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

2. Duke Raleigh Hospital has recently become the first hospital in the region to achieve certification in Total Joint procedures. This prestigious designation signifies Duke Healthcare’s commitment in providing excellent care.

3. 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 knee replacement surgery.

4. 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.

5. When you arrive on the Orthopaedic Unit, you will notice a baseball poster in your room. As each goal is achieved, your healthcare team will sign off each goal to track your progress. We will also ask you what you would like us to focus on for each day so that we can individualize your care. This will be written in the “Patient’s Priority” section on the poster.

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

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

8. 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 if you do not have a Care Card and one will be filled out for you.

9. 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 product 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.

10. 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, shorts or baggy pants should be worn so that the knee dressing can be easily changed.

11. 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 knee area to reduce the chance of infection.

12. 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.

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

14. 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.

15. 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.

16. Dressings and Drains Large dressing initially
Drains and dressings removed 1st or second day after surgery
Dressing will be
changed
Your initial dressing in surgery will extend from the mid-thigh towards the ankle. After the initial dressing is removed, a smaller dressing will be placed over the incision. Your surgeon may also place a drainage catheter in the wound to help reduce fluid on the wound and, likewise, reduce swelling.

17. 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.

18. 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.

19. Femoral Nerve Block/Catheter ***Some surgeons prefer not to use this***
Numbs the front part of the leg from the groin to the knee
Stays in about two days
May cause you to have a “noodle leg”
Need to wear a knee
immobilizer while standing
or walking
Your surgeon may or may not place a femoral nerve block prior to surgery. If so, the catheter will be fed down to the femoral nerve on the side where surgery will be performed. The nerve will be bathed in numbing medicine and will help with reducing pain in the front part of the leg. It usually stays in place for about two days. Whenever this is infusing, you will need to wear a knee immobilizer when out of the bed or the chair.

20. Knee Immobilizer
May wear when out of bed if you have a nerve block/catheter (dependent on your Therapist)
May also wear at night to remind you to keep the leg straight
Used for safety reasons
Note: You may or may not walk with the knee immobilizer on while exercising with a Therapist. However, you should
ALWAYS continue to wear it with Nursing until
you are able to do a full straight leg raise (with no
bend at the knee)
There are times when your Therapist may have you remove the knee immobilizer while walking. Your surgeon may also have you wear it at night in bed to remind you to keep your leg straight.

21. Cryotherapy - “Polar Care” Device
Cryotherapy - “Polar Care” Device **Some surgeons prefer to use ice instead of the Polar Care Device** **Some surgeons may choose not to use the Polar Care Device or ice**
For total knee patients
Sends a cold signal to the brain to help with pain management
Helps with pain and
swelling
You take this home
with you (if it is ordered by your surgeon)
Your surgeon may also order a Polar Care device for you after surgery. This device will pump ice cold water to a pad wrapped around the knee. It will help reduce pain and swelling. If it is not ordered, ice packs will be supplied as needed. Never place ice or the Polar Care directly on the skin. Always keep a barrier (bandage, pillowcase, towel) between the ice and skin.

22. CPM Machine ***Some surgeons prefer not to use this***
Continuous Passive Motion machine
May be used for total knee patients (if ordered)
Passively bends knee while in bed
Your surgeon may order a CPM machine as part of your post-op care. This machine lies in bed with you, and your leg will be placed in it. This machine will gently and slowly flex and extend your leg for you.

23. 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.

24. 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.

25. 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.

26. Preventing Pneumonia Incentive Spirometer
Breathe in times an hour
while awake
Helps to expand air sacs in lungs
Surgical patients are at a higher risk of pneumonia following surgery. You will be given an incentive spirometer and encouraged to perform breathing exercises throughout your stay. Your Nurse will explain these exercises to you.

27. 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.

28. Coumadin and Lovenox ***Please check with your surgeon as to which blood thinner will be prescribed***
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. You will take 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).

29. 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 foot and/or calf muscle. These devices will inflate with air and squeeze the foot and calf to push blood back towards the heart. These will be worn while in bed or in the chair but will be removed when walking.

30. Walking and Exercising
Helps to prevent blood
clots from forming
Exercise in and out of bed
Ankle circles, foot pumps,
tightening leg 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.

31. 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.

32. 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.

33. 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.

34. 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 .

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

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

37. 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.

38. 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.

39. 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
If you are “safe” to return home, then the Case Manager will arrange for Home Health to visit you at home. Typically, this involves a Registered Nurse and Physical Therapist. If needed, an Occupational Therapist may be ordered.

40. Discharge Plan Options: Home Health
Equipment ordered…
Rolling Walker
Bedside Commode
CPM (if ordered by Doctor)
***Your Case Manager will order your equipment for you from an agency of your choice
The Case Manager will also order any equipment you will need for home (if you go directly home from the hospital). A rolling walker and bedside commode are ordered and delivered to your hospital room prior to discharge. If you have a walker at home, please bring it into the hospital for our Therapist to perform a safety and height check. If you need a CPM machine, the Case Manager will arrange for it to be delivered to your home. If you go directly to a Rehab facility from the hospital, then the Rehab facility will order any equipment for you.

41. 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.

42. Discharge Plan Options: Short-Term Rehab
Two types of Rehab Facilities…
SNF: 1 to 3 hours of therapy/day
Average Length of Stay: 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.

43. 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.

44. 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.

45. 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)
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.

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

47. 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
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.

48. Precautions Knee Replacement
Do not stay in one position for longer than an hour without standing up, walking a short distance, and straightening and bending your knee
Do not sleep or rest with a pillow or anything under your knee
Operated leg out in front while sitting or standing
As part of your therapeutic regimen, your Therapist will teach you about knee precautions, or what NOT to do with your new knee.

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

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

51. 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..

52. Treatment Demonstration of equipment Reacher Sock aid Bathing sponge
***Knee patients rarely need this equipment at discharge. The Therapist will determine your specific needs.
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. Knee patients rarely require any of these equipment at discharge. If you go directly to Rehab from the hospital, you will receive this equipment from the Rehab facility, if needed.

53. Helpful Tips
How to properly carry items in pockets and/or basket while driving a walker
Safety in the shower (have someone close by)
While at home 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 your discharge
Your Therapist will also teach you helpful tips related to using the walker, shower safety, and home preparation.

54. 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.

55. The following slides contain questions based on the Powerpoint.
Assessment
The following slides contain questions based on the Powerpoint.

56. Question 1
One risk of a blood thinner medication is: ___________?____________

57. Answer
Increased bleeding (Can also be increased bruising)

58. Question 2
You should call your Doctor immediately if you notice any sign of a blood clot. Name a symptom of a blood clot in your leg: _____________________ Name a symptom of a blood clot in your lung: ______________________

59. Answer
Leg: Pain in the back of the leg (usually in the calf, but can radiate throughout the leg) Lung: Difficulty breathing (may also have a rapid heart rate)

60. Question 3
True or False When standing up or sitting down, you should keep your operated leg slightly in front of your non-operated leg.

61. Answer
True

62. Question 4
True or False When lying in bed, you should keep your operated knee in a straight position as much as possible. You should never place a pillow or rolled-up towel under the knee.

63. Answer
True

64. Question 5
Some pain is normal and expected after surgery, but the best way to keep your pain at a manageable level is to:
Take pain medication when it reaches a “5” on a “0 to 10 pain scale”
Take pain medication only when the pain is unbearable
Use medication as well as other methods to control pain. For example: ice, positioning, etc.
Try distracting yourself from the pain by watching television for an hour or two

65. Answer
3. Use medication as well as other methods to control pain. For example: ice, positioning, etc.

66. Question 6
The best and safest way to raise the height of a chair in your home is to:
Stack pillows on the chair
Stack folded blankets on the chair
Place a small book under each leg of the chair
Place two large telephone books on the chair

67. Answer
2. Stack folded blankets on the chair

68. Question 7
One side effect of pain medication is constipation. List 3 ways to prevent it:

69. Answer Increase fiber Increase fluids Increase activity
You may also take a stool softener or laxative if needed.

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