Perioperative Care. Kay S. Jones, Elizabeth A. Potts, and J. W. Thomas Byrd. Preoperative Care

Transcription

1 Periopertive Cre Ky S. Jones, Elizeth A. Potts, nd J. W. Thoms Byrd 34 In hip rthroscopy, the physicin plces gret emphsis on ptient selection, the surgicl procedure, nd the rehilittion process fter surgery. It is lso importnt to provide the necessry periopertive cre to the ptient during this time of disility nd ltered functionl stte. The clinicl nurse nd physicin extender hve multifceted roles nd ply n integrl prt in the ptient s periopertive experience. This commences even efore the decision for surgery is mde nd continues until recupertion nd rehilittion re complete. Much of the clinicl nurse s efforts re spent prepring the ptient nd the ptient s fmily, which will e referred to s cregivers, for the postopertive period. It is importnt for the nurse to ssure tht the expecttions of ptients nd cregivers re resonle nd pproprite nd tht they re prepred for wht is to come. The physicin extender cn provide physicl exm nd dignostic informtion to the surgeon to help guide the ptient through the periopertive process. The clinicl nurse nd physicin extender provide comprehensive cre, eduction, continuity, nd support to ptients undergoing hip rthroscopy. They serve s resource not only for the ptients ut lso for the surgeon, outptient personnel, physicl therpists, nd other ncillry gencies. The clinicl nurse s role includes consulting nd collorting with others to help increse the effectiveness, ef fi ciency, nd sfety of the cre rendered to the ptient. Both the clinicl nurse nd physicin extender ply n importnt role in fcilitting communiction mong memers of the helth cre tem. As helth cre resources nd ptient needs ecome more sophisticted, so must the skills of the person to whom the ptients nd stff turn for ssistnce nd direction. To function most effectively in these multiple roles, the clinicl K. S. Jones, MSN, RN ( ) E. A. Potts, MSN, APN, ACNP-BC J. W. T. Byrd, M.D. Nshville Sports Medicine Foundtion, 2011 Church St., Suite 100, Nshville, TN 37203, USA e-mil: ky@nsmfoundtion.org; info@nsmfoundtion.org nurse nd physicin extender must e knowledgele of ll spects of hip rthroscopy including ntomy nd physicl exmintion of the hip, pproprite dignostic testing, the surgicl procedure nd its indictions, expected outcomes, possile complictions, nd the postopertive rehilittion process. This knowledge enles the nurse to provide the necessry nursing cre nd enles the physicin extender to perform the dvnced prctice roles of provider, eductor, prctitioner, consultnt, nd collortor. Preopertive Cre An outptient surgicl setting is routine for mny surgicl procedures. It is dvntgeous ecuse it reduces costs nd llows ptients to recuperte in their own environment. This requires tht the ptient nd cregivers ecome ctively involved in nd responsile in the periopertive cre [ 1 ]. Ptient preprtion strts with the fi rst visit to the orthopedic of fi ce. This visit my e for dignostic purposes, conservtive tretment mesures, or for the decision for surgery. It is importnt to estlish n open nd trusting reltionship with the ptient nd other cregivers from the fi rst encounter. It is through this specil reltionship nd unique interction tht the foundtion for the periopertive course is lid. It is importnt to provide continuity of cre through direct ptient interction. Both the nurse nd physicin extender cn serve s resource with whom ptients cn feel comfortle conversing nd sking questions. This is importnt in helping ptients nd cregivers mnge their nxiety nd to provide informtion regrding dignoses, testing, surgery, nd postopertive recovery. It tkes comprehensive systemtic pproch to cre for the ptient undergoing hip rthroscopy. The providers must demonstrte n ptitude to foresee nd discuss cre options including potentil short-term nd long-term consequences. This requires continul ssessment, dignosis, intervention, nd evlution of the ptient nd the pln of cre. J.W.T. Byrd (ed.), Opertive Hip Arthroscopy, DOI / _34, Springer Science+Business Medi New York

2 442 K.S. Jones et l. Ptient Helth History To otin thorough helth history, dequte time must e spent with the ptient. This is done on the ptient s fi rst visit to the of fi ce. This history is composition of sujective nd ojective dt tht will ssist in identifying dignoses nd collortive helth prolems. In our opinion, the history is the single most essentil element in ptient evlution. The surgeon my use some of the informtion provided y the clinicl nurse specilist or physicin extender, ut he or she my lso sk their own set of questions sed on their dilogue with the ptient. Nonetheless, this initil history is importnt for two resons. First, it provides the ptient n opportunity to formulte nd orgnize their thoughts, mking the susequent interction with the surgeon more time-ef fi cient. Also, just s prt of humn nture, it is not uncommon to encounter contrdictions in the ptient s response etween the two interviews. This provides n opportunity to estlish clri fi ction since the informtion otined my hve signi fi cnt in fl uence on the susequent course of tretment. Sujective Dt The ptient interview is communiction process tht focuses on developmentl, psychologicl, socioculturl, nd spiritul responses. It is importnt to e cogniznt of the ptient s comfort nd nxiety levels, ge, nd current helth sttus. These fctors cn in fl uence the ptient s ility to fully prticipte in the interview. The interview process hs three phses. During the introductory phse, the nurse or extender nd the ptient get to know ech other. At this time, the ptient is given rief overview of the interview process, nd its purpose is explined. The second phse is the working phse, in which the history is otined. It is importnt to tke cues from the ptient, listen, nd use criticl thinking skills in interpreting nd vlidting the informtion received from the ptient. The fi nl phse of the interview process is the summry phse, in which the informtion otined is summrized to ensure ccurcy nd to vlidte prolems nd gols. Possile plns for prolem resolution re discussed with the ptient during the summry phse [ 2 ]. A few speci fi c communiction techniques cn e employed to fcilitte the interview nd ensure its ef fi ciency. It is importnt to sk open-ended questions to otin ptient perceptions. These questions egin with Wht, When, Where, nd How nd re importnt ecuse they encourge the ptient to use more thn one-word response. Closeended questions re lso importnt to help otin fcts nd elicit speci fi c informtion. This my help keep the ptient from rmling. Offering the ptient list of words to choose from my help otin speci fi c nswers while reducing the chnce tht ptients will perceive nd try to provide n expected nswer. For exmple, in reference to the qulity of pin, one might sk, Is the pin dull, shrp, or sting? When dt is otined tht digresses from norml, further explortion is necessry. These questions re useful: Wht llevites or ggrvtes the prolem? How long hs it occurred? When does it occur? Ws the onset grdul or sudden? Throughout the interview, it is importnt to rephrse the ptient s responses to clrify informtion otined [ 2 ]. There re severl key points to rememer when interviewing ptient. The fi rst is to void eing judgmentl. This will help put the ptient t ese nd more inclined to provide speci fi c informtion. It is importnt to utilize silence to help ptients orgnize their thoughts. It is lso helpful to provide nswers to questions s they rise during the interview. Avoid leding questions, rushing the ptient, nd performing other tsks while tking the history [ 2 ]. By employing these principles during the interview, the informtion otined is used in developing pln of cre nd in providing informtion necessry for mking dignosis. While otining the ptient s history, one must e wre tht mny disorders cn present s pinful hip, including prolems of the lower ck s well s viscerl disorders nd tht the ptient my descrie hip pin tht ctully represents referred symptoms from different origin. Once the prolem hs een loclized to the hip re, distinction must e mde etween intr-rticulr nd extr-rticulr symptoms. A few chrcteristic fetures my clue the exminer to suspect n intr-rticulr hip prolem. These hllmrks include complints of nterior, inguinl, or medil thigh pin. Complints of lterl hip pin or posterior or uttock symptoms re more commonly cused y extr-rticulr sources such s trochnteric ursitis, ductor muscle injury, or scitic. A history of ctching or popping in the hip my e relted to intr-rticulr pthology ut cn lso occur with disorders outside the joint. Ptients with norml intr-rticulr hip pthology commonly complin of pin in the groin with stnding nd multion. They my relte tht they cnnot sit for prolonged periods of time nd tht sitting with the hip in fl exed position is especilly uncomfortle. Incresed pin my e experienced with weight-ering ctivities nd when scending or descending stirs. The ptient my report dif fi culty with putting on socks nd shoes or getting in nd out of the cr. Usully, correltion is seen etween the ctivity level nd the pin perceived. Ojective Dt: Physicl Exmintion After the sujective informtion hs een otined, the ojective spects of the ptient s complints cn e explored. The physicin extender or surgeon my otin this informtion,

3 34 Periopertive Cre ut it is importnt for the clinicl nurse to understnd the physicl ssessment process. This is discussed in detil in Chp. 2 nd summrized here. Exmintion of the ptient with complint of hip pin is strightforwrd ut inclusive of the lumr spine nd pelvis. Mny ptients present with chief complint of hip pin ut do not hve n intr-rticulr hip prolem. Therefore, the exminer must fi rst consider extr-rticulr sources tht could cuse the ptient s hip pin. Once the extr-rticulr sources re ruled out, intr-rticulr sources of the ptient s pin cn e considered. Some extr-rticulr disorders my mimic hip prolem nd my sometimes coexist with hip disorder. A common exmple mong thletes is thletic pulgi ( sports herni ), which cn occur in conjunction with femorocetulr impingement (FAI). Some ptients with erly signs of hip disese my lso hve component of lumr spine disese. Ptients with chronic hip prolems my demonstrte glutel tenderness to plption simply s these muscles hve een overworked ttempting to protect the joint. Snpping of the iliopsos tendon is incidentlly present in up to 10% of norml ctive popultion nd could simply e present in conjunction with joint prolem. For every one of these pprent extr-rticulr prolems, there re numerous less ovious disorders of the lumr spine, pelvis, nd viscer tht my e the source of symptoms. Oservtion of the ptient s git pttern is meningful. The git my e ntlgic or possily revel n ductor lurch, which reduces the forces generted cross the hip. The ptient my use n ssistive device such s cne or crutches. It is importnt to note the ptient s se of support. While stnding, the ptient my ssume slightly fl exed position of the ffected hip. When seted, the ptient my slouch to void excessive hip fl exion or len to the uninvolved side with the hip in slightly ducted, externlly rotted position. It is importnt to inspect the ptient s hips nd lower extremities for ny symmetry, gross trophy, spinl mllignment, or pelvic oliquity tht my e fi xed or ssocited with gross leg length discrepncy. Leg lengths cn e mesured s routine prt of the exm. In some situtions, documenting thigh circumference my re fl ect the chronicity of the prolem nd my e rough indictor of the response to therpy. It is lso importnt to document rnge of motion of the ffected hip compred with the unffected hip. It is helpful to sk the ptient to use one fi nger to point to the re of most discomfort. This is useful wy of determining the re of mximl involvement. Intr-rticulr hip pthology typiclly hs component of nterior hip pin. The ptient my lso relte senstion of deep, lterl discomfort or posterior pin, ut this is usully in conjunction with signi fi cnt nterior component. Often, the ptient will demonstrte the C-sign in descriing deep hip pin. This sign is chrcterized y plcing the index fi nger nd thum 443 round the hip, forming C-shped pttern over the re of involvement. The index fi nger rests in the groin re nd the thum rests over the posterior spect of the trochnter. Plption is rrely helpful in determining intr-rticulr pthology, ut it is importnt in the overll ssessment of other sources of pin in the hip region, such s trochnteric ursitis or ductor tendinopthy. The exminer plptes the lumr spine, scroilic joints, ischium, ilic crest, nd the lterl hip round the greter trochnter, lwys compring the unffected to the ffected side nd exmining the unffected hip fi rst. Rnge of motion should e ssessed nd recorded, looking for symmetry or ilterl nomlies. While reduced rottion often ccompnies FAI, excessive moility my imply dysplsi or cpsulr lxity. Popping or snpping my e present nd cn occur from vriety of intr-rticulr nd extr-rticulr sources which cn e indictive of pthology or sometimes just norml fi nding. Mnul muscle testing is crude mesure of hip function ut my elicit symptoms loclized to speci fi c muscle injury. The most speci fi c indictor for hip joint pin is log rolling of the ptient s leg. This ction moves only the femorl hed in reltion to the cetulum nd the surrounding cpsule. The sence of pin on log rolling does not preclude the hip s the source of symptoms, ut the presence of pin with this mneuver gretly rises the suspicion of mechnicl joint pthology. Extreme forceful end rnges of motion my elicit pin with even sutle hip pthology. Mximl fl exion with internl rottion is referred to s n impingement test, ut we hve found this mneuver to e uncomfortle in ssocition with virtully ny intr-rticulr pthology nd not just speci fi c for impingement. The Ptrick or FABER ( fl exion, duction, externl rottion) test hs een used to induce symptoms from oth the hip nd scroilic joint. The distinction is usully sed on the origin of the pin. An ctive stright leg rise will often elicit symptoms. This mneuver cretes force of severl times ody weight cross the rticulr surfces nd ctully genertes more force thn wlking. Ojective Dt: Dignostic Testing Ptient history nd clinicl exmintion re importnt tools, ut dignostic testing lso plys lrge role in the evlution of hip rthroscopy cndidtes. This egins with plin rdiogrphs nd my include vrious dvnced imging s discussed in Chp. 3. Beyond the norml clinicl ssessment, the est indictor of true joint pthology is pronounced temporry pin relief from n intr-rticulr injection of nesthetic. We hve reported tht positive nesthetic relief of hip pin hs een found to e indictive of norml intrrticulr pthology with 90% ccurcy [ 3 ]. Trditionlly, fl uoroscopy hs een used for this type of injection, which is not redily ville in most orthopedic of fi ces.

4 444 K.S. Jones et l. Fig ( ) Visuliztion of the hip is performed y plcing the trnsducer fi rmly over the re of the femorl hed/neck junction in long xis nd slightly olique. A slight olique ngle to the trnsducer llows more lterl entry site for the needle into the joint nd increses the distnce etween the needle nd the femorl neurovsculr structures nterior to the hip. The skin hs een sterilely prepped nd sterile gel is used. Prior to the injection, scn should e performed to visulize the loction of the neurovsculr undle. ( ) Ultrsound imge of nterior hip joint with proe positioned over femorl hed/neck junction s descried ove. (All rights re retined y Dr. Byrd) Fig ( ) The needle is inserted in plne with the trnsducer which llows visuliztion of the needle throughout the course of its dvncement to the cpsule. ( ) The needle cn e seen entering the joint cpsule t the se of the femorl hed. (All rights re retined y Dr. Byrd) Ultrsonogrphy There hve een sustntil technologicl dvncements in ultrsonogrphy since the second edition of this textook. It is now ville in n of fi ce setting with numerous dignostic nd interventionl roles pplicle to surgeons nd physicin extenders. Intr-rticulr hip injections for dignostic nd therpeutic purposes cn e relily performed under ultrsound guidnce (Video 34.1: ) (Figs. 34.1, 34.2, 34.3, nd 34.4 ). We hve found the technique to e very reproducile. Perhps most importntly, our ptients hve uniformly found tht the experience of n in-of fi ce ultrsound injection of the joint is much gentler experience thn one performed under fl uoroscopy. This is especilly compounded y the convenience when the ptient does not hve to trvel to hospitl or imging center for fl uoroscopy. The clinicl dvntge is sustntil, s rel-time ssessment of the ptient s pre- nd postinjection pin level is redily otined. Sometimes this my necessitte speci fi c functionl ctivities on the prt of the ptient in order to mke this determintion. Ultrsound is much more thn just n injection tool. It cn e used to look for n effusion which, historiclly, hs een one of the most relile positive indictors of hip pthology. Extr-rticulr structures cn e ssessed including the iliopsos tendon (Video 34.2: ), (Video 34.3: ) (Figs. 34.5, 34.6, 34.7, nd 34.8 ), ductor ters (Figs. 34.9, nd ), (Video 34.4: goo.gl/7aod1 ) nd the piriformis (Video 34.5: FOSiu ) (Figs , 34.12, 34.13, nd ), mong others. Dignostic nd therpeutic injections of these res cn e

5 34 Periopertive Cre 445 Fig ( ) The trnsducer remins in the sme plne throughout the injection. ( ) The mediction cn e visulized entering the joint cpsule. (All rights re retined y Dr. Byrd) Fig ( ) After completing the injection process, the syringe is removed nd smll ndge is pplied. ( ) The mediction cn e visulized in the joint cpsule. (All rights re retined y Dr. Byrd) performed with relile locliztion for corticosteroids or pltelet-rich plsm for select conditions. Ultrsound lso offers the ility for dynmic exmintion of numerous soft tissue structures, including muscles nd tendons, ligments, nd neurovsculr structures. There is much ongoing work in this re evluting the contriution of these numerous structures s cuses of pin nd dysfunction in the hip region. Postopertive Cre By the time the ptient rrives in the operting suite, the eductionl process should e complete nd the ptient prepred to hndle the events tht will follow. As discussed erlier, this eductionl process is est ccomplished efore the ptient rrives t the hospitl. Three slient fetures re importnt in the postopertive cre of the ptient: pin control, wound cre, nd ctivity level. It is importnt tht these re understood y the ptient nd the cregivers. These concepts my e dif fi cult to comprehend preopertively ut should e discussed. I t i s h e l p f u l t o h ve w r i t t e n p o s t o p e r t ive i n s t r u c t i o n s f o r the ptient nd cregiver ( Appendix ). T h i s w i l l r e i t e r t e much of the informtion tht hs een verlized preopertively nd immeditely postopertively. Providing written dischrge instructions will help increse retention nd understnding of the informtion provided [ 4 ]. T h e study y Oerle et l. [ 5 ] showed tht timing of preopertive teching is criticl to retention nd ptient stisfction. Approximtely 25% of the ptients in the study reported eing given little or no informtion out their surgery even through nurses hd provided informtion during the periopertive period. This report suggests tht ptients nd their cregivers do not lwys her nd understnd the informtion eing conveyed. Written postopertive dischrge instructions cn serve s reference once the ptient hs returned home.

6 446 K.S. Jones et l. Fig ( ) Visuliztion of the iliopsos is performed with the trnsducer plced over the re of the iliopsos in short xis. ( ) Short xis ultrsound imge illustrtes visuliztion of the iliopsos ( ILP ) tendon, musculture, lood vessels, nd femorl hed ( FH ). (All rights re retined y Dr. Byrd) Fig ( ) The needle is inserted in plne with the trnsducer to llow visuliztion of the needle during the injection. The tip of the needle should e plced just lterl to the tendon nd into the nterior recess of the urs. ( ) Ultrsound imge depicts position of needle in reltion to the iliopsos tendon. (All rights re retined y Dr. Byrd) Pin Control Postopertive pin is one of the gretest fers ptients hve out surgery nd is often poorly ddressed y physicins [ 6 ]. Pin control should e discussed preopertively to lly ptient pprehension. Ptients should expect postopertive pin nd/or discomfort. The pin experienced is typiclly the worst in the recovery room. Once the cute postsurgicl pin is controlled, mny ptients re surprised t the low intensity of pin they ctully experience. Ptients descrie postopertive pin s urning che in the hip, ut the severity depends on the pthology ddressed. For exmple, ptient with loose odies my fi nd tht the postopertive pin is less thn the discomfort experienced preopertively. Conversely, ptient undergoing ony work for impingement my experience considerly more discomfort immeditely fter surgery. Educting ptients out postopertive pin is n importnt step in the preopertive discussion. The ptient should

7 34 Periopertive Cre 447 Fig ( ) The mediction is injected. ( ) The mediction is visulized entering the nterior recess of the iliopsos urs. (All rights re retined y Dr. Byrd) Fig ( ) After the injection, plcing the trnsducer over the iliopsos in long xis will llow visuliztion of the mediction in the urs etween the joint cpsule nd the iliopsos musculture. ( ) Long xis ultrsound imge fter injection of mediction into the urs. The imge shows clerly de fi ned lyers indicting the femorl hed, joint cpsule, urs, nd the iliopsos musculture. (All rights re retined y Dr. Byrd) know to expect pin from instrumenttion of the joint nd ny ony work performed s well s musculr soreness in the opertive leg tht is often noted fter the cute surgicl pin hs ted. This musculr soreness cn e cused y mnipultion of the hip, trction forces pplied during the procedure, nd the use of the perinel post. The typicl description is overll soreness round the hip nd mny ptients report feeling like they hve ridden horse nd hve soreness in the sddle re. Ankle soreness in the opertive leg is lso common complint nd is relted to the trction oot. It is ressuring for the ptient to know tht these vrious ches normlly resolve in 5 7 dys. The mount of discomfort is vrile, ut we generlly fi nd the gretest pin control issues in conjunction with extensive ony work to the cetulum nd concomitnt lrl re fi xtion. The pek of pin usully susides within 8 10 h. Adequte pin control is one criterion for dischrge from the recovery room. Occsionlly, some ptients my not chieve dequte control with orl nlgesics. For these circumstnces, ptients my e well suited for regionl lock performed y the nesthesi service. We do not use these routinely for ll ptients, ut ll ptients re ssessed in the recovery re nd, if initil pin control is prolemtic, regionl lock cn e chosen.

8 448 K.S. Jones et l. Fig ( ) The peritrochnteric region is scnned over the lterl hip. The loction of the trnsducer will vry depending on the loction of the pthology nd desired injection site. ( ) Ultrsound imge shows the sucutneous tissues ( ST ), gluteus mximus ( MAX ), gluteus medius ( GLUT MED ), nd the greter trochnter ( GT ). (All rights re retined y Dr. Byrd) Fig ( ) The needle is plced in plne with the trnsducer to llow visuliztion of the needle throughout the procedure. Visuliztion of the needle ensures tht the mediction is injected into the desired loction. ( ) Ultrsound imge demonstrtes the needle entering the tissue of the gluteus medius s it ners its insertion on the greter trochnter. (All rights re retined y Dr. Byrd) Fig ( ) Inspection of the piriformis is performed with the ptient prone nd the trnsducer plced fi rmly over the piriformis in long xis. With the knee fl exed, n ssistnt cn internlly nd externlly rotte the leg llowing visuliztion of the piriformis in motion throughout the suglutel spce. ( ) This long xis ultrsound imge depicts the reltionship etween the sucutneous tissue ( ST ), gluteus mximus ( MAX ), piriformis, nd scitic nerve. (All rights re retined y Dr. Byrd)

9 34 Periopertive Cre Fig The needle is plced in plne with the trnsducer. This llows the needle to e visulized throughout its dvncement to the piriformis, voiding the scitic nerve. (All rights re retined y Dr. Byrd) 449 A lterl femorl cutneous nerve lock or fsci ilicus comprtment lock is most commonly used. These types of regionl nerve locks re preferred ecuse they give mostly sensory nerve nesthesi with very little motor nerve nesthesi. Occsionlly, these locks do not provide the ptient with dequte pin control so femorl nerve lock is used. One cution out femorl locks is tht there is concomitnt motor inhiition of the qudriceps. Ptients must e educted regrding the potentil for flls nd should e instructed on strict protected weight ering until they regin full motor function. Nrcotics or orl centrlly cting medictions, such s oxycodone 5 mg with cetminophen 325 mg, re prescried for pin control. Prescription pin medicine is generlly used for the fi rst 5 7 dys fter surgery. By the end of the fi rst postopertive week, the need for nrcotic pin control is more spordic. Ptients should e reminded to tke medictions with food to prevent gstrointestinl discomfort. They Fig ( ) The needle is inserted into the musculture of the piriformis voiding the scitic nerve. ( ) The ultrsound imge shows the needle entering the piriformis sfe distnce from the scitic nerve. (All rights re retined y Dr. Byrd) Fig ( ) The mediction is injected. ( ) The mediction is visulized entering the muscle tissue of the piriformis. (All rights re retined y Dr. Byrd)

10 450 K.S. Jones et l. should lso e instructed to refrin from driving or operting hevy mchinery while medicted. With the introduction of impingement surgery, the need to prevent heterotopic ossi fi ction must e considered y the surgeon. This is routinely ccomplished with nonsteroidl nti-in fl mmtory drugs. The ptient should e educted on the purpose of the drug regime nd the importnce of their complince in the prevention of heterotopic ossi fi ction. The ptient should lso e reminded out the potentil side effects tht cn e experienced nd to cll the surgeon s of fi ce if they experience ny such effects. After nrcotics re discontinued, lterntive nonprescription medictions such s cetminophen, iuprofen, or other nonsteroidl nti-in fl mmtories my e useful to meliorte discomfort. It is importnt to note tht nlgesics, possily nrcotics, my e needed when physicl therpy is initited or when performing exercises. Some ptients my experience prolonged discomfort or more intense pin. The resons for this should e explored y the clinicin. The use of ice (cryotherpy) hs severl ene fi cil effects for tissues tht hve een injured, whether from trum or surgery. When ice is pplied immeditely fter surgery, the ody ttempts to preserve core het y constricting super fi cil cutneous vessels, cusing decresed cpillry permeility nd hemorrhging. This therpeuticlly lters the physiologic response of the tissues to injury y reducing in fl mmtion, swelling, nd pin [ 7 ]. Ice is most effective when used immeditely fter surgery. The ice g cn fi rst e pplied y the recovery room nurse. The ptient should e instructed to pply ice for min every 3 h for the fi rst 24 h nd even for 2 3 dys fter surgery if it helps llevite discomfort. There re severl different cold therpy devices ville tht re effective to help control pin. They re convenient in tht they often cycle through the cooling process nd re designed to mintin constnt cool temperture over the joint. Ptients who use cold compression therpy devices rve over the difference tht they mke compred to trditionl ice pcks. Cryotherpy is not without hzrds. Cold should not e used for longer thn 30 min with conventionl methods (ice gs/pcks) due to the potentil for freezing the skin. This could result in frostnip or frostite. Nerve plsies cn result from the ppliction of cold to n extremity for longer thn 30 min, or when cold is improperly pplied to vulnerle res [ 8 ]. Contrindictions to cryotherpy include ptients recovering from n epidurl infusion or spinl/nerve lock. Ice should not e used until full senstion hs returned in oth lower extremities. Cryotherpy should not e used t ll in the ptient with suspected neuropthy, such s with dietes or on ptients with true hypersensitivity or llergy to cold [ 8 ]. Fig A fi rst postopertive dy wound site following correction of FAI including cetuloplsty with lrl re fi xtion nd femoroplsty. The three stndrd portls ( lck rrows ) were used for ccess to the centrl comprtment. A distl puncture wound ( green rrow ) ws used for percutneous nchor plcement, nd n ccessory proximl portl ( gry rrow ) ided in ccess to the periphery nd femoroplsty. (All rights re retined y Dr. Byrd) Wound Cre A ulky dressing is pplied to the surgicl site. This dressing is left in plce until the fi rst postopertive dy, llowing time for extrvsted fl uid from surgery to e sored into the dressing. Usully, this hs susided enough to remove the dressing within the fi rst 24 h. The ptient should e ressured tht it is norml for the dressing to feel wet from the irrigtion fl uid nd tht it my e lood-tinged. The ptient should e wre tht the surgeon will mke severl rthroscopy portls. Ech of these portls is typiclly out 1 cm ut could e lrger nd will e closed with sutures. Ptients, nd even llied helth professionls, re often surprised t the ntomic loction of the portls. They envision them eing locted more cephld (Fig ). The portls re clened dily with hydrogen peroxide nd wter. A smll dhesive ndge cn then e plced over ech portl site until the sutures re removed. The ptient my shower on the fi rst postopertive dy, tking cre to keep wter from running directly over the portls. If the portls show signs of dequte heling, the sutures my e removed pproximtely 7 dys postopertively nd Steri- Strips pplied. It tkes pproximtely dys for the portls to hel completely. During this time, showering is llowed, ut the ptient should void sumersing the opertive hip in thtu, hot tu, or swimming pool. It is importnt to educte ptients regrding the signs nd symptoms of infection. They should e dvised to contct the nurse if they develop ny redness or dringe t the portl sites or if they develop high fever.

11 34 Periopertive Cre Activity Level The ctivity level prescried fter hip rthroscopy is vrile, depending on the pthology found t the time of surgery nd the surgeon s preference. Assistive devices, usully crutches, re used t lest until the git pttern is normlized nd limp resolved, which cn tke 5 7 dys. At minimum, ptients re encourged to use their ssistive devices until they hve een seen y the physicl therpist or return to the surgeon s of fi ce. More complex procedures such s correction of FAI, lrl repir or re fi xtion, microfrcture or cpsulr stiliztions my require more protrcted period of protected weight ering rnging from 4 to 8 weeks. The speci fi cs of this must e directed y the surgeon nd cn e implemented y the clinicl nurse nd physicin extender. The ptient will e most comfortle immeditely fter surgery in reclining or sitting position. The most comfortle sleeping positions re usully supine or on the nonopertive side with pillow etween the legs. Sleeping on the opertive side hs no known dverse effects, ut this is usully not comfortle for severl weeks postopertively. Ptients need to e reminded tht it is esy for them to overdo in the fi rst few dys fter surgery nd should e encourged to limit their ctivities. Once they feel like eing up nd round, dily ctivities cn e performed to tolernce, ut they should e respectful of ny discomfort felt in the hip. Oftentimes, for simpler procedures, ptients experience honeymoon phse for the fi rst 3 4 weeks postopertively. During this time, the ptient experiences pronounced pin relief compred to their preopertive sttus. They do need to e reminded tht they hve just hd hip surgery nd need to pce themselves ccordingly. Often, the ptients re not ck to regulr ctivities of dily living, nd when they do return to their norml level of functioning, they will experience pin nd soreness. When this does hppen, the ptient often gets discourged or thinks tht the surgicl procedure ws not successful. The nurse cn explin to them tht it relly tkes month to get over the ctul surgicl procedure. After tht initil month, it cn tke 3 4 months efore they my ctully pprecite the ene fi ts of the surgery. For more complex procedures such s FAI, it is not uncommon for ptients to spontneously experience setck t round 8 10 weeks postopertively. The etiology is not lwys cler, ut it is proly comintion of the ptient strting to do more nd the joint experiencing forces for the fi rst time since surgery. This requires ttention on ehlf of the ptients to ssure them tht this is not necessrily worrisome sign ut my oligte some ltertion in the reh strtegy to ccommodte their discomfort nd perhps rief course of nti-in fl mmtory mediction. It is est to wrn ptients preopertively out this occsionl occurrence. Thus, they will hve more con fi dence in your 451 explntion nd encourgement tht things will e oky when this occurs postopertively. Ftigue is one of the iggest considertions fter surgery [ 4 ]. This cn e relted to severl fctors including the nesthetic, nlgesics, pin, or sleep disruption. The nurse should inform the ptient tht this will generlly dissipte fter postopertive dy 3 ut cn lst s long s severl weeks. Physicl therpy is usully initited 1 2 dys fter surgery. The rehilittion progrm for the postopertive ptient is individulized to the pthology nd the procedure performed. The primry focus of the rehilittion process is to reduce discomfort nd improve function. A successful result fter surgery is often dependent on properly constructed rehilittion progrm. This is n importnt concept to e relyed to the ptient ecuse there my often e reluctnce to go to physicl therpy. When the hip hurts, the ide of exercise my not e ppeling to the ptient. The most frequently sked question regrding ctivity is When cn I drive? Generl guidelines include the following two prmeters: the ptient must hve discontinued the use of nrcotic nlgesics nd hve regined dequte leg control to operte the ccelertor nd rke pedls or clutch. Right hip rthroscopy often delys the resumption of driving. Restrictions for up to month my e necessry for complex procedures, especilly with lrl repir in the driving leg. It is importnt for the clinicl nurse nd physicin extender to rememer severl things pertinent to the postopertive recupertion. Ptients wnt nd need to her tht they re doing well nd re on schedule in their recovery. Ptients re often imptient nd my expect to recover more quickly thn they ctully do. Rrely will ptient tell you tht their recovery ws quicker thn they hd nticipted. Mny prefer to hve guidelines y which to guge their progress. They wnt to know how other ptients normlly respond under the sme circumstnces [ 5 ]. Ptients nd their cregivers my hve selective hering or my forget to red postopertive instructions; therefore, frequent contct y telephone is one of the keys to the successful recovery of the hip rthroscopy ptient [ 9 ]. The frequent contct etween the clinicl nurse nd the ptient nd/or their cregivers cn hve positive effect on ptient stisfction nd lso provides mechnism for feedck [ 4 ]. Conclusions Approprite ptient selection nd eduction, skillful implementtion of the surgicl procedure, nd properly constructed rehilittion progrm re ll importnt fctors in the success of hip rthroscopy. Of equl importnce, the ptient s expecttions must e properly mtched with the results nticipted y the surgeon. The clinicl nurse nd physicin extender ply crucil role in ssuring the integrtion of these fctors, ll of which re criticl to n optiml outcome.

12 452 K.S. Jones et l. The role of the clinicl nurse is n integrl prt of the periopertive experience. While the ptient is crefully guided through surgery nd the rehilittion process, the nurse monitors expecttions to ssure the most likely degree of overll ptient stisfction. The clinicl nurse s perspective, ttined through direct ptient ssessment nd interction, cn help to de fi ne coexistent conditions or circumstnces tht could potentilly in fl uence the success of rthroscopy. Physicin extenders fcilitte l l spec ts o f p tient cre ut lso provide useful dditionl dignostic nd therpeutic resource for surgeons. The history nd physicl exmintion direct most ptient cre, ut djunct imging such s of fi ce ultrsonogrphy gretly enhnces oth dignosis nd tretment while leving the surgeon free to steer ll spects of the ptient s cre. Success is lso dependent on ptients ility not only to understnd wht is hppening ut lso to e n ctive prticipnt in their periopertive cre. The focus on multory outptient surgery llows more ef fi cient utiliztion of resources ut plces more responsiility on ptients nd cregivers. Ptients undergoing rthroscopic surgery of the hip must e equipped to hndle their postopertive course. This is est ccomplished with detiled eduction nd nursing cre, eginning preopertively. An optiml outcome is dependent on coordintion of the periopertive cre, from preopertive ssessment through postopertive rehilittion. The clinicl nurse nd physicin extender help fcilitte the ptient s smooth trnsition through this experience nd serve s vitl resource for other memers of the helth cre tem. The nurse nd extender re eductors, prctitioners, consultnts, nd collortors. By serving in this multifceted role, they ensure pproprite nd ef fi cient utiliztion of resources through close ptient follow-up nd timely response to chnges in the clinicl circumstnce. This llows the other memers of the helth cre tem, whether it is s the ptient, cregiver, surgeon, operting room personnel, or physicl therpist, to etter ful fi ll their respective roles. Appendix: Postopertive Instructions J. W. Thoms Byrd Arthroscopic Surgery of the Hip The following informtion is designed to nswer some of the frequently sked questions regrding wht to expect nd wht to do fter rthroscopic surgery. These re generl guidelines, if you hve ny questions or concerns, plese give us cll. Dressing nd Wound Cre During rthroscopic surgery, the joint is irrigted with wter. There will typiclly e 3 to 5 smll incisions closed with sutures. Your hip will e covered with ulky dressing. Wter my grdully lek through these incisions, sturting the ndge. This lood-tinged dringe my persist for h. If it hs not signi fi cntly decresed y this time, plese cll our of fi ce. The ndge my e removed the dy fter surgery. The incisions should e clened with hydrogen peroxide then covered with nd-ids. As soon s the incisions re dry, you my leve them uncovered. Do not use ointments such s Neosporin on the incisions. You my shower the dy fter surgery, ut void wter running directly over the incisions. The incisions should not e soked under wter (e.g., thtu, hot tu, swimming pool, etc.). The sutures should e removed 7 10 dys fter surgery. If the incisions show ny signs of infection, plese contct our of fi ce. Speci fi clly, if there is incresed redness, persistent dringe, if you hve fever, or if the pin does not progressively decrese, you should cll the of fi ce. ICE During the fi rst 48 h, ice cn e helpful to decrese pin nd swelling nd is especilly importnt during the fi rst 24 h. Ice gs/pcks should never e pplied directly to the skin. They should e wrpped in towel nd pplied for 15 min t time every 2 3 h. If the skin ecomes very cold or urns, discontinue the ice ppliction immeditely. If you re using the Gme Redy system, plese use the progrm outlined t the time of your instruction on how to use the mchine. Amultion nd Movement Unless you hve een otherwise instructed, you will e llowed to er s much weight on your leg s is comfortle immeditely fter surgery. Crutches should e used nd re necessry to help decrese discomfort nd to protect your hip while wlking fter surgery. If there is ny question out how much weight to plce on your leg or how long to e on crutches, plese cll our of fi ce. Your level of discomfort will most often e your est guide in determining how much ctivity is llowed. Rememer tht it is very esy to overdo in the fi rst few dys fter surgery nd ny increse in pin or swelling usully indictes tht you need to decrese your ctivities. Plese e creful on slippery surfces, steps, or nywhere you might fll nd injure yourself. Medictions You will e given prescription for pin mediction. You my lso e given prescription for n ntiin fl mmtory mediction tht you will need to tke twice dy for 3 weeks. It is very importnt tht you strt this mediction the night of your surgery nd tht you tke this mediction for the full 3 weeks. If there is ny prolem with you tolerting this mediction, plese cll nd let the nurse know. If you hve ny known drug llergies, check with the nurse prior to tking ny mediction. Some medictions do hve side effects. If you hve ny dif fi culty with itching, nuse, or other side effects,

13 34 Periopertive Cre discontinue the mediction immeditely nd cll our of fi ce. Pin mediction often cuses drowsiness nd we dvise tht you do not drive, operte mchinery, or mke importnt decisions while tking mediction. Plese note tht we re unle to cll in prescriptions for nrcotics ( pin pills ) fter of fi ce hours. If you need re fi ll, plese cll erly in the dy or efore the weekend so the nurses cn tke cre of tht for you. If you re le to tke spirin, you should tke one spirin (325 mg) twice dily for two weeks following your surgery. Aspirin serves s mild lood thinner nd my decrese the chnce of lood clots forming in the leg. Although this is uncommon, it cn e dif fi cult prolem. It is est to tke one in the morning nd one in the evening nd to void tking them on n empty stomch. If you re under the ge of 16 or hve ny unusul medicl prolems, plese check with the nurse out whether you should tke spirin. Exercise / Physicl Therpy Physicl therpy usully egins within few dys fter your surgery. The therpist will outline n exercise progrm speci fi c to your type of surgery. The purpose of physicl therpy is to help you regin the use of your hip in sfe nd progressive fshion. If you hve ny questions regrding your exercise progrm, plese contct the physicl therpist. If you re unwre of when or where your therpy is, plese cll the nurse nd she cn help you determine this. First Post - Opertive Visit Your fi rst post-opertive ppointment will e within one week of your surgery. The fi ndings t surgery, long-term prognosis, nd plns for rehilittion will e discussed t this ppointment. If you re 453 unsure of when your fi rst post-op visit with Dr. Byrd is, plese cll the of fi ce nd someone will help get one scheduled. Communictions If you re hving ny prolems, contct us right wy. If it is fter of fi ce hours, the nswering service will contct the nurse or doctor on cll. Rememer, if your pin increses, check for signs of infection ( redness, fever, etc.), decrese your ctivities, use ice, nd tke your pin mediction s prescried. If the pin persists, or if there re signs of infection, cll our of fi ce ( 615 ) References 1. Sutherlnd E. Dy surgery: ll in dy s work. Nurs Times. 1991;87(11): Weer J. Nurses hndook of helth ssessment. Phildelphi: J.B. Lippincott; p Byrd JWT, Jones KS. Dignostic ccurcy of clinicl ssessment. MRI, gdolinium MRI, nd intrrticulr injection in hip rthroscopy ptients. Am J Sports Med. 2004;32(7): Dougherty J. Sme-dy surgery: the nurse s role. Orthop Nurs. 1996;15(4): Oerle K, Allen M, Lynkowski P. Follow-up of sme dy surgery ptients. AORN J. 1994;59(5): Stephenson ME. Dischrge criteri in dy surgery. J Adv Nurs. 1990;15(5): Knight KL. Cryotherpy. Am Fm Physicin. 1990;23(3): McDowell JH, McFrlnd EG, Nlli BJ. Cryotherpy in the orthopedic ptient. Orthop Nurs. 1994;13(5): Burden N. Telephone follow-up of multory surgery ptients following dischrge is nursing responsiility. J Post Anesth Nurs. 1992;7(4):