Pre-Op Spine Information Welcome! Welcome to Duke Raleigh Hospital! We look forward to caring for you and your family during your stay.

Goals Inform the patient about what to expect… Before Surgery During Surgery After Surgery This outline will explain what to expect before, during, and after spine surgery.

Goals Reduce anxiety Answer questions Help you become better-prepared We also hope to reduce your anxiety, answer questions, and help you become better prepared after this presentation.

Sections Nursing Case Management Physical Therapy Occupational Therapy This presentation will be divided into four sections: Nursing, Case Management, Physical Therapy, and Occupational Therapy.

Information From The Nurse About Care And Your Concerns First, let’s discuss Nursing Care.

We Care About You!!! In an effort to personalize your care while in the hospital, please let us know of any needs ahead of time Please complete the enclosed “Care Card” and forward it to the Patient Navigator at the end of class In an effort to personalize your care while in the hospital, please let us know of any needs ahead of time. Please complete a pink “Care Card” and forward it to the Patient Navigator. You may also contact the Patient Navigator at 866-552-9357 if you do not have a Care Card and one will be filled out for you.

What To Bring List of medications and allergies Glasses, hearing aids, dentures Toiletry items Toothbrush Toothpaste Flat, supportive, non-slip walking shoes (with a backing) Incontinence products (you may prefer a specific brand not provided by hospital) On the day of surgery, please bring anything you need to operate on a regular day (i.e. glasses, hearing aids, dentures). If you forget toiletry items, then we can supply these for you. Most importantly, bring supportive walking shoes with a backing and rubber sole.

What To Bring Night clothes/pajamas, loose clothing Books, magazines, hobby items On the day of surgery and the day after surgery, you will be wearing a hospital gown. On post-op days 2 and 3, we will help you dress in your normal clothing. Ideally, baggy clothing including an oversized, button-down shirt is most comfortable for spine patients.

While in surgery… CHG wipes will be used to cleanse and disinfect the surgical site before surgery begins CHG reduces bacterial growth on the body CHG will help reduce the chance of infection following surgery Prior to beginning surgery, Chlorohexadene Gluconate (CHG) wipes will be used to cleanse and disinfect the spine and back area to reduce the chance of infection.

Orientation to Room Call bell TV Controls/Volume Thermostat When you arrive to the Orthopaedic Unit, your Nurse will orient you to the Call Bell TV Controls, and the Thermostat.

Equipment After Surgery We would like to review what equipment you may have following surgery.

Oxygen Used a short time Let us know if you have sleep apnea or use oxygen or CPAP at home You may have oxygen in place when you wake from surgery. Typically, it will be nasal cannula oxygen with the two prongs fitting inside the nostrils. If you use a CPAP or BiPAP at home for sleep apnea, please bring your machine into the hospital.

IV or Intravenous Therapy May have one or two lines Fluids-body water, blood, antibiotics, pain medication Will leave it in until discharge You will have one or two IV lines in your hand and/or your arm to give you any fluids or medications. It will be left in until you are discharged.

Dressings and Drains Drains and dressings removed 1st or second day after surgery Dressing changed daily after that Your Surgeon may use a padded “island” dressing over the incision. He may also place a drainage catheter in the wound to help reduce fluid on the wound and, likewise, reduce swelling.

Foley catheter to drain urine Stays in no longer than 2 days Helps to keep track of fluid balance Good initially when not moving well Put in after you are asleep Does not hurt to come out You will have a drainage catheter placed in your bladder to help drain urine during and after surgery. It will be inserted while you are asleep. Typically, this will be removed on the morning of Post-Op Day 2. It will not only help drain urine, but it will also let us know how well your kidneys are working.

PCA - Patient Controlled Analgesia “Pain Button” Administer to self Close monitoring NO ONE IS TO PUSH THE BUTTON EXCEPT THE PATIENT!!! ***Please ask your surgeon if this is an option for you Your surgeon may order a PCA machine as one of many pain options for you. You may push the button to administer a dose of pain medicine. It is programmed so that you will only get a certain dose in a specified amount of time. Please let visitors know NOT to push the button for you as this is very powerful pain medication.

Medications Different color and number Always ask nurse what meds are for “Combination medications” that you may take at home may be given as separate pills while in the hospital Medications come in different colors and numbers depending on the brand. If you take a “two-in-one” combination drug at home, you may receive the two separate medications that make up that pill while in the hospital. Please do not bring home medications into the hospital.

Rating Pain 0 to 10 pain scale Pain patterns Mechanical Pain Surgical Pain You will be asked what your pain level is many times throughout your stay. “0” means “No Pain” and “10” means “Horrible Pain”. Our goal is to get your pain at a 3 or 4 out of 10 or less. At this level, you will be awake and alert enough to participate in therapy and learn what we will be teaching you.

Know the Zone! Our staff will make every effort to help control your pain We will automatically give you pain medication around the clock We ask that you partner with us and ask for additional pain medicine if needed Alternative pain options may be used such as cold therapy and distraction Our goal is to keep you in the 3-4 Pain Zone (or less) You will receive pain medication around the clock without asking for it. However, if you experience “breakthrough pain”, please ask for that additional pain medication. This is typically written on your white board in your room along with the times it can be taken.

Preventing Pneumonia Incentive Spirometer or Acapella Perform breathing exercises while awake Helps to expand air sacs in lungs Surgical patients are at a higher risk of pneumonia following surgery. You will be given a breathing device and encouraged to perform breathing exercises throughout your stay. Your Nurse will explain these exercises to you.

Preventing Blood Clots Medication (“Blood Thinners”) “Calf/Foot Pumps” Walking and Exercising Surgical patients are also at a higher risk of having a blood clot following surgery. There are three ways that we prevent blood clots from forming: medication, “calf/foot pumps”, and walking/exercising.

Coumadin and Lovenox ***Your surgeon may or may not place you on a blood thinner after spinal surgery Will help to prevent blood clots from forming Will need to learn how to take these medications safely Will need to watch a video Medication is one way to help reduce blood clot formation. Your Surgeon may or may not prescribe a blood thinner while in the hospital as well as for a short time after discharge from the hospital. Two common blood thinners are Coumadin (a pill) and Lovenox (an injection).

Compression Devices Foot or calf pumps Help to push the blood back into circulation Wear them when you are in bed or in the chair The second way to help reduce blood clot formation is to use compression devices on the calf muscles. These devices will inflate with air and squeeze calf muscles to push blood back towards the heart. These will be worn while in bed or in the chair but will be removed when walking.

Walking and Exercising Helps to prevent blood clots from forming Exercise in and out of bed Ankle circles, foot pumps, tightening leg and buttocks muscles The third way to help reduce blood clot formation is through walking and exercising. Not only will our staff walk with you, but they will also teach you exercises to perform while lying in bed or sitting in the chair.

Diet Initial diet is typically clear liquid unless otherwise designated by your physician Diet will advance as tolerated Constipation High fiber Increase activity Fluids Nausea Your first meal after surgery will be clear liquid. If you tolerate this, your diet will be advanced to your regular diet. Pain medication may cause constipation, so we encourage you to eat foods high in fiber, increase your activity, and increase your fluid intake. We also have medications if you experience nausea.

Call for Help Never get out of bed or chair unless you call for assistance Call as soon as possible. Try to ask for help when a staff member is already in the room. Never get up without calling for help. You may experience changes in blood pressure, lightheadedness, dizziness, and nausea which may cause you to fall and injure your new implant(s).

Condition H (help) Dial 3111 and give room number Gives family and friends a way to call a Medical Emergency team to the bedside Call if… You notice a change in your loved one’s condition You still have serious concerns about your loved one’s condition after speaking to the healthcare team If a family member or friend notices a change in your condition, they may dial extension “3111” and a Medical Emergency team will be sent immediately to the patient’s bedside.

Sleep Dial L.O.U.D. (5683) on phone if sleep disturbed Anonymous call TIGR TV Channels Relaxation/Meditation channels Comfort Cart We make every effort to reduce noise in the hospital. If your sleep is being disturbed, you may dial “LOUD” (5683) on your phone, and someone will address the noise issue. We also have relaxation/meditation channels on our television. A Volunteer will also bring a Comfort Cart to your room .

Case Management Joan Paramore RN Case Manager (919) 954-3878 Joan Paramore is the Nurse Case Manager for the Orthopaedic Unit.

Goal: To get you home safely!!! Discharge Plan Goal: To get you home safely!!! Our goal is to get you home safely.

Discharge Plan Everyone is assigned a Case Manager who will usually meet with you the day after surgery Average Length of Stay: 2-4 nights That means you should be ready for discharge around the 2nd, 3rd, or 4th day after surgery The Case Manager will meet with you the day after surgery and each day after to track your progress. The average length of stay is 3 nights.

Discharge Please remember that once the Physician has written orders to discharge you home, there are still many things that have to be completed before you will be leaving the hospital. We want to make sure you have everything you need-prescriptions, home health or rehab arrangements, and information about your home care. Sometimes this process can take up to 4 or 5 hours. We know you’ll be eager to leave the hospital, and we want to be sure everything’s in place to ensure a smooth and safe transition.

Discharge Plan Options: Home Health You will choose agency (list provided) RN (if on Coumadin) Physical Therapy (2-3 times/wk) Occupational Therapy (if ordered by Doctor) ***Your Case Manager will set up a Home Health Agency (of your choice) for you Most spine patients are “safe” to return home and do not require home health services. In the event that home health is required, your Case Manager will arrange it. Typically, this involves a Registered Nurse and Physical Therapist. If needed, an Occupational Therapist may be ordered.

Discharge Plan Options: Home Health Equipment ordered… Rolling Walker (if needed) Bedside Commode (if needed) ***Your Case Manager will order your equipment for you from an agency of your choice Most spine patients do not require any equipment for home. If any equipment is needed, then the Case Manager will order it for you before going directly home. If you do not go directly home, then the Rehab facility will order it for you instead.

Discharge Plan Options: Short-Term Rehab If not safe to return home, Short-Term Rehab may be an option. Based on… 1. Your insurance 2. How well you progress with Therapy while in the hospital If you are not “safe” to return home, then your healthcare team may recommend that you go to Rehab for a short-term stay before returning home. Your Case Manager will help arrange a Rehab stay for you, if needed.

Discharge Plan Options: Short-Term Rehab Two types of Rehab Facilities… SNF: 1 to 3 hours of therapy/day Average Length of Stay: 1-2 weeks-as needed 2. Acute: 3 to 5 hours of therapy/day Average Length of Stay: 5 days There are two types of Rehab facilities. Most patients that need Rehab go to “SNF’s” (Skilled Nursing Facilities). Acute Rehabs are usually hospital-based facilities. Your Case Manager will meet with you and discuss Rehab facility options.

Discharge Plan Options: Outpatient Therapy Usually set up after Home Health is completed Rarely set up at time of discharge from hospital Outpatient Rehab may also be an option for you immediately after discharge from the hospital, Rehab facility, or when Home Health is completed.

Discharge Plan Transportation (depends on what is medically necessary) Car Wheelchair Van Not covered by insurance Cost: $55-$120 Ambulance Covered by insurance if “medically necessary” ***Your Case Manager will set up your Wheelchair Van or Ambulance for you (if needed) Most patients have a family member or friend drive them home or to Rehab from the hospital. The Case Manager can also arrange for transportation if you have no one to transport you.

If You Are Going Home… You may fill your prescriptions at our Plaza Pharmacy (Located on the First Floor of the hospital) Hours of Operation: Mon-Fri (9:00AM-4:30PM) (919) 954-3921 Use the Main Pharmacy on weekends or after 4:30PM (but make payment arrangements with Plaza Pharmacy Mon-Fri 9:00AM to 4:30PM If you are going directly home from the hospital, you may fill your prescriptions either the day before discharge or the morning of discharge at our hospital pharmacy.

Physical Therapy The next portion of the presentation will cover Physical Therapy.

Treatment Sessions Seven days/week One or two sessions per day with the Therapist Your therapeutic activity will also involve walking with Nursing staff Typical treatment session Post-op Days 1, 2, and 3

Specific Exercises Your Therapy will involve a lot of walking with our staff Depending on your individual needs, Therapy will work with you either once or twice a day. Your therapeutic regimen will not only involve walking/exercising with Therapists, but it will also involve working with Nurses and Nurse Assistants as they help you up to the chair, bathroom, and hallway.

General Precautions No “BLT’s” !!! No Bending No Lifting No Twisting Your Therapist will also teach you how to “logroll” Your Therapist will teach you spine “precautions”…or what NOT to do following spine surgery. Typically, this involves no “BLT’s” (no bending, no lifting, and no twisting). You will also be taught how to properly logroll to get out of bed.

Homeward Bound Gym Stair training Car transfer exercises If needed, you may be brought to the Gym to perform stair training and transfer exercises.

Medical Equipment Walker Bedside Commode Your Therapist will also teach you how to properly use a walker and how to properly and safely sit and stand.

Occupational Therapy An Occupational Therapist may work with you prior to discharge if needed. Occupational Therapy deals with Activities of Daily Living (ADL’s)-bathing, dressing, eating, etc..

Treatment Post-op Day 2 visit Demonstration of equipment Reacher Sock aid Bathing sponge If your Occupational Therapist feels that you need any adaptive equipment prior to discharge, then she will give you the necessary equipment and teach you how to properly use it. If you go directly to Rehab from the hospital, you will receive this equipment from the Rehab facility, if needed.

Helpful Tips How to properly carry items in pockets and basket while driving a walker Safety in the shower (have someone close by) Prior to surgery, move low- and high-lying items to waist level (i.e. in kitchen/bathroom cupboards, refrigerator) Make arrangements to have appropriate-sized car available for day of discharge Your Therapist will also teach you helpful tips related to using the walker (if needed), shower safety, and home preparation.

Before Surgery… Assess your home environment and let the Therapist know the following once you are in the hospital… Tub/Shower (location, height, grab bars) Number of steps (outside of home and upstairs) Height of bed Your Therapists will ask many questions about your home environment including your bathroom, stairs, and bed. Please be prepared to answer questions regarding these areas so that your Therapy can be customized to your individual needs.

Thank You!!! We look forward to caring for you and your family! Thanks for choosing Duke Raleigh Hospital for your surgery!