hello everyone this is Professor Witherspoon this will be a recorded discussion about the musculoskeletal system disorder of osteoarthritis and the often performed surgeries related to that of the total knee arthroplasty total hip arthroplasty and total shoulder arthroplasty I am recording this from my home right now and I have a cockatiel who sometimes sings and sometimes talks and so if you hear bird noises that's my my dear cockatiel his name is Jimbo and sometimes he can't stop talking all right let's get started all right so the point of this discussion is to meet these objectives and that would be for you to be able to identify the pathophysiology clinical manifestations medical Surgical and nursing management of osteoarthritis use the nursing process as a framework for care of the patient undergoing total hip arthroplasty total knee arthroplasty or total shoulder arthroplasty examine the assessment of a post-operative patient after a TKA identify the pathophysiology clinical manifestations and medical Surgical and nursing management of post-operative complications all right so we'll discuss the first objective which you see here on the screen talking about the past o clinical manifestations and the different managements of osteoarthritis it's always best to make sure that you understand the patho of whatever disease process or disorder that we're talking about you guys should make it a point of understanding the patho because the patho is the basis of what's going on in the body it's the basis of the clinical manifestations of what's going on inside the patient and it's a way for us to determine the appropriate interventions to do in our nursing care to aim at the problems that can be corrected so let's discuss this osteoarthritis is sometimes also called degenerative joint disease it is generally idiopathic which means it doesn't have a specific event or disease process that sets It Off it does happen to most people over time it is often called wear and tear arthritis which just means after repetitive use the The Joint suffers damage and a person ends up with osteoarthritis in some of their joints it does differ from rheumatoid arthritis which we're not going to go into depth about but I do don't want you to be confused about the two rheumatoid arthritis is caused from an autoimmune disorder and it has a specific pathway that it follows patients get certain signs and symptoms this this type of osteoarthritis that we're talking about the degenerative joint disease is not autoimmune and most people believe that if you live long enough you'll end up with some form of arthritis some joints that are affected by the wear and tear that happens with use and age it it says in your book that it's non-inflammatory now we'll know that we learned that itis means inflammation so for it to say that it's non-inflammatory I think needs a little bit more explanation it does not mean that there is no inflammation in the joints it's just not the primary manifestation of it um there's not a huge amount of swelling in the joints where in rheumatoid arthritis sometimes there is okay um it is considered Progressive so it could be that a person starts in even in their 30s starting to feel a little bit of um osteoarthritis in their joints and then it progresses through aging your book does say that by the time you're 40 years of age 90 of the population has some form of degenerative joint changes in their weight-bearing joints um so there are some risk factors obviously on any disease that has risk factors sometimes they're modifiable and sometimes they're not um if you're a female especially if you're Hispanic or African-American you have a higher risk factor and those things can't be changed those are non-modifiable however and then of course aging is another risk spectrum and you can't modify that either um but there are some modifiable factors like weight obesity tends to put more stress on the joints making them deteriorate a little bit faster dietary choices can impact this and lifestyle changes can can be modified um losing weight helps a lot of people feel better in their joints um there are studies being done now about dietary changes that can impact not just arthritis but all kinds of inflammatory responses within the body and they're finding that people who modify their diets to eat less or no carbohydrates especially your concentrated sweets like anything made with sugar or high fructose corn syrup those kind of things changing their diet to exclude those things is improving the inflammation in their body systemically so sometimes can help a lot and then Lifestyle Changes sometimes patients just have to change the way they do things um to cause less of the continued degeneration or manage their um or discomfort day to day they may do some Lifestyle Changes so your clinical manifestations in general are pain in stiffness in the joint that's affected and functional impairment which means that they can't do the same things the same motions and activities as previously they could do because the joints don't allow that motion um it is localized to the affected joints this picture shows you some specifics about the finger joints the phalangeal joints and the different nodes that can develop on a patient's hands in this area um don't let that fool you into thinking that the hand joints are the only joints that get affected by arthritis people can get arthritis in any joint their neck their back knees and hips are very common sometimes shoulders wrists any any joint you can think of can develop this degenerative joint disease often patients complain of pain with movement and then there can be some warmth in the joint generally speaking that's pretty minor um warmth would be more of a sign that there's maybe an infection going on in that area so there might be some small amount of warmth to the joints um stiffness for sure because the joints lost its mobility and it's difficult to move the fingers or the hips or the knees as previously so therefore it does impair Mobility it also impairs other activities not just getting up and walking around so if you have arthritis in your hands it may impair your ability to cook or do other activities like crafting like maybe sewing or crocheting or even just cutting something with a pair of scissors can be impacted by that because those joints are affected um the joints are sometimes enlarged as you can see with these nodes um and then there's carpenters and we talked about crepitus with fractures and we talked about how that's actually bone pieces that are scraping this is not the same kind of prefetus this is the crepitus where the bones are still intact but the cushion between them in the joint space is decreased or sometimes even gone it can be destroyed in the process and where patients um bones are just rubbing against one another and that's the kind of crap it is that we're talking about that will be manifested in this um in osteoarthritis so we always want to start where nurses we start with assessment every time we start a process with a patient we're assessing so in this case our focus is going to be on the musculoskeletal system we want to check the affected joints and the non-affected joints for the range of motion for strength in those in those um joints and if they have limited Mobility are they able to still bear weight and use those joints are they doing um things differently because of this arthritis that they have that's causing them pain and stiffness and difficulty are they avoiding some of their activities because of it is it impacting their activities of daily living is it changing their quality of life because pain and stiffness um this is the kind of thing that a patient will suffer daily okay and it can start like we said when you're in your 40s unless for the rest of your life so sometimes patients start to um just depression and things like that because this is impacting their quality of life they're not able to do the things that they used to do or want to do and that that can cause mental health issues as well and then we need to find out how much pain they're in and what they're doing about that what kind of care are they doing in their home day to day to deal with the pain so now let's talk about some of the medical management that's done for a patient with osteoarthritis it is diagnosed generally with imaging sometimes just simple x-ray other times MRIs or CT scans are done to look at the the bones and the joints this will have some kind of orthotic which is just um considered like braces or splints or some kind of wrap that helps to support that joint where they're having pains and they may have like a wrap on their knee or they may have some kind of a brace or a rat for their wrist if that's where their pain is and their joint damage additionally patients will sometimes be using canes or walkers For assistance with the the pain the stiffness and the weakness in that joint um they they feel better when they can bear their weight sometimes through their arms like by using a walker so that the knee and the hip joints that maybe have arthritis don't don't have to hold all of the body's weight and that is helpful sometimes patients are prescribed exercise to strengthen the muscles to help that um have a stronger support system for the joint often they have some form of pain management a lot of patients are not necessarily under medical care for osteoarthritis they may just know that they've got joint pain and so they take some Tylenol or they take some ibuprofen and they just manage it at home if this be the case we need to find out a little bit more about how they're taking care of that so that we can educate them about safely using those meds and make sure that they are not over medicating themselves and maybe putting themselves in danger of other complications because of their medication use and then some patients will actually be on prescription medications we covered some of that in the medication uh unit the medication lecture that I recorded so I would refer you back to that to see this stuff on different meds for the musculoskeletal system we have also some surgical interventions that are sometimes done osteotomy which is just you know removal of part of the affected area and then arthroplasty where the joint is basically rebuilt replaced with an artificial joint I'm going to talk more about that when we get to those specific joints of the knees hips and shoulders and the surgical procedures for those I always like to make sure we consider what labs might be impacted by the condition or what labs might be used for diagnosing a condition in this case no labs are necessary for diagnosing it there's not a lab that's going to say that the joint is degenerated in your knee that's generally got to be diagnosed by your signs and symptoms and some kind of Imaging however sometimes labs are important to determine if the lever or the kidneys are not functioning properly before the provider decides on what medications to use and also that could tell us if they're safely using some of the over-the-counter meds like Tylenol for instance acetaminophen if a patient is taking too much of that at home or when we see their Labs we might see elevated liver enzymes and that might be a catalyst for us to have a discussion with the patient about the proper use of that medication and protecting their liver from further injury and damage I put on here if the patient is going to have some kind of joint surgery those are generally considered elective surgeries meaning that it's not a life or death situation the patient could continue on without this surgery and not be at risk of dying however most patients consider that the quality of life that they have and the um deterioration puts their quality of life at high risk okay so they opt to have these surgeries to improve their quality of life however sometimes the surgeon will insist that they have good control of their blood glucose levels before they do any operation on them especially one that's elective so they'll often have their hemoglobin A1c checked to make sure that they're in a safe range and it's simply because there has definitely been proof that evidence that when a patient has high blood glucose they have a higher risk of infection and a slower rate of healing so providers will I've known doctors who have turned down a patient for a total knee or total hip surgery until they had better control of their blood glucose so that patient would have to go home change their diet change their maybe their medications if they're diabetic change their medication regiment and got that A1C under control before they were allowed to have that joint surgery so sometimes that test will be conducted prior to the surgical procedures here I will just very briefly touch on these medications you've heard me already mention acetaminophen and ibuprofen which is one of the NSAIDs the Cox II inhibitors opioids and topicals are sometimes used to help manage the patient's pain who has osteoarthritis once again I refer you to the recording on medications to get more in-depth about those things foreign that pretty much covers the general information about osteoarthritis and the patient's met presentation and our management of it now we'll specifically talk about the nursing process when a patient is undergoing arthroplasty surgery either for their hip their knee or their shoulder okay one of the most common elective joint surgeries that's done is a total knee arthroplasty or a TKA nurses that work on Orthopedic units take care of these patients daily um we would start our plan of care as always with an assessment we want to do a post-operative assessment I'm going to go a little more detail on a slide a few slides in here where we talk about assessment after surgery the nurse will also have to be responsible for monitoring for post-operative complications once again there's a slide that's going to kind of specifically talk about post-op complications and what we're monitoring for in our nursing care for that and keeping the patient safe remember that this is a patient that has had an elective surgery that means that they went into surgery as a healthy individual it doesn't mean they don't have comorbidities or other problems they may be a healthy person with well-managed hypertension but we then we still have to help with their hypertension while they're in the hospital um they may be a healthy person with well-managed diabetes and we still have to monitor and care for their diabetes so those are the kind of the aspects we have to think about in terms of patient safety in addition to the fact that now they will have impaired mobility now they've had me um osteoarthritis probably for years at this point when they've had surgery so they've had weakness and pain in that joint for a long time but what they're facing now post-operatively is going to be a different kind of pain and a different kind of of weakness in the joint the nice thing about these total joint surgeries for the knee and the hip is that once a patient comes out of surgery that joint is now stabilized now with the um they remove surgically cut out parts of the bone and the joint and replace it with man-made mechanical elements um to substitute for the natural Bone and Joint and attach them permanently and now that joint is stabilized so the joint itself isn't actually what's causing the patient pain it's all the surroundings of tissue that's been damaged through the surgical procedure and manipulation but the joint itself is stable which means it's safe for patients to walk on them they'll they won't feel comfortable walking on them these these patients in the hip and the knee surgery will come out from surgery with generally with orders that say they are weight-bearing as tolerated which means it's totally safe for them to put their full weight on that joint the joint is stable however sometimes patients pain and discomfort from the procedure makes them not able to tolerate putting their full weight so that's when these patients need our assistance with their ambulation and they'll need assistive devices such as generally a walker is used and not the kind with the four wheels and the seat that's um not safe for them because that Walker can roll away too easily and then the patient can end up falling um this patient if we are getting them up and moving this patient will have to have a gate belt and a walker and at least one person watching over them and helping them with their ambulation often these patients at United Regional when a patient comes back from a knee surgery if it's early enough in the day they go to physical therapy that same day so um they'll go straight from recovery to their room if they're awake and alert enough then we let them eat because they're usually hungry and there's no reason for them not to unless they're nauseous or they're not awake enough um also we want to make sure their vowel sounds are functioning before we feed them um but if all of those things are okay then we want to feed this patient and they generally speaking want to eat something and then they get up and start doing their physical therapy almost immediately sometimes I've seen the physical therapy folks go to the post-operative care unit and actually start doing physical therapy with the patients in the pacu because the room that they need and the ortho unit isn't ready yet and so the PT just goes down to the pacu and starts working with the patients so they get up and get moving rather quickly because we found through years of studying and caring that the evidence shows that the sooner they get up and moving the fewer complications that they have but we do have to maintain their safety so we have to always be thinking about the patient safety safety while we're doing these cares for them now a few words about the total hip arthroplasty once again I'll go specific on post-operative assessment and complications on that slide that's coming up but let's talk about specific safety for a person that's had a hip arthroplasty um this patient is also generally going to be weight bearing is tolerated they're also going to be requiring assistance with ambulation with a person a gait belt and a walker um they're also going to be having um Physical Therapy straight straight away if it's early enough in the day they're going to have physical therapy that day generally speaking at United Regional these patients and and the knee surgery patients go to what they call joint camp twice a day they go two times a day for physical therapy in the unit on the there's a section of the the floor that's dedicated to the physical therapy and the patients will walk to that area do their physical therapy and then walk back to their room um even on the day of surgery um additional protections for patients that have had hip surgeries is the the movement of that joint we have to protect the patient from great use the their joint can't bend greater than 90 degrees um that means that they can't sit in a low chair that makes their knees higher than their hips um if they're going to sit on the toilet then we would have a raised toilet seat or an over the commode chair that elevates them and that's twofold one and it hurts a lot and the less they have to lift their whole body weight from a lower position up the easier that's going to be for them to do it themselves or with as little help as possible but additionally that motion um if we have too much of a Bend in that joint then sometimes the The Joint can pop out the ball part of the side ball and socket joint can become dislodged and now we have a dislocation which will require the surgeon to come back and do another intervention to put everything back together again so we have what we call hip precautions and the degree of the bend is one of them and then another thing we we teach our patients is they can't cross their legs so the um you can't whether that be sitting up in a chair they can't cross one leg over the other like cross at the knees um or at the ankles we just want them not to cross their legs and that same is true if they're laying in the bed sometimes people just have a habit of that's how they lay as they cross one leg over the other whether they're sitting or laying down and they need to not do that um so Crossing that across the midline puts that joint at risk of popping out and then additionally um we don't want them to uh abduct their leg too far out to the side that's not as big of a concern as the adduction where it crosses the midline and goes past that point when a patient has had a total shoulder arthroplasty this is a different situation this patient obviously you're still going to do a good post-op assessment we're still going to be monitoring for post-op complications they'll be a little bit different in light of the fact that this isn't upper body joint that's been affected rather than the the lower body joints in the legs like the knees and the hips um patient care in this situation this patient will not generally be weight bearing is tolerated okay they will come to you with their arm in a sling and a swath so the slang is going to support the weight of the arm so that it's not pulling on that shoulder joint and then the swath is going to kind of pin the arm to the body so the you you've probably all seen somebody with a sling okay um in this case they generally are gonna let's say they had their right shoulder uh joint replaced that slaying is going to be such that that right arm that right hand is is almost going to be touching their left shoulder that's the extreme stream of how um this sling will support that and then there'll be an additional um part of the brace the swath part that goes all the way around the Torso that pins that arm to the to the chest not tightly but to keep that joint in that um position okay it helps because um the patient won't be able to Bear the weight of that arm on that shoulder for a while generally speaking these people their physical therapy is going to be more um distance in from post-op then the knees and hips knees and hips go to therapy right away shoulder surgery patients debt will have some form of physical therapy but it's mostly just where they'll be moving the fingers and the wrist joints so that they don't lose mobility in those while the shoulder heals up some and then sometime later sometimes even a few weeks is when they'll actually start having physical therapy for the shoulder joint to strengthen that back up um so when we're talking about um mobility and this patient one of the things we want to consider is do they have feeling in their fingers and can they wiggle their fingers because that would be a sign if they cannot that there's something impinging upon their nerves or their blood flow to that distal part of that extremity and that could be a trigger us to think that that there's some kind of a compartment syndrome or a impingement going on of the blood flow or the nerves that's keeping them from being able to move and feel those those fingers okay so that's a safety concern this patient will have some balance issues because generally speaking we balance based on having two arms that can freely swing and that helps us with our walking and our standing so this patient will require some assistance with their ADLs based on the fact that now they only have one one functional arm while they're recovering um and there will be some things that they can't do that a patient with a hip surgery can do each one of these is going to require its own different kind of assistance with the ADLs so you guys should kind of consider what if a person's had a knee surgery what can they do for themselves and what they can't do for themselves same thing if they've had a hip surgery or this shoulder so the each one of these is going to require a little bit of a different approach from the nurse in how they're going to help that patient to be their most independent but help them with the things that they're unable to do for themselves all right so now we've gotten to the objective of the two objectives of examine the assessment of a post-operative patient specifically after a total knee arthroplasty and then identify the pathophysiology clinical manifestations and medical Surgical and nursing management of post-operative complications all right so first let's make sure you understand and if you're the nurse on the med surg unit I want you to to recognize the pathway the patient has taken to get to your unit at that time so this patient for a total knee arthroplasty will have been planning this for weeks or months that they're having this procedure they will have worked with their doctor to schedule this they'll have a date and time that they're supposed to come in to um the pre-op they'll have had pre-op nurses assess them and prepare them for surgery they will have had or nurses that continually assessed them and took care of their needs and assisted during surgery then they will have been out of surgery and gone to the post-anesthesia Care Unit which we usually call the pacu which is the same letter as abbreviated right at the pacu then the patient will spend at least an hour watched over by that nurse while they come out of the anesthesia okay because the anesthesia has the potential to cause problems for the patient and so those pacu nurses spend about an hour or so with each patient they start monitoring them from the minute they come out of surgery and at the beginning they're monitoring them very very closely they may be checking their vital signs as frequently as every five minutes to see that their breathing is okay they're um blood pressure is doing okay not too high not too low they're checking their their pain they're watching their oxygen saturation all those things because the potential for a problem is still high at that point the more the patient is waking up from the anesthesia the less frequently they have to be monitored so they may check Vital Signs every five minutes for the first 15-20 minutes and then as the patient's waking up more and everything seems to be going along the expected pathway then they can maybe only check vitals every 10 minutes and then after a little while they'll check vitals every 15 minutes and generally speaking about this time it's been roughly an hour the patient is usually pretty well awake their pain is reasonably managed their vital signs are stable and the patient will come up to the pack from the pacu to the med surg unit this is the point where you would receive the patient onto the floor if you were the med surg nurse that's the pathway that the patient has taken that's what they've been through sometimes in the pack you if the patient is awake enough and the nurse has done the proper assessment they may already have had some ice chips or even nibbled on a cracker and had some soda or juice because remember this patient will have been NPO from at least midnight the night before until whatever time they come out of surgery um so at this point this patient comes to you on the med surg unit you're looking to do a good head to toe this is your first time laying eyes on this patient anytime it's your first time looking at a patient you want to do a head to toe assessment okay you want to look at all the major body systems and you want to um look at all of their skin to see that there is no injuries or sores anywhere that are unexpected so that we can document that and take care of those right away um the the systems that we're going to be focused on for a post-op patient will always be we want to do a good lung assessment we want to do a good cardiac assessment um we want to listen for bowel sounds because I don't want to feed this patient if their bowel sounds aren't present that would be dangerous um and then we want to do whatever is focused is necessary for the procedure that they have done so in this case I'm concerned that this is a post-op patient and they've had knee surgery so I'm definitely going to want to look at that part of their body you know you cannot remove their surgical dressing and look underneath it but you can assess the dressing and ensure that it's not bleeding through which is called strike through when there's bleeding through the dressing that's called strike through um and you definitely want to check that that leg in particular distal to the surgery to make sure that they have good cardiac and neuro function all the way to their toes this is where we do that neurovascular assessment to make sure that there's good blood flow and good nerve conduction all the way down to the toes and then we want to also be monitoring for any potential complications that should always be on our radar remember our job is to keep this patient safe and one of the ways we do that is monitoring for complications so we have to go in there knowing that these complications are possible and we're watching for them thank you in general your most frequently seen complications are going to be pain and you might say well that's an expected thing yes it is definitely expected that this patient will be in pain however it is still considered a complication because it's not normal to be in pain it may be expected in this situation and there's a difference and then the other complications that are very frequently seen are atelectasis and that's not necessarily a completely collapsed lung but it's a post-op complication from having them laying flat on a table having a tube down your throat where it's doing your breathing for you and you're not expanding your lungs fully so in the bases of the lungs little bits of fluid can build up and the alveoli can collapse so this is where when you listen to the patient's respiratory sounds their breath sounds they sound clear until you get to the bases and then you hear those little popping and find crackles that's out of like this is that's your your um the patient's alveoli are collapsed and then they take a breath and they pop back open and then after they release that breath they close again that's what's causing the popping sound they breathe in and it pops open they exhale and they close so the next time they breathe in they pop open so it just keeps going that's where you hear these crackles um and the nursing interventions for that would be to get the patient to do some deep breathing that pops them open but they have to cough to clear the secretions once they cough and clear the secretions then the alveoli will stay open and the crackles should go away okay other signs of atelectasis that you might see are a little bit of an elevation in temperature and that's not an indication of infection um the crackles the low oxygen saturation because they're not getting good gas exchange so their O2 set May reflect that and a patient that's not getting good oxygen is likely to start being confused or agitated so you may see some mental status changes in this patient as well but if you do the intervention of either grabbing the incentive spirometer and having them use it or just having them do the deep breathing and coughing you should see those things clear up based on your intervention that you did another complication that can happen but usually it's not immediate is the patient can become constipated and that's due to immobility perhaps not drinking as much fluid as they would normally if they were at home and the pain medications that we often use to treat these patients can lead to constipation because that's one of the main issues with opioids and opioids are often used to deal with the patient's pain think I spoke with you guys previously but I'll go ahead and discuss it again when you're dealing with pain for a patient one of the reasons we get a really good pain assessment including where they're hurting when it started what makes it better what makes it worse what what has helped in the past that kind of stuff as well as the rating on the 0 to 10 scale we get that good information and it helps us choose the right intervention to help this patient feel better sometimes the right intervention is to put an ice pack on on the patient's painful area sometimes the right intervention is to offer them a medication sometimes it's as simple as acetaminophen or ibuprofen or as strong as morphine or fentanyl that will depend upon the patient's presentation what they describe their pain as as well as what the provider has ordered for them this um pain reading often dictates what medications we give to the patient or how frequently we get it I have seen um some of the best doctor's orders for pain will give you choices based on the patient's pain assessment if the patient's pain is from one to three they get X medication which is generally speaking going to be like Tylenol or Ibuprofen if their pain is moderate from four to six they're going to step up that that pain medication and they may give them a small dose of hydrocodone like um a hydrocodone that's five milligrams plus 325 of acetaminophen and a combination that's appropriate for a moderate level of pain if the patient's pain is severe at a 7 8 9 or 10 then they will have a order for a stronger pain medication and so it's our job to get a decent pain assessment and then match the needs of the the pain assessment to the available orders that the provider has given us and then if we notice that the intervention's not working we we can do one or two things we can educate the patient perhaps what they're rating their pain at a five and we give them that notice and that's appropriate for that pain level it's not effective maybe their pain is really not a five maybe their pain is more like a seven and we need to teach them how to do the pain rating better or perhaps the provider hasn't given us anything that is able to help them when they're in severe pain maybe the medication that's ordered for the pain rooting of an eight is not sufficiently helping the patient get control of that pain and we need to go to the provider and ask for additional assistance that some stronger medicine more frequently something another formulation a different Med something that will help to control this patient's pain that's in what way we can advocate for our patients and help them check out what they need all right so now some of the potentially life-threatening complications that can occur post-operatively anytime that a patient has been cut upon there is the potential for bleeding and hemorrhage and that's true also with these knee surgeries sometimes they bleed quite a bit post-operatively generally speaking they they have some strikethrough and what we are told to do when a patient has some Bleeding Through the dressing is to reinforce the dressing and let the provider know obviously document so one of the things we do is we estimate the amount in a percentage of the dressing that's now saturated with blood um and then we place more absorbent pads on top of the already there current dressing and wrap it with more of the elastic Ace Wrap okay that's called reinforcing the dressing we're going to do that regardless of how much bleeding there is okay the first thing you're going to do is try to control that bleeding by putting more padding on top and wrapping it I don't mean to wrap it tightly because now you can be contributing to some pressure issues and then you let the doctor know okay but if the bleeding is excessive then you're going to see other things you're going to see Vital sign changes you're going to see um the patients may be looking pale because of the blood loss you know they'll probably be tachycardic because of the blood loss okay so some of those things you need to be able to recognize and monitor for so we're always going to look at the dressing and we're going to look at the dressing pretty frequently and if I start seeing some strange vital signs I'm going to start wondering are we bleeding okay so another one is a DVT deep vein thrombosis okay this can happen it's it can happen for any patient that's immobilized okay some more more frequently than others and Joint surgeries in the legs have a higher risk of developing a DVT in that surgical leg because that leg's been manipulated including manipulating blood vessels along that pathway so the blood vessels are more prone to developing uh thrombosis okay so we need to know what that looks like we need to know that that patient will complain of pain in their calves um that they'll have warmth and tenderness in that area and then if that DVT any a part of that clot breaks off it tends to end up in the lungs which case will have a PE pulmonary embolism and that will show up as a patient with tachycardia and tachypnea altered mental status because of the change in the oxygen saturation they may have this impending sense of Doom um low oxygen saturation I can't remember if I said that already and that's an emergency situation that's where um it's potentially life-threatening okay DBT by itself generally speaking not life-threatening can be damaging to those veins but when it becomes a PE is when that shifts to be not just lower extremity problem but a systemic issue because now we're dealing with the oxygenation and that can be life-threatening um infections can be a life-threatening complication but remember these patients that we're talking about came into the hospital healthy to have an elective surgery so if they get an infection it's not going to be something they came in with it's something that happened since the surgery okay surgical site infections tend to not show up for about three days it takes about that long for enough bacteria to be growing in there to start showing those we're watching for those signs and symptoms though same thing with pneumonia if your patient starts having a temperature a low grade temperature on the first day think about atelectasis because atelectasis causes a small amount of temperature elevation whereas if it's three days later and now they're starting to run a temperature now I'm thinking some kind of infection no that could be infection in the surgical site it can be a UTI it can be pneumonia those are the ones they tend to to happen um and that can be life-threatening as well and then the last one on the list is a paralytic Ileus paralytic Lis is generally going to happen right after surgery because when the anesthesia hits the body one of the things that happens is the GI tract goes into sleep it's like resting and uh sometimes it takes a little while for the GI tribe to quote wake up again and start functioning doing this peristalsis and movement so when you listen to a patient's abdomen for their bowel sounds there may be one area or all the areas where bowel sounds are absent okay if that be the case then you you're really your only recourse is to notify the provider because there's no real nursing interventions we can do without orders and the provider needs to know because if the bowels aren't moving at all then we're in a situation where some other problems can develop and complications can escalate all right so in general when you're dealing with a patient that's had any kind of surgical procedure for a joint we always want to look at patient education and promoting health and safety we will always educate the patient about any medications that they are receiving in the hospital any medications that they're going to go home on and we want to verify that they understand their education on any medicines that they were previously on it's our opportunity to make sure that they know what they're taking the doses that they're taking the reason that they're taking them what the effect should be when they take that medicine what and that would be their therapeutic effect is the medicine doing what we're asking it to do and then we want to know that they need to know what the side effects are and then we need to ask them are they having any of those side effects because that's the non-therapeutic effects of this medicine so for instance a patient that has hypertension they're on mysinopril my Center Pearl is going to help with the blood pressure and bring it back to normal levels so we need to know are their blood pressures normalized now is that medication being therapeutic but we also know that medications that lower blood pressure sometimes can cause orthostatic hypotension so we need to explain this to the patient you know or the sciatic hypotension is where you feel dizzy or lightheaded because you went from laying down to sitting up or from sitting to standing and maybe you got a little light-headed maybe you felt a little dizzy maybe you felt like the road was blacking out that's orthostatic hypotension are you experiencing that that's a non-therapeutic effect of that medication doesn't mean that that's a bad Med for them it means they need more education on it so if that be the case then we need to explain to them okay this is the best way to deal with that you need to change positions slowly you need to sit you need to sit up from laying down slowly and then wait for a couple of breaths before you stand up because changing positions too quickly can lead to a fault that way we know that the medicines being therapeutic we identify any non-therapeutic effects that are going on with the medicine and we teach the patient how to handle that so that they're safe um as they progress and go on home that second bullet point on the list about safety that's all aspects of safety so we want to check that they're taking their medication safely that they're ambulating safely that they know how to do their ADL safely at home they know whether they should be able to take a shower or not can I get the dressing wet how soon will I be able to drive those that kind of safety issues okay and sometimes our our answer is when you go to your follow-up the provider will tell you when you'll be safe to drive or how soon you can take your own your shower um that kind of leads into the hygiene area so we need to know if they need equipment to help them that's the durable medical equipment they may need a walker at the house they may need a shower chair they may need one of those seats that go over the commode so that they are have the handles on the side to push up and down with because they're going to be using their upper body shoulders and arms to supplement that weakened joint in the leg okay they're going to need to know when their therapy is going to be when they leave the hospital they're not done with therapy they're going to continue therapy for weeks and sometimes months afterward until they get that joint built back up so those are the things that we're going to educate the patient about and at discharge we have um kind of a lengthy discussion with them to make sure they understand all of this however we don't wait until discharge to start teaching we should be teaching a little bit every single day with this patient so that we're building on it and testing their knowledge we do that teach back where we explain to the patient some information and then we ask them to explain it back to us so that we can verify that they understand it and clarify any problems in their understanding we always want to be thinking about the psychosocial and holistic care aspects for our patient and in this case this is an elective surgery they usually have come to this surgical procedure having experienced maybe years of pain and now they're coming to get this joint repaired replaced and hopefully get a better quality of life but sometimes it ends up hurting more than they thought it would and that is paying out of proportion to the expectation that can be a concern for patients sometimes they're very fearful and anxious pain can cause us fear and anxiety and even depression so we need to consider that and discuss with the patient about how yes it hurts let us help you deal with the pain let's find the appropriate interventions for you and you reassure the patient at any time that pain will reduce um sometimes they are surprised by the length of time for the recovery um taking care of some patients who felt like this shouldn't be taken this long I should be over this I'm bigger than this stronger than this and why is this taking so long for me to to get my Mobility back um it can be surprising to patients and it can cause them serious concerns we want to help them address that aspect and you know tell them to be patient with themselves to keep working hard but to know that sometimes it just takes longer than we we want it to to get better some patients have a hard time accepting assistance they are used to being independent and we want to encourage Independence however sometimes it's not safe for them to do things completely independently so we need to help them accept help during their recovery and and encourage them that as soon as possible they'll be able to do these things for themselves again um once again like I said just now resuming independent care of themselves eventually these things are going to switch back from I need help to I can do it on my own again and and they need to be re um educated and encouraged that that eventually they will have those abilities for themselves um sometimes patients are concerned about work and family responsibilities sometimes the recovery takes a different track than what they're thinking maybe they expected that they just get up out of bed on the day of surgery that afternoon and they'd be walking and moving and it didn't work out that way maybe the pain is greater than they expected maybe the strengthening of that leg is not what it needs to be for them to safely go home and so maybe their recovery takes a different turn and now they end up having to go to Rehabilitation at a facility and now that's going to change things for who's going to take care of the family while I'm at a facility having Rehabilitation or how soon am I going to be able to get back to my job so that I can take care of myself and my family well these are some other concerns and some patients are very concerned about becoming dependent on pain medication and so we do have to consider that aspect and teach them about safely using the meds or maybe alternative means to handle the pain sometimes we have to teach the patient that it's safer to take the med than to deal with the pain sometimes patients can deal with the pain and that's okay and they have that right to choose but sometimes when the pain is causing them trouble with their blood pressure or keeping their blood sugars too high that might impact their ability to heal or create a higher risk of infection sometimes managing the pain will actually create a safer situation for the patient so we'll have to work with them to educate them how the pain medicine um yes it has a risk of dependence we need to be honest with them about that but most people that take it short term for a need such as recovery from a surgery don't get dependent upon the medicine especially people who are worried about becoming dependent on the medication generally speaking those people don't become dependent because they're Vigilant about only taking it when it's necessary and stopping it as soon as possible all right so that's all I have to present to y'all on these topics um it could be that you still have questions about some things and I would be happy to answer them if you'll just make them known to me whether that would be the next time we see each other and in the classroom if you come by my office hours or you want to send me an email I will be happy to look at your concerns and your questions and try to answer those to the best of my ability so do let me know if there's anything that you need from me and I will hope to see you guys soon