A Patient's Guide to Shoulder Surgery: St. Agnes Hospital

Before, During & After Shoulder Replacement Surgery

Joint Replacement Surgery: A Patient’s Guide

AgnesiAn HeAltHCAre is sponsored by tHe CongregAtion of sisters of st. Agnes

Shoulder Replacement Surgery

A P A T I E N T ’ S G U I D E

Welcome Welcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1Important Phone Numbers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Joint Replacement Patient Information Sheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Case Managers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Medicare Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Before Surgery Planning For Your Hospital Stay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7What to Expect From Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Frequently-Asked Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Home Safety Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Surgery Care Guidelines - Day of Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Care Guidelines - Day One . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Care Guidelines - Day Two . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Preparing for Discharge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Exercises Restrictions/Exercises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

After SurgeryPain Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Durable Medical EquipmentAgnesian Health Shoppe - Durable Medical Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

ResourcesHome Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28Common Terminology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

(SAH 04/15)

Table of Contents



Thank you for choosing the Agnesian Center for Bone & Joint Health for your joint replacement surgery . We hope our mission of providing compassionate care that brings hope, health and wellness to all we serve is evident in the care you receive . We trust that our associates and your surgeon provided you with the educational opportunity to prepare yourself adequately for your joint replacement surgery .

The Agnesian Center for Bone & Joint Health has been designed to give outstanding care of patients in need of joint replacements . We have assembled a special team of healthcare professionals that take great pride in ensuring that you receive the best quality care available . You can have extra confidence knowing that the Agnesian Center for Bone & Joint Health serves several hundred joint patients each year; our professionals have extensive experience .

As you will remember, to prepare you for surgery, our team has reviewed your specific joint replacement procedure with you, and our highly-trained associates have provided you with this detailed educational binder . Through our surgical skills, our superior healthcare team and your determination, together we can accomplish a great result for you .

Again, thank you for choosing the Agnesian Center for Bone & Joint Health; we are certain that you will find your care to be extraordinary . During your hospitalization, please inform our associates if we can do anything for you to help you have an excellent care experience .

Thank you again and we wish you the best in your recovery!

Welcome to Agnesian HealthCare!

SAH Shoulder Replacement | 1



Surgeon

Name of Surgeon: _________________________________________________________________

Office Phone Number: _______________________________________________________________

Primary Care Provider

Name of Primary Care Provider: ________________________________________________________

Office Phone Number: _______________________________________________________________

Pharmacy

Name of Pharmacy: ________________________________________________________________

Address: ________________________________________________________________________

Phone Number: ___________________________________________________________________

St. Agnes Hospital

Information/Switchboard . . . . . . . . . . . . . . . . . . . . . . . . . (920) 929-2300 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (800) 922-3400

Inpatient Physical Rehabilitation . . . . . . . . . . . . . . . . . . (920) 926-4237

Surgical Inpatient Unit . . . . . . . . . . . . . . . . . . . . . . . . . . (920) 926-4240

Anticoagulation Management Services . . . . . . . . . . . . . . (920) 926-4580

Case Managers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (920) 926-4750

Important Phone Numbers




St. Agnes Hospital • (920) 926-4500 • (800) 458-8182

Date of Surgery: _______________________________________ ❑ Right Shoulder ❑ Left Shoulder

Unless your provider gives you other instructions, please prepare yourself for your surgery using this checklist .❑ Make sure to stop the medications as directed by your provider:

______________________________________________________________________________

Day before surgery:❑ Eat a regular meal unless your provider instructs you otherwise .

❑ Stay away from greasy, spicy and/or salty foods to help avoid upset stomach .

❑ Remove all nail polish on your toenails and fingernails .

❑ Prepare anything you will need to bring with you to the hospital .

___ robe and slippers

___ comb/hairbrush

___ glass case and/or contact case and solutions

___ toothbrush/toothpaste

___ deodorant

___ bring along any prosthetic devices; i .e ., braces, walkers, crutches, etc .

❑ Do not have anything to eat or drink including water starting at midnight on:

______________________________________________________________________________

❑ Call the hospital’s Surgical Service Department at 926-4500 (800-458-8182, ask for extension 4500) the day before your surgery anytime after 1 p .m . to find out your arrival time . If you do not call the hospital by 6 p .m ., they will call you .

❑ Arrival time according to the hospital: ________________________________________________

Day of surgery:❑ Take the following medications with a sip of water at:

______________________________________________________________________________

❑ Bring to the hospital your Durable Power of Attorney papers for your chart if already have .❑ Brush your teeth but do not swallow any water .❑ Do not wear makeup or nail polish .❑ Wear comfortable clothing to the hospital .❑ Leave jewelry and all other valuables at home .❑ When coming to the hospital, stop at the Registration department and then go to the Surgical Services department .

Patient Information Sheet

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A case manager is a nurse or social worker . Case managers are available to assist you with:

Power of Attorney (POA) for Healthcare The Wisconsin statutes recognize two forms of advance directives: the Power of Attorney for Healthcare and the Declaration to Physicians (Living Will) . All hospitals are required by law to make this information available to patients . You may call the case manager at (920) 926-4750 and request that a copy be mailed to you .

A POA for Healthcare is a thoughtful process and should not be rushed . We recommend you complete the POA forms prior to your admission if you wish to have your POA in place for this surgery . Your signature requires two witnesses . Family members are not eligible to witness your signature . The only hospital associates eligible to witness your signature are Spiritual Care Services associates or a social worker, and they may not be readily available the day of your surgery .

Insurance-Related Questions Insurance companies may preauthorize an initial one to two-day hospital stay . During your hospitalization, the insurance company will call the case manager to evaluate your progress . The insurance company will then determine if your stay is to be extended .

Discharge PlanningDischarge planning includes setting up home care, equipment or arranging for inpatient rehabilitation or a subacute (skilled nursing home) stay .

We recommend that you pre-plan your ride home with a family member or friend . Insurance companies only pay for medically-necessary ambulance transportation . Insurance will not cover wheelchair van transport .

If outpatient services are needed for physical therapy or lab tests, you will need to arrange for the appointment and the transportation . Know before you come into the hospital where you want to go for your therapy and blood work .

After you are admitted to the hospital, your case manager may stop in and ask if you have any questions or discharge concerns . You or your family may request to see the case manager at any time .

Case Managers




Healthcare benefits change constantly; therefore, it is important for you to review your insurance benefits and/or any alternative plans for payment before you come to the hospital . The medical and rehabilitation team will work with you to decide which options are most appropriate for you .

Medicare A and B provides benefits for the following services:

Rehabilitation • Inpatient rehabilitation at St . Agnes Hospital may be covered . However, patients must meet certain criteria

for admission .

• Subacute (skilled nursing home): If you think that your recovery may progress more slowly, you may want to consider skilled nursing facilities before you come into the hospital . Medicare may provide coverage for a short period of time . Criteria for admission, discharge and payment are based on the need for skilled care as described by Medicare .

Home Care (see page 28)Medicare may cover home care at 100 percent if you meet the following criteria:• The home care needed is skilled in nature . This means you require a nurse and/or physical therapist .

• You must be homebound . This means that leaving the home requires a considerable and taxing effort or leaving the home is medically contraindicated .

Outpatient Therapy Benefits • Medicare provides benefits for outpatient services based on skilled care needs at the time the service is

provided . This may be covered at 80 percent of the charge .

Durable Medical Equipment (see page 27) • You may have to pay a portion or all of the cost depending on your insurance benefits for a walker, crutches

or cane .

• If you were issued a cane or any other equipment within the last one to five years, your insurance carrier may not cover the cost again .

• Items not covered include raised toilet seats, grab bars, shower transfer bench or chair, reacher, long-handled sponge, sock aid and shoehorn .

Medicare Benefits




If you have private or a Medicare-replacement insurance:

Read the written information you have at home about your insurance coverage . Call the number on the back of your insurance card if you have any questions . In general, insurance companies follow the same criteria as Medicare to determine eligibility for outpatient therapy, home care, acute or subacute rehabilitation services . Let the insurance representative know that you will be having surgery . Keep in mind that the person answering your questions is a service representative who will speak in general terms and will not know all the details about your surgery .

There may be a difference between having the benefit and qualifying for the benefit . Qualifying for the insurance benefit is not a surgeon or primary care provider’s decision . Your insurance company will determine your qualification for benefits based on their standards and policies .

Questions you may want to ask about your benefits.Write down the name of the person you are talking with: _______________________________________

Do I have outpatient physical therapy benefits? ❑ Yes ❑ No

If yes, what are they? _______________________________________________________________

Is there a preferred provider? _________________________________________________________

Do I have home health benefits for in-home therapy or nursing? ❑ Yes ❑ No



Do I have durable medical equipment benefits (walker, crutches)? ❑ Yes ❑ No



Do I have acute inpatient rehabilitation benefits? ❑ Yes ❑ No


Do I have skilled nursing facility benefits? ❑ Yes ❑ No

If yes, who are the preferred providers? __________________________________________________

Is there a deductible or co-pay for any of these services? ______________________________________

Insurance Benefits




Prior to Your Surgery DateDo not shave your legs or cut/clip your fingernails and toenails for one week prior to your surgery date . .

Anti-inflammatory medications (over-the-counter or prescription) that you are currently taking for your joint pain may be requested by your surgeon to stop prior to surgery, so make sure your surgeon has an up-to-date list of your medications . If your surgeon does request you to stop these medications, inquire what you can take in place of them for your joint discomfort .

What to Bring to the Hospital • If you bring your own pillow, please make sure your pillowcase is brightly colored or patterned, so that it

won’t be mistaken with the hospital linens .

• Bring loose-fitting, comfortable clothes such as pajamas, lightweight robe, sweatpants and shorts for therapy . Bring shirts with buttons in the front that will allow room for your arm in the immobilizer sling . Bring at least two sets of clothing with you .

• Bring comfortable, easy slip-on, low-heeled shoes that have an enclosed heel and toe, such as walking or tennis shoes . Non-skid or rubber-soled shoes are preferred .

• Bring personal hygiene toiletries and incontinence products . You may also want to include lip balm .

• Bring any special equipment that you have at home, such as wrist splints, orthopedic shoes .

• Bring a book, magazine or hobby item to help you relax .

• Bring a list of your medications (both prescribed and over-the-counter) with any changes if any from the time you attended the education class .

• Do not bring medications from home unless told to do so (It is OK to bring your eye drops and inhalers) . Check with your provider regarding which medications to take on the day of your surgery .

• Do not bring any jewelry, checkbook, credit cards or more than $5 cash with you to the hospital .

When to Stop Eating and Drinking• Do not eat or drink anything after midnight the night before your surgery unless otherwise instructed .

This includes gum, hard candy, water, soda, coffee, tea, beer, wine or other alcoholic beverages, etc .

• Brush your teeth, making sure not to swallow any water or toothpaste .

• Take your medications as instructed with a small sip of water .

Planning For Your Hospital Stay




While in the Hospital• As a patient of St . Agnes Hospital, we are pleased to offer you an innovative dining program, which allows

you to select meals from an expansive menu designed to make you feel as though you were at home or at a favorite restaurant .

• If one of your guests wishes to have a room service meal, they can call the room service line at #33 or 4673 to place their order . Breakfast orders are $5, and lunch or supper meals are $7 . Meals include an entrée, two side orders, a beverage and dessert/fruit . The guest must have exact change upon delivery of the guest tray . No checks or credit cards will be accepted .

Suggestions to Make Your Return Home an Easier One• Ensure hallways and rooms are free of clutter and tripping hazards .

• Organize your living areas to avoid lifting, bending or reaching .

• Arrange for extra help with household tasks if needed .

• You will have a cooling device after surgery that you can take home and continue to ice affected extremity .

Planning For Your Hospital Stay




What to Expect From AnesthesiaYour anesthesiologist should discuss two main aspects of care with you: the anesthesia provided during the surgical procedure and the plan for pain control after surgery . This information is being distributed to you ahead of time to help guide discussion about your care on the day of surgery .

Anesthesia for Your Surgery In almost all instances, a general anesthetic is administered in the operating room for total shoulder replacement . During general anesthesia, you are unconscious and have no awareness or other sensations . There are many types of general anesthetic drugs . Some are gases inhaled through a breathing mask or tube, and others are medications injected into a vein . After you are asleep, a breathing tube may be inserted into the windpipe to maintain proper breathing and administer anesthetic gases . During a general anesthetic, you are carefully monitored and treated by your anesthesia provider . The amount of anesthesia is calculated and contantly adjusted . At the conclusion of surgery, your anesthesiologist will reverse the process and you will regain awareness in the recovery room .

Pain Control Following SurgeryAt St . Agnes Hospital, we take a multi-modal approach to pain relief for joint replacement surgery . Your anesthesia provider can also help keep your pain at tolerable levels during your stay in the hospital after surgery . All patients are candidates for narcotic pain medication given through the IV or by mouth, and most patients also receive non-steroidal anti-inflammatory drugs such as acetaminophen or ketorolac, or other pain reducing medications .

Most patients will be offered a type of regional anesthesia, called an interscalene block, to help with postoperative pain . This is a block of the brachial plexus, the cluster of nerves that sense pain from and send signals to your arm . For a total shoulder replacement, the brachial plexus is blocked in your neck as it travels between the scalene muscles . This block is most often performed prior to the surgical procedure . Your anesthesia provider may use an ultrasound machine to locate the cluster of nerves . A small electric current is given through the needle causing brief contractions of some neck and arm muscles . This may also cause your diaphragm to contract . Placement of this block is generally simple and involves minimal discomfort .

The block can last between eight and 48 hours . It can numb all or parts of your arm . In addition to providing pain relief, the block may also cause some drooping on the same side of the face, a hoarse voice (from numbing of the vocal cord on the same side), and some subjective shortness of breath (from numbing of the diaphragm on the same side) . These side effects should last only as long as the block lasts . In some patients who have difficulties with their lung or vocal cord opposite to the anticipated side of surgery, it may not be safe to perform an interscalene block for pain control after surgery .

Anesthesia




SummaryMost patients who have total shoulder athroplasty at St . Agnes Hospital will be offered an interscalene block prior to surgery and a general anesthetic during the surgical procedure . Together, you and your anesthesiologist will decide what is best for you .

Anesthesia




Frequently-Asked Questions

Q: How long will I be in the hospital following my total joint replacement?A: Typically following a total joint replacement, you will have a two to three-day stay in the acute care hospital .

During your acute care stay, you will meet with a case manager who will assist you with your discharge plans . Based on your recovery status, rehabilitation associates and your provider will provide you with discharge recommendations .

Q: How much pain will I have after the surgery?A: Your comfort is very important to our associates . In order for our associates to better serve your needs, we

will be asking you to “rate” your pain . The scale will be from 0 to 10, with 0 being no pain and 10 being the worst pain possible . Our associates will be establishing a pain goal with you to provide adequate pain control . This rating will give associates an idea of how you feel and how to treat your discomfort .

Q: How can I succeed after total joint replacement while in the hospital?A: During the first few days following surgery, you must rely on hospital associates to assist you with many

things . However, during this time, you can assist with your recovery in the following ways:

• Drink plenty of fluids. • Perform ankle pumps, wrist and hand exercises, and deep breathing exercises frequently while awake. • Actively participate in your rehabilitation program.

Q: How long until I can return to my normal activities following surgery?A: Typically, when you are discharged from your acute care stay, you will be independent with basic activities

of daily living such as dressing and bathing, which will be practiced with occupational therapy before your discharge home . Within six months, you will be able to resume most of your pre-surgical activities based upon your provider’s recommendation . Your provider or therapist can answer specific questions concerning your activities . It will take up to one year to fully recover .

Q: Will I need special equipment at home following surgery?A: During your acute care stay our rehabilitation associates will assess your equipment needs and make

recommendations . Your case manager will coordinate obtaining the appropriate equipment through an agency .

Q: What restrictions will I have following surgery?A: See restrictions section found on page 21 in your binder .




Home Safety Assessment

The majority of falls that occur happen at home . The good news is that most falls can be prevented through environmental changes and safety precautions . To decrease your risk of falling after your total joint surgery, we recommend that you ask your spouse, family member or a neighbor to go through your home and answer the following questions .

If you answer “No” to any of the questions, it is recommended that you change the environment to allow for better safety . While correcting these common concerns will decrease your risk of a fall, it is also recommended that you have a safety network of friends, family or neighbors to provide a daily check-in, either by phone or in person, should you fall and be unable to solicit help independently .

General Household Areas Are light switches easily accessible upon entering a room? . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ Yes ❑ No

Do you have throw rugs in your home? (remove them) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ Yes ❑ No

Are hallways free from clutter? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ Yes ❑ No

Are raised door thresholds clearly marked? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ Yes ❑ No

Are electrical cords and telephone cords away from hallways? . . . . . . . . . . . . . . . . . . . . . . . . . ❑ Yes ❑ No

Do you have a portable phone with emergency numbers easily at hand? . . . . . . . . . . . . . . . . . ❑ Yes ❑ No

Do you have furniture with good back and arm support that you can get in and out of easily? . . . ❑ Yes ❑ No

StairwaysAre stair treads in good condition? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ Yes ❑ No

Is there a sturdy handrail on both sides of the stairs? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ Yes ❑ No

Are the stairs brightly lit? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ Yes ❑ No

BedroomIs there a lighted pathway from the bedroom to the bathroom? . . . . . . . . . . . . . . . . . . . . . . . . ❑ Yes ❑ No

Is there a clear pathway from the bedroom to the bathroom? . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ Yes ❑ No

Do you keep a charged flashlight near your bed for emergencies? . . . . . . . . . . . . . . . . . . . . . . ❑ Yes ❑ No

BathroomDo you have safety rails or grab bars by toilet and shower/tub? . . . . . . . . . . . . . . . . . . . . . . . . ❑ Yes ❑ No

Do you have skid resistant strips or a rubber mat both in and in front of the bathtub? . . . . . . ❑ Yes ❑ No

Do you have an adjustable shower chair? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ Yes ❑ No




Home Safety Assessment

KitchenDo you use a wide-based, sturdy step to reach into high cabinets? . . . . . . . . . . . . . . . . . . . . . ❑ Yes ❑ No

Are spills immediately wiped up? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ Yes ❑ No

Do you avoid using a high gloss floor wax? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ Yes ❑ No

Do you store frequently used items at waist level and less frequently used items in higher cabinets? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ Yes ❑ No

Is your laundry located on first floor? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ Yes ❑ No

Will you have assistance with laundry? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ Yes ❑ No

Will you have assistance with meal preparation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ Yes ❑ No

Could you prepare microwave meals in advance? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ Yes ❑ No




Care Guidelines - Day of Surgery

We are pleased to welcome you to St . Agnes Hospital and the Surgical/Orthopedics unit . We look forward to providing you the best care possible in an environment that encourages you to actively participate in the rehabilitation process .

Today’s Itinerary:• You will have an IV .

• The pulses in your wrists and feet will be checked .

• We will remind you to do ankle pumps every one to two hours .

• Take frequent “cat naps” and limit visitors .

• An immobilizer sling will be used to keep your arm in a safe, secure position .

• You will reposition in bed and the chair frequently to prevent damage to skin .

• Your blood pressure, pulse, respirations, temperature and oxygen levels (vital signs) will be checked frequently .

• We will remind you to use your incentive spirometer and to take deep breaths and cough every hour while you are awake (if you are watching television, you can do this during each commercial or approximately 10 per hour) .

• If you return from surgery in the morning, the physical therapist may get you out of bed today . If not, your nurse will have you sit at the side of the bed today .

Pain ManagementWe take pain management seriously and want you to be comfortable . You will be asked to rate your pain using a 0 to 10 pain scale . Zero means no pain and 10 means the worst pain you can imagine . Your nursing associates will be checking you frequently and will be asking you about your level of pain . Remember to let your nurse know when your pain is starting to increase .

There are several options for pain management after total joint surgery and these will be ordered by your surgeon or anesthesiologist . Pain management can be complex so please feel free to ask questions of your nurse or provider .

Today’s Goals ❑ Pain controlled ❑ No pneumonia

❑ Nausea controlled ❑ Carry out shoulder precautions

❑ No blood clots ❑ Get some rest!




Care Guidelines - Day of Surgery

MedicationsYou will have medications to keep you comfortable after surgery and to prevent complications . Many of these are taken by mouth so controlling nausea is important . You have provided a list of your home medications and if not contraindicated, these will be ordered to begin this evening or tomorrow .

If you were told to bring your medications from home, please provide these to your nurse . They will be reviewed by a pharmacist for identification and then kept in a secure bin assigned to you . The nurse will provide these as ordered .

Food for ThoughtYou have been without food or drink since midnight and had surgery… so be good to your stomach . Slow and steady wins the race for getting back to normal meals .

Start with ice chips, followed by a few sips of water . If all is well, Jell-O, clear soups and juices are good choices . These are available on your unit 24/7 . Once you are able to pass gas, you can try portions of solid food .

Remember, you have an IV so you can do without food or drink if your stomach is just not feeling quite right . If you experience nausea, let your nurse know .

The menu in your room will tell you how to order your meals from dietary . We also have regular and diet soda, juice, soup, cold cereals, saltines, graham crackers, milk, ice cream and popsicles on the unit if you want a snack .

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Don’t Take a “Trip” to the Bathroom! You may have a catheter in your bladder to drain urine. If not, ask for assistance with a bed pan, urinal or to get up to a bedside commode. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Dress Code• Patient gown for comfort; save your personal comfortable clothing for the upcoming days .• Nasal prongs to provide oxygen .• Elastic stockings (TED hose) and/or sequential compression devices (SCDs) to aid circulation and prevent

blood clots .• A dressing over your surgical site (the nurse may need to add to your dressing if there is drainage on the

surgeon’s dressing) .• Cooling device will be connected to you to assist with pain control and to help decrease swelling .

Sneak Peak at Tomorrow • Blood draw for lab work at a very early hour . That’s why cat naps are so important . • Physical therapy begins, usually once in the morning and once in the afternoon . • Up in the chair three times .




Care Guidelines - Day One

Today’s Itinerary• Your vital signs will be checked every four hours .

• IV fluids continued if needed .

• IV antibiotics discontinued .

• If you no longer require oxygen, it will be discontinued .

• Continue to cough and deep breathe every hour, and use your incentive spirometer as directed .

• The pulses in your wrists and feet will be checked .

• Do ankle pumps every one to two hours while awake .

• Up in chair three times .

• Rest between activity and limit visitors .

• Reposition in bed and sit up in chair to prevent damage to skin .

• If a bladder catheter is in place, it will be discontinued today .

• Write down questions for your physician, nurse and therapist in the back of your binder, as you think of them .

• Shoulder precautions as ordered .

• Occupational therapy and physicial therapy will see you today as scheduled .

Fashion Statement• It’s time to get out your own clothes and say goodbye to the patient gown!

• Your therapist will help with any challenges while getting bathed and dressed .

Training Table for Rehabilitation• Your appetite may be less than normal for the first couple of weeks .

• Your diet will be advanced when you are able to pass gas .

• Choose food high in iron, protein, fiber and calcium .

• Drink plenty of water .

• Limit fat and sweets .

Today’s Goals ❑ Pain controlled ❑ Walking

❑ No blood clots ❑ Up in chair two to three times

❑ No pneumonia ❑ Initial plan for discharge

❑ Exercise ❑ Maintain shoulder precautions




Care Guidelines - Day One

Let’s Get Moving!Your therapist will talk to you about shoulder precautions (what to do to prevent dislocation) and what exercises are OK to perform .

You will get out of bed in the morning with assistance from therapy associates . You will learn about getting in and out of bed and transferring to a chair . You will begin your exercise program .

Therapy associates will return in the afternoon . Perhaps you will go to the gym to continue your exercises .

Keeping Ahead of the PainNursing associates will ask you to rate your pain from 0 (none) to 10 (worst imaginable) . Let your nurse or therapist know when your pain is starting to increase .

Try additional means to reduce your pain: music, massage, repositioning, reading, television, meditation, prayer, etc .

You will be able to take part in therapy most effectively when your pain is controlled . With medication and other pain relieving measures (repositioning, etc .), the goal is for you to have a pain level of four or less . Pain medication is more effective when pain levels are maintained at lower levels .

Associates from our Care Management department will visit you to plan for your discharge and identify any equipment you will need .

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Sometimes what you’ve lost needs to be replaced! Some blood loss is expected with surgery. We check your blood count daily to determine if you need a blood transfusion. If you do, you may notice how much better you feel when your blood count increases after the transfusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

We Say “NO” to Blood Clots!In the hospital and after discharge, you will continue to wear the TED hose to aid circulation . SCDs will be worn in the hospital .

Continue to do your ankle pumps every one to two hours and participate in your exercises . The more active you are means less risk of getting a blood clot .




Care Guidelines - Day Two

Today’s Itinerary• Your vital signs will be checked every eight hours and as needed .

• The pulses in your wrists will be checked .

• You will continue to cough and deep breathe, and use your incentive spirometer .

• Alternate rest and activity .

• Up in chair three times daily .

• Shoulder immobilizer sling at all times except for bathing .

• Reposition frequently in bed or chair .

• TED hose on (off for 30 minutes in the morning and evening for bathing and skin inspection) .

• The surgeon will change your surgical dressing today .

• SCDs will be discontinued today .

It’s Time to Get to the Gym• You will go to the Inpatient Therapy room .

• You will continue to work on the exercises you did yesterday and add some new exercises .

Back in Your Room• You will continue to do your ankle pumps every one to two hours .

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Pain, Pain Go Away!While the pain will probably not disappear completely, your pain medication taken by mouth should keep it at a level of four or less. Communicate pain concerns with your nurse or therapist.

Try some additional means of reducing pain. If you tried something yesterday and it didn’t help, try it again today or try something different.

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Care Guidelines - Day Two

Today’s Goals ❑ Pain controlled ❑ Up in chair three times

❑ No pneumonia ❑ Continue all exercises

❑ Walk safely ❑ Discharge plan completed

❑ No blood clots

There’s No Place Like Home• Your return home is an important part of getting the best results from your surgery . Day by day at home, you

will return to your usual routines and increase activity naturally . While in the hospital, your provider, nurses and therapists observe your progress and look for signs that you will be safe at home . Occasionally, a patient may need an additional day in the hospital or perhaps some time in another facility before returning home . Our Care Management associates will assist in your transition home or to another facility .

• If you need additional instruction on assistive devices, a therapist will work with you .

• You may want to send some of your things home with family or friends to make your discharge day easier to organize .

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All Systems Go?If you don’t have a bowel movement (BM) today, let your nurse know. Remember to eat foods high in fiber and drink plenty of liquids, especially water. Walking and exercise also helps a lot!

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How Does My Incision Look? The edges of your incision have started to come together but some drainage may still be present, especially with activity . Redness, swelling and tenderness should be starting to decrease .

To promote healing and rehabilitation, choose foods high in iron, protein, fiber and calcium . Avoid foods high in fat and sugar . Do not smoke . Smoking interferes with the healing process .




Preparing for Discharge

Day of Discharge• Today may be the day you are discharged home or to another facility .

• Your intravenous catheter will be discontinued today .

• Continue your activities of the previous days unless discontinued by your provider (ankle pumps, coughing and deep breathing .)

• You will continue all of your exercises and outpatient therapy .

• If your home has certain features, such as stairways, steps or lack of handrails, your therapist will provide instruction on staying safe .

Today’s Goals ❑ Pain controlled

❑ Labs within your normal limits

❑ No blood clots

❑ No pneumonia

❑ Walk safely and independently

❑ Able to dress and perform personal activities safely and independently while maintaining shoulder precautions

❑ Maintain shoulder precautions

❑ Questions answered

❑ Discharge instructions understood

To-Do List for Discharge• Pack up belongings .

• Take purchased assistive devices with you .

• Check the closet, bathroom and drawers for personal items .

• Go over your provider’s written discharge instructions with your nurse, including prescriptions and appointments .

• Put all important discharge papers in the binder so you will have them when you arrive home .

• Let your nurse know when you are ready and a member of the nursing staff will assist you to your car when all discharge paperwork is complete .

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Thank you for letting us serve you! We wish you continued success with improved mobility. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .




Reverse Total Shoulder Restrictions

Dislocation is the biggest risk with this type of approach. To prevent dislocation, follow these restrictions:

• No reaching behind back or hip for 12 weeks .

• Immobilizer sling at all times except for therapy exercises for six weeks .

• Sling must be worn at all times except when showering and dressing .

• Underarm care - lean forward while arm remains in sling .

• Elbow and wrist exercises - squeeze ball, rotate wrist, and straighten elbow, flexion/extension without moving shoulder joint .

• Polar care ice unit as indicated .

• Don’t push yourself up from bed or chair with affected extremity .

• No shoulder motion unless directed by surgeon or therapist for the first six weeks .

• No lifting greater than one pound for the first six weeks after surgery with surgical arm .

• Strength will be limited and pain improved, but much less motion in new shoulder joint . - Goal of right shoulder arthroplasty is pain relief and improve quality of life - Expect four to six months of therapy

• Once deemed fully recovered by surgeon, you may gradually increase weight lifting from one to two pounds after six weeks to 15 pounds maximum as tolerated .

• No heavy lifting .

• After approximately three months you may increase external rotation as tolerated when directed by surgeon .




Total Shoulder Restrictions

Dislocation is the biggest risk with this type of approach. To prevent dislocation, follow these restrictions:

• Immobilizer sling worn for six weeks .

• Sling may be removed for elbow flexion and extension, underarm care and wrist exercises .

• Avoid external rotation of arm (Codman’s Pendulum exercises are OK with sling off) .

• Polar care ice unit as indicated .

• Don’t push yourself from bed or chair with affected extremity .

• No lifting more than one pound for six weeks (glass of water) with surgical arm .

• Once deemed fully recovered by surgeon, you may return to previous activities, including: golf, fishing, light exercise, aerobics, swimming and normal household activity .

• After six weeks, gradually increase lifting restriction to 25 pounds when OK with surgeon .

• No heavy lifting .

• No throwing a ball .

• Expect four to six months of therapy .




Exercises

Pendulum Circular

Pendulum Side-to-Side

Bend forward 90 degrees at waist using table for support . Rock body in a circular pattern to move arm clockwise _______ times then counterclockwise _______ times .

Do _______ sessions per day .

Bend forward 90 degrees at waist using table for support . Rock body from side to side and let arm swing freely .

Repeat ________ times .Do ________ sessions per day .




Exercises

Pendulum Forward/Back

Bend forward 90 degrees at waist, leaning on table for support . Rock body forward and back to swing arm .

Repeat ________ times .Do ________ sessions per day .




The associates at the Agnesian Center for Bone & Joint Health are concerned about managing your pain after surgery . Pain that is poorly controlled can interfere with sleep, appetite, activity, relationships and your emotional outlook .

Pain is to be expected following joint replacement surgery, but by working with your nurses, therapists and providers we should be able to control the pain enough for you to actively participate in your recovery . Do not let your pain get out of control because as pain becomes more severe it is harder to treat . Ask for assistance from your nurse if you feel your pain level is increasing .

Ways for You to Help Us Manage Your Pain• You can give us a rating on a 0 to 10 pain scale . A rating of 10 reflects the worst pain you could ever

imagine, a rating of 5 means you feel a moderate amount of pain and a 0 rating reflects no pain .

• Your therapists and nurses will ask you to rate your pain after activity, therapy and at rest .

• When you are able, describe what type of pain you are having such as throbbing, shooting, aching, burning or pressure . This will assist the medical staff and getting you the right type of pain control .

Things to Keep in Mind• It is easier to treat pain when it is mild or moderate rather than waiting until it is severe . Take your pain

medications on a regular schedule to prevent severe pain .

• It is nearly impossible to eliminate all pain during the first few days after your surgery . However, your medical team will work with you to control your pain at a level that allows you to rest and participate in your recovery, including your therapies .

• Pain will gradually diminish or decrease in the days after your surgery . You should expect to have good days and bad days with regards to your pain and your ability to perform activities .

• Studies have shown that when pain medications are used appropriately to treat surgical pain, addiction to the medication occurs in only a small number of patients . Please let us know if you have a history of addiction or intolerance to pain medications .

Pain Management

No Mild Moderate Severe Pain Pain Pain Pain

0 1 2 3 4 5 6 7 8 9 10




Pain Scale and FacesAgnesian HealthCare professionals will be able to give you more specific information on how to use these scales and identify an achievable goal for your pain control .

Medications Used to Treat PainThere are many forms and types of medications used to treat pain . You may be on a combination of pain medications with some taken orally (by mouth) or through your intravenous (IV) line . Because medications can work in different ways, taking more than one medication for pain can sometimes provide greater relief while minimizing side effects .

Some of the common side effects from the pain medication include: nausea, sedation, confusion, constipation and itching . Most of these side effects will improve after taking the medication for a period of time . To prevent side effects, take pain medication with food. Constipation may be experienced during the time you are taking the medication, but it can be prevented and/or treated after discussion with your healthcare professional . If you experience any of these side effects or any others, tell your healthcare professional right away .

Additional Options for Treating Pain• Repositioning

• Cold application

• Relaxation/medication/imagery

• Physical/occupational therapy

• Massage therapy

Pain Management




327 Winnebago Drive, Fond du Lac, WI 54935 (920) 926-5277 • (800) 732-1313 Store Hours: weekdays from 8 a.m. to 6 p.m. www.agnesian.com (click on the Agnesian Health Shoppe)

Durable Medical Equipment Our durable medical equipment (DME) specialist, customer service representative or delivery technician personally teaches every patient how to use their equipment . We provide and maintain only the most modern, attractive, quality equipment . Each item is carefully inspected and regularly serviced . We provide personal, one-on-one service for each individual’s needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

We deliver and install equipment! . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Durable Medical Equipment Following Hip SurgeryWheelchairs, walkers, crutches Lift chairs

Raised toilet seat or commode chair Long-handled reacher, shoehorn

CPM machines for the knee Sock aids

Handheld shower hose Chair/foam cushions

Grab bars Other aids for daily living

Wheelchair cushions Other bathroom safety products

Compression stockings Specialty mattresses

Wound dressings

Shower chair (shower) or tub transfer bench (bathtub)

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We will gladly help with special orders too. Call us today! . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Durable Medical Equipment




When to Consider Home Care • Recurrent hospitalizations • Medication monitoring (new and current) • Home oxygen needs • Conditions of: CHF, COPD, diabetes, post CVA, cancer and other chronic illnesses• Post-surgical care (orthopedics, cardiac) • Pain management/education • Safety concerns • Ostomies, tube feedings, catheter care • Need for adaptive equipment/rehabilitation needs • Symptom management/palliative care management

Services Provided • Special medical treatments (Lovenox B-12 injections) • Wound care with certified wound/ostomy/continence nurse (wound vac therapy)• Home infusion services (IV therapy/line cares) • Telehealth monitoring• Physical therapy, occupational therapy, speech therapy, home health aides, medical social worker• Medication box fills/medication management • Pediatric clinical nurse specialist • Chemotherapy • Palliative care• Diabetic management

Coverage • Accept Medicare/Medicaid assignment • Insurance • Self-pay • Community Care

Hours of Service Regular office hours are 7:30 a .m . to 4:30 p .m . weekdays . Office phone number: (920) 923-7950After 4:30 p .m . an Agnesian HealthCare operator will page the on-call nurse . Nurse available 24 hours a day, seven days a week

Agnesian HealthCare Home Care




EquipmentIntravenous (IV) CatheterThis catheter allows for fluids and medications to be delivered through your bloodstream .

Endotracheal Tube This tube may be placed in your trachea (windpipe) by anesthesiology to keep your airway open during surgery .

Foley Catheter This tube is used to eliminate urine from the bladder . It is used both during surgery and for a short time after surgery .

Hemovac Drain This drain collects blood and body fluid and is placed near your operative site .

Incentive Spirometer This breathing exercise device is designed to help you improve your ability to expand your lungs after surgery .

Continual Passive Motion (CPM) Machine This machine may be available for use to exercise your knee while increasing blood circulation, decreasing swelling and increasing range of motion .

Sequential Compression Device (SCD) These are inflatable plastic sleeves that are wrapped around your leg and may be used to improve blood flow in your legs .

TEDs These are elastic stockings that help prevent blood clots from forming in your legs .

Pulse Oximeter This clip is attached to one of your fingers to monitor the percentage of oxygen carrying blood in your body .

Epidural Catheter This catheter will be placed in your lower back for pain relief .

Femered Nerve Catheter This catheter is placed by an anesthesiologist in your groin pre-operatively to deliver continuous pain medication .

Patient Controlled Analgesic Pump (PCA Pump)This is a pump that allows the patient to give themselves pain medication by pressing a button . The pump delivers a specific amount of pain medication as ordered by your physician .

Common Terminology




PeoplePhysical Therapy (PT)Physical therapy associates will assist you in regaining mobility and function following your surgery .

Occupational Therapy (OT)Occupational therapy associates will assist you in regaining independence with your activities of daily living (ADLs) . Activities of daily living include: dressing, bathing, homemaking tasks and training in the use of adaptive equipment .

Social Workers/Case ManagersSocial workers/case managers will assist you and your family with discharge planning such as arranging home care and necessary equipment . They ensure quality, efficiency and most importantly your satisfaction during your hospital stay .

MiscellaneousInternational Normalized Ratio (INR) This ratio is taken through a blood test to determine the appropriate dose of warfarin to prevent complications .

Deep Vein Thrombosis (DVT) Deep vein thrombosis is a blood clot in your leg .

Pulmonary Embolism (PE)Pulmonary embolism is a blood clot that forms in your lungs .

Common Terminology




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Questions


Health & Medicine

A Patient's Guide to Shoulder Surgery: St. Agnes Hospital