Arthroplasty Care

by Sultan Review Nursing Review on Thursday, September 29, 2011 at 12:37pm Arthroplasty is the surgical replacement of all or part of a joint. The most common arthroplastic procedures are cup arthroplasty and total hip replacement. The former involves the insertion for a moveable cup between the hip joint surfaces. Bone ingrowth is promoted as the prosthesis has a porous coating. Usually indicated for young patients, this procedure is done for rheumatoid arthritis, a degenerative joint disease from traumatic injury or an acetabulum fracture. Total hip replacement, on the other hand, is usually performed to patients over 50 years old and may be used to treat osteoarthritis and a severe crippling rheumatoid arthritis. More commonly this procedure is used to treat severe joint pain, joint contractures, joint surface deterioration and any condition that prohibits full extension or flexion.

Goals of Arthroplasty Care After the arthroplastic procedure, the following are the goals of patient care:

  

Help restore mobility Restoration of normal use of the affected extremity Aid in preventing complications such as infection, phlebitis and respiratory problems

Nursing Responsibilities in Arthroplasty Care (M-A-P-S) M A P S Maintaining alignment of the affected joint Assisting with exercises Providing routine postoperative care Selecting appropriate home care and exercises for the patient depending on the type of arthroplasty performed and

patient s condition. These exercises and home care should be taught to the patient as these activities may continue for several years.

Equipments Needed

               

Traction frame with trapeze Comfort devices such as static air mattress overlay, low-air-loss bed, or sheepskin Bed sheets Incentive spirometer Continuous passive motion machine for total knee or hip replacement Compression stocking Sterile pads or dressings Hypoallergenic tape Ice bag Skin lotion Warm water Crutches or walker Pain medications Closed-wound drainage system and slings Abduction splint Anticoagulants

Arthroplasty Care Preparation (P-R-E-P) P Prepare the patient s bed. After the patient goes to the operating room, a Balkan frame with a trapeze on his bed frame

should be made. This will allow the patient to move after the operation. R E Rigorously make the bed using a comfort device and clean bed linens. Enable immediate placement of the patient on his hospital bed after the surgery by having the prepared bed taken to

the operating room. P Prevent or eliminate the need for an additional movement of the patient in his bed on the postanesthesia care unit by

having the prepared bed transported to the operating room.

Arthroplasty Care: General Guidelines or Key Steps (A-R-T-H-R-O-P-L-A-S-T-Y C-A-R-E) A Alert the physician for any changes in the patient s vital signs. Alterations in vital signs may indicate infection,

hemorrhage or other postoperative complications. Check patient s vital signs every 15 minutes, twice, every 30 minutes until stable and then every 2 to 4 hours and routinely thereafter. R Respiratory complications prevention:

 

Encourage the patient to perform deep breathing and coughing exercises. Assist patient with incentive spirometry is ordered.

Thorough neurovascular status assessment and monitoring:

  

Assess the patient s neurovascular status every 2 hours for the first 48 hours and then every 4 hours for signs of complications. Check the affected leg for color, temperature, toe movement, sensation, edema, capillary refill and pedal pulse. Investigate complaints of pain, burning, numbness or tingling.

Have a compression stocking applied to the unaffected leg to promote venous return, prevent phlebitis and pulmonary

emboli. Remove the compression stocking once every 8 hours and check the leg especially the heel for pressure ulcers and reapply it. R O P Reduce or eliminate pain by administering pain medications as ordered. Ordered I.V. antibiotics should be administered for 24 hours after the surgery to minimize the risk of wound infection. Prevent or minimize the risk of thrombophlebitis and embolus formation by administering the ordered anticoagulant

therapy. Observe the patient for bleeding and the leg for signs and symptoms of phlebitis such as warmth, tenderness, redness and a positive Homan s sign. L Loss of blood should be checked through dressing inspection. Circle any drainage on the dressing and mark it with the

nurse s initials, the date and the time. Sterile dressings should be applied as needed using a hypoallergenic tape. Excessive bleeding should be reported to the physician immediately. A Assess the closed-wound drainage system for discharge color and amount. A proper drainage prevents hematoma.

Presence of a purulent drainage and fever indicates infection. Using a clean technique, empty and measure the drainage as ordered.

Screen or monitor the patient s fluid intake and output every shift. Wound drainage in the output measurement should

be included. T To reduce swelling, reduce pain and control bleeding, an ice bag should be applied to the affected site for the first 48

hours. Y Your patient should be repositioned every 2 hours. Position changes enhance comfort, prevent pressure ulcers and help

prevent respiratory complications. C Coach the patient for the use of trapeze and help him or her reposition every 2 hours. Skin care should be provided for

the back and buttocks, using warm water and lotion as indicated. A Affected and unaffected extremities should be moved by performing muscle strengthening exercises per doctor s order

to help maintain muscle strength and range of motion and to help prevent phlebitis. R Relieving pain before an acitivity or exercise should be done by administering pain medication before ambulation as

ordered. Movement is very painful, thus, analgesic should be given 30 minutes before mobilization. E Encourage the patient during exercises. Help the patient with progressive ambulation, suing adjustable crutches or a

walker when needed.

Specific Arthroplasty Care: Care after Hip Arthroplasty

 

Affected leg should be maintained in abduction and in neutral position to promote hip stability and keep the cup and femur head in the acetabulum. Pillows should be placed between the legs of the patient to help maintain hip abduction. Proper patient positioning after hip arthroplasty depends on the surgical approach used and surgeon s preferences:

If the surgical approach used is ANTERIOR approach take note of the following guidelines: 1. 2. 3. No adduction past midline Flexion should NOT be greater than 90 degrees External rotation should NOT pass the midline

For POSTERIOR approach, follow the listed guidelines: 1. 2. 3. 4. Adduction should NOT pass the midline Flexion should NOT be greater than 60 to 90 degrees NO internal rotation past midline NO extension past neutral

  

For 1 hour three times per day and at night make sure to put the patient in the supine position with the affected hip in full extension. Doing so prevents hip flexion contracture. Have the patient start plantar flexion and dorsiflexion exercises of the foot on the affected leg on the day after the surgery. Instruct the patient to start performing quadriceps exercises if ordered by the physician. In most cases, the patient is allowed to start transfer and progressive ambulation with assistive devices on the first postoperative day.

Specific Arthroplasty Care: Care after Total Knee Replacement

To reduce swelling, elevate the affected leg as ordered.

 

Quadriceps exercises and straight leg-raising can be initiated by the patient when ordered by the physician. These activities are usually done on the first postoperative day. Usually, after the first dressing change, flexion-extension exercises can be encouraged to be done by the patient when ordered. If CPM machine is ordered, the practitioner will adjust the machine daily to increase the degree of flexion of the affected leg gradually. Weight bearing status and the degree of flexion and extension depend on the practitioner s specific orders, surgical approach used and the preferences of the surgeon.

Arthroplasty Care: Special Considerations

   

Explain the procedure to the patient before the surgery. This helps gain patient cooperation and at the same time letting the client know what to expect during and after the procedure. Inform the patient and give emphasis on the frequent assessment needed including vital signs, neurovascular integrity and wound drainage. Let the patient know that these procedures are normally done after the operation. Tell the client that he will be receiving an IV of antibiotics for 2 days. Make sure that the client understands the reason of medication administration round the clock. Explain the need for immobilization of the affected leg and mobilization of the unaffected leg.

Arthroplasty Care: Possible Complications

     

Pulmonary embolism Pneumonia Phlebitis Paralytic ileus Urine retention Bowel impaction

Arthroplasty Care: Health Teaching (T-E-A-C-H) T E Tell the patient not to drive after the 2-month follow-up. Encourage and teach the patient to perform muscle strengthening exercises for the affected and unaffected extremities

to maintain muscle strength and ROM to prevent phlebitis. A C H Advise the patient that he or she may return to work in 3 to 6 months or per physician s instructions. Coach the patient about home care and exercises before discharge. Have the patient wear the elastic stockings until the two-month follow-up.