Pedretti Ch. 40 -- Total Joint Replacement and Hip Fracture pt. 2 Flashcards
Psychological factors in joint replacement
- Many in this population have a chronic disability, life-threatening disease or facing the aging process
- Adjusting to loss (of mobility or physical ability) requires physical and emotional energy
- Often experience: disease of a body part, fear, anxiety, change in body image, decreased functional ability, joint deformity, pain
- Potential concerns of elderly: fear of dependence, relocation trauma
- prolonged grieving may be needed before adjustment
- some may use dependence for secondary gain (increased attention, avoiding responsibility for self or others)
- Individuals may feel confusion disorientation and emotional lability after removal from familiar environment
Psychological factors in joint replacement - intervention
- Intervention must provide support and address the grieving process
- Address questions, provide information, ensure client understands intervention & likelihood of a positive prognosis
Hip fracture/LE joint replacement can affect sexual activity
- Hip fracture/LE joint replacement can affect sexual activity
- Refrain for 6 weeks to maintain precautions
- OT must create an environment where client is comfortable to ask these types of personal questions
- OT may need to provide suggestions on positioning of operated leg during sexual activity
(side-lying on non-operated side one option; pillows between knees for abduction precautions; In supine, pillow under knees to prevent excessive external rotation at hips; caution to refrain from kneeling (knee replacements or weight bearing precautions);
written info/diagrams helpful with personal info to read privately)
Rehabilitation
- Healthcare team relies on good communication & clear role delineation, normally outlined via a protocol or critical pathway
- protocol also gives each member a timeline to complete each assigned task
- Regular team meetings to discuss progress and discharge plans and coordinate individual intervention plans
Team usually consists of:
Physician
- inform team of medical status including medical history, current diagnosis, orders for medication/therapy/pain management and an account of surgical procedures (type of appliance used, anatomic approach, precautions)
- approves any change/progression in therapy or medication regimen
Nursing staff
- responsible for physical care of patient (including care of incision site), carries out proper positioning of patient, works closely with OT & PT to carry out self-care and mobility skills learned in therapy
- orthopedic nurses must know & understand surgical procedures and movement precautions
OT or COTA
PT or PT assistant
- musculoskeletal evaluation & intervention, LE sensation, pain, skin integrity, mobility (especially gait),
- obtains baseline info including ROM, strength of extremities, muscle tone and mobility.
- For THA/hip fracture, PT begins 1 day post-op
- Recommends assistive devices for ambulatory
stair climbing, managing curbs, outside ambulation
Dietician
- ensures adequate nutrition to aid in healing process
monitors drug therapy program & assists with pain management
Pharmacist
Social worker or case coordinator
- ensures discharge to appropriate living situation and availability of DME, arranges ongoing therapy
- usually an RN or social worker w/community resource knowledge
- OTs sometimes serve in role as case manager
- coordinates discharge plans of the team
Role of Occupational Therapy
OT for LE joint replacement or repair usually begins 1-3 days post-op (depends on age & health of patient, surgical events or medical complications)
Role of OT is to teach client ways to perform daily occupations safely, while observing precautions
Role of Occupational Therapy - Evaluation and Intervention
- OT is responsible for performing necessary assessments
- Assesses psychosocial issues related to surgery and its impact on lifestyle
- Baseline physical evaluation taken to determine limitations unrelated to surgery which prevent functional independence
- Cognitive skills assessed, ADLs, IADLs, functional mobility evaluated for intervention planning
- Document signs of pain and fear
- Intervention may include training in assistive devices, transfer techniques, ADL/IADL techniques that maintain precautions
- OTA may also play role in training. Also involved in treatment planning, documentation and discharge planning
Role of Occupational Therapy - Client Education
- Unlike fractures, LE joint replacements are normally planned
- OTs often provide education classes for those at risk of fractures or planning on a replacement
- Fall prevention education includes: home modifications, safe transfer techniques, use of public transit, community mobility
- Classes before surgery may be of benefit: describes procedures and precautions, assistive devices, therapy process and typical recovery period
Role of Occupational Therapy - Specific Training Techniques
Assistive devices susceptible as sock aid, dressing stick, long-handled sponge, long-handled shoe horn, reacher, elastic shoe laces, leg lifter, elevated toilet/commode seat, three-in-one commode, shower chair/bench, walker bags
Training Procedures for Persons with Hip Surgery - Bed Mobility
a. supine position with abduction wedge/pillow
b. If sleeping in side-lying, sleeping on operated side is recommended if tolerable
c. When sleeping on nonoperated side, keep legs abducted with abduction wedge supporting the operated leg to prevent hip adduction and rotation
d. Instruct how to get out of bed on both sides, although initially may be easier on nonoperated side
e. determine height of bed at home
f. Initially, when getting out of bed, client may use a leg lifter to move operated leg from one surface to another
g. overhead trapeze bar may be put in place, important to wean client off this device
h. to move from supine to sitting on edge of bed,
1. have client support upper body by propping up on elbows
3. then moving LEs in small increments toward side of bed
3. follow with trunk and UEs
i. Extension of hip & knee assists in maintaining precautions
Training Procedures for Persons with Hip Surgery - Transfers from Chair
Chair - firmly based with armrests
- Moving from standing to sitting:
a. back up to chair
b. extend operated leg forward
c. reach for armrests and slowly lower to sitting position (take care not to lean forward while sitting) - From sitting to standing:
a. Extend operated leg and push up from armrests
b. once standing, reach for ambulatory aid - Because of hip flexion precaution, client should sit on front part of chair and lean back
- cushions or blankets can be used to increase height of chair especially for taller patients
- low chairs, soft chairs, reclining chairs and rocking chairs should be avoided
Training Procedures for Persons with Hip Surgery - Transfers with Commode Chair
Commode Chair - three in one commode chair w/armrests can be used in hospital and at home
- For patient with posterolateral approach, height and angle can be adjusted so front legs of chair are one notch lower than back legs
- For anterolateral approach, may have enough hip mobility to use standard toilet seat
- To wipe, all patients should wipe from front while sitting OR wipe from back while standing, use caution to avoid forward flexion or rotation of hip
- Stand up, step to turn to face toilet and flush. Avoid hip rotation!
Training Procedures for Persons with Hip Surgery - Transfers with Shower Stall
- Utilize nonskid strips or stickers
- When entering stall, walker/crutches enter first, then operated leg, then nonoperated leg
- Alternative is to back up to edge of stall with walker, then step into shower while looking down at feet/shower rim for safety
- Shower chair with adjustable legs, OR a stool with grab bars are strongly encouraged
Training Procedures for Persons with Hip Surgery - Transfers with Tub Shower without Shower Doors
- Client prohibited from taking bath sitting on floor of tub b/c of severe risk of causing damage to impaired joint
- Tub chair or transfer bench recommended
- To enter:
a. back up to tub chair /bench using walker or crutches for support
b. Reach for backrest, extend operated leg and slowly lower to seated position
c. legs then lifted into tub (via towel or leg lifter) as client leans back - Alternative is sponge bath at sink w/long-handled sponge
Training Procedures for Persons with Hip Surgery - Car
- bucket seats in small cars should be avoided, bench-type seats recommended
- Have someone move front passenger seat as far back as it will go and recline back support to preserve precautions
- To enter:
a. back up to seat
b. hold onto stable part of car, extend operated leg and slowly sit in car
c. while leaning back, client slides buttocks towards drivers seat
d. upper body and LEs move as one unit to turn to face forward direction - pillows in seat may be needed to increase height of seat
- prolonged sitting in car should be avoided
- alternative is transferring to backseat of four door car, sliding back far enough so leg is fully supported on seat.
- Clients should not return to driving until cleared by surgeon even if operated leg is not driving leg
