best practice in elderly orthopedic...
TRANSCRIPT
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Best practice in Elderly
Orthopedic patients
ผศ.นพ.วราห ยนยงววฒน
ภาควชาศลยศาสตรออรโธปดกสและกายภาพบ าบด
คณะแพทยศาสตร มหาวทยาลยสงขลานครทร พว. ธญลกษณ ณรงคกล
หอผ ปวยศลยกรรมกระดกและขอหญง
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Introduction
Common elderly problem
◦ Hip fracture
◦ OA hip and knee
Scope
◦ Disease information
◦ Treatment
◦ Nursing care
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Hip fracture
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Hip fracture
Fracture neck of femur
Intertrochanteric fracture
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Epidemiology
250,000 Hip fractures annually in USA
◦ Expected to double by 2050
At risk populations ◦ Elderly: poor balance&vision, osteoporosis, inactivity,
medications, malnutrition
incidence doubles with each decade beyond age 50
◦ higher in white population
◦ Other factors: smokers, small body size, excessive
caffeine & ETOH
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Hip fracture incidence
Melton et al. Calcif Tissue Int 1987; 41:57
500
1000
1400
40 50 60 70 80
500
1000
1400
40 50 60 70 80
Femoral Neck
Men Women
Femoral Neck
Intertrochanteric Intertrochanteri
c
Inci
dence
per
100,0
00 p
ers
on
-years
Age (years) Age (years)
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Cause
Most hip fractures occur in elderly result
of minimal trauma
- a fall from standing height
Prevent by environment prepared
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Neck femur & Intertrochanteric
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Clinical presentation
History
thigh or groin pain.
unable to ambulate. some cases may be able to walk.
(Nondisplaced or impacted fractures)
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Physical examination
Observation
Posture
Shortening and rotation of the lower extremity
Skin and soft tissue
Swelling
Ecchymosed(Intertroch fracture)
Range of motion
Limited range of motion due to pain
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Investigation
Plain -ray
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Fracture neck of femur
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Fracture neck of femur
Normal x-ray Fracture
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Intertrochanteric fracture
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Intertrochanteric fracture
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Loss of
function
50%
Mortality
20%
Regained
functional
capacity
30%
Sernbo 1993
Outcome after hip fracture
The situation one year after fracture
Sernbo et al. Osteoporos Int. 1993; 3:148-53
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Outcome
mortality rate of hip fractures is 15-20%,
increase to 36% over the year of fracture
Rate of mortality is greatest in the first
few months following injury
(remains high for 1 year)
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Outcome
Mobidity
- Morbidity from immobilization
- Morbidity from surgical procedures
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Outcome
Morbidity from immobilization
- deep vein thrombosis
- pulmonary embolism
- pneumonia
- muscular deconditioning
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Outcome
. Morbidity from surgical procedures
- complications of anesthesia
- postoperative infection
- loss of fixation
- malunion or nonunion
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Treatment
Goals of treatment of a hip fracture
reducing mortality early ambulation as
soon as possible
return the patient to walking
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Treatment
Pre-operative Considerations Surgical Timing
- Surgical delay
Increased mortality, complications,
length of stay
- If delayed > 2 days , have a 17% higher mortality rate at 1 month.
◦ If patient unstable --> Can delay surgery up to 72 hours
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Treatment
Phase of treatment
Initial treatment
Definite treatment
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Initial treatment
Goal
-Supportive pain
-Prevent complication before definite treatment
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Initial treatment
Supportive pain
Immobilization
Analgesic
Prevent complication
Pressure sore
Pneumonia
Urinary tract infection
Deep vein thrombosis/Pulmonary embolism
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Immobilization
Skin traction
Pillow
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Definite treatment
Surgery
-Main treatment
Non operative treatment
-Patient who excessively high risk for
operation(extremely medical condition)
-Non ambulate patient who have minimal comfort from fracture
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Non operative treatment
Traction non displace fracture
Early mobilization
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Fracture neck of femur
Surgery
Internal fixation
- Non displace fracture
Prosthetic replacement - Displacement fracture in elderly (Avoid chance for further surgery)
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61 years : Neck impact fracture
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80 years : Neck total displace
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Intertrochanteric fracture
Easy to union internal fixation
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Complication
Pressure sore
Pneumonia
Deep vein thrombosis/Pulmonary embolism
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Pressure sore
Prevention
-Adequate analgesia
-Frequence change position
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Pneumonia
Prevention
Upright as tolerate
Breathing exercise
Triflow
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Deep vein thrombosis/Pulmonary embolism
Prevention
Calve exercise
Pneumatic pump
Medical prevention
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Post op complication
Wound care
Early ambulation
Avoid hip dislocation
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Nursing care
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Nursing care : Hip fracture
1.Pre operative 2.Post operative 3.Pre-discharge
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Pre operative
History ประวตการใชยา การพลดตกหกลม ภาวะเสยงดานตางๆ
โรคประจ าตว
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Pre operative
ประเมนความรความเขาใจและความพรอมดานรางกายกอนผาตด
ประเมนดานจต สงคม Care giver
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Pre operative
ประเมนผล Lab เบองตน : ◦ CBC ◦ Blood chemistry ◦ UA ◦ EKG ◦ CXR
การใหความร สอนและค าแนะน าการปฏบตตวกอนและหลงผาตด
informed consent
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Pre operative
Acess pain
◦ NRS, VAS ,Face pain scale
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Pre operative
การดแลผปวยกอนการผาตด
◦ ปองกนผลแทรกซอนจากการนอน
◦ เสรมสรางความแขงแรงของกลามเนอ
◦ ดแลอปกรณทผปวยใช
Skin traction
Pneumatic calve compression
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Prevention of DVT
Nonphrmacologic prophylaxis
General Preventive Measures
- adequate pain control
- elevation of the foot
- early mobilization and rehabilitation
Mechanical Prophylaxis
- pneumatic compression boots
- plantar foot compression devices
- elastic compression stockings
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เครองบบไลเลอดเปนจงหวะ ( Intermittent pneumatic compression )
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Pneumatic compression
• 1. ตวเครองท าหนาทสบลม
• 2.ปลอกขา
เพมความความเรวในการไหลกลบของหลอดเลอดด าและลดการคง
ของเลอดในหลอดเลอดด าบรเวณขา
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Pharmacologic Prophylaxis
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เฝาระวง
• เพมภาวะเลอดออกงาย • ภาวะทเกดขนเมอรางกายไดรบสงแปลกปลอม/ ภาวะตอบสนองไวเกนของรางกาย (Hypersensitivity )
• การตกเลอดในผสงอาย (> 80 ป) • ไตท าหนาทลดลง (ปรบขนาดยา) • ภาวะทรางกายมเกลดเลอด (platelets) ตากวาปกต < 140,000 cells/cu.mm.) (Thrombocytopenia)
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สงทไมควรปฏบต
- หามฉด I.M.
- หามฉด หากยามการเปลยนสหรอ ผลตภณฑฉกขาด - หามไลฟองอากาศออก หรอดดอากาศเขาไป เพราะอาจมยาบางสวนสญหาย
-หามถหรอ คลงบรเวณทฉด เพราะจะท าใหเกดรอยช าหรอ bleeding
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Pre operative
◦ ปองกนผลแทรกซอนจากการนอนนาน
Upright as tolerate
Triflow
Deep Breathing
Effective cough
Bed sore prevention protocol
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Pre operative
เสรมสรางความแขงแรงของกลามเนอ
◦ กลามเนอสวนบน
◦ กลามเนอตนขาและขอเทา
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Pre operative
Skin traction
หลกการ Traction
-Couter traction -Friction -Continuous traction -Line of pull -Position
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Pre operative : skin traction
-Effective Traction -ปองกนผลแทรกซอน skin traction
-ดานจตใจ อารมณและสงคม -ลดอาการปวด
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Pre operative
การปองกนการ Delirium
•S-Stress reduction
•M-Keep Memory
•R-Recall event
•T-Time and date orientation and
•Pain control
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Post op hip fracture
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Post operative hip surgery
Complication -Complication from anesthesia
-Bleeding/Shock -Pain management -Wound infect -DVT -Pulmonary embolism -Pneumonia
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Post operative hip surgery
Evaluate
◦ Vital sign
◦ Sedation score
◦ Bleeding แผลผาตด
Content RD < 200 ml
off drain 24-48 hr post op
◦ DVT, PE
◦ Neurovascular status
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Post operative hip surgery
Acess Venous Thombosis and Thrombophebitis
อาการเรมแรกของการเกดภาวะกอนเลอดอดตน ◦ อาการปวด ◦ บวม ◦ อณหภม ◦ ความผดปกตของสผวและเลบเทา ◦ ประเมนชพจรขา 2 ขางความรสก และการเคลอนไหวเคลอนไหวของขาทก 2hr
**ถามอาการกดเจบทนอง/ขาหนบ และมอาการบวมรบรายงานแพทยทนท**
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Post operative hip surgery
Position
หลงการผาตด THA : นอนหงายขาขางทท าผาตดกางออกประมาณ 15-20 องศาปลายเทาตงตรงไมบดเขาหรอออกอาจใชหมอนวางกนระหวางขากไดไมงอสะโพกเกน 90 องศา
Foley’s catheter :เอาออกภายใน 24 ชม.
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Post operative hip surgery
Walk with support
◦ 1-2 วนหลงการผาตด
◦ Walker
Exercise ◦ ท าไดทนททออกจากหองผาตด
◦ Quadricep exercie
◦ Ankle pump
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Pre discharge
รวมกบทมสหสาขาวชาชพ
ประเมนการดแลตอเนองทบานตนเอง care giver แหลงประโยชน
สภาพครอบครว
ประเมนความเสยงตอการเกดภาวะแทรกซอน/ การกลบเขารกษาซ า
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Pre discharge
ประเมนดานจตใจ สงคมและเศรษฐกจ การสงตอหนวยงานทเกยวของหรอแหลงประโยชน
ตดตามอาการผปวยทางโทรศพท
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Pre discharge ใหค าแนะน า
◦ ยา,การดแลแผล,อาหาร
◦ Exercise , การเดน :Walker
◦ Risk for infection
◦ Risk for trauma: falls
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Pre discharge
ใหค าแนะน า ◦ การนงยองๆ
◦ การคกเขา
◦ การยกของหนก
◦ การเดนบนพนทขรขระ
◦ นงพบเพยบ/นงขดสมาธ
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Pre discharge
ใหค าแนะน า อาการทตองมาพบแพทยกอนนด ◦ แผลบวม แดงรอน ม discharge
◦ มไข
◦ ขาสนลงกวาปกต
◦ ขาบวมมาก
◦ ลนลม
◦ ขอสะโพกเทยมเคลอนหลด
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Pre discharge
การเตรยมสถานท
-แสงสวางเพยงพอ -ก าจดสงกดขวาง -พนไมลน -มราวจบ
-หองน า
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Osteoarthritis
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Osteoarthritis (OA)
Slowly evolving disease of articular cartilage
degeneration
More than 75% of person over 75 years of age
show radiographic evidence of the OA
•Howell D,Treadwell DV,Tripple SB,Upjohn, 1983
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Etiology of Osteoarthritis
Multifactorial
Primary or idiopathic OA
: not known cause
Secondary OA
: injury, infection, hereditary, developmental,
metabolic, neurologic
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Risk factor
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Risk factor
Obesity
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Risk factor
Aging
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Risk factor
Activity
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Risk factor
Prior injury
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Clinical features of OA
Symptoms ◦ joint pain
Pain on motion(early) Pain at rest (later) Pain aggravated by prolong activity, relieve by rest
◦ joint instability or bulking
◦ loss of function
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Signs
Localized tenderness Crepitus an cracking on motion
Mild joint enlargement with firm
consistency from proliferation of bone and cartilage
Synovitis(less common) Gross deformity(later)
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Knee osteoarthritis
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Normal knee joint
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Knee Joint: Synovial Joint
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OA knee
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Investigation
X-ray
joint space narrowing
osteophytes
sclerosis
Subchrondral bone cyst
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Treatment
Non surgery
- Weight reduction
- Life style modification
- Exercise
- Brace
- Medication
Surgery
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Surgical treatment
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Surgical treatment
◦ Treatment in patient who fail conservative
treatment
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Joint replacement
- Partial replacement - Total replacement
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Partial repalcement
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Unicondylar knee arthroplasty
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Total knee replacement
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Total knee replacement
Good candidate ◦ Old age (>60 year old)
◦ All compartment OA ◦ Limit range of motion
◦ Gouty arthritis / Rheumatoid arthritis
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Total knee replacement
PSU : 200 TKA / year
Hospital stay 3-5 day
Walk post-op day 1-2
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Nursing care : TKA
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Nursing care: TKA
1.Pre operative 2.Post operative 3.Pre-discharge
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Pre operative
การตรวจซกประวตและตรวจรางกาย
ประวตการใชยา การพลดตกหกลม
ภาวะเสยงดานตางๆ
โรคประจ าตว
ประเมนแหลงตดเชอในรางกาย:ฟนผ เหงอกอกเสบ
สภาพผวหนงทเขาทจะผาตด
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Pre operative
ประเมนความรความเขาใจและความพรอมดานรางกายกอนผาตด
ประเมนสภาพแวดลอมทบานเพอปรบใหเหมาะสม การใหความร สอนและค าแนะน าการปฏบตตวกอนและหลงผาตดปฏบตตว
ประเมนผล Lab เตรยมพรอมเพอการผาตด ,EKG informed consent
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Post op TKA
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Post operative
-Complication SB/GA
-Bleed/Shock
-Pain management -ประคบ cold pack
-Position :บนหมอน วางตรง สนเทาลอย -Prevent complication
:Wound ,Pneumonia, UTI
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Post operative การประเมน Deep vein thrombosis ◦ ประเมนบวม ตง อณหภมบรเวณขาขางทผาตด ◦ อาการปวด กดเจบทนอง ชา ◦ ประเมน pulse ขา 2 ขาง
สงสยภาวะ Fat Embolism ◦ เหนอย แนนหนาอก ◦ Pulse เรว ◦ BP drop ◦ Petechia **ถามอาการรบรายงานแพทยทนท**
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Post operative
การเดน ผปวยสามารถเดนลงน าหนกไดเตมทหลงผาตด walker
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Post operative
Exercise : เพมความแขงแรง
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Post operative
Exercise : เพมความแขงแรง
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Post operative
Exercise : เพมความแขงแรง
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Post operative
Exercise : เพมพสยการเคลอนไหว
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Post operative
Exercise : เพมพสยการเคลอนไหว
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Pre discharge
รวมกบทมสหสาขาวชาชพ
แนวทางเดยวกบการผาตดขอสะโพก ประเมนดานจตใจ สงคมและเศรษฐกจ การสงตอหนวยงานท
เกยวของหรอแหลงประโยชน Care giver การดแลแผล อาการทตองมาพบแพทยกอนนด การรบประทานยา ตดตามอาการผปวยทางโทรศพท
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หอผปวยศลยกรรมกระดกและขอหญง พ.ค. 59 – ม.ย.59การผาตด
TKA 17 ราย ตวชวด ผลการประเมน
LOS 5 วน LOS 6 วน
Hypovolumic shock 0 ราย 0 ราย
Infect wound 0 ราย 0 ราย
DVT 0 ราย 1 ราย
การหลวมหลดของขอเขา 0 ราย 0 ราย
องศา การงอเขา 80 องศา 6 ราย ,<80 องศา 2 ราย ,ไมมขอมล 9 ราย
เดนไดหลงผาตด 2 วน 10 ราย ,หลงจาก 2 วน 5 ราย ,ไมมขอมล 2 ราย
UTI 0 ราย 0 ราย
bed sore Gr. 2 0 ราย 0 ราย
ความพงพอใจในการจดการความปวดระดบด > 85 % 5 ราย ไมทราบขอมล 12 ราย
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THA /THR 15 ราย
ตวชวด ผลการประเมน
LOS 7 วน LOS 10.93 วน
Hypovolumic shock 0 ราย 0 ราย
Infect wound 0 ราย 0 ราย
DVT 0 ราย 0 ราย
Hip dislocation 0 ราย 0 ราย
เดนไดหลงผาตด 3 วน 8 ราย (เดนได D4 1 ราย เดนไมได 2 ราย
แพทยไมใหเดน 4 ราย )
UTI 0 ราย 0 ราย
bed sore ระดบ 2 0 ราย 0 ราย
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Internal fixation :PFNA 12 ราย
ตวชวด ผลการประเมน
Hypovolumic shock 0 ราย 0 ราย
Infect wound 0 ราย 1 ราย
DVT 0 ราย 1 ราย
Aspirate pneumonia 0 ราย 0 ราย
UTI 0 ราย , severe sepsis 0 ราย 0 ราย
bed sore Gr. 2 0 ราย 0 ราย
ภาวะแทรกซอนอน ๆ ไมม
Re-admit 3 ราย 1 ราย (admit 2 ครง)
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ตวชวด
ผปวยและญาตมความรและทกษะในการดแลตนเองระดบด ≥ 85 %
• ความพงพอใจในการจดการความปวดระดบด ≥85 %
(THA ,Internal fixation :PFNA )
• ความพงพอใจตอการดแลและการใหค าแนะน า ≥4.5
ไมมขอมล (ปรบแบบฟอรมใหม )
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Conclusion
Old age patients : fragile than young age
Common problem
◦ Hip fracture
◦ OA hip and knee
Prevent complication : Pre op / Post op
Multidisciplinary team
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Thank you
Prince of Songkla university