Download Joint Replacement Transformed a Life

Joint Replacement
Transformed A Life
A Patient’s Journey
By Jenks 4 West
Presenters
 Deana
Hamilton, BSN, RN, ONC
 Kennelle Butterfield, BSN, RN
 Dr. Daniel Ward, MD
 Danielle Burdo, PA
 Irene Chapski, BSN, RN
 Jason Skypeck, PT, CCCE
 Susan Collins, BSN, RN, CCM
Disclosure of Conflict of Interest

The speakers have nothing to disclose, in
regards to the existence of any significant
financial interest or other relationship associated
with today’s educational presentation
 This education presentation received no
commercial support
Lunch courtesy of Forest Pharmaceuticals
“Reminder”
 Request
everyone to sign in
 Complete and return a program evaluation
form at the end of the presentation
 1.0 contact hour to be awarded to RNs
Objectives:



Review the life saving joint replacement
surgical procedures for Mr. M
Describe the nursing and rehabilitative
challenges encountered by the team in
helping the patient move towards
recovery
Discuss the multi-complex discharge
plan for Mr. M
Surgical Preparation Presented by
Deana Hamilton
Case Study

Mr. M



62 years old
5’11”, 230 lbs (BMI 33)
PMH





OA
HTN
Hyperlipidemia
Obesity
NIDDM



Renal insufficiency
Recurrent UTI’s
Partial paralysis d/t
MVA
Mr. M

PSH in Bermuda




1962- L2-L4
Laminectomy
1964- Right femur
ORIF
1990- Right Hip
surgery
1997- Left MCL/ ACL
repair

PSH at NEBH



4/00- Left TKR
10/00- Left THR
(After left hip
dislocation and
femoral neck fracture
sustained in fall)
10/06- Right TKR
Patient Presentation

Fell at home (11/08)


Developed right knee pain & swelling
Evaluated in Bermuda
• Right knee aspiration showed MSSA

Admitted to NEBH under
Dr. Ward’s service
Patient Presentation
S


& S upon arrival
Mild fever
C/O pain
•
•
•
•


Right knee
Left elbow
Left hip
Left abdomen
↓ urine output with occasional incontinence
Constant dry, hacking cough
Surgical Clearance

Labs:






Elevated WBC
Elevated blood sugar
U/A, C+S
(+enterococus)
Joint fluid aspiration
(+ staph aureus)
Pre-op CXR- WNL
Cardiac Clearance





Echo- WNL
D-dimer elevated
CXR, VQ scan & CTA
of lungs (-for PE)
PFT’s performed d/t
cough
I+D Consultation


Blood cultures
(+Staph areus)
Kefzol 2 gm IV started
Diagnosis
 Collaboration
of Dr. Ward and Infectious
Disease MD
 Osteomyelitis & Sepsis (3 septic joints)
 Surgical interventions required
Surgical Interventions
1st Admission
 11/10/08- Left Hip Resection Arthoplasty
 11/12/08- Bilateral Knee Resection & placement of
antibiotic spacers
 2nd Admission
 3/18/ 09- Left TKA Revision
 3rd Admission
 5/05/09- Left Hip Girdlestone Procedure
 4th Admission
 10/10/09- Right TKA Revision postponed
 10/16/09- Right TKA Revision performed

Pharmacological Interventions
 Treatment

with IV/PO antibiotics
Medications Included:
•
•
•
•
•
•
•
Kefzol
Rifampin
Oxacillin
Ertapenem
Ceftriaxone
Tobramycin
Vancomycin
Psychosocial and Emotion Factors
Presented by
Kennelle Butterfield
Psychosocial Assessment

Psychosocial information









Psychologist
Married X 35 yrs
Lived with wife in Bermuda
2 adult children
Partially paralyzed at 17
Immobile
Wears AFO braces 2˚ bilateral foot drop
Pivots on & off scooter
Family History


Mother- 86 yrs-alive & well
Father-deceased
(Heart disease & obesity)
Psychosocial Stressors
Husband
Infections
Business
Prognosis
Father
Psychologist
Multiple Hospitalizations
Emotions

Experienced feelings:
 Grief
 Anger
 Anxiety
 Depression
 Frustration
 Hopelessness
 Powerlessness

Expressed feelings:
 Verbal
 Non-verbal
• Body language
Emotional Support and Coping

Goal:



Provide non-pharmacological intervention
Help patient & wife cope with stressors
Interventions:






Provide privacy
Encouragement
Acceptance
Question time
External Social & Emotional Support
Referral
Role Transitions
 Mr.

M’s role
Bread winner
 Wife’s

Patient
role
Reliable companion
• Running his business
• Managing finances

Caregiver
Surgical Procedures Presented by
Dr. Ward
Challenges to Mr. M.’s Recovery
Presented by
Danielle Burdo PA
Septic Shock
 Definition




Organ dysfunction
Hypoperfusion
Hypotension
Requiring inotropic support
 Perfusion



of Sepsis
abnormalities include:
Lactic acidosis
Oliguria
AMS despite aggressive fluid resuscitation
Characteristics of Sepsis that Influence
Outcomes
 Abnormal
host response to infection
 Site and type of infection
 Timing of ABX
 Offending organism
 Any underlying chronic diseases of the
host
Mr. M with Polymicrobial Sepsis

Laboratory Workup
 MSSA in 3 joints
 Blood cultures:
• + MSSA (11/7/08)
• + Enterococcus faecalis & Staph hominis (11/16/08)
• + Gram Neg Rods, Pseudomonas (11/24/08)
 Central line culture:
• + Pseudomonas, E. Coli & Enterococcus faecalis (11/15/08)


VRE in rectum
C-Diff (11/28/08)
Causes of Septic Shock

Lower Respiratory Tract


Cause of septic shock in 25% of patients
Common pathogens include:
•
•
•
•
•
•
•
•
Strep pneumoniae
Klebsiella pneumoniae
Staph aureus
E coli
Legionella
Haemophilus sp.
Gm negative bacteria
Fungi
Causes of Septic Shock

Urinary Tract Infections
 Cause of septic shock in 25% of patients
 Common pathogens include:
•
•
•
•
•
•
E coli
Proteus
Klebsiella
Enterobacter
Serratia
Pseudomonas
Causes of Septic Shock

Soft Tissue Infections
 Incidence of septic shock 15% of patients
 Common pathogens include:
•
•
•
•
•
•
Staph aureus
Staph epi
Streptococci
Clostridia
Gm negative bacteria
Anaerobes
Causes of Septic Shock

Foreign Bodies
 Lead to septic shock in 5% patients
 Incidence: 5-18.4% (JCAHO 2008)
 Common pathogens include:
•
•
•
•
Staph aureus
Staph epi
Candida
Polymicrobial sepsis has become a more prevalent cause of sepsis
Circulatory Shock
 Subdivided
on the basis of underlying
mechanism into 4 distinct classes:




Hypovolemic
Obstructive
Distributive
Cardiogenic
Septic Shock

Treatment



Fluid management
Moderate to high levels of PEEP: TV 6ml/kg body
weight; PEEP titrated to keep SaO2 88-95% or PO2
55-80
Nutritional support via feeding tube:
• Low carbohydrate
• High fat & essential fatty acids

No medical consensus on pharmacological
interventions:
• Steroids
• TNF antagonists
Acute Respiratory Distress Syndrome
(ARDS)

Definition:




Bilateral pulmonary infiltrates
Severe hypoxemia in the absence of evidence for
cardiogenic pulmonary edema
Severity of hypoxemia defined by PaO2/FiO2 ratio:
Incidences:


< 200: ARDS
< 300: ALI ( Acute Lung Injury)
ARDS
 Early




ARDS characterized by:
Increase in permeability of the alveolarcapillary barrier
Lead to influx of fluid into alveoli
Injury occurs on the vascular endothelium in
systemic sepsis
Alveoli damaged, making it difficult to clear
fluid from alveolar space
ARDS

Morbidity and Mortality

Mortality rates range from 30-70% in USA:
• Major factors include age and timing of interventions

Morbidity is considerable:
• Patients develop Nosocomial infections (esp. ventilator
associated pneumonia)


ARDS usually manifests 12-48 hrs after inciting event
Most common risk factors include:
•
•
•
•
•
Sepsis
Pancreatitis
Trauma
Long bone fracture
Narcotic over dose
ARDS
 Treatment
 Danielle,
we need treatment of ARDS,
please fill in the blank. Thank you.
Nursing Diagnosis and Interventions
Presented by
Irene Chapski
Nursing Diagnosis

Alteration in Mobility

Assessment
• Multiple health issues




Neurological
Respiratory
Cardiovascular
Musculoskeletal
• History of immobility

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Wheelchair bound
Partial paralysis
Current surgical procedures
Interventions
• Interdisciplinary collaboration

Alteration in Skin Integrity

Assessment
• Wound Assessment
• Prevention of Skin Breakdown
Nursing Diagnosis
 Alteration

Pain Assessment
 Alteration




in Thermal Regulation
Vital Sign Assessment
Monitor Lab work
 Alteration

in Comfort
in Tissue Perfusion
Lung and Heart Assessment
O2 sat
DVT Prevention
Nursing Interventions

Related to Immobility

With Rehab Involvement
• Perform active & passive ROM




Assist with self care independence
•
•
•
•
•

Foster muscle strength
Maintain joint mobility
Prevent contractures
Overhead frame
Sling
CPM
Knee Immobilizer
Hoyer lift for transfer
Related to Alteration in Skin Integrity

Turn & reposition Q2 hrs
•
•
•
•

Prevent skin breakdown
Air mattress applied
Skin integrity maintained
No skin breakdown noted
Wound care treatment
Nursing Intervention

Related to Pain




Related to Thermal Regulation



Assessed and medicated for pain
Ice therapy
Repositioned
Antibiotic therapy
Encouraged IS
Related to Tissue Perfusion




Oxygen therapy as needed
Lab work
Blood Transfusion as needed
Encouraged IS
Physical Therapy Presented by
Jason Skypeck
Physical Therapy
1st Admission

L Hip Resection and Bilateral Knee Resection (November 2008)

Evaluate and Treatment during 15 day intubation
• Repositioning to prevent skin breakdown, Mgt. Of anasarca
• Bed mobility and trunk control activities MAX A of 3
• Isometrics exercise, ROM of upper extremities
• Chest PT for pulmonary hygiene
• Use of Hoyer lift to get OOB to chair
• Use of Knee Immobilizers to maintain joint alignment and
comfort

Discharge
• Acute Level of Rehab
Physical Therapy
2nd Admission

L TKA Re-implantation (March 2009)
 Treatment
• PT with focus on ROM, strengthening of L Knee
• Pressure relief strategies
• Scapular depressors, triceps work
• Bed mobility strategies progressing to CG level
without the use of overhead frame
• Slide board transfer to motorized scooter
 Discharge
• Return to Bermuda
Physical Therapy
3rd Admission

L Hip Girdlestone to THA Re-implantation (May 2009)
• Spacer remains in right knee
• MOD A of two for standing activities and transfers to
chair/ commode

Discharge
• Acute Level of Rehab (Spaulding)
• Working at Spaulding with Lite gait harness system
• 16 lb weight loss, BMI 36 to 32
Physical Therapy
4th Admission
 R TKA Revision Reimplantation (October 2009)
•
Surgery delayed four days 2˚ UTI

• Pain Management
•
Continuous Femoral Nerve Block for pain management
• Swelling
• Lightheadedness
• Low blood count requiring blood transfusion
• Fatigue
Treatment
• POD # 1
 AAROM
 Tactile facilitation of quadriceps
 SAQ/SLR with assist
 CPM TID for 2 hrs
 Use of over head frame for repositioning to prevent skin breakdown
Physical Therapy

Treatment Continued


POD # 2
• Progressed bed level exercise program
• AAROM to 5-75 degrees
• Unable to stand with MAX assist of 2 secondary to quad weakness
and fatigue
POD # 3
• Goal of the Day
 Commode transfer
 Improve knee stability in wt bearing using Knee immobilizer (KI)
• Activities
 Tolerated 30 seconds of static standing
 Performed wt shifting pre-gait activities
 Took 4 steps with min assist of 2 using SW for commode
transfer
Physical Therapy


POD#4
“This is my best day in 49 weeks”





AAROM now 5-90 degrees, partial SLR
Transition made to a rolling walker secondary to his
compensatory method of walking due to previous spinal cord
injury
Incredible energy expenditure during gait training secondary B
foot drop and proximal hip weakness
Able to walk total of 15 feet using the KI on the right leg
Seen TID at this point with NU co-op staff supplementing efforts
by working on carrying out exercise protocol and CPM
Physical Therapy
 True

inspiration
Activities
•
•
•
•
•
AAROM now 5-108 degrees
KI discontinued
Independent with his bed mobility, d-on/d-off AFO’s
Close supervision for transfer to/from his motorized scooter
Ambulated total 70 feet with B AFOs, CG of one, second to follow
with W/C
• Cleared to leave the floor to have lunch with his wife

“I finally feel like a complete person again”

Discharge
• Discharged home 9 AM following morning to Bermuda
Case Management

Roles and Responsibilities

Role of case manager for the international patient:
• Link to Insurance Company




To certify acute hospital stay
To determine the discharge date & place
• Home VS Acute Rehabilitation
Provide daily updates to insurance company
• What we are doing for the patient
• How the patient is doing
Discharge planning to ensure safe, smooth &
uninterrupted transition
Discharge Planning for Mr. M
 Interdisciplinary

Collaboration
Input from Nursing, PT & OT required
• To determine the best discharge plan
 Goals

developed
To help Mr. M reach maximum level of
independence prior to discharge home to
Bermuda
 Spaulding
Acute Rehabilitation selected
for 1st & 3rd discharge
At Spaulding

Goals:

After 1st discharge
• Being independent transfer to scooter

After 3rd discharge
• Working with different modalities preparing to walk again

Treatments include:



Wound management
IV antibiotic to treat overwhelming sepsis
Work with PT/OT to develop upper & lower
extremities strengthening
Rehab Service in Bermuda
 No
acute rehabs
 No short term rehab facilities
 No VNA services
 Patient aware of rehab services in his
homeland
Discharge Planning for Mr. M
 Transitioning
back to Bermuda for 2nd & 4th
discharge
 Work closely with Insurance Co. &
Transitional Social worker
 Function of Transitional Social Worker


Work with NEBH, PCP, Orthopedic doctor &
Hospital in Bermuda
Set up daily PT program
Future Rehab in Bermuda
 Ongoing
and future programs between
Spaulding & King Edward hospital
 Goal: to increase rehab services in
Bermuda
 Patients from Bermuda attend PT training
from Spaulding or vice versa
This patient’s journey ended here…….
This Concludes Our Presentation
Questions Are
Welcome At This
Time
Thank You