Joint Replacement Surgery at Carle Patient Name Surgery Date Doctor
Table of Contents Welcome Welcome...3 A Team Approach...4 Thank you for choosing Carle for your procedure. Each year, more than 12,500 patients trust our team to perform their surgery and improve their health. You can feel confident Table of Contents Before Your Procedure...6 Hospital Stay...11 Follow-up Care...16 in our medical expertise, state-of-the-art facilities and commitment to national quality standards. With your joint replacement, our goal is to have you on your feet as soon as possible so you can get back to enjoying life. The Carle team includes fellowship trained orthopedic surgeons, physical and occupational therapists, compassionate nurses and other dedicated staff. To provide a healthy environment for patients, staff and visitors, all Carle buildings and grounds are tobacco-free. welcome If you have any questions, please let us know. We re happy to help. Welcome 2 3
A TEAM APPROACH A TEAM APPROACH At Carle Foundation Hospital, we strive to provide the best care possible. If you have any questions about your surgery or the care before or after your surgery, please ask your physician or nurse. Surgeons/Physicians Your surgeon will see you every day, starting the day after surgery, and will care for you until you leave. In addition to your surgeon, you may see hospitalists as well. This team of doctors is made up of board certified internal medicine and family practice physicians who care for patients in the hospital. From admission through discharge, they are in the hospital around the clock to plan your care, seeing you at least once a day to talk about your care and answer any questions. They work closely with your surgeon and primary care doctor, to make sure you receive the best possible care. These physicians will also take care of medical concerns not related to your joint replacement (i.e. diabetes, blood pressure, home medications, etc.) Carle is a teaching hospital working with the University of Illinois College of Medicine. You may see medical students or residents in addition to your physician. Patient Case Managers A case manager will work with you and your insurance company to assist with insurance coverage questions. They can also arrange for equipment and coordinate services for after you go home, including home health care and transfer to an extended care facility if needed. Social Worker Social workers are available during your hospital stay and can support you and your family with the increased stress and emotions that happen while you are in the hospital. The social worker can also help you find community and/or financial resources if you need them during or after your hospital stay. If you have questions about Advanced Directives or Living Wills, the social worker will also be able to help you complete those forms. A TEAM APPROACH Anesthesiologist The anesthesiologist provides anesthesia medication in the operating room and monitors your condition during surgery. They may also take care of your pain management after surgery. Pharmacist The pharmacist helps the doctors manage your medications and will also teach you about your medications. Nursing Team Nursing care is provided around the clock by a team of highly trained registered nurses and healthcare technicians while you are in the hospital. Your nurse and the team caring for you are here for you, so please feel free to ask any questions you may have before, during, and after your stay. From the nurses in the clinic to those at the bedside, they will help guide you and your family through your joint replacement experience. Physical Therapy Carle provides dedicated physical therapists providing evaluation/treatment twice a day starting the day of your surgery. These therapists are trained in joint mobility and will teach you your home exercise program before you go home from the hospital. Occupational Therapy This type of therapy focuses on your activities of daily living (bathing, cooking, dressing, etc.) Therapists will provide you with a plan to make these activities easier for you. 4 5
BEFORE YOUR PROCEDURE BEFORE YOUR PROCEDURE Whether you receive home care or not, you will need to make some changes at your house for a safe recovery at home. Use the following guidelines to make your stay as safe and comfortable as possible. Outdoors If you have stairs leading to your door, consider installing railings or a grab bar by the entrance. Keep walkways well-lit and free of clutter. Keep your sidewalks free of ice and snow. Whenever possible, salt your sidewalks and driveway before it snows to prevent ice from forming. Use a footstool for gardening (if deemed safe by your doctor or therapist) or construct raised flower beds. Kitchen Use a barstool for activities that require standing for an extended period of time (such as washing dishes or preparing meals). Use a wheeled utility cart to transport multiple items. If you use a walker, consider attaching a bag or basket to help you transport things. Place the heaviest items and the items you need most on shelves closest to the countertop to avoid unneeded bending or reaching. Bathroom Place nonskid strips or a mat on the bottom of your tub or shower. Install grab bars on the walls of your tub or shower to increase safety. Make a hole in your soap bar and thread it with twine or a thin rope so you can wear it around your neck while bathing. If your toilet seat is low, purchase a raised seat, armrests or a combination of the two. When stepping in and out of the tub, take your time and make sure you always maintain your balance. Bedroom Night lights will provide enough light for you to walk around safely in case you need to get up in the middle of the night. Keep a lamp and telephone on the bedside table closest to your side of the bed. General Remove all throw rugs; it s very easy to trip on them. If you purchase new shoes, get ones with Velcro closures to eliminate tying. Make sure you have emergency phone numbers posted on each phone in your home. Also, make sure you have an emergency escape route planned in case you need it. If your chairs or sofas are too low, you can raise them up on blocks or place extra cushions or folded blankets on them to elevate them to a safe height. If you have difficulty bathing or dressing, consider buying assistive devices to help you maintain your independence until you can accomplish those tasks without them. For more information on assistive devices, call your physical or occupational therapist. [Note: You can find support rails and other helpful supplies at Carle Medical Supply and other medical supply stores.] JUST FOR HIP PATIENTS Bathroom Before your surgery: Sit on your toilet. If your knees are higher than your hips, you will need an elevated toilet seat. If you also have trouble standing up from the toilet, you will benefit from an additional grab bar system. Transferring to and from the bathtub is safest when using a transfer tub bench (a bench that is heightadjustable, with a back and extends over the side of the tub). When sitting on this transfer bench, it is important that your hips are higher than your knees and your feet flat and secure on the floor of the bathroom and/or tub. Remember not to use a non-height-adjustable seat since these are often too low. This might cause your hip replacement to dislocate. A flexible hose handheld shower with an on/off water control button on the handle. (If you have arthritis in the hands, choose one with a large on/off button). If you have glass shower doors, remove both glass doors to allow safe tub entry/exit and use of a transfer tub bench. Install a secure tension rod and shower curtain if desired. BEFORE YOUR PROCEDURE 6 7
Pre-Op Strengthening Exercises After surgery, you will need to perform exercises to strengthen the muscles that affect the replacement joint. It is also important to strengthen your body BEFORE surgery. This will make it easier for you to function while your body heals from surgery. These exercises can be done with or without weights. If you do not have hand weights, large cans of soup or vegetables can be used. All exercises should be performed SLOWLY. Elbow Extension Hold a weight weighing 8-16 ounces. Point elbow up and out, and straighten arm without moving shoulder. This can be done while lying down. Repeat 10-15 times. BEFORE YOUR PROCEDURE Chair Push Ups Sit in a chair with armrests. Place your hands on the arms of the chair. Push down with your arms to lift your buttocks up from the chair. Hold yourself off the chair for 10 to 30 seconds. Return to start position to rest. Repeat 10-15 times. Do 2-3 sessions per day. Do 2-3 sessions per day. BEFORE YOUR PROCEDURE Shoulder Flexion Raise arm to point to ceiling, slowly keeping elbows straight. Repeat 15-20 times. Do 2-3 sessions per day. Elbow Flexion Hold a weight weighing ounces in hand and bend elbow, keeping wrist straight. Support elbow with folded towel on table or hold close to body. Repeat 10-15 times. Do 2-3 sessions per day. Shoulder Abduction Lift arms out to side, elbows straight, palms downwards. Do not shrug shoulder or tilt trunk. Repeat 10-15 times. Do 2-3 sessions per day. 8 9
Getting Ready for Surgery BEFORE YOUR PROCEDURE 1. You and your surgeon will schedule a date for your surgery. 2. Your doctor may suggest that you donate one unit of blood before surgery. 3. Special X-rays may be taken to decide the best position for the new joint implant. This will be done within six months before your surgical date. 4. Please do not schedule any dental work three weeks before, or three months after surgery. If a dental emergency happens, please call your surgeon s office with any questions. 5. About 10 days before your surgery, you will be called by the Pre-op Center. You will be scheduled to see a physician or advanced practitioner to make sure you are medically ready for surgery. Plan to answer questions about your medical history including previous surgeries, your family s medical history, your allergies and all medicines that you are taking. Based on your exam, you may need other tests/consultations. 6. A visit with the surgeon and/or nurse will be scheduled to make sure everything is in order for your surgery. This is your chance to ask questions and make sure you are as comfortable as possible with the procedure you re about to have. 7. Your surgeon may have you stop taking aspirin, blood thinners, and arthritis medications sometime before surgery. The Pre-op Center will tell you what medications to take the day of surgery. 8. Please do not shave your legs for at least four days before your surgery. 9. You will be told how to use Hibiclens/surgical scrub on the night before or the day of surgery. 10. The pre-op center will call you sometime between 1:30 and 4:30 p.m. on the working day before your surgery to tell you what time to arrive. 11. You will be admitted to the hospital on the day of your surgery, unless there are unusual medical reasons that make it necessary to be admitted earlier. 12. If you are scheduled for a procedure or other treatment at Carle and you have insurance, you should check with your insurance company before receiving care to make sure you know which costs will be covered. Day of Surgery Before coming to the hospital unless told otherwise, do not eat or drink after midnight before your surgery. You can brush your teeth, but do not swallow. Take only the medications that the anesthesiologist or your doctor has told you to take with a sip of water. Do not wear any makeup, lipstick, or nail polish on the day of surgery. Check in to the location as told to you by the pre-operative nurse who called you. After checking in, you will be given instructions for getting ready for surgery. This includes changing into a hospital gown. You will be asked to remove dentures, wigs, hairpieces, contact lenses and underwear. The area where you will be having surgery will be cleansed and shaved, and IV started. The IV will be used for fluids and medications. After getting the anesthesia, a catheter may be placed in your bladder as you are prepared for surgery in the operating room. You will be asked to initial or mark the leg you are having surgery on prior to the procedure. An anesthesiologist will talk with you about types of anesthesia medication and choices for managing your pain after surgery. The Operating Room Your surgery will last about two hours. The surgery room will likely seem cold to you. If you have spinal anesthetic, you may hear operating room noises made by the staff and the instruments used for surgery. If hearing the noises will bother you, you may ask the anesthesiologist for a medication to sedate you. Monitor pads/stickers will be placed on your body so the anesthesia staff can monitor your vital signs. Family members should wait in the surgical waiting room so the surgeon can speak to them after surgery. Family members should always check in and out with the volunteer if they plan to take a break or leave the hospital. The nursing staff in the operating room will try to call about every hour to let them know that surgery is still in progress. For additional information on what to expect, refer to your HAVING SURGERY AT CARLE guidebook. Recovery Room/Post Anesthesia Care Unit (PACU) Patients are usually in the recovery room for one to three hours, depending on the type of anesthesia you received and your response to it. The nurses in PACU are trained to care for patients who are recovering from anesthesia. They will check on you often, checking blood pressure, temperature, pulse, looking at your incision, and the feeling/ sensation in your legs and feet. You may wake up wearing an oxygen mask. Oxygen and deep breathing help your body get rid of anesthesia. The nurse will have you cough and take deep breaths frequently. This is to help you wake up and to prevent pneumonia. Your family and friends will not be able to see you while you are in the PACU. Your surgeon will be contacting them in the waiting room to tell them your surgery is over. When you are released from PACU, the nurse will take you to the orthopedic unit and your family/friends may visit you after the nurse checks you in. 10 11
Hospital Stay-Day of Surgery The focus of this day is to monitor your recovery process, introduce you and your family to the orthopedic unit and discuss your plan of care. Pain Medication Pain can be controlled in a number of ways after surgery, so let your nurse know if you are uncomfortable. Continue to check your vital signs, blood glucose levels, and check pulses in the leg and foot that you had surgery on every four hours. Finish antibiotics from surgery. Monitor fluid intake. When you get to your hospital room, you will be able to start a liquid diet. You will slowly increase to regular solid food. Control any upset stomach. Watch your incision. Measure your urine to make sure you are hydrated. Physical therapy evaluation. You may have a drain near the incision that removes blood and fluids to reduce swelling. If you had a knee replacement you will have a special drain called a Stryker drain. This drain will collect the blood and fluid so it can then be given back to you through your existing IV if needed. The Stryker drain is emptied only once, depending on the amount collected. This drain is typically removed the day after surgery. A urinary catheter (a tube used to drain urine) may also be inserted while you are in the operating room, because the anesthetic may make it hard to urinate after surgery. The catheter will be taken out on the first or second day after surgery. It is still important to drink fluids during your recovery to stay hydrated and avoid constipation. You will be taught how to use a device called an incentive spirometer. This will help you to take deep breaths, and we will encourage you to use the incentive spirometer eight to ten times every hour while you are awake. This is important to help decrease the risk of blood clots in the lungs and pneumonia. You will use this every day that you are in the hospital. You will be wearing Jobst pumps/ted hose immediately after surgery. Jobst pumps provide pressure on and off to your legs, similar to blood pressure cuffs, which will increase the circulation of blood to your heart by gently squeezing your calves for short periods of time. You may also wear support stockings called TED hose in addition to the Jobst pumps. TED hose need to be worn for two weeks after surgery. Patients who undergo surgery are at a higher risk for falling. You will be given a yellow armband and yellow non-skid socks to wear after surgery plus a sign will be posted above your bed. These along with a bed alarm will help us keep you safe and free from injury. We also ask family members to help prevent falls by decreasing clutter in rooms, reducing the number of visitors at one time, telling the staff of any physical or mental changes, and letting staff know if you see wet or slippery floors. Patient-Controlled Analgesic (PCA) Pump After surgery, a patient-controlled analgesia (PCA) pump may be connected to your IV. PCA (patientcontrolled analgesia) allows you to push a button when you are having pain to receive pain medication. You will get a safe dose of pain medication each time you push the button. These pumps have a safety lock on them that will not allow you to have too much medication. You are the only person who will know when you are hurting and when it is necessary to have a dose of pain medicine. Your nurse will remind you frequently how to use the PCA pump. Your family and friends are not to press the PCA button. It is important that you identify an acceptable pain level that will allow you to participate in therapy, activities of daily living (ADL s) and be comfortable at rest. The evening of your surgical day (if appropriate) and into the first day, you will be transitioned to oral pain medications. Oral pain medications last longer, and will be the medication that you will take at home. Our surgeons have preferences, but you and your nurse will decide which will work best for you. Assessing and evaluating pain are the keys to treating it. Tell your nurse when you are having pain and give as much information as possible. What type of pain? Describe the type you are having. You may use descriptive words such as dull, sharp, burning, stabbing, shooting, or pins and needles. How much pain? You can describe the amount of pain on a scale of 0 to 10: 0 being no pain and 10 being the worst pain you can imagine. 0 1 2 3 4 5 6 7 8 9 10 No pain Moderate pain Worst pain 12 13
Where is the pain? Tell or show the nurse where the pain is. Make sure you are eating and drinking enough. Do not wait until the pain is awful. The worse the pain, the harder it is to get under control. Many people are able to manage their pain with other methods. Some suggestions are: Non-narcotic medications, ice, elevation, repositioning, distraction, listening to relaxation tapes, and imagery. Other medications that will be used along with the pain medications are for nausea, constipation, reflux, and muscle spasms. Hospital Stay-Day One/Two The focus of this day is to increase activity with therapy, remove lines and drains, and maintain adequate pain control. Monitor lab test results. You will have your blood taken for lab work at least once a day. Patients that have joint replacement surgery are at a higher risk for blood clots. Part of your recovery will include making sure that you do not develop a blood clot by keeping your blood thin. This is called anticoagulation. Some of the lab tests will tell us how long it takes your blood to clot. We will be teaching you about the medication that you will need to take to keep your blood thin. There are two ways you take medication that are used to thin the blood: injection ( shot ) or tablet, Medications used are Coumadin, Lovenox, Arixtra, heparin and aspirin. Your surgeon will decide which is best for you. Your anticoagulation medicine will be: (will be assigned during hospital stay) You will be out of bed with physical and occupational therapy and nursing staff, using walker/crutches. Therapy will review with you exercises for home and how to use equipment, walking and muscle strengthening. Meet with case manager to discuss getting the equipment you will need once you go home and other discharge arrangements. (Who can pick you up and take you home?) Occupational therapy will meet with you on Therapy Day 1 or Therapy Day 2. Occupational therapy will determine if you need equipment for home use, such as a shower chair or elevated toilet seat. Occupational therapy will also show you how to use adaptive equipment for tasks such as getting dressed. Physical therapy will work with you two times, and will talk to your nurse after they have worked with you. Therapy Day 1 First visit: Transfers, exercise and walking. Second visit: Transfers, exercise, and increase walking distance. Therapy Day 2 First visit: Walking into the hall. You should be walking between 40 and 50 feet by this visit. If you have any stairs in your home you will need to do them at this visit. Even if you have one stair, you will need to practice. If you have diabetes, your blood sugar should be within the target range. Hospital Stay-Day Three (Discharge Day) The focus of this day is discharge. This may be to home or an extended care facility. A time of discharge will be planned after your doctor sees you. Make sure that all equipment needed at home is ordered. Finalize transportation plans. Physical therapy will see you one last time in the hospital and make sure you understand all activities and exercises. Discharge instructions with you and your family members, including follow-up appointments and outpatient therapy schedule. Review medications that you will be taking at home. Your medications will be phoned in to the pharmacy of your choice. Please make sure to have any medication insurance information available for the pharmacy when you pick up your medications. You will be fitted with your CPM (continuous passive motion) machine after your first therapy visit. While in the hospital, you will use the machine one to two hours twice a day. The physical therapist will teach you and your family/friend how to use the CPM. During your hospital stay, you will be encouraged to increase the settings 5-10 degrees during each two-hour session. Before you go home, we d like to see you: Get in and out of bed with very little or no help Move from sitting to standing with no help Walking between 40-50 feet with an assistive device (walker, cane) without losing your balance Go up and down stairs as you need to do at home with very little help Continuous Passive Motion Machine (CPM) 14 15
Follow-up Care Your Discharge Options If care at a skilled nursing facility is needed, your case manager will tell you about available locations. We understand the decision to continue your rehabilitation in another facility may be difficult and we are here to help you. Our goal is to make this transition a smooth and comfortable one. If needed, the case manager will contact your insurance company to learn about your benefits and arrange for precertification. Prevention of infection Take care of your incision as instructed Take antibiotics before having dental work or other procedures. Tell all of your healthcare providers and dentist that you have had a total joint replacement Follow-up Care If you have Medicare, they will cover up to 20 days of skilled nursing care at one hundred percent. If you need to stay past 20 days then you may have a 20 percent copayment depending on your supplemental insurance. If you think you may need a skilled nursing facility, you do have the option of visiting local facilities before your surgery. Depending on your progress and your doctor s instructions, you might be able to go home while receiving help from a home health agency. Home health is a service that sends a nurse and therapist to your house. The therapist usually visits about two to three times a week for about an hour each time. The nurse visits one or two times total to check on your recovery. Your nurse case manager will tell you about home healthcare choices or refer you to an agency of your choice; they will also call your insurance company for benefits and precertification if needed. Within 24 to 48 hours after getting home, you should expect a home care nurse to call you and make the first visit to your home. Your nurse s role will be to supervise your health and recovery; care will include a review of your medications, care of your incisions, staple removal and checking vital signs. A physical therapist will also call and make plans to visit you for more therapy. How often you have therapy depends on both your needs and goals that you and your therapist set together. Depending on your needs, an occupational therapist may also visit you at home. The home therapist will work with you until you meet your goals or are able to do your normal daily activities again. Before rehabilitation is finished, you may need outpatient physical therapy. Your home care nurse or therapist will help you make these arrangements. If you need help at home with personal care, there are agencies that provide this service. Assistance in bathing, dressing, and household chores is usually an out-of-pocket cost as it is not covered by your insurance. If you need information on in-home caregivers, a social worker is available to give you this information. Blood Clots Signs of blood clots in legs Swelling in thighs, calves or ankle that does not go down with elevation and use of ice Pain, heat and tenderness in calf, back of knee or groin area Prevention of blood clots Foot/ankle pumps and walking Adequate fluid intake Blood thinners Signs of blood clots in lungs Sudden chest pain Difficulty and/or rapid breathing Severe shortness of breath not relieved by resting Profuse sweating Confusion Prevention of blood clot in lungs Prevent blood clots in leg Activity Proper fluid intake A blood clot could break away from the vein and travel to the lungs. This is an emergency and you should call 911 if suspected. Follow-up Care Incision Your incision will need to be covered while showering for two weeks after surgery. No tub baths or soaking your incision in water. (This includes swimming and hot tubs.) You must cover your incision while showering with saran wrap and tape. Your nurse will teach you how to do this. Please allow your incision to dry completely before applying a new dressing. After your staples are removed, you will be allowed to get your incision wet. Infection Signs and symptoms of infection Increased redness or streaking Drainage of foul odor/color Temperature >101.5 for more than 12 hours Pain not controlled with pain medication prescribed JUST FOR HIP PATIENTS Dislocation Signs and symptoms of hip dislocation Severe pain Turning and/or shortening of operative leg Inability to walk or move operative leg Prevention of dislocation - follow at all times Do not cross legs Do not bend at the hip >90 degrees Do not twist the operative leg 16 17
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