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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 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