My job is to take care of patients after orthopedic surgery, especially after total joint replacement. I see patients the morning after their surgery, and follow through to the day of discharge, when they leave the hospital. I handle pain control, medications, and discharge planning, and I coordinate with nursing, physical therapy and the attending physician. I have some information to make your recovery a little smoother, so I’ll take things day by day.
Immediately after surgery, you should wake up in the recovery room, (or PACU, for Post Anesthesia Care Unit). You should expect to feel pretty lousy all over. You may experience confusion or disorientation from the anesthesia and pain medications, as well as nausea. You may be stiff from lying in one position for a while, and of course, you will probably have some pain from the surgical site. However, if you had either a spinal block or what is known as a regional block, you may experience very little pain immediately after the surgery, but you may also be numb, and unable to move your leg or legs. A spinal block may also cause you to be incontinent, or unable to empty your bladder. For this reason, you might have a catheter (a tube inserted into your bladder that drains urine). Expect to be in the recovery room for several hours, so the staff can make sure that you are fully awake, and that your vital signs are stable. Assuming everything has gone well, you will then be moved to the surgical unit.
On the surgical unit, you will be transferred onto a regular hospital bed that may or may not have a trapeze bar overhead. A trapeze bar is something that hangs down, allowing you to support your weight to shift in bed. A nurse will perform a physical assessment, and probably complete a form or two, either on paper or on a computer. You will have your vital signs (blood pressure, heart rate, breaths per minute, temperature, and oxygen saturation) taken, and you will be asked to rate how bad your pain is, usually on a 0-10 scale, with 10 being the worst pain you can imagine. Many hospitals use something called PCA or Patient Controlled Analgesia for pain control. This is an electronic box loaded with painkiller (usually morphine) connected to your IV. You press a button on a wire every time you have pain. The box is programmed with a timed lockout and maximum dose per hour, so you cannot overdose. All you have to do is press the button when you hurt. If you are due for a dose, the machine will give you one. If you get several doses in a short period, you will probably fall asleep, and stop pressing the button. It is important that no one but you presses the PCA button. You may also receive a dose of a blood thinner.
You may also be connected up to various other devices. Depending on your surgeon, you may or may not have your leg placed in something called a Continuous Passive Motion machine, or CPM. This will gently (and as the name implies, continuously) move your leg so the knee bends and straightens. Over the next few days, the amount of bend will be increased. You may be fitted with some tight support stockings that cover your calf, or even up to your thigh. These help prevent blood clots from forming in your calves by keeping the blood moving. You may also be fitted with devices like blood pressure cuffs around your lower legs that gently squeeze and relax continuously, also to prevent blood clots. You may have a cold pack on your knee, either in the form of an ice bag, or a machine that pumps ice water through a pad on your knee and back down to a cooler at the bedside. There may also be red light taped to one finger that is connected to a monitor at the bedside that measures something called oxygen saturation or O2Sat. This is a measure of how well your blood is carrying oxygen. You should also be given a device called an incentive spirometer, which you breathe through 10 times an hour while you are awake. This helps inflate your lungs to prevent pneumonia.
You should also be given a nurse call device of some kind or another. Use it. If you are in pain, and whatever pain medications are ordered aren’t working, call your nurse. If you are nauseated, call your nurse. If you need to go to the bathroom, call your nurse. If you just want to change position in bed and you can’t quite do it, CALL YOUR NURSE! Do not worry about “putting someone out” or “being a bother.” It is your nurse’s job to help you, and there will be one available 24 hours a day. Your nurse can call your physician for orders if something isn’t working, so if something isn’t working, CALL YOUR NURSE!
On post-operative day 1 (the morning after your surgery), you will most likely have blood tests drawn first thing in the morning, so the results will be available when the doctor visits. At my facility, residents under the direction of attending physicians, do the daily rounds. At other hospitals, it may be the attending physicians themselves rounding. Let your doctor know how you feel. If you feel lousy, let him know. Maybe he can do something about it. Don’t tell him everything is fine because you want to be a good patient. That being said, don’t inflate your problems either, because more pain medicine may not be a good thing either. You probably won’t have slept very well the night before, due to a combination of pain, nausea, a strange bed, and people taking your vital signs at ungodly hours. That is okay. You will probably sleep well tonight. If you had a spinal the day before, it will be wearing off by now. If you have a regional block (usually something in your groin that numbs the front of your leg) it may be stopped or turned down. This is because it can make your leg weak, and you will need all your strength for what comes next. Physical therapy usually starts on post-op day 1. The therapists will do their own assessment, and then its time to get up. That’s right, get up and walk. Most doctors let their patients bear as much weight as they are comfortable with right away, although your circumstances may be different. You will need a walker for stability, and you may get dizzy or lightheaded when you stand up. If this happens, let someone know, because patients have been known to black out. This is usually because their pain medication causes a drop in blood pressure. We do not expect a marathon on the first day. If all you can do is stand up, and take a step or two to a chair and sit, that is okay too. Spend a little time sitting up before you go back to bed. Do this exercises the therapist recommends, then rest up, because they will probably be back in the afternoon to do it again.
This will pretty much define the routine for the next few days. Labs in the morning, physical therapy twice a day, interspersed with meals, and naps. Usually the PCA will be stopped on post-op day one or two, and you will be switched pain pills, usually with some kind of shots for backup. Don’t forget the deep breathing exercises. You will probably notice that your surgical pain is getting better, or at least more bearable, as time goes on. Hopefully, your knee will be bending more and straightening more as well. You will also notice that you get tired very easily. This is also normal. I tell people that their body energy bank account is flat broke right after surgery, and they will have to spend a few months taking it easy to build up some reserves again.
Around this time, the staff should start talking to you about discharge plans. If you live alone, you might consider going to a rehabilitation center for a week or two longer, as it will be basically impossible for you to go grocery shopping, or do much in the way of household chores for a while longer yet. You can also get more physical therapy if you go to rehab. On the other hand, if you have someone at home, and you are doing well with therapy, there is no reason you can’t go home. My rule of thumb for “doing well” is relatively simple: A) can you get in an out of bed or a chair by yourself, and B) if your house caught fire, could you get out? If you answered yes to both, then you should go home. I usually arrange for a home physical therapist to visit and check your home for hazards that you may not think about (like loose rugs or power cords), and to continue working on your therapy exercises. Depending on your blood thinner, you may or may not need a nurse to draw blood a few times a week. You will need a walker at home, and a CPM (if your physician uses them). Chances are you will have to keep your incision clean and dry until the staples are removed (which may be done at the doctor’s office, or by home care personnel.)
By your first follow-up appointment at your doctor’s office, you should be using less pain medications, and noticing that your knee is moving better. As time goes on, the pain should disappear, and the knee will begin acting more like a natural knee. While it will never be the knee you had when you where 19, it should allow you to take a walk, go to a dance, bowl, play golf, or swim. Good luck!
