JOINT REPLACEMENT PREOPERATIVE TEACHING

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JOINT REPLACEMENTPRE-OPERATIVE TEACHING

• FOR THE
• WHITE PLAINS HOSPITAL CENTER ORTHOPEDIC INSTITUTE
  PATIENTS

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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.

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• 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.

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• 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.

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• 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.

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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.

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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.)

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• 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.

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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.

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• 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.

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

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• 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.

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• 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.

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• 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.

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• 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.

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• 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.

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• 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.

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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.

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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.

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• 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.

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• 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.

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• 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.

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• 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.

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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.

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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.

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• 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.

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• 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.

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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

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• 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.

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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
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• 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.

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An Orthopedic Unit Room,the Dining Area and the
Gym
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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.

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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.

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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.

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• 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.

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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.

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• 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.

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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.

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• 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

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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.

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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.

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• 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.

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• 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.

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• 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.

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• 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.

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• 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.

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

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• 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.

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• 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.

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• 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.

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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.

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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.

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

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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.

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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.

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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

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• If you have any further questions about therapy,
  call the
• White Plains Hospital Center
• Physical Medicine Department at
• [phone]

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• 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)
• [phone]

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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.

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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

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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.

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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.

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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.

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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.

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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.

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Discharge Considerations Continued..

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

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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.

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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.

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• 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.

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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.

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• 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.

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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.

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• 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.

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• 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.

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• 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.
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• 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.

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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.)