N2261: Total Hip Replacement/ Total Hip Arthroplasty – Flashcards

- chronic, progressive joint disease - most common joint disease - primary cause is unknown - secondary causes may be due to trauma (ex: sports injury), metabolic disease, decreased oestrogen production following menopause, overuse (ex: running), infection, joint instability, being overweight or obese

Patients may wait months before coming in to see their physician. The pain is what brings them in and the swelling can be intense Symptoms: - pain (may be slow progression of localized pain) - stiffness and swelling around the joint(s) lasting > 2 weeks - limitation of joint movement (stiffness) - crepitus (grating sound caused by bone rubbing against bone) - may effect any joint in body (ex: spine, knees, hips, hands, and shoulders etc)

Diagnostics: - rheumatoid factor (to eliminate the possibility of RA) - erythrocyte sedimentation rate (ESR), which is the gross measure of inflammation - C-reactive protein - bone scan (radioactive nucleotide is injected 60 minutes prior to scan; radioactive dye is picked up on scan in bone that is fractured or porus, callused or weak) - Dual X-Ray Absorptionmetry (DXA): scan for osteoporosis; important to conduct prior to a hip replacement to determine whether the femur is strong enough to support the prosthetic (determines areas of porousness)

Treatment: - heat/cold (preference or physician, client and physio) - protect joints - avoid heavy lifting, use proper body mechanics, grab bars and assistive devices (braces and canes) - weight loss - pain management is key (NSAIDs and tylenol) - use of glucosamine and chondroitin - steroid injections

- common causes are falls and major trauma (ex: MVA) - risk factors include age, chronic medical conditions (ex: A. fib, HTN, TIA - diseases that make patients light-headed and dizzy, putting them at risk for fall), being female, nutrition (ex: diet ), physical inactivity, tobacco/alcohol use; medications (ex: corticosteroids), environmental hazards (ex: mats, extension cords, clutter) - diagnosed by x-ray, physical exam, CT scan, ESR, RF, DXA scan

- fractures occur commonly the femoral neck (ex: intertrochanteric, subtrochanteric, subcapital, transcervical) - where fracture is will influence type of prosthetic used (unipolar, cementless, intramedullary nailing - doing whatever supports bone the best) - based on age, co-morbidities and physical condition

Manifestation: - external rotation - muscle spasm causing shortened extremity - pain and tenderness - unable to use limb or walk - displaced femoral neck fracture can cause serious interruption of blood supply leading to avascular necrosis

Treatment: - Total Hip Replacement (THR) or Total Hip Athroscopy (THA); reconstruction or replacement of joint to relieve pain, to improve ROM or to correct a deformity - THR/THA usually lasts for 10-15 years in most individuals

Pre-Operative Nursing Care - assessment - consent and prep re: hospital policy - NPO at least 8 hours prior - bed rest and frequent tipping/turning - Foley catheter - pain, nausea and constipation management - teach post-op mobility restrictions - pillow between knees when in bed - hips cannot be lower than knees - do not cross legs (ankles or knees) - raised toilet seat to avoid 90 degree limit of hips - don't reach in bed for items, use a grabbing device - maintain proper hip and pelvic alignment - don't bend over, use sock puller or shoe horn

- under general anaesthetic or spinal anaesthesia - incision over hip and down thigh - head of femur removed - hip socket is cleaned out, remaining cartilage and bone reemed out - new socket is implanted with metal stem inserted into femur - artificial components fixed into place - muscles and tendons replaced against bones - incision closed Surgery is aggressive, so there is a fair amount of pain and blood loss

Post-Operative Nursing Care - IV fluids (NS @ 100-125 mL/hr) - pain, nausea and constipation management - physiotherapy will usually mobilize the patient initially - LMWH self injection teachings - encourage foot and ankle movement - use methods to decrease swelling (ex: icepacks) - discuss the importance of mobilization to avoid pneumonia, DVT, pressure sores - the incision line and dressing will stay in place for 7 days (write on it when it should come off) - monitor hemoglobin and CBC (post-op days 1 and 3) - maintain abduction with pillows and/or a brace - once the dressing is off, don't get incision line wet; if it gets wet, pat it dry - cover it with elastoplast or tape dressing if the incision is bothering them - sutures are removed 14 days post-operatively by the surgeon or the physician (patient will likely be given a pair of staple removers) - Pehr splint may be used; it is screwed into place between the knees, preventing adduction from occuring

Complications - anaemia - dislocation (sudden severe pain, lump in buttock, shortening of limb and external rotation) - 50% more likely to experience post-operative delerium than any other surgery; complete CAM assessments and monitor closely) - urinary retention - DVT/PE - infection - atelectasis

Discharge Planning - dietician consult (needs lots of calcium and orange juice) - PT and OT ensure patient can mobilize and home and will go over exercises and outpatient PT/OT therapy - ensure patient understands the importance of diet, rest, mobilization, pain control, constipation prevention, and proper use of medication - ensure patient is capable of self-injection and have them demonstrate the skill - teach the signs and symptoms of infection (redness, pain, heat, heaviness, fever, SOB, swelling, unusual drainage) - if staples are not removed at hospital, ensure patient knows they must see surgeon or physician to have them out - question the patient about coping and home and if they have the support they need

- pulling force on injured part of body or extremity - counter traction or opposing force must be applied - counter traction may be supplied by patient body, position of bed or by weights

Purpose - prevent or reduce pain - immobilize a joint or body part - reduce fracture or dislocation - prevent soft tissue damage or expand joint space prior to surgery

Application: - when traction is applied, orders include type of traction, amount of weight and if traction can be removed for nursing care

4 types (Manual, Skin, Skeletal and External Fixation Skeletal: - aligns bones or joints - used for complex fractures (ex: 3 breaks or more) - longer term use - pin or wire is inserted into the bone to align and immobilize fracture - weights range from 2-20 kg - increased risk of infection due to pin site and prolonged immobility - pin sites are a portal of entry of microbes and they require fastidious care to prevent osteomyelitis and other infections - uses weights and needs to be maintained in a certain position (some surgeons insist that weights not be removed; others allow 20 minutes at a time twice a day for skin care etc.) - the patient is in bed for 6-8 weeks (risk or pressure sore, muscle wasting, weakness, renal stones, pneumonia, skin irritation and hypotension Skin: - short term use (ex: 72 hours prior to surgery) - maintains alignment, assists in reduction and decreases spasm - weight is usually 2.3-4.5 kg - most commonly used for fractured hip - ex: Buck's Extension is a velcro boot wrapped around effected limb with a weight on the end with the individual acting as counter traction; the patient is constantly being dragged towards the end of the bed and so frequent repositioning is required; if the patient gets too low in bed, there is no counter traction External Fixation (Hoffman's Apparatus) - metal pins are inserted into bone and attached to rods to stabilize fracture while it heals - the device can be adjusted to realign bone - used to immobilize bone when casts or other methods are innappropriate - do not use the device to move limbs; limbs must be supported at proximal and distal ends and lifted Circoelectric Beds: - used to tilt patients into a near standing position - engages vasculary system (particularly in lower legs to prevent DVT and avoid hypotension) Manual: - simple, closed reduction can be used prior to putting on a cast - pulling force in applied by hand to provide temporary immobilization, usually accompanied by sedation and anaesthesia to assist with application of immobilizing device

Nursing Actions - safety: ensure that ropes and pulleys are free of knots, fraying, loosening or improper positioning at beginning of each shift; rope should be checked throughout shift - assess neurovascular status of affected body part hourly for first 24 hours and the q4hrs - monitor body alignment; if the patient is in pain, they may be out of alignment - ensure that weights are not on the floor; if removing from care, remove them together and slowly with another nurse - if accidentally dislodged, remove them and replace them slowly with another nurse - monitor skin integrity - critical - pin sites are cleaned with NS with sterile q-tips once or twice a shift, monitor sites for redness and drainage; serous crusting in normal and due to oedema (NCLEX: serous crusting may be left in place and cleaned with chlorehexidine)

- a temporary circumferential immobilization device usually applied following closed reduction of a fracture - permits patient to perform many of their ADLs while providing stability for the site - generally incorporates the joints above and below the fracture site, restricting tendinoligamentous movement facilitating stability (extra stability but stiffness after cast is removed) - plaster of paris casts are heavy and not water resistant; they set in 15 minutes but require 24-72 hours to completely dry - fibreglass is light, strong and water resistant, porous (allowing for air flow and < skin irritation); sets in 30 minutes and completely dries in 3 hours

Application - skin is cleaned and dried prior to casting - moleskin or gauze padding is placed over bony prominences before cast is applied - windows may be left in cast for observation of wound and for procedures such as auscultating bowel sounds; this is important for patients in trunk casts because they are susceptible to "cast syndrome" where the superior mesenteric artery is compressed against the duodenum due to cast weight; bowel sounds will stop, developing an ischemic bowel; patients will be nauseas and an NG tube may need to be placed for decompression - casts may be bivalved (split up sides due to swelling) and wrapped in a tensor bandage for support - once cast is dry, the edges are petalled (turned back and taped), to provide smooth, non-irritating edge against skin

Types - short, long and longer arm and leg casts - walking casts with rubber sole applied to bottom, assists patient with weight bearing - spica cast (portion or trunk and extremities are casted), commonly used for children with hip dysplasia - body casts or body jackets (circulates trunk and is generally used for thoracic or lumbar spine fractures)

Immediate Care - monitor neurovascular status - assess pain (pain should not be increasing and there should be no numbness or tingling) - handle damp casts with gloved palms (fingers and dirt create points of pressure inside the cast the can cause pressure ulcers and infections) - position so that warm dry air can circulate around cast - rest cast on pillows and not table edges so that pressure points are avoided - do not cover with a blanket (encourages growth of bacteria in a warm, dark space) - if drainage is present, outline the mark and write the date and time so it can be reassessed later

Patient Education - keep cast clean and wipe with a damp cloth - protect from knocks and bangs that could cause cracking and misalignment - protect toes and fingers from the cold with socks and mittens - use circulation exercises (wriggling fingers and toes), frequently (ex: at least q1hour) - keep cast dry (cover it with a plastic bag when showering or going out in the rain) - notify physician if cast becomes wet through to lining - elevate limb whenever possible to reduce/avoid swelling - where sling and restrict activities as per doctor's orders - do not put anything inside cast to itch, including powders (can cause and abrasion and infection) - casts are removed or replaced by physician only - remember to keep all follow up appointments Report to physician if: - fingers or toes become painful, numb or discoloured - if cast feels too tight or too loose - if cast cracks or breaks - if unpleasant smell or discharge is noticed

- medical emergency - acute medical condition that may follow surgery, injury or repetitive, extensive muscle use in which increased pressure (usually inflammation) within confined space (fascia compartment), impairs blood supply - the fascia is unforgiving and non-elastic - increased pressure within compartment exerts pressure on the blood vessels diminishing capillary perfusion - increased pressure compromises nerve and muscle viability - body reacts by releasing histamine causing vasodilation, oedema and pressure - oedema, haemorrhage and restrictive casts, bandages and burns all contribute - irreversible muscle damage and loss of function occurs after 6 hours - requires urgent or emergent fasciotomy

The Six P's of Compartment Syndrome Early Signs: - pain; severe pain with passive motion that is out of proportion to the injury and not relieved by analgesics (this is the CARDINAL SIGN) - pressure; skin is tight and shiny, swollen and feels rock hard to touch - paresthesia; decreased sensation or tingling sensation due to pressure on nerves Late Signs: - paralysis; progressive motor weakness and decreased movement - pallor; prolonged capillary refill, pale skin, and cold due to lack of peripheral perfusion - pulselessness; very weak or nonexistent pulse due to lack of arterial perfusion

Immediate Healing Initiatives - position limb at heart level to decrease pressure - collect frequent vital signs and neurovascular checks - provide analgesia - assess for swelling or tightness around cast or bandage - remove or loosen anything constrictive - call physician (cast may need to be bi-valved) - check urine for myoglobulin; indicative of soft tissue injury

- emergent limb saving surgery - relieve tissue pressure to re-establish perfusion - done through the incision of skin and the cutting of muscle fascia to relieve pressure and promote relaxation - incision is left open for several days with bulky saline soaked dressings on top - in 3-5 days, patient will require surgery to close incision and may need skin graft - rehabilitation may also be needed - a large incision is made (ex: wrist to elbow or knee to ankle) - closed fasciotomy due to haemorrhage is used to evacuate blood and is closed - fasciotomies to remove oedema are left open (packed with saline soaked sponges and require closing and possibly skin grafting) Hoffman's Apparatus (external fixation device): - is used because the patient cannot have a cast with a fasciotomy - placed into bone above and below fracture - may be adjusted to realign bone

Discharge Teaching - PT and OT to ensure that the patient can mobilize at home and will review exercises and arrange outpatient OT and PT therapy - ensure client understands the importance of rest, diet (calcium, orange juice, proteins), mobilization, pain control and medications - pin site incision care (sterile q-tips and NS) - know signs and symptoms of complications (swollen, red, heavy, hot, fever and drainage) - know and keep follow up appointments - enquire about support at home - may be necessary to organize