TKR question

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.

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.

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.

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!

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.

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.