Saguaro Joint Replacement In-Service Training

SAGUARO
In-service
training 032018

© 2017 Saguaro Home Care. All Rights Reserved. | INTERNAL
JOINT
REPLACEMENT

1) DESCRIPTION
2) ANATOMY and PHYSIOLOGY
3) TYPES of JOINT REPLACEMENT
4) PURPOSE OF THE PROCEDURE
5) PATIENT PREPARATION
6) DIAGNOSTICS
7) PATHOPHYSIOLOGY/PROCEDURE
8) RISK for JOINT REPLACEMENT SURGERY
9) NURSING MANAGEMENT - POST PROCEDURE CARE
10)SBAR – Report to a Physician about a Critical situation
11)MANAGING A PATIENT post JOINT REPLACEMENT in the HOME
SETTING
CONTENTS

• Total or partial replacement of a joint with a synthetic
prosthesis
• Restores joint mobility and stability and relieves pain
• May involve any joint except a spinal joint
• Most commonly involves the hip, knee, and shoulder
• Alternately called Arthroplasty
DESCRIPTION

ANATOMY AND PHYSIOLOGY
Quick look at the
JOINTS

Type Description
Total Hip Replacement • Surgery in which the diseased ball and socket
of the hip joint are completely removed and
replaced with artificial materials.
• A metal ball with a stem (a prosthesis) is
inserted into the femur (thigh bone) and an
artificial plastic cup socket is placed in the
acetabulum (a "cup-shaped" part of the
pelvis.)
Types of Joint Replacement

Total Knee
Replacement
• A surgical procedure in which damaged
parts of the knee joint are replaced with
artificial parts.
• The surgery is done by separating the
muscles and ligaments around the knee to
expose the inside of the joint.
• The ends of the thigh bone (femur) and the
shin bone (tibia) are removed as is often
the underside of the kneecap (patella).
• The artificial parts are then cemented into
place

Uni-compartmental
Knee Replacement • surgical procedure used to relieve arthritis
in one of the knee compartments in which
the damaged parts of the knee are
replaced.
• UKA surgery may reduce post-operative
pain and have a shorter recovery period
than a total-knee replacement.

Shoulder Joint
Replacement
• Surgical procedure in which all or part
of the gleno-humeral joint is replaced
by a prosthetic implant.
• Such joint replacement surgery
generally is conducted to relieve
arthritis pain or fix severe physical joint
damage.

Total Elbow
Replacement
A complicated procedure partly
because the elbow has several
moving parts that balance each
other with great precision to control
the movements of your forearm.

Wrist Joint Replacement
• The wrist joint is replaced with an artificial
joint (also called a prosthesis) much less
often than other joints in the body, such as
the knee or the hip.
• When necessary, this operation can
effectively relieve the pain caused by wrist
arthritis.
• When severe arthritis has destroyed the
wrist joint, artificial wrist replacement
surgery (also called wrist arthroplasty) can
help restore wrist strength and motion for
many patients.

• To treat severe chronic arthritis
• To treat degenerative joint disorders
• To treat extensive joint trauma
PATIENT PREPARATION
• Make sure the patient has signed an appropriate consent
form.
• Reassure the patient that analgesics will be available as
needed.
• Provide emotional support.
PURPOSE

DIAGNOSTICS

Laboratory Studies Rationale
Hematocrit Usually done 24–48 hr postoperatively for evaluation of blood
loss, which can be quite large because of high vascularity of
surgical site in hip replacement. Note: Monitoring of CBC or
repeated count may also be indicated for patients receiving
enoxaparin (Lovenox).
Coagulation studies. Evaluates presence or degree of alteration in clotting
mechanisms and effects of anticoagulant and/or antiplatelet
agents when used. Note: Not necessary for patients receiving
enoxaparin (Lovenox); however, stool occult blood tests may be
indicated.
Administer medications as
indicated: warfarin sodium
(Coumadin), heparin,
aspirin, low-molecular-
weight heparin, e.g.,
enoxaparin (Lovenox).
Anticoagulants and/or antiplatelet agents may be used to
reduce risk of thrombophlebitis and pulmonary emboli.

PATHOPHYSIOLOGY/PROCEDUR
E

Risks for Joint replacement surgery
1. Heart attack
A serious concern is the risk for heart attack, which is up to 31 times
higher in people after joint replacement surgery than in the general
population, particularly in the first two weeks post-op
2. Blood Clot
This risk is due to the body’s increased tendency to form blood clots
after any major surgery, the risk can be minimized by having a
cardiology evaluation before surgery and taking medications to prevent
blood clots after surgery.
• anyone who smokes should quit before having surgery.

3. Infection
• Infection may occur superficially in the wound or deep
around the prosthesis.
• It may happen while the patient is in the hospital or after
discharge.
• It may even occur years later.
• Minor infections of the wound are generally treated with
antibiotics.
• Major or deep infections may require more surgery and
removal of the prosthesis.
• Any infection can spread to the joint replacement site.

4. Leg-length Inequality
• Sometimes after a hip replacement, one leg may feel longer or
shorter than the other.
• Surgeons will make every effort to make leg lengths even, but
may lengthen or shorten the leg slightly in order to maximize
the stability and biomechanics of the hip.
• Some patients may feel more comfortable with a shoe lift after
surgery.

5. Dislocation
• This occurs when the ball comes out of the socket.
• The risk for dislocation is greatest in the first few months
after surgery while the tissues are healing.
• Dislocation is uncommon.
• If the ball does come out of the socket, a closed reduction
usually can put it back into place without the need for more
surgery.
• In situations in which the hip continues to dislocate, further
surgery may be necessary.

6. Loosening and Implant Wear
•Over years, the hip prosthesis may wear out or loosen.
•This is most often due:
• everyday activity
•To a biologic thinning of the bone called Osteolysis.
NOTE:
If loosening is painful, a second surgery called a
revision may be necessary.

NURSING MANAGEMENT

RISK FOR INFECTION
•Promote good hand washing by staff and patient.
•Use strict aseptic or clean techniques as indicated to
reinforce or change dressings and when handling drains.
Instruct patient not to touch or scratch incision.
•Maintain patency of drainage devices (Hemovac, Jackson
Pratt) when present. Note characteristics of wound
drainage.
POST-PROCEDURE CARE

• Assess skin/incision color, temperature, and integrity;
note presence of erythema or inflammation, loss of
wound approximation.
• Investigate reports of increased incisional pain,
changes in characteristics of pain.
• Monitor temperature. Note presence of chills.
• Encourage fluid intake, high-protein diet with
roughage.

Impaired Physical Mobility
•Maintain affected joint in prescribed position and
body in alignment when in bed.
•Medicate before procedures and activities.
•Turn on un-operated side using adequate number of
personnel and maintaining operated extremity in
prescribed alignment. Support position with pillows
and/or wedges.

•Demonstrate and assist with transfer techniques and
use of mobility aids, e.g., trapeze, walker.
•Determine upper body strength as appropriate.
Involve in exercise program.
•Perform and assist with range of motion exercises to
unaffected joints.

•Inspect skin, observe for reddened areas. Keep
linens dry and wrinkle-free.
•Massage skin and bony prominences routinely.
•Protect operative heel, elevating whole length of
leg with pillow and placing heel on water glove if
burning sensation reported.
•Perform and assist with range of motion
exercises to unaffected joints

Risk for Peripheral Neurovascular Dysfunction
•Palpate pulses on both sides. Evaluate capillary refill
and skin color and temperature. Compare with non-
operated limb.
•Assess motion and sensation of operated extremity.
•Test sensation of peroneal nerve by pinch or pinprick in
the dorsal web between first and second toe, and
assess ability to dorsiflex toes after joint replacement.

•Monitor vital signs.
•Monitor amount and characteristics of drainage
on dressings and from suction device. Note
swelling in operative area.
•Ensure that stabilizing devices (abduction pillow,
splint device) are in correct position and are not
exerting undue pressure on skin and underlying
tissue. Avoid use of pillow or knee gatch under
knees.

Acute Pain
•Assess reports of pain, noting intensity (scale of 0–10),
duration, and location.
•Maintain proper position of operated extremity.
•Provide comfort measures (frequent repositioning,
back rub) and diversional activities.
•Encourage stress management techniques (progressive
relaxation, guided imagery, visualization, meditation).
•Provide Therapeutic Touch as appropriate.

•Medicate on a regular schedule and before
activities.
•Investigate reports of sudden, severe joint pain
with muscle spasms and changes in joint mobility;
sudden, severe chest pain with dyspnea and
restlessness.

•Administer narcotics, analgesics, and muscle
relaxants as needed. Instruct and monitor use of
PCA and/or epidural administration.
•Apply ice packs as indicated.
•Initiate and maintain extremity mobilization:
ambulation, physical therapy, exercise and/or CPM
device.

S- Situation:
I am calling about: Mr. Smith
The patient’s code status is
The problem I am calling about is (I am having
intermittent chest pain )
I have assessed the patient personality:
Vital Signs are:
Blood pressure
Pulse:
Respiratory :
Temp:
S-B-A-R Report to Physician about a critical
situation

B- Background:
The patient’s mental status is:
Alert and oriented to person, place and time
Confused___; Cooperative: _____ Non cooperative;____
Agitated_____; Combative: _____
Lethargic but conversant and able to swallow_____
Stuporous: ____ Comatose: ____
The skin is:
Warm and dry: _______ Pale: ______
Mottled: _______ Diaphoretic: _______
Extremities are cold: ____
The patient is not: _____ or is in _____ oxygen:
The patient has been on ____(l/min) oxygen for___ min(hours)
The oximeter is reading_______%
The oximeter does not detect a good pulse and is giving erratic
reading

A- Assessment:
This is what I think the problem is:(say what you think the
problem is)
The problem seems to be: Cardiac: ____ Infection:___
Neurologic :___ Respiratory:______
I am not sure what the problem is but the patient is
deteriorating: yes/No
The patient seems to be unstable and may get worse, we
need to do
Something: ____

R- Recommendation:
I ___suggest or ___request that you: (say what you would like to see done)
Transfer the patient to critical care:______
Come to see the patient at this time: _____
Talk to the patient or family about the code status: ____
Ask the on-call family practice resident to see the patient now: ____
Ask for a consult to see the patient now: _____
Are any test needed:
Do you need any test like CXR: ___ ABG:___ EKG: ___ CBC:
___Urinalysis:___ Others:_____
If a change in treatment is ordered then ask:
How often do you want the vital signs? ____
How long do you expect this problem will last ?______
If patient does not get better when would you want us to call again?_____

MANAGING A
PATIENT post
JOINT
REPLACEMEN
T
in the
HOME
SETTING

I. Before
your
Initial visit

A. Take time to review supporting papers that will
assist in the comprehensive assessment such as:
1. History & Physical form the facility
2. M.D office papers
3. Latest progress notes from the PCP
I. Before the initial visit:

B. Important data needed:
1. Provide skilled nursing care including wound care
and medication management
2. Identify any diagnoses at risk for mobility
problems
3. Ask about patient’s fall history
4. Obtain current medication list Identify meds
potentially impacting mobility

5. Identify if pain management is an issue
6. Ensure that patient’s home is suitable for
recovery
7. Orders for therapy disciplines and
interventions for gait and transfer training, fall
prevention and home safety assessment.

II. During your
Comprehensive
Visit

A. Perform a comprehensive head-to-toe assessment and
Medical History of the patient.
B. Assess for the following:
1. Support group
2. Socio-economical status
3. Cognitive status
4. Environmental status
5. Education provided
II. During the Comprehensive Assessment visit:

C. Check for the following:
1. Passed days after surgery and presence of
staples
2. Next appointment with surgeon and PCP
3. Any take-home medications for the pain such
as Opiates
II. During the Comprehensive Assessment visit:

4. Any prophylactic Antibiotics and/or
anticoagulants prescribed
5. Wound Care instructions
6. Activity restrictions
7. Activity level prior to surgery
8. Opinion about therapy services

III. Head-to-toe assessment
focusing on the following M Items
of the OASIS that will affect the
formulation of the POC:

M Item Action MEDICATION
M 1242
Frequency of PAIN
interfering with
patient’s activity or
movement
Assessment
Procedure:
Inspection, Palpation,
Percussion &
Auscultation
1.Opioids
2.NSAIDS – Non-
steroidal anti-
inflammatory drugs
3.Other non-opioid
pain reliever
4.Other psychoactive
drugs
III. Perform a head-to-toe assessment focusing on the following M Items of
the OASIS that will affect the formulation of the POC:

M Items Action Diagnostic Tests &
Labs
Medication/
Intervention
M 1242
Frequency
of PAIN
interfering
with
patient’s
activity or
movement
Assessment
Procedure:
Assess at every skilled
visit: Homan’s Sign:
1. Ultrasound.
2. Blood test
3. Venography
4. CT or MRI
scans
1. Blood
thinners
2. Compression
stockings

M 1400
When is the
patient
dyspneic or
noticeably
Short of
Breath?
Inspection &
Auscultation:
• Assess for s/sx
of Pulmonary
Embolism
• Auscultate
lung sounds
1.Blood test
2.Chest X-ray
3.Ultrasound
4.Pulmonary
angiogram
Blood thinners
(anticoagulants)

M1350
Does this patient
have a Skin
Lesion or Open
Wound
(excluding bowel
ostomy), other
than those
described above
that is receiving
intervention by
the home health
agency?
Inspection &
Palpation:
• Extremities –
edema
If patient is
with edema,
the answer to
M1350 will be a
YES.
1. Blood Tests - D
Dimer
2. Doppler
Ultrasound
1. Blood
thinners
2. Compression
stockings

M1340
Does this
patient have a
surgical
wound
Quick look at Surgical wounds (OASIS)
Any surgical wound that has been
epithelialized for 30 days or less.
1.Primary intention: wound edges are
approximated with sutures, staples, or
glue at the time of surgery, and
completely seal within 24-48 hours,
‘healing’ in 8-10 days

M1340
Does this patient
have a surgical
wound
Secondary intention:
• Wound is intentionally left open
post surgery to fill with granulation
tissue (similar to chronic wound
healing).
• The ‘healing’ duration is dependent
upon the extent of the deficit

M1340
Surgical
wound
Tertiary intention: a.k.a. delayed primary
closure.
• The wound is left open (often for seven
days or less) to allow for drainage of
exudates, control of contamination,
and/or further surgical procedures, and
then is closed with sutures, staples or
glue.

Surgical Wounds
• Pressure Ulcers with Muscle Flaps
• Dialysis Catheter Exit Sites
• ON-Q catheter sites
• Implanted pumps IF pump is still present
• Cardiac catheter or other procedure by cut-down
• Pacemakers until epithelialized for 30 days
• VP Shunts
• Donor sites for grafts
• Arthoscopy (electrodessication/curettage)
• I&D with drain
• Excision
• Wound with drain even after drain pulled
• Shave, punch or excisional biopsy
• Repair of an internal trauma
• Take down Ostomy
• Any surgical wound that has been epithelialized for 30 days unless it dehisces or becomes
infected

NOT a Surgical Wound
• Pressure Ulcers with Skin Grafts
• Pressure Ulcers sutured close
• Paracentesis
• Toenail Removal
• Retention sutures that utilizes a button
• Cardiac catheter or other procedure by needle puncture
• Pace-makers once epithelialized for 30 days
• Retention Sutures, staple sites
• Cataract Surgery
• I&D without drain
• Mucus Membrane (dental)
• Removal of callus
• Repair of a traumatic laceration (external trauma)
• Burn with a skin graft
• Thoracotomy or any wound ending in OTOMY/OSTOMY
• A grain placed in any organ is an OSTOMY therefore NOT a surgical wound
• Ostomy allowed to close on its own

Labs
Medications
M 1342
Status of Most
Problematic
Surgical
Wound that is
observable.
Inspection: SSI
• Inspect surgical
incision site(s)
Assess:
wound edges if
healing by
primary/
secondary
intention.
• Blood Test
• Wound
Culture
• Blood
cultures
• Serum
investigation
• Antibiotic
Therapy
 Wound
dressing
 Iodine
 Silver

Labs
Medications
M 1342
Status of Most
Problematic
Surgical
Wound that is
observable.
SSI typically
occurs w/in
30days.
1. Superficial
incisional SSI
2. Deep
incisional SSI
3. Organ or space
SSI
• Blood Test
• Wound
Culture
• Blood
cultures
• Serum
investigation
• Antibiotic
Therapy
 Wound
dressing
 Iodine
 Silver

Signs and symptoms of surgical site infections
• Any SSI may cause redness
• delayed healing
• Fever
• Pain
• Tenderness
• Warmth
• swelling.

M Items Action
• M1800
Grooming
• M1810
Dressing upper body
• M1820
Dressing lower body
• M1830
Bathing
INSPECTION/
OBSERVE

• M1840
Toilet Transfer
• M1845
Toilet Hygiene
• M1850
Transferring
• M1860
Ambulation
INSPECTION/
OBSERVE

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