Doris Henley - Total Hip Replacement Evaluation Notes

Patient Information

• Name: Doris Henley

• Date of Birth: February 2, 1943 (81 years old)

• Date of Evaluation: Current date (date of video viewing)

Pre-Evaluation

• Therapist explained the procedure and obtained patient consent.

• Patient expressed readiness for physical therapy to assess mobility for potential discharge home.

• Patient is being evaluated under referral from Dr. Carl Payne.

• Order: Physical therapy evaluate and treat, weight bearing as tolerated (WBAT) on right lower extremity.

• Patient's Goal: Return home to her dog.

Medical History

• Past Medical History:

  • Osteoarthritis

  • History of left total knee replacement

  • Hypertension (High Blood Pressure)

  • Hyperlipidemia (High Cholesterol)

  • Remote history of two C-sections

• Reason for Admission: Osteoarthritis of the right hip

• Procedure: Total hip arthroplasty 24 hours prior to evaluation

Patient Interview

• Sleep: Patient reported getting some sleep overnight.

• Pain Level (0-10):

  • Current: 0 (aware of hip but no pain)

  • Overnight: Occasional pain

• Pain Management:

  • Patient used the PCA (Patient Controlled Analgesia) pump upon waking to use the bathroom.

  • Understanding of PCA pump usage.

• Pain Location: Primarily in the groin, some in the hip and upper leg.

• No pain behind the knee or in the calf.

Observations

• Lines and Tubes:

  • Sequential Compression Devices (SCDs) - white wraps

  • IV in right upper extremity with PCA pump

  • Dressing to right hip (clean and dry)

  • TED hose (white)

  • 2 liters of oxygen via nasal cannula

• Social History:

  • Retired church secretary

  • Widowed

  • Lives alone with a small dog

Physical Assessment

• Palpation:

  • No soreness or tenderness in the back of the calf

  • Back of the knee is fine.

  • Tenderness upon palpation near the incision site on the hip

• Vitals:

  • Blood Pressure: 102/68 mmHg

  • Heart Rate: 88 bpm

  • Oxygen Saturation: Monitored throughout the session

• Neurological:

  • No deficits in cognition or communication

• Circulation & Sensation:

  • Good pulse in the right foot

  • Feet feel warm

  • Able to feel touch in the right foot

  • Able to wiggle toes and ankle

  • Plantarflexion and dorsiflexion intact

• Range of Motion (ROM):

  • Upper Extremities: Within normal limits (WNL)

  • Left Lower Extremity: WNL

  • Right Lower Extremity: See comments

    • ROM assessed grossly while patient supine in hospital bed.

    • Full ROM at right ankle.

    • Knee ROM observed while sitting at edge of bed due to hip precautions.

    • Right hip ROM not tested due to precautions.

• Strength:

  • Upper Extremities: 5/5 bilaterally

  • Left Lower Extremity: 5/5

  • Right Lower Extremity: Limited (see comments)

    • Right plantarflexion: 5/5

    • Right dorsiflexion: 5/5

    • Right knee flexion: 4/5

    • Right knee extension: 3/5

    • Right hip flexion: 2/5

    • Right hip abduction: 1/5

    • Right hip extension: 3/5

    • Hip adduction: Not tested due to hip precautions

• Tone and spasticity were not tested.

Functional Mobility Assessment

• Supine to Sit:

  • Overhead trapeze used with bilateral upper extremities.

  • Moderate assistance required.

  • Rolling: Not tested.

• Hip Precautions Maintained: Throughout the transition.

• Sitting Balance: Good, unsupported with standby assistance.

• Sit to Stand: Assessed next.

• Standing Pivot: Not tested.

• Maximum assistance required to move right lower extremity off the bed.

Exercises & Interventions

• Long arc quads (LAQ) on right leg (not documented as separate intervention, used to activate quad muscles for standing).

• Practice standing and sitting.

  • Therapist provided verbal cues: "Nose over toes" for weight shifting.

  • Gait belt applied for safety.

• Weight shifting: Side to side while standing (preparatory, not a separate intervention).

Ambulation

• Assistive Device: Rolling walker (RW)

• Level of Assistance: Minimal assist (Min Assist) - therapist had a hand on the gait belt.

• Gait Distance: 40 feet

• Gait Pattern: Step-to gait pattern, leading with right lower extremity.

• Cues:

  • Lift right heel first, then toe.

  • Weight bear through walker to relieve pain on right lower extremity.

  • Maintaining hip precautions (avoid pivoting on right lower extremity).

  • Straighten the right leg when sitting down.

• Gait Description: Slow pace, flexed at both hips, heavily weight bearing through upper extremities.

• Patient was able to ambulate to a point equivalent to the distance from her bed to the bathroom at home.

Standing Balance

• Minimal assistance with rolling walker.

• Therapist maintained hand on gait belt.

Safety and Risk Management

• Patient returned to sitting in bedside chair.

• Call light and PCA button within reach.

• Patient verbalized understanding of the need to call for assistance to return to bed.

Additional Information

• Start and end times of the evaluation were not provided in the video and should be based on actual viewing time.

Based on the provided patient information, potential therapy diagnoses could include:

1. Impaired mobility related to total hip arthroplasty

2. Impaired muscle performance (weakness) associated with post-surgical deconditioning and hip precautions

3. Impaired balance related to weakness and altered gait pattern

4. Pain (primarily in the groin, hip, and upper leg) impacting functional activities

5. Activity intolerance due to post-operative status and pain

Patient is an 81-year-old female who presents s/p total hip arthroplasty due to osteoarthritis of the right hip. Patient demonstrates impaired mobility, muscle weakness, and altered gait pattern with minimal assistance required for ambulation with a rolling walker. Patient will benefit from skilled physical therapy to improve mobility, strength, and balance to return home to her prior level of function. Patient's prognosis is good due to patient's motivation to return home to her dog. Patient's case is complicated due to age which puts the patient at risk for falls. Patient's case is further complicated by post-operative pain which may limit participation in therapy. Special considerations for monitoring vitals, using a gait belt, and close supervision will be required. Consultation with case management may be beneficial to ensure a safe discharge plan.

Problem List:

• Impaired mobility related to total hip arthroplasty

• Impaired muscle performance (weakness) associated with post-surgical deconditioning and hip precautions

• Impaired balance related to weakness and altered gait pattern

• Pain (primarily in the groin, hip, and upper leg) impacting functional activities

• Activity intolerance due to post-operative status and pain

Goals:

Short Term Goals (5 days):

• Patient will demonstrate improved bed mobility, transitioning from supine to sit with minimal assistance within 5 days.

• Patient will increase right lower extremity strength, achieving 4/5 MMT grade in hip flexion and abduction within 5 days.

• Patient will ambulate 50 feet with rolling walker and minimal assistance, using a step-through gait pattern within 5 days.

Long Term Goals (10 days):

• Patient will ambulate 150 feet with rolling walker and supervision maintaining hip precautions within 10 days.

• Patient will independently perform exercises to maintain or improve strength and range of motion of lower extremities to allow safe functional mobility within 10 days.

• Patient will demonstrate the ability to ascend/descend 3 steps with supervision within 10 days.

• Patient will return home and resume prior activities of daily living (ADLs) with modified independence within 10 days.

Discharge Recommendations:

1. Home Exercise Program:

   • Continue with exercises prescribed during physical therapy to maintain and improve strength and range of motion in lower extremities.

   • Focus on exercises that promote hip stability and balance.

2. Assistive Device Use:

   • Continue using a rolling walker for ambulation until cleared by the physical therapist or physician.

   • Ensure proper fit and maintenance of the rolling walker.

3. Hip Precautions:

   • Adhere to hip precautions at all times to prevent dislocation:

     • Avoid bending past 90 degrees at the hip.

     • Do not cross legs.

     • Keep the operated leg slightly abducted (away from the midline).

4. Activity Modification:

   • Modify activities of daily living (ADLs) as needed to accommodate hip precautions and mobility limitations.

   • Use adaptive equipment to assist with dressing, bathing, and toileting.

5. Fall Prevention:

   • Assess home environment for potential fall hazards (e.g., loose rugs, poor lighting).

   • Use nightlights and install grab bars in the bathroom as needed.

   • Wear supportive, non-slip shoes.

6. Follow-Up Appointments:

   • Schedule follow-up appointments with the orthopedic surgeon and physical therapist as recommended.

   • Attend all scheduled therapy sessions to maximize recovery.

Home Equipment Needs:

1. Rolling Walker:

   • Essential for safe ambulation and weight-bearing.

   • Ensure proper height adjustment for optimal posture and support.

2. Raised Toilet Seat:

   • To maintain hip precautions and ease of sitting and standing.

3. Shower Chair or Bench:

   • Provides a safe seating option during showering or bathing.

4. Long-Handled Shoehorn and Sock Aid:

   • To assist with dressing while adhering to hip precautions.

5. Reacher/Grabber Tool:

   • To avoid bending and reaching for items.

6. Firm Chair with Armrests:

   • Provides support for sitting and standing, and maintains hip precautions.

Treatment Plan:

1. Neuromuscular Re-education:

   • Focus on improving balance and coordination to prevent falls by performing exercises that challenge balance and proprioception.

2. Therapeutic Activity:

   • Maximize independence with functional mobility through activities such as sit-to-stand transfers, bed mobility, and walking.

3. Therapeutic Exercise:

   • Improve strength in lower and upper extremities using exercises such as ankle pumps, knee extensions, hip abduction, and upper body exercises with light weights or resistance bands.

4. Patient/Family Education:

   • Educate the patient and family on the use of assistive devices, safety precautions, activity modifications, and energy conservation techniques.

   • Provide written instructions and demonstrations as needed.

5. Gait Training:

   • Improve ambulation with a rolling walker, focusing on proper gait pattern, weight-bearing, and hip precautions.

   • Progress to more challenging walking surfaces and distances as tolerated.