mission's Disease Specific Care Certification Program provides an evaluation of a clinical program that delivers care to a defined patient population
- The certification process is designed to evaluate the program's chronic disease management and clinical care provided to patients
- The Orthopedic Service Line Certified Programs at ECH include:
- Care of Total Hip and Total Knee Arthroplasty at both campuses
- Hip Fracture care at the Mountain View campus
- Spine Fusion care at the Los Gatos campus
- *Applied for Certification in Total Shoulder Arthroplasty at both campuses
- TJC Program certification shows our organization's commitment to continuous performance improvement providing high quality patient care
- Certified programs are required to have a site visit by the Joint
Commission every 2 years and must meet the three core requirements:
- Standards
- Clinical practice guidelines
- Performance measurement
ECH Orthopedic and Spine - Clinical Practice Guidelines (CPGs)
Total Knee Arthropiasty (TKA) and
Total Hip Arthroplasty (THA)
Hip Fracture
• AAOS Clinical Guideline on Management of Hip Fracture in
• American Academy of Orthopaedic Surgeons (AAOS): Clinical
Elderly: Thromboembolism Prophylaxis, surgical timing
Guideline on Osteoarthritis
of the Knee - Postoperative Mobilization
• Association of periOperative Registered Nurses (AORN): Guideline
of the Hip - Non-Narcotic Management
for Preoperative Patient Skin Antisepsis
• National Association of Orthopedic Nurses (NAON): Clinical
• AAOS Clinical Guideline on Management of Hip Fracture in
Guideline for Surgical Site Infection Prevention
Elderly: Interdisciplinary Care Programs
• Enhanced Recovery after Surgery (ERAS): Safety Program for
• National Association of Orthopedic Nurses (NAON): Clinical
Improving Surgical Care and Recovery Guidelines
Guideline for Thromboembolic Disease Prevention
• Enhanced Recovery after Surgery (ERAS): Safety Program for
Improving Surgical Care and Recovery Guidelines
Total Shoulder Arthroplasty (TSA)
AAOS Clinical Guideline on Management of Glenohumeral
Joint Osteoarthritis: Multimodal Pain Management
NAON: Clinical Guideline for Surgical Site Infection Prevention
Enhanced Recovery after Surgery (ERAS): Safety Program for
Improving Surgical Care and Recovery Guidelines
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Spine Fusion
North American Spine Society (NASS): Antithrombotic Therapies -
Mechanical Prophylaxis
AORN: Guideline for Preoperative Patient Skin Antisepsis
NASS: Guideline for Diagnosis and Treatment of Degenerative
Lumbar Spinal Stenosis
Enhanced Recovery after Surgery (ERAS): Safety Program for
Improving Surgical Care and Recovery Guidelines
- Early mobilization within 6.5 hours upon return from PACU
- Patient Pre-Operative Class
- Attendance
- Multimodal Analgesics
- Surgical Site Infection
- Regional Anesthesia
- Postoperative Ambulation on Day of Surgery
- Preoperative Functional/Health Status Assessment
- Discharge to Home
Hip Fracture
- • Early mobilization within 10 hours upon return from PACU
- Avoiding Readmissions
- Scheduled Acetaminophen
- Nutrition Education
- Multimodal Analgesics
- Surgical Site Infection
- Preoperative Education
- Length of Stay
Follow orders and protocols for
- Vital signs
- Neurovascular assessment
- Pain management
Prevention of complications
Deep vein thrombosis (DVT)
Pneumonia
Surgical site infection (SSI)
Constipation
Orthopedic and Spine Neurovascular Assessment
A good neurovascular assessment can alert caregivers to the development of potential complications and prevent permanent damage to the function of the limb. Assessment should include Color, Temperature, Capillary Refill, Pulse Strength, Edema, Sensation, Pain, and Motor Strength.
Obtain baseline and always perform bilateral assessment for comparison
Frequency of Neurovascular checks per MD order or more frequently per patient condition
Document on flowsheet, preferably by adding "neuro-vascular" flowsheet section
• Palpate peripheral pulses using the fingertips;
Weak
Moderate
Strong
Bounding
+ 1
+2
+ 3
+4
Doppler
Absent
Unable to assess
Other (Comment)
Palpation of Peripheral Arterial Pulses
Brachial Pulse
• Flex the elbow slightly, and with the thumb of your opposite hand palpate the artery just medial to the biceps tendon at the antecubital crease
Radial Pulse
• Palpate on the flexor surface of the wrist laterally
Femoral Pulse
• Press deeply below the inguinal ligament and about midway between the anterior superior iliac spine and the symphysis pubis
Popliteal Pulse
• The patient's knee should be somewhat flexed, the leg relaxed. Place the fingertips of both hands so that they just meet in the midline behind the knee and press them deeply into the popliteal fossa.
Dorsalis Pedis Pulse
• Feel the dorsum of the foot just lateral to the extensor tendon of the great toe
Tibialis Posterior Pulse
• Curve your finger behind and slightly below the medial malleolus of the ankle
Neuromuscular assessment
- Dorsiflexion
- planter flexion
• Total Shoulder Arthroplasty (TSA) is a highly successful procedure to reduce pain and restore mobility in patients with end-stage shoulder arthritis and, in some cases, after a severe shoulder fracture. Shoulder replacement surgery relieves pain and helps restore motion, strength and function of the shoulder.
• Total Hip Arthroplasty (THA) is similar to TKA but involves the Hip joint. It is also performed to relieve pain and improve function and stability of the hip joint.
• Total Knee Arthroplasty (TKA) refers to the surgical replacement of a damaged Knee with artificial (such as, metal or acrylic) components. Knee replacement surgery alleviates pain and improves function in patients with knees that are painful, deformed, and unstable secondary to degenerative or inflammatory conditions.
Patients and caregiver/patient-coach are encouraged to attend a pre-operative class.
Some of the topics included are:
Pre-surgical skin prep
Therapy routines and mobilization expectation
Deep vein thrombosis (DVT) and infection prevention
Expectations around discharge planning to home
ERAS Protocols are introduced:
Patients are instructed to perform a pre-surgical shower wash the night before surgery and the morning of surgery with an Antiseptic Solution
Once patients arrive to the pre-operative unit, they are given an antibacterial nose swab, mouthwash solution, and additional skin prep
Patients are instructed to consume the pre-surgical carbohydrate drink 3 hours before the surgery start time - if applicable
Patients with type 2 diabetes should only consume half the drink
Reduce acute postoperative pain and discomfort
Reduce the risk for, detect, and manage potential complications
Post Operative Treatment Goals
Reduce risk of venous thromboembolism (VTE)
Reduce risk of infection
Reduce risk of pneumonia
Prevent constipation
Promote appropriate nutrition
Promote return to patient's functional goal
Provide emotional support and educate
Potential Complications Following Surgery -
Early/Late in recovery could include:
- Surgical site infection
- Bleeding
- Hematoma
- Pain
- Constipation
- Venous thromboembolism (VTE)
- Deep vein thrombosis (DVT)
- Pulmonary embolism (PE)
- Arthrofibrosis (i.e., formation of excessive scar tissue which limits range of motion - primarily seen with TKA)
- Injury to nerves
- Injury to blood vessels
- Acromial fractures
- Femoral fractures
- Instability
- Dislocation
- Extremity length changes
- Component loosening
- Residual pain and stiffness
Hip Precautions...until cleared by surgeon
Posterolateral approach
Avoid hip flexion greater than 90 degrees-bending over from trunk
No adduction/internal rotation beyond neutral
Do not cross legs
Avoid pivoting or turning your toes inwards on the operative leg
Avoid low soft chairs
Do keep knees lower than hips when sitting
Do sleep in supine position using abduction wedge if ordered/pillow
Do transfer toward uninvolved side
Anterior Hip approach
Avoid hip hyperextension and external rotation
Knee Precautions until cleared by surgeon
- Avoid pillows under the knee
- Avoid prolonged sitting without elevation
- Avoid ambulating patients without assistive devices
- Avoid kneeling on the surgical leg
- Avoid exercises with high impact
- Do put a small towel roll under the ankle for 10 minutes or so several times during the day
- Do elevate leg on several pillows in straight position several times a day
- Do Utilize ice therapy (polar ice)
- Shoulder Precautions...until cleared by surgeon
- Avoid shoulder active range of motion (AROM)
- No lifting of objects
- No supporting of body weight by hand on involved side
- Avoid holding anything heavier than a cup of coffee on involved side
- Avoid exercises with high impact
- Do wear sling continuously until otherwise instructed by surgeon
- Do use pillows for proper positioning when lying in bed and sitting in chair. Sling remains on.
- Do Utilize ice therapy (polar ice)
: Tenth becad
Mouth Rinse
• Suction toothette toothbrush
The following must also be selected when selecting the above inclusion Criteria or credit will not be given for the
intervention:
With mouthwash
With chlorhexidine (only if ordered by MD)
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2x/day:
Brush teeth or
Denture Care or
Suction toothette toothbrush and rinse with mouthwash
1x/day:
Mouth rinse with
mouthwash
Clinical Documentation for Compliance and Credit
To meet documentation requirements:
2 interventions must be selected under 'Oral Care' and documentation must be done from 0700-2300.
You may choose from the options below:
After Breakfast:
- Teeth brushed and With mouthwash
- Suction toothette toothbrush and With mouthwash
- Denture care and With mouthwash
After Lunch:
• Mouth rinsed and With mouthwash
Before Bedtime
- Teeth brushed and With mouthwash
Suction toothette toothbrush and With mouthwash - Denture care and With mouthwashi’m
Pain Management
- Pre-op pain management with multimodal analgesia: Acetaminophen, NSAIDs, Celebrex (COX-2 inhibitor), gabapentin/pregabalin and/or opioid
- Peri-op pain management:
- Regional Anesthesia is preferred where there are no contraindications
- Periarticular injections, such as, R.E.C.K (Ropivacaine, Epinephrine, Clonidine, and Ketorolac) and Zynrelef (Bupivacaine, Meloxicam) local injection into the surrounding tissue in the surgical field
- Post-op pain management: administer scheduled doses of Acetaminophen, Dexamethasone, Celebrex and oral pain medications
- Ice packs or cold therapy machine (from central supply) if ordered by surgeon
Postop pain that is not managed becomes difficult to control
Early Patient Mobilization
- Associated with reduced pain, improved joint function and reduced hospital length of stay (AAOS, 2015)
- Assist with early ambulation on the day of surgery or within 4 hours of arrival from PACU
- When stable, mobilize patient utilizing front wheel walker (except for shoulder) and 2 staff members if indicated for safety
- Document ambulation in Cares/Safety Flowsheet; if ambulation does not occur within 4 hours, document the reason why
- A hip fracture is a break in the upper quarter of the femur (thigh) bone
- The extent of the break depends on the forces that are involved
- The type of surgery used to treat a hip fracture is primarily based on the bones and soft tissues affected or on the level of the fracture
Proper Nutrition
- Nutrition is critical to healing, especially protein, Vitamin C and D, and Zinc
- Proper nutrition intake decreases risk of constipation
- Administer prescribed anti-emetics as needed for nausea or vomiting
- Educate patients on importance of probiotics to restore intestinal flora after peri-op antibiotics
- Order Nutrition Consult if needed
- Early nutrition associated with Enhanced Recovery After Surgery (ERAS) protocols have beneficial effects
- Educate to and administer Juven as ordered
Fractures of the proximal femur cause significant mortality and morbidity in older people. 30% of patients sustaining a hip fracture die within 12 months of the Injury and 50% will not return to a previous level of functioning.
Patients with hip fracture are more likely to be malnourished at the time of fracture and suboptimal intake is common in those recovering after hip fracture surgery in the hospital.
Malnutrition in the elderly population ranges from 16-63% and is an important risk factor for poor outcomes in patients recovering after hip fracture surgery.
© El Camino Health
Types of Hip Fracture
- Intracapsular Fracture: break occurs below the ball or in the neck of the femur (repaired with screw, hemi or partial arthroplasty or arthroplasty)
- Intertrochanteric Fracture: break occurs between the greater trochanter and lesser trochanter (repaired with screw or IM Nail)
- Subtrochanteric Fracture: break occurs below the lesser trochanter or further down the femur (repaired with IM
Nail with large lag screws)
Nursing Care for Hip Fracture:
Treatment and Care to Reduce Complications
- ICOUGH Bundle to reduce the risk of pneumonia
- Remove Foley catheter early to reduce CAUTI
- Provide assistance with early mobilization to maintain muscle tone and prevent pressure injuries
- Apply Low Air Loss Pump for patients whom surgery is delayed beyond
24-48 hours to prevent pressure injuries
- Early surgery may reduce pain and decrease length of stay
- Patients should be prepared with an antibacterial bath, antibacterial mouth rinse and nasal swab
- Perform Neurovascular Assessment as ordered
- SCDs and anticoagulants to prevent deep venous thrombosis
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Nursing Care for Hip Fracture:
Treatment and Care to Reduce Complications (continued)
- Provide adequate pain management by incorporating non-opioid methods to reduce the opioid use in older patients (Tylenol, peripheral nerve block, local anesthetic injections) allowing for improved patient mobility
- Encourage PO intake and prevent constipation
- Delirium is a common complication in hospitalized older adults, and occurs in as many as 61% of patients with hip fracture
- Minimize patient's risk for delirium by:
- Using alternatives to opioids, such as, acetaminophen, anti-inflammatories and ice
- Having patient wear their glasses or hearing aids
- Ensuring adequate rest
- Radiculopathy: extremity pain due to nerve compression
(arm = cervical, leg = lumbar) - Myelopathy: loss of balance and motor function, bowel and bladder dysfunction due to spinal cord compression (stenosis)
- Spondylolisthesis: vertebra slips forward onto the bone below it
- Spinal Fusion: surgery to permanently join together two or more vertebra so there is no movement between them
Post-Operative Care:
Anterior Cervical Fusion (ACF)
- Positioning: HOB elevated
- One pillow or folded towel, occipital support
- Cervical Collar at all times except showering
- Mobility: no flexion, extension or rotation
- Pain Management:
- Oral med transition is goal to prepare patients for discharge
- Ice packs to shoulders
- Airway Assessment:
- Vocal quality, Swallowing ability, Airway restriction
- Continuous pulse oximeter
- Neurovascular Checks: *KNOW YOUR PATIENT'S BASELINE*
- Motor Function
- Strength Assessment
- Numbness or Tingling Upper Extremities
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Mobilize! SCDs! Incentive Spirometer! Bowel
Potential Complications
Anterior Cervical Fusion (ACF)
- Tracheal/Esophageal Injury
- If intra-op - repair by thoracic surgeon
- If post-op - dysphagia or aspiration
- Hoarseness/Dysphonia (change in voice quality)
- Swelling
- Laryngeal Nerve injury
- Potential vocal cord paralysis
- Difficulty Swallowing
- Edema
- Clear chilled liquids
- Swallow Evaluation
- Brachial Plexus Stretch/Shoulder Soreness
- Often from a short neck, broad shoulders: pull down of shoulders
- Numbness/tingling in Upper Extremity (UE)
- Ice packs to shoulders
- Position to comfort
Alphabet Soup of Spine Fusion
ALIF: Anterior Lumbar Interbody Fusion
DLIF: Direct Lumbar Interbody Fusion
TLIF: Transforminal Lumbar Interbody Fusion
XLIF: Extreme Lateral Interbody Fusion
PLIF: Posterior Lumbar Interbody Fusion
ACDF: Anterior Cervical Discectomy and Fusion
PCF: Posterior Cervical Fusion
Post-Operative Care:
Lumbar Spine Fusion (continued)
- VS, 02 Sats
- If patient had ALIF, apply continuous pulse oximetry
- Neurologic Function Assessment
- Strength and function
- Numbness/tingling upper extremities:
- Numbness/tingling/pain lower extremities:
- Same or different from Pre-op?
- KNOW YOUR PATIENT'S BASELINE
* Weakness NOT ok if not present pre-op *
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- Pain Management:
- Assess pain quality, intensity, location and duration
- PCA (if ordered) and Oral Med Transition
- Ice packs or cold therapy machines
- NO NSAIDS for - fusions
Post-Operative Care:
Lumbar Spine Fusion (continued)
- Hemovac Drain (if placed)
- 1&0 every 8 hours
- If clear drainage call MD
- Cerebral Spinal Fluid (CSF)
- Serosanguinous ok
- N/ checks after drain d/c
- Urinary Output:
- Discontinue foley ASAP or POD1
- Monitor for urinary retention
- Ambulate: Walk, Walk, Walk!
- FW for safety
- OOB day of surgery
- Early ambulation and SCDs for VTE prophylaxis
- Diet:
- Assess Gl Function, Bowel Sounds: potential for ileus
- Advance diet gradually
Potential Complications:
Lumbar Spine Fusion
- Spinal Headache CSF Leak
- Light and sound sensitive
- Occipital/positional headache
*upright is worse if post lumbar or thoracic surgery*
- Diagnose w/ CT myelogram
- Treatment:
- Position, hydration
- Ly • Drain management
- Epidural blood or fat patch
- CSF shunt
- Surgical re-exploration
- Lumbar Epidural Hematoma
- Neurologic pain worse than pre-op
- Motor weakness (loss of motor strength)
- Bowel or bladder dysfunction
- Diagnose/Assess
*time is of the essence*
- Frequent N/V checks
- Pain Assessment
- Imaging: CT/MRI
- Treatment:
- Return to OR for evacuation
Potential Complications:
Lumbar Spine Fusion
. Deep vein thrombosis
- Redness, swelling,
tenderness legs
- Mobilize early and often!
- SCDs
- No anticoagulants for
spine patients, especially
first 24 hours
. Pulmonary Embolus
- Patient looks "sick"
- Usually sudden onset of pain
with a breath or cough
- Impending Doom
- Diaphoretic, tachycardic
- Decreased O2 saturations
- Abnormal blood gas
- Likely started as a DVT
Remember: Early Recognition of Post-Op Complication is key
Reaching:
Arching:
Neutral Spine Principles - Brat Precautions
Bending: No bending forward, sideways or backward
Reaching: No reaching your arm behind or across your body
Arching: No arching your back or bridging; scoot in bed lying on
your side
Twisting: No turning shoulders to look or reach behind you,
move your feet and turn your entire body around to see behind
you, log roll
No Lifting greater than the amount prescribed by surgeon
(generally no greater than 5 lbs.)
Bending:
Twisting:
· Diagnosis
. Diet and Juven instructions
· Activity, bathing, incision care
. Weight bearing status and precautions
. Home medications - include "Next
dose due info"
Discharge Instruction for Ortho and Spine Patients
Discharge instructions should be provided to all patients verbally and
in written form on the After Visit Summary (AVS).
Discharge instructions should include information on:
· Signs and symptoms of
possible complications and
what to report to doctor
· Discharge therapy plan: home
exercises vs. home health PT
vs. outpatient PT
. Follow-up appointments
Orthopedic and Spine Care m24 Post Test
Question 1 of 16 Correct
Question 2 of 16 Correct
Question 3 of 16 Correct
Question 4 of 16 Correct
Question 5 of 16 Correct
Question 6 of 16 Correct
Question 7 of 16 Correct
Question 8 of 16 Correct
Question 9 of 16 Correct
Question 10 of 16 Correct
Question 11 of 16 Correct
Question 12 of 16 Correct
Question 13 of 16 Correct
Question 14 of 16 Correct
Question 15 of 16 Correct
Question 16 of 16 Correct
