Hip Replacement Article & Hip Surgery and DVT PPT – Flashcards

-Hip replacement surgery removes damaged or diseased parts of a hip joint and replaces them with new, man-made parts. -The goals of this surgery are to: relieve pain, help the hip joint work better, and improve walking and other movements

-The most common reason for hip replacement is osteoarthritis in the hip joint Your doctor might also suggest this surgery if you have: -Rheumatoid arthritis (a disease that causes joint pain, stiffness, and swelling) -Osteonecrosis (a disease that causes the bone in joints to die) -Injury of the hip joint -Bone tumors that break down the hip joint Your doctor will likely suggest other treatments first including: -Walking aids, such as a cane -An exercise program -Physical therapy -Medications -These treatments may decrease hip pain and improve function, but sometimes the pain remains and it makes daily activities hard to do. If this happens your doctor may order an x ray to look at the damage to the joint. If the x ray shows damage and your hip joint hurts, you may need a hip replacement.

Healthy active people often have very good results after hip replacement surgery. But your doctor may not suggest this surgery if you have: -A disease that causes severe muscle weakness -Parkinson's disease -A high risk of infection -Poor health

-Learn what to expect before, during, and after surgery -Ask the doctor for booklets about the surgery -Ask someone to drive you to and from the hospital -Arrange for someone to help you for a week or two after coming home from the hospital -Put things you need in one place at home (for instance, put the remote control, radio, telephone, medicines, tissues, and wastebasket next to your chair or bed) -Place items you use every day at arm level to avoid reaching up or bending down -Stock up on food -Make and freeze meals

-Soon after surgery you will meet with a respiratory therapist and a physical therapist -The respiratory therapist may ask you to breathe deeply, cough, or blow into a device to check your lungs. Deep breathing helps to keep fluid out of your lungs after surgery. -The physical therapist will teach you how to sit up, bend over, and walk with your new hip. The therapist will also teach you simple exercises to help you get better. In some cases within 1 to 2 days after surgery, you may be able to sit on the edge of the bed, stand, and even walk with help. -Usually people do not spend more than 3 to 5 days in the hospital after hip replacement surgery. To be completely well takes about 3 to 6 months based on the type of surgery, your health, and how quickly exercises help. -After you go home, be sure to follow the doctor's instructions. Tips for getting better quickly include: -Work with a physical therapist -Wear an apron to carry things around the house. This leaves your hands and arms free for balance or to use crutches -Use a long handled "reacher" to turn on lights or grab things you need. Your nurse at the hospital may give you one or tell you where to buy one.

-Most common problem after hip replacement surgery is hip dislocation. Because man-made hips are smaller than normal ones, the ball can come out of the socket. This can happen if you are in certain positions, such as pulling the knees up to the chest. -Sometimes the person's body reacts to the man made joint. If that happens, there is usually inflammation (or swelling), and then special cells may eat away some of the bone, causing the joint to loosen. To treat this problem, your doctor may suggest medicines or surgery to replace the joint. -Most people (more than 90%) who have hip joints replaced do not need more surgery. Researchers are trying out joints made of different materials that last longer and cause less inflammation. -Less common problems after surgery are: infection, blood clots, and bone growth past the normal edges of the bone. -Risks of problems after hip replacement surgery are much lower than they used to be.

-Exercise can reduce joint pain and stiffness. It can increase muscle strength and joint range of motion. -Most physical therapists begin with exercises that: increase range of motion and make muscles strong. -Your doctor or physical therapist will determine when you can do harder exercises. Your doctor may say not to jog or play basketball or tennis. These can damage or loosen the new hip joint. *Exercise goals after hip replacement surgery are to:* -Increase muscle strength -Increase your blood circulation and overall fitness -Avoid injuring the new joint *The types of exercises that may help you meet these goals are:* -Walking -Bicycling (on a bike machine) -Swimming -Cross-country skiing

To improve hip replacement surgery, researchers are studying: -Which patients are more likely to do well after a hip replacement -New ways to do hip replacement surgery -How to make better man-made hip joints -Ways to keep the body from rejecting the man-made hip joints -Ways to reduce swelling after hip replacement surgery -How to improve recovery programs used after surgery.

-In patients with osteoporosis the hip is a frequent fracture site. In order to repair a fractured hip, there are two types of surgeries that can be done. An unintended consequence of these surgeries can be deep vein thrombosis which we want to prevent/guard against.

Hip surgery is done for multiple reasons: 1. To repair a fracture 2. To reduce pain and to improve quality of life -Hip surgery allows patients who have pain from arthritis to sleep better, move better, and just enjoy life better. Most common types of hip surgery include Open Reduction Internal Fixation (ORIF) and Total Hip Replacement (THR)

-Use of plates or screws to stabilize bone fractures and allow healing to occur -Less invasive than a THR, usually hip bone and socket are healthier -Must keep hip/leg in good alignment post op -In this kind of repair nothing is done to the pelvic bone or the acetabulum, simply holding the femur together -Usually you have a fracture that is right across the neck of the femur and the bone itself is quite healthy. If the bone has a lot of osteoporosis or if it is just not healthy bone, it makes for a difficult repair so this kind of patient might be a good candidate for a total hip replacement

-Artificial prostheses are used to replace the femoral head and acetabulum Replacing the entire joint: -Ball: often metal and replaces head of the femur -Cup: often plastic and replaces the worn acetabulum -Stem: Inserted into femoral shaft for stability -This is all done using sterile carpenter tools: screws, screw drivers, hammers, drills; so you appreciate why these patients have discomfort after watching one of these surgeries. -THR can either be done cemented or non cemented. Kind of up to the surgeon whether or not they use cement. -The cement is recast to the body heat so it configures to the appropriate shape for a solid prosthetic placement. -In the pics in the ppt you can see where there is a porous coating that can be placed in for non cemented, which will encourage the bone to grow and dig into it. In cemented it is not quite as necessary for the bone to grow over it.

-Very important -When your patient first comes back to the room, you have to be really careful about the care of this patient -Pain management: Very important; they do not have as much pain as you'd think after watching this kind of surgery, but the incision site can be quite sore. We encourage the use of pain meds, especially for the first 48 hours -Positioning: Very important; Have to make sure patient maintains hip precautions if they had a THR and if patient had an ORIF need to make sure hip/leg stays in alignment. -Circulation: Very important to assess; Since it is a fairly major surgery and you are dealing with veins and arteries that go through the surgical site down to the lower extremities, you want to make sure that circulation is maintained. So frequent checks of toes for warmth and pedal pulses for good circulation. -Wound care: Assessing the wound is important; Not particularly blood surgeries, usually pretty clean. The patient will have a dressing on for 24-48 hours, and then the surgical incision is open to air. -Vital signs: We want to assess vital signs to make sure the patient tolerated the surgery and isn't showing signs of infection (like an increased temp)

-One of the major complications that you will see from a THR is a hip dislocation. It is something we really want to avoid, because it involves the patient going back to surgery. *Symptoms of dislocation:* -Acute groin pain (the ball of the joint slides out of the socket and causes this pain) -The extremity is shortened (b/c the muscles pull up the leg so it appears shortened) -Patient commonly complains of a popping noise/sensation that can be heard or felt when the dislocation occurs -A dislocation can be repaired even manually in the operating room as a closed reduction where they put the patient under anesthesia and pop the hip back into the socket -It may also require surgery; sometimes if multiple dislocations occur the patient needs to wear an abduction brace post op for a period of time -Once patient dislocates their hip once, they are at a much higher risk of it happening again. -Acute groin pain, shortened extremity, popping sound/sensation heard/felt can also be signs of a hip fracture in some people.

-Patient has to maintain total hip precautions for 3 months (b/c of the anatomy of the hip) 1. Do NOT bend the hip past 90 degrees (Make sure knee is never higher than the hip); Need to sit in a hard (solid) chair not a soft chair b/c in a soft chair the weight goes to the back and to the buttocks which makes their hip go higher than 90 degrees and then their knee will be higher than the hip -Have patient used a raised toilet seat (prevents knees from being higher than the hip!) 2. Do NOT bring leg across the middle of the body; Can't cross knees or ankles, etc; Abductor wedge can prevent this. (Can't move the leg across the middle of the body b/c this will cause the ball to pop out of the socket. 3. Do NOT let the leg roll inward (Puts patients at higher risk for dislocation); Do not want toes to be pointed toward the middle of the body or toward each other. Want toes pointed outward. -The goal of total hip precautions is to prevent dislocation through proper positioning in immediate post op period and throughout rehabilitation.

-Used to maintain proper positioning (patient has an order for it) -When patient is in bed they need to have the wedge in place b/c it separates the legs and keeps the hip in proper alignment. -Can be somewhat uncomfortable b/c the patient can't move, but it does keep them in proper alignment.

Total Hip Replacement: -Total replacement of ball and socket -Requires use of abductor wedge to prevent dislocation; total hip precautions -Used to replace hip socket due to arthritic changes, osteoporosis, hip fracture, etc. Open Reduction Internal Fixation: -Use of plates/screws to stabilize the fractured bone to allow healing -Bones and hip socket is healthier -Less invasive than a THR -Keep hip/leg in good alignment

-Assistive devices are really important in the rehabilitation of a patient who had a fractured hip. -Assistive devices are prescribed by the physical therapist -Good upper body strength is necessary for a walker, if patient has one side weaker than the other a cane is more appropriate. -Sometimes occupational therapists can prescribe them, but usually PT does

-Total weight bearing (TWB): patient can put full weight on both legs; no restrictions -Weight bearing as tolerated (WBAT): Patient can put as much weight on the affected side as they are comfortable with (usually means they are having some discomfort and need an assistive device to remain steady) -Partial weight bearing (PWB): Patient can only put 50% of weight on the affected leg -Touch down weight bearing (TDWB): They can only put their toe on the floor (touch down) for stability/balance -Non weight bearing (NWB): There is absolutely no floor contact or application of body weight on the affected extremity; this is not seen often *Usually start with TDWB to PWB to WBAT to TWB*

patient can put full weight on both legs; no restrictions

Patient can put as much weight on the affected side as they are comfortable with (usually means they are having some discomfort and need an assistive device to remain steady)

Patient can only put 50% of weight on the affected leg

They can only put their toe on the floor (touch down) for stability/balance

There is absolutely no floor contact or application of body weight on the affected extremity; this is not seen often

-Blood flows slowly in the veins and has a longer time to clot. Incidence of DVT is very high unless precautions are taken. -One of the problems we see sometimes in patients who had bone surgery or any kind of surgery that requires them to be immobilized is DVT (huge complication of any joint surgery b/c of immobility) -Patients w/ hip surgery tend not to be as mobile/active as they used to be so they are at risk for DVT -Want to take precautions to prevent DVT -DVT occurs when the blood flows slowly in the veins and has a longer time to clot; usually it is from immobility (b/c activity and muscle contraction helps move blood back to the heart from the extremities. If there is no activity (and no push to keep the blood moving) it tends to pool and when it pools a clot can form

-Injury -Surgery (injury and surgery are risk factors b/c of immobility) -History of thrombosis or varicose veins (blood gets stuck and veins swell, puts patient at much higher risk for DVT) -Decreased muscle tone -Changes in activity Age over 40 -Hormone therapy -Tumors -Infection -Pregnancy: b/c the baby tends to press down on those major arteries in the pelvis *Most of these risk factors have some implications of immobility

-DVT can be life threatening b/c the clot can move to the lungs, brain or heart. -If it moves to the lungs it can cause a pulmonary embolus which can cut off circulation to the lungs -If it moves to the heart it can get lodged in one of the cardiac vessels and cause a heart attack -If it moves to the brain it can cause a stroke

-Anticoagulation therapy:If we know activity is going to be decreased (like after a surgery that affects mobility) put them on anticoagulants -ROM/Position Changes: need to move muscles and joints -CPM for TKR -TED stockings: Anti-embolism stockings, they are tight and are placed on the lower extremities to assist the return of blood through pressure. (Need to measure for patients b/c they need to be snug to work) -Ambulation: Early ambulation; the day after surgery get patient up and moving -Adequate fluid intake: To keep the blood from getting too concentrated. If they go into a hypovolemic state it increases chance of DVT (do not want blood to be more concentrated b/c it will clot more easily) -Assess lower extremities each shift: DVT tends to happen in the lower extremities because its the furthest place from the heart and it has the lowest arterial pressure there, so that's where blood tends to pool. -So want to keep blood moving: Need pressure from heart, muscle movement, and valves in lower extremities (keeps blood from moving backwards)

-Might see swelling of the legs (one leg may be more swollen than the other) so sometimes measure calves with tape measurer to see if one leg is more swollen than the other. The swelling occurs because of the blockage in the vein that does not allow the blood to return, so blood is backed up/clogged up and blood is still being pushed down through the arterial system from the heart, but gets stuck in the venous system. -DVT most commonly occurs in calves -Warm to touch -Pain in affected area: b/c the blood circulation is cut off -Fever: sometimes but not always -Increased spasticity or stiffness *There may be no signs at all!- if it is a small thrombus we may not see any signs at all*

-Anticoagulation therapy is the prime way to prevent DVT -Surgical patients are at high risk for DVT, including hip replacement patients -Want to make sure we teach about anticoagulation therapy so patients know what it does and so when they are discharged they will know what precautions to take; Someone should be checking on the patient, and they should be avoiding activities that put them at risk for bruisng, bleeding, falling, and sharp objects -DVT is a preventable but often under diagnosed condition since 50% of patients have no symptoms -Anticoagulant medications can be monitored by lab tests -Heparin: monitored by PTT (a test to see if blood is anticoagulated enough); Heparin has a very narrow therapeutic range; want to prevent clots but do not want patient to have excessive bleeding. -Need to check for too much bruising and bleeding -Lovenox: monitored by AF-Xa level; Lovenox is synthetic heparin; safer than heparin -Coumadin: monitored by PT/INR; most common oral anticoagulant (Requires frequent monitoring); Want patients on coumadin to avoid green leafy veggies. Also want them to use an electric razor, a soft tooth brush, to be careful when cutting nails, and cooking. Want them to avoid sharp objects b/c bleeding can get out of control -Heparin and lovenox are common when patient is admitted b/c they are given as a SubQ injection, but they are difficult to send them home with b/c injections. Once a patient has been anticoagulated to the point that the physician wants, they will be placed on an oral anticoagulant (coumadin) that they will be discharged on. -Elaquis is a lot safer and doesn't require the constant monitoring of blood (like coumadin does)

-Home safety assessment, including family/caregiver teaching; Patient has to know that they will bruise easily and can have some serious bleeding issues if they are not careful. Safety is huge, we do not want them falling, or using sharp knives (so family and caregivers need to be aware and keep sharp objects away) -Medication teaching: Should be wearing a medic alert bracelet for anticoagulant Rx so that if they get into an accident, medics will know they are on anticoagulants; Patient needs to go to the hospital/lab for follow up labs every couple of weeks or so and every month to make sure their levels of anticoagulants are therapeutic. -Precautions for post THR/TKR; physical therapy & positioning and exercise program -Activity plan as ordered by physician

-Impaired physical mobility r/t hip or knee replacement as evidenced by inability to ambulate independently -Alteration in comfort r/t hip or knee replacement as evidenced by surgical pain. -Other diagnoses may also come up, but these two are common and specifically related to hip, unless there are unanticipated complications like a dislocation. -Nursing diagnoses have to be individualized b/c every patient is different.

-Fall/Safety risk assessment -Clear handling precautions -Pain assessment -Wound assessment -CSM (circulation, sensation, motion) -Skin Assessment -Home assessment prior to discharge -ADL assessment -Anticoagulation therapy teaching