HIP JOINT REPLACEMENT CASE STUDY
This paper will focus on Mrs. ’s hip joint replacement, the main physical processes and the structures involved, the key biopsychological factors that may influence the patient’s experience of this problem and how consideration of these factors that may influence the management and outcome of the case.
The hip is a ball and socket joint. The ball is the femoral head, which forms three-fourths of a sphere. The socket is the acetabulum, which is not a true hemisphere, but rather forms a horseshoe-shaped joint surface with a depression in the middle called the fossa. The transverse acetabular ligament connects the bony portions to complete the rim of the socket. The ligamentum teres arises from the confluence of the acetabular fossa, and the transverse ligament then inserts into a small depression in the femoral head. This structure provides the head with blood flow early in development, but it is not essential for blood flow in adults.
The ligamentum teres does appear to provide some stability for the hip, especially in the flexed/abducted/externally rotated position or with hyperabduction. The anterior rim of the acetabulum has a small depression called the psoas notch; the iliopsoas muscle tendon is located extracapsularly in this area. The iliopsoas attaches to the lesser trochanter of the femur and functions as the primary flexor of the hip. A series of ligaments connects the acetabulum to the femoral neck; collectively, this structure is called the hip capsule ( 2005).
The hip joint allows the leg an amazingly wide range of motion. Luckily, the joint itself is relatively simple, mechanically-a ball-and-socket arrangement in which the rounded upper end of the femur moves inside the acetabulum, a socket in the pelvis. In the operation, the worn or diseased end of the femur is replaced with a new ball part, and the worn and damaged parts of the acetabulum are removed and replaced with a concave bearing cup to match the ball. The artificial ball and socket have surfaces that glide against each other in a way that mimics the natural joint ( 2006).
The standard hip replacement involves making a large incision down the side of the upper thigh, cutting through muscle and exposing the hip joint. The head of the femur (thigh bone) is then removed with a saw and replaced by a prosthesis, which is driven into the thigh bone and cemented in place. The operation causes extensive pain, bruising and swelling and requires one to two weeks in hospital.
Like any surgery, hip joint replacement carries certain life-threatening risks, such as infection, blood clots and complications from anesthesia. Other complications include nerve damage, dislocation of breakage after surgery, and wearing out or loosening of the joint over time (2004). After the operation, there can be wound infection and worse, infection of the hip replacement. These may require prolonged antibiotics and possible removal of the implants
Patient factors include age, gender, race, and living arrangement. These factors are either nonmalleable traits or pre-existing states that each patient possesses before joint replacement surgery. Clinical factors include comorbidities and preoperative physical status indicators (eg, total lymphocyte count [TLC], hematocrit). Body mass index (BMI), an indicator of total body fat, also is a relevant clinical indicator because joint stress can be caused by an increased BMI. Treatment factors include surgical factors, such as length of time in surgery and type of anesthesia, and postoperative factors, such as type and amount of postoperative analgesia and postoperative complications ( 2004).
After the hip replacement surgery, it is expected that the care of the patient can become complex as a result of physiological changes that may occur. Another thing is that, the patient now has an artificial hip in him and this is something that the client has to get used to.
To assess the patient’s condition after the hip replacement surgery, the nurse should apply critical thinking while relying on information from the preoperative nursing assessment, knowledge regarding the surgical procedure performed, and the events that occurred after surgery (2004). The information that the nurse gathered from the client will help the nurse to detect any change and make decisions about patient’s care. A variation from the patient’s normal signs may indicate the onset of surgically related complications (2004).
The health care professional like the nurse should thoroughly document the assessment, including vital signs, level of consciousness, comfort level, pain, range of motion or mobility among other things. The initial findings are a baseline for comparing changes before and after the surgery. The nurse also has the responsibility of explaining to the patient and his/her family the purpose of post-operative procedures or equipment and the status of the patient.
Two acute needs of the patient after total hip replacement surgery are pain and mobility. The physiology of these two are altered after surgery. The pain after undergoing hip replacement surgery is intense but is still somewhat manageable (2003).
It is imperative that the nurse and other health care professionals set the stage for the relationship that allows for open communication about pain. Simple measures such as sitting when talking to patients about pain lets patients know that the nurse has the time and the interest to assess the pain felt by the patient (2004). The kind of pain that the patient experiences after surgery is acute pain which everyone experiences some level of during one’s lifetime. It is actually protective and has an identifiable cause, in this case, the surgery itself was the cause of the pain. This kind of pain has limited tissue damage and emotional response.
Since acute pain is expected to be healed and the cause can be identified, healthcare teams are usually willing to treat the acute pain experienced by the client. Nurses should be aware that unrelieved acute pain can progress to chronic pain (2004). Assessment of the patient’s mobility enables the nurse to determine the client’s coordination and balance while walking, bending, and doing usual movements with the knee. The assessment of mobility has three components: range of motion, gait, and exercise (2004).
Assessing the range of motion is used to determine the degree of damage or injury to the joint or it could be from recovery. The nurse should ask questions about joint stiffness, swelling, pain, limited movement, and unequal movement. Assessing the client’s gait or the manner and style in walking allows the healthcare professional like the nurse to draw conclusions about balance and posture (2004).
Other than that, malignant hypothermia could occur and is a potentially lethal condition that can occur in patients who underwent hip replacement surgery and received general anesthesia. This should be suspected when there is unexpected tachycardia and tachypnea, jaw muscle rigidity, body rigidity of limbs, abdomen and chest, or hyperkalemia (2004).
Patients who have temperature elevations should be assessed and nursing interventions should be planned for a possible infectious process. Postoperative interventions of deep breathing and coughing, early ambulation, and aseptic care of the surgical wound of the hip will decrease the patient’s risk of postoperative infections.
The patient may be recommended to rest, the use of hip supports, the use of walking aids such as canes and walkers. Physical therapy and appropriate exercises may also be suggested. Occasionally, steroid injections into the hip may decrease pain and inflammation. A variety of drugs for arthritis exists. These range from painkillers aspirin and acetaminophen to NSAIDs (nonsteroidal anti-inflammatory drugs) such as diclofenac, meloxicam, piroxicam, mefenamic acid, ibuprofen, to the latest COX-2 inhibitors (rofecoxib and celecoxib).
Patients whose pain level is reported as tolerable should to be more active and willing to engage in physical therapy. With emphasis being placed on providing quality care while striving for cost-effectiveness, such adverse outcomes need to be targeted for prevention from all possible angles (1999).
Approximately six weeks after surgery, comfortable hip motion usually is regained, and strength training can begin. Low impact exercises, such as walking, swimming, and biking, are well-tolerated and can be performed up to five or six times per week. Optimally, strength training is performed three times per week and includes using a leg press machine and doing hamstring curls and squats and lunges. The therapist should instruct the patient to be careful during isolated hip movements with resistance on the ankle because these movements can generate high hip joint loads. Strength training should be varied for maximal gains, alternating between low resistance/high repetition and high resistance/low repetition workouts ( 2005)
Hip replacement surgery is a safe and cost-effective treatment for persistent hip pain and disability, and increasing numbers of patients like Mrs. are seeking it in order to minimize or eliminate pain and difficulty in moving the hip joint. After surgery, health care professionals and the family of the patient still have many important factors to assess in order to make sure that the patient is doing well after the surgery. Health care professionals and families should continue assessing the patient until the critical factors are on a less intensive basis.
Annotated Reference
1. and Fundamentals of Nursing sixth edition, published in 2004 by , is a textbook for nursing students which prepares the nursing student’s of today for the challenges of tomorrow. This was a revised copy from the previous editions and contains new chapters, new ideas and new issues. This textbook is designed for beginning students in all types of professional nursing programs as well as for other health care or non-health care professionals who are doing research on nursing and other health aspects. The textbook also has a comprehensive coverage providing fundamental concepts, skills, and techniques of nursing practice and a firm foundation for more advanced areas of study.
The book also provides a contemporary approach to nursing practice, discussing the entire scope of primary, acute, and restorative care. Nursing concepts like concept maps which visually demonstrate the relationship between multiple nursing diagnoses for associated medical diagnoses, nursing skills and nursing care plans, contemporary nursing issues such as emerging practice issues and nursing shortage, and the increased focus on research and evidence-based practice in skills and care plans to influence and guide clinical decision making are just a few of the many contents of this book.
2. Review of Medical Physiology 20th edition, published in 2001, is designed to provide a concise summary of mammalian and, particularly, of human physiology that students of the medical profession and others can use by itself or can supplement with other readings in current texts, monographs, and reviews. Pertinent aspects of general and comparative physiology are also included in this textbook. Summaries of relevant anatomic considerations are found in every section of the book, but it is with warning that the author mentions that this book is written primarily for those who have some knowledge of anatomy, chemistry, and biochemistry. Examples from clinical medicine were given where pertinent to illustrate physiologic points.
Review of Medical Physiology also includes a self-study section to help students review for examinations and also has an appendix that contains general references, a discussion of statistical methods, a glossary of abbreviations, acronyms, and symbols commonly used in physiology, and several other useful tables. In this 20th edition, as previous editions, the entire book has been thoroughly revised, with a view to eliminating errors, incorporating suggestions of readers, updating concepts, and discarding material that is no longer considered relevant. In a way, the book has been kept as up-to-date and accurate as possible.
3. and 10th edition of the Textbook of Medical Physiology was published in 2000. The first edition of this book was written around 50 years ago by Dr. alone. In this 10th revision, Dr. joined as coauthor and helped in the revisions needed for the textbook. Both the authors thoroughly revised the textbook throughout in order to improve clarity of the concepts and to include new physiological principles where necessary.
The goal of this textbook is to present new and more recent physiologic principles in the terminology of molecular and physical science rather than merely as a series of separate unexplained phenomena. The field of physiology and medicine as a whole is continually evolving and changing, therefore certain concepts may not be true or useful in the present. Another goal of this text is to be as accurate as possible. Suggestions and critiques from many physiologists, students, and clinicians throughout the world have been sought and then used for checking factual accuracy as well as balance in the text. The sources referenced in the textbook have been chosen primarily for their presentation of physiologic principles and for the quality of their own references.
4. article in the AORN Journal is about predictors in joint arthroplasty patients. This particular article was published in the May 1, 2004 issue. The AORN Journal, available in printed and online editions, is an award-winning source of perioperative nursing information. It is published monthly and provides articles on clinical management and research topics; updates on clinical issues, perioperative pharmacology, operating room nursing law and legislation; and features such as book reviews, practical innovations, Board reports, conference reports, and home study programs.
In this particular article, focus is given to elderly arthroplasty patients. The study explored the effect of patient, clinical, and treatment factors on length of stay (LOS), discharge disposition, and total acute care hospital charges for older adults undergoing elective total hip arthroplasty or total knee arthroplasty. A causative retrospective design was used, and data analysis included descriptive statistics, multiple regression, and logistic regression. The results of the study showed significant differences in predictor variables between patients who were discharged to home and those who were discharged to another facility. Only postoperative complications contributed significantly to LOS. Total surgical time and postoperative complications contributed significantly to hospital charges.
4. This next article is also from the AORN Journal. This articled is about arthroscopic hip surgery and is written by and published on December 1, 2005. Arthroscopic hip surgery has become an accepted surgical procedure with well-defined indications and expected outcomes, primarily because of recent advances in surgical in surgical instrumentation and techniques. Hip arthroscopy is said to be performed as a same-day procedure using a fracture table to apply distraction to the hip joint. The article “Arthroscopic hip surgery” is the basis for this AORN Journal independent study. The article also provided a short background on the anatomy and function of the hip joint, as well as the major health concerns and diseases that affect the hip joint. Diagnostic testing (like Physical examination of abnormal gait, tenderness, hip range of motion, muscle flexibility, and baseline neurovascular status) and surgical indications regarding hip replacement are also included in the article.
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