Hip Replacement Guidebook

About our physicians…

HRRMC Orthopedic Sports Medicine CENTER Robert Hunter, M.D., is director of the Orthopedic Sports Medicine Center and the Orthopedic Center of Excellence at Heart of the Rockies Regional Medical Center. He came to Salida in 2009 from the University of Arizona in Tucson, where he served as director of sports medicine for the Department of Orthopaedic Surgery and director of the Arizona Institute for Sports Medicine. Prior to his time in Tucson, Dr. Hunter spent 14 years with an orthopedic group in Aspen. He is the founding director of the Aspen Foundation for Sports Medicine, Education and Research Fellowship Program. Dr. Hunter has published more than 40 articles in refereed journals on sports medicine topics and is coauthor of the medical textbook, “AANA Advanced Arthroscopy: The Knee.”

Orthopedic

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Dr. Hunter specializes in the management of athletic injuries and the treatment of knee and shoulder injuries, including: • Total (and reverse) shoulder replacement • Complex rotator cuff repair • Arthroscopic and open repair of torn ligaments • ACL reconstruction He sees patients at the HRRMC Medical Clinics, 550 West Highway 50, Salida. Office: (719) 530-2000. • Board Certification: American Board of Orthopaedic Surgery • Medical Degree: University of Minnesota School of Medicine, Minneapolis • Residency: Orthopaedic Surgery, University of Minnesota, Minneapolis • Fellowship: Independent Sports Medicine Traveling Fellowship with four orthopedic surgeons

HRRMC Orthopedic Joint Replacement Center E. Andrew Jonassen, M.D., is director of the HRRMC Orthopedic Joint Replacement Center. His practice complements Dr. Robert Hunter’s sports medicine practice in the HRRMC Orthopedic Center of Excellence. Before joining HRRMC’s medical staff in 2012, Dr. Jonassen practiced in metro Denver for more than 20 years. He was medical director of orthopedic trauma at The Medical Center of Aurora, a Level II Trauma Center, and also affiliated with Rose Medical Center, Sky Ridge Medical Center and Swedish Medical Center. Dr. Jonassen specializes in joint replacement and trauma surgery including: • Anterior minimally invasive hip replacement surgery • Total knee replacement • Complex fractures • Limb reconstruction He sees patients at the HRRMC Medical Clinics, 550 West Highway 50, Salida. Office: (719) 530-2000. • Board certification: American Board of Orthopaedic Surgery • Medical Degree: University of Calgary, Calgary, Alberta, Canada • Residency: University of Calgary, Calgary, Alberta, Canada • Fellowship: Adult Reconstruction/Arthritis, University of Colorado Health Sciences Center, Denver Orthopaedic Traumatology, University of Washington, Seattle

Welcome Heart of the Rockies Regional Medical Center (HRRMC) has developed this guidebook to assist you in preparing for your hip replacement (arthroplasty). This book will provide you with valuable information and will serve as an information resource before, during and following your hospitalization. Please read this book prior to finalizing your decision to have surgery. Once your surgery has been scheduled, you will need to bring this book with you when you meet with the preoperative care nurse and physical and occupational therapists, and when you are admitted for your surgery.

HRRMC Orthopedic Center of Excellence Mission Statement The Orthopedic Center of Excellence is a program dedicated to a multidisciplinary approach to clinical problem solving, education and research. The Center seeks to build a collaborative relationship between orthopedic surgery, primary care, physical therapy, athletic training and Heart of the Rockies Regional Medical Center, with the capacity to become a regionally recognized center ensuring that our patients and their families experience comprehensive quality care from preadmission through rehabilitation.

Vision Provide state‐of‐the‐art, comprehensive, evidence‐based and cost‐effective care for all musculoskeletal disorders. Ensure prompt care and treatment by responsive and compassionate healthcare providers thereby achieving the best outcome for every patient.

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Welcome HRRMC Orthopedic Center of Excellence (719) 530-2042 (719) 530-2454 (after hours and weekends)

Heart of the Rockies Regional Medical Center 1000 Rush Drive P.O. Box 429 Salida, CO 81201

HRRMC Medical Clinics 550 West Highway 50 Salida, CO 81201

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Table of Contents Your Hip Replacement Team ..................................... 4 Anatomy and Pathology of the Hip ......................... 6 Hip Replacement Surgical Techniques..................... 8 Hip Replacement Components ................................. 9 Risk Factors and Possible Complications .............. 11 Consents ...................................................................... 17 Financial Information................................................ 19 Pre-Hospital Assessment.......................................... 20 Day of Surgery ............................................................ 23 Case Management/Discharge Planning ................ 26 Post-Surgery Care ...................................................... 30 Physical and Occupational Therapy ....................... 42 Managing at Home After Surgery .......................... 59 Your Roadmap to Surgery: Patient Checklist ....... 61 Forms to Complete .................................................... 62

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Your Hip Replacement Team Undertaking a successful hip replacement is a complex process requiring the hard work of many highly skilled healthcare providers and other team members. HRRMC is dedicated to providing you with the services and support needed to help your surgery be a success; however the person who must work the hardest to obtain the optimal result is YOU, the patient. Listed below are the members of Heart of the Rockies Regional Medical Center’s hip arthroplasty team. With your help, they will work together to return you to an active, independent and rewarding lifestyle. Heart of the Rockies Regional Medical Center (HRRMC) has designed its orthopedic program around a “team approach” to help you through your surgery and recovery. The team consists of your surgeon, primary care physician, nurses, therapists, case managers, discharge planners, technicians and patient financial services representatives who work together with you to make your surgery and recovery as successful as possible. At the center of the team is the patient. Your commitment and cooperation are vital to a rapid and successful recovery. Orthopedic Surgeon: Your orthopedic surgeon and his staff are extremely well-trained in the surgical techniques involved in hip replacement. They will see you in the preoperative period, in the surgical suite, postoperatively in the hospital, and after discharge in their office. They can thoroughly describe the surgical procedure and what your expectations may be at any point in this process. Physician Assistant (PA) / RN-First Assist (RNFA) / Nurse Practitioner (NP): These individuals may assist the surgeon in the operating room and may assist with the care of patients in the hospital after surgery or in clinics. Anesthesia Provider: The healthcare provider who will provide anesthesia and loss-of-pain sensation during and immediately after surgery. He or she will discuss your anesthesia options with you including: general anesthesia, spinal anesthesia, regional nerve blocks and other techniques as may be appropriate for you. Your anesthesia provider will monitor your condition during the operation. Internists and Local Primary Care Physicians: Every hip replacement patient is required to have a preoperative evaluation by a primary care physician. This physician is specifically trained to make the general preoperative assessment that you are medically fit for this surgery and to follow your medical progress after surgery. If your primary care physician is not on HRRMC’s medical staff, a HRRMC hospitalist will closely communicate with your doctor so that your care can be effectively managed while you are here. Preoperative Care Nurse (POC): The liaison for the orthopedic program between the ancillary departments, surgery and the patient. This nurse will coordinate your preoperative visits and diagnostic tests with the primary care physician, case management and physical therapy.

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Your Hip Replacement Team Occupational Therapist (OT): The OT will assist you with your self‐care needs and adaptive equipment as needed during your hospital stay, as well as making sure your home is safe upon your discharge from the hospital. Case Manager/Discharge Planner: These individuals will help guide you through the process of your hip replacement from start to finish, and will be an important resource to answer questions and help coordinate your discharge needs and care. Dietitian: A HRRMC dietitian will review dietary restrictions or special diets your condition may warrant. Home Health Services: Your doctor may order home health for a period of time after surgery to prepare you for outpatient rehabilitation therapy. Physical Therapist (PT): This individual is critical to your progress in movement and strength and ultimately the success of your hip replacement. You will spend many, many hours with your therapist postoperatively in a classic love/hate relationship…follow his or her instructions carefully. Nursing Staff: The nursing team has been specifically trained to care for patients having joint replacement surgery and will assist you in meeting your goals. Patient Financial Services: This team consists of registration and billing personnel, as well as account representatives. They will ensure that your personal and insurance information is correctly recorded and process all claims information necessary to secure payment for your healthcare services from your insurance carrier. Planning, loan processing and counseling services are also provided to assist you in resolving financial obligations not covered by insurance. Every member of this team exists to take care of you from a financial perspective. Patient: You, the patient, are vital to the team. By preparing yourself prior to surgery and understanding the course of events during and after your hospitalization, you will be contributing in a positive way to a successful outcome. Please read this entire book in advance of your surgery. Bring it to your pre‐surgery physical therapy evaluation and to the hospital on the day of your surgery. Use the page at the end of this book to write down any questions you have. Your hospital team will work together to be sure your questions are answered. It cannot be emphasized enough that the success of your surgery depends significantly on your hard work! These team members will help you achieve your goals. The rest of this guide and resource book will go into important details about this process.

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Anatomy and Pathology of the Hip Normal Hip Structure A joint is the junction where two or more bones meet. The hip joint is a ball and socket joint that is formed by the ball‐shaped end of the thighbone (femur) and the cup-shaped socket of the pelvis (acetabulum). This structure allows the leg to move forward, backward, sideways and in a rotating fashion. These bones are covered with cartilage which provides a smooth, cushioning surface that decreases friction during motion. The joint is surrounded by a capsule which maintains the lubricating fluid. Ligaments connect the head of the thighbone to the socket, with muscles and tendons providing additional support and elasticity.

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Anatomy and Pathology of the Hip Problem Hip The smooth surface of the bones, known as the articular cartilage, can be worn away, allowing the bones to rub together. This results in an irregular joint with rough surfaces that cause pain and swelling. When there is significant wear of the joint and uneven loss of the supporting bone, the hip joint becomes painful and loses range of motion. Destruction of articular cartilage can occur as a result of: 1. Aging or wear and tear (osteoarthritis) 2. Inflamed or thickened synovium (rheumatoid arthritis) 3. Loss of blood supply (osteonecrosis) 4. Injury (traumatic arthritis) When the destruction is advanced and rest, medication, heat or cold, and other therapies fail to relieve the pain, surgery may be indicated.

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Hip Replacement Surgical Techniques Standard Hip Replacement Surgery to allow removal of the arthritic hip joint and insert joint-replacement components may be by an anterior (from the front) or posterior (from the backside) approach. In the posterior approach to total hip replacement, the surgeon accesses the hip joint through an incision close to the buttocks. This approach goes behind the major walking muscles (abductors) and does not disrupt them. The anterior approach is a more recent approach to total hip replacement and is rapidly growing in use because of its definite advantages for patients. Rehabilitation is simplified and accelerated, dislocation risk is reduced, leg length is more accurately controlled and the incision is small.

Minimally Invasive Hip Replacement (MIS-THA) This is a newer technique for doing hip replacements. It limits and minimizes injury to the soft tissues during the operation. The bony procedure and implants used are generally the same as the standard hip replacement. Using this technique though, patients have less pain, spend less time in the hospital, and recover faster. In general, most patients (75 - 80%) go home the day after surgery, but your length of stay depends on many individual factors such as pre-existing medical conditions and pain management. Most patients are off of narcotic pain medicines around 2 weeks after surgery. The risk of dislocation is about 0.3%. Not all patients are candidates for this procedure, and not all surgeons are trained in this technique. Obese patients, patients who have had previous hip surgery, or patients with unusual bony anatomy generally are not candidates for minimally invasive hip replacement (MIS-THA).

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Hip Replacement Components Total Hip Replacement Your total hip replacement involves replacing your joint with metal and/or plastic and/or ceramic components. There are three basic parts to the replacement joint: 1. The acetabular cup is metal. It may be a one‐piece cup, or it may have a liner made out of plastic, metal or ceramic. Sometimes screws can be placed through the metal cup to help stabilize the cup while your bone grows to it.

2. The femoral head (ball) snaps onto the stem and rotates just like a natural hip in the hip socket. It may be made out of metal or ceramic. In some cases, the head may be a combination of a metal or ceramic head inside of a plastic head.

3. The femoral stem is a metal shaft that is inserted into your thighbone.

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Hip Replacement Components The cup and stem are usually designed with a roughened surface to have your own bone grow and adhere to the implant. In special cases, sometimes the components are cemented to the bone. All parts of your replacement joint are extremely strong and made of special, long‐lasting materials that work efficiently and are well tolerated inside your body. The type of replacement joint and how it is inserted into your hip will be selected by your surgeon based on your age, bone density, medications and anatomy.

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Risk Factors and Possible Complications Controlling Risk Factors With any major surgery there are certain risks. It is important that you understand the risks involved in having a hip replacement, as well as what can be done to minimize those risks and prevent the incidence of post-surgical complications. Conditions that may increase your risk of having a postoperative complication include:

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Obesity Heart and lung disease Smoking Diabetes Tooth disease Open wounds Any sign of infection such as a recent cold, flu or sore throat

By having potential problems identified before surgery, you can work with the healthcare team to prevent post-surgical complications. Prior to your admission for surgery, you will be examined by a primary care physician and have routine laboratory tests, either at your physician’s office or at HRRMC. After reviewing the results of your tests, physical exam and medical history, the physician will be able to identify any particular health-risk factors that you may have. If high risks are identified, your doctor may recommend additional tests or may discuss with you the need to delay surgery until these risks can be brought under reasonable control. Even now, before you have your preadmission testing, there are things that you can begin doing to reduce the risk of postoperative complications.

Nutrition Both poor nutrition and obesity can increase your risk for infection and/or delay wound healing. While excessive weight can make your recovery period more difficult, a crash diet is not the answer. If you are obese and would seriously like to lose weight before or after surgery, we recommend that you join a physician-supervised weight-loss program. As you lose weight, you may see some improvement in your hip function and a decrease in hip pain. When your weight is under control and you are preparing for hip replacement surgery, it is important that your diet be nutritionally sound.

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Risk Factors and Possible Complications Herbal Supplements that can pose risk in surgery Like prescription drugs, herbal supplements also carry a risk of side effects and drug interactions. Please inform your surgeon and anesthesia provider about all supplements you are taking. The following list of supplements should be stopped two (2) weeks prior to surgery due to possible side effects and drug interactions: • Echinacea • Ephedra • Feverfew

• Fish Oil • Garlic • Ginko

• Ginger • Ginseng • Kava

• St. John’s Wort • Valerian

Infection Bacteria travel through the bloodstream and are attracted to an artificial prosthesis. Therefore, an infection anywhere in the body can present a problem to a patient with a joint replacement. It is important that you are free of infection before you have your hip replaced, and that you obtain immediate treatment for any infection that may occur after your hip replacement surgery – and for the rest of your life. The most common sources of bacteria in the body are the teeth and the genitourinary tract. Any problems should be corrected before preadmission testing. If you have not had a dental check‐up within the last 6 months, you should do so now. If you have any problems with urinating – frequency, burning or difficulty passing urine – you should see your urologist or family doctor. Let your surgeon know if you have a cold, sores, cuts or inflamed areas anywhere on your body. Making sure that you are free of infection may avoid having to delay your surgery. In order to have your skin as clean as possible to help prevent infections, you will be instructed to bathe with a special soap or use a special antiseptic cloth wipe after your bath/shower for two (2) evenings prior to your surgery. The soap or wipes and detailed instructions for use will be provided to you at the time your procedure is scheduled. You should change your bed sheets when you begin your skin preparations. Clean towels, washcloths, and sleepwear should be used at the beginning of this process. Your spouse/significant other is also encouraged to wear clean nightwear. Your pets should not sleep with you while you are undergoing this skin preparation. Do not shave your legs during the three (3) days prior to surgery (skin nicks are a potential source of infection).

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CHG: Bathing with Chlorhexidine Gluconate Wipes What are CHG wipes? Chlorhexidine gluconate (CHG) wipes are antiseptic (germ-killing) cloths used to wash the skin. The living skin is a constant source of germs. CHG kills 99% of the germs on the skin to help to prevent germs from getting into an open wound or your bloodstream and causing serious infection. If you have had a sensitivity to any products containing CHG (Hibiclens) in the past, please contact your surgeon for new instructions. When should you NOT use these Chlorhexidine (Hibiclens) wipes? Do not use on children under two months of age. Do not use these wipes if you: • Have an allergy to chlorhexidine (CHG, Hibiclens) • Currently have severe skin breakdown, rash or burns • Are receiving radiation therapy • Are receiving Thiotepa (chemotherapy drug)

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1. Wash your hands with warm soapy water or use hand sanitizer. 2. Wipe the cloths using a circular or back and forth motion over the surface to be cleaned. Wipe each area thoroughly but do not scrub. Do not use the cloths on your face, head or neck. 3. Use three packages (6 cloths) of CHG prep wipes: Cloth 1) Wipe your chest and abdomen. Cloth 2) Wipe both arms, starting with the shoulder and ending at fingertips. Then thoroughly wipe the armpit areas. Cloth 3) Wipe both legs, starting at the thigh and ending at the toes. Be sure to thoroughly wipe behind your knees. Cloth 4) Wipe your back starting at the base of your neck to your waistline. Help may be required. Cloth 5) Wipe your right and left hip followed by your groin. Be sure to wipe folds in the groin area, avoiding privates. Cloth 6) Wipe the buttocks. Wash hands or use hand sanitizer. 4. Do not rinse or wipe off the skin after using the CHG wipes. Do not apply lotions, moisturizers or makeup. Let the skin air dry. Skin may feel sticky for a short time as it dries. Put on clean clothing. Do not put the clothing back on you were wearing before you used the CHG wipes.

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Home use before surgery: Take an evening bath or shower and wait at least one hour, until skin is dry and cool, before using the CHG cloths. Cool and dry skin is less likely to get irritated from the chemicals. Do not shave your legs or your underarms before or after using this product. If you do experience redness or itching, rinse the area with cool water. Dress in clean sleepwear. Do not shower or bathe on the morning of surgery.

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Risk Factors and Possible Complications Smoking If you are a smoker, you should join a program to STOP SMOKING NOW. Smoking increases your chances of lung complications, can delay wound healing, and interferes with bone healing. A helpline you can contact is 1-800-QUITNOW (1-800-784-8669). Allergies If you have any type of metal allergy, especially nickel, let your surgeon know. A different type of hip prosthesis may need to be used. Exercise will be described in detail in the Physical and Occupational Therapy section.

Possible Complications of Surgery Complications that can occur following hip replacement include: Blood Clots Research has shown that blood clots in the leg can occur in as many as 50% of people having a hip replacement if preventive measures are not taken. Using preventive measures, the risk of a blood clot is 3 - 5%. Most of these clots do not cause symptoms and do not present any problems to the patient. Blood clots that occur high in the leg above the knee can break loose and move to the lungs (pulmonary embolism) resulting in breathing problems, but these are rare. In very rare instances, a pulmonary embolus can be fatal (risk is 1 in 10,000). To prevent these clots from occurring, we will

a. Get you out of bed and walking as soon as possible.

b. Give you medication after surgery to prevent abnormal clotting. The medication may be an injection (Lovenox) or tablet (Xarelto or Coumadin). With Coumadin, a daily blood test may be required to monitor the effect of the medication. You may be required to continue these medications when you go home. It is very important for you to follow your medication instructions exactly. c. Apply an intermittent compression device to increase circulation in your legs until you are able to be up and walking.

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Risk Factors and Possible Complications Your part in preventing a blood clot includes: a. moving your ankles up and down when in bed. b. wearing the compression device as much as possible. c. walking as much as you can. d. limiting sitting – no longer than 45 minutes at a time without walking. e. being sure to take your anticoagulant. f. during the first three (3) months after surgery, if you do any long distance traveling, it is recommended that you 1. Take a regular aspirin (325 mg) each day. 2. Do some walking every hour and a half. If driving, stop the car and get out and walk. If on a plane/train, get up and walk the aisle. 3. While sitting, move your legs and ankles to keep the blood moving in your legs. Occasionally, bleeding into the hip joint from anticoagulation therapy can occur. Usually slowing physical therapy will allow for natural reabsorption of the bleeding. Very rarely, surgical evacuation is needed. Because blood clots are a well‐known problem following hip replacement surgery, we are constantly monitoring ways to prevent this complication.

Nerve Damage Patients with certain severe hip problems may be at risk for nerve damage due to stretching that occurs during correction of the deformity. In addition, postoperative swelling around the hip can cause increased pressure on the nerve, causing tingling, numbness or weakness in the foot. Members of your health team will: 1. Check the motion and sensation in your foot frequently after surgery. 2. Remind you to begin ankle‐pump exercises as soon as you can feel your legs again. It is important that you tell the nurse immediately: 1. If you are unable to do the ankle pumps. 2. If you feel any tingling, numbness or burning pain in your foot, as these may be signs of pressure on the nerve. The sooner we can relieve pressure on the nerve, the sooner it will function normally again. A nerve recovers very slowly, but with time usually returns to normal.

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Risk Factors and Possible Complications Infection Although it occurs in only 1-2% of patients (in diabetics, the risk is 3-5%), infection in a joint replacement is one of our greatest concerns. If it occurs within the first few weeks after surgery, frequently the wound can be washed out and the patient can be placed on antibiotics for six (6) weeks. In this scenario, there is an 80% chance of getting rid of the infection. If an artificial joint is chronically infected, it necessitates removal of the prosthesis, followed by at least six (6) weeks of intravenous antibiotics and then possible reinsertion of the prosthesis. This is called a 2-stage procedure for treating infection, and is 90% successful at getting rid of the infection. It does require though two big operations and several months of treatment. In addition to considerable expense, this can cause additional suffering, increase disability and prolong recovery. Your role is to safeguard yourself against infection and obtain immediate treatment if a problem does occur. In addition, you must be aware that certain routine procedures (e.g. dental cleaning, cystoscopy, proctoscopy) can stir up bacteria and present a risk to your hip. See the Post-Surgery Care section for more information on preventing infection.

Mechanical Problems Although rare, mechanical problems can occur. Some of these are:

• Loosening of the prosthesis – this could require revision surgery to correct the problem.

• Dislocation – usually due to excess motion outside the range of motion appropriate for your surgical repair. This may require a return to the operating room to surgically relocate the prosthesis. The risk ranges from 0.3% - 5%. • Fractures – can occur during or after the operation if bones are very brittle. A brace may be needed to stabilize the fracture, and revision surgery may be necessary. The risk is about 1%. • Poly Wear – the “plastic” can wear out, necessitating another surgery to replace the polyethylene component. • Stiffness – Sometimes soft tissue adhesions prevent you from freely bending your hip. Physical therapy can help prevent and correct any joint stiffness.

• Leg length difference can often be addressed with a simple shoe lift if bothersome.

Even taking these problems into account, the success rate for hip replacement is very high. The short‐term success rate is about 98‐99%. The long‐term success rate is 90‐95% at 10 years, and 80‐85% at 15 years.

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Consents It is important for you to understand the risks and benefits of your surgery, anesthesia and postoperative care, as well as what alternatives are available to you. Your surgeon will discuss the details of your surgery with you and address any issues or concerns with you prior to your hospitalization. Due to prior or current medical conditions, you might be at higher risk for complications with this surgery. We want to be sure that you have had every opportunity to have your questions answered. On the following page is the hospital consent form that you will be requested to sign. Please read this and make sure you understand it. You may call our pre-op care nurse with your questions or concerns regarding these forms. You may also direct questions to your surgeon or to other members of your healthcare team at any time prior to or during your stay.

Blood Transfusions After hip replacement surgery, you may require a blood transfusion. A consent is needed for blood transfusions. Today, there are several ways to replace blood lost during surgery. Your surgeon will decide which method is best for you. Some methods available are: Directed Donor/Autologous A donor that you specify, who has your blood type, may donate blood in your name for your use if needed. Or you can bank your own blood (autologous). Both options must be arranged in advance of the surgery. Either type of blood donation can be done in the following locations: Pueblo, Colorado Springs, Denver or Gunnison (on occasion). To arrange for a blood donation, contact Bonfils at 1-800-750-4483. Auto Transfusion (Blood Salvaging) Your own blood collected during and/or immediately after surgery from a drain in your hip is given back to you. (Confirm with your surgeon.) Homologous Blood (Banked Blood) This is blood donated by someone else, screened and matched with your own blood. If you are to receive auto transfusion or banked blood, no special preparation is required. The risk of needing a blood transfusion is less than 5%.

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Consents

Patient Label

Date: ________________________ Time: ________________________ Age: _________________________

PATIENT INFORMED CONSENT (Operation, Blood Usage and other Medical Services)

1. Operation or Procedure and Alternatives: I, ___________________________________________________________________________ (patient or patient’s guardian), authorize Dr. ____________________________________________ to perform the following operation or procedure: ___________________________ __________________________________________________________________________________________________________________. I understand the reason for the procedure is: ______________________________________________________________________ __________________________________________________________________________________________________________________. Alternatives include: ________________________________________________________________________________________________. 2. Risks: This authorization is given with the understanding that any operation or procedure involves some risks and hazards. The more common risks include: infection, bleeding, nerve injury, blood clots, heart attack, allergic reactions, and pneumonia. These risks can be serious and possibly fatal. Some significant and substantial risks of this particular operation include: _______________________________ ___________________________________________________________________________________________________________________ 3. NA Anesthesia: This procedure may require the use of medications for anesthesia and/or analgesia should my physician deem necessary. There are risks associated with using these medications including, but not limited to, allergic reactions to the medications; pneumonia; itching; reaction(s) requiring assistance for breathing; and very rare complications resulting in death. By signing this consent, I affirm that I have had an opportunity to ask questions regarding the use of these medications, agree to their administration by my physician or other qualified provider, and to the treatment of any complication(s) associated with their use. 4. NA Blood Transfusions: It has been explained to me that I need or may need a blood transfusion. I understand that there are risks associated with transfusion of blood or blood products. If blood products are transfused, A SERIOUS REACTION IS POSSIBLE, but very unlikely since blood is carefully matched prior to transfusion. Infectious diseases known to be transmittable by blood include HEPATITIS and HUMAN IMMUNODEFICIENCY VIRUS (HIV) infection, a viral infection known to cause ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS). The risk of acquiring infectious disease from transfused blood is extremely low and the blood units are tested to avoid Hepatitis and HIV, however, these laboratory tests are not foolproof. The chance I will require a transfusion with this procedure is:  Not likely, but possible  Likely (probable) Alternatives to blood transfusion in the case of an elective transfusion include pre-donation of my own blood (autologous blood donation). I understand that receiving my own blood also includes risks. I understand that autologous blood can require up to ten (10) days to process.  I have donated my own blood, and the likelihood of this being used in this procedure is:  Not likely, but possible  Likely (probable) Please initial next to one of the following: ____ I consent to a blood transfusion if my physician determines it is needed. ____ I consent to a blood transfusion using my own blood, only. ____ I consent to autologous platelet gel application. I have reviewed the procedure information sheet provided. ____ I DO NOT consent to a blood transfusion. 5. NA Additional Procedures: If my physician discovers a different, unsuspected condition at the time of the procedure, I authorize my physician to perform such treatment as he/she deems necessary. 6. NA Observers/Visitors: I authorize the presence of medical professionals, other than my physician, during the operative procedure. I understand my physician approves of and assumes responsibility for their presence during the operative procedure. 7.

I understand that no guarantee or assurance has been made as to the results of the procedure and that it may not cure the condition.

8. Patient’s Consent: I have read and fully understand this consent form, and understand that I should not sign this form if all items, including all my questions, have not been explained or answered to my satisfaction or if I do not understand any of the terms or words contained in this consent form. **********W A R N I N G!*********

IF YOU HAVE ANY QUESTIONS AS TO THE RISKS OR HAZARDS OF THE PROPOSED SURGERY OR TREATMENT, OR ANY QUESTIONS CONCERNING THE PROPOSED SURGERY OR TREATMENT, ASK YOUR SURGEON NOW BEFORE SIGNING THIS CONSENT FORM. DO NOT SIGN THIS CONSENT UNLESS YOU HAVE READ AND THOROUGHLY UNDERSTAND THIS FORM!

__________________________________________ Witness

______________________________________________ Patient or Person with Authority to Consent for Patient

9. PHYSICIAN DECLARATION: I have explained the contents of this document to the patient and have answered all the patient’s questions, and to the best of my knowledge, I feel the patient has been adequately informed and has consented. ______________________________________________ Physician’s Signature \Operative & Blood Consent Form 2010.doc

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Financial Information We understand that billing for healthcare services can be confusing. To assist you in understanding these systems and to answer any questions you have in advance, please review the following material. To reach HRRMC’s Patient Financial Services Department, call (719) 530-2475. The Patient Hospital Bill Prior to your services, you may contact Patient Financial Services for an estimate of charges. Because treatment plans may change during your stay, it is difficult to know your final total charges at the time of admission or discharge from the hospital. It is possible that charges may be added to your account after discharge. As a routine practice the hospital attempts to collect all known patient expenses prior to the delivery of services. This includes deductibles, copays and coinsurance amounts. Processing Your Bill If you have current insurance coverage, the hospital will bill your insurance carrier shortly after healthcare services have been rendered. While we will attempt to provide all information and paperwork to your insurance company, sometimes they require a response from you to resolve issues related to your account or insurance coverage. If your health plan has not made a payment within a reasonable period of time (usually 60 days after billing) and has not responded to our attempts to resolve payments on your behalf, the balance may become your responsibility. If you do not have insurance, a bill will be sent to you after discharge requesting payment of any remaining balance. If you are unable to pay the entire amount, or wish to make payment arrangements, please contact the Patient Financial Services Department at (719) 530-2475. Doctors’ Bills/Other Providers’ Bills HRRMC’s hospital bill for a hip replacement does not include fees for physician services. Because your treatment includes the services of a surgeon, anesthesia provider, and perhaps other physician specialists, you will receive a separate bill from these providers. If you have any questions regarding any of your care invoices, please call the telephone number printed on the invoices. Payment Options For your convenience, Heart of the Rockies Regional Medical Center accepts cash, personal checks, debit cards, money orders, Visa, MasterCard and Discover. Payment plans, loan processing and financial assistance may also be available.

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Pre-Hospital Assessment Our goal is to make this experience as smooth as possible for you and your family. You will likely have concerns and questions regarding your surgical procedure. At HRRMC, our professional staff provides pre-surgical and post-surgical counseling. Please let us know how we can assist you! STEP ONE: Preoperative history and physical by a primary care physician (PCP) or physician’s assistant (PA): You will be required to have a complete medical history and physical prior to your surgery. This will need to occur within 30 days before your surgery. If your primary care physician is a member of our HRRMC medical staff, you may make arrangements for him/her to do this for you. If your primary care physician is not on our medical staff, the pre-op care nurse or your surgeon’s office will assist you in obtaining the necessary information from your doctor’s office. STEP TWO: Registration This is the financial component of your procedure. It is important that you preregister for your surgery as soon as possible. Patient registration services are located just inside the hospital’s main entrance and to your left. Please be prepared to: • Answer registration questions • Provide a copy of your insurance card(s) • Finalize financial arrangements • Sign paperwork You may also preregister by calling the Patient Financial Services Department at (719) 530-2360, Monday through Friday, 8 a.m. - noon and 1 - 4:30 p.m. Please call as soon as you are scheduled for surgery. STEP THREE: Preoperative Assessment About one (1) week prior to surgery, a preoperative nurse from HRRMC’s Surgical Services Department will call you to conduct a preoperative assessment, which includes a review of your medical history. This assessment is necessary to help provide the highest quality of patient care for you. In addition to the pre-op interview with the pre-op care nurse, you will meet with the physical therapy and case management/discharge planning members of the joint replacement program. We will work together to ensure the best outcome for you during your stay at HRRMC and your follow-up treatment after discharge.

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orthopedic center of excellence

HIP REPLACEMENT GUIDEBOOK

Pre-Hospital Assessment STEP FOUR: Preoperative Testing If your primary care physician and/or surgeon has ordered lab work, an EKG, and/or radiology tests, you will need to complete these tests seven (7) days prior to surgery. Seven (7) days prior to surgery, a nasal swab should be performed to test for Methicillin-Resistant Staph Aureus (MRSA), bacteria (germs) that are found on the skin or in the nose and do not respond to normal antibiotic treatment. You will need to remove this bacteria by using a nasal antibiotic for five (5) days before surgery. You will also need to increase the showers with chlorhexidine to five (5) days prior to your surgery. If you are found to carry MRSA, you will be placed in “contact precautions.” This means that health care staff will be wearing gowns and gloves while caring for you. We do this to make sure we do not spread MRSA to another patient we are caring for.

NASAL MEDICATION TREATMENT PATIENT INSTRUCTIONS Staphylococcus aureus or “Staph” is a germ that lives on the skin and in the nose of some healthy people. Your skin protects from those germs. When you have surgery, we will be cutting your skin. Sometimes germs can get into those cuts and cause infection. How do we screen for Staph? In your physician’s office they will swab your nose to see if you have Staph. It will take 3 – 4 days for the test results. A positive test does not mean you have an infection. Your surgery will not be canceled or delayed. If my test is positive, what happens? If your test is positive, your physician’s office will call you and tell you to get Mupirocin (another name is Bactroban) at your pharmacy. The medicine will come in one large tube or many small packets. It is the same medicine that will kill the germs. They just look different.

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Pre-Hospital Assessment •

If you get a big tube of Bactroban, place enough medicine to cover the tip of a cotton swab. Place the cotton swab inside your nose. Then reapply to the other side of your nose.

•

If you get individual tubes, put half the tube on a cotton swab and put the medicine in one side of your nose. Then put the other half in the other side of your nose.

•

Gently press your nose together for about a minute (while breathing through your mouth) to get the medicine all over the inside of your nose, then release. Do this once in the morning and once at night for five (5) days.

If I have Staph, will I be treated differently in the hospital? If you have a type of Staph called MRSA, you will be in a single room on “Contact Precautions.” This means your doctors and nurses will wear gloves and gowns when taking care of you. We do this to make sure we do not spread MRSA to another patient we are caring for.

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orthopedic center of excellence

HIP REPLACEMENT GUIDEBOOK

Day of Surgery The day of your surgery will be a busy one. You will stop briefly at Admissions before being escorted to the Same Day Surgery area. Once there, you will be asked additional questions by your day surgery nurse, and some of the information already provided will be reviewed and confirmed. Your surgeon will visit you and confirm with you which hip will be operated on. He will then mark the surgical site with an indelible pen. You will have an IV inserted to allow the anesthesia provider to administer the necessary medications. During this time, the anesthesia staff will interview you. When everything has been completed, you will be taken into the operating room where you will be attended by the anesthesia provider, your surgeon and the rest of the operating room team. The amount of time that you are in the operating room will depend upon the complexity of your procedure. Family and Friends We will do our best to keep you and your family/friends informed of any changes to the schedule that result in a delayed start or the procedure taking longer than planned. Waiting rooms are available immediately outside of the surgery area. There is WiFi access and a television for your enjoyment while you wait. The cafeteria provides free coffee and tea. During your stay, your friends and family are invited to visit the gift shop, the healing garden by the main entrance, or walk the trail around the hospital campus if they choose.

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Day of Surgery Please read the following information about the day of surgery very carefully. Ask any questions about these instructions in advance of your surgery day. • Do not eat solid food after midnight the night before you are scheduled for surgery. If your surgery is after 12:00 p.m., a preoperative nurse will provide specific instructions. If you do eat, we will have to cancel your surgery! • Do not smoke, chew gum, or take hard candy or breath mints on the day of your surgery. • Do not take any medications before surgery that your physician or the pre‐op care nurse did not approve beforehand. Bring a list of your medications, but leave the medications at home. • Please come to the hospital at the time given to you at your pre‐assessment meeting. • If you suddenly catch a cold or other ailment or suffer changes in your physical condition, please notify your surgeon immediately. • Follow instructions regarding the use of antiseptic wipes as ordered by your physician. Wash your hair before surgery (night before or morning of ). Do not apply makeup, lotion, powder or deodorant after showering. • Do not shave or wax your legs for three (3) days prior to surgery. We will use special clippers to prepare the area. • Remember to bring personal‐care items such as a toothbrush, toothpaste, shaving equipment, deodorant, eyeglasses/contacts, comb or brush, makeup, non‐skid slippers, and other items you wish to have while at the hospital. • Wear loose, comfortable clothing and flat‐heeled, closed‐toe shoes to the hospital. You may bring loose clothing such as knee‐length gowns, robes or nightshirts if you desire. For physical therapy you may want to bring loose‐fitting shorts or sweats and T‐shirts. Bring an extra set of soft, stretchable pants (like sweatpants) to go home in. • Remember, no jewelry/piercings (including wedding rings), contact lenses, or money. Leave your valuables at home or give them to a relative or friend for safekeeping. • You may bring special music that you would like to listen to during the preoperative and recovery portions of your surgery. • Bring this guidebook with you on the day of surgery along with your driver’s license and your health insurance card for identification. It is also important to bring a positive attitude and commitment to being involved in your care while at the hospital. J • Under most circumstances, one person may accompany you to the Same Day Surgery area. • Your family and friends are welcome to wait in the lobby waiting area until you are taken to your room postoperatively.

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orthopedic center of excellence

HIP REPLACEMENT GUIDEBOOK

Day of Surgery Examples of clear liquids that you may drink, if instructed: • Clear apple juice, cranberry juice, white grape juice • Black coffee or tea (no cream or milk) • Chicken or beef broth • Clear JELL‐O only (no added fruits or whipped cream, etc) • Water • Gatorade • Clear carbonated liquids (soda) Examples of liquids NOT to drink: • Orange juice • Milk • Any liquid with a nectar or pulp • Alcohol • Coffee or tea with cream or milk

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Case Management and Discharge Planning There are many arrangements to be made prior to your discharge home. Equipment that will be needed upon discharge includes a walker, toilet riser (with or without arms), and a shower chair or tub bench. You may obtain the equipment from family or friends. There are several medical‐supply companies that have equipment available. We can also assist you in obtaining these items during your hospital stay. Our goal is to make this as easy for you as possible. We will arrange for home health care and short‐term rehabilitation if needed. Please check with your insurance company for benefits. If you have any special needs during your stay with us, please advise us during your preoperative assessment appointment, so we can ensure everything is ready on the day of your surgery. Please call the Discharge Planning Department at (719) 530‐2284 with any questions or concerns you may have prior to surgery. The discharge planner will provide patient education, is available to answer questions, and can assist in coordinating your care. They will visit you while you are in the hospital to discuss your plans for managing at home after surgery and keep you informed (along with your physician) of your discharge status. The discharge planner is also there to help you arrange for assistive devices, arrange home health services, or to assist in your transfer to a transitional care unit. The case manager works as your patient advocate and will try to address any questions or concerns that come up during your hospital stay. The case manager also helps coordinate your care with your insurance carrier(s).

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orthopedic center of excellence

HIP REPLACEMENT GUIDEBOOK

Case Management and Discharge Planning PLANNING FOR YOUR DISCHARGE Home Health Care Services Your doctor and case manager may determine that you need home health care upon leaving the hospital. If so, a case manager will discuss your needs and set up the appropriate services. Home health can provide many services, including a registered nurse, a home health aide, in-home physical therapy and occupational therapy. It is important to remember that your insurance company may determine the agency used and the amount of services you will receive. Be sure to call your insurance company to verify your benefits prior to surgery to check on what type of service is available to you. Each insurance carrier has rules and regulations and makes decisions based on its own criteria, regardless of what your surgeon requests. Medicare will cover physical therapy in the home for a patient who is homebound. Medicare may also provide for a nurse and a nurse’s aide, but only if there is a skilled need. While we understand that the initial adjustment to being home after surgery is not easy, most patients manage very well, especially those who have prepared in advance. Rehabilitation Services Your surgeon may determine that you need more therapy before you can return home and may recommend that you be admitted to the hospital’s Swing Bed program (where the level of care swings from acute to skilled rehabilitation) or to a skilled nursing facility of your choice for a short stay. The major goal of the skilled nursing facility is to improve your ability to perform key activities of daily living. You will be expected to do as much as possible for yourself, by dressing yourself in everyday clothes, participating in a minimum of two to three hours of therapy per day, and scheduling other activities around therapy times in order to receive the maximum benefit from your sessions. Please understand that the decision for acceptance to any rehab facility is not controlled by your surgeon. If you meet the criteria set by both the rehab facility and your insurance carrier and a bed is available, you will be discharged to the facility when medically appropriate. Medicare does pay for up to 20 days of inpatient skilled nursing/physical therapy per benefit period. If you have completed a health care proxy or living will, bring a copy with you to the hospital. If you have a MOST form, please bring your original green copy with you on the day of surgery. For more information about these subjects, please speak with the pre‐op care nurse or your case manager. Free on‐site interpreter services are available for those who need assistance communicating with the staff in Spanish or other languages.

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Case Management and Discharge Planning Durable Medical Equipment Suppliers of oxygen, walkers, toilet risers and other equipment in this area: Adaptive/Medical Equipment Caring and Sharing in Salida – (719) 539-3686 New Bees Thrift Store in Buena Vista – (719) 395-6295 American Legion in Buena Vista – (719) 395-8024 AeroCare in Salida – (719) 539-3406 PS HomeCare in Buena Vista – (719) 395-8613 Rocky Mountain Home Health Supplies in Salida – (719) 539-2396 Transportation Chaffee County Shuttle -- (719) 530-8980 Home Modifications Rich Longwell cell phone – (719) 966-9999 Food Assistance Food Bank at the Presbyterian Church – (719) 539-6422 Grainery – (719) 530-9050 Meals on Wheels – (719) 539-3341 Personal Care Services Argus Home Health Care – (719) 275-1101 or (719) 543-2634 Beo Personal Care – (719) 539-7343 Hildebrand Home Care, Inc. – (719) 539-3400 Home Instead – (719) 545-0293 Premier Home Care – (719) 395-3124 Touch of Care – (719) 539-4090 Help for Seniors (i.e. yard work, driving to medical appointments, etc.) A Little Help - (719) 966-7366

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Case Management and Discharge Planning Home Health Associations Suppliers of home nursing, physical therapy, etc. The following agencies provide skilled nursing and allied health professional services. Listing here does not constitute endorsement of a particular provider. Heart of the Rockies Home Health and Hospice 301 Oak Street, Unit E Salida, CO 81201 (719) 539-7638 (719) 530-0166 Fax A joint venture with Heart of the Rockies Regional Medical Center. Serving Salida, Maysville, Western Fremont Co., Buena Vista and Granite Prospect Home Health Care P.O. Box 6270 (mailing address) 321 West Henrietta (phys. address) Woodland Park, CO 80866 (719) 687-0549 (719) 687-8558 Fax Covers Hartsel (depending on address) Centura Home Health Agency 1338 Phay Avenue Cañon City, CO 81212 (719) 269-2286 (719) 566-6606 Fax (877) 546-8253 Referrals Intake

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Alamosa County Nursing Service 403 Santa Fe Avenue Alamosa, CO 81101 (719) 589-6639 (719) 589-1103 Fax Mountain View Home Health Care 711 N. Taylor Gunnison, CO 81230 (970) 641-7279 (970) 641-7239 Fax Premier Home Care 430 Cedar St. Buena Vista, CO 81211 (719) 395-3124 Phone (719) 395-1885 Pager (719) 395-3128 Fax Serving Buena Vista, Salida, Leadville, Hartsel, Fairplay and Western Fremont County. At Home Health Care 240 Craft Drive Alamosa, CO 81101 (719) 589-6425 (719) 589-1021 Fax (719) 588-3540 On-Call Cell

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Post-Surgery Care Post-Anesthesia Care Unit (PACU) When your surgery is complete, you will be taken to our Post-Anesthesia Care Unit (PACU). This is a critical care unit with specially trained registered nurses who will watch you closely (one nurse to one patient) while you begin your recovery from the anesthetic you were given. Your care will be essentially the same whether you have had general or spinal anesthesia. If there is a difference, it is specified in bold below. While you are in PACU your vital signs—including your pain level, based on a scale of 0 -10, with 10 being the most severe—will be monitored every five minutes, or as needed, and addressed/medicated with the pain medication ordered by your physician according to the amount of pain you are experiencing. The medication will be given to you through your intravenous access. You will be connected to a blood pressure cuff, heart monitors, and a device called a pulse oximeter that will be placed on your finger to monitor how much oxygen is in your blood. Your temperature will be taken on arrival to the PACU and as needed to ensure you are warm enough, as the operating room is kept cool. A Bair Hugger (warming device) will be applied until you reach and maintain normal body temperature. If you have chosen a general anesthetic, you may arrive in PACU with the breathing tube still in your airway depending on how well you are breathing. When your breathing is stable enough, the nurse will remove the tube and apply an oxygen mask or cannula. You may experience a bit of a sore throat after the breathing tube comes out. This is normal. If the breathing tube is out prior to your coming into the PACU, an oxygen mask will be put on you when you arrive in the PACU. If you have chosen a spinal anesthetic you may be groggy, because you may have gotten some relaxing medication through your IV, but you will be awake. Since you may be groggy and the relaxing medication you were given affects your breathing, you will be put on an oxygen mask until your vital signs are stable. If you had a spinal anesthetic, the level of anesthesia relative to your body will be assessed every 5 - 10 minutes. Prior to surgery, an antiembolism stocking and pump were applied to your unaffected leg to help prevent blood clots. The stocking will also be applied to the surgical leg prior to arrival in PACU, and the pump will be applied and plugged in on arrival to PACU. HRRMC has included this important step to help minimize the risk of postoperative blood clots.

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Post-Surgery Care A urinary catheter (tube in your bladder) may have been inserted after you fell asleep in the operating room. Do not be alarmed by this when you get to PACU. If you have had a general anesthetic, you may feel like you need to urinate. The tube often causes this sensation, but you will be reminded that it is there and it is okay to urinate as the tube will catch the urine and go to a drainage bag. This is important for monitoring how much fluid you are excreting compared to what has gone in intravenously. If you have had a spinal anesthetic, the catheter will relieve your bladder, because you will not feel the sensation to urinate for awhile. When you regain this sensation, you may feel the urge to urinate, but remember the catheter is there to catch the urine. Surgical bandages, as well as any drains that may have been put in at the surgical site, are checked every time your vital signs are checked to ensure that there is not excessive bleeding. Ice packs, therapy equipment, and abductor pillows for hips are applied as ordered by your physician. An X-ray of the surgical area may be taken in the PACU for the physician to compare with the preoperative X-ray and to show the hardware that was implanted in you for accuracy and comparison to your unaffected joint. Under most circumstances, your total time in PACU will be 45 minutes to one hour. However, you will be observed there until you are awake enough to be transferred to your room on the Medical/Surgical Unit.

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Post-Surgery Care Medical/Surgical Unit (Med/Surg) When you arrive on Med/Surg, you will have a registered nurse (RN) or licensed practical nurse (LPN) caring for you. The nurse will frequently monitor your vital signs (blood pressure, pulse, respirations, temperature and pulse oximetry), movement and sensation of your legs, and pain level. As your anesthetic wears off, the frequency of monitoring your vital signs will decrease. The nurse also assesses and manages many other components of your care with help from a certified nursing assistant (CNA), including the following: IV An IV is in place to administer IV fluids. The IV may be capped when you are able to take adequate fluids by mouth. Urinary Catheter If you have a urinary catheter, it will remain in place after surgery to drain your urine into a bag. The catheter may make you feel like you have to urinate. When the catheter is taken out, you can urinate on your own. Intake and Output Your caregivers may need to know the amount of liquid you are getting. They may also need to know how much you are urinating. Caregivers often call this “I and O” (Intake and Output). • When you are allowed, drink 6 to 8 cups of water each day. Follow your caregiver’s advice if you must change the amount of liquid you drink. If you are on I & O, tell your caregiver how much liquid you drink. • Ask your caregiver if you need to urinate in a container. The urine may need to be measured before it is flushed. Ice You may use ice to decrease pain or swelling. Ice is best started right after surgery and used 24 to 48 hours afterwards. Caregivers may place an ice-cooling unit (or ice bags) on and around your hip. Take care not to place the cooling unit or ice directly on bare skin as it may cause frostbite. Follow your caregivers’ instructions for how often and how long to use ice or the ice-cooling unit. Activity Activity will be initiated and directed by physical therapy and by nursing staff. See page 42.

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Post-Surgery Care Deep breathing and coughing A possible complication that may occur is breathing issues that sometimes lead to pneumonia. To prevent any lung issues, you can do breathing exercises. Deep breathe and cough every hour while you are awake even if you wake up during the night. • Deep breathing opens up tubes going to your airways. Coughing helps to bring up sputum (mucus) from your lungs for you to spit out. Take a deep breath and hold the breath as long as you can. Then push the air out of your lungs with a deep, strong cough. Put any sputum that you have coughed up into a tissue. • Take 10 deep breaths in a row every hour while awake. Remember to follow each deep breath with a cough. • You may be asked to use an incentive spirometer. This helps you take deeper breaths. Instructions will be provided. BMs This is also called having a bowel movement, a BM or a stool. At first you may not be able to get out of bed to urinate or have a BM, so you may need to use a special bedpan. Your caregiver will tell you how to get on and off the bedpan so you do not hurt your hip. Foods like fruit, bran and prune juice can help you have a BM. Drinking water can help, too. Your caregiver may give you a stool softener to prevent constipation. Drains These are thin rubber tubes put into your skin to drain fluid from around your incision. The drains are taken out based on the surgeon’s preference. Eating If you do not have problems after drinking liquids, caregivers may let you eat soft foods. If you do OK with soft food, you may begin eating your regular diet. Oxygen You may need extra oxygen to help you breathe easier. It may be given through a mask or nasal cannula. A cannula is a pair of short thin tubes that rest just inside your nose. Sequential Compression Devices These are plastic boots or leggings put on your feet or legs over pressure stockings or ace wraps. The boots or leggings are connected to an air-pump machine. The pump tightens and loosens different parts of the pneumatic boots. This helps push the blood back up to the heart to keep clots from forming.

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Post-Surgery Care Abduction Pillow Some patients may be asked to have this type of pillow between their legs while in bed; your surgeon will decide if this pillow is appropriate for you after surgery. Anesthesia Most patients will receive a spinal anesthetic to help control the pain during and after surgery. Based on the preference of your anesthesia provider, a light general anesthetic may be added to keep you asleep and comfortable during the operation. There are also other anesthesia options if you are unable to receive a spinal anesthetic. Pain Ball Your surgeon may use a pain ball to aid in postoperative pain control. It consists of a rubber bladder about the size of a softball filled with numbing medicine (Marcaine). It may also contain an NSAID called Toradol, so please let your surgeon know if you are allergic to NSAIDs. The numbing medicine goes from the rubber bladder into the hip through one or two small tubes that go through the skin. This helps numb the operative hip, and cuts down on narcotic-pain-medicine requirements. In addition, it does not block muscle or nerve function; therefore you can participate in physical therapy sooner, usually the same day of surgery. The pain ball tubes are usually removed from the hip the second day after surgery. Pain Management Acute pain after an orthopedic procedure can occur in varying intensity and is usually of short duration. Your pain will be assessed immediately after surgery and at regular intervals afterward. You will be asked to assist us in evaluating your pain by answering the following questions about your pain:

1. Intensity 2. Location 3. Quality (burning, diffuse) 4. Other symptoms (nausea, vomiting, dizziness) 5. Aggravating factors (variables that worsen the pain) 6. Alleviating factors (positioning, ice, medications)

Individualized pain management will be established for you by your doctor and your pharmacist, with your input. The use of analgesic medication is common and may be administered by IV or orally. We are committed to making your recovery the best possible experience, with the least amount of pain. The Med/Surg staff will work closely with your physician, case manager and other ancillary departments to ensure appropriate recovery and discharge. An average hospital stay for joint replacement patients is three (3) nights, but your length of stay will vary based on the type of surgery and your recovery, which is influenced by many factors such as other pre-existing conditions, pain management, and your participation in therapy. Some patients who have more needs, or who don’t have help at home may need to stay in the hospital longer, or be transferred to another facility for longer-term care (skilled nursing facility, nurse home, Swing Bed).

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Post-Surgery Care Carbon Dioxide Monitor If you have been admitted to the hospital after your surgery, you may be placed on an endtidal carbon dioxide monitor. This clear tube in your nose monitors your breathing and gives you oxygen as needed. Your healthcare provider believes you need this because of your condition or because the medication you are getting can affect your ability to breathe. The tube in your nose is attached to a device that will monitor your breathing. Be sure the tube is placed in both nostrils at all times. If you hear the device alarm, take a deep breath. It is not uncommon to hear more alarms while you are sleeping because your breathing is more relaxed. Think of the alarms as an alarm clock reminding you to take a deep breath. Reprinted with permission of CareFusion.

Managing Your Pain Pain Management is an important part of your care. Pain that does not get better can slow healing and recovery. Only you know what your pain is like. It is important to talk to your doctors and nurses about your pain. What is pain? Pain is a feeling of hurt. Everyone’s pain is different. It may burn or ache, or feel sharp, dull, heavy or something different. You are the only one who knows how your pain feels. Pain may be acute, like the kind you have following an injury, surgery or childbirth. It goes away as the body heals. Pain may be chronic and ongoing like with arthritis or another condition that does not go away over time. You have the right to have your pain assessed and cared for. It may not be possible to take away all the pain, but many things can be done to reduce the pain. Why do I need pain relief? Some people think they should “tough it out,” but research has shown that pain can be harmful to you. Pain that does not get better can slow healing, increase complications and cause other problems. What is a pain rating scale? Only you know how badly your pain hurts. To help the doctors and nurses manage your pain, you will be asked to “rate” it. You do this by giving your pain a number from 0 to 10 or pointing to a face that shows how much you hurt. What about children or others who cannot rate their pain? Pain is rated by watching the person’s behavior or actions. A special pain-rating scale is used. Treating pain is important even if someone cannot talk about the pain.

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Post-Surgery Care This is the 0-10 pain rating scale 0 is no pain 5 is moderate pain 10 is worst pain imaginable

How will I get pain medicine? The best way to take pain medicine is to take pills by mouth (orally). Pain medicine can also be given by injection, suppository or patch. Sometimes an anesthesia provider will put medicine near the spine. When you are in the hospital, PCA (Patient-Controlled Analgesia) may be used. When you push the PCA button, a small dose of medicine goes into the vein. Safety features are built in to stop you from getting too much medicine. It is important that only the patient pushes the button of a PCA device. Family and other visitors should never push the PCA button. Will I get addicted to opioid medicine? It is rare to become addicted to opioids when they are taken as prescribed by your doctor. Pain management is an important part of your care and helps in your recovery. If you need to take the medicine for several weeks, your body can get used to the medicine, and it is important that you do not stop suddenly. Your doctor will gradually decrease the dose. This is not addiction. If you have had problems with addiction or drug abuse in the past, be sure to talk to your doctor. Even past addiction does not rule out the use of strong pain medicine.

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Post-Surgery Care What are the side effects of pain medicines? The most common side effects are an upset stomach and sometimes vomiting. Others are constipation, itching, drowsiness, and sometimes slowed breathing. These side effects usually go away in a few days. Part of treating your pain is checking for side effects and treating them if needed. When taking opioid pain medicines, constipation can be a problem. If you are able, drink plenty of liquids. If you do not have diet restrictions, increase your fìber by eating more uncooked fruits and vegetables, and whole grain breads and cereal. Ask your doctor or nurse about a stool softener. What can I do to help myself? Take the medicines prescribed by your doctor. Do not focus on your pain. Use the following activities to help manage your pain: Distraction—focus on something besides pain. Try reading, watching TV or talking with a friend or family member. Relaxation—listen to soothing music or imagine a calm scene like the ocean or mountains. Meditation—focus on one word, object or idea. Imagery—think about your favorite places. Imagine pain flowing out of your body and relaxation flowing into your body. Deep breathing—use slow, rhythmic breathing and let your muscles relax as you breathe out. Hot or cold packs—ask your doctor or nurse about using them. Acupuncture—if you choose, you can contact your local acupuncturist for an appointment.

Remember: • Only you know what your pain feels like or when you have pain. • Talk to your doctor and nurse about your pain. • Take your pain medicines. • Do not focus on your pain. Use distraction, relaxation, meditation, imagery and deep breathing to help control your pain.

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Post-Surgery Care Tips for Family after Surgery 1. Please wash your hands with soap and warm water for at least 15 seconds or use alcohol hand sanitizer located in the patient rooms prior to touching the patient or their personal-use items or their immedi- ate environment. 2. It is okay to bring your family member’s favorite foods to the hospital, if the treats are within their dietary restrictions. 3. Be sure the car used to bring your family member home is large enough to get into easily. Small, compact cars are not appropriate and can cause unnecessary discomfort. Tall cars that need to be climbed into are also not appropriate. 4. Encourage your family member to follow all the instructions and guidelines that have been given. This is especially important, since he or she might be discouraged by the pain and fatigue that often follows surgery. 5. Call your surgeon’s or physician’s office if you have any questions or concerns. 6. Your family member’s temperature will tend to rise in the evening (the patient might even experience “night sweats”), but will go down to near normal during the day. If the patient’s temperature stays elevated for 24 - 48 hours without going down, please contact the surgeon’s office. 7. When your family member is home from the hospital, encourage him or her to do as much as possible without your assistance. This will help the patient recover more quickly and give a greater sense of independence. 8. Remind the patient of any precautions, and when helping the patient with transfers or mobility, please keep the precautions in mind. Precautions are listed under the Physical and Occupational Therapy section of this guidebook. 9. Keep the number of visitors/hours to a minimum, so the patient utilizes energy for rehab.

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Post-Surgery Care Infection Prevention Signs of Infection • Increased swelling and redness at incision site • Change in color, amount, odor of drainage • Increased pain in hip • Fever greater than 101.5 degrees F. • Continued wound drainage for more than 5 days Prevention of Infection • Take proper care of your incision as explained below. • Take prophylactic antibiotics when having dental work or other potentially contaminating procedures. • Notify your physician and dentist that you have a joint replacement. • Do not allow your animal(s) to lick your face or your incision. Wash your hands with soap and warm water for at least 15 seconds after playing with or handling your animals, as well as after cleaning their cages, water bowls, toys or other equipment. Dressing Change Procedure 1. Wash hands with soap and warm water for at least 15 seconds or use an alcohol hand sanitizer prior to touching the dressing or the incision including drain sites. 2. Open all dressing change materials (ABD pads, 4x4 if needed, Betadine swab if indicated). 3. Remove stocking and old dressing. 4. Inspect incision for the following: redness, swelling, and/or increased drainage. 5. Wash hands again. 6. If Betadine swab ordered, take one swab and paint the incision from top to bottom. Then turn the swab over and paint the incision from bottom to top. Use remaining swab to paint the drain site if you have one. 7. Pick up ABD pad by one corner and lay over incision. Be careful not to touch the inside of the dress- ing that will lie over the incision. 8. Place one ABD pad lengthwise and place the other ABD crosswise to form a “T” (to cover the drain site if necessary). 9. Tape dressing in place.

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Post-Surgery Care Medications after Joint Replacement Surgery The most commonly prescribed medications after surgery are antibiotics to prevent infection, anticoagulants to prevent blood clots and analgesics to control the pain. Antibiotics Antibiotics reduce or eliminate bacteria and are prescribed before and after joint replacement surgery to guard against infections. Antibiotics are routinely given for at least 24 hours following your operation. It is important to notify your doctor or nurse if you have any history of drug allergies or recent infections.

Analgesics (pain medicine) We would like to assure you that pain or discomfort following your surgery will be closely monitored and controlled. There are various types and methods of medication used depending on the severity of your pain. The best method for you will be determined by your surgeon. Non-narcotics such as Tylenol are given orally for mild to moderate pain. This medication can be obtained without a prescription, but your surgeon needs to be aware of all non-prescription medications you are taking. (Do not take aspirin, Advil, Motrin, Nuprin, Naproxen, Aleve, or ibuprofen while you are on Coumadin, Vicodin, or Codeine.) Possible side effects of nausea, vomiting or stomach pain sometimes occur so it is best to take these medications after meals with a full glass of water in order to avoid such problems. However, if you experience severe dizziness, headaches, ringing in the ears or skin rash you should contact your doctor immediately. Narcotic medications such as Demerol, Fentanyl, Morphine and Dilaudid are prescribed for moderate to severe pain. These medications are usually given intravenously or by injection for the first 12 - 24 hours after surgery, but as your pain decreases you will be given pain medications orally. Common side effects from narcotics include nausea, vomiting, constipation, drowsiness or dizziness. Taking the medication orally with food will decrease many of the stomach problems. Narcotics are habit forming so you shouldnot take them more often or for longer periods than your doctor prescribes for you. If a pain ball is used, most patients can have their pain adequately controlled with oral pain medicines only such as Percocet (oxycodone) or Vicodin (hydrocodone).

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Post-Surgery Care Anticoagulants (blood thinners) Blood clots sometimes occur due to the long periods of bed rest after surgery. Anticoagulants are prescribed to prevent blood clots from forming or getting larger. Your orthopedic surgeon will discuss this with you. The most common medications used are: Coumadin (Warfarin) is a powerful blood thinner. It requires frequent blood draws to monitor the PT/INR to make sure your blood is not too thin. The therapeutic goal is to keep the level between 2 - 3. While you are taking this medication, you cannot take any aspirin, Ibuprofen or arthritis medications. Avoid foods with large amounts of Vitamin K, such as broccoli, Brussels sprouts, cabbage and green leafy vegetables. Vitamin K reduces the blood-thinning effect. Lovenox (Enoxaparin) is an injectable medication that works to thin the blood. It requires daily injections for 2 weeks. It does not require monitoring with blood draws. The nursing staff will teach you or your family member how to give the medication prior to discharge home. This medication can be expensive if not covered by insurance. Xarelto (Rivaroxaban) is a new oral blood thinner. Like Lovenox, Xarelto does not require monitoring blood levels with blood draws. It also offers the advantage of being a pill like Coumadin. In addition, it is significantly cheaper than Lovenox. You may have home health services in place, in which case your home health nurse will monitor your anti-coagulant therapy in coordination with your physician. As with all medications, keep them out of the reach of children!

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Physical and Occupational Therapy Rehabilitation Department Preoperative Information for Hip Replacement Patients This packet is designed to give you, the hip replacement patient, general knowledge of what to expect, and what is expected of you, as you prepare for your upcoming surgery. The following could be altered slightly by your doctor or physical therapist, according to your individual needs. Your physical therapist will work with you after surgery to • become independent getting in and out of bed. • teach you how to use a walker. • teach you how to go up and down stairs. • be independent with the postoperative exercise program started in the hospital to strengthen your leg and improve your gait • teach you certain temporary restrictions/precautions to prevent dislocation. You will have physical therapy twice a day.

Post-op Day #0 (Day of Surgery) Physical Therapy begins in the afternoon on the day of surgery. You will be expected to: • Do exercises to strengthen the hip and gain range of motion. • Sit up at the edge of the bed. • Get out of bed and sit in a chair. • Review range-of-motion limitations according to the surgical approach. If you have had a minimally invasive hip replacement, depending on what you can tolerate, you may also: • Walk down the hallway with a walker. • Learn to go up and down the stairs. • Go home on the day of surgery if you can clear physical therapy and are tolerating pain on oral pain medicines.

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Physical and Occupational Therapy Post-op Day #1 through Discharge Your program will progress as you tolerate it, working toward more independent walking, exercising and activities of daily living. Most standard hip replacements go home by Post-op day #3. Most minimally invasive hip replacements go home by Post-op day #1, but your length of stay will vary depending on your recovery, which is influenced by many factors such as other pre-existing conditions, pain management and your participation in therapy. The following goals should be achieved prior to discharge: • Get in and out of bed independently • Get up and down from seated position safely (including the toilet) • Walk safely with appropriate assistive device • Show good understanding of your home-exercise program • Tolerate pain on oral pain medicines only Icing You will come out of surgery with an ice machine on your hip. The ice needs to be refreshed at times, and you may need to remind your nursing staff if you don’t feel the cold. Bathroom Needs If you have a urinary catheter and have had an epidural, the catheter will be removed after the epidural has been removed. This is usually the second day after surgery (post-op day #2). Generally, MIS-THA patients will have the urinary catheter removed before they leave the recovery room. After the urinary catheter has been removed, you are encouraged to use the bedside commode or walk to the bathroom. Because of the equipment, you will need to ask for the assistance of the nursing staff. Try to avoid using the bedpan. Meals Beginning the day after surgery, you should be eating all your meals while sitting in the bedside chair. You should ask for nursing assistance to get into the chair for your meals. Attire You are encouraged to bring clothing that is easy to move in such as shorts or sweat pants and a T-shirt to wear during the day once the IVs have been removed. You will be more comfortable exercising in these clothes than in the hospital gown. Soft-soled, tie-on shoes are also recommended.

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Physical and Occupational Therapy Total Hip Replacement Precautions for ANTERIOR Approach Avoid placing your leg behind you and putting weight on it. If you need to turn, use small pivot steps.

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Physical and Occupational Therapy Total Hip Replacement Precautions for POSTERIOR Approach There are three motions and/or positions that you MUST AVOID to protect your new hip. These motions must be restricted until your doctor tells you otherwise. • Don’t bend your hip past a 90-degree angle. • Don’t cross your legs. • Don’t twist your hip inwards — keep knees and toes pointed forward. Hip Flexion This means that your legs and trunk should never be bent more than 90 degrees. For example, when sitting, your knees should not be higher than your hips. Avoid low, deep or soft seats. Do not bend over to touch your feet or to pick up items from the floor. When you need to bend over, use reachers, sock aids or tongs. Do not sit on a low toilet seat or in a tub. Use an elevated toilet seat and a tub transfer bench/board or a shower chair/bench when bathing. Install grab bars in bathrooms to help you with rising. Adduction Do not adduct the involved leg. Adduction is bringing your leg inward across the midline of your body. Do not cross your legs or ankles. When sleeping on your side, place a pillow between the knees. Internal Rotation Do not internally rotate involved leg. This is the motion of rotating your leg inward as when standing “pigeon-toed.” It commonly occurs while sleeping on your side or not being careful when turning.

See illustrations on next page.

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Physical and Occupational Therapy Total Hip Replacement Precautions for POSTERIOR Approach (cont.)

For the best outcomes, follow these guidelines: Take charge of your mobility, and follow these four important guidelines! 1. Limit sitting to 20 minutes in order to avoid swelling. 2. Change positions every 20 minutes; perform gentle bed exercises; get up and walk with help multiple times throughout the day.



3. Ice as needed; it will help with pain and inflammation. 4. Massage your thigh to decrease muscle soreness throughout the day. Bed Positioning The preferred sleeping position is lying on your back. If you sleep on your side, it is required that you keep pillows between your knees. Also, it is recommended you sleep on your side that was not operated on.

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Physical and Occupational Therapy Total Hip Replacement Precautions for POSTERIOR Approach (cont.) Bed Transfers Getting out of bed: 1. Lean up on your elbows or hands, semi-reclined. 2. Begin pivoting on your buttocks to ease the first leg over the edge of the bed. 3. Use the leg lifter to help your operated leg by sliding the leg to the edge of the bed. 4. Continue to pivot as you move the other leg off the bed. Getting into bed:

1. 2. 3. 4. 5. 6.

Sit on the edge of the bed. Scoot back as far as is comfortable. Using your leg lifter if needed, begin pivoting on your buttocks as you lift one leg into bed. Pivot more as you lift in the other leg. Keep your legs straight and your head behind your buttocks. Lie down on your back, NOT your side.

Chair Transfer Sit on a firm chair with arm rests. The chair seat must be at knee height or higher. Use a pillow or cushion to raise the height of the chair if needed.

1. Face away from the chair so that the back of your knees touch the chair.



2. Straighten your operated leg and place it 6 inches ahead of your unoperated leg.



3. Reach back with the hand opposite your operated leg and grab the armrest.

4. Reach back with your other hand for the armrest and begin lowering yourself into the chair. Keep your head up and your trunk straight. Car Transfers 1. 2. 3 4. 5. 6. 7 8.

Position the passenger seat of the car as far back from the dashboard as possible. While standing between the car and the open car door, turn until the back of your knees or legs touch the car seat. Place one hand on the car door and one on the side of the car or seat. Straighten your operated leg and place it 6 inches in front of the unoperated leg. Lower yourself to the edge of the seat. Bring your upper body and buttocks into the seat as far as possible. Bring your legs into the car, using your leg lifter if needed. To get out of the car, reverse the process.

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Physical and Occupational Therapy The Role of Occupational Therapy Your occupational therapist (OT) will, in most circumstances, see you on the day of surgery or the first day after surgery, depending upon whether you had an MIS‐THA or a standard hip replacement respectively. Based on your needs, you may need to see the OT only once, or you may see him/her a couple of times. Your occupational therapist will work with you to • show you how to dress your lower body with techniques, or adaptive equipment until your hip has functional range of motion again. • show you how to access your shower at home. • assist you with any equipment that is most appropriate for your needs and financial situation. • show you how to put on your compression stockings. • answer any questions or concerns you have about your home environment, changes or adaptations you may need. • provide hip‐precaution education for modifying home tasks. Our occupational therapists will ensure that your home environment is safe and well-equipped for your return. If you would like to speak with an OT about home preparation prior to surgery, feel free to call the HRRMC OT staff at (719) 530‐2392. In addition, your occupational therapist will give you some equipment while you are at the hospital. You may not need all of the pieces. Each piece of equipment and its function is as follows: 1. Reacher ‐ 32” long grabber that picks up things less than two pounds and assists with putting on and taking off pants if you have difficulty reaching down to the floor. 2. Sock‐Aid ‐ device that helps you put on your own socks and compression stockings by yourself with out having to lean over or bend your knee. 3. Long‐Handled Sponge – for ease of washing yourself while sitting. 4.. Long‐Handled Shoe Horn – to help put on your shoes until you have more hip range of motion. You will need comfortable pants and shoes with you to practice these techniques with your occupational therapist before your discharge home. On behalf of the Rehabilitation Department of Heart of the Rockies Regional Medical Center, we look forward to working with you. Please call us at (719) 530‐2040 with any questions.

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Physical and Occupational Therapy Name

Date

HOME EXERCISES: Elevated ankle pumps

• Lie on back with foot elevated up on pillow.



• Move foot up and down, pumping the ankle.



• Perform 1 set of 20 Repetitions, three times a day.

Special Instructions:

Issued by: Heart of the Rockies Regional Medical Center. These exercises are to be used only under the direction of a licensed, qualified professional. Except as to user-supplied materials, Copyright 1995‐2007 BioEx Systems, Inc.

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Physical and Occupational Therapy Name

Date

HOME EXERCISES: Heel slides

• Lie on back with legs straight



• Slide heel up to buttocks.



• Return to start position.



• Repeat with other leg.



• Perform 2 sets of 10 Repetitions, three times a day.

Special Instructions:

Issued by: Heart of the Rockies Regional Medical Center. These exercises are to be used only under the direction of a licensed, qualified professional. Except as to user-supplied materials, Copyright 1995‐2007 BioEx Systems, Inc.

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Physical and Occupational Therapy Name

Date

HOME EXERCISES: Short arc

• Lie on back with involved leg bent to 45 degrees supported with a pillow, as shown.



• Straighten leg at knee.



• Return to start position.



• Perform 2 sets of 10 Repetitions, three times a day.

Special Instructions:

Issued by: Heart of the Rockies Regional Medical Center. These exercises are to be used only under the direction of a licensed, qualified professional. Except as to user-supplied materials, Copyright 1995‐2007 BioEx Systems, Inc.

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Physical and Occupational Therapy Name

Date

HOME EXERCISES: Long arc

• Sit, with involved leg bent to 90 degrees, as shown.



• Straighten leg at knee.



• Return to start position.



• Perform 2 sets of 10 Repetitions, three times a day.

Special Instructions:

Issued by: Heart of the Rockies Regional Medical Center. These exercises are to be used only under the direction of a licensed, qualified professional. Except as to user-supplied materials, Copyright 1995‐2007 BioEx Systems, Inc.

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Physical and Occupational Therapy Name

Date

HOME EXERCISES: Supine side leg

• Lie on back on firm surface, legs together.



• Move leg out to side, keeping knee straight



• Return to start position.



• Perform 2 sets of 10 Repetitions, three times a day.

Special Instructions: Use a pillow case to reduce friction.

Issued by: Heart of the Rockies Regional Medical Center. These exercises are to be used only under the direction of a licensed, qualified professional. Except as to user-supplied materials, Copyright 1995‐2007 BioEx Systems, Inc.

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Physical and Occupational Therapy Name

Date

HOME EXERCISES: Side leg kickout • Stand.

• Place weight on uninvolved leg.



• Keep knee straight, moving involved leg outward.



• Return to start position.



• Perform 2 sets of 10 Repetitions, three times a day.

Special Instructions: Keep trunk upright.

Issued by: Heart of the Rockies Regional Medical Center. These exercises are to be used only under the direction of a licensed, qualified professional. Except as to user-supplied materials, Copyright 1995‐2007 BioEx Systems, Inc.

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Physical and Occupational Therapy Adaptive Equipment Options There are many pieces of equipment available to you if you desire to purchase or get them on loan to aid in your recovery. The following are some recommendations for home setup following a total hip replacement: Tub transfer bench / Tub transfer board – intended for tub showers

Shower Chair/Bench – intended for shower stalls

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Physical and Occupational Therapy Commode /High Toilet Seat The commode is intended for bedside toileting and can also serve as a shower chair for shower stalls. It may be placed above your existing toilet and used for its height and arm holds. The raised toilet seat fits on your existing toilet and is appropriate when hand holds are close.

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Physical and Occupational Therapy Physical Therapy Centers Buena Vista

Alamosa

HRRMC Rehabilitation Services: Physical, Occupational and Speech Therapy HRRMC Buena Vista Health Center 28374 County Road 317, Buena Vista, CO 81211 (719) 395-9048 Ark Valley Therapy 106 Isabel Ct., Buena Vista, CO 81211 (719) 395-8711 Body Mechanics Physical Therapy 411 Chestnut Street, Buena Vista, CO 81211 (719) 966-9269 Premier Therapies 301 US Highway 24 North, Buena Vista, CO 81211 (719) 395-3124 Salida HRRMC Rehabilitation Services: Physical, Occupational and Speech Therapy 550 West Highway 50, Salida, CO 81201 (719) 530-2040 Arkansas Valley Physical Therapy 735 Blake Street, Salida, CO 81201 539-3626 Columbine Rehab Services Columbine Manor Care Center 530 West 16th Street, Salida, CO 81201 (719) 539-9080 Rebound Physical Therapy 233 F Street, Salida, CO 81201 (719) 539-6144

HRRMC

SLV Health Physical Therapy Services (Pro Therapy) 2115 Stuart Avenue, Alamosa, CO 81101 (719) 589-8100 Valley Wide Health Systems San Luis Valley RMC Medical Offices 106 Blanca Avenue, Suite 300, Alamosa, CO 81101 (719) 589-5149 Canon City Canon City Physiotherapy 903 Macon Avenue, Canon City, CO 81212 (719) 269-1142 Canon Lodge Care Center 905 Harding Avenue, Canon City, CO 81212 (719) 275-4106 Hildebrand Care Center 1401 Phay Avenue, Canon City, CO 81212 (719) 275-8656 Skyline Ridge Nursing & Rehabilitation Center 515 Fairview Avenue, Canon City, CO 81212 (719) 275-0665 St. Thomas More Rehabilitation Services 1338 Phay Avenue, Canon City, CO 81212 (719) 285-2600 TLC Rehab 312 S. 9th Street, Suite E, Canon City, CO 81212 (719) 275-1014

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Physical and Occupational Therapy Physical Therapy Centers Crestone

Monte Vista

Rebound Physical Therapy 53 South Baca Grant Road, Crestone, CO 81143 (719) 539-6144

Avalanche Physical Therapy St. Vincent Hospital 822 West 4th Street, Leadville, CO 80461 (719) 486-0230

Del Norte Rio Grande Hospital Physical Therapy 310C CR 14, Del Norte, CO 81132 (719) 657-4140 Fairplay Fairplay Therapy Center 540 Front Street #C, Fairplay, CO 80440 (719) 836-1833 La Jara Conejos County Hospital 19021 Highway 285, La Jara, CO 81140 (719) 274-6025 Leadville Avalanche Physical Therapy & Sports Rehabilitation St. Vincent Hospital 822 W. Fourth Street, Leadville, CO 80461 (719) 486-0230

SLVRMC Pro Therapy 2360 Sherman Avenue, Monte Vista, CO 81144 (719) 852-5144 Valley Wide Health Systems 925 Second Ave., Monte Vista, CO 81144 (719) 852-2512 Saguache Rebound Physical Therapy 405 Denver Avenue, Saguache, CO 81149 (719) 539-6144 Westcliffe Custer County Medical Center 704 Edwards Ave., Westcliffe, CO 81252 (719) 783-2380

Parker Physical Therapy 1601 N. Poplar Street, Leadville, CO 80461 (719) 486-2000

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Managing at Home after Surgery Reasons to Call Your Doctor Following discharge to your home, if you experience any of the following, call your doctor immediately:

1. Excessive redness around your incision



2. Temperature greater than 100.5 degrees



3. Increased drainage from the wound



4. Worsening pain not relieved by pain medication



5. Continued wound drainage for more than 5 days



6. Sudden onset of shortness of breath, or chest pain

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Managing at Home after Surgery Home Setup after Joint Surgery Rearranging a few items in your home, assessing what equipment you will need, and understanding how to adapt to your environment will help facilitate a smooth transition from the hospital setting back to your home. Kitchen 1. Make sure all frequently used items are taken out of low storage places and placed on the counter for easy access. 2. Move all food in refrigerator to the top shelves. 3. Remove all throw rugs as they present a tripping hazard. 4. On cooking days, cook for 3‐4 meals instead of one, so cooking is kept to a minimum. 5. Place a high stool or chair in the kitchen area to sit on while working (chopping food, washing the dishes, stirring on the stove or using the microwave). 6. Use the reacher tool to grab items less than two pounds in high and low places to help maintain balance. 7. Empty trash when only half full. Living Room 1. Do not sit on low couches without arm rests, as they are difficult to get out of. 2. Place a pillow on a low chair or recliner to increase the seat height. 3. Before sitting down, make sure all items are within reach (i.e. telephone, remote control, water, snacks). Bedroom 1. Sleep on the side of the bed that is closest to the bathroom. 2. Place a night light in the room for easy visibility when getting up. 3. If using a commode, place it at a 90‐degree angle to the bed, and keep mobility-assistive devices close. Bathroom 1. If a tub/shower is the only option for showering, consider a tub‐transfer bench with or without legs. (If a shower stall is an option, it is recommended to use commode for both the toilet and as a shower chair.) 2. Place the bench in a position so that water controls are within reach. It is best if the bench is placed on the side of the faucet, and a hand‐held shower head is used. 3. A high raised toilet seat is recommended if there are places next to the toilet to hold onto when standing up. A commode is recommended if there is nothing next to the toilet to hold onto when standing up or lowering down.

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Your Roadmap to Surgery: Patient Checklist If you have not had a dental checkup within the last six (6) months, schedule one prior to surgery.

Schedule an appointment with your primary care physician at least three (3) weeks prior to surgery but not more than 30 days prior to surgery.



Have lab work done (CBC, CMP, Urinalysis), Chest X-ray, and/or Electrocardiogram if ordered by your PCP. As soon as you are scheduled for surgery, preregister for admission by calling (719) 530-2360.



If you have questions about your insurance coverage or the balance you may be responsible for, please call the HRRMC Patient Financial Services Department at 719-530-2475.



Select an outpatient physical therapy (PT) provider. Schedule a preoperative PT visit so the therapist can assess your current functional status and review your postoperative exercises with you. You should also schedule a postoperative PT visit to ensure timely follow-up after your dis- charge from the hospital.



About one (1) week prior to surgery, a preoperative nurse from HRRMC’s Surgical Services Department will call you to conduct a preoperative assessment, which includes a review of your medical history. This assessment is necessary to help provide the highest quality of patient care for you.



Seven (7) days prior to surgery have lab work done, as ordered by your physician, to include Blood Type and Screen and MRSA swab. Follow instructions on Skin Preparation List. Obtain durable medical equipment if needed (walker, toilet riser or shower bench).



Check with insurance company on home health services benefits for physical therapy and lab/ nursing services.



Check with insurance company for skilled-nursing facility benefit for short-term rehabilitation if indicated.



Check with insurance/prescription plan for coverage for Lovenox injectable or Xarelto oral medication if if recommended by your physician.



If you are planning on short-term rehabilitation or have any concerns about caring for yourself at home, call the discharge planner at (719) 530-2284 as soon as possible to make arrangements.

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Forms to Complete Appointments Please fill in dates as you receive this information. Surgery: Date

Time



DATE

Preoperative Appointments Preoperative History and Physical with Primary Care Physician



Preoperative Physical Therapy



Preoperative Nurse



Postoperative Appointments Physical Therapy Visit (Please schedule your post-op physical therapy appointment prior to surgery.)



Staple Removal with Ortho



6‐Week Visit



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Forms to Complete HRRMC Orthopedic Center of Excellence 719-530-2042 • 719-530-2454 (After hours and weekends) Important phone numbers and contacts during your hip replacement process. Please fill in this page as you receive this information.

phone #

Orthopedic Surgeon



719-530-2002

HRRMC



719-530-2200

Primary Care Physician



Case Manager Pre-Op Care Nurse

719-530-2255

Physical Therapist Occupational Therapist

Close Family/Friend Contacts Name Name Name Name

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Forms to Complete Discharge Planning Form Please complete this form prior to your assessment with the pre‐op care nurse and bring it with you to your appointment. 1. Where will I stay after leaving the hospital? My home Relative’s home Other 2. Who will pick me up from the hospital? 3. If ordered, when will home health services begin? 4. Will I be alone during the day?

o Yes o No

a. If yes, whom will I call that lives nearby?

5. Are there stairs in your home?

o Yes o No

If yes, how many?

6. Do you already have a

o o o o

shower chair grab bars raised toilet seat walker

7. Are you currently on home oxygen?

o Yes o No

8. Do you have an Advance Directive? If yes, please bring it to the hospital with you. Insurance Carrier & Policy Number Contact name and Phone number: (Please bring your card with you)

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Forms to Complete Insurance Carrier and Policy Number Contact name and Phone number (Please bring your card with you)

Call your Insurance and ask these specific questions (unless you have Medicare).

o Yes o No

1. Am I covered for home physical therapy? 2. For how many visits am I covered?



3. Do my covered visits combine nursing, physical therapy and home health aide visits?

o Yes o No

4. Do I have a pharmacy benefit for Lovenox or Xarelto?

o Yes o No

5. Do I have benefits to go to a skilled nursing facility for further rehabilitation if needed?

o Yes o No

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Forms to Complete HOME OXYGEN CARE SERVICES Cloud City Medical -No Liquid 735 Highway 24 South Leadville, CO 80461 (719) 486-2950 FAX (719) 486-2959 Serving Lake and Chaffee Counties

Canon City Office-Liquid 1232 Main Street Canon City, CO 81212 (877) 681-8668 FAX (719) 275-1807 Serving Fremont County

LINCARE:

Adult & Pediatric Specialists (APS) - Liquid 28350 County Rd. 317, Suite 7 Buena Vista, CO 81211 (719) 395-8613 FAX (719) 395-4857 Serving Chaffee, Lake and Park Counties

Buena Vista Office-No Liquid 115 E. Arkansas P.O. Box 4785 Buena Vista, CO 81211 (719) 395-2535 FAX (719) 395-3773 Serving Chaffee, Lake, Park and Summit Counties Alamosa Office-Liquid 1103 Main Street Alamosa, CO 81101 (877) 681-8667 FAX (719) 589-9266 Serving Alamosa and Saguache Counties

AeroCare - No Liquid 1535 G Street Salida, CO 81201 (719) 539-3406 (719) 539-2857 Serving all of Colorado

Patient Signature Patient’s Physical Address Employee Signature

Date

Referring Physician Patient ID Label

66

HRRMC

orthopedic center of excellence

HIP REPLACEMENT GUIDEBOOK

Forms to Complete Questions for My Hip Replacement Team Use this page to record your questions or concerns so that they can be answered before the day of surgery.

HRRMC

orthopedic center of excellence

HIP REPLACEMENT GUIDEBOOK

67

Forms to Complete Notes

68

HRRMC

orthopedic center of excellence

HIP REPLACEMENT GUIDEBOOK

Forms to Complete Notes

10/16

HRRMC

orthopedic center of excellence

HIP REPLACEMENT GUIDEBOOK

69