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TOTAL HIP REPLACEMENT

Replacement of both joints surfaces. Head of the femur and acetabulum.

●Most common reason: is d/t osteoarthritis - degenerative disease - unclear reason - cartilage breakdown and wear - bone rub each other - synovial fluid lost its consistency – causes pain, stiffness, and reduced joint mobility leads to functional impairment and difficulty performing ADL. ●Others: Unclear associated with aging-obesity, mechanical stress, endocrine and metabolic disease and hereditary.

Goal of treatment: relieve pain and improve joint mobility.

POST-OPERATIVE MONITORING: Take into account of the types of analgesia, anesthesia, nature and scope of surgery.

  • Head to toe assessment including vital signs, LOC, and pain.

  • PCA parameters and other equipments (IV, foley, hemovac, blood transfusion etc).

  • Assess intake and output.

  • Assess neurovascular signs and dressing.

  • Proper patient position – in order to prevent dislocation of prosthesis.

  • Abduction cushion must kept be b/n the legs at all times.

SIGNS AND SYMPTOMS OF HIP OR PROSTHESIS DISPLACEMENT:

●Asymmetry of the legs.

●External rotation.

●Adducted

●Swelling/edema.

●Loss of mobility.

●Rigidity, stiffness or spasms.

●Pain.

RESPIRATORY DEPRESSION INTERVENTIONS:

 

1. Take the PCA button out of the patient’s hand.

 

2. Encourage the patient to breathe and wake up.

 

3. Administer naloxone as prescribed.

PCA: Allows the patient to relieve their pain INDEPENDENTLY!

Nursing responsibilities:

●Check integrity of the system.

●Check the medication and if the dose is match those on the medical prescription.

●Assess the effectiveness of pain relief.

●Check the availability and proximity of the material required to treat complications – Narcan (naloxone).

●Assess for the presence of any side effects.

Morphine side effects: Nausea and vomiting, constipation, mild flushing, rash, sedation (Respiratory depression and dependence is very rare).

●Pay attention to:  patient respiratory function – rate, rhythm and depth as well as O2 saturation.

●Use sedation scale.

●Report to anesthesiologist any profound drowsiness, snoring, decrease RR <8/min, shallow breathing.

PRECAUTION TO PREVENT DISLOCATION OF PROSTHESIS

1. Do not CROSS your leg (avoid adduction).

●Use abduction cushion or pillow when lying.

2. Do not BEND forward past 90˚.

●Avoid sitting on low chair.

●Do not squat.

●Do not reach forward when sitting.

●Do not pick items on the floor.

●Use a sock aid to put on socks and shoes.

3. Do not TWIST on your operated leg.

●Avoid pivoting on the operated leg.

4. Do not JAR (heavy impact/hard hit) your hip.

●Avoid slippery surface.

●Wear non slip-sole.

●Avoid impact activities like dancing, jumping and sports.

5. Do not PUSH OR CARRY heavy items.

6. Use chair with armrest to help get up.

7. Use elevated toilet seat.

8. No weight bearing on the affected side (use walker).

ADDITIONAL:

9. Increase fiber and fluids – to prevent constipation.

10. Prophylactic antibiotic therapy (cefazoline) - ↓ post-op infection.

11. Use ice pack to decrease inflammation and pain.

12. Take sponge baths until your surgeon says you may take a shower.

13. Avoid swimming, tub baths and hot tubs.

Initial intervention for patient with nausea: d/t to severe pain and S/E of anesthetic and analgesic.

●Instruct the patient to take deep breaths.

●Change patient position.

●Lastly anti-emetics as prescribed – check respiratory depression.

Lateral position – if vomited to prevent pulmonary aspiration.

DVT preventions:

●Exercise.

●Early mobilization.

●Anti-coagulants.

●Anti-embolism stocking: fitted by trained professional – compression is higher in the ankle, decrease gradually toward the knee.

THR: ADVICE PATIENT TO NOTIFY MD if:

●Pain in your chest, difficulty breathing or shortness of breath.

●An increase in pain, swelling or tenderness in your leg that is not relieved by elevation and icing.

●Your incision becomes red, hard, hot and swollen, or begins to drain of foul smelling odour.

●Redness or pain in your lower legs, even when resting.

●Chills and a fever (above 38.5° C).

●A painful ‘click’ or decreased movement in your hip or sudden difficulty walking.

●Blood in your stool, urine or sputum, and increased bruising.

●Other infections such as a cold or bladder infection.

Total Knee Replacement: NURSING CARE

●Use Continuous Passive Motion machine.

●Towel roll should be placed under the ankle. No pillows under the knee. Do not cross leg.

●ICE pack for 15 mins 3 xs per day minimum (more as needed).

●Pain relief. Meds plus non-pharmacologic interventions.

●Bedside exercises which include ankle pumps, quadriceps sets, gluteal sets, and heel slides.

●Ambulate with assistance.

●Sitting in a chair for at least 30 mins x2/day, in addition to all meals.

 

CAST 

●Immobilize fracture. ●Support and stabilize weakened joint. ●Correct deformity.

COMPLICATIONS:

1. Compartment syndrome: Increase tissue pressure within a limited space that compromised the circulation and the function of the tissue within the confined space.

Assess 6 P’s: Pain, Pallor, Pulselessness, Paresthesia, Poikilothermia, and Paralysis. ●To relieve pressure: Cast should be bivalved, elevate the extremity lower than the heart level. ●Fasciotomy (relieve pressure within the muscle compartment).

2. Pressure Ulcers disuse syndrome:

Instruct patient to tense or contract muscles (isometric muscle contraction) without moving the part to reduce atrophy and maintain muscle strength.

 

HOW TO SUPPORT CAST DURING HARDENING:

●Handle hardening cast with palms of hands.

 

●Support cast on firm smooth surface.

 

●Do not rest cast on hard surface or on sharp edges.

 

●Avoid pressure on cast.

CAST CARE: PATIENT AND FAMILY TEACHINGS GUIDE

DO

  • Apply ice directly over fracture site for first 24 hours (avoid getting cast wet by keeping ice in plastic bag and protecting cast with cloth).

  • Leave cast uncovered and exposed to air.

  • Dry cast thoroughly after exposure to water by:

●Blot dry with towel.

●Use hair dryer on low setting until cast is thoroughly dry.

  • Elevate extremity above level of heart for first 48 hours.

  • Move joints above and below cast regularly.

  • Report signs of possible problems to health care professional.

●Increase pain/pain during movement.

●Swelling and discoloration of toes/finger.

●Burning or tingling under cast.

●Sores or foul odour under cast.

●Keep appointment to have fracture and cast checked.

DO NOT

  • Get plaster cast wet.
  • Remove any padding.
  • Insert any objects inside cast.
  • Bear weight on new cast for 48 hours.
  • Do not cover cast with plastic for prolonged periods.

SPRAIN AND STRAINS

Sprain:  Injury related to the stretching or tearing of ligament tissue surrounding a joint.

 

Clinical manifestations: self-limiting with full function returning within 3-6 weeks.

1. Pain.             3. Decrease in function.

2. Edema.         4. Bruising.

Strains:  Injury caused by twisting or pulling a muscle or tendon and can range from a simple overstretching to a partial and complete tear.

Acute intervention: “RICE”

R-est

I-ce         “PRN  analgesic”                         C-ompression

E-levation

CARPAL TUNNEL SYNDROME

Compression of the MEDIAN NERVE beneath the transverse carpal ligament.

Manifestations: weakness, burning pain, numbness or impaired sensation, and clumsiness in performing fine hand movements.

Management:

●Wrist splints.                                   ●Proper positioning.

●Special keyboards.                       ●Frequent breaks.

●Ergonomic changes.

Repetitive strain injury: Result from prolonged, forceful, or awkward movements.

●Can be prevented by proper ergonomics.

TRACTION: Purpose: ●Minimize muscle spasm. ●Reduce deformity. ●Reduce, align, and immobilize fracture.

NURSING CARE: ●Weights must hang freely! ●Skeletal traction is NEVER interrupted. ●Maintain body alignment. ●Prevent skin breakdown. ●Monitor neurovascular status. ●Pin site care. ●Promote exercise.

COMPARATIVE TABLE OF ARTHRITIS

Rheumatoid Arthritis

Cause:

●Autoimmune (attacking body joints).

Onset:

●Anytime in life.

Symptoms:

●Painful joints, swollen, and stiff. Area is warm, tender or red.

●Usually mornings or inactivity.

Common exams and tests:

●Blood rheumatoid factor and X-ray.

●↑ ESR.

● (+) C-reactive protein.

● (+) Antinuclear antibody.

Treatments:

●Medications: Aspirin, cortisone, methotrexate (Rheumatrex), hydroxychloroquine.

●Rest.

● Joint-strengthening exercises, joint protection.

● Patient (and family) education.

Osteoarthritis

Cause:

●Mechanical wear and tear.

Onset:

●Later in life (45 and older).

Symptoms:

●Joints ache and may be tender but have little or no swelling/redness. Seldom warm.

Common exams and tests:

●X-ray.

●Joint fluid study.

●Arthroscopy.

Treatments:

●Medications (NSAIDS, aspirin, acetaminophen).

●Exercise (Weight loss).

●Heat and cold therapy.

●PT and OT.

●Use of assistive devices.

●Surgical interventions.

Gouty Arthritis

Cause:

●Excessive uric acid in the blood.

Onset:

●N/A. But higher risk on overweight, ↑ alcohol intake or ↑ purine in diet (meat, sea foods etc).

Symptoms:

●Painful, warm, swelling, extreme tenderness. BIG TOE JOINT.

Common exams and tests:

●Joint fluid analysis (arthrocentesis).

●Increase uric acid in the blood and urine.

Treatments:

●Colchicine.

●Allopurinol (Zyloprim).

●Corticosteroids.

●Medications (NSAIDS, aspirin, acetaminophen)

●Weight control.

●Diet and Exercise.

OSTEOPOROSIS

Disease characterized by low bone mass and deterioration of bone tissue. This leads to increased bone fragility and risk of fracture particularly of the hip, spine, wrist and shoulder. Osteoporosis is often known as “the silent thief” because bone loss occurs without symptoms.

RISK FACTORS:“ACCESS”

A-lcohol use, Age >65.

C-orticosteroid use, Caffeine excessive.

C-alcium low.

E-strogen low (early menopause or being a woman).

S-moking.

S-edentary lifestyle (overweight).

DIAGNOSTIC STUDY:

●DEXA (Dual Energy X-ray Absorptiometry).

●History and physical exam.

●Serum calcium, phosphorus, and alkaline phosphatise levels.

 

COLLABORATIVE THERAPY:

A-ctivity (exercise programs).
B-one fractures prevention.
C-alcium supplement and Cacitonin (Calcimar).
D-vitamin (20 min/d exposure to the sun) and Diet rich in calcium.
E-strogen replacement therapy, Evista (raloxipine).
F-osamax (alendronate).

SOURCES OF CALCIUM:

Milk.

Yogurt.                

Broccoli.

Bok choy.

Cheese.                                              

Almonds.

Hazelnuts.

Salmon.

Sardines.

Shrimps.

AMPUTATION

Last resort d/t ensuing physical limitations and psychological effects (altered body image and work).

GOAL OF AMPUTATION:

●To preserve as much of the limb including knee joint.

●The higher the level of the amputation, the greater the energy expenditure needed to ambulate with prosthesis.

TEACHINGS ON STUMP CARE:

The ultimate goal of stump care is to prepare it for prosthesis.

●In order to promote the proper fit and optimal use of the prosthesis a number of principles must be respected:

1.   Keep the stump healthy.  

2.   Prevent contractures by maintaining proper body alignment.  

3.   Shape the stump correctly by using the elastic bandage properly.

SKIN CARE:

1. Staples: Do not penetrate the cutaneous layer as deeply as sutures.

●Removed between 3rd and 15th post-op.

●Normal saline is best product to use for cleaning.

●Assess wound for: infection, hematoma, pain, and discharge.

 2. Recommended hygiene care:

●Wash stump daily with lukewarm water.

●Use mild, unscented soap – harsh soap can cause irritation.

●Avoid soaking the stump in the bath to prevent the skin from being fragile.

●Rinse the stump thoroughly to remove all traces of soap.

●Dry the skin gently to avoid any friction that could cause irritation.

“Prosthesis can only be fashioned when the wound or scar has healed completely”.

POSITIONING:

Proper body alignment can prevent hip and knee joint contractures.

1. How to prevent contractures?

●Keep the knee joint extended and avoids bending the knee.

2. How to avoid bending the patient’s knee?

●Do not put a pillow under the knee thigh or b/n legs, do not abduct, externally rotate or bend the legs.

●Do not allow the stump to hang off the edge of the bed or chair, for this not only obstructs venous return and causes edema, but also increase the risk of knee flexion contractures.

3. Teach the patient to lie on his stomach for at least 30 minutes 3-4x a day and also at night if not contraindicated.

ELASTIC BANDAGING: Must be worn continuously in the first 10 days after surgery.

Purpose: ●Protects the scar.● Reduce hematoma. ●Promotes healing. ●Controls edema.

After 10 days: Worn to prepare the stump for prosthesis by giving it a conical shape – allowing proper fit and comfort.

How to apply:

  • Apply decreasing pressure to the elastic bandage tightly at the distal part, loosely at the proximal.

  • Use crisscross or figure of 8: Because circular bandage restricts circulation by producing tourniquet effect.

  • Maintain compression over the stump “ears” or a lateral squeeze to give the stump a conical shape.

  • Avoid creating wrinkles on the skin with bandage to protect skin integrity.

  • Compression bandage must be worn at all time except during hygiene care and physiotherapy session.

  • It should be replaced at least be replaced at least twice a day to ensure proper compression, to check the condition of the stump skin and to massage the area to stimulate blood flow.

2 Phenomenon after amputation:

  • Phantom limb sensation:

  • Term given to any non-painful sensations felt in an amputated limb.

  • Sensation may be r/t: position, heat/cold, touch or movement.

  • Phantom pain/algohallucinosis:

  • Painful sensation on the missing limb.

  • Pain gradually decreases and occur less frequent but can persist for years or never go away fully.

  • Peripheral nervous system injury or reactivation by the nerve section of pain experienced prior to amputation and memorized by nociceptive pathways.

TEACHINGS:

●Explain to the patient that it is normal phenomenon.

●Medications are available to help them.

TREATMENTS:

1. Analgesics: Atasol 30 (acetaminophen + codeine).

2. Anti-epileptics: Gabapentin (neurontin) – treating nerve pain by quieting damaged nerve to slow or prevent uncontrolled pain signals.

3. Tricyclic antidepressants.

4. Electrostimulation or mental stimulation methods.

RESTRAINT

Anything used to limit a persons movement.

●Physical effects: Panic/fear, Incontinence, Infection, Constipation, Muscle atrophy, Dehydration.

●Emotional effects: Loss of self-esteem, Independence, Dignity, Anger or Agitation, Isolation, Depression.

●Other effects: Pneumonia, Strangulation, Fall, Death.

Types:

1. Physical: Attached to persons body: Hand ties, side rails, Posey belt, etc.

2. Environmental:  Seclusion, secured ward or timeout room.

3. Chemical:  Haldol, nozinan.

RESTRAINT BASICS:

R-equires a physician order.

 

E-mergency cases, get MD order ASAP.

 

S-hort duration only, and choose least restrictive.

 

T-o protect patient and others.

 

R-enew order q 24h.

 

A-ssess circulation q 15-30 mins and document your assessments.

 

I-ndividualize supervision is advised (one-on-one).

 

N-ever used as punishment.

 

T-otal ducomentation (Explanation given to patient or family, type of restraint, specific behavior of patient, exact time the restraint applied and removed.

 

S-hould use alternatives first (Personal items on door or wall i.e. pictures, distractions (radio/TV), attempt to alleviate the cause, allow for close observation by staff, use bed/chair alarms and door alarms or sitter and/or family member).

NURSING CONSIDERATIONS AND INTERVENTIONS:

R-eassurance provide.

 

E-nsure restraint is fit properly.

 

S-hould be release q 2h (depending on patients behavior or situation).

 

T-oileting and movement should be adequate if possible.

 

R-eassess the patient needs always (thirst, toileting), and justification for restraint (patient behavior and related risk).

 

A-ssess circulation q15-30 minutes.

 

I-nclude all safety measures: i.e. patient’s V/S, proper placement, fall precaution, remove all dangerous objects.

 

N-eed to check patient comfort and safety.

 

T-ake a look for alternatives first (always but except emergency).

 

S-hould always be a doctors order.

Fosamax (alendronate)

C-Biphosphonate, bone-resorption inhibitor

H-Morning, before food and other medications.

E-Decreased symptoms or treatment or prevention of osteoporosis.

C-Take with full glass of water (8oz) 30 mins before 1st food.

   ●Patient to remain upright for 30 mins after dose (prevent esophageal irritation).

   ●Store in cool environment out of direct sunlight.

   ●If missed dose, skip dose, do not double the doses or take later in day.

   ●Teach to take calcium + vit. D as prescribed.

   ●Teach the patient if pregnancy is planned, suspected, or if nursing.

   ●Advise to maintain good oral hygiene.

K-Assess for serious reactions: angioedema, SJS, toxic epidermal necrolysis, and atrial fibrillation.

   ●Assess dental status (regular dental check-up).

   ●Hormonal status if woman prior to treatment.

   ●Bone density testing.

   ●Monitor renal studies and Ca, P, Mg, K.

   ●Assess for hypercalcemia: paresthesia, twitching, laryngospasm, Chvostek’s, Trousseau’s signs.

REFERENCES:

 

Preparation guide for professional examination of the OIIQ, PRN comprendre pour intervenir guide d'evaluation, de surveillance clinique, et d'intervention infermieres, Fundamentals of nursing potter-perry, Ultimate learning guide nursing review, The ABC's of passing philippine nursing exam, Medical-surgical nursing assessment and management of clinical problem, Saunders Comprehensive review for the NCLEX-RN examination, Mosby drug guide for nurses, Critical thinking in nursing Winningham & Pressure

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