[P_RN]

http://www.medicalnewstoday.com/articles/40103.php

This is an older article without some of the more recent info on the COX-2s. But some good info here.

Nonsteroidal anti-inflammatory drugs (NSAIDs), including over-the-counter aspirin and ibuprofen, are the most prescribed medications to relieve pain and reduce inflammation post-surgery. A lesser prescribed -- and more potent -- set of pain relievers are COX-2 inhibitors, a special category of NSAIDs. Unlike COX-2 inhibitors, NSAIDs prevent blood from clotting, so patients are required to stop taking these medications one to two weeks prior to surgery to prevent excessive bleeding.

So they may inhibit bone healing; nsaids increase bleeding/inhibit clotting.

[JaredCNA]

Originally Posted by P_RN

So they may inhibit bone healing; nsaids increase bleeding/inhibit clotting.

Good info. I'm just full of questions right now because I've been flipping through my Pharmacology book for next semester.

Now I'm wondering why our lumbar lams and ACDs get Toradol. And the doc who does the ACDs will schedule the Toradol q4h for his pts...not prn.

[november551]

Originally Posted by JaredCNA

Good info. I'm just full of questions right now because I've been flipping through my Pharmacology book for next semester.

Now I'm wondering why our lumbar lams and ACDs get Toradol. And the doc who does the ACDs will schedule the Toradol q4h for his pts...not prn.

I think it's really a matter of surgeon/facility preference. Most of the orthopedic surgeons where I work will prescribe PRN toradol, but we DC it before the patient starts any anti-coagulation therapy (like warfarin/lovenox). So usually we can give toradol for the first 24 hours. Sometimes patients don't get anti-coag therapy and in those cases I think we can give PRN toradol for up to 5 days. At that point it gets DCed so the pt's kidneys don't get screwed up. We just have to be on our toes and aware of the other meds the patient is on or conditions they have (like a hx of stomach ulcers) before we make the decision to go ahead and push toradol.

Personally, I like toradol - since it is not an opiate type pain med. Not that I have a problem with opiates, but opiates have a LOT of side effects that toradol doesn't (like respiratory depression or making elderly people go off their rocker). For some people it really really works well. There are others that it doesn't work well on at all. I will usually try it in conjunction with an oral medication like oxycontin or vicodin. If toradol isn't cutting it I switch to SQ dilaudid. Believe me, if the toradol isn't working it usually pretty obvious within an hour or so!

Like I said, it's just a matter of surgeon preference, so don't wrack your brain too hard trying to figure out the whys. At my facility there are 3 neurosurgeons who do lamis and discectomies. Surgeon A always prescribes IM demerol for pain control (and sometimes vicodin if the pt is lucky). Surgeon B will prescribe every pain med under the sun, except he will always choose morphine instead of dilaudid for the IV push pain med. Surgeon C only prescribes IV valium, SQ dilaudid, and tylox. It's not really consistent, but that's just the way they practice. I personally find that no one pain med is ever better than another 100% of the time, it's really just a matter of finding what works for the individual patient. If you are really curious about it, you could just ask the surgeon why they prescribe med A over med B, they'd probably be happy that you asked and would explain their point of view (they love talking about that kind of stuff).

[JaredCNA]

Originally Posted by november551

but opiates have a LOT of side effects that toradol doesn't (like... making elderly people go off their rocker)....

Damn, tell me about it! Our joint docs do about 15 surgeries each week. I work specifically with our joint replacements most night. EVERY...SINGLE...ONE gets Morphine PCA. Top that off with Ambien that a new nurse always gives elderly patients, and at least two or three each night end up in restraints.

It really bites for me because I've been doing this for some time and they don't know how to deal with loonies so I usually have to go in there alone.

[NJNursing]

Originally Posted by november551

NJ: It's important to get that knee bending as soon as possible. It's a proven fact that the patient will recover faster to their pre-op level of functioning. I don't think approximation is a big deal if the skin is stapled together. (So far) I've never seen or heard of an incision splitting open due to ROM exercises in the immediate postoperative period. We usually start at 65 degrees flexion on the day of surgery and often get the patient up to 90 degrees flexion by day 2 or 3. If it is a young patient they can usually get to 90 even faster.

I wasn't talking about CPM. I was talking about the pillow under the knee that the OP was talking about. I'm all for CPM and PT on the first POD. However, I've walked into some rooms where the previous RN/LPN's had put 1-2 pillows under the knees and not only were the pt's in more pain, but there was more bleeding in the hemovacs/dressings and leading to lower H/H's post-op. I've also never seen skin split apart with the staples, but I've seen the undue swelling under the staples to where the skin is visibly stretched and the pt in pain. We have now changed our policy to have pillows under the HEELS but not directly under the knee.

[NJNursing]

Originally Posted by JaredCNA

Damn, tell me about it! Our joint docs do about 15 surgeries each week. I work specifically with our joint replacements most night. EVERY...SINGLE...ONE gets Morphine PCA. Top that off with Ambien that a new nurse always gives elderly patients, and at least two or three each night end up in restraints.

It really bites for me because I've been doing this for some time and they don't know how to deal with loonies so I usually have to go in there alone.

Morphine/Dilaudid/Ambien works very different with different people. I've seen it make a 50-something person end up all confused and pulling at lines. I've seen 90-year-old be ok with it. I've seen it make people so sick we end up d/c-ing it because Zofran/Reglan/Phenergan don't help. Sometimes they end up so snowed, you worry about them.

Our orthos however do NOT prescribe Toradol at all for the risk of increased bleeding. They'd rather use Lovenox/Coumadin in a controlled setting instead. I could see on the 2nd or 3rd DPO to allow the Toradol, but not just ban it forever.

[LouisianaNurse2006]

Originally Posted by rntoon

why can't a pillow be placed under the knee while asleep for a patient that had a total knee replacement?

Back to the original topic... (pain meds/ anticoagulants are physician/ pt specific).....
In our ortho unit (we have 2 drs that do most of our TKRs), #1 begins ROM with PT on POD#1, #2 Dr starts POD#2 with ROM. Until ROM is allowed, the pt still ambulates, but with Knee Brace ON, to keep knee straight. The oxfords all ambulate w/ROM on POD#1. (The day of surgery we allow them to rest, and PT starts the next morning.)

The pillow question, which btw has nothing to do with whether the pt is sleeping or awake, has more to do with bending the knee. (and of course it could be more painful)

We put pillows under our pts legs longways (not crossways), so as to elevate the extremity, but not bend the knee. The whole reason for having the knee brace (full length that is) post-op is to keep the leg/ knee straight immediately post-op, correct??

We have a hard straight knee brace, elevation, ice immediately post-op, then once that first dressing change is done, be have our "fishnet" dressing over gauze, and continue with ice/elevation.

Is that how most of you guys are required to do it? From my experience, we don't really have alot of say so, each of our orthopedic surgeons have their own ideas and let us know how they want it done.

Have a nice day!

[NJNursing]

yeah, that's pretty much how it is here. Our doctors have a pretty standard set of PO orders based on which group is doing the surgery and which doctor in the group.

[Emmjay]

Toradol is contraindicated cuz it can increase bleeding......
I've read that research is not clear regarding the effectiveness of the CPM. You'd think it would certainly increase ROM, but research is not indicating that.
The pillow under the knee not only isn't good for all of the above posted reasons, but it also decreases extension of the knee or straightening of the knee......which is just as critical as flexion.....ya don't want your patient 'stuck' in a flexed position.