Total hip replacement, or arthroplasty, is a surgical procedure designed to replace a damaged hip joint with an artificial joint, known as a prosthesis. This intervention is typically considered when the hip joint is irreversibly damaged due to conditions like osteoarthritis, rheumatoid arthritis, fractures, or avascular necrosis, leading to significant pain, reduced mobility, and impaired quality of life. Joint replacement surgeries, while commonly performed on the hip and knee, can be applied to almost any joint except the spine, offering patients a chance to regain function and alleviate chronic pain.
Nursing Care Plans and Management
Post-operative nursing care is paramount for patients undergoing total hip replacement to ensure optimal recovery and minimize complications. The primary goals of nursing care plans are to prevent potential complications, facilitate the restoration of mobility, effectively manage pain, and educate patients about their diagnosis, prognosis, and ongoing treatment needs. A well-structured nursing care plan is essential in guiding interventions and achieving positive patient outcomes.
Nursing Problem Priorities
The immediate nursing priorities for patients following total hip replacement surgery are centered on:
- Preventing infection at the surgical site.
- Managing post-operative pain effectively.
- Promoting early mobilization and preventing complications associated with immobility.
- Ensuring adequate peripheral tissue perfusion to support healing.
- Educating the patient and family for successful recovery and home care.
Nursing Assessment
A thorough nursing assessment is crucial for identifying specific patient needs and potential problems. This involves collecting both subjective and objective data, focusing on the following areas:
Subjective Data:
- Patient reports of pain and discomfort at the surgical site and surrounding areas.
- Patient’s perception of stiffness in the hip joint.
- Description of any abnormal sensations such as numbness or tingling around the surgical area.
- Patient’s account of difficulty performing Activities of Daily Living (ADLs) due to hip impairment.
Objective Data:
- Visible swelling at the surgical site and in the affected leg.
- Observable bruising and discoloration around the hip and thigh.
- Assessment of muscle weakness in the affected leg.
- Measurement of limited Range of Motion (ROM) in the hip joint.
- Evaluation of decreased muscle strength and control in the affected limb.
- Inspection of the surgical incision for signs of infection (redness, drainage, warmth).
Assessment of Contributing Factors:
To formulate an accurate nursing diagnosis, it’s essential to assess factors that may contribute to the patient’s problems. These factors include:
- Compromised skin integrity (broken skin, surgical incision) increasing risk of infection.
- Weakened immune system (immunosuppression) due to conditions or medications like long-term corticosteroid use or cancer treatments.
- Increased susceptibility to infection due to invasive procedures, surgical manipulation, and the presence of a foreign body (prosthesis).
- Reduced physical activity and decreased mobility post-surgery.
- Experiencing pain and discomfort related to surgery and musculoskeletal impairment.
- Effects of surgery and restrictive therapies such as dressings or braces.
- Impact of orthopedic surgery itself, mechanical compression from dressings or casts, potential vascular obstruction, and immobilization.
- Presence of injuring agents, both biological and physical/psychological, such as muscle spasms, the surgical procedure, pre-existing chronic joint diseases, advanced age, and pre-operative anxiety.
Nursing Diagnosis
Based on the assessment data, relevant nursing diagnoses for patients after total hip replacement may include:
- Risk for Infection related to surgical incision, invasive procedures, and implanted prosthesis.
- Acute Pain related to surgical trauma, tissue manipulation, and inflammation.
- Impaired Physical Mobility related to surgical procedure, pain, and musculoskeletal impairment.
- Risk for Peripheral Neurovascular Dysfunction related to surgical procedure, edema, and mechanical compression.
- Deficient Knowledge related to post-operative care, rehabilitation, and home management.
- Risk for Deep Vein Thrombosis (DVT) related to surgical procedure, decreased mobility, and venous stasis.
- Risk for Injury related to impaired mobility, muscle weakness, and potential for falls.
These nursing diagnoses provide a framework for developing individualized care plans aimed at addressing the patient’s specific needs and promoting recovery.
Nursing Goals
The overarching goals for nursing care following total hip replacement are to ensure the patient:
- Achieves timely wound healing without signs of infection, such as purulent drainage or erythema, and maintains a normal body temperature.
- Maintains optimal joint position and function, avoiding contractures and promoting proper alignment.
- Demonstrates improved strength and function of the affected hip and leg, actively participating in ADLs and rehabilitation programs.
- Maintains adequate neuromuscular function in the affected limb, evidenced by normal sensation and movement.
- Exhibits adequate tissue perfusion in the operative limb, indicated by palpable pulses, brisk capillary refill, warm and dry skin, and normal skin color.
- Reports effective pain management and demonstrates comfort.
- Appears relaxed and is able to rest and sleep adequately to support recovery.
Nursing Interventions and Actions
Nursing interventions are designed to address the identified nursing diagnoses and achieve the established goals. Key interventions for patients after total hip replacement include:
1. Preventing Infection Risk and Promoting Infection Control
Preventing infection is critical following total hip replacement to avoid surgical site infections (SSIs) which can lead to serious complications.
Nursing Actions:
- Assess skin/incision site regularly: Monitor color, temperature, and integrity of the skin and incision. Note any signs of erythema, inflammation, or wound dehiscence as early indicators of infection.
- Investigate pain characteristics: Explore reports of increased incisional pain and changes in pain quality. Deep, dull, aching pain might suggest a developing joint infection.
- Monitor temperature and watch for chills: While mild temperature elevations are common post-surgery, persistent fever (especially after the first few days) or chills should be promptly investigated as they may indicate infection.
- Promote rigorous hand hygiene: Emphasize and practice thorough hand washing for all staff and educate patients on its importance in preventing infection spread.
- Maintain aseptic techniques: Utilize strict aseptic or clean techniques during dressing changes and drain management to prevent wound contamination. Instruct patients to avoid touching or scratching the incision.
- Ensure patency of drainage devices: Maintain proper function of drains like Hemovac or Jackson-Pratt to prevent fluid accumulation, which can be a medium for bacterial growth. Document the characteristics of wound drainage.
- Encourage optimal nutrition and hydration: Promote adequate fluid intake and a high-protein diet to support tissue perfusion, cellular regeneration, and wound healing.
- Consider protective isolation: In specific cases, such as for elderly, immunosuppressed, or diabetic patients, reverse or protective isolation may be implemented to minimize exposure to pathogens.
- Administer antibiotics as prescribed: Prophylactic antibiotics are typically given pre-operatively and post-operatively to reduce the risk of surgical site infections. Ensure timely administration and monitor for any adverse reactions.
Surgical site of a patient after a total hip replacement, showing incision and dressing.
2. Improving Physical Mobility & Peripheral Tissue Perfusion
Restoring physical mobility is essential for regaining joint function and preventing complications. Maintaining peripheral tissue perfusion is crucial for wound healing and preventing pressure injuries.
Nursing Actions:
- Inspect skin and ensure pressure relief: Regularly assess skin for redness or breakdown. Keep linens dry and wrinkle-free. Routinely massage skin and bony prominences. Protect the operative heel by elevating the leg with a pillow and using a water glove if needed.
- Monitor for prosthesis slippage: Investigate sudden increases in pain, limb shortening, or changes in skin color, temperature, and sensation, as these could indicate prosthesis slippage.
- Maintain prescribed joint position and body alignment: Ensure proper positioning of the affected joint and body alignment while in bed to stabilize the prosthesis and minimize the risk of dislocation.
- Pre-medicate before activity: Administer pain medication before procedures and activities to reduce pain, muscle tension, and spasms, facilitating patient participation in therapy.
- Assist with safe turning and positioning: Turn patients to the unoperated side using sufficient assistance, maintaining proper alignment of the operated extremity supported with pillows or wedges.
- Demonstrate and assist with transfer techniques and mobility aids: Teach and assist with safe transfer techniques and the use of mobility aids like trapeze bars and walkers to promote independence and prevent falls.
- Assess upper body strength: Evaluate upper body strength as patients will rely on it more for transfers and ambulation, especially after lower extremity joint replacement.
- Implement Range of Motion (ROM) exercises: Perform and assist with ROM exercises for unaffected joints to prevent stiffness, especially in patients with pre-existing degenerative joint disease.
- Promote participation in a rehabilitation exercise program:
- For total hip replacement: Encourage quadriceps and gluteal muscle setting, isometrics, leg lifts, and ankle exercises (dorsiflexion, plantar flexion).
- For total knee replacement: Focus on quadriceps setting, gluteal contraction, flexion/extension exercises, and isometrics.
- For other joint replacements: Implement exercises tailored to the specific joint, such as toe and knee movements or finger and wrist exercises.
- Enforce activity limitations: Observe and enforce limitations based on the replaced joint. Avoid excessive hip flexion/rotation, knee flexion/hyperextension, and adhere to weight-bearing restrictions. Use knee immobilizers if prescribed.
- Encourage participation in ADLs: Promote patient involvement in daily activities to enhance self-esteem, control, and independence.
- Provide positive reinforcement: Offer encouragement and positive feedback to motivate patients in their therapy efforts.
- Assess peripheral circulation: Palpate pulses in both limbs, evaluate capillary refill, skin color, and temperature, and compare findings with the non-operated limb to detect circulatory compromise.
- Evaluate sensation and motion: Assess sensation and motor function in the operated extremity. Increasing pain, numbness, tingling, or inability to move as expected may indicate nerve injury, circulatory issues, or prosthesis dislocation.
- Test peroneal nerve sensation: Assess peroneal nerve function by testing sensation in the dorsal web space between the first and second toes and evaluating the ability to dorsiflex toes.
- Monitor vital signs regularly: Track vital signs, noting any tachycardia or hypotension which may indicate hypovolemia, blood loss, or anaphylaxis.
- Monitor drainage and swelling: Observe and record the amount and characteristics of drainage from dressings and suction devices. Note any excessive swelling in the operative area.
- Assess for DVT signs: Evaluate for calf tenderness, positive Homan’s sign (though less reliable), and inflammation, which may indicate deep vein thrombosis.
- Observe for bleeding signs: Monitor for continued bleeding, oozing from puncture sites, mucous membranes, or ecchymosis, which may indicate coagulation issues.
- Monitor for signs of fat embolism: Be vigilant for restlessness, confusion, sudden chest pain, dyspnea, tachycardia, fever, and petechiae, which can indicate fat embolism, particularly in the first 72 hours post-surgery.
- Monitor laboratory studies: Regularly review hematocrit and coagulation studies as ordered to assess blood loss and coagulation status.
- Ensure correct use of stabilizing devices: Verify that abduction pillows or splint devices are correctly positioned and not causing undue pressure. Avoid using pillows under the knees or knee gatch to prevent circulatory compromise.
- Administer medications as ordered: Administer anticoagulants (warfarin, heparin, enoxaparin) as prescribed to prevent thromboembolism, and analgesics for pain management.
- Apply cold or heat therapy: Use ice packs initially to reduce edema and hematoma formation, followed by heat therapy to enhance circulation and resolve tissue edema.
- Maintain intermittent compression: Utilize intermittent compression stockings or foot pumps as prescribed to promote venous return and prevent venous stasis.
- Prepare for surgical procedures if needed: Be ready to prepare the patient for potential surgical interventions like hematoma evacuation or prosthesis revision if circulatory compromise occurs.
Alt text: Nurse assisting a post-operative hip replacement patient with leg exercises in bed to promote mobility and recovery.
3. Managing Pain and Discomfort
Effective pain management is crucial for patient comfort and participation in rehabilitation.
Nursing Actions:
- Assess pain comprehensively: Evaluate and document pain intensity (using a 0-10 scale), duration, and location regularly to tailor pain management strategies.
- Investigate sudden pain changes: Promptly investigate reports of sudden, severe joint pain with muscle spasms or signs of pulmonary embolism such as sudden chest pain, dyspnea, and restlessness.
- Maintain proper extremity position: Ensure correct positioning of the operated extremity to minimize muscle spasms and tension on the new prosthesis.
- Provide comfort measures and diversional activities: Offer comfort measures like frequent repositioning, back rubs, and diversional activities. Encourage stress management techniques such as relaxation exercises, guided imagery, and meditation. Therapeutic touch may also be beneficial.
- Administer medication regularly and proactively: Provide pain medication on a regular schedule, especially before activities, to maintain comfort and facilitate participation in therapy.
- Administer prescribed analgesics and muscle relaxants: Administer narcotics, analgesics, and muscle relaxants as prescribed. Manage Patient-Controlled Analgesia (PCA) or epidural analgesia if used. Monitor for effectiveness and side effects. Avoid NSAIDs like ketorolac when patients are on enoxaparin.
- Apply ice packs: Use ice packs to reduce bleeding, edema, and pain perception in the surgical area.
- Promote extremity mobilization: Encourage early mobilization including ambulation, physical therapy, exercise, and use of Continuous Passive Motion (CPM) devices as prescribed.
4. Initiating Health Teachings and Patient Education
Patient education is vital for ensuring a smooth recovery and preventing complications at home.
Nursing Actions:
- Educate on signs and symptoms requiring medical attention: Instruct patients to recognize and report signs of infection (fever, chills, incision inflammation, unusual drainage), DVT (calf pain), or other complications (strep throat, dental infections).
- Review disease process and surgical procedure: Explain the disease process that led to surgery, details of the surgical procedure, and realistic expectations for recovery to empower informed decision-making.
- Advise on rest and activity balance: Emphasize the importance of alternating rest periods with activity to conserve energy and prevent fatigue.
- Stress adherence to exercise and rehabilitation programs: Educate patients about the importance of continuing prescribed exercises (crutch walking, weight-bearing exercises, stationary cycling, swimming) within their tolerance to enhance strength and mobility.
- Instruct on CPM device use: If applicable, provide detailed instructions on the in-home use of Continuous Passive Motion (CPM) devices.
- Review activity limitations: Discuss specific activity restrictions related to the replaced joint, such as avoiding prolonged sitting, low chairs, jogging, jumping, excessive bending, lifting, twisting, or crossing legs.
- Discuss home safety modifications: Recommend creating a safe home environment by removing hazards like scatter rugs and unnecessary furniture. Advise on using assistive devices like handrails, raised toilet seats, and canes.
- Demonstrate wound care: Review and have the patient or caregiver demonstrate proper incisional and wound care techniques to promote self-care and reduce infection risk.
- Review medication regimen: Explain the prescribed medication regimen, including anticoagulants and prophylactic antibiotics, and the importance of adherence.
- Notify of bleeding precautions: Educate patients on bleeding precautions if they are on anticoagulants, such as using a soft toothbrush, electric razors, and avoiding trauma.
- Encourage balanced diet and hydration: Promote a balanced diet rich in fiber and adequate fluid intake to support healing and bowel function.
5. Administering Medications and Pharmacologic Support
Pharmacologic support is a cornerstone of post-operative care, focusing on preventing complications and managing pain.
Medications Commonly Used:
- Anticoagulants: Low molecular weight heparin (LMWH) or warfarin are used to prevent blood clots, reducing the risk of Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE).
- Antibiotics: Prophylactic antibiotics are administered peri-operatively to minimize the risk of surgical site infections.
- Analgesics: Pain relievers, including opioids (morphine, oxycodone) and non-opioids (acetaminophen, NSAIDs like ibuprofen), are prescribed to manage post-operative pain and enhance comfort.
6. Monitoring Laboratory and Diagnostic Procedures
Laboratory studies are essential for monitoring the patient’s condition and the effects of treatment.
Common Laboratory Tests:
- Hematocrit: Usually checked 24-48 hours post-operatively to assess blood loss, which can be significant in hip replacement surgery. May be monitored repeatedly, especially for patients on enoxaparin.
- Coagulation Studies: Evaluates clotting mechanisms and the effects of anticoagulant or antiplatelet agents. Generally not needed for enoxaparin but may be relevant for warfarin or heparin. Stool occult blood tests might be indicated, particularly with enoxaparin use.
Recommended Resources
For further in-depth information and resources on nursing care plans and diagnoses, consider these recommended books:
- Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
- Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
- Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
- Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
- All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health
These resources provide comprehensive guidance on nursing diagnoses, interventions, and care planning, enhancing your ability to deliver effective patient care following total hip replacement.
See also
Explore these related resources for further information on musculoskeletal nursing care:
