Surgical Joint replacement
Joint replacement surgery removes damaged or diseased parts of a joint and replaces them with new, man-made parts.
Replacing a joint can reduce pain and help you move and feel better. Hips and knees are replaced most often. Other joints that can be replaced include the shoulders, fingers, ankles, and elbows.
Points To Remember About Joint Replacement Surgery
Joint replacement surgery removes damaged or diseased parts of a joint and replaces them with new, man-made parts.
The goals of joint replacement surgery are to relieve pain, help the joint work better, and improve walking and other movements.
Risks of problems after joint replacement surgery are much lower than they used to be.
An exercise program can reduce joint pain and stiffness.
Wearing away of the joint surface may become a problem after 15 to 20 years.
Check vital signs, including temperature and level of consciousness, every 4 hours or more frequently as indicated.Report significant changes to the physician.These routine assessments provide information about the client’s cardiovascular status and can give early indications of complications such as excessive bleeding, fluid volume deficit, and infection.
Perform neurovascular checks (color, temperature, pulses and capillary refill, movement, and sensation) on the affected limb hourly for the first 12 to 24 hours, then every 2 to 4 hours.Report abnormal findings to the physician immediately.Surgery can disrupt the blood supply to or innervation of the affected extremity. If so, rapid intervention is important to preserve the function of the extremity.
Monitor incisional bleeding by emptying and recording suction drainage every 4 hours and assessing the dressing frequently.Significant blood loss can occur with a total joint re-placement, particularly a total hip replacement.•Reinforce the dressing as needed.The dressing is usually changed 24 to 48 hours after surgery but may need reinforcement if excess bleeding occurs.
Maintain intravenous infusion and accurate intake and output records during the initial postoperative period.The client is at risk for fluid volume deficit in the initial postoperative period be-cause of blood and fluid loss during surgery, as well as the effects of the anesthetic.
Maintain bed rest and prescribed position of the affected extremity using a sling, abduction splint, brace, immobilizer, or other prescribed device.Proper positioning of the affected extremity is vital in the initial postoperative period so that the joint prosthesis does not become dislocated or displaced.
Help the client shift position at least every 2 hours while on bed rest.Shifting of position helps prevent pressure sores and other complications of immobility.
Remind the client to use the incentive spirometer, to cough,and to breathe deeply at least every 2 hours.These measures are important to prevent respiratory complications such as pneumonia.
Assess the client’s level of comfort frequently. Maintain PCA,epidural infusion, or other prescribed analgesia to promotecomfort.Adequate pain management promotes healing andmobility.
Help the client get out of bed as soon as allowed. Teach and re-inforce the use of techniques to prevent weight bearing on theaffected extremity, such as the over-head trapeze, pivot turn-ing, and toe-touch.Early mobility prevents complications such aspneumonia and thromboembolism, but appropriate techniquesmust be used to prevent injury to the operative site.
Initiate physical therapy and exercises as prescribed for thespecific joint replaced, such as quadriceps setting, leg raising,and passive and active range-of-motion exercises.These exer-cises help prevent muscle atrophy and thromboembolism andstrengthen the muscles of the affected extremity so that it cansupport the prosthetic joint.
Use sequential compression devices or antiembolism stock-ings as prescribed.These help prevent thromboembolism andpulmonary embolus for the client who must remain immobilefollowing surgery.
For the client with a total hip replacement, prevent hip flexionof greater than 90 degrees or adduction of the affected leg.Provide a seat riser for the toilet or commode.These measuresprevent dislocation of the joint.
Assess the client with a total hip replacement for signs of pros-thesis dislocation, including pain in the affected hip or short-ening and internal rotation of the affected leg.
For the client with a total knee replacement, use a continuouspassive range-of-motion (CPM) device or range-of-motion exercises as prescribed.Dislocation is not a problem with a kneereplacement, and moreemphasis is placed on range-of-motionexercises in the early postoperative period.
Maintain fluid intake and encourage a high-fiber diet.Administer stool softeners or rectal suppositories as needed.Immobility contributes to the potential problem of constipation;these measures help maintain regular fecal elimination.
Encourage consumption of a well-balanced diet with adequateprotein.Adequate nutrition promotes tissue healing.
Teach or reinforce postdischarge exercises and activity restric-tions. Emphasize the importance of scheduled follow-up physi-cian visits.Clients are discharged from the acute care facilitybefore healing is complete. Exercises are prescribed and activitiesare resumed gradually to protect the integrity of the joint replace-ment and prevent contractures.
Referrals as needed to home health agencies and physical therapy.Clients often require home health care for both nursing care needs and continued physical therapy following dis-charge from acute or long-term care.
Post disc replacement care:
In order for you to recover after lumbar artificial disc replacement surgery, your spine needs to be properly aligned — so twisting your back and bending at the waist are not allowed.
Your physical therapist will help you learn how to move more safely. Some things to keep in mind:
Getting out of bed: You will learn a “log-rolling” technique to get out of bed without twisting the spine.
Heavy lifting: Right after surgery, you shouldn’t lift anything heavier than five pounds. As your muscles grow stronger, you will be able to slowly return to lifting more weight.
Showering: Your surgical incision should stay dry until it is fully healed, about two weeks after surgery. Avoid taking baths and cover the incision with a bandage when you shower. You should use a shower chair and stool while in the shower to protect your spine from falls or sudden movements. You may also want to have someone nearby to help you get in and out of the shower.
Driving: You will not be able to drive until your pain is under control. You also can’t drive while taking opioid pain medications.
Returning to Work
After artificial disc replacement surgery, your main job is to rest, so you should plan to not work right away. How long it takes for you to return to work depends on the type of work that you do.
If your job involves light activities, you may be able to return to work within two to three weeks. For more physically demanding work, expect at least six weeks. If your job includes heavy lifting, you may need to wait at least 12 weeks before going back to work.
Also, if your job involves driving, you will not be able to do it while you are on opioid pain medications.
Resuming Physical Activities
Soon after surgery, your healthcare team will encourage you to start walking to speed up your recovery. From then on, you will need to slowly work up to your regular activities and exercise. While everybody's recovery is a little bit different, many patients can expect something like the following:
Two to four weeks after surgery, a physical therapist will typically start working with you on developing the strength, stability and aerobic fitness that you need to return to your being active. Continue to do your physical therapy activities each day.
Many people will be able to return to light exercise and recreational sports at about six weeks after surgery, although your physical therapist might ask you to wait longer. Avoid impact sports until your healthcare team has told you it is okay. Walking, though, is always a good way to stay active.
After surgery, you can resume sexual activity when you feel ready, as long as it doesn’t involve twisting or bending at the waist. If a position hurts, don’t do it. If you are unsure about any sexual activity or position, talk to your doctor before attempting it.
During recovery, remember not to twist your back or bend at the waist while moving. You should also talk to your doctor or physical therapist about how much weight you can safely lift. It may be less than you expect.
Recovering at Home
You will be sent home a few days after your artificial disc replacement surgery. Your healthcare team will give you instructions on how to take care of yourself during the first couple weeks at home. This includes information on:
Changing your bandage: Your doctor or nurse may show you how to change your bandage, unless you have a health care professional visiting you regularly. The incision should stay clean and dry to avoid getting an infection.
Medications: If you still have pain or nausea, your doctor may prescribe you medications or recommend an over-the-counter drug. If you have questions about your medications, call your doctor’s office.
Follow-up appointments: You will have a follow-up visit with your doctor around three weeks after surgery to check your symptoms and overall health. You may also have X-rays or other medical imaging to check the artificial disc device.
Planning ahead can make your recovery safer and more restful. This includes asking family or friends to take care of your needs at home, drive you when you need to go to your doctor’s appointments, or pick up your prescriptions.
Setting up the space around your bed can also make recovery more restful. Keep everything you will need nearby, such as telephone, books or magazines, clothing, toiletries, snacks and drinks.
Keep your walker or other assistive device near your bed so you can easily get to the bathroom when you need to. Ask your caregiver to be nearby the first few times so they can assist you.
If you develop any of the following symptoms, call your doctor:
Bleeding, redness, swelling, or discharge from your incision site
Pain that does not respond to pain medication
Numbness or weakness
Voice change or hoarseness
Because artificial disc replacement surgery doesn’t require the bones of the spine to heal, recovery after this procedure is faster than for other back surgeries, including spine fusion.
Full recovery from artificial disc replacement surgery will take anywhere from a few weeks to a few months. This includes a period of limited motion and some discomfort for a few weeks after surgery, followed by several weeks of rehabilitation. As your body heals, you will be able to slowly add more activities to your daily routine.
Artificial disc replacement recovery time depends on many factors, including your overall health, whether you smoke cigarettes, and how well you are able to follow the instructions and rehabilitation program prescribed by your physician and physical therapist.
Success over the long-term
Once you have resumed your normal activities, there are other lifestyle changes that you can make to ensure your long-term success. These include:
Quit nicotine: Smoking contributes to back pain, and nicotine can interfere with the healing process.
Avoid excess alcohol: Alcohol is a depressant that can affect your moods. It can also interact with certain medications.
Drink water: Some medications can cause constipation, so drink plenty of water throughout the day.
Mange your weight: Excess weight can put more pressure on the discs in your low back. Eat healthy and stay physically active to maintain a healthy weight.
Get plenty of sleep: Sleep is essential for the healing process. It will also keep you healthy long-term.
Planning for surgery
Before surgery you will likely have a discussion with your surgeon or other members of your care team about pain management, treatment options and your particular needs. This conversation may include the following ideas:
Pain expectations. Ask your doctor about pain typically associated with the procedure and the expected duration of recovery.
Previous experiences with pain. Talk to your doctor about your experience with pain and different methods of pain control. Mention what has worked for you and what hasn't in the past.
Chronic pain. If you take drugs to treat chronic pain, your body may be less sensitive to pain medication. Your doctor will discuss options for treating both chronic pain and post-surgical pain.
List of your medications. Include all prescription and over-the-counter medications plus any supplements or herbs you've taken in the past month. Your doctor needs to know about anything that might interact with post-surgical pain medications. You may need to change your drug regimen before and after surgery.
Alcohol and drug use. Accurately describe your current use of alcohol, tobacco or illicit drugs. Your doctor needs to know if you are recovering from an addiction to — or currently misuse — alcohol or drugs, including prescription medications, in order to plan and monitor your pain management.
Side effects. Ask for written information about the drugs you will be prescribed and their side effects. Ask questions about what can be done to minimize side effects and when to get help for serious side effects.
Additional pain management. Ask your doctor about interventions that may support your treatment plan, such as psychobehavioral interventions to address anxiety or coping skills.
Discussion of your concerns. If you're afraid of side effects or overdosing on pain medications, talk to your doctor. He or she can help you understand strategies to safely manage your pain.
Types of pain medication
Post-surgical pain is usually managed with multiple pain-reducing medications (analgesics). The appropriate type, delivery and dose of medications for you depend on the type of surgery and expected recovery, as well as your own needs.
Pain medications include the following:
Opioids, powerful pain medications that diminish the perception of pain, may be given after surgery. Intravenous opioids may include fentanyl, hydromorphone, morphine, oxycodone, oxymorphone and tramadol. Examples of opioids prescribed in pill form after surgery include oxycodone (OxyContin, Roxicodone, others) and oxycodone with acetaminophen (Percocet, Roxicet, others).
Local anesthetics, such as lidocaine and bupivacaine, cause a short-term loss of sensation at a particular area of the body.
Nonsteroidal anti-inflammatory drugs (NSAIDs) — such as ibuprofen (Advil, Motrin IB, others), naproxen sodium (Aleve, Anaprox, others), celecoxib (Celebrex) or ketorolac — lessen the inflammatory activity that worsens pain.
Other nonopioid pain relievers include acetaminophen (Tylenol, others) and ketamine (Ketalar).
Other psychoactive drugs that may be used for treating post-surgical pain include the anti-anxiety medication midazolam or the anticonvulsants gabapentin (Gralise, Horizant, Neurontin) and pregabalin (Lyrica).
While opioids may or may not be appropriate to use after your surgery, your surgeon will likely prescribe a combination of treatments to control pain, lessen side effects, enable you to resume activity appropriate for recovery and lower risks associated with opioids.
Managing the risks of opioid use
Opioids are often critical for post-surgical pain management because of their powerful effect. But their side effects can be significant, including nausea, vomiting, constipation, urinary retention, drowsiness, impaired thinking skills and poor respiratory function.
Overdosing and misuse of opioids also are risks, particularly when opioids are used to treat ongoing (chronic) pain. Although the use of opioids after surgery is intended as a short-term strategy to relieve pain while the body heals, the risk of misuse is still a concern.
Because of the risks associated with opioids and their potential side effects, these drugs should be used carefully, if at all. Opioids should be used at the smallest dose effective for the shortest possible time.
You and your doctor should discuss steps you can take to reduce the risks associated with opioid use, including:
Taking medication only as directed, minimizing dose and length of opioid use
Talking to your doctor when your pain is not under control
Not using alcohol while taking opioids
Following your doctor's instructions about other drugs not to take while using opioids
Storing drugs safely
Disposing of unused drugs, ideally through a pharmacy take-back program
Not sharing your medication with other people
Pain relief after major surgery
A primary goal of pain management after major surgery is for you to awaken relatively comfortable and to experience an uninterrupted transition to pain control, but some discomfort is common and should be anticipated after surgery.
Intravenous (IV) pain medication
Before surgery, you'll probably have a slender plastic tube (catheter) inserted into a vein in your hand or arm to give you fluids, sedatives, anesthetics, antibiotics or pain medications. The catheter can be used for delivering pain medications until you can take pills by mouth.
Pain relievers, such as opioids, are usually injected into your IV catheter at regular intervals. Most hospitals also offer patient controlled analgesia (PCA) — a system that allows you to give yourself a fixed dose of the medication by pushing a button. This way you don't have to ask a nurse for each dose of pain medicine.
The PCA system has built-in safeguards to prevent you from overdosing on pain medication. If you push the button more than once within a set period of time, the dispenser ignores the second request.
In epidural analgesia, pain medications are injected through a catheter inserted into the epidural space within your spinal canal but outside your spinal fluid. An epidural catheter is often used for labor and delivery, and sometimes before an operation, such as a cesarean section or a major abdominal surgery.
The epidural catheter can be left in place for several days if needed to control postoperative pain. A continuous infusion of pain relievers, including local anesthetics or opioid medications, can be delivered through the catheter to control pain.
Patient controlled epidural analgesia (PCEA), similar to PCA, enables you to give yourself a dose of the pain medication by pushing a button. It, too, has built-in safeguards so that you don't give yourself too much medication.
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