Nursing Care of the Hip Replacement Patient

Regina M. Barden

Kim Chandler

Introduction

Hip replacement surgery can be a life altering event for the patient with advanced painful hip disease. This can often be a difficult and anxiety-provoking decision for the patient to make. During this time the nurse has the opportunity to develop a relationship with the patient to promote a positive surgical experience. The role of the nurse in the care of the hip replacement patient is to educate, provide safe and competent care, and help coordinate the care provided by the multidisciplinary team. The nurse is a critical link in providing the continuity of care required for these patients throughout the perioperative phase.

Over 285,000 hip replacements are performed in the United States annually (1). As the number of surgeries has increased over the past decade the demands on the staff caring for this cohort of patients have also increased. Surgeons now have the ability to perform hip replacements and send patients home as quickly as the same day of surgery. This has led to major alterations in how nursing and other healthcare disciplines on the joint replacement team need to coordinate patient care to provide a safe environment and optimize the outcome of the surgery. As the mandate continues for decreasing length of stay while maintaining high quality care, greater importance is placed on the quality and efficiency of patient care in the perioperative period.

Patient Education

The nurse has a commitment to educate patients throughout the perioperative experience.

It is imperative that a patient is prepared both physically and emotionally before a surgical procedure. Patient education begins when the patient is first informed by the physician that they are a candidate for joint replacement surgery. The patient must be informed of the preoperative requirements, the mechanics of the surgical procedure including implant alternatives and choices, as well as the postoperative plan of care, rehabilitation, and expectations after discharge. To optimize implant longevity, patients should be made aware of recommendations regarding lifestyle changes which may include modifications of job responsibilities and recreational activities.

Studies have shown that preoperative education helps to alleviate patient fears, and decreases anxiety, length of stay, and postsurgical pain. It also improves patient satisfaction (2). Once a patient has been informed that they are a candidate for hip replacement surgery, it is the responsibility of the surgeon and his/her staff to provide the necessary education. The purpose of educating patients is to provide information about the surgical intervention and to help the patient develop realistic expectations. This will ultimately allow them to make an educated, informed decision about consenting to surgery.

The combination of verbal instruction and written materials along with website-based programs is an approach that can be very effective for patients and caregivers. These are all acceptable methods to educate patients, but one has to remember that there are barriers that affect how much information a patient retains with any one method. Barriers to learning may include education level, illiteracy, language differences, hearing or visual impairment, psychological and physical disabilities, and lack of access to electronic equipment to view teaching.

Formal preoperative classes allow for a multidisciplinary approach for preparing the patient for surgery and may be provided by any combination of hospital-based nurses, office nurses, therapists, social workers, and physicians. In addition to being an efficient and effective way to teach multiple patients at one time, patients often find it beneficial to be able to listen to the questions being asked by other patients. This also provides an opportunity for patients to network with each other which may help alleviate many of their fears and concerns.

Educating patients and families for hip replacement surgery requires a coordinated approach. Studies have shown that retention of medical information given in a verbal session with a healthcare provider may be less than 50% (3). Therefore repetition of teaching materials and reinforcement of important concepts can help patients gain a better understanding of the material. Making available additional educational material such as videos, teaching websites, and custom or standardized teaching books or pamphlets can be
very useful for patients to take home for additional review. Family members should be encouraged to participate in classes or individual teaching sessions to gain a better understanding of how they can be a support for the patient. A contact phone number and person for patients to call with additional questions or concerns can decrease patient anxiety and make them feel well cared for as they approach surgery.

An alternative to group or classroom style teaching is to provide patient and family education on a one-on-one basis. This can be done by a nurse working within a physician’s practice and provides the healthcare professional a better opportunity to get to know the patient and their specific physical and psychosocial issues that may affect their surgical experience. The educational information can be individualized and made understandable for each individual patient. It is especially useful for patients who require a translator. This teaching format provides an atmosphere that may be more comfortable for many patients and families and provides a more intimate way for the patient to communicate with the healthcare provider, where individual concerns can be more easily discussed.

Content of Teaching Session

Anatomy of hip/disease process
Overview of surgical procedure
Risks and benefits of surgery
Hospital stay
Equipment used
Pain management protocol
Discharge planning
Rehabilitation/physical therapy
Recovery period/restrictions

Healthcare professionals need to help guide patients in making the decision to undergo surgery while maintaining realistic expectations. The ultimate goal of preoperative education is to prepare the patient for surgery with an appropriate understanding of the surgical procedure, risks and benefits, recovery after surgery, and what can be done to optimize their outcome and the longevity of their prosthesis. This can be accomplished with good communication between the patient and the multidisciplinary healthcare professionals.

Preoperative Nursing Assessment

A comprehensive preoperative nursing assessment of the total hip patient is important in helping to achieve a positive outcome. Preoperatively identifying a patient’s individual needs and comorbidities can assist in this process. In preparing a patient for surgery, the following areas should be addressed.

History and Physical

A thorough medical history and physical examination can identify comorbidities that may adversely affect one’s outcome. Further consultation may be necessary when a patient has a significant cardiac, respiratory, hematologic, dermatologic, renal, vascular, or neurologic condition. Certain conditions may predispose a patient to a perioperative infection. Evaluating any previous infection history is important to determine what additional preoperative testing may be recommended. A patient’s skin should be examined for ulcerations, infections, and abnormalities that may affect incision healing postoperatively. Psoriasis, acne, and other skin conditions around the hip area should be treated and cleared prior to surgery.

Dental Clearance

Discussing a patient’s dental hygiene and the importance of an updated dental examination is suggested to lower the risk of a hematogenous infection. The dentist should assess the state of a patient’s oral health. It is important that gum disease and active infections are treated and managed several weeks before surgery. This can help minimize the risk of a perioperative joint infection.

Blood Management

Total hip replacement surgery may cause significant blood loss and may lead to adverse patient outcomes (4). Identifying and discussing patients’ beliefs and concerns about perioperative blood management should take place in the preoperative education setting.

It is necessary to discuss with the patient the physician’s recommended protocol on bloodless surgery and blood replacement options. These may include the storing of autologous or direct donor blood, and the possible use of a cell saver device. In the anemic population, patients may be identified for preoperative erythropoietin therapy or the intraoperative administration of tranexamic acid.

Psychosocial

It is most effective when both the patient and medical staff have similar expectations both preoperative and postoperative. An assessment of the patient’s preoperative functional level, mental health status, home environment, and available support system is helpful to identify what the patient’s needs may be. Addressing patients’ and families’ concerns about surgery, recovery, and expected outcomes can help to alleviate anxiety. Studies have shown that patients with anxiety and depression prior to surgery tend to have poorer pain relief after surgery (5).

Anesthesia and Pain Management

Anesthesia concerns by a patient can be anxiety provoking. It is important to recognize a patient’s previous adverse experience with anesthesia, complex medical issues, or spinal abnormalities that may alter the recommended anesthesia technique. This group of patients should be evaluated by anesthesia prior to surgery. It is also of value to assess the patients’ current and past use of narcotics. Patients who may be opioid sensitive or opioid tolerant should be evaluated by a pain specialist/anesthesiologist in the preoperative period as this group of patients can be difficult to manage after surgery. A pain medication plan preoperatively will decrease the anxiety of the patient and the staff caring for the patient in the perioperative period.

Insurance Authorization

This is mandatory for coverage of the surgical procedure and hospitalization. Patients should be made aware of the number of inpatient hospital days their insurance will allow for this surgery. A discussion should be had about what types of services and facilities are covered after discharge. This information can help keep the patient’s expectations regarding their hospital stay and posthospital treatments realistic. With shorter hospital stays, it is extremely important that medical, psychosocial, environmental, and economic issues are addressed prior to admission (6).

This process is often coordinated by an orthopedic nurse with a strong commitment to collaborative practice (7). The nurse should have clinical expertise in issues specific to hip replacement surgery as well as interdisciplinary team building, problem solving, communication, and relationship skills. Coordination of patient-focused care across a continuum from preadmission through postdischarge promotes quality care and patient satisfaction. A nurse who knows the patients’ medical and social issues prior to surgery can share this information with the necessary healthcare providers on the team which allows for improved planning and individualization of patient care.

Physical Therapy/Prehabilitation

End stage arthritis is a painful condition which leads to joint stiffness, muscle weakness, and difficulty performing activities of daily living (ADLs).

Recovering from hip replacement surgery can place a significant stress on a person’s functional capacity. The prehabilitation process is a way to enhance the functional capacity of an individual and prepare that person for the physical stressors associated with this surgery. The goal of prehabilitation is to help prepare the patient for surgery by improving muscle strength, functionality, and range of motion. This may help them to better withstand the stress of surgery, decreasing the length of time required to regain independence postoperatively and enable them to return to an independent living level more quickly (8).

Lavernia et al. (9) noted a correlation between preoperative and postoperative function in total hip and total knee replacement patients. This showed that patients with advanced functional limitations preoperatively did not recover as well as those with fewer functional limitations.

It remains controversial as to the positive effects of a prehabilitation program. Gilbey et al. (10) and Huo and Muller (11) found that patients with greater fitness preoperatively will have faster rehabilitation after major surgery. Ferrara et al. (12) found that preoperative physiotherapy is not useful in the hip replacement population. They did feel it is appropriate as a method of conservative treatment for end stage hip arthritis to decrease pain.

Physical therapy programs should be individualized for each patient. Not all patients may be candidates for prehabilitation. Contraindications for prehabilitation may include patients with severe medical conditions, acute trauma, or who are so debilitated from their orthopedic condition that they are unable to exercise (10). Some of the key components to this program should include warm-up, cardiovascular conditioning, strength training, and flexibility.

The physical therapist will focus on the techniques and protocols that will be used to help the patient gain functional independence. This may include a demonstration on the use of assistive devices such as crutches or a walker, and specific exercises that the patient may be able to practice preoperatively. The postoperative goal of the eventual safe return to their own home or environment is stressed along with the necessary hip precautions.

Social Work/Discharge Planning

The discharge planner is usually a nurse or a social worker who will provide emotional support and guidance while coordinating a patient’s discharge from the hospital to home with a homecare agency or to a rehabilitation-type facility. Ideally, this should be initiated in the preoperative phase and continued throughout the course of hospitalization. Anxiety about posthospital issues can be alleviated before admission when a plan is in place that the patient and family are comfortable with. Along with being knowledgeable about patient insurance benefits, and cost-effective strategies for the hospital, they will interact with patients and families to facilitate the discharge process. Although many patients do want to return home after a short hospital stay, this is not always a viable option. Appropriate discussion of support systems, psychosocial issues, and home needs can help with patient and family concerns regarding the necessary care and support the patient will require after discharge. Their close interaction with the multidisciplinary orthopedic team is necessary to streamline the discharge process and promote patient well-being and satisfaction.

Management of Critical Pathways

A critical pathway is a tool used to coordinate nursing practice and patient care objectives during the perioperative period. It should include a structured approach to routine patient assessment, testing, medications, pain management, wound care, nutrition, activity progress, psychosocial issues, and discharge planning. It can be used as a bedside tool to guide and manage patient progress during their postoperative course.

The use of a pathway allows healthcare professionals to determine if a patient’s recovery is progressing as expected. Variances from the pathway can be documented and the patient can be resumed to the pathway in a timely manner.

Pathways are developed and maintained through a multidisciplinary approach. A regular meeting of pathway members may consist of a physician, RN case manager, staff nurse, physical therapist, anesthesiologist, pain management RN, occupational therapist, utilization management, and social services. This is an opportunity to discuss pathway compliance issues, problems with current order sets, and recommended changes for improvement of patient care.

Based on critical pathways, standardized order sets can be developed. This allows for consistency of care among joint replacement patients at an individual institution while still allowing for variations in individual surgeon’s practices. An example of a critical pathway for hip replacement patients can be found in Chapter 34. A challenge for the pathway system is the variation of lengths of stay that is
being developed among the individual surgeons. Because of these altered lengths of stay, it can be difficult for institutions to adhere to one pathway for all patients undergoing hip replacement surgery. The development of surgeon-specific pathways for one procedure can make it a less effective tool in the management of the hip replacement patient.

Surgery Day

In general, patients are usually admitted approximately 2 hours prior to the procedure. Certain medical conditions may require the admission of a patient 1 or more days prior to surgery. Preparing the patient for surgery should focus on decreasing patient anxiety by providing reassurance and answering additional questions. The preoperative nurse initiates correct site verification policies, reviews the consent, medical record number, and availability of blood products requested. Correct site identification is based on the fourth goal developed by The Joint Commission on Accreditation of Healthcare Organization (13).

A thorough preoperative nursing assessment should include a chart review, to check for the presence of the medical history and physical examination, laboratory reports, chest x-ray and other necessary imaging studies, ECG results, and current medications. Vital signs, allergies, and previous surgeries are reviewed. The nurse should assess the patient’s mental status, and identify any communication barriers. Following this review, she can individualize the needs of the patient throughout the surgical experience. Once the preparation is complete the patient is taken to the operating room.

Operating Room

In the operating room, the nurse may serve as a scrub nurse who will help with selection and passing of instruments and supplies to be used during the surgery.

A circulating nurse manages the overall nursing care in the OR and helps to maintain a safe and comfortable environment. Following the completion of surgery, the patient will be transferred to the postanesthesia care unit (PACU).

PACU

In the PACU, the anesthesiologist/nurse anesthetist will report to the nurse the patient’s condition, type of anesthesia, estimated blood loss, input of fluids, and urine output during surgery. The nurse should be made aware of any complications and variations in hemodynamic stability during the procedure. Assessing the patency of a patient’s airway, vital signs, and level of consciousness are initial priority. The nurse will closely monitor the patient’s cardiac, respiratory, and neurovascular status (NVS) along with the surgical dressing and drain for overt signs of excessive bleeding. Acute pain management is coordinated with the anesthesia team. The patient will remain in the recovery room until they are stabilized following general and/or regional anesthesia and their pain is under control. The time the patient remains in the PACU will be dependent upon the anesthetic agents used and the response of the individual patient. Once the patient meets the institution’s established criteria for discharge, including mobility, respiratory status, circulation, and consciousness, they will be discharged to the surgical or orthopedic unit.

Postoperative Care

The orthopedic/surgical inpatient care unit is the place where patients progress to increasing independence for eventual discharge to home, rehabilitation, or a skilled care unit.

Caring for the postoperative hip replacement patient is a multidisciplinary responsibility. However, the nurse is the main caregiver for the patient in this environment.

Immediate concerns include medical stability, NVS assessment, and adequate pain management. The usual nursing treatment plan upon arrival of the patient will include a set of vital signs along with assessment of the patients’ mental, cardiovascular, respiratory, integumentary, GI, and NVS with particular attention to the operative extremity. Patient equipment that is in use is checked at this time, including infusion pumps for intravenous (IV) fluids or pain medications, urinary Foley catheters, surgical drains, and immobilizers, braces or splints that may be in place. Postoperative complications such as bleeding, nausea and vomiting, venous thromboembolic events, hemodynamic instability, and adverse reactions to medications are assessed throughout a patient’s hospital stay.

Identifying a high-risk patient, based on pre-existing conditions or intraoperative findings, is crucial in decreasing postoperative complications. This cohort of patients may need closer observation and continuous electronic monitoring during the immediate postoperative period. Nurses need to be trained on rapid response to adverse changes.

Depending on the nurse to patient ratio, some orthopedic units may utilize patient care technicians or nursing assistants to aid the nurse in the care of patients. The nurse is able to delegate certain tasks to nursing assistants while ultimately maintaining responsibility for all patient care. Duties typically delegated include the taking of vital signs, ADLs, toileting, ambulation of patients, measuring of drain output, and feeding patients when necessary. Any information or data gathered by the nursing assistant needs to be interpreted by the treating nurse.

Positioning

Appropriate positioning of the postoperative total hip patient is important to minimize the risk of dislocation of the hip prosthesis. Patients typically arrive on the floor with their legs abducted with the surgical leg in neutral alignment by means of an abductor pillow, blanket, or regular pillow placed between their legs (Fig. 30.1A

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