Agnesian HealthCare is Sponsored by the             Congregation of Sisters of St. AgnesJoint Replacement Surgery:  A Pati...
Table of ContentsWelcomeWelcome  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . ...
Welcome to Agnesian HealthCare!Thank you for choosing the Agnesian Center for Bone & Joint Health for your joint replaceme...
Important Phone NumbersSurgeonName of Surgeon:__________________________________________________________________Office Pho...
Patient Information SheetSt. Agnes Hospital • (920) 926-4500 • (800) 458-8182Date of Surgery:_____________________________...
Case ManagersA case manager is a nurse or social worker. Case managers are available to assist you with:Power of Attorney ...
Medicare BenefitsHome Care (see page 36)Medicare may cover home care at 100 percent if you meet the following criteria:•	 ...
Insurance BenefitsQuestions you may want to ask about your benefits.Write down the name of the person you are talking with...
Planning for Your Hospital StayPrior to Your Surgery DateDo not shave your legs or cut/clip your toenails for one week pri...
Planning for Your Hospital StayWhile in the Hospital•	 As a patient of St. Agnes Hospital, we are pleased to offer you an ...
AnesthesiaWhat to Expect From AnesthesiaYour anesthesiologist will discuss two main aspects of care with you: the anesthes...
AnesthesiaSome of the many possible advantages of spinal anesthesia...1)	 More rapid recovery of mental function.2)	 No ne...
Pain Control Following SurgeryOptions For Pain Control After SurgeryAt St. Agnes Hospital we take a multi-modal approach t...
Frequently-Asked QuestionsQ:	How long will I be in the hospital following my total joint replacement?A:	 Typically followi...
Home Safety AssessmentThe majority of falls that occur happen at home. The good news is that most falls can be prevented t...
Home Safety AssessmentKitchenDo you use a wide-based, sturdy step to reach into high cabinets? .  .  .  .  .  .  .  .  .  ...
Knee Care Guidelines - Day of SurgeryWe are pleased to welcome you to St. Agnes Hospital and the 6 South inpatient unit. W...
Knee Care Guidelines - Day of SurgeryPain ManagementWe take pain management seriously and want you to be comfortable. You ...
Knee Care Guidelines - Day of Surgery .......................................................................................
Knee Care Guidelines - Day OneToday’s Itinerary•	   Your vital signs will be checked every four hours.•	   IV fluids conti...
Knee Care Guidelines - Day OneIt’s Time to Get Moving!You will get out of bed in the morning with assistance from therapy ...
Knee Care Guidelines - Day TwoToday’s Itinerary•	   Your vital signs will be checked every eight hours and as needed.•	   ...
Knee Care Guidelines - Day Two	Today’s Goals	 ❑ Pain controlled	                         ❑ No blood clots	 ❑ No pneumonia	...
Knee Care Guidelines - Day ThreeToday’s Itinerary•	   Today may be the day you are discharged home or to another facility....
ExercisesAnkle PumpsWith left leg relaxed, gently flex and extend ankle.Move through full range of motion. Avoid pain.Repe...
ExercisesTerminal Knee ExtensionWith right knee over bolster, straighten knee by tighteningmuscles on top of thigh. Keep b...
ExercisesHeel Slide (Supine)Slide right heel toward buttocks until a gentlestretch is felt. Hold 2 seconds. Relax.Repeat 1...
ExercisesStanding Hip/Knee FlexionWith support, lift surgical legbending hip and knee.Repeat _____ times per set.Do _____ ...
ExercisesChair SquatKeeping feet flat on floor, shoulder widthapart, squat as low as is comfortable.Use support as necessa...
Pain ManagementThe associates at the Agnesian Center for Bone & Joint Health are concerned about managing your painafter s...
Pain ManagementPain Scale and FacesAgnesian HealthCare professionals will be able to give you more specific information on...
Coumadin (Warfarin) Information  ®What is warfarin?Warfarin (generic name) or Coumadin® (brand name) is an oral medication...
Coumadin (Warfarin) Information  ®How often do I need my INR performed?In general, when you first start warfarin, you will...
Coumadin (Warfarin) Information  ®What if I miss a dose?It is very important to take your warfarin at the same time each d...
In rare cases, warfarin can cause an allergic reaction. Get help right away if you have an allergic reaction.Symptoms of a...
Coumadin (Warfarin) Information                 ®This is a partial list of foods that contain higher levels of vitamin K:V...
Durable Medical Equipment327 Winnebago Drive, Fond du Lac, WI 54935(920) 926-5277 • (800) 732-1313Store Hours: weekdays fr...
Agnesian HealthCare Home CareWhen to Consider Home Care•	   Recurrent hospitalizations•	   Medication monitoring (new and ...
Common TerminologyEquipmentIntravenous (IV) CatheterThis catheter allows for fluids and medications to be delivered throug...
Common TerminologyPeoplePhysical Therapy (PT)Physical therapy associates will assist you in regaining mobility and functio...
Questions_________________________________________________________________________________________________________________...
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A Patient's Guide to Knee Replacement Surgery: St. Agnes Hospital

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Thank you for choosing the Agnesian Center for Bone & Joint Health for your joint replacement surgery. We hope our mission of providing compassionate care that brings hope, health and wellness to all we serve is evident in the care you receive. We trust that our associates and your surgeon provided you with the educational opportunity to prepare yourself adequately for your joint replacement surgery.

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A Patient's Guide to Knee Replacement Surgery: St. Agnes Hospital

  1. 1. Agnesian HealthCare is Sponsored by the Congregation of Sisters of St. AgnesJoint Replacement Surgery: A Patient’s Guide Before, During & After Knee Replacement Surgery
  2. 2. Table of ContentsWelcomeWelcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1Important Phone Numbers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Joint Replacement Patient Information Sheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Case Managers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Before SurgeryPlanning For Your Hospital Stay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7What to Expect From Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Pain Control Following Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Frequently-Asked Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Home Safety Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13SurgeryKnee Care Guidelines - Day of Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Knee Care Guidelines - Day One . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Knee Care Guidelines - Day Two . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Knee Care Guidelines - Day Three . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Exercises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22After SurgeryPain Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28Coumadin®/Warfarin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30Durable Medical EquipmentAgnesian Health Shoppe - Durable Medical Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35ResourcesHome Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36Common Terminology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37(SAH Knee Replacement 01/13)
  3. 3. Welcome to Agnesian HealthCare!Thank you for choosing the Agnesian Center for Bone & Joint Health for your joint replacement surgery. Wehope our mission of providing compassionate care that brings hope, health and wellness to all we serve isevident in the care you receive. We trust that our associates and your surgeon provided you with the educationalopportunity to prepare yourself adequately for your joint replacement surgery.The Agnesian Center for Bone & Joint Health has been designed to give outstanding care of patients in needof joint replacements. We have assembled a special team of healthcare professionals that take great pridein ensuring that you receive the best quality care available. You can have extra confidence knowing that theAgnesian Center for Bone & Joint Health serves several hundred joint patients each year; our professionalshave extensive experience.As you will remember, to prepare you for surgery, our team has reviewed your specific joint replacementprocedure with you, and our highly-trained associates have provided you with this detailed educational binder.Through our surgical skills, our superior healthcare team and your determination, together we can accomplisha great result for you.Again, thank you for choosing the Agnesian Center for Bone & Joint Health; we are certain that you will findyour care to be extraordinary. During your hospitalization, please inform our associates if we can do anythingfor you to help you have an excellent care experience.You may receive a phone call survey after you are discharged from the hospital. Please give your feedback sowe know how we did in providing your care, along with any opportunities for improvement.Thank you again and we wish you the best in your recovery! SAH Knee Replacement | 1
  4. 4. Important Phone NumbersSurgeonName of Surgeon:__________________________________________________________________Office Phone Number:________________________________________________________________Primary Care ProviderName of Primary Care Provider:_________________________________________________________Office Phone Number:________________________________________________________________PharmacyName of Pharmacy:_________________________________________________________________Address:_________________________________________________________________________Phone Number:____________________________________________________________________St. Agnes HospitalInformation/Switchboard . . . . . . . . . . . . . . . . . . . . . . . . . (920) 929-2300 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (800) 922-34006 South Surgical Inpatient Unit . . . . . . . . . . . . . . . . . . . . (920) 926-5160Anticoagulation Management Services . . . . . . . . . . . . . . (920) 926-4580Case Managers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (920) 926-4750 SAH Knee Replacement | 2
  5. 5. Patient Information SheetSt. Agnes Hospital • (920) 926-4500 • (800) 458-8182Date of Surgery:______________________________________________ ❑ Right Knee ❑ Left KneeUnless your provider gives you other instructions, please prepare yourself for your surgery using this checklist.❑ Make sure to stop the medications as directed by your provider:______________________________________________________________________________❑ One week prior to surgery, do not shave your legs or cut/clip your toenails. Make sure to remove all nail polish from toenails. ve Dri eb agoDay before surgery: Scott Street Winn Park Avenue❑ Eat a regular meal unless your provider instructs you otherwise.❑ Stay away from greasy, spicy and/or salty foods to help avoid upset stomach. Hwy 23❑ We recommend you take a shower or bath on your day of surgery. Johnson Street Fond du Lac❑ Prepare anything you will need to bring with you to the hospital. Regional St. Agnes Clinic Hospital ___ comb/hairbrush Division Street entrance entrance ___ glass case and/or contact case and solutions ue National Aven ___ toothbrush/toothpaste Vincent St. Everett St. Second Street ___ deodorant ___ bring along any prosthetic devices; i.e., braces, walkers, crutches, etc.❑ Do not have anything to eat or drink including water starting at midnight on:______________________________________________________________________________❑ Call the hospital’s Surgical Services department at 926-4500 (800-458-8182, ask for extension 4500) the day before your surgery anytime after 1 p.m. to find out your arrival time. If you do not call the hospital by 6 p.m., they will call you.❑ Arrival time according to the hospital:_________________________________________________Day of surgery:❑ Take the following medications with a sip of water at:______________________________________________________________________________❑ Bring to the hospital your Durable Power of Attorney papers for your chart if already have.❑ Brush your teeth but do not swallow any water.❑ Do not wear makeup.❑ Wear comfortable clothing to the hospital.❑ Leave jewelry and all other valuables at home.❑ When coming to the hospital, stop at the Registration department and then go to the Surgical Services department. SAH Knee Replacement | 3
  6. 6. Case ManagersA case manager is a nurse or social worker. Case managers are available to assist you with:Power of Attorney (POA) for HealthcareThe Wisconsin statutes recognize two forms of advance directives: the Power of Attorney for Healthcare and theDeclaration to Physicians (Living Will). All hospitals are required by law to make this information available topatients. You may call the case manager at (920) 926-4750 and request that a copy be mailed to you.A POA for Healthcare is a thoughtful process and should not be rushed. We recommend you complete the POAforms prior to your admission if you wish to have your POA in place for this surgery. Your signature requires twowitnesses. Family members are not eligible to witness your signature. The only hospital associates eligible towitness your signature are Spiritual Care Services associates or a social worker, and they may not be readilyavailable the day of your surgery.Insurance-Related QuestionsInsurance companies may preauthorize an initial one to two-day hospital stay. During your hospitalization,the insurance company will call the case manager to evaluate your progress. The insurance company will thendetermine if your stay is to be extended.Discharge PlanningDischarge planning includes setting up home care, equipment or arranging for inpatient rehabilitation or asubacute (skilled nursing home) stay.We recommend that you pre-plan your ride home with a family member or friend. Insurance companies onlypay for medically-necessary ambulance transportation. Insurance will not cover wheelchair van transport.If outpatient services are needed for physical therapy or lab tests, you will need to arrange for the appointmentand the transportation. Know before you come into the hospital where you want to go for your therapy and bloodwork.After you are admitted to the hospital, your case manager may stop in and ask if you have any questions ordischarge concerns. You or your family may request to see the case manager at any time. SAH Knee Replacement | 4
  7. 7. Medicare BenefitsHome Care (see page 36)Medicare may cover home care at 100 percent if you meet the following criteria:• The home care needed is skilled in nature. This means you require a nurse and/or physical therapist.• You must be homebound. This means that leaving the home requires a considerable and taxing effort or leaving the home is medically contraindicated.Outpatient Therapy Benefits• Medicare provides benefits for outpatient services based on skilled care needs at the time the service is provided. This may be covered at 80 percent of the charge.Durable Medical Equipment (see page 35)• You may have to pay a portion or all of the cost depending on your insurance benefits for a walker, crutches or cane.• If you were issued a cane or any other equipment within the last one to five years, your insurance carrier may not cover the cost again.• Items not covered include raised toilet seats, grab bars, shower transfer bench or chair, reacher, long-handled sponge, sock aid and shoehorn.If you have private or a Medicare-replacement insurance:Read the written information you have at home about your insurance coverage. Call the number on the backof your insurance card if you have any questions. In general, insurance companies follow the same criteria asMedicare to determine eligibility for outpatient therapy, home care, acute or subacute rehabilitation services.Let the insurance representative know that you will be having surgery. Keep in mind that the person answeringyour questions is a service representative who will speak in general terms and will not know all the detailsabout your surgery.There may be a difference between having the benefit and qualifying for the benefit. Qualifying for the insurancebenefit is not a surgeon or primary care provider’s decision. Your insurance company will determine yourqualification for benefits based on their standards and policies. SAH Knee Replacement | 5
  8. 8. Insurance BenefitsQuestions you may want to ask about your benefits.Write down the name of the person you are talking with:________________________________________Do I have outpatient physical therapy benefits? ❑ Yes ❑ NoIf yes, what are they?________________________________________________________________Is there a preferred provider?__________________________________________________________Do I have home health benefits for in-home therapy or nursing? ❑ Yes ❑ NoIf yes, what are they?________________________________________________________________Is there a preferred provider?__________________________________________________________Do I have durable medical equipment benefits (walker, crutches)? ❑ Yes ❑ NoIf yes, what are they?________________________________________________________________Is there a preferred provider?__________________________________________________________Do I have acute inpatient rehabilitation benefits? ❑ Yes ❑ NoIf yes, what are they?________________________________________________________________Do I have skilled nursing facility benefits? ❑ Yes ❑ NoIf yes, who are the preferred providers?___________________________________________________Is there a deductible or co-pay for any of these services?_______________________________________ SAH Knee Replacement | 6
  9. 9. Planning for Your Hospital StayPrior to Your Surgery DateDo not shave your legs or cut/clip your toenails for one week prior to your surgery date.Anti-inflammatory medications (over-the-counter or prescription) that you are currently taking for your joint painmay be requested by your surgeon to stop prior to surgery, so make sure your surgeon has an up-to-date list ofyour medications. If your surgeon does request you to stop these medications, inquire what you can take in placeof them for your joint discomfort.What to Bring to the Hospital• If you bring your own pillow, please make sure your pillowcase is brightly colored or patterned, so that it won’t be mistaken with the hospital linens.• Bring loose-fitting, comfortable clothes such as pajamas, lightweight robe, sweatpants, shorts and T-shirts for therapy. Bring at least two sets of clothing with you.• Bring comfortable, low-heeled shoes that have an enclosed heel and toe, such as walking or tennis shoes. No open heel/toe shoes or slippers. Non-skid or rubber-soled shoes are preferred.• Bring personal hygiene toiletries and incontinence products. You may also want to include lip balm.• Bring a walker and/or crutches, if you have them. Your physical therapist will check them for a proper, safe fit.• Bring any special equipment that you have at home, such as wrist splints, orthopedic shoes, long handle reacher, sock aid, shoehorn, etc.• Bring a book, magazine or hobby item to help you relax.• Bring a list of your medications (both prescribed and over-the-counter) with any changes if any from the time you attended the education class.• Do not bring medications from home unless told to do so (It is OK to bring your eye drops and inhalers).• Do not bring any jewelry, checkbook, credit cards or more than $5 cash with you to the hospital.When to Stop Eating and Drinking• Do not eat or drink anything after midnight the night before your surgery unless otherwise instructed. This includes gum, hard candy, water, soda, coffee, tea, beer, wine or other alcoholic beverages, etc.• Brush your teeth, making sure not to swallow any water or toothpaste.• Take your medications as instructed with a small sip of water. SAH Knee Replacement | 7
  10. 10. Planning for Your Hospital StayWhile in the Hospital• As a patient of St. Agnes Hospital, we are pleased to offer you an innovative dining program, which allows you to select meals from an expansive menu designed to make you feel as though you were at home or at a favorite restaurant.• If one of your guests wishes to have a room service meal, they can call the room service line at 4673 to place their order. There is a $7 charge per meal which includes an entrée, two side orders, a beverage and dessert/fruit. The guest must have exact change upon delivery of the guest tray. No checks or credit cards will be accepted.Suggestions to Make Your Return Home an Easier One• Ensure hallways and rooms are free of clutter and tripping hazards.• Organize your living areas to avoid excessive lifting, bending or reaching.• Store heavy and frequently-used objects at or above waist level (counter height). Consider moving items in the lower parts of the fridge/freezer to a higher shelf.• Consider preparing a bedroom area on the main living level for short-term use upon your return home.• Set up a firm chair with armrests.• Arrange for extra help with household tasks if needed.• Keep an ice pack in your freezer for possible joint swelling after surgery. A bag of frozen peas will also work. SAH Knee Replacement | 8
  11. 11. AnesthesiaWhat to Expect From AnesthesiaYour anesthesiologist will discuss two main aspects of care with you: the anesthesia provided during thesurgical procedure and the plan for pain control after surgery. There are several options your anesthesiologistmay discuss with you. This information is being distributed to you ahead of time to help guide discussion aboutyour care on the morning of surgery and to dispel common misconceptions about certain types of anesthesiayou may be offered.Anesthesia for Your SurgeryThere are two main choices for surgical anesthesia: general and regional. During general anesthesia, you areunconscious and have no awareness or other sensations. There are many types of general anesthetic drugs.Some are gases inhaled through a breathing mask or tube, and others are medications injected into a vein.After you are asleep, a breathing tube may be inserted into the windpipe to maintain proper breathing andadminister anesthetic gases. During a general anesthetic, you are carefully monitored and treated by youranesthesiologist. The amount of anesthesia is calculated and constantly adjusted. At the conclusion of surgery,your anesthesiologist will reverse the process and you will regain awareness in the recovery room.During a regional anesthetic, your anesthesiologist makes an injection near a cluster of nerves to numb thearea of your body that requires surgery. There are many kinds of regional anesthesia, but the most commonlyused regional technique for knee surgery at our hospital is spinal anesthesia. A spinal anesthetic is performedby injecting local anesthetic (sometimes combined with other medicines) through a needle in your lower backdirectly into the fluid surrounding your spinal cord producing numbness from about your belly button and down.This is most often done in the operating room with a patient in a sitting position or lying on his/her side.You generally will not feel much discomfort with placement of the spinal medication. There is a slight, briefdiscomfort associated with the placement of some medication to numb the skin first. After that, a patient mayfeel pressure. Once the medication is injected, it works quickly, usually taking full effect within five minutes(you may begin to feel warmth, tingling and numbness almost immediately).One of the most common misconceptions about spinal anesthesia relates to safety. You can rest assured thatif offered to you, spinal anesthesia is a safe choice for joint replacement surgery. Some patients are concernedabout serious side effects, such as paralysis, and also about troubling but less dangerous side effects, suchas headache. There seems to be a common perception that these complications occur often. In fact, spinalanesthesia has a long track record of safety, with a rate of serious complications (low!) about equal to the rateof major problems with general anesthesia (also low!). SAH Knee Replacement | 9
  12. 12. AnesthesiaSome of the many possible advantages of spinal anesthesia...1) More rapid recovery of mental function.2) No need for insertion of breathing tubes.3) Lower risk of nausea or vomiting.4) Less pain immediately after surgery.Serious complications like paralysis, bleeding and infection after spinal anesthesia are very rare. The numberof patients who develop a headache is also quite low – in expert hands, fewer than one percent of patientsdevelop a headache from the spinal. Although a “spinal headache” is troublesome, it is not life-threatening,and treatment is available during your hospital stay.Many patients think that choosing a spinal means they have to be awake during the surgical procedure. Mostpatients, in fact, choose to be sedated during the procedure (in addition to the spinal anesthetic). Most patientswho choose a spinal with sedation have no discomfort or memories from their time in the operating room.However, if you want to remain completely awake and receive no sedation, that is also an option.Unfortunately, not all patients are candidates for spinal anesthesia. We do not offer this technique to patientswho are at risk for internal bleeding issues or to patients with infection in the area where the needle is inserted,or certain other medical conditions. We try to offer a realistic explanation of the different anesthetic techniques,their risks and benefits. When offered, spinal anesthesia is the most popular choice for joint replacementsurgery at St. Agnes Hospital. Assuming there is not a compelling reason to choose one anesthetic over another,we usually allow the patient to choose between general or spinal. SAH Knee Replacement | 10
  13. 13. Pain Control Following SurgeryOptions For Pain Control After SurgeryAt St. Agnes Hospital we take a multi-modal approach to pain relief for joint replacement surgery. Youranesthesiologist can also help keep your pain at tolerable levels during your stay in the hospital after surgery.All patients are candidates for narcotic pain medications given through the IV or by mouth, and most patientsalso receive non-steroidal anti-inflammatory drugs such as acetaminophen or ketorolac, or other pain alteringmedications. Instead of IV or oral narcotics, some patients may be candidates for narcotic pain medicationgiven in the spine, if this is the anesthetic choice you make. Adding a narcotic, such as morphine, to the spinalcan give significant pain relief for up to 24 hours after injection. Not all patients offered a spinal are goodcandidates for spinal morphine. We do not offer this to patients with obstructive sleep apnea or some othermedical conditions. Your anesthesiologist can discuss whether spinal morphine is a good idea for you on theday of surgery.Most patients will be offered a type of regional anesthesia, called a femoral nerve block, to help withpostoperative pain. The femoral nerve is most easily blocked as it crosses your groin, and your anesthesiologistmay use an ultrasound machine to locate the nerve. A small electric current is given through the needle causingbrief contractions of some leg muscles. Placement of this block is generally simple and involves minimaldiscomfort. Your anesthesiologist may choose to do a single injection or to leave a catheter in place to givemedicine continuously for a set period of time. The block may be done before or after surgery, and if necessary,it is possible to repeat the block after the first one has worn off.SummaryThere are two types of surgical anesthesia offered for knee replacement and several options for pain controlafterward. The most common combination used at St. Agnes Hospital is spinal anesthesia with or withoutmorphine, along with a femoral nerve block. Together, you and your anesthesiologist will decide what is bestfor you. SAH Knee Replacement | 11
  14. 14. Frequently-Asked QuestionsQ: How long will I be in the hospital following my total joint replacement?A: Typically following a total joint replacement, you will have a three to four day stay in the acute care hospital. During your acute care stay, you will meet with a case manager who will assist you with your discharge plans. Based on your recovery status, rehabilitation associates and your provider will provide you with discharge recommendations.Q: How much pain will I have after the surgery?A: Your comfort is very important to our associates. In order for our associates to better serve your needs, we will be asking you to “rate” your pain. The scale will be from 0 to 10, with 0 being no pain and 10 being the worst pain possible. This rating will give associates an idea of how you feel and how to treat your discomfort.Q: How can I succeed after total joint replacement while in the hospital?A: During the first few days following surgery, you must rely on hospital associates to assist you with many things. However, during this time, you can assist with your recovery in the following ways: • Drink plenty of fluids. • Perform ankle pumps and deep breathing exercises frequently while awake. • Actively participate in your rehabilitation program.Q: How long until I can return to my normal activities following surgery?A: Typically, when you are discharged from your acute care stay, you will be independent with basic activities of daily living such as dressing and bathing. Within six months, you will be able to resume most of your pre-surgical activities based upon your provider’s recommendation. Your provider or therapist can answer specific questions concerning your activities.Q: Will I need special equipment at home following surgery?A: During your acute care stay our rehabilitation associates will assess your equipment needs and make recommendations. Your case manager will coordinate obtaining the appropriate equipment through an agency. SAH Knee Replacement | 12
  15. 15. Home Safety AssessmentThe majority of falls that occur happen at home. The good news is that most falls can be prevented throughenvironmental changes and safety precautions. To decrease your risk of falling after your total joint surgery,we recommend that you ask your spouse, family member or a neighbor to go through your home and answerthe following questions.If you answer “No” to any of the questions, it is recommended that you change the environment to allow forbetter safety. While correcting these common concerns will decrease your risk of a fall, it is also recommendedthat you have a safety network of friends, family or neighbors to provide a daily check-in, either by phone or inperson, should you fall and be unable to solicit help independently.General Household AreasAre light switches easily accessible upon entering a room? . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ Yes ❑ NoDo you have throw rugs in your home? (remove them) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ Yes ❑ NoAre hallways free from clutter? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ Yes ❑ NoAre raised door thresholds clearly marked? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ Yes ❑ NoAre electrical cords and telephone cords away from hallways? . . . . . . . . . . . . . . . . . . . . . . . . . ❑ Yes ❑ NoDo you have a portable phone with emergency numbers easily at hand? . . . . . . . . . . . . . . . . . . ❑ Yes ❑ NoDo you have furniture with good back and arm support that you can get in and out of easily? . . . ❑ Yes ❑ NoStairwaysAre stair treads in good condition? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ Yes ❑ NoIs there a sturdy handrail on both sides of the stairs? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ Yes ❑ NoAre the stairs brightly lit? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ Yes ❑ NoBedroomIs there a lighted pathway from the bedroom to the bathroom? . . . . . . . . . . . . . . . . . . . . . . . . . ❑ Yes ❑ NoIs there a clear pathway from the bedroom to the bathroom? . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ Yes ❑ NoDo you keep a charged flashlight near your bed for emergencies? . . . . . . . . . . . . . . . . . . . . . . . ❑ Yes ❑ NoBathroomDo you have safety rails or grab bars by toilet and shower/tub? . . . . . . . . . . . . . . . . . . . . . . . . ❑ Yes ❑ NoDo you have skid resistant strips or a rubber mat both in and in front of the bathtub? . . . . . . ❑ Yes ❑ NoDo you have an adjustable shower chair? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ Yes ❑ No SAH Knee Replacement | 13
  16. 16. Home Safety AssessmentKitchenDo you use a wide-based, sturdy step to reach into high cabinets? . . . . . . . . . . . . . . . . . . . . . . ❑ Yes ❑ NoAre spills immediately wiped up? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ Yes ❑ NoDo you avoid using a high gloss floor wax? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ Yes ❑ NoDo you store frequently used items at waist level and less frequently used items inhigher cabinets? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ Yes ❑ NoIs your laundry located on first floor? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ Yes ❑ NoWill you have assistance with laundry? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ Yes ❑ NoWill you have assistance with meal preparation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ Yes ❑ NoCould you prepare microwave meals in advance? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ Yes ❑ No SAH Knee Replacement | 14
  17. 17. Knee Care Guidelines - Day of SurgeryWe are pleased to welcome you to St. Agnes Hospital and the 6 South inpatient unit. We look forward toproviding you the best care possible in an environment that encourages you to actively participate in therehabilitation process.Today’s Itinerary:• You will have an IV.• You will have a cooling device to your knee as directed.• The pulses in your feet will be checked.• We will remind you to do ankle pumps every one to two hours.• Take frequent “cat naps” and limit visitors.• You will reposition in bed frequently to prevent damage to skin.• Your blood pressure, pulse, respirations, temperature and oxygen levels (vital signs) will be checked frequently.• We will remind you to use your incentive spirometer (breathing machine) every hour while you are awake (if you are watching television, you can do one breath with the incentive spirometer during each commercial or approximately 10 per hour.• A Continuous Passive Motion (CPM) device for bending and straightening your knee will be applied and used three times daily for two hours at a minimum.• If you return from surgery in the morning, the physical therapist may get you out of bed today. If not, your nurse will have you sit at the side of the bed today.Hourly Rounding• Nursing associates will check on you every one to two hours to make sure that you are comfortable and that your needs are met.• You can arrange with your nurse if you choose to “not be disturbed” to allow for rest and sleep. Today’s Goals ❑ Pain controlled ❑ Nausea controlled ❑ No pneumonia ❑ No blood clots ❑ Get some rest! SAH Knee Replacement | 15
  18. 18. Knee Care Guidelines - Day of SurgeryPain ManagementWe take pain management seriously and want you to be comfortable. You will be asked to rate your pain using a0 to 10 pain scale. Zero means no pain and 10 means the worst pain you can imagine. Your nursing associateswill be checking you frequently and will be asking you about your level of pain. Remember to let your nurse knowwhen your pain is starting to increase.There are several options for pain management after total joint surgery and these will be ordered by yoursurgeon or anesthesiologist. Pain management can be complex so please feel free to ask questions of yournurse or provider.MedicationsYou will have medications to keep you comfortable after surgery and to prevent complications. Many of theseare taken by mouth so controlling nausea is important. You have provided a list of your home medications andif not contraindicated, these will be ordered to begin this evening or tomorrow.If you were told to bring your medications from home, please provide these to your nurse. They will be reviewedby a pharmacist for identification and then kept in a secure bin assigned to you. The nurse will provide theseas ordered.Food for ThoughtYou have been without food or drink since midnight and had surgery… so be good to your stomach. Slow andsteady wins the race for getting back to normal meals.Start with ice chips, followed by a few sips of water. If all is well, Jell-O, clear soups and juices are goodchoices. These are available on your unit 24/7. Once you are able to pass gas, you can try portions of solid food.Remember, you have an IV so you can do without food or drink if your stomach is just not feeling quite right.If you experience nausea, let your nurse know.The menu in your room will tell you how to order your meals from dietary. We also have regular and diet soda, juice,soup, cold cereals, saltines, graham crackers, milk, ice cream and popsicles on the unit if you want a snack. SAH Knee Replacement | 16
  19. 19. Knee Care Guidelines - Day of Surgery ........................................................................................ Don’t Take a “Trip” to the Bathroom! You may have a catheter in your bladder to drain urine. If not, ask for assistance with a bed pan, urinal or to get up to a bedside commode. ........................................................................................Dress Code• Patient gown for comfort; save your personal comfortable clothing for the upcoming days.• Nasal prongs to provide oxygen.• Elastic stockings (TED hose) and/or sequential compression devices (SCDs) to aid circulation and prevent blood clots.• A dressing over your surgical site (the nurse may need to add to your dressing if there is drainage on the surgeon’s dressing). Sneak Peak at Tomorrow • Blood draw for lab work at a very early hour. That’s why cat naps are so important. • Occupational and physical therapy begins, usually once in the morning and once in the afternoon. • Up in the chair for at least two meals. • CPM device for bending and straightening your knee usually applied for at least two hours, three times a day. SAH Knee Replacement | 17
  20. 20. Knee Care Guidelines - Day OneToday’s Itinerary• Your vital signs will be checked every four hours.• IV fluids continued if needed.• IV antibiotics discontinued.• If you no longer require oxygen, it will be discontinued.• Continue to cough and deep breathe every hour.• The pulses in your feet will be checked.• Do ankle pumps every one to two hours while awake.• Up in chair three times.• Rest between activity and limit visitors.• Reposition in bed to prevent damage to skin.• Hip precautions as ordered; hip abduction pillow may be used while in bed.• If a drain and/or bladder catheter is in place, it will be discontinued today.• Write down questions for your physician, nurse and therapist as you think of them.Training Table for Rehabilitation• Your appetite may be less than normal for the first couple of weeks.• Your diet will be advanced when you are able to pass gas.• Choose food high in iron, protein, fiber and calcium.• Drink plenty of water. At least three full Agnesian HealthCare water bottles, which is given to you upon admission.• Limit fat and sweets. Today’s Goals ❑ Pain controlled ❑ Up in chair two to three times ❑ No blood clots ❑ Walking exercise ❑ No pneumonia ❑ Initial plan for dischargeFashion Statement• It’s time to get out your own clothes and say goodbye to the patient gown!• Your therapist will help with any challenges while getting bathed and dressed. SAH Knee Replacement | 18
  21. 21. Knee Care Guidelines - Day OneIt’s Time to Get Moving!You will get out of bed in the morning with assistance from therapy associates. Using a walker, you may takesome steps in your room or in the hallway. You will learn about getting in and out of bed and transferring to achair. You will begin your exercise program.The CPM machine will be applied for at least two hours, three times a day, increasing bending as tolerated.Therapy associates will see you in the afternoon to continue working with you on bending and straighteningyour leg and walking. You may go to the gym to continue your exercises.Keeping Ahead of the PainNursing associates will ask you to rate your pain from 0 (none) to 10 (worst imaginable). Let your nurse ortherapist know when your pain is starting to increase.Try additional means to reduce your pain: music, massage, repositioning, reading, television, meditation, prayer,room darkening, etc.You will be able to take part in therapy most effectively when your pain is controlled. With medication andother pain relieving measures (repositioning, etc.), the goal is for you to have a pain level of four or less. Painmedication is more effective when pain levels are maintained at lower levels.Homesick?Associates from our Care Management department will visit you to plan for your discharge and identify anyequipment you will need......................................................................................... Sometimes what you’ve lost needs to be replaced! Some blood loss is expected with surgery. We check your blood count daily to determine if you need a blood transfusion. If you do, you may notice how much better you feel when your blood count increases after the transfusion. ........................................................................We Say “NO” to Blood Clots!You will continue to wear the TED hose and/or SCDs to aid circulation.Your nurse will provide you with the medication to prevent blood clots, as ordered by your provider.Continue to do your ankle pumps every one to two hours and participate in your exercises. Getting up andmoving decreases your risk of getting a blood clot. SAH Knee Replacement | 19
  22. 22. Knee Care Guidelines - Day TwoToday’s Itinerary• Your vital signs will be checked every eight hours and as needed.• The pulses in your feet will be checked.• You will continue to use your incentive spirometer.• Continue cooling device to knee.• Alternate rest and activity.• Up in chair two to three times daily.• Reposition frequently in bed.• TED hose on (off for 30 minutes in the morning and evening for bathing and skin inspection).• IV fluids may be discontinued if drinking adequate amounts of fluids.• SCDs on when in bed.• Hourly rounding continues as discussed.It’s Time to Get to the Gym• You will go to the therapy gym today.• You will continue to work on the exercises you did yesterday with progression as tolerated.Back in Your Room• The CPM settings will be increased to your tolerance.• You will continue to do your ankle pumps every one to two hours. ........................................................................................ Pain, Pain Go Away! While the pain will probably not disappear completely, your pain medication taken by mouth should keep it at a level of four or less. Communicate pain concerns with your nurse or therapist. Try some additional means of reducing pain. If you tried something yesterday and it didn’t help, try it again today or try something different. Try music, massage, repositioning, reading, television, meditation, prayer, room darkening, etc......................................................................................... SAH Knee Replacement | 20
  23. 23. Knee Care Guidelines - Day Two Today’s Goals ❑ Pain controlled ❑ No blood clots ❑ No pneumonia ❑ Up in chair two to three times ❑ Walk safely with assistive device ❑ Continue all exercises ❑ Progress with transfers ❑ CPM settings increased ❑ Discharge plan completed ❑ Progress toward independence with straight leg raisesThere’s No Place Like Home• Your return home is an important part of getting the best results from your surgery. Day by day at home, you will return to your usual routines and increase activity naturally. While in the hospital, your provider, nurses and therapists observe your progress and look for signs that you will be safe at home. Occasionally, a patient may need an additional day in the hospital or perhaps some time in another facility before returning home. Our resource management associates will assist in your transition home or to another facility.• If you need additional instruction on assistive devices, a therapist will work with you.• You may want to send some of your things home with family or friends to make your discharge day easier to organize.How Does My Incision Look?The edges of your incision have started to come together but some drainage may still be present, especiallywith activity. The dressing will be changed as instructed. Redness, swelling and tenderness should be startingto decrease. Upon discharge, it is not uncommon to have swelling and bruising. This may continue for sometime after you are at home.To promote healing and rehabilitation, choose foods high in iron, protein, fiber and calcium. Avoid foods highin fat and sugar. ........................................................................................ All Systems Go? If you don’t have a bowel movement (BM) today, let your nurse know. Remember to eat foods high in fiber and drink plenty of liquids, especially water (total of three water bottles of fluid per day). Walking and exercise also helps a lot! ........................................................................................ SAH Knee Replacement | 21
  24. 24. Knee Care Guidelines - Day ThreeToday’s Itinerary• Today may be the day you are discharged home or to another facility.• Continue your activities of the previous days (ankle pumps, cooling device, incentive spirometer, CPM, etc.)• You will go to the therapy gym and continue all your exercises.• If your home has certain features, such as stairways, steps or lack of handrails, your therapist will provide instruction on staying safe. Today’s Goals ❑ Pain controlled ❑ Labs within your normal limits ❑ No blood clots ❑ No pneumonia ❑ Walk safely and independently with assistive device ❑ Able to dress and perform personal activities safely and independently with assistive device(s) ❑ Independent with straight leg raises ❑ Questions answered ❑ Discharge instructions understoodTo-Do List for Discharge• Pack up belongings.• Go over your provider’s written discharge instructions with your nurse, including prescriptions and appointments.• Put all important discharge papers in the binder so you will have them when you arrive home.• Let your nurse know when you are ready and a member of the nursing staff will assist you to your car when all discharge paperwork is complete.........................................................................................Thank you for letting us serve you!We wish you continued success with improved mobility......................................................................................... SAH Knee Replacement | 22
  25. 25. ExercisesAnkle PumpsWith left leg relaxed, gently flex and extend ankle.Move through full range of motion. Avoid pain.Repeat 20 times per set.Do 1-2 sets per session.Do 10 sessions per day.Quadriceps SetTighten muscles on top of thighs by pushingknees down into surface. Hold 5 seconds.Repeat 10-20 times per set.Do 2-3 sets per session.Do 2-3 sessions per day. SAH Knee Replacement | 23
  26. 26. ExercisesTerminal Knee ExtensionWith right knee over bolster, straighten knee by tighteningmuscles on top of thigh. Keep bottom of knee on bolster.Repeat 10-20 times per set.Do 2-3 sets per session.Do 2-3 sessions per day.Straight Leg RaiseTighten muscles on front of right thigh, then lift leg_____ inches from surface, keeping leg locked.Repeat _____ times per set.Do _____ sets per session.Do _____ sessions per day. SAH Knee Replacement | 24
  27. 27. ExercisesHeel Slide (Supine)Slide right heel toward buttocks until a gentlestretch is felt. Hold 2 seconds. Relax.Repeat 10-20 times per set.Do 2-3 sets per session.Do 2-3 sessions per day.Sitting Knee FlexionGently push surgical leg back with other leguntil a stretch is felt. Hold 5 seconds. Relax.Repeat _____ times per set.Do _____ sets per session.Do _____ sessions per day. SAH Knee Replacement | 25
  28. 28. ExercisesStanding Hip/Knee FlexionWith support, lift surgical legbending hip and knee.Repeat _____ times per set.Do _____ sets per session.Do _____ sessions per day.Standing Knee FlexionWith support, bend surgical kneeas far as possible.Repeat _____ times per set.Do _____ sets per session.Do _____ sessions per day. SAH Knee Replacement | 26
  29. 29. ExercisesChair SquatKeeping feet flat on floor, shoulder widthapart, squat as low as is comfortable.Use support as necessary.Repeat 10-20 times per set.Do 2-3 sets per session.Do 2-3 sessions per day. SAH Knee Replacement | 27
  30. 30. Pain ManagementThe associates at the Agnesian Center for Bone & Joint Health are concerned about managing your painafter surgery. Pain that is poorly controlled can interfere with sleep, appetite, activity, relationships and youremotional outlook.Pain is to be expected following joint replacement surgery, but by working with your nurses, therapists andproviders we should be able to control the pain enough for you to actively participate in your recovery. Do not letyour pain get out of control because as pain becomes more severe it is harder to treat. Ask for assistance fromyour nurse if you feel your pain level is increasing.Ways for You to Help Us Manage Your Pain• You can give us a rating on a 0 to 10 pain scale. A rating of 10 reflects the worst pain you could ever imagine, a rating of 5 means you feel a moderate amount of pain and a 0 rating reflects no pain.• Your therapists and nurses will ask you to rate your pain after activity, therapy and at rest.• When you are able, describe what type of pain you are having such as throbbing, shooting, aching, burning or pressure. This will assist the medical staff and getting you the right type of pain control. 0 1 2 3 4 5 6 7 8 9 10 No Mild Moderate Severe Pain Pain Pain PainThings to Keep in Mind• It is easier to treat pain when it is mild or moderate rather than waiting until it is severe. Take your pain medications on a regular schedule to prevent severe pain.• It is nearly impossible to eliminate all pain during the first few days after your surgery. However, your medical team will work with you to control your pain at a level that allows you to rest and participate in your recovery, including your therapies.• Pain will gradually diminish or decrease in the days after your surgery. You should expect to have good days and bad days with regards to your pain and your ability to perform activities.• Studies have shown that when pain medications are used appropriately to treat surgical pain, addiction to the medication occurs in only a small number of patients. Please let us know if you have a history of addiction or intolerance to pain medications. SAH Knee Replacement | 28
  31. 31. Pain ManagementPain Scale and FacesAgnesian HealthCare professionals will be able to give you more specific information on how to use these scalesand identify an achievable goal for your pain control.Medications Used to Treat PainThere are many forms and types of medications used to treat pain. You may be on a combination of painmedications with some taken orally (by mouth) or through your intravenous (IV) line. Because medications canwork in different ways, taking more than one medication for pain can sometimes provide greater relief whileminimizing side effects.Some of the common side effects from the pain medication include: nausea, sedation, confusion, constipationand itching. Most of these side effects will improve after taking the medication for a period of time.Constipation may be experienced during the time you are taking the medication, but it can be preventedand/or treated after discussion with your healthcare professional. If you experience any of these side effectsor any others, tell your healthcare professional right away.Additional Options for Treating Pain• Repositioning• Cold application• Relaxation/medication/imagery• Physical/occupational therapy• Massage therapy SAH Knee Replacement | 29
  32. 32. Coumadin (Warfarin) Information ®What is warfarin?Warfarin (generic name) or Coumadin® (brand name) is an oral medication used to prevent clotting in the blood.It is called an anticoagulant, which means to prevent blood clots. Warfarin is often referred to as a “bloodthinner” but does not actually make the blood “thinner.” Warfarin works to slow the blood’s ability to make aclot. Blood will still continue to form clots but will take slightly longer while taking warfarin.Warfarin is a very special medication that requires a blood test to monitor how the medication is working.Based on the result of the blood test, the dose of warfarin may change.Why do I need warfarin?Sometimes the postsurgical recovery period can have complications. Warfarin is used to decrease the chanceof one type of complication. This potential complication is the formation of blood clots in different areas ofthe body. Following your surgery, you are at an increased risk of forming blood clots for two reasons. First, youwill not be as mobile following surgery. Being less active increases your risk of clotting. Second, the processof healing following surgery increases your risk of clotting. Warfarin works to prevent clots from forming inthe blood. This reduces your risk of developing a deep vein thrombosis (DVT) - a blood clot in your leg, or apulmonary embolism (PE) - a blood clot in your lungs.How long do I need to take warfarin?Following your surgery, warfarin is typically prescribed for four to six weeks.How do I know it is working? What is an INR?In order to assure you are getting the right dose of warfarin, you will be required to have frequent blood tests.Warfarin is monitored with a lab test called the INR (International Normalized Ratio). INR can also be called aprotime (PT). INRs are used to determine the correct dose of warfarin to give. Your INR should be near 1 if youare not taking warfarin. Your INR will rise when the warfarin is working. 1 2 3 4 5 “Normal” INR à à à not on warfarin Warfarin cause the INR to riseIt is very important to have your INR tested regularly. Your healthcare provider will tell you when to have yourINR tested. If your INR is too high, you are at increased risk of bleeding complications. If your INR is too low,you are at increased risk of clotting. The INR is used to determine the appropriate dose of warfarin and preventcomplications. It is very normal to have the dose of warfarin change based on the INR results. SAH Knee Replacement | 30
  33. 33. Coumadin (Warfarin) Information ®How often do I need my INR performed?In general, when you first start warfarin, you will need to get your INR checked about one to two times a weekfor the first two weeks. As your level begins to stabilize, the INR can be done one to two times a month. Thefrequency will vary, depending on the stability of your INR. Your healthcare provider will tell you when to haveyour INR checked.If the INR is not within goal range, or your dose is changed, you will need to go for INR checks more often. Whena person first starts taking warfarin, the INR tends to fluctuate up and down until the correct dose of warfarinis found that keeps your level within the goal range. It is, therefore, very important to get your level checkedfrequently when your healthcare provider tells you to do so.What factors may change my INR test results?Besides warfarin dose changes, several factors, such as sickness, diet, other medicines (prescription, over-the-counter, herbal, etc.) or physical activities, may affect your blood test results. Tell your healthcare provider aboutchanges in your health, medicines or lifestyle.Where do I get my INR checked, and who adjusts the dose?Agnesian HealthCare has an Anticoagulation Management Service Clinic that can check your INR. The clinic,located on the main floor of St. Agnes Hospital, specializes in warfarin management. Your provider may referyou to the clinic where your INR is checked and warfarin dose is adjusted at your 10- to 15-minute appointment.Alternatively, you may have blood drawn at a local lab and your provider will adjust your dose. If you are not ableto leave your home, you may be eligible for a home care service to come to your home and draw your blood test.How should I take warfarin?It is important to take your warfarin once daily at the same time each day. It is best to take warfarin before yourevening meal. Take your warfarin exactly as your healthcare provider instructed you to take it. Your dose maychange frequently based on your INR. It is common to take full tablets on some days and half tablets on otherdays. For this reason, a pill box or recording your daily dose on a calendar is highly recommended. If you havequestions regarding your dosing, please call your healthcare provider. Do not change your warfarin dose withouttalking to your healthcare provider.Warfarin can be taken with or without food. SAH Knee Replacement | 31
  34. 34. Coumadin (Warfarin) Information ®What if I miss a dose?It is very important to take your warfarin at the same time each day. If you miss your dose, take the missed doseas soon as possible on the same day. DO NOT take a double dose of warfarin the next day to make up for themissed dose unless instructed to do so by your healthcare provider.What are the side effects of warfarin?Side effects from warfarin may occur from time to time. If you notice anything abnormal that you believe may becaused by the medication, please call your provider.Two types of side effects that sometimes occur are concerns with bleeding and allergic reaction.Symptoms of minor bleeding include:• gum bleeding while brushing teeth• occasional nosebleed• easy bruising• bleeding after a minor cut that stops within a few minutes• menstrual bleeding that is a little heavier than normalIf you have minor bleeding that does not stop, please contact your provider, go to the emergency department orcall 911.Symptoms of major bleeding include:• dark brown or red urine• bowel movements containing blood or very dark, tar-like stool• excessive bleeding from the gums or nose• throwing up coffee-colored, bright red or red-tinged secretions• severe pain (headache or stomachache)• dizziness/weakness• bleeding from a cut that will not stop• sudden appearance of bruises for no known reason• excessive menstrual bleeding• pain, discomfort or swelling in any area, especially after an injuryIf you have major bleeding, contact your provider, go to the emergency department or call 911 right away. Theseare signs that your INR may be high.The chance of bleeding increases with increasing INR. Keeping your INR within target range will reduce your riskof bleeding. SAH Knee Replacement | 32
  35. 35. In rare cases, warfarin can cause an allergic reaction. Get help right away if you have an allergic reaction.Symptoms of an allergic reaction include:• difficulty breathing• swelling of your throat, tongue or face• hives and/or a rash• itchingWarfarin can also cause skin necrosis or gangrene, which can cause dark red or black areas on the skin. This isa rare complication that may occur during the first several days of warfarin therapy. If either of these conditionsoccur, contact your physician, go to the emergency room or call 911 right away.What medications interact with warfarin?Warfarin can interact with many other medications. Your healthcare providers should be aware you areon warfarin. While on warfarin, it is always best to discuss starting or stopping any medication with yourhealthcare provider. This includes over-the-counter and herbal medications in addition to prescriptionmedications.Are there over-the-counter medications to avoid?While taking warfarin, Tylenol® (acetaminophen) is the only recommended over-the-counter pain medication.The use of aspirin (unless recommend by your healthcare provider), Aleve®, Motrin® (ibuprofen) and Advil®(ibuprofen) should be avoided.Why do I need to pay attention to my diet?Many foods you eat contain vitamin K. Vitamin K can decrease the effectiveness of warfarin. You can continueto eat foods that contain vitamin K, however, you need to eat a consistent amount of these foods. Eating a dietthat is not consistent may affect your INR and your warfarin therapy.Avoid drastic changes in dietary habits. In general, leafy, green vegetables and certain legumes and vegetableoils contain high amounts of vitamin K. Foods that generally contain low amounts of vitamin K include mostfruits, cereal grains, dairy products and most meats such as beef, chicken, pork, shrimp and turkey. SAH Knee Replacement | 33
  36. 36. Coumadin (Warfarin) Information ®This is a partial list of foods that contain higher levels of vitamin K:Vegetable Serving SizeBroccoli (raw or cooked) . . . . . . . . . . . ½ cupBrussels Sprouts . . . . . . . . . . . . . . . . 5 sproutsCabbage (raw) . . . . . . . . . . . . . . . . . . 1 ½ cupsCollard greens . . . . . . . . . . . . . . . . . . ½ cupCucumber peels . . . . . . . . . . . . . . . . . 1 cupEndive (raw) . . . . . . . . . . . . . . . . . . . . 2 cups choppedGreen scallion (raw) . . . . . . . . . . . . . . 2/3 cupMustard greens . . . . . . . . . . . . . . . . . 1 ½ cups shreddedSpinach (raw leaf) . . . . . . . . . . . . . . . 1 ½ cupsTurnip greens (raw) . . . . . . . . . . . . . . 1 ½ cups choppedWatercress (raw) . . . . . . . . . . . . . . . . 3 cups choppedRemember, it is important that you keep your diet consistent.What about alcohol?Alcohol can also affect how warfarin works in your body. Alcohol combined with warfarin can increase your riskof bleeding. It is best to avoid alcohol while on warfarin. However, having up to one to two drinks in a day maybe acceptable.We encourage you to contact your healthcare provider if you have any questions. SAH Knee Replacement | 34
  37. 37. Durable Medical Equipment327 Winnebago Drive, Fond du Lac, WI 54935(920) 926-5277 • (800) 732-1313Store Hours: weekdays from 8 a.m. to 6 p.m.www.agnesian.com (click on the Agnesian Health Shoppe)Durable Medical EquipmentOur durable medical equipment (DME) specialist, customer service representative or delivery technicianpersonally teaches every patient how to use their equipment. We provide and maintain only the most modern,attractive, quality equipment. Each item is carefully inspected and regularly serviced. We provide personal,one-on-one service for each individual’s needs. ........................................................................................We deliver and install equipment!........................................................................................Durable Medical Equipment Following Knee SurgeryWheelchairs, walkers, crutches Lift chairsRaised toilet seat or commode chair Long-handled reacher, shoehornCPM machines for the knee Sock aidsHandheld shower hose Chair/foam cushionsGrab bars Other aids for daily livingWheelchair cushions Other bathroom safety productsCompression stockings Specialty mattressesWound dressingsShower chair (shower) or tub transfer bench (bathtub)........................................................................................We will gladly help with special orders too. Call us today!........................................................................................ SAH Knee Replacement | 35
  38. 38. Agnesian HealthCare Home CareWhen to Consider Home Care• Recurrent hospitalizations• Medication monitoring (new and current)• Home oxygen needs• Conditions of: CHF, COPD, diabetes, post CVA, cancer and other chronic illnesses• Post-surgical care (orthopedics, cardiac)• Pain management/education• Safety concerns• Ostomies, tube feedings, catheter care• Need for adaptive equipment/rehabilitation needs• Symptom management/palliative care managementServices Provided• Special medical treatments (Lovenox  B-12 injections)• Wound care with certified wound/ostomy/continence nurse (wound vac therapy)• Home infusion services (IV therapy/line cares)• Telehealth monitoring• Physical therapy, occupational therapy, speech therapy, home health aides, medical social worker• Medication box fills/medication management• Pediatric clinical nurse specialist• Chemotherapy• Palliative care• Diabetic managementCoverage• Accept Medicare/Medicaid assignment• Insurance• Self-pay• Community CareHours of ServiceRegular office hours are 7:30 a.m. to 4:30 p.m. weekdays.Phone number: (920) 923-7950After 4:30 p.m. an Agnesian HealthCare operator will page the on-call nurse.Nurse available 24 hours a day, seven days a week SAH Knee Replacement | 36
  39. 39. Common TerminologyEquipmentIntravenous (IV) CatheterThis catheter allows for fluids and medications to be delivered through your bloodstream.Endotracheal TubeThis tube may be placed in your trachea (windpipe) by anesthesiology to keep your airway open during surgery.Foley CatheterThis tube is used to eliminate urine from the bladder. It is used both during surgery and for a short time aftersurgery.Incentive SpirometerThis breathing exercise device is designed to help you improve your ability to expand your lungs after surgery.Continual Passive Motion (CPM) MachineThis machine may be available for use to exercise your knee while increasing blood circulation, decreasingswelling and increasing range of motion.Sequential Compression Device (SCD)These are inflatable plastic sleeves that are wrapped around your leg and may be used to improve blood flow inyour legs.TEDsThese are elastic stockings that help prevent blood clots from forming in your legs.Pulse OximeterThis clip is attached to one of your fingers to monitor the percentage of oxygen carrying blood in your body.Epidural InjectionThis injection may be placed in your lower back for delivering a one-time injection for pain relief.Femerol Nerve CatheterThis catheter is placed by an anesthesiologist in your groin pre-operatively to deliver continuous painmedication, or can be a one-time injection.Patient Controlled Analgesic PumpThis is a pump that allows the patient to give themselves pain medication by pressing a button. The pumpdelivers a specific amount of pain medication as ordered by your provider. SAH Knee Replacement | 37
  40. 40. Common TerminologyPeoplePhysical Therapy (PT)Physical therapy associates will assist you in regaining mobility and function following your surgery.Occupational Therapy (OT)Occupational therapy associates will assist you in regaining independence with your activities of daily living(ADLs). Activities of daily living include: dressing, bathing, homemaking tasks and training in the use ofadaptive equipment.Social Workers/Case ManagersSocial workers/case managers will assist you and your family with discharge planning such as arranging homecare and necessary equipment. They ensure quality, efficiency and most importantly your satisfaction duringyour hospital stay.MiscellaneousInternational Normalized Ratio (INR)This ratio is taken through a blood test to determine the appropriate dose of warfarin to prevent complications.DVTDeep vein thrombosis is a blood clot in your leg.PEPulmonary embolism is a blood clot that forms in your lungs. SAH Knee Replacement | 38
  41. 41. Questions____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ SAH Knee Replacement | 39

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