Strictly Clinical

BONES: A postoperative plan of care and education program for total joint replacement patients

According to the Centers for Disease Control and Prevention, about 719,000 total knee replacement and 332,000 total hip replacement procedures were performed on inpatients in 2010. For both procedures, these statistics reflect a large increase from 2000. Many factors help explain the rise, including an aging and growing population, obesity as an osteoarthritis precursor, and better healthcare access. The growing number of joint replacement patients underscores the need for nurses and other healthcare professionals to be prepared to provide specialty care and education.

In 2015, Eisenhower Medical Center (EMC), a Rancho Mirage, California, hospital with Magnet Recognition®, acknowledged the growing need for a comprehensive approach to total joint replacement surgery. Physicians, physician assistants, registered nurses (RNs), nurse practitioners (NPs), nurse educators, physical therapists, occupational therapists, case managers, and administrators worked together to develop an evidence-based system that focuses on patient satisfaction, preventing complications, timely care transitions, and patient education.

As part of the application process for Joint Commission certification in total hip and total knee replacement surgery, the multidisciplinary care team chose many performance improvement measures. The team wanted to ensure not only that patients are aware of their plan of care, but also that elements of the plan travel with the patient in various perioperative settings. EMC nurses proved instrumental in developing an education program, called BONES, which patients can easily understand and that travels across the continuum of care. BONES stands for:

B: Blood thinner

O: On a bowel regimen

N: Need for pain control


E: Exit plan/equipment

S: Stay active/safety.

Blood thinner

After hip or knee replacement, patients are at higher risk for blood clots. Methods that help prevent blood clots include:

  • blood-thinning medication (for 4 to 6 weeks)
  • early and frequent ambulation
  • sequential compressive devices (SCDs).

On a bowel regimen

Constipation is a common side effect of certain pain medications. Proper hydration is key in preventing and managing this problem. Patients should receive scheduled stool softeners and as-needed laxatives; before discharge, they should be able at least to pass gas. At discharge, patients typically are prescribed a stool softener.

Ask patients if they’re already using a regimen to keep them regular. Advise them to contact their surgeon if they go longer than 3 days without a bowel movement. Inform them that going longer than this may indicate the need for a different type of stool softener—or could signal a complication, such as postoperative ileus or bowel obstruction. These complications warrant additional assessment and possibly a trip to an urgent care clinic or even the emergency department.

Need for pain control

Techniques used to minimize pain include:

  • administering pain medication, as needed
  • using ice and elevation
  • repositioning and mobilizing patients frequently
  • having patients meditate and use breathing techniques.

To keep the patient’s pain at a tolerable level, assess it regularly using a numeric pain scale. Also, be aware that patients should receive pain medication 30 to 60 minutes before physical therapy. Instruct patients to inform the nurse or other care-team members when they’re in pain.

Exit plan/equipment

At EMC, our goal is to enable patients to go home:

  • within 1 or 2 days of surgery
  • with a home health care arrangement
  • with needed prescriptions.

We complete a medication reconciliation (a review of home and hospital medication to eliminate duplicates) and ensure the patient has scheduled follow-up appointments. NPs or physicians complete medication reconciliation and write prescriptions as needed at discharge. EMC partners with an on-campus Walgreens pharmacy for bedside prescription medication delivery before discharge. If the patient opts into this program, we send the prescription directly to Walgreens. Before discharge, the care coordinator assesses what equipment the patient will need at home. (See Home equipment.)

Stay active/safety

Patients should be up and out of bed on the day of surgery. To regain their physical strength, they must be prepared to work hard. Encourage them to:

  • maximize their effort in physical therapy
  • stay active but pace themselves
  • walk, walk, walk—but don’t overdo it.

Inform patients that postoperative swelling is common and normal. Elevate the operative leg above heart level, and apply ice to decrease swelling. Teach the patient to apply ice at home after discharge as well, as swelling may take months to resolve.

BONES teaching

BONES teaching begins in the preoperative total joint replacement patient-education class offered weekly at EMC. Patients are required to attend this hour-long class before elective joint replacement surgery. Presented by orthopedic NPs, the class gives patients the chance meet inpatient care-team members and ask questions to address their concerns. Also, BONES is included in a PowerPoint presentation and in preoperative printed education materials given to patients in the class.

In the inpatient setting, BONES education is included in post-joint replacement physician order sets. The Orthopedic Wellness Unit at EMC also features BONES teaching in the patient’s room via the communication board. Nurses and certified nurse assistants are trained to write the BONES plan of care on this board. Ideally, the patient, orthopedic surgeon, and other care-team members can reference the board at all times to stay updated on how each area is being addressed. (See Communication board: BONES plan.)

Since BONES was implemented, the orthopedic wellness unit has achieved some of EMC’s highest patient satisfaction scores, with hospital stays and readmission rates among the lowest. Nursing staff currently are working on developing similar teaching tools through unit-based councils for other elective surgeries.

The authors are nurse practitioners in the orthopedic surgery line at Eisenhower Medical Center in Rancho Mirage, California.

Selected references

Centers for Disease Control and Prevention. National Center for Health Statistics. Hospitalization for total hip replacement among inpatients aged 45 and over: United States, 2000–2010.

Centers for Disease Control and Prevention. National Center for Health Statistics. Hospitalization for total knee replacement among inpatients aged 45 and over: United States, 2000–2010.

Green UR, Dearmon V, Taggart H. Improving transition of care for veterans after total joint replacement. Orthop Nurs. 2015;34(2):79-88.

Marcus-Aiyeku U, DeBari M, Salmond S. Assessment of the patient-centered and family-centered care experience of total joint replacement patients using a shadowing technique. Orthop Nurs. 2015;34(5):269-79.

Moore TB, Kim K, Schwarzkopf R. Patient compliance with total joint arthroplasty preoperative instructions. Qual Prim Care. 2015;23(4):231-4.

Wittig-Wells D, Higgins M, Davis E, et al. Impact of a focused approach for discharge teaching regarding the use of aspirin as anticoagulant after joint replacement surgery. Orthop Nurs. 2015;34(4):211-22.

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