• Internal Code :
  • Subject Code : NUR2203
  • University : University of Southern Queensland
  • Subject Name : Nursing

Introduction

While the mean age in general population is increasing, the total hip replacement is gaining importance not only for the patients but also for their social environment. Total joint replacement and especially total hip replacement represent one of the most successful surgical procedures regarding cost and effectiveness ratio. In recent years, there has been an increase in the number of total hip replacement procedures performed, which is an effective treatment for severe degenerative joint disease of the hip. In the following parts, pathophysiology of hypovolemia is described, pre and postoperative care to the patient is also discussed.

The principal symptoms of osteoarthritis include pain, stiffness and locomotor restriction. Pain is specifically severe with joint use (mechanical pain) and relieved by rest. However, some patients can have early morning or nocturnal pain. The early morning stiffness in osteoarthritis is usually less than 30 minutes and there may be short-lived inactivity-related stiffness (also known as gelling). Patients with osteoarthritis have a limited range of movement of the affected joint (equal for both active and passive movement), which may be due to development of marginal osteophytes, capsular thickening and/or joint effusion. This might have led to Total hip replacement of Sarah.

Part A:

Pathophysiology of The Hypovolemia

The outcome of hypovolemia include lowering of circulating blood volume, reduction in Venous return and, in severe cases, arterial hypotension. Myocardial failure may result from increased myocardial oxygen demand in addition to reduced tissue perfusion. Reduced perfusion leads to anaerobic metabolism which may produce acidosis and, in conjunction with dysfunction of the myocardium may lead to multi-organ failure. In specific the splanchnic organs are vulnerable to the severe effects of hypotension and hypovolemic shock, and these effects, depending upon their duration and severity, may be irreversible despite restoration of normovolemia by fluid administration. The chief goal of fluid management, based upon current understanding of the pathophysiology of fluid imbalance, should be to ensure adequate oxygen delivery by optimizing blood oxygenation, perfusion pressure and circulating volume.

Decrease in volume of blood ( hypovolemia) decreases the filling pressure and the Heart Rate to values below that necessary to maintain tissue perfusion leading to shock. The decrease in blood pressure (BP) stimulates the renin-angiotensin system, releasing angiotensin II, a potent vasoconstrictor, and stimulates the secretion of aldosterone, which promotes the conservation of water and salt. It also leads to a neuroendocrine response via the autonomic nervous system, where adrenaline and noradrenaline released in the circulation increase cardiac contractility, heart rate (HR) and promote vasoconstriction, triggered mainly by baroreceptors and low pressure vascular stretching receptors. Due to the secretion of corticotrophin releasing hormone (CRH), ACTH (adrenocorticotrophic hormone) , there is also an increase in cortisol production and reduction of cortisol by negative feedback.

Increased adrenergic activity also favors the flow of some organs like brain, myocardium, and adrenals. In the acute phase of the disease, when BP falls to a sufficiently low level, there is also a decrease in coronary blood flow, which decreases the contractile capacity of the heart muscle and thus further decreases the DC, making the shock increasingly severe. Blood stagnation in the microvessels and tissue metabolism continues to increase. A large amount of acid (carbonic and lactic acid) continues to be produced and released into the local blood vessels, increasing the acidity of blood with other products of ischemic tissue degradation, lead to blood clumping, clot formation and consequent obstruction of microvascular bed. After a few hours of hypoxia, there is an increase in capillary permeability and a large amount of fluid begins to flow to the tissues and edema formation.

From her past medical history she was suffering from osteoarthritis of both hips and knees, she also had hypercholesterolemia and hypertension, obstructive sleep dyspnea and myocardial infarction. The hypovolemia might have been brought by decreased blood volume due to surgery which leads to lower venous return and thus causes o arterial hypotension. Compensatory systemic release of catecholamines promotes peripheral vasoconstriction, increased cardiac contractility and tachycardia. Systemic blood pressure may therefore remain stable in the face of continuing hypovolemia. Tachycardia promotes increased myocardial oxygen demand that, in conjunction with reduced tissue perfusion, may result in myocardial failure.

Finally, anerobic metabolism occurring in response to reduced perfusion may produce acidosis and, together with myocardial dysfunction, contribute to multi-organ failure. Simvastatin works to reduce the amount of cholesterol that the body absorbs in aiding of reduction to the cholesterol levels in the body. Atenolol is a beta- blocker and it works to ensure healthy blood flow through the veins and arteries and treat hypertension and angina. The pain is reduced by the intake of Aspirin, rantidine and paracetamol. The infused sodium chloride helps in fluid stability.The fundamental requirement of Sarah is oxygen, and sufficient oxygen delivery is a paramount goal of fluid management that can be attained by ensuring adequate pulmonary function. Another important goal is satisfactory perfusion pressure, which depends upon myocardial performance and vascular tone. Most importantly, however, adequate circulating volume must be maintained, and for this purpose the intravascular compartment needs to be the chief focus of fluid management.

Blood pressure is affected only in the presence of hypovolemia exceeding 20% of normal blood volume. Heart rate may be increased due to pain and stress from the operation. Increased heart rate will lead to increased cardiac output which increases the blood pressure. Therefore it's important to manage the pain and also ensure the mental stability of the patient. This should be done by reassuring Sarah that she's going to get well soon and since she's a pharmacist you can also tell her the medication she's under and therefore she can be more confident of getting well quickly. Checking the levels of her pain should also be a priority to ensure the patient is not in too much pain. Moniter the oxygen levels and ensure the fluid infused is the right quantity.

Part 2:

Clinical Problems for Sarah:

  1. Blood loss: Wounds with disrupted blood supply heal slowly. For example, the healing of leg wounds in patients with varicose veins is prolonged. Ischemia due to pressure produces bed sores that then prevent their healing. Ischemia can be caused by obstruction of arterial blood flow – the most common cause, or by decreased perfusion of tissues by oxygen-carrying blood as occurs in cardiac failure, hypotension, & shock.

  2. Infections: some of the signs of infection will include the serous ooze I'm the hip dressing and the mild swelling. There may be bruises at the wound site after operation. They will go away after a few days after the patient’s condition has been normalized and no bleeding disorder appeared. To add, the portable suction device to collect bloody drainage can usually be removed within one day after the operation. Upon removal, the nurse should clean the drain tube site with antiseptic solution and with a small sterile dressing applied where there is an oozing at the site. The nurse will also perform simple dressing to the main wound without crepe bandage applied. Subject to the physician’s prescription for reducing the risk of deep vein thrombosis, the nurse will apply anti-embolism (TED) stockings and sequential compression device to prevent the development of blood clots in deep vein in the lower extremities. The nurse will remove wound stitches upon physician’s prescription after operation as part of the post-operative nursing care.

  3. Dislocation: Regarding to their Lower Extremity Functional Scale(LEFS):used at home and acute care system, this is a functional test for lower extremities. If not positioned well may get a dislocation. The right position is therefore important. And due to pain one may not stand the position for long enough. Its important to therefore stick to learned position for recovery purposes.

Nursing Goals According to Clinical Problems:

  1. For the blood loss: On the affected limb, perform neurovascular checks (color, temperature, pulses and capillary refill, movement, and sensation) hourly for the first 12 to 24 hours, then every 2 to 4 hours. Report abnormal findings to the physician immediately. Surgery can disrupt the blood supply to or innervations of the affected extremity. If so, to preserve the function of the extremity, rapid intervention is important. By emptying and recording suction drainage every 4 hours and assessing the dressing frequently, monitor incision bleeding. With a total joint replacement, significant blood loss can occur, particularly a total hip replacement. As needed, reinforce the dressing which is usually changed 24 to 48 hours after surgery but may need reinforcement if excess bleeding occurs. During the initial postoperative period, maintain intravenous infusion and accurate intake and output records. Sara is at risk for fluid volume deficit in the initial postoperative period because of blood and fluid loss during surgery, as well as the effects of the anesthetic. Maintain prescribed position and bed rest of the affected extremity using a sling, abduction splint, brace, immobilizer, or other prescribed device. Proper positioning of the affected extremity is vital in the initial postoperative period so that the joint prosthesis does not become dislocated or displaced.

  2. For infection: Regarding local complications in the site of the operation:, Increased pain in leg and leg appears shorter , Increased swelling, tenderness, or redness in either leg , Temperature above 38•C taken at least 30minutes after eating or drinking , Increased drainage from the incision, redness, or opening of incision edges and Increased difficulty with walking

  3. For dislocation: Maintain bed rest and prescribed position of the affected extremity using a sling, abduction splint, brace, immobilizer, or other prescribed device. Proper positioning of the affected extremity is vital in the initial postoperative period so that the joint prosthesis does not become dislocated or displaced. While on bed rest, help the client shift position at least every 2 hours because shifting of position helps prevent pressure sores and other complications of immobility. At least every 2 hours, remind the client to use the incentive spirometer, to cough, and to breathe deeply .These measures are important to prevent respiratory complications such as pneumonia. Assess the client’s level of comfort frequently. Maintain PCA, epidural infusion, or other prescribed analgesia to promote comfort. Adequate pain management promotes healing and mobility. As soon as allowed, help the client get out of bed. Teach and reinforce the use of techniques to prevent weight bearing on the affected extremity, such as the over-head trapeze, pivot turning, and toe-touch. Early mobility prevents complications such as pneumonia and thromboembolism, but appropriate techniques must be used to prevent injury to the operative site. Initiate physical therapy and exercises as prescribed for the specific joint replaced, such as quadriceps setting, leg raising, and passive and active range-of-motion exercises. These exercises help prevent muscle atrophy and thromboembolism and strengthen the muscles of the affected extremity so that it can support the prosthetic joint. Use sequential compression devices or antiembolism stockings as prescribed. These help prevent thromboembolism and pulmonary embolus for the client who must remain immobile following surgery. For Sarah now with a total hip replacement, prevent hip flexion of greater than 90 degrees or adduction of the affected leg. Provide a seat riser for the toilet or commode. These measures prevent dislocation of the joint.Assess the client with a total hip replacement for signs of prosthesis dislocation, including pain in the affected hip or shortening and internal rotation of the affected leg.

Nursing Interventions that Will Assist in Achieving the Goals

  1. Emphasize the importance of scheduled follow-up physician visits. Maintain fluid intake and encourage a high-fiber diet. Administer stool softeners or rectal suppositories as needed. Encourage consumption of a well-balanced diet with adequate protein. Immobility contributes to the potential problem of constipation; these measures help maintain regular fecal elimination. Adequate nutrition promotes tissue healing. Teach or reinforce post discharge exercises and activity restrictions. Clients are discharged from the acute care facility before healing is complete. If she is needing additional direct care after discharge, arrange placement in a long-term care or rehabilitation facility. Activity restrictions may preclude discharge to home. Make referrals as needed to home health agencies and physical therapy. Sarah will require home health care for both nursing care needs and continued physical therapy following discharge from acute or long-term care. Exercises are prescribed and activities are resumed gradually to protect the integrity of the joint replacement and prevent contractures.

  2. Dislocation may occur when the hip is in full flexion, legs together an Advices will be given to the to maintain correct positioning and keep the knees apart at all times. The nurse will also provide abduction pillow to the patient when sleeping, and remind the patient to avoid flexed hip more than 90°, and use fracture bedpan to avoid flexing the affected hip. She should also be reminded to maintain limited flexion during transfer and when sitting up. High-seat chair with arm rests and raised toilet seat can be used to minimize hip joint flexions internally rotated. It is essential for the nurse to educate the Sarah about protective positioning and hip precaution.

Part C:

Discharge Planning

The nurse will provide education to the patient and the carers to promote continuity of therapeutic regimen (e.g. limbs exercise), active participation and understanding of the rehabilitation process and home care after total hip replacement. For example, the patient will be advised to maintain ideal body weight, and be extra careful when walking down the stairs or ramps to prevent weight bearing and joint hazard and damage of prosthesis. The patient should also maintain regular limb and walking exercise to regain mobility. The nurse will also remind the patient to notify health care providers of discomfort such as increased body temperature, pulse and respiration rate, signs of influenza, redness, purulent drainage, tenderness, swelling, and pain, some of which could be vital signs of infective complications. The patient will also be taught to note any shortening of the affected extremity that may reflect dislocation of the prosthesis.

If in doubt or concern, he or she should seek for medical consultation. lts important to remind the patient on follow-up consultation. Regular time schedule for follow-up appointments will then be arranged. The patient is encouraged to carry a medical identification (e.g. implant card) indicating that she has a joint replacement and may be sensitive to security check at port control when she takes a trip. Important post-operative nursing health care services is to encourage the patient to adopt and practise good health measures, stable ambulation and function of the extremity to achieve good quality of life. In order to assess the progress and ensure compliance of home care and exercises, the patient is followed up at the fast track physiotherapy clinic 2 weeks post discharge. Home-based exercises, and joint care are revised and modified. Patient who achieves the goal of physiotherapy is advised to continue home exercises and is discharged immediately after the clinic. Patient who need further physiotherapy training is referred outpatient accordingly. This fast track process ensures timely intervention to maximize favorable result after the surgery.

Conclusion:

Patients usually suffer from joint pain and dysfunction as well as walking difficulties long before the operation. Joint replacement surgery is a significant advance in treatment of a painful and disabling joint condition. Postoperative rehabilitation is of utmost importance following total joint replacement to ensure pain-free function of the joint and improve the patient’s quality of life. Early and intensive physiotherapy is one of the keys to success. Fast-track rehabilitation ensures timely intervention to achieve best outcome of surgery.

Reference:

Abhishek, A., & Doherty, M. (2013). Diagnosis and clinical presentation of osteoarthritis. Rheumatic Disease Clinics, 39(1), 45-66.

Bedson, J., & Croft, P. R. (2008). The discordance between clinical and radiographic knee osteoarthritis: a systematic search and summary of the literature. BMC musculoskeletal disorders, 9(1), 116.

National, C. G. C. U. (2014). Osteoarthritis: care and management in adults. London: National Institute for Health and Care Excellence

Sauaia, A., Moore, F. A., Moore, E. E., Moser, K. S., Brennan, R., Read, R. A., & Pons, P. T. (1995). Epidemiology of trauma deaths: A reassessment. Journal of Trauma and Acute Care Surgery, 38(2), 185-193.

Wolfe, F., & Lane, N. E. (2002). The longterm outcome of osteoarthritis: rates and predictors of joint space narrowing in symptomatic patients with knee osteoarthritis. The Journal of Rheumatology, 29(1), 139-146.

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