Pre-Op Total Joint Class

Pre-Op Knee InformationWelcome!

1

Welcome to Duke Raleigh Hospital! We look forward to caring for you and your family during your stay.12

Duke Raleigh Hospital has recently become the first hospital in the region to achieve certification in Total Joint procedures. This prestigious designation signifies Duke Healthcares commitment in providing excellent care.2GoalsInform the patient about what to expectBefore SurgeryDuring SurgeryAfter Surgery3

This outline will explain what to expect before, during, and after knee replacement surgery.3GoalsReduce anxietyAnswer questionsHelp you become better-prepared

4

We also hope to reduce your anxiety, answer questions, and help you become better prepared after this presentation.4

5

When you arrive on the Orthopaedic Unit, you will notice a baseball poster in your room. As each goal is achieved, your healthcare team will sign off each goal to track your progress. We will also ask you what you would like us to focus on for each day so that we can individualize your care. This will be written in the Patients Priority section on the poster.5SectionsNursing

Case Management

Physical Therapy

Occupational Therapy

6

This presentation will be divided into four sections: Nursing, Case Management, Physical Therapy, and Occupational Therapy.6Information From The Nurse About Care And Your Concerns

7

First, lets discuss Nursing Care.7We Care About You!!!In an effort to personalize your care while in the hospital, please let us know of any needs ahead of timePlease complete the enclosed Care Card and forward it to the Patient Navigator at the end of class

8

In an effort to personalize your care while in the hospital, please let us know of any needs ahead of time. Please complete a pink Care Card and forward it to the Patient Navigator. You may also contact the Patient Navigator at 866-552-9357 if you do not have a Care Card and one will be filled out for you.

8What To Bring List of medications and allergiesGlasses, hearing aids, denturesToiletry itemsToothbrushToothpasteFlat, supportive, non-slip walking shoes (with a backing)

Incontinence products (you may prefer a specific product not provided by hospital)

9

On the day of surgery, please bring anything you need to operate on a regular day (i.e. glasses, hearing aids, dentures). If you forget toiletry items, then we can supply these for you. Most importantly, bring supportive walking shoes with a backing and rubber sole.9What To BringNight clothes/pajamas, loose clothing

Books, magazines, hobby items

10

On the day of surgery and the day after surgery, you will be wearing a hospital gown. On post-op days 2 and 3, we will help you dress in your normal clothing. Ideally, shorts or baggy pants should be worn so that the knee dressing can be easily changed.10While in surgery

CHG wipes will be used to cleanse and disinfect the surgical site before surgery beginsCHG reduces bacterial growth on the bodyCHG will help reduce the chance of infection following surgery

11

Prior to beginning surgery, Chlorohexadene Gluconate (CHG) wipes will be used to cleanse and disinfect the knee area to reduce the chance of infection.11Orientation To RoomCall bell

TV Controls/Volume

Thermostat

12

When you arrive to the Orthopaedic Unit, your Nurse will orient you to the Call Bell TV Controls, and the Thermostat.12Equipment After Surgery 13

We would like to review what equipment you may have following knee surgery.13OxygenUsed a short timeLet us know if you have sleep apnea or use oxygen or CPAP at home

14

You may have oxygen in place when you wake from surgery. Typically, it will be nasal cannula oxygen with the two prongs fitting inside the nostrils. If you use a CPAP or BiPAP at home for sleep apnea, please bring your machine into the hospital.14IV or Intravenous TherapyMay have one or two linesFluids-body water, blood, antibiotics, pain medicationWill leave it in until discharge

15

You will have one or two IV lines in your hand and/or your arm to give you any fluids or medications. It will be left in until you are discharged.15Dressings and DrainsLarge dressing initiallyDrains and dressings removed 1st or second day after surgeryDressing will be changed

16

Your initial dressing in surgery will extend from the mid-thigh towards the ankle. After the initial dressing is removed, a smaller dressing will be placed over the incision. Your surgeon may also place a drainage catheter in the wound to help reduce fluid on the wound and, likewise, reduce swelling. 16Foley Catheter To Drain UrineStays in no longer than 2 daysHelps to keep track of fluid balanceGood initially when not moving wellPut in after you are asleepDoes not hurt to come out

17

You will have a drainage catheter placed in your bladder to help drain urine during and after surgery. It will be inserted while you are asleep. Typically, this will be removed on the morning of Post-Op Day 2. It will not only help drain urine, but it will also let us know how well your kidneys are working.17PCA - Patient Controlled AnalgesiaPain ButtonAdminister to selfClose monitoring

NO ONE IS TO PUSH THE BUTTON EXCEPT THE PATIENT!!!***Please ask your surgeon if this is an option for you

18

Your surgeon may order a PCA machine as one of many pain options for you. You may push the button to administer a dose of pain medicine. It is programmed so that you will only get a certain dose in a specified amount of time. Please let visitors know NOT to push the button for you as this is very powerful pain medication.18Femoral Nerve Block/Catheter***Some surgeons prefer not to use this*** Numbs the front part of the leg from the groin to the kneeStays in about two daysMay cause you to have a noodle legNeed to wear a knee immobilizer while standing or walking

19

Your surgeon may or may not place a femoral nerve block prior to surgery. If so, the catheter will be fed down to the femoral nerve on the side where surgery will be performed. The nerve will be bathed in numbing medicine and will help with reducing pain in the front part of the leg. It usually stays in place for about two days. Whenever this is infusing, you will need to wear a knee immobilizer when out of the bed or the chair.19Knee ImmobilizerMay wear when out of bed if you have a nerve block/catheter (dependent on your Therapist)May also wear at night to remind you to keep the leg straightUsed for safety reasons

20

There are times when your Therapist may have you remove the knee immobilizer while walking. Your surgeon may also have you wear it at night in bed to remind you to keep your leg straight.20Cryotherapy - Polar Care Device**Some surgeons prefer to use ice instead of the Polar Care Device****Some surgeons may choose not to use the Polar Care Device or ice**For total knee patientsSends a cold signal to the brain to help with pain managementHelps with pain and swellingYou take this home with you (if it is ordered by your surgeon)

21

Your surgeon may also order a Polar Care device for you after surgery. This device will pump ice cold water to a pad wrapped around the knee. It will help reduce pain and swelling. If it is not ordered, ice packs will be supplied as needed. Never place ice or the Polar Care directly on the skin. Always keep a barrier (bandage, pillowcase, towel) between the ice and skin.21CPM Machine ***Some surgeons prefer not to use this*** Continuous Passive Motion machineMay be used for total knee patients (if ordered)Passively bends knee while in bed

22

Your surgeon may order a CPM machine as part of your post-op care. This machine lies in bed with you, and your leg will be placed in it. This machine will gently and slowly flex and extend your leg for you. 22Medications Different color and numberAlways ask nurse what meds are forCombination medications that you may take at home may be given as separate pills while in the hospital

23

Medications come in different colors and numbers depending on the brand. If you take a two-in-one combination drug at home, you may receive the two separate medications that make up that pill while in the hospital. Please do not bring home medications into the hospital. 23Rating Pain0 to 10 pain scale

Pain patternsMechanical Pain Surgical Pain

24

You will be asked what your pain level is many times throughout your stay. 0 means No Pain and 10 means Horrible Pain. Our goal is to get your pain at a 3 or 4 out of 10 or less. At this level, you will be awake and alert enough to participate in therapy and learn what we will be teaching you.24Know the Zone!Our staff will make every effort to help control your pain We will automatically give you pain medication around the clock We ask that you partner with us and ask for additional pain medicine if needed Alternative pain options may be used such as cold therapy and distraction Our goal is to keep you in the 3-4 Pain Zone (or less)

25

You will receive pain medication around the clock without asking for it. However, if you experience breakthrough pain, please ask for that additional pain medication. This is typically written on your white board in your room along with the times it can be taken.25Preventing PneumoniaIncentive Spirometer

Breathe in 10-12 times an hour while awakeHelps to expand air sacs in lungs

26

Surgical patients are at a higher risk of pneumonia following surgery. You will be given an incentive spirometer and encouraged to perform breathing exercises throughout your stay. Your Nurse will explain these exercises to you.26Preventing Blood Clots Medication (Blood Thinners)Calf/Foot PumpsWalking and Exercising

27

Surgical patients are also at a higher risk of having a blood clot following surgery. There are three ways that we prevent blood clots from forming: medication, calf/foot pumps, and walking/exercising.27

Coumadin and Lovenox***Please check with your surgeon as to which blood thinner will be prescribed***Will help to prevent blood clots from formingWill need to learn how to take these medications safelyWill need to watch a video

28

Medication is one way to help reduce blood clot formation. You will take a blood thinner while in the hospital as well as for a short time after discharge from the hospital. Two common blood thinners are Coumadin (a pill) and Lovenox (an injection).28Compression DevicesFoot or calf pumpsHelp to push the blood back into circulationWear them when you are in bed or in the chair

29

The second way to help reduce blood clot formation is to use compression devices on the foot and/or calf muscle. These devices will inflate with air and squeeze the foot and calf to push blood back towards the heart. These will be worn while in bed or in the chair but will be removed when walking.29

Walking and ExercisingHelps to prevent blood clots from formingExercise in and out of bedAnkle circles, foot pumps, tightening leg muscles30

The third way to help reduce blood clot formation is through walking and exercising. Not only will our staff walk with you, but they will also teach you exercises to perform while lying in bed or sitting in the chair.30Diet Initial diet is typically clear liquid unless otherwise designated by your physicianDiet will advance as toleratedConstipation High fiberIncrease activityFluidsNausea

31

Your first meal after surgery will be clear liquid. If you tolerate this, your diet will be advanced to your regular diet. Pain medication may cause constipation, so we encourage you to eat foods high in fiber, increase your activity, and increase your fluid intake. We also have medications if you experience nausea.31Call for Help Never get out of bed or chair unless you call for assistanceCall as soon as possible.Try to ask for help when a staff member is already in the room.

32

Never get up without calling for help. You may experience changes in blood pressure, lightheadedness, dizziness, and nausea which may cause you to fall and injure your new implant. 32Condition H (Help)Dial 3111 and give room number

Gives family and friends a way to call a Medical Emergency team to the bedside

Call ifYou notice a change in your loved ones conditionYou still have serious concerns about your loved ones condition after speaking to the healthcare team

33

If a family member or friend notices a change in your condition, they may dial extension 3111 and a Medical Emergency team will be sent immediately to the patients bedside.33Sleep Dial L.O.U.D. (5683) on phone if sleep disturbedAnonymous call

TIGR TV ChannelsRelaxation/Meditation channels

Comfort Cart

34

We make every effort to reduce noise in the hospital. If your sleep is being disturbed, you may dial LOUD (5683) on your phone, and someone will address the noise issue. We also have relaxation/meditation channels on our television. A Volunteer will also bring a Comfort Cart to your room . 34Case ManagementJoan Paramore RNCase Manager(919) 954-3878 35

Joan Paramore is the Nurse Case Manager for the Orthopaedic Unit.35Discharge PlanGoal: To get you home safely!!!

36

Our goal is to get you home safely.36Discharge Plan Everyone is assigned a Case Manager who will usually meet with you the day after surgeryAverage Length of Stay: 2-4 nightsThat means you should be ready for discharge around the 2nd, 3rd, or 4th day after surgery11:00AM Discharge Time

37

The Case Manager will meet with you the day after surgery and each day after to track your progress. The average length of stay is 3 nights. The hospital aims for an 11:00 AM discharge time.37Discharge Plan Options:Home Health You will choose agency (list provided)RN (if on Coumadin)Physical Therapy (2-3 times/wk)Occupational Therapy (if ordered by Doctor)

***Your Case Manager will set up a Home Health Agency (of your choice) for you

38

If you are safe to return home, then the Case Manager will arrange for Home Health to visit you at home. Typically, this involves a Registered Nurse and Physical Therapist. If needed, an Occupational Therapist may be ordered. 38Discharge Plan Options:Home HealthEquipment orderedRolling WalkerBedside CommodeCPM (if ordered by Doctor)

***Your Case Manager will order your equipment for you from an agency of your choice

39

The Case Manager will also order any equipment you will need for home (if you go directly home from the hospital). A rolling walker and bedside commode are ordered and delivered to your hospital room prior to discharge. If you have a walker at home, please bring it into the hospital for our Therapist to perform a safety and height check. If you need a CPM machine, the Case Manager will arrange for it to be delivered to your home. If you go directly to a Rehab facility from the hospital, then the Rehab facility will order any equipment for you.39

Discharge Plan Options:Short-Term RehabIf not safe to return home, Short-Term Rehab may be an option. Based on1. Your insurance2. How well you progress with Therapy while in the hospital40

If you are not safe to return home, then your healthcare team may recommend that you go to Rehab for a short-term stay before returning home. Your Case Manager will help arrange a Rehab stay for you, if needed.40Discharge Plan Options:Short-Term RehabTwo types of Rehab FacilitiesSNF: 1 to 3 hours of therapy/dayAverage Length of Stay: 1-2 weeks-as needed2. Acute: 3 to 5 hours of therapy/dayAverage Length of Stay: 5 days

41

There are two types of Rehab facilities. Most patients that need Rehab go to SNFs (Skilled Nursing Facilities). Acute Rehabs are usually hospital-based facilities. Your Case Manager will meet with you and discuss Rehab facility options.41Discharge Plan Options:Outpatient TherapyUsually set up after Home Health is completedRarely set up at time of discharge from hospital

42

Outpatient Rehab may also be an option for you immediately after discharge from the hospital, Rehab facility, or when Home Health is completed.42Discharge Plan Transportation (depends on what is medically necessary)CarWheelchair Van Not covered by insuranceCost: $55-$120Ambulance Covered by insurance if medically necessary

***Your Case Manager will set up your Wheelchair Van or Ambulance for you (if needed)

43

Most patients have a family member or friend drive them home or to Rehab from the hospital. The Case Manager can also arrange for transportation if you have no one to transport you.43If You Are Going HomeYou may fill your prescriptions at our Plaza Pharmacy (Located on the First Floor of the hospital)Hours of Operation:Mon-Fri (9:00AM-4:30PM)(919) 954-3921Use the Main Pharmacy on weekends or after 4:30PM (but make payment arrangements with Plaza Pharmacy Mon-Fri 9:00AM to 4:30PM

44

If you are going directly home from the hospital, you may fill your prescriptions either the day before discharge or the morning of discharge at our hospital pharmacy.44Total Joint Wellness ClassThis free class addresses methods of maximizing the Health and Wellness of your new knee or hip jointThe class outlinesCreative ways to perform aerobic, strength, and resistance exercises within the home setting Healthy nutrition choices while eating at home and restaurantYou are welcome to bring a spouse, friend, or Coach to the classClass is held once a month on Tuesday from 3:30 to 4:30 in the Wellness Center behind Duke Raleigh Hospital

Please register with the Patient Navigator at 866-552-9357

45

You are invited to attend a free 1-hour Total Joint Wellness Class before or after your surgery takes place. You will learn creative ways to exercise in the home to maintain the health of your new joint. You will also learn about nutrition. Please contact the Patient Navigator at 866-552-9357 to register.45Physical Therapy

46

The next portion of the presentation will cover Physical Therapy.46Treatment Sessions Seven days/weekOne or two sessions per day with the TherapistYour therapeutic activity will also involve walking with Nursing staff Typical treatment session Post-op Days 1, 2, and 3

47

Depending on your individual needs, Therapy will work with you either once or twice a day. Your therapeutic regimen will not only involve walking/exercising with Therapists, but it will also involve working with Nurses and Nurse Assistants as they help you up to the chair, bathroom, and hallway.47PrecautionsKnee ReplacementDo not stay in one position for longer than an hour without standing up, walking a short distance, and straightening and bending your kneeDo not sleep or rest with a pillow or anything under your kneeOperated leg out in front while sitting or standing48

As part of your therapeutic regimen, your Therapist will teach you about knee precautions, or what NOT to do with your new knee.48Homeward Bound GymStair training

Car transfer exercises

49

If needed, you may be brought to the Gym to perform stair training and transfer exercises. 49Medical EquipmentWalkerProper use

Bedside CommodeProper use

50

Your Therapist will also teach you how to properly use a walker and how to properly and safely sit and stand.50Occupational Therapy

51

An Occupational Therapist may work with you prior to discharge if needed. Occupational Therapy deals with Activities of Daily Living (ADLs)-bathing, dressing, eating, etc..51TreatmentDemonstration of equipment***Knee patients rarely need this equipment at discharge. The Therapist will determine your specific needs.

Reacher

Sock aid

Bathing sponge

52

If your Occupational Therapist feels that you need any adaptive equipment prior to discharge, then she will give you the necessary equipment and teach you how to properly use it. Knee patients rarely require any of these equipment at discharge. If you go directly to Rehab from the hospital, you will receive this equipment from the Rehab facility, if needed.52Helpful Tips How to properly carry items in pockets and/or basket while driving a walker Safety in the shower (have someone close by)While at home prior to surgery, move low- and high-lying items to waist level (i.e. in kitchen/bathroom cupboards, refrigerator)Make arrangements to have appropriate-sized car available for your discharge

53

Your Therapist will also teach you helpful tips related to using the walker, shower safety, and home preparation.53Before SurgeryAssess your home environment and let the Therapist know the following once you are in the hospital

Tub/Shower (location, height, grab bars) Number of steps (outside of home and upstairs)

Height of bed

54

Your Therapists will ask many questions about your home environment including your bathroom, stairs, and bed. Please be prepared to answer questions regarding these areas so that your Therapy can be customized to your individual needs.54AssessmentThe following slides contain questions based on the Powerpoint. 55

Question 1One risk of a blood thinner medication is:

___________?____________56AnswerIncreased bleeding (Can also be increased bruising)57Question 2You should call your Doctor immediately if you notice any sign of a blood clot.

Name a symptom of a blood clot in your leg:_____________________Name a symptom of a blood clot in your lung:______________________58AnswerLeg: Pain in the back of the leg (usually in the calf, but can radiate throughout the leg)

Lung: Difficulty breathing (may also have a rapid heart rate)59Question 3True or False

When standing up or sitting down, you should keep your operated leg slightly in front of your non-operated leg.60AnswerTrue61Question 4True or False

When lying in bed, you should keep your operated knee in a straight position as much as possible. You should never place a pillow or rolled-up towel under the knee.

62AnswerTrue63Question 5Some pain is normal and expected after surgery, but the best way to keep your pain at a manageable level is to:

Take pain medication when it reaches a 5 on a 0 to 10 pain scaleTake pain medication only when the pain is unbearableUse medication as well as other methods to control pain. For example: ice, positioning, etc.Try distracting yourself from the pain by watching television for an hour or two64Answer 653. Use medication as well as other methods to control pain. For example: ice, positioning, etc.Question 6The best and safest way to raise the height of a chair in your home is to:

Stack pillows on the chairStack folded blankets on the chairPlace a small book under each leg of the chairPlace two large telephone books on the chair66Answer2. Stack folded blankets on the chair67Question 7One side effect of pain medication is constipation. List 3 ways to prevent it:68AnswerIncrease fiberIncrease fluidsIncrease activity

You may also take a stool softener or laxative if needed.69Thank You70We want to hear from you! Please complete our simple form to let us know that you have viewed this presentation and to share any questions or concerns you may have.We look forward to caring for you and your family! Thanks for choosing Duke Raleigh Hospital for your joint replacement surgery!70