Jeri Ward is a registered orthopedic nurse who has helped design an educational process for pre-op patients. Jeri says it’s really a team approach when it comes to joint replacements. The first thing Jeri says a patient—and a patient’s caretaker—needs to be education about the process. Anesthesia is one of the first things she tackles. Two weeks before their surgery patients will come in for this educational class and also get tests done to make sure if there are any health issues the staff can address it. Infection is the biggest worry for a patient and a doctor. Jeri shows patients exactly what they need to do to keep their wound clean. The patients and caretakers, such as spouses, are given literature about what is going to happen after the surgery so they won’t feel lost or confused.
My name is Jerry Ward and I’m a registered nurse. I started out as an orthopedic technician many years ago in the hospital and I started nursing school and decided to be an orthopedic nurse.
We focus on the team approach to joint replacement because it really does take a team to see people through this and years ago we would have the patient come in, do the surgery, the patient would go home, everybody had a lot of angst. I think people didn’t even really understand what joint replacement, which is such a weird term, because we’re not going to take your joint out, we don’t pull your knee out and put a whole new mechanical thing in, we’re resurfacing the ends of the bones.
So we show people models and we explain what the materials are and first of all, people need education before they even come in. We talk about anesthesia. I always wonder why do people pick an outstanding surgeon and then just take the roll of the dice who their anesthesiologist is. I mean that guy is really important. And we have learned the importance of not using a general anesthetic for every patient. Some patients have to have it, but for the most part we do the epidural and the IV sedation, which is great as you get older for your brain and that sort of thing.
We have our patients come in for the pre-op class two weeks before surgery because we feel like we need that amount of time to prepare them. And they come in and they have class, they get their blood drawn, chest x-ray, they see the internist, EKG, etcetera. That gives us a chance that if we find something, maybe their potassium is high, maybe they have a urinary tract infection, it gives us time to clear that up. If they need a cardiac workup then they have time to do it and we don’t cancel their surgery at the last minute.
I have each patient fill out a calendar for themselves based on their surgery date when there’s things that they need to do to be prepared. That way I tell them, you know, “You’re going to go home, you’re going to take all these papers and then in a week you’re going to pick them up and say, ‘Now when am I supposed to do this, when am I supposed to do that?’” No problem. You’re just going to go to your calendar and you’re going to say, “That’s my day to start my special wash, that’s my day to stop my aspirin, my anti-inflammatories. It’s all laid out there for you. So, you know, we try we’re—we’re—we try to educate the patients about complications that can and do occur with joint replacement surgery.
Infection is huge. That’s devastating to the patient, it’s devastating to the doctor, it’s devastating to our whole team so we really want to prevent that. So we have our patients do a wash starting six days prior to surgery. We have them wash with an antibacterial soap. Although if they have a history of an infection in their body, if they’ve even had an infection that put them in the hospital where they had to have IV antibiotics.
So in our practice, what we do is we start the discharge at the time of the pre-op class. So we ask the patients to bring someone with them, if they’re going to have a caregiver at home so they can hear what’s going to happen. Two sets of ears are better than one. In the class, the physical therapists and the occupational therapists talk to the patient about safety because we don’t want the patients to fall. They talk about removing throw rugs, putting, uh, your pots and pans at waist level. And it isn’t like you couldn’t get something high or low, but why stress yourself at that time? We talk about pets. You’re going to walk in the door and your dog’s gonna miss you for a day or two, they might jump all over you.
We also give them a sheet that has their discharge instructions on it. And I tell the patient, “I want you to go home today and I want you to read this thing three or four times before you ever come to the hospital because when it’s time to be discharged the nurse if going to come in and she’s going to tell you all this and you’re not going to remember any of it, you’re going to be anxious, you’re going to be maybe hurting, you’re going to be nervous about going to get in the car.” That’s not a good time to tell people about discharge. Tell them upfront.
You got to wear those crazy stockings for so many weeks. That goes on your calendar. We have them wash with a stronger soap. They wash with that for one minute over their joint at the end of surgery for five days and then on the sixth day they take their shower and after the shower they’re dry for an hour and then they do a full body wipe with, um, chlorhexidine wipes. I think that’s what everybody is using now.
With our patients I make everybody do a test. I have them come out, you set your timer when an hour is up, I have them open their wipes, they get six wipes, they open one wipe and they do a test on their forearm because you can be allergic or have a reaction to the chlorhexidine and I don’t like a patient calling me and saying I’m red and itchy all over my body. It’s unnecessary.
So they do the wipe and we teach them not to shave, not to put lotion. Lotion can harbor bacteria. They also have to understand you’re in the real world. You’ve got a dog, you’re putting clothes on, you’re going to work every day, you’re out in the world so you’re not sterilizing your leg, you’re cutting the bacteria count down for the operation.
It used to be that people waited as long as they could before they had surgery, but now people look more at the quality of their life and, you know, 20 years ago my 50, 55 year old patients would be grandma and grandpa and now they’re mom and dad and they have sometimes four, five year old kids at that age that they have to take care of or they have very active teenagers and things they want to be involved in.
When you go into the operating room that’s the part that scares a lot of patients. It’s different when you’re sitting up, but when you lay down on the gurney and all’s you can see is the ceiling and somebody’s wheeling you in well people don’t like that and I always tell the patients, “You need to communicate with us, tell us what you want to see or do.” Because some people come in and they say, “As soon as I pass the 1,500 sign I don’t want to see or do anything, I don’t want to know anything, I just want it to be over with.” Other patients will say, “Can you ask if I can be awake during the surgery?” I mean people are different.
You know, it takes an hour to position people, wash and drape, hook up the computer, get the spacesuits on and then the surgery starts and we always give them an hour, an hour and a half to do the surgery, sometimes it’s less. That’s about average. And then they go to the recovery room for an hour.
In the recovery room they’re asking the patients to wiggle their toes and pump their ankles, but a lot of times you cannot move for a while. But if nobody ever told you that you’re going to freak out. We’re asking you to keep trying to move so we can see when your legs are awake enough that you can go up and get out of bed. After you’re in your room two hours or so you’ll get up with a therapist, you’ll walk to the door, you’ll sit up in a chair, you’ll walk to the bathroom.
Used to be if you closed your eyes in an operating room somebody was sticking a catheter in you, but we don’t do that anymore. You’re out of bed so quickly why not just go to the bathroom yourself?
We know that if you lay in bed that’s where you get the complications so when you tell people, “That’s why we’re getting you up, you need to start walking, you need to put weight on your legs, on the bottom of your foot, let’s get the blood pumping up and down, you know, the things that will keep you from getting a blood clot, early ambulation,” and taking some form of a blood thinner for us is typically just aspirin.
So I think a big part of patient care is psychology. You know, if you’re sure that that patient is going to get up and walk and get to the nurse’s station and walk around the hall they’ll do it.
We do send some of our hip patients home the same day very successfully. I’m sure there’s been over 1,000 now that have gone home the same day. By the time they come to class I know who’s a same day patient or who will spend one night and you have to just dispel the whole idea that you’re going to be in the hospital for three or four days. Those patients are few and far between.
I—one thing I always tell the patients that the doctors don’t tell you you’re going to be tired. You might not have a lot of pain, but you’re going to be exhausted a week, two after surgery you just have to still take a nap and you think what’s wrong with me. So even though we have a lot of things that make the surgery easier in so many ways, you still are a human being and you have a body that’s got to heal.
So we usually say, “Go home those first six weeks, walk every day, outside so you get some fresh air and sunlight and do the exercises we teach you twice a day and then when you come back at six weeks, if we find that you still have a bit of a limp or a weak muscle or there’s some strength issue, then we can send you to therapy and make it count, then you can go to an outpatient therapist and do some real work.”
The knees need therapy. Hips don’t necessarily need it. So I’m going to say there’s probably like 70 percent of patients never do anything but walk and do the isometrics. And then, you know, you get back to what you want to do. I mean you have the surgery for a reason. You might want to golf, you might want to swim, uh, dance, bowl, whatever and you want to get, that’s part of your therapy is getting back to your activity.
You know, I always tell the patients, you know, “Your hip is buried under, uh, a ball of muscle and fat, it’s deep in the body, but your knee is like right there under the skin so knees hurt more.” Hips are more stiff, numb, tight, but the knee is more achy. There’s more therapy with the knee. It’s uncomfortable for a longer time, swollen for months. Hips are swollen, too. Uh, people always call me two, three weeks after surgery and they’ll say, “I still have swelling.” It’s going to be swollen for three to six months.
It just doesn’t look the same and after a while it just flattens out and it’s normal again. The discharge criteria is you have to be able to go up and down stairs. Even if you went home the same day you’re going to encounter a curb, if you don’t have stairs in the house you’re going to need to negotiate them. Some people say, “Well, do I have to move everything downstairs, do I have to bring my bed downstairs?” No, you’re going to be able to do stairs. You go lay in your own bed and it’ll feel normal and good. You have to be able to get on and off the toilet, in and out of bed, on and off a chair.
You want to—want to have a chair with arms for a while so you have some leverage to help put yourself up. You have to be able to get in and out of a shower so we ask them in pre-op class, “Do you have a step over tub, do you have a walk in shower,” so we can practice with what they have at home.
So we really do start ahead of time to prepare them. And the way that we close our wound is with, uh, subcuticular suture. So we close everything from the inside out. There’s no suture that will have to come out or anything. We know it takes five days for skin to stick together so we lay a piece of mesh over the top of the incision and we do use small incisions as much as we can and then we just glue the mesh down to the skin. Now the wound care of that kind of goes against everything that we’ve been taught about wound care and we worry a lot about infection.
So water can’t get in, bacteria can’t get in, you’re able to take a shower. If you have any—any drainage, sometimes people drain and drainage is not a bad thing. If the incision gets a lot of tension on it it could put out a little drainage, but patients always should report that to us. Anywhere drainage can come out of the wound it—and bacteria could go in the same opening so you always report drainage.
People are a little confused when they go home because they’re not always on an antibiotic. We give all the antibiotics in the hospital through the IV which is the most effective way to give them. But if you have drainage at home of course we would put you on an oral antibiotic until it stopped.
The thing about that mesh and the—the glue, you just blot it dry and then leave it alone. Don’t put ointment or betadine or anything on it because it breaks the glue down too soon. And I had a lady not too long ago who put, um, cortisone cream on it because she was itching. You know how you start to heal you start to itch. So she put a little cortisone cream and of course it just blew up and made all the glue come off. So that was a good lesson.
Infection is something that we always are concerned about and there are some signs that you should look for, things that you should report to us. One thing is if your incision is red or warm and it’s very difficult because after surgery it’s normal for the skin around an incision to look pink. It’ll be pink because it’s granulating and—and healing itself. And it will be warm because blood comes to the area to heal it and blood makes it feel warm. So there’s a fine line between pink and warm and hot and red and you’re running a fever. So if you start running a fever that means that something is going on and then you need to call us and then, you know, nowadays people are taking pictures of things with cell phones and shooting it to us and then we’ll tell you to come in so we can look at it. Don’t second guess it. Things can go bad quickly with an infection. But it’s human nature.
You don’t want to bother someone. I tell patient, a patient will call me and say, “Oh I didn’t want to call ‘cause I already called you like ten times last week,” and it’s like, “You can call me 20 times or 50 times, as long as you’re okay.” So incisions that are red, the red area’s getting bigger, it starts to spread out more, you fe- it feels hot to the touch. And again, you’re running a fever, that’s a clear sign that you have an infection. But infections can come other ways after surgery, too. It’s not just the wound. One big trick thing is the bladder infection. Very typical for women to get home after joint surgery and they stop drinking a lot. They don’t want to drink water and juice and stuff because every time they do they got to get up and run for the bathroom. Well, when your leg is hurting, after you’ve been up ten times you start to think, ah I’m just going to push that away and not drink so much and that’s how they get bladder infections.
So I always tell people that’s part of your therapy, drink and get up as many times as you need to use the bathroom. If you’re not drinking enough fluid, you’ll notice that when you start getting out of bed and you sit up at the side of the bed you might feel a little de- a little, uh, lightheaded and it’s because you’re dehydrated. So people don’t even think about that.
Another thing that will catch people up is really hot showers. When you first come home from the hospital your blood count might be down a notch or two, you might be a little dehydrated and when you get into all that steam it can make you feel lightheaded and you could faint and mess up our brand new hip replacement.
Orthopedic nurses for years the biggest problem, pain, pain, pain and now the pain is so well managed, it’s constipation. So that’s rough and so we put that on their calendar, this is the day to take a laxative before surgery if you need it, this is the day to do it after because if you’re not looking at that there’s too many other things to pay attention to, how far am I walking, am I icing, am I elevating, am I doing all these things. You don’t think about that until you have a stomachache and then you’re on the phone to me ten days later and it’s hard for me to take care of you.
You could be back in the hospital. And then talk about embarrassing. So okay it’s embarrassing to talk about it in class for some people, but you know, if they’re dragging you back in in an ambulance ‘cause you’re constipated that’s going to be more embarrassing.
Yeah, I think every patient needs to have some help when they go home from the hospital. Even though they’re doing well, I mean we do a lot of young patients who are very active patients, have surgery, and they’re just ready to tear off and, you know, this is going to be really easy, but I know in my time of taking care of joint patients is if you don’t follow the rules it just extends your recovery. Yes, we want you to go back to work quickly, yes we want you to be able to do everything you want to do, but what you do in those first six weeks is going to determine the long term longevity of your joint. So if you’re putting a lot of stress on the tissues and you’re doing things you shouldn’t do so you’re swollen all the time and in pain all the time it’s not good because you need to let someone help you.
And if you live alone then there’s lots of different options. There’s neighbors, friends, family that can, someone doesn’t have to be there with you 24 hours a day, you don’t need a nurse, you just need, uh, some moral support, somebody to run your errands, somebody to do the heavy stuff. Like I always tell the patient, “You—you can go home and get up in the morning and get coffee for yourself, you can get around your house just fine, but you’re not going to be doing big loads of laundry, you’re not going to be cooking Thanksgiving dinner, you’re not going to be running all your errands initially, not until you’re able to drive.” And driving is a big thing because we all want to be independent, but you need to know that you got to be off your pain medication for liability purposes. You got to have control of the pedal leg so you don’t roll into another car at the stop sign.
One of the benefits of having a caregiver with you in class is that it gives them a chance to ask questions, too, and also to hear questions that other family members are asking. It actually develops kind of a comradery. But the family gets a chance to hear what we’re telling the patient they can and can’t do so the patient can’t go home and say, “Oh yeah, they told me I could drive the day after I got home,” because the family just heard you’ve got to wait until you meet those parameters.
We know that the patient’s goal is to get home and return to normal. Why do you have the surgery? There’s things you want to do, right. You want to get back to those things. And with common goals and all of us working together to achieve them and having the patient as a part of that team, I can’t imagine myself doing any other work but this. I love the patients, I love seeing people get back to a life where they’re happy, pain free, doing the things that they want to do.