
  • The anesthesiologist will give you an antibiotic
    before the surgery.
  • The surgical team will take you to the operating
    room and they will go through a process of site
    verification to ensure that the correct procedure
    and site are identified.

14
  • Generally you will be given a spinal anesthesia
    to anesthetize your body from the waist down.
  • In addition to spinal anesthesia, patients having
    knee surgery may have a peripheral nerve block.
    If this applies to you, expect to have less leg
    control for about 24 hours. Youll need to wear
    a knee immobilizer when you get out of bed.

15
  • An anesthetic procedure called On-Q might be used
    in the period after your surgery to deliver local
    anesthesia to the nerves of the knee. This
    procedure helps with pain control in the area of
    the incision. Your anesthesiologist will discuss
    this if it is an option for you.

16
  • After the spinal anesthesia, you will be sedated
    for the surgery so you will not be awake for the
    surgical procedure.
  • The incisions that will be made are minimally
    invasive and are generally around three inches in
    length.

17
  • Once the procedure is completed, the surgeon will
    close the incision and you may have a drain
    placed into the surgical area. The drain will
    collect bloody drainage from the area. If it is
    felt that there is a large amount of bloody
    drainage, the drainage will be filtered and
    transfused back to you (auto-transfusion) to keep
    your blood volume up.

18
Post-operative/Recovery Room
  • After the surgery, you will arrive in the
    Recovery Room (Post Anesthesia Care Unit).
  • The Recovery Room nurses will monitor your vital
    signs and provide care and comfort measures until
    your anesthesia wears off. Let the nurse know if
    you are experiencing nausea or pain.
  • You can expect to be transferred to your room
    after you have re-gained sensation and movement
    in your legs.

19
Pain Control after your surgery and during your
hospital stay
  • Starting in the immediate postoperative period
    and continuing throughout the day, the nursing
    staff will use a Pain Assessment Tool to evaluate
    your level of pain or discomfort. This will
    generally be a scale of 0-10.

20
(No Transcript)
21
  • Once a level of pain or discomfort has been
    determined, the nurses providing your care will
    refer to the doctors orders for pain
    medications. They will administer the appropriate
    pain control medication to you.
  • It is our goal to help you achieve a tolerable
    and functional pain level.
  • It is your responsibility to inform the nurse if
    the pain control is not effective.

22
  • You may also have an ice pack machine or ice bag
    applied to your operative joint to assist in
    controlling swelling and pain of the joint and
    surrounding area. Frequent use of an ice pack is
    helpful for pain control throughout your stay.
    Speak-up so staff can provide this as needed.

23
  • For your safety, the hospital has implemented a
    bar code scanning system for medication
    administration. On admission you will be given a
    bar coded bracelet. Whenever you are given
    medication, the nurse will scan both your
    bracelet and the medication.
  • If you have questions, we encourage you to speak
    up and ask the nurse.

24
  • You will receive an anti-coagulant to reduce the
    chance of blood clots forming in your legs.
  • If it has been ordered by your doctor, you will
    be instructed in how to self-administer the
    anti-coagulant upon discharge.

25
Post-Operative Care-continued
  • In the post-operative period you will have
    light-weight leg wraps called SCDs (sequential
    compression devices) placed on your legs. You are
    also encouraged to do the ankle pumping exercises
    throughout your stay and after. These will assist
    in diminishing your chances of having a problem
    with blood clots in your legs in the
    postoperative period.

26
Incentive Spirometry
  • After the surgery, you will need to actively work
    on breathing deeply.
  • As a tool to help you with this deep breathing,
    you will be given an incentive spirometer. This
    is a tube with a mouth piece attached to a casing
    with a small ball inside.

27
  • As you inhale through the mouthpiece, you should
    try to have the ball lift up in the tube and keep
    it up for as long as possible.
  • When you use the incentive spirometer, you should
    take long, slow breaths. Be sure to concentrate
    on breathing in deeply and directing air to the
    base of your lungs.

28
  • You should be able to feel the bottom of your rib
    cage expand outwardly in all directions if you
    are doing this correctly.
  • It is important to do not only deep breathing,
    but to also cough up any phlegm that may be in
    your airways. You can help avoid having
    respiratory problems after the surgery if you
    follow these guidelines.

29
Your Arrival on 4I-the Orthopedic Unit
  • Your room set-up on 4I will include
  • Phone availability (at a small charge)
  • TV availability (at a small charge-and run by an
    outside company)
  • There will be a trapeze placed over the bed for
    you to use in positioning yourself

30
  • A special orthopedic chair will be at your
    bedside for sitting.
  • A raised commode will be in the room to keep you
    at the proper height to protect your newly
    replaced joint.
  • As part of providing very good care during your
    stay on 4I, the staff will do hourly rounding to
    ensure that your needs are met.

31
You will be provided with our Joints are made
for Walking race track to record your progress.
  • Your Joints are Made for Walking

START
FINISH
32
  • Visiting hours are from 800am to 900pm. If
    friends and family are ill, request that they not
    visit.
  • We encourage family members to be involved in
    patient care in collaboration with the hospital
    staff caring for the patient.

33
An Orthopedic Unit Room,the Dining Area and the
Gym
34
Good Hygiene Preventing infections is important !
  • After your surgery, the 4I staff will provide you
    with a liquid hand-sanitizer to enable you to
    clean your hands when you are in the bed. Once
    you are able, you can clean your hands at the
    sink.
  • There is hand sanitizing foam at the doorway of
    each room. Caregivers should use this prior to
    rendering care. Speak up if your
    caregivers forget.

35
Good Hygiene Continued..
  • Ask visitors from the outside not to sit on your
    bed.
  • Ask visitors not to use your hospital bathroom.
    There are public restrooms for visitors use.
  • If the dressing is not intact, ask the nurse to
    reinforce it.

36
Activity
  • You can expect to be assisted out of bed by the
    physical therapist on post-op day one, generally
    by noon time. If for some reason you are not out
    of bed and sitting in your chair by noon, you
    must let your nurse know. Your nurse will check
    with the rehabilitation department to determine
    when the therapist will make the first PT visit.

37
  • On subsequent days, the nurse/nursing tech will
    assist you out of bed in the morning and have you
    ready for your morning therapy session. The 4I
    staff will bring you to the gym at the time
    designated for your therapy.
  • We expect that you will be out of bed walking
    with therapy or the nursing staff at least 4
    times a day to aid in your recovery.

38
Rehabilitation
  • The first day after your surgery, you will be
    seen by the Physical Therapist. The therapist
    will evaluate how you are functioning and will
    get you out of bed. Depending on how you are
    moving, you will be assisted to the chair at your
    bedside or you may walk a short distance before
    returning to your chair.

39
  • You will remain seated out of bed for part of the
    morning-a minimum of an hour is the goal.
  • In the afternoon, the therapist will return and
    have you do exercises and walk again.

40
Post-operative days 2 3
  • On the second and third post-operative days, the
    physical therapist will see you in the 4I Gym
    area in the morning where you will do exercises
    and walking. This session will include stair
    climbing on the 3rd day, if not sooner.
  • In the afternoon, the therapist will see you for
    another session of walking and/or exercises.

41
  • In addition to walking and exercises, your
    therapy sessions will include instruction and
    practice in
  • getting in and out of bed
  • getting up and down to/from a chair
  • getting in and out of a shower
  • using special equipment for dressing and reaching
    while maintaining hip precautions

42
Further post-operative days
  • It is anticipated that you will be discharged on
    the 3rd postoperative day. If you need to stay
    longer for medical reasons, then on the fourth
    post-operative day, the therapy frequency will
    become once daily, and will remain as such,
    unless your medical status dictates otherwise.
  • These sessions will include exercises and/or
    ambulation as indicated by your need.

43
Precautions to observe if you are having a Total
Hip Replacement (to minimize the risk of
dislocating your hip)
  • DO NOT bend the operative hip more than 90
    .
  • DO NOT rotate the operative leg inward. As you
    lie in bed, the toes should remain pointing up
    toward the ceiling or rotated outward slightly.
    They should not rotate inward toward each other.
  • Keep the legs apart. DO NOT cross your legs.

44
  • Further hip precautions to observe after
  • Hip Replacement surgery are
  • 1. You must avoid twisting your body around
    either while in the bed, in your chair, or while
    standing. Position items close to you in bed or
    in the chair so you can avoid reaching or
    twisting to get them.
  • 2. You will need to avoid leaning forward when
    seated in a chair.

45
  • 3. To turn while walking with the walker, turn
    incrementally. Place the walker a little to the
    side and move your feet in small steps in the
    direction of the walker. Keep repeating this
    until you are turned around. Avoid pivoting
    around on your operative hip.

46
  • 4. Sit in a firm, upright chair with a pillow or
    extra cushion to raise the height of the seat. A
    chair with armrests is suggested. DO NOT sit on a
    soft or low chair.
  • 5. Use a raised toilet seat or place a raised
    commode directly over the toilet. DO NOT sit on a
    standard height toilet.

47
  • 6. You must avoid bending at the operative hip
    and using your hands to pick items up off the
    floor.
  • Use a reacher to pick up light items, or ask for
    assistance.

48
  • 7. You must use adaptive equipment to dress your
    lower body.
  • Use a sock aid to put on your socks.
  • Use a dressing stick or reacher to put on your
    underpants and slacks.
  • Use elastic shoelaces for your shoes or use
    slip-on loafer style shoes with a back to them.
  • Use a long handled shoe horn to put on your shoes.

49
  • 8. You must use adaptive equipment to wash your
    lower body.
  • Use a long handled sponge or back scrubber to
    wash below your knees.

50
  • 9. You may not shower until the staples are out
    and your doctor has given permission.
  • Hold on to a safety bar in order to enter the
    bath tub for showering. Step over side of tub
    by bending your knee up behind you to clear the
    tub side. (Do not bend at the hip). Straighten
    knee once it has cleared the tub side. You will
    only be able to shower.
  • You must not sit down in the tub. A bath seat for
    ease of showering may be recommended by your
    therapist.

51
  • 10. You will not enter a car as you did before
    your surgery. As a passenger
  • Sit in the front passenger seat.
  • Have the car seat positioned as far back and as
    high as possible. You may place 1-2 pillows on
    the seat if needed.
  • Open the passenger car door as wide as possible.
  • Using walker/crutches walk up to car door, then,
    turn facing away from the car and back up to car
    seat. Place one hand on dashboard or car door
    and the other on the seat back. Sit slowly.
    With legs separated, pivot onto the seat.

52
  • 11. For kitchen tasks, keep the following in
    mind
  • Place all items used frequently in storage areas
    from hip level to any easy reach above your
    chest.
  • Sidestep along counter top, keeping walker or
    crutches within reach.
  • Use a walker basket or the counter top to
    transport items.
  • To reach lower surfaces, extend operated leg
    behind you as you bend at your waist.

53
If you are having a Total Knee Replacement-
  • Your surgeon may order a CPM or Continuous
    Passive Motion machine to be used on your
    operative knee. This is a machine that will
    gently move your leg through an easy range of
    motion. If ordered, it will be used 1 to 3 hours
    daily from the day it is ordered. The therapist
    will set it up on the first day of use. The
    nursing staff will set it up thereafter.

54
Walking Devices
  • Generally patients who have had total joint
    replacements will begin ambulating with a walker.
    They may progress to using crutches before
    discharge.
  • Stair climbing is taught using 2 rails and
    progressing to a railing and cane/crutches.

55
  • If you are being discharged home, discuss
    concerns of your home environment with your
    therapist.

56
Safety Tips
  • Do a safety check of your home before you come to
    the hospital
  • Remove potential hazards like throw rugs and
    electrical cords from the floor area.
  • Have a clear path from your bedroom to your
    bathroom.
  • Have a sturdy chair with arms and a firm seat
    available for your use.

57
Safety Tips Continued-
  • Place items that you use often within easy reach
    of the chair.
  • If you have a commode, raised toilet seat, or tub
    bench at home, check that the equipment is in
    good condition.
  • If you have crutches or a walker at home, check
    that the equipment is in good condition.

58
Items to bring for your stay
  • Under shorts/underpants, and if desired, loose
    fitted clothing such as shorts, T-shirts, sweats,
    pajamas or short bathrobe
  • Eyeglasses, hearing aids, if used
  • Any braces or orthotics you normally use
  • Personal toiletries
  • Shoes and sweat suit/loose fitting clothes for
    going home-these can be brought in at a later
    date
  • Leave valuables home

59
  • If you have any further questions about therapy,
    call the
  • White Plains Hospital Center
  • Physical Medicine Department at
  • (914) 681-2430

60
  • For Outpatient Physical Therapy before or after
    your surgery, consider our
  • expertly staffed White Plains Hospital
  • Physical Therapy Center at Rye Brook
  • 111 South Ridge Street, Rye Brook, NY
  • (Across from the Rye Ridge Shopping Center)
  • (914) 681-1116

61
Discharge Planning
  • We expect your length-of-stay in the hospital
    will be 3 days or less.
  • Once you have had your surgery, the staff
    responsible for discharge planning will begin to
    make arrangements for your discharge.

62
Discharge Plan
  • The discharge plan is formulated based on the
    following factors
  • -your post-operative medical status
  • -how mobile you are around the time of
    discharge and whether you have anyone who can
    assist you at home
  • -your insurance and financial considerations

63
Discharge Plan Insurance Considerations
  • The discharge process is heavily dependent on
    what arrangements your insurance company agrees
    to cover. Some insurance companies rule out some
    of the discharge options.

64
Discharge Plan Insurance Considerations
cont.
  • Prior to your admission you should familiarize
    yourself with your own insurance benefits related
    to discharge options.
  • Be aware that the customer service
    representatives you contact by phone do not
    always give the accurate discharge options.
    These are decided by the insurance company case
    manager assigned to your admission once you are a
    patient and are based on your level of
    functioning.

65
Discharge Options
  • The options may include
  • Returning home with Home Care services being
    provided by a Certified Home Health Agency.
  • Going to a facility for sub-acute physical
    therapy services. This is generally a service
    offered in a nursing facility that has beds set
    aside for short-term rehabilitation.
  • Going to a rehabilitation center.
  • Going home with out-patient therapy.

66
Discharge Considerations
  • Many people are functioning well enough after
    their hospital stay to go home. Home care
    services would start the next day after you
    return home. These would include physical
    therapy, a nurse if indicated, occupational
    therapy, if indicated, and some home health aid
    hours if needed.
  • Alternatively, you could go home and receive
    therapy on an out-patient basis.

67
Discharge Considerations Continued..
  • Sub-acute rehabilitation is less demanding than
    the therapy in a rehabilitation center. Generally
    there will be one daily physical therapy and one
    daily occupational therapy session 5-7 days per
    week, depending on the facility. Some facilities
    upon patient assessment may provide more
    sessions.
  • Therapy at a rehabilitation center will involve
    more extensive and intense therapy sessions.

68
Discharge Considerations Continued..
  • For any facility transfer, patients must be
    screened for eligibility and approved by the
    receiving facility.

69

Final Discharge-
  • The discharge planner submits the required
    information to your insurance case manager in
    order to obtain authorization to cover your
    discharge plan option.
  • The discharge planner at White Plains Hospital
    will advocate for the plan developed by the team.
    However, our staff can only work within the
    constraints of what your insurance company,
    represented by your case manager, will approve.

70
Post Discharge Concerns
  • Signs and symptoms to be concerned about are
  • Fever
  • Redness
  • Increased swelling
  • Calf pain
  • Drainage from your incision
  • Trouble breathing
  • Call your physician if you have any of these or
    other unusual symptoms.

71
  • Avoid driving until cleared by your surgeon.
  • If you travel by plane or cruise ship, remember
    that your new joint may set off the security
    alarms. Allow extra time to get through security.

72
Long term issues after joint replacement
  • After you have had joint replacement surgery, you
    will need antibiotic prophylaxis (prevention)
    for any dental work-even cleaning. Ask your
    physician for a prescription and coordinate this
    with your dentist.
  • Your surgeon may suggest antibiotic prophylaxis
    for other times when infection prevention is
    important. Ask about this.

73
  • If you are experiencing symptoms and seek medical
    attention for an infection (i.e. a urinary tract
    infection or infected wound), be sure to remind
    the attending doctor that you have had a joint
    replacement.
  • Each time you go to a new physician, make them
    aware of your joint replacement.

74
Pain management at home
  • Use your prescribed medication as directed. If
    pain is not relieved, speak with your doctor.
  • As pain diminishes, try decreasing your pain
    medication.
  • Pain medication becomes effective about 20
    minutes after taking it. Plan ahead so the
    medication will have taken effect by the time you
    need it.

75
  • Pain medications can be constipating. Drink
    plenty of liquids and eat high- fiber foods
    (fresh fruits and vegetables) to avoid a problem.
  • You can continue to use ice packs for pain
    management.

76
  • If you will not be able to tell others that
    your stay at White Plains Hospital Center was
    VERY GOOD, please speak to us about it before you
    leave. We are continually trying to improve our
    program and would very much appreciate your input
    on how we could make it better.

77
  • We hope this information has been helpful. It is
    meant as an overview of what your hospital stay
    will entail. The staff will be going through
    the process with you step by step upon your
    arrival and will answer your questions as you go
    along.
  • If you need further information about what to
    expect, you can call Carol Smullen, RN, ONC, at
    681-2259.

Prepared by Wendy C.Busch, M.S., PT and Anila
George, MSPT Contributions by Carol Smullen, RN,
ONC Betty Leung, RN, MSN, ONC Sally Tortora,
RN, ONC Janet Gaynor, RN Maria Hood, CSW and
other members of the following Discharge
Planning/Social Services Dept. , PACU, PMR
Dept., Orthopedic Institute Committee members.
78
  • WHITE PLAINS HOSPITAL
  • Pre-Surgical Testing-Surgical Site Skin
    Antisepsis
  • Information Sheet-
  • ADULT PATIENTS ONLY
  • It has been proven by the Centers of Disease
    Control that washing the surgical site area with
    an antiseptic antimicrobial solution (Hibiclens)
    the night before, and the morning of surgery, is
    extremely important to promote good patient
    outcomes.
  • White Plains Hospital Center is committed to
    providing you with every opportunity to have a
    safe and speedy recovery from your surgery. In
    an effort to do just that, we are supplying you
    with two 15 ml. Packets of Hibiclens.
  • Please follow the directions below.
  • Shower both the evening before and the morning of
    surgery with Hibiclens
  • Using a freshly laundered washcloth, shower with
    warm water from the neck down.
  • Rinse the washcloth with warm water.
  • Apply a small amount of Hibiclens to the
    washcloth with warm water and then squeeze the
    cloth until it becomes sudsy.
  • Wash from the neck down.
  • Rinse the area and the washcloth with warm water.
  • Re-apply a small amount of Hibiclens to the
    washcloth with warm water and then squeeze the
    cloth until it becomes sudsy.
  • Again, wash from the neck down and rinse
    thoroughly.
  • Allow to air dry or, if necessary, gently pat dry
    with a clean towel.

79
Hibiclens use continued
  • Following each preoperative shower
  • The skin should be thoroughly rinsed
  • Dry the with a fresh clean dry towel
  • You should don clean clothing.
  • If you are allergic to Chlorhexidine (Hibiclens)
    or any other soap preparation- DO NOT PERFORM THE
    WASH OF THE SURGICAL SITE AREA.
  • If you have a history of any skin condition such
    as eczema, psoriasis, contact dermatitis, etc.-DO
    NOT PERFORM THE WASH OF THE SURGICAL SITE AREA.
  • Caution should be exercised to avoid Hibiclens
    contact with the eyes, inside the ears or other
    mucus membranes.
  • (If you have been unable to pick up your packets
    from the hospital, you should be able to obtain
    Hibiclens from your local drug store. You will
    need only 2 ounces. Speak to the pharmacist if
    you have trouble locating it.)
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