After total hip replacement, a client is receiving epidural analgesia to relieve pain.
Which of the following is a nursing priority for this client?
- a. Changing the catheter site dressing every shift
- b. Assessing capillary refill time
- c. Assessing for sensation in the legs
- d. Keeping the client flat in bed
Answer C.
For epidural analgesia, a catheter is placed outside the dura mater in the epidural space. Catheter displacement, which may cause spinal injury, is signaled by loss of motion and sensation in the legs. Therefore, the nurse should assess closely for sensation and ask about numbness of the legs. The nurse should change the catheter site dressing every day or every other day. Capillary refill time has no bearing on epidural analgesia. A client with an epidural catheter may ambulate and need not be confined to bed.
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If you have just begun exploring treatment options or if you have already decided to undergo hip replacement surgery, this information will help you understand the benefits and limitations of total hip replacement. This article describes how a normal hip works, the causes of hip pain, what to expect from hip replacement surgery and what exercises and activities will help restore your mobility and strength, and allow you to return to daily activities.
If your hip is damaged as a result of arthritis, a fracture or other conditions, common activities such as walking, sitting or getting up from a chair can be painful and difficult. Your hip may be stiff and it may be difficult to put on shoes and socks. You may even feel uncomfortable while resting.
If medications, changes in your daily activities and the use of walking supports do not adequately help your symptoms, you may consider hip replacement surgery. Hip replacement surgery is a safe and effective procedure that can relieve your pain, increase movement and help you regain the pleasure of doing normal daily activities.
Hip replacement surgery was first performed in 1960 and is one of the most successful operations in all medicine. Since 1960, improvements in surgical techniques and joint replacement technology have greatly increased the effectiveness of total hip replacement. According to the Agency for Healthcare Research and Quality, more than 285,000 total hip replacements are performed each year in the United States.
Anatomy:
The hip is one of the largest joints in the body. It is a spherical joint (head and cavity). The joint cavity is formed by the acetabulum, which is part of the large bone of the pelvis. The spherical part is the head of the femur, the upper end of the thigh bone.The bony surfaces of the head and cavity are covered with articular cartilage, a soft tissue that covers and cushions the ends of the bones and allows them to move easily.
A tissue called synovial membrane surrounds the hip joint. In a healthy hip, this membrane generates a small amount of fluid that lubricates the cartilage and eliminates almost all friction during hip movement.
Tissue bands called ligaments (hip capsule) connect the head to the cavity and provide stability to the joint.
Common causes of hip pain:
- The most common cause of chronic pain and hip disability is arthritis. Osteoarthritis, rheumatoid arthritis and post-traumatic arthritis are the most common forms of this disease.
- Osteoarthritis. This is a type of age-related "wear and tear" arthritis. It usually occurs in people 50 years of age or older, and often in people with a family history of arthritis. The cartilage that cushions the hip bones wears out. The bones then rub with each other, causing pain and stiffness of the hip.
- Osteoarthritis can also be caused or accelerated by subtle irregularities in the way the hip developed in childhood.
- Rheumatoid arthritis. This is an autoimmune disease in which the synovial membrane becomes inflamed and thickens. This chronic inflammation can damage the cartilage, causing pain and stiffness. Rheumatoid arthritis is the most common type of a group of disorders called "inflammatory arthritis."
- Post-traumatic arthritis. This can follow a serious injury or a hip fracture. The cartilage can be damaged and lead to pain and stiffness of the hip over time.
- Avascular necrosis. A hip injury, such as a dislocation or fracture, can limit the blood supply to the head of the femur. This is called avascular necrosis. Lack of blood can cause the bone surface to collapse, and will result in arthritis. Some diseases can also cause avascular necrosis.
- Childhood hip disease. Some newborns and children have hip problems. Although problems are treated successfully during childhood, they can still cause arthritis at a later stage in life. This occurs because the hip cannot grow normally, and the joint surfaces are affected.
Description:
- In a total hip replacement (also called total hip arthroplasty), the damaged bone and cartilage are removed and replaced with prosthetic components.
- The head of the damaged femur is removed and replaced with a metal stem that is placed in the hollowed center of the femur. The femoral stem can be cemented or "pressure footwear" inside the bone.
- A metal or ceramic head is placed on the top of the stem. This head replaces the damaged head of the femur that was removed.
- The damaged cartilage surface of the cavity (acetabulum) is removed and replaced with a metal cavity. Sometimes screws or cement are used to hold the cavity in place.
- A plastic, ceramic or metal spacer is inserted between the new head and cavity to allow a smooth sliding surface.
Is hip replacement surgery what suits you?
The decision to undergo hip replacement surgery should be a collaborative decision between you, your family, your primary care physician and your orthopedic surgeon. The process of making this decision typically begins with a referral made by your doctor to an orthopedic surgeon for an initial evaluation.
Candidates for surgery:
There are no absolute weight or age restrictions for total hip replacement.
The recommendations for surgery are based on a patient's pain and disability, not their age. The majority of patients undergoing total hip replacement are between 50 and 80 years old, but orthopedic surgeons evaluate patients individually. Total hip replacements have been successfully performed at all ages, from the young adolescent with juvenile arthritis to the elderly patient with degenerative arthritis.
When surgery is recommended:
There are several reasons why your doctor might recommend hip replacement surgery. People who benefit from replacement surgery often have:
- Hip pain that limits everyday activities, such as walking or flexing
- Hip pain that persists at rest, either day or night
- Rigidity in a hip that limits the ability to move or lift the leg
- Inadequate pain relief if anti-inflammatory medications, physical therapy or walking supports are used
The orthopedic evaluation:
- An evaluation with an orthopedic surgeon consists of several elements.
- Medical history. Your orthopedic surgeon will gather information about your general health and ask questions about the extent of hip pain and how it affects your ability to perform everyday activities.
- Physical exam. This will assess the mobility, strength and alignment of the hip.
- Radiographs (X-rays). These images help determine the degree of damage or deformity in your hip.
- Other exams. Occasionally other tests, such as an MRI, may be necessary to determine the condition of the bone and soft tissues of your hip.
The decision to undergo hip replacement surgery
Talk to your doctor:
- Your orthopedic surgeon will review the results of your evaluation with you and discuss whether hip replacement surgery is the best method to relieve pain and improve your mobility. Other treatment options - such as medications, physical therapy or other types of surgery - may also be considered.
- In addition, your orthopedic surgeon will explain the potential risks and complications of hip replacement surgery, including those related to the surgery itself and those that may occur over time after surgery.
- Never hesitate to ask your doctor questions when you do not understand. The more you know, the better you can handle the changes that replacement surgery will make in your life.
Realistic Expectations:
An important factor in the decision to undergo hip replacement surgery is to understand what the intervention can do and cannot do. Most people who undergo hip replacement surgery experience drastic reduction in hip pain and a significant improvement in their ability to perform common activities of daily living.
With normal use and activity, the material between the head and the cavity of each implant in the hip replacement begins to wear out. Excessive activity or overweight can accelerate this normal wear and cause the hip replacement to loosen and become painful. Therefore, most surgeons do not advise high impact activities such as running, jogging, jumping or other high impact sports.
Realistic activities after a total hip replacement include unlimited walking, swimming, golfing, car driving, hiking, biking, dancing and other low-impact sports.
With proper modification of activities, hip replacements can last for many years.
Preparation for surgery:
Medical evaluation:
If you decide to have a hip replacement surgery, your orthopedic surgeon may ask that your primary care physician do a complete physical exam before the surgery. This is necessary to be sure that you are healthy enough to have surgery and complete the recovery process. Many patients with chronic medical conditions, for example heart disease, may also be evaluated by a specialist, such as a cardiologist, before surgery.
Exams:
Several tests, such as analysis of blood and urine samples, an electrocardiogram (EKG) and chest x-rays may be needed to help plan your surgery.
How to prepare your skin:
Your skin should not have any infection or irritation before surgery. If you have an infection or skin irritation, contact your orthopedic surgeon for treatment to improve your skin before surgery.
Blood donations:
You may be advised to donate your own blood before surgery. This will be stored in the event that you need blood after surgery.
Medications:
Tell your orthopedic surgeon about the medications you are taking. The surgeon or your primary care doctor will advise you which medications you should stop taking and which ones you can continue to take before surgery.
Weightloss:
If you are overweight, your doctor may ask you to lose weight before surgery to minimize the strain on your new hip and possibly reduce the risks of surgery.
Dental evaluation:
Although infections after hip replacement are not common, an infection can occur if bacteria enter your blood. Because bacteria enter the blood during dental procedures, major dental procedures (such as tooth extractions and periodontal work) must be completed before your hip replacement surgery. Routine cleaning of your teeth should be postponed for several weeks after surgery.
Urinary evaluation:
People with a history of recent or frequent urinary infections should have a urological evaluation before surgery. Older men with prostate disease should consider completing the required treatment before having surgery.
Social planning:
- Although you can walk on crutches or a walker soon after surgery, you will need some help for several weeks with tasks such as cooking, shopping, bathing and washing clothes.
- If you live alone, your orthopedic surgeon's office, a social worker or a hospital discharge planner can help you coordinate in advance for someone to help you at home. A short stay in a long-term care facility during recovery after surgery may also be coordinated.
Planning for your home:
Several modifications can make your home easier to navigate during your recovery. The following articles can help with everyday activities.
- Safety bars or handrails firmly attached in your shower or bathtub
- Safe handrails along all the stairs
- A stable chair for recovery in the first stage, with a firm seat cushion (which allows your knees to remain lower than your hips), a firm backrest and two armrests
- A high toilet seat
- A stable bench for shower or bathtub chair
- A sponge with a long handle and hand shower
- A stick with a hook to help you get dressed, a device to put on socks and a shoehorn with a long-handled shoe to put on and take off socks and shoes without excessively bending your new hip
- An achiever that allows you to grab objects without excessively bending your hips
- Firm pillows for your chairs, sofas and cars that allow you to sit with your knees lower than your hips
- Remove all loose mats and electrical wires from the areas where you walk in your home.
Your operation:
Most likely, you will be admitted to the hospital the day of your surgery.Anesthesia:
After admission, you will be evaluated by a member of the anesthesia team. The most common types of anesthesia are general anesthesia (you sleep completely), spinal, epidural, or regional anesthesia with nerve block (you stay awake but your body is numb from the waist to the bottom). The anesthesia team, with your input, will determine what type of anesthesia will be best for you.Implant components:
Many different types of designs and materials are currently used in artificial hip joints. They all consist of two basic components: the head component (made of strong polished or ceramic strong metal) and the cavity component (a hollow space or durable plastic, ceramic or metal cup, which can have an external protective coating of metal).The prosthetic components can "snap under" in the bone to allow their bone to grow over the components or they can be cemented where they go. The decision to press fit or cement the components is based on a number of factors, such as the quality and strength of your bone. A combination of cemented stem and non-cemented cavity could also be used.
Your orthopedic surgeon will choose the type of prosthesis that best suits your needs.
Process:
The surgery takes a few hours. Your orthopedic surgeon will remove damaged cartilage and bone and then place new metal, plastic or ceramic implants to restore the alignment and function of your hip.After surgery, you will be transferred to the recovery room where you will stay for several hours while monitoring your recovery from anesthesia. After you wake up, you will be taken to your hospital room.
Your hospital stay:
Most likely, you will stay in the hospital for a few days. To protect your hip during the first recovery period, a positioning splint, for example a foam pillow placed between your legs, could be used.Pain management:
After the surgery, you will feel some pain but your surgeon and the nurse will provide you with medication so that you feel as comfortable as possible. Pain management is an important part of your recovery. The movement will begin soon after surgery and when you feel less pain, you can start moving earlier and recover your strength faster. Talk to your surgeon if postoperative pain becomes a problem.Physical therapy:
Walking and light activity are important for your recovery and will begin the day of your surgery or the day after your surgery. Most patients who undergo total hip replacement begin to stand up and walk with the help of a walking support and a physical therapist the day after surgery. The physical therapist will teach you specific exercises to strengthen your hip and restore movement for walking and other normal daily activities.Pneumonia Prevention:
It is common for patients to have shallow breathing in the initial postoperative period. This is usually due to the effects of anesthesia, pain medications and the longer they stay in bed. This shallow breathing can lead to a partial collapse of the lungs (called "atelectasis") that can create susceptibility to pneumonia in patients. To help prevent this, it is important to take frequent deep breaths. Your nurse can provide you with a simple breathing apparatus called a spirometer to stimulate you to take deep breaths.Recovery:
The success of your surgery will depend largely on how you follow your orthopedic surgeon's instructions regarding home care during the first weeks after surgery.Wound care:
You may have stitches or staples along your wound or a suture under the skin. The stitches or staples will be removed approximately 2 weeks after surgery.Avoid wetting the wound until it has completely sealed and dried. You can continue selling the wound to prevent irritation caused by clothing or support stockings.
Feeding:
It is common to lose a little appetite for several weeks after surgery. A balanced diet, often with an iron supplement, is important to promote proper tissue healing and restore muscle strength. Be sure to drink plenty of fluids.Activity:
Exercise is a critical component of home care, especially during the first weeks after surgery. You should be able to resume most of the normal light activities of daily life in about 3 to 6 weeks after surgery. It is common to feel a little discomfort with the activity and at night for several weeks.Your activity program should include:
- A gradual walking program to slowly increase your mobility, initially at home and later outdoors
- Resume normal household activities, such as sitting, standing and climbing stairs
- Specific exercises several times a day to restore movement and strength of your hip. You can probably do the exercises without help, but you may have a physical therapist to help you at home or at a treatment center the first few weeks after surgery.
Possible complications of surgery:
The complication rate after hip replacement surgery is low. Serious complications, such as joint infection, occur in less than 2% of patients. Major medical complications, such as heart attack or stroke, occur even less frequently.However, chronic diseases can increase the potential for complications. Although rare, when these complications occur they can prolong or limit full recovery.
Infection:
Superficial infection of the wound or deep infection around the prosthesis may occur. It could happen while you are in the hospital or after you go home. It could happen even years later.Minor wound infections are usually treated with antibiotics. Major or deep infections may require more surgery and remove the prosthesis. Any infection in your body can spread to the replacement of your joint.
Blood clots:
Blood clots in the veins of the leg or pelvis are the most common complication of hip replacement surgery. These clots can be life-threatening if they are released and travel to your lungs. Your orthopedic surgeon will design a prevention program that may include anticoagulant medications, bra stockings, inflatable leg covers, ankle exercises and early mobilization.Inequality of the leg length:
Sometimes after a hip replacement, one leg may feel longer or shorter than the other. Your orthopedic surgeon will make every effort to make your legs match, but may slightly lengthen or shorten your leg to maximize the stability and biomechanics of the hip. Some patients may feel more comfortable with a shoe modification (raise it) after surgery.Dislocation:
This occurs when the head leaves the cavity. The risk of dislocation is greater in the first months after surgery while the tissues are healing. Dislocation is uncommon. If the head leaves the cavity, a closed reduction can usually put it back in place without the need for further surgery. In situations where the hip is still dislocated, additional surgery may be necessary.Loosening and implant wear:
Over the years, the hip replacement may wear out or loosen up. This is most often due to daily activities. It can also be the result of a biological tuning of the bone called osteolysis. If the loosening is painful, a second surgery, called revision surgery, may be necessary.Other complications:
Lesions of the blood vessels and nerves, bleeding, fracture and stiffness may occur. In a small number of patients, some pain may persist or new pain may occur after surgery.Avoid problems after surgery:
Recognize the signs of a blood clot:
Follow your orthopedic surgeon's instructions carefully to reduce the risk of developing blood clots during the first weeks of your recovery. The surgeon may recommend that you continue taking the anticoagulant medications that you started in the hospital. Notify your doctor immediately if you develop any of the following warning signs.Warning signs of blood clots. Warning signs of possible blood clot in your leg include:
- Pain in your calf and leg that is not related to the incision
- Pressure pain or redness in your calf
- Inflammation of the thigh, calf, ankle or foot
- Sudden difficulty breathing
- Sudden establishment of chest pain
- Chest pain localized with cough
Infection prevention:
A common cause of infection after hip replacement surgery is by bacteria that enter the blood during dental procedures, urinary tract infections or skin infections.After surgery, you may need to take antibiotics before dental work, including dental cleanings or any surgical procedure that may allow bacteria to enter your blood. For many people with joint replacements and normal immune systems, the American Academy of Orthopedic Surgeons (AAOS) recommends taking preventive antibiotics before undergoing dental work.
Infection warning signs. Notify your doctor immediately if you develop any of the following signs of possible hip replacement infection:
- Persistent fever (greater than 100ºF oral)
- Chills with tremors
- Increased redness, pressure pain or inflammation of the hip wound
- Secretion of the hip wound
- Increased hip pain with activity and also at rest
Avoid falls:
A fall during the first weeks after surgery can damage your new hip and may result in the need for more surgery. Stairs in particular are a danger until your hip is strong and mobile. You should use a cane, crutches, a walker or handrail, or have someone help you until you improve your balance, flexibility and strength.Your orthopedic surgeon and physical therapist will help you decide what assistive devices will be required after surgery, and when those devices can be safely used.
Other precautions:
To ensure proper recovery and prevent dislocation of the prosthesis, you may be asked to take special precautions, usually during the first 6 weeks after surgery:- Do not cross your legs
- Do not flex your hips more than a right angle (90 °)
- Do not turn your foot excessively in or out
- Use a pillow between your legs during the night when you sleep or until your orthopedic surgeon advises you to stop using it.
Outcome:
How your new hip is different:
You may feel some numbness in the skin around the incision. You may also feel some stiffness, especially with excessive flexion. These differences often decrease over time and most patients find that they are minor differences compared to the pain and limited function they experienced before surgery.Your new hip can activate metal detectors required for security in airports and some buildings. Inform the security agent about your hip replacement if the alarm is activated. You can ask your orthopedic surgeon for a card that confirms that you have an artificial hip.
Protection of your hip replacement:
There are many things you can do to protect your hip replacement and extend the life of your hip implant.- Participate in a program of regular light exercises to maintain the proper strength and mobility of your new hip.
- Take special precautions to avoid falls and injuries. If a bone in your leg is fractured, you may need more surgery.
- Make sure your dentist knows that you have a hip replacement. You will need to take antibiotics before any dental procedure.
- See your orthopedic surgeon periodically for follow-up and routine exams and x-rays, even if your hip replacement appears to be working well.
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