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MGUH Joint Replacement Class
- 1. What To ExpectFor Your Total Joint Replacement 1
- 2. • Preparing forSurgery • What to expect on the Day of Surgery and During Your Hospital Stay • Nursing Care and Pain Management • Physical & Occupational Therapy • What Happens After Discharge? – Patient Care Coordination (PaCC) Class Outline
- 3. • Complete apre-surgical medical clearance with your Primary Care Provider, following the guidelines provided in your mailed surgery packet – If you also see a specialist, such as a cardiologist or pulmonologist, they may also need to clear you for surgery • Depending on medical history, you may also need to complete a visit at GUH Pre-Surgical Department – They will call you approx 2 weeks prior to surgery to conduct a phone screening – If you do not hear from them by 2 weeks prior, please call 202-444-2746 Preparing for Surgery
- 4. • Ask aboutwhich medication you should stop prior to surgery, and which medication you should still take the day of surgery (with a small sip of water) • Otherwise, no food or drink after midnight the day of surgery • Follow instructions for use of Hibiclens skin cleanser the night before and morning of surgery • Can be purchased at GUH pharmacy on Ground PHC or any local CVS, Rite Aide, Walgreens, etc Preparing for Surgery
- 5. • Report toRegistration, 1st floor of Main Building – Use Entrance #2 – Bring ID and insurance cards • You will be escorted to Surgery Center, Ground Floor CCC Building • Surgical Holding Area • Operating Room – Surgery is approx 1.5 - 2 hours • Recovery Room (PACU) • Family Waiting Area, 2nd floor CCC building Day of Surgery
- 6. • Regional Anesthesia(preferred) – Spinal or Epidural Anesthesia – Plus…Deep IV sedation – Pros: gentler recovery, less bleeding during surgery, lower incidence of postoperative blood clots, possibly less pain afterwards • General Anesthesia – May be necessary if taking blood thinners, have had prior back surgery, or if spinal/epidural does not work • Discuss the choices with your anesthesiologist • In either case you will be asleep during surgery Anesthesia Options
- 7. • Oxygen forbreathing support • IV in your arm • Bandage on hip or knee • Knee immobilizer (knee replacement) • Abduction pillow (hip replacement) • Elastic stockings and/or compression stockings • Foley catheter in place to drain your urine Immediately After Surgery…Waking Up in the PACU
- 8. • Nursing assessmentand monitoring – Vitals signs checked every 4hrs first night • Call Don’t Fall! • Breathing exercises – Incentive Spirometer • Blood clot prevention – Continued use of elastic and/or compression stockings while in bed • Ice packs – Knee patients only • Continuous Passive Motion (CPM) – Knee patients only, your surgeon may or may not order this for you Transfer to the Nursing Unit
- 9. • Rate yourpain on a scale of 0-10 – 0 is no pain at all – 10 is the most pain you can imagine – Don’t wait till a “10” to ask for pain medication! • Pain medication: – Oral Pain Pills • Long acting – IV Medication • Short acting • For breakthrough pain • You can not be discharged home or to a rehab center while taking IV Pain Medication Pain Management
- 10. • What arethey? • Why do you need to take them after surgery? • How often and when will you take them? • If you are already taking an anticoagulant, be sure to check with your surgeon for any instructions on stopping or changing before surgery. Anticoagulants
- 11. At Home • Youmay take a shower and get your incision site wet, pat with clean towel to dry • Do NOT: – Submerge the site in water • No baths, No hot tubs, No whirlpools, No swimming – Apply any lotions or creams • Contact us for any fever > 101 degrees, increasing redness or pain in calf, drainage from the wound • Wash hands thoroughly before re-dressing or touching the site in any way – post-op infection is the number one reason for re-admission! • If your surgeon used staples or sutures to close the surgery site, these will be removed at your first follow up visit November 11, 2015 11
- 12. What Does MyNew Knee or Hip Look Like? November 11, 2015 12 GUH surgeons use either DuPuy or Zimmer products. Ask your surgeon’s office for specific details of your replacement. GUH does not perform metal on metal replacements
- 13. • Role ofPhysical Therapy (PT) • Role of Occupational Therapy(OT) Physical & Occupational Therapy
- 14. • Toiletries – Toothbrush,denture care, glasses, contacts, etc • Clothing – Undergarments, sweat pants, gym shorts, T-shirt, nightgown • Clothing should be loose fitting • Avoid: jeans and flip-flops • You will receive hospital traction socks, you may bring shoes if you prefer • Please pack lightly! • Family and Friends – Encouraged to observe therapy sessions to learn how to assist you properly at home What to Bring to the Hospital
- 15. • Average Lengthof Stay – For both hip and knee patients average stay is 2 nights • Day of Surgery – Our goal is to get you OUT OF BED SAME DAY – You will either have your full PT evaluation that evening, or your nurse will help you to get out of bed and to the chair • Post-Operative Day 1-2 – You will be seen by PT twice each day – You will be seen by OT once each day, until you no longer need their services Physical and Occupational Therapy Plan
- 16. • Physical Therapy •Strengthening exercises, walking, stairs, group sessions • For knee patients, goal is 90 degree bend by time of discharge • Recommend the safest assistive device for walking • Occupational Therapy • Daily Activities: transferring to toilet, dressing • Recommend adaptive equipment Physical and Occupational Therapy Plan
- 17. • Do notcross your legs • No bending forward at the hip • Do not rotate your leg inward • Weight bearing as tolerated Posterior Hip Precautions (to be followed for approx 6 wks post surgery)
- 18. • There areno movement restrictions except for avoiding a figure of four position with the operated hip. • You may cross your ankles • Weight bearing as tolerated Anterior Hip Precautions (to be followed for approx 6wks post surgery)
- 19.
- 20. Adaptive and AmbulatoryEquipment 3 in 1 Commode * CaneWalker * Many insurances do not cover Commodes. If you are tall, or have low toilets, considering purchasing this ahead of time at home improvement stores, medical supply stores, or thrift stores Raised Toilet Seat
- 21. • Pages 13-18in your Guidebook • Do as many as you can, without pain, before surgery • Your therapist will give you specific ones to do after Exercises
- 22. • Two importantexercises: – Seated knee extension (quad mobilization): – Seated hip flexion (hip flexor mobilization): Anterior Total Hip Replacement Exercises
- 23. Your Patient CareCoordinator (PaCC) will assist with discharge planning from the hospital and help you make arrangements for rehabilitation services. Patient Care Coordination(PaCC)
- 24. • Outpatient Services –Traveling to physical therapy appointments 2-3 times/wk – More equipment with broader range of exercises • Home Health Care – Physical therapist comes to your home 2-3 times/wk • If you are not safe to discharge home, your PaCC will discuss other options with you during your care plan. Our goal is for you to safely discharge HOME from the hospital! Rehabilitation Options (Not all options are covered by all insurances)
- 25. What Factors Affectthe Rehabilitation Option that is Right for Me? • Your insurance coverage • The recommendation of your surgeon and therapists • Level of activity and independence prior to surgery • Existing medical conditions November 11, 2015 25
- 26. Prepare BEFORE Surgery: •Attend Total Joint Replacement Class • Read the Surgery Guide and other materials provided by your surgeon’s office • Think of homecare agencies and outpatient physical therapy facilities that you or others have used in the past • Get recommendations and visit facilities • If you have commercial insurance, call ahead to check which facilities are in-network • You will speak with your PaCC prior to surgery for an individualized Care Plan Meeting
- 27. • Your PaCCwill be in communication with your medical team and therapists to determine appropriate discharge plan • Your PaCC will meet with you in your room to review your discharge plan and discuss your preferences • Your PaCC will make all necessary arrangements for transfer to your next location, whether that be home or a rehabilitation facility. During Your Stay at Hospital
- 28. • Your PaCCremains available to address any questions or problems and facilitate transitions to the next level of care. • For many patients, rehabilitation will involve outpatient services at some point, regardless of where you go after your hospital stay – Identifying a location early and getting appointments pre-scheduled avoids a lapse in therapy! – You must obtain a prescription for physical therapy and bring to your first appointment • First follow-up appointment with your surgeon’s office approx 2 weeks after surgery After Your Discharge from Hospital
- 29. • 2-4 wksbefore your doctor will recommend driving • Proper vehicles for transportation: Avoid anything too compact or too low to ground • Up to 6wks before your doctor will recommend flying Transportation Plan for TRANSPORTATION home from the hospital, and for all outpatient appointments.
- 30. • Raise theheight of chairs and beds if necessary • 3 in 1 commode or raised toilet seat if necessary • Remove throw rugs and cords from walkways • Ensure adequate lighting; nightlights are a good idea! • Have footwear available that is easy to slip on but also provides protection for your toes and heel • Make arrangements for care of young children and pets • Do laundry and stock up on groceries prior to surgery • Ask for help when you need it !!! Preparing Your Home for Discharge
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Editor's Notes
- #3 Welcome to the Medstar Georgetown University Hospital Total Joint Replacement Class! During the course of this class, we will review the surgery process for knee and hip replacements. We will review preparing for surgery, what to expect on the day of surgery and during your hospital stay, nursing care and pain management, and physical and occupational therapy. Finally, we will discuss your patient care coordination and what happens after you discharge from the hospital.
- #4 Prior to your surgery, you’ll be required to complete a medical clearance with your primary care provider and any specialists that you see. You will receive a surgical packet in the mail with the guidelines. Based off of your medical history, you may also need to have a pre-surgical visit here at the hospital. The pre-surgical department calls you about 2 weeks prior to your surgery, and conducts a phone screening regarding your health and medications. Based on this screening, they may require you to come into the hospital for a more in depth visit. If, for some reason you don’t hear from them by 2 weeks before your surgery, be sure to call them at 202-444-2746.
- #5 When you go in for your primary care and/or pre-surgical appointments, be sure to bring a list of your medications to review. This includes all supplements and vitamins. Your providers will let you know which medications you should or should not be taking the day of surgery. You should not eat of drink after midnight the day of your surgery, this includes water, coffee, gum, hard candy etc. The only exception is any medication your doctor has asked you to take. When you take the medication you are allowed to drink a small sip of water to swallow the pill. Your surgical packet will include instructions on a Hibiclens skin cleanser. The surgeons want you to take a shower the night before and the morning of your surgery using Hibiclens skin cleanser. Hibiclens is a very strong soap that cleans your skin, and decreases your risk of infection. Be sure to wash your body from the neck down; do not use it on your face or your hair. You can get this cleaner over the counter at any pharmacy, including Georgetown’s outpatient pharmacy.
- #6 The day of surgery you’re going to arrive to the hospital 2 hours prior to the start of your surgery and use Entrance 2. You’ll drive past the Emergency Room entrance to the Main entrance, which is a circular road underneath the building. A valet can park your car for you. Walk in, take a left, and go to the Registration desk. Be sure to bring your ID and insurance cards. Once you’re done with Registration, they will escort you to the Surgery Center which is on the ground floor of the CCC Building. Once you get to the surgery center, you will be escorted to the Holding Area, where you’ll change into a gown, have an IV placed, and answer some questions. The surgeon and anesthesiologist will visit you and confirm what surgery you’re having and what body part the surgery is being performed on. The surgeon will write on your knee or hip, marking the correct body part. Your family member can come with you to the holding area, but once you go to the OR, family will go to the Family Waiting Area on the 2nd floor of the CCC Building. You’ll be in the OR for about an hour and a half to two hours, and after you will go to the Recovery Room or PACU.
- #7 There are two anesthesia options. The first is Regional Anesthesia, which is spinal or epidural anesthesia and deep IV sedation. The Pros are a gentler recovery, less bleeding during surgery, a lower incidence of blood clots after surgery, and possibly less pain afterwards. This is the preferred method, but it is possible that you may need General Anesthesia. General Anesthesia may be necessary if you’re taking blood thinners, if you’ve had prior back surgery, or if for some reason the spinal or epidural does not work. The anesthesiologist will discuss these two options with you prior to surgery and based off of your medical history, they will decide which option will be best for you. You will be asleep no matter which anesthesia you receive.
- #8 After surgery, you will wake up in the PACU or recovery room. You will have oxygen on for extra breathing support, which will be a small tube that wraps around your ears and under your chin. You will have an IV in your arm, which will be hooked up to some fluids to make sure you don’t get dehydrated. You will have a bandage on either your hip or your knee depending on your surgery. If you’ve had a knee replacement, you’ll have a knee immobilizer on. This is a brace that doesn’t allow you to bend your knee. We usually keep that on for the first day to give extra support and stability since your muscles are very weak after surgery. If you’ve had a hip replacement, you may have an abduction pillow which is a large yellow foam wedge that sits between your legs and keeps your legs spread apart. The point of this is to make sure you don’t cross your legs. Once you get to the nursing unit, we will review the physical movements you can and cannot do to protect your new joint. All of the surgeons will order a compression device. These are legs wraps that are connected to a machine at the end of the bed. The machine pumps air into the leg wraps and gives you a small leg massage. The point of it is to get your blood from your feet back up to your heart, and prevent blood clots. You are at a higher risk for blood clots because you’ve had surgery, so we have multiple ways to decrease your risk. Some of your surgeons will also order compression stockings, which are nylon stockings that are very tight to help circulate your blood. You may wake up with a foley catheter, which is a catheter that goes straight into your bladder. A tube is attached to an external bag which hangs on the side of your bed. Foley catheters are not placed very often, but we like to mention it just in case you have one. If you have one, they will usually remove it the next morning.
- #9 Once you are stable in the recovery room, which means your vital signs look good and your pain is well controlled, you’ll be transferred to a nursing unit. We try to place all total joint patients on 6 Main, our orthopedic unit, however the hospital isn’t always able to accommodate that. No matter what unit you go to in the hospital, you will receive the same care Once you get to the nursing unit, the nurse will come in and do an assessment. The nurse will listen to your heart, lungs, and belly; look at your dressing, and feel your feet to check your pulses They will do a head to toe assessment to make sure everything is as it should be. A tech will come in to take your vital signs. We will be checking your vital signs every 4 hours for the first 24 hours. We will also draw blood for labwork during the night, every night that you are in the hospital. 6 Main, the orthopedic unit, has a tagline “Call, Don’t Fall”. We make everyone who comes to our unit sign a contract to agree they will not attempt to get out of bed by themselves. Since you’ve had surgery, your muscles are weak and you can get dizzy from the anesthesia, so you’re at an increased risk to fall. Please call someone to assist you anytime you’d like to get up. We give everyone an incentive spirometer, so you can do breathing exercises which will increase your oxygen intake. This will help heal your body, prevent fever, and pneumonia. The surgeons want you to use it 10 times an hour, every hour you are awake, and we will explain how to use it once you arrive to the unit. You will continue to wear your elastic and/or nylon compression stockings on the unit. Some knee patients like to use ice to help control pain, just let your nurse or tech know. The continuous passive motion machine, or CPM machine, is for knee patients only. Almost every surgeon orders this while you’re in the hospital. The machine bends and straightens your knee for you. It helps to loosen your muscles and get them back to their regular activity. Some surgeons may also order it for you for home.
- #10 We will constantly be asking you to rate your pain on a scale of 0-10, 0 being no pain and 10 being the worst pain you can imagine. We ask this to get an idea of what your pain is so we can best help to control it. Do NOT wait until your pain is a 10 before asking for pain medication. It is much easier to control pain at a lower level. We usually recommend that if you’re having pain around a 4-5 level, call and ask for pain meds. There are 2 different forms of pain medications: pills and IV. Pills are longer acting and when you go home you will be using pills only. Therefore we will try to get you on a pill regemine that works for you as soon as possible. We also have IV medication. It is very short acting, usually only for 1-2 hours, but it does start working within 15 minutes. We use IV for breakthrough pain only. This means that if you’ve taken your pills and are not due for more, but your pain spikes up to a high level, we will give you the IV medication to bring your pain level down. There are many types of pain medications, so if what you’re on isn’t working, we can change the type, dosage, or frequency. We also have an Acute Pain Service team at GUH which we may consult for your pain management. You will not have no pain, but our goal is to get your pain to a tolerable level and keep it there.
- #11 Anticoagulants are blood thinners. You need to take them after surgery because you’re at a higher risk for a blood clots due to 1) the surgery itself, and 2) you aren’t up and walking around like you normally would be. How often and when you take the medication depends on which particular one you’re on. There are a variety of different types and your surgeon will choose the appropriate one for you based on your medical history. If you’ve been on a blood thinner, make sure you let your surgeon know before surgery. You will need to stop it prior to your surgery, and each blood thinner has a specific timeframe in which it needs to be stopped.
- #12 The following information will be reviewed with you again the day of your discharge from the hospital. Once you get home, you can take a shower and get your incision wet. Just be sure to pat it dry with a clean towel after your shower, and continue to keep your incision clean and dry. You cannot submerge your incision, so this means no baths, swimming pools, hot tubs, or standing water. You cannot apply any lotions or creams directly onto the incision; everywhere else on your body is ok. The reason you can’t do these things is because your skin isn’t completely healed yet, and water or lotions can introduce bacteria into your incision which will cause an infection. If you have a fever, increased redness or pain in your calf, or drainage from the wound, call the surgeon right away as they are all signs of an infection. Be sure to wash your hands thoroughly before and after you touch your incision to prevent infection. Infection is the number one reason people come back to the hospital. If your surgeon used staples or sutures, those will be removed at your first post-op appointment.
- #13 This is a picture of what your new hip or knee will look like. The surgeons here use either Dupuy or Zimmer products. If you want to know more details on the products they are using, be sure to ask your surgeon as each surgeon has their own preference. As a note, MGUH does not perform metal on metal replacements. We perform either metal on ceramic or metal on plastic.
- #14 Now we are going to discuss what to expect from Physical and Occupational Therapy during your stay here a Georgetown.
- #15 These are some of the things that we recommend that you bring with you to the hospital. If you want to bring clothes, we recommend shorts or loose fitting sweat pants. You will be walking in the hallways and may feel more comfortable wearing bottoms instead of just our gowns. Family is welcome to attend your therapy sessions in order to learn how to assist you at home. Please let your therapist know so that a time can be coordinated. Please leave walking devices such as walkers, canes and crutches at home so that they do not get misplaced.
- #16 The average length of stay for both hips and knees is two nights. If you are having an anterior hip replacement your stay may be one night. Our goal is to get you out of bed on the day of surgery. If your surgery is late, nursing will assist you out of bed. We will only do what you are able to do on that first day. If you are only able to get to the chair, that is all we will do. If you feel up to walking, we will take a short walk. PT will see you twice a day and OT will see you daily until you are independent with self care.
- #17 Here is the Physical and Occupational plan while you are here. Therapy will continue to progress your function each day. There is overlap between Physical and Occupational Therapy in the hospital setting. Both will work on mobility and endurance. Physical Therapy will focus on strengthening your leg, walking longer distances, and going up and down stairs. Occupational Therapy will focus on being able to take care of yourself at home, and getting in and out of the bathroom safely.
- #18 Posterior Hip Precautions should be followed for about 6-8 weeks after surgery. We will remind you frequently about these precautions while you are in the hospital. DO NOT cross your legs. DO NOT bend forward at hips. DO NOT rotate your leg inwards. You may put as much weight as you can tolerate on the leg when standing and walking.
- #19 If you are having an Anterior Hip Replacement there are no movement restrictions except for avoiding a figure 4 position with the operated leg. You may cross your ankles. If you are unsure which hip procedure you are having please check with your surgeon. With all types of surgery you can progress to the least restrictive walking device.
- #20 Here is a photo of some of the equipment that may be given to you while you are in the hospital to assist you with bathing and dressing. The Occupational Therapist will evaluate if these are appropriate for you and provide them to you before you leave.
- #21 This photo is some additional equipment that may be appropriate for you for safe transfers and mobility. Your Patient Care Coordinator will review what is available and what is covered by your insurance.
- #22 In your guidebook (provided by your surgeon), there are some recommended exercises on pages 13-18 that you can do prior to your surgery. All will be reviewed with you after your surgery. Please focus on the quad sets on page 16, the elevated ankle pumps on page 17, and buttock squeezes on page 17. These three are great to do in preparation for the surgery and can also be done as soon as you wake up in the recovery room.
- #23 If you are having an anterior hip replacement these are two exercises the doctor wants you to focus on- seated knee extension and seated hip flexion
- #24 During your surgery process, you will be assigned to a patient care coordinator (PACC). Your PACC is your case manager and helps you navigate the surgery process from beginning to end. Your PaCC will assist with discharge planning from the hospital and help you make arrangements for your rehabilitation services after your inpatient stay.
- #25 Most patients discharge home, either to outpatient services or with home health services. For patients who are high functioning prior to surgery and progress quickly during their hospital stay, outpatient therapy is an appropriate option. This requires traveling to an outpatient clinic 2-3 times per week. Outpatient therapy clinics offer a broader range of exercises and equipment. If you are not physically appropriate for outpatient services immediately following or discharge, or do not have transportation options available, then you will set up with in-home care. A home therapist and/or nurse will come to your home 2-3 times per week for 2-3 weeks. After home therapy is completed, the surgeon may recommend outpatient therapy services. If you are not safe to discharge home, your PACC will discuss other options with you during your individualized care plan. Please keep in mind that our goal is always for patients to discharge home after surgery.
- #26 The following factors affect the rehabilitation option that is right for you. -Your insurance coverage, including the services your insurance approves and authorizes -Your progress with therapy after the surgery, and your therapists’ recommendation -Your surgeon’s recommendation -Your level of activity and independence prior to surgery -Any existing medical conditions that may interfere with your rehab We will consider your preference and all of these factors in coming to a decision that will work for you and the medical team.
- #27 We recommend the following steps in preparation for surgery: -Attend the total joint replacement class, or review the class slides online -Read the surgery guide and any other materials provided to you by your surgeon’s office -Start thinking about which homecare agencies, and outpatient centers you will want to use after surgery. -If you have commercial insurance, such as Blue Cross, United, Aetna, Cigna, or Tricare, call your insurance company ahead of time to check facilities and agencies that are in network with your insurance. Your PACC coordinator can also assist you in finding this list. -Your PACC coordinator will contact you one to two weeks prior to surgery, and complete an individualized care plan. During this call, we will discuss your specific insurance coverage, social situation, medical history, caregiver support, and preferences – then develop an anticipated discharge plan. Keep in mind, discharge plans can change after surgery, but we plan ahead to make your discharge from the hospital as smooth as possible.
- #28 During your hospital stay, your PACC coordinator will be in communication with you, your medical team, and the therapy team to determine the best discharge plan. Your PACC will meet with you in your hospital room to discuss your preferences and update you on the discharge plan. Your PACC will make the necessary arrangements for your transfer to the next level of care.
- #29 After your discharge from the hospital, your PACC will remain available to you to address any questions or problems you may encounter and help you transition to the next level of care. For most patients, your rehabilitation process will include outpatient therapy services at some point. This is especially true for knee replacement patients. We recommend identifying a location early and making appointments ahead of time to avoid a lapse in therapy. We can help you locate a facility, make appointments, and obtain an order. You will have a follow up appointment with your surgeon’s office 2-3 weeks after your surgery.
- #30 It is important to plan for transportation home from the hospital, and to follow up appointments and outpatient appointments within the first month. You will not be able to drive for 2- 4 weeks after surgery so you will need to make sure you have a ride or transportation services set up. Your PACC can help you with applications for Metro Access or Medicaid transportation. When you arrange a ride, try to avoid vehicles that are too compact or too low to the ground, such as sports cars. Sedans and SUVs are usually fine. Flying is not recommended for 6 weeks after surgery due to the increased risk of blood clots. Please consult your surgeon about any travel plans.
- #31 We recommend the following to help prepare your home for discharge: -Raise the height of chairs and beds in your home, or avoid low furniture -If your toilets are low or you are very tall, you may want to purchase a raised toilet seat or bedside commode prior to surgery. Most insurances do not cover these items, and it is cheaper to purchase them ahead of time. If you are getting a posterior hip replacement, you will be on height precautions for the first 6 weeks, so these items can be very helpful. -Please remove throw rugs and cords from walkways to avoid falls. -Have footwear that is comfortable and supportive. We recommend shoes that protect your heel and toe and are easy to slip on. Flip flops are not recommended. -Make arrangements for young children and pets ahead of time. -Stock up on groceries and do laundry -Ask for help when you need it
- #32 Thank you so much for attending our pre op joint replacement class! We hope it was helpful for you!