joint replacement patients

Arthro

joint

Arthroscopy

the repair of joint problems through the operating arthroscope or through open joint surgery

Arthroplasty

forming a “new joint”

Hemiarthroplasty: 

the replacement of one of the articular surfaces    

Osteotomy:

surgical cutting of the bone

Prosthesis:  

artificial substitute for a missing part of the body

THA

total hip arthroplasty = total hip replacement or THR

TKA

Total knee arthroplasty = total knee replacement or TKR

replaceable parts

Hip

Knee

Finger joints

Less frequently:

Shoulder

Elbow

Wrist

Ankle

who are typically joint replacement patients

Arthritis

Osteoarthritis

Rheumatoid arthritis

Trauma → functional joint damage

Certain hip fractures

Congenital deformity → functional joint damage

Tumors

Avascular necrosis

why do people get joint replacments

To increase mobility

To increase use

To increase joint stability

To relieve pain

when do people turn to total joint replacement

Usually after all other, more conservative therapies for healing and health have failed:

PT

Medication

Joint injections

Weight loss

Activity modification

component materials

1. plastic (polyethylene)

2. metal

3. ceramic

4. cement

metal material

Cobalt-chrome or titanium

ceramic material

actually a metal oxide

cement

Actually more of a filling compound

Holds “after market parts” in place

cementless hip prosthesis

Prosthesis is hammered into more precisely bored hole in the femur

advantages of cementless hip prosthesis

Avoid cement-related problems

Minimal risk of prosthesis-bone bond loss

disadvantages of cementless hip prosthesis

Risk of bone marrow chunks forced into circulation during shaft placement

Potential need for weight-bearing restriction

Thigh pain (larger prosthesis)

Loosening of fibers from porous coated surface

Requires good circulation to injury site so it may not be appropriate

cemented hip prosthesis

The prosthesis is placed into a bored opening in the femur and surrounded by the bone cement

Bored opening does not have to be precise

advantages of cemented hip prosthesis

Surgical skill deviations

Early weight-bearing

Is smaller, lighter prosthesis

Is cost effective

disadvantages of cemented hip prosthesis

Cement may cause circulatory interruptions

With age, cement can crack Ú  bonding loss between prosthesis and bone Ú joint instability

complications of joint replacement

Dislocation/loosening (osteolysis) of the artificial joint

lnfection at the surgical site

Thromboembolism

Complications of immobility

long term complications of joint replacement

Heterotopic ossification: bone formation in the wrong place

Avascular necrosis

Loosening of the joint

nursing goals with total joint replacements

Minimize discomfort/pain

Prevent infection of surgical site

Prevent/minimize negative consequences of immobility

Prevent dislocation/loosening of prosthesis

post op nursing resonsibilities

Vital signs/neurovascular checks as ordered (q 1-2 hours)

Control pain

Monitor incision

Prevent DVT

maintain body/limb alignment

respiratory toilet

assess skin integrity

nutrition/hydration

home health/social service for rehab referrals

ways to monitor pain post op nursing responsibilities

Medications:  IV, PO, PCA, nerve block

As needed and before planned activities

Individualized strategies

Reposition

monitoring incision post op nursing responsibility

lnfection

Bleeding

Record drainage/drain output

Maintain clean, dry dressing

preventing dvt post op nursing responsibility

Thrombus-prevention therapy - (Lovenox/Coumadin/Eliquis/aspirin, others)

AE hose/SCDs

Activity and weight-bearing as allowed by surgeon

“OOB ASAP, with order”

PROM

respiratory toilet post op nursing responsibilities

C-DB (coughing and deep breathing) and Incentive spirometer

assess skin integrity post op nursing

lnvestigate:

Complaints of itching, burning

Especially heels

Redness of bony prominences

nutriiton/hydration post op resposilities

Balanced diet for healing

Energy for PT/activity

neurovacular assessment 3 early Ps

Pain

Unrelieved with medication or repositioning/elevation

Paresthesia

Numbness, tingling, pins/needle sensation

Pallor

Cap refill time > 3 sec, bluish fingers, toes

late 3 Ps neurovascular assessment

Polar

Skin temperature – cool/cold fingers/toes

Paralysis

Unable to move fingers/ toes

Pulses

Palpable pulses, Doppler pulse, or no pulse

human response to dislocation of hip prosthesis

Increased pain, swelling, immobilization

Shortening of affected leg

Abnormal internal/external rotation

Restricted movement

“Popping” sensation of affected hip

preventing prosthesis dislocation

Proper positioning:  Maintain abduction for some replacements

Sometimes instructions to not flex hip > 90 degrees

No internal or external rotation of the affected leg/hip

hip dislocation risk

Risk is greatest during the first 3 months post-op

Other risk factors: age, bone loss, RA, cognitive impairment, implant issues

Important to know the SPECIFIC precautions from the surgeon (depends on surgical approach).

Give printed literature with pictures to patient and review before discharge

dislocation of knee prosthesis human repsonse

Pain or swelling after movement

An obvious deformity of the knee 

Numbness in the foot

No pulses in the foot

nursing intereventions to prevent knee dislocation proper positioning

Proper positioning

Maintain leg in full extension

Towel roll under ankle of operative leg

Reposition towel roll frequently to prevent peroneal nerve damage

nursing intervenetions maintain joint function w knee replacement

1. polar pack to reduce post op swelling

2. knee immbolizier to maintain joint stability when OOB

3. CPM (continuous passive movement) to prevent joint flexion contracture

documentation

Note and document differences

In time on operative limb

Differences between operative limb and non-operative limb

general discharge instructions restrictions

Hip:  Follow specific positioning guidelines (approach- dependent)

Knee:  Avoid prolonged kneeling positions

Knee:  No running or involvement in sporting activities requiring high-speed running and/or jumping until OK with MD/PT

genreal discharge instrcutions

1. restrictions

2. continue wih PT as ordered

3. medication education

4. when to cotnact PCP/surgeon

when to contact PCP/surgeon after discharge

Elevated temperature/fever, drainage from surgical site, sudden increase in pain, significant change in range of mobility, gait instability