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CHAPTER 39 / Nursing Care of Clients with Musculoskeletal Disorders 1243

NURSING CARE OF THE CLIENT HAVING TOTAL JOINT REPLACEMENT

PREOPERATIVE CARE fected extremity. If so, rapid intervention is important to preserve


Assess the clients knowledge and understanding of the the function of the extremity.
planned operative procedure. Provide further explanations Monitor incisional bleeding by emptying and recording suc-
and clarification as needed. It is important that the client have a tion drainage every 4 hours and assessing the dressing fre-
clear and realistic understanding of the surgical procedure and quently. Significant blood loss can occur with a total joint re-
expected results. Knowledge decreases anxiety and increases the placement, particularly a total hip replacement.
clients ability to assist with postoperative care procedures. Reinforce the dressing as needed. The dressing is usually
Obtain a nursing history and physical assessment, including changed 24 to 48 hours after surgery but may need reinforcement
range of motion of the affected joints. This information not only if excess bleeding occurs.
allows nurses to tailor care to the needs of the individual but also Maintain intravenous infusion and accurate intake and output
serves as a baseline for comparison of postoperative assessment records during the initial postoperative period. The client is at
data. risk for fluid volume deficit in the initial postoperative period be-
Explain necessary postoperative activity restrictions. Teach cause of blood and fluid loss during surgery, as well as the effects
how to use the overhead trapeze for changing positions. The of the anesthetic.
client who learns and practices moving techniques before surgery Maintain bed rest and prescribed position of the affected ex-
can use them more effectively in the postoperative period. tremity using a sling, abduction splint, brace, immobilizer, or
Provide or reinforce teaching of postoperative exercises spe- other prescribed device. Proper positioning of the affected ex-
cific to the joint on which surgery is to be performed. Exercises tremity is vital in the initial postoperative period so that the joint
are prescribed postoperatively to (a) strengthen muscles provid- prosthesis does not become dislocated or displaced.
ing joint stability and support, (b) prevent muscle atrophy and Help the client shift position at least every 2 hours while on bed
joint contractures; and (c) prevent venous stasis and possible rest. Shifting of position helps prevent pressure sores and other
thromboembolism. complications of immobility.
Teach respiratory hygiene procedures such as the use of incen- Remind the client to use the incentive spirometer, to cough,
tive spirometry, coughing, and deep breathing. Adequate respi- and to breathe deeply at least every 2 hours. These measures
ratory hygiene is imperative for all clients undergoing joint re- are important to prevent respiratory complications such as
placement to prevent respiratory complications associated with pneumonia.
immobility and the effects of anesthesia. In addition, many clients Assess the clients level of comfort frequently. Maintain PCA,
undergoing total joint replacement are elderly and may have epidural infusion, or other prescribed analgesia to promote
reduced mucociliary clearance. comfort. Adequate pain management promotes healing and
Discuss postoperative pain control measures, including use of mobility.
patient-controlled analgesia (PCA) or epidural infusion as ap- Help the client get out of bed as soon as allowed.Teach and re-
propriate. It is important for the client to understand the purpose inforce the use of techniques to prevent weight bearing on the
and use of postoperative pain control measures to allow early affected extremity, such as the over-head trapeze, pivot turn-
mobility and reduce complications associated with immobility. ing, and toe-touch. Early mobility prevents complications such as
Teach or provide prescribed preoperative skin preparation pneumonia and thromboembolism, but appropriate techniques
such as shower, shampoo, and skin scrub with antibacterial so- must be used to prevent injury to the operative site.
lution. These measures help reduce transient bacteria that may Initiate physical therapy and exercises as prescribed for the
be introduced into the surgical site. specific joint replaced, such as quadriceps setting, leg raising,
Administer intravenous antibiotic as ordered.Antibiotic therapy and passive and active range-of-motion exercises. These exer-
is initiated before or during surgery and continued postopera- cises help prevent muscle atrophy and thromboembolism and
tively to further reduce the risk of infection. strengthen the muscles of the affected extremity so that it can
support the prosthetic joint.
POSTOPERATIVE CARE Use sequential compression devices or antiembolism stock-
ings as prescribed. These help prevent thromboembolism and
Check vital signs, including temperature and level of con- pulmonary embolus for the client who must remain immobile
sciousness, every 4 hours or more frequently as indicated. following surgery.
Report significant changes to the physician. These routine as- For the client with a total hip replacement, prevent hip flexion
sessments provide information about the clients cardiovascular of greater than 90 degrees or adduction of the affected leg.
status and can give early indications of complications such as Provide a seat riser for the toilet or commode. These measures
excessive bleeding, fluid volume deficit, and infection. prevent dislocation of the joint.
Perform neurovascular checks (color, temperature, pulses and Assess the client with a total hip replacement for signs of pros-
capillary refill, movement, and sensation) on the affected limb thesis dislocation, including pain in the affected hip or short-
hourly for the first 12 to 24 hours, then every 2 to 4 hours. ening and internal rotation of the affected leg.
Report abnormal findings to the physician immediately.
Surgery can disrupt the blood supply to or innervation of the af-
(continued)
1244 UNIT XI / Responses to Altered Musculoskeletal Function

NURSING CARE OF THE CLIENT HAVING TOTAL JOINT REPLACEMENT (continued)

For the client with a total knee replacement, use a continuous cian visits. Clients are discharged from the acute care facility
passive range-of-motion (CPM) device or range-of-motion before healing is complete. Exercises are prescribed and activities
exercises as prescribed. Dislocation is not a problem with a knee are resumed gradually to protect the integrity of the joint replace-
replacement, and more emphasis is placed on range-of-motion ment and prevent contractures.
exercises in the early postoperative period. For those clients needing additional direct care after discharge,
Maintain fluid intake and encourage a high-fiber diet. arrange placement in a long-term care or rehabilitation facility.
Administer stool softeners or rectal suppositories as needed. Activity restrictions may preclude discharge to home for some
Immobility contributes to the potential problem of constipation; clients.
these measures help maintain regular fecal elimination. Make referrals as needed to home health agencies and physi-
Encourage consumption of a well-balanced diet with adequate cal therapy. Clients often require home health care for both nurs-
protein. Adequate nutrition promotes tissue healing. ing care needs and continued physical therapy following dis-
Teach or reinforce postdischarge exercises and activity restric- charge from acute or long-term care.
tions.Emphasize the importance of scheduled follow-up physi-

Health Promotion Suggest applying heat to painful joints using the shower, a
Although OA cannot be prevented, maintaining a normal tub or sitz bath, warm packs, hot wax baths, heated gloves,
weight and having a program of regular, moderate exercise will or diathermy, which uses high-frequency electrical currents
reduce risk factors. Glucosamine and chrondroitin are popular to generate heat. Heat application reduces accompanying
nutritional supplements for OA that are increasingly popular muscle spasm, relieving pain. Moist heat penetrates deeper
and have been found to be of benefit in reducing manifesta- than dry heat; diathermy delivers heat directly to lesions in
tions. Clients should discuss these supplements with their deeper body tissues.
health care provider before using them. Emphasize the importance of proper posture and good body
mechanics for walking, sitting, lifting, and moving. Good
Assessment body mechanics and posture reduce stress on affected joints.
Encourage the overweight client to reduce. Excess weight
Collect the following data through the health history and phys-
places abnormal stress on joints, particularly the knees.
ical examination (see Chapter 37).
Teach the client to use splints or other devices on affected
Health history: family history of OA, occupation, recre- joints as needed. These assistive devices help maintain the
ational activities, joint pain and stiffness, ability to carry out correct anatomic position of the joint and relieve stress.
ADLs and self-care activities Encourage the client to use nonpharmacologic pain relief
Physical assessment: height/weight; gait, joints: symmetry, measures such as progressive relaxation, meditation, visual-
size, shape, color, appearance, temperature, pain, crepitus, ization, and distraction. These adjunctive pain relief mea-
range of motion, Heberdens nodes, Bouchards nodes sures can reduce the clients reliance on analgesics and in-
crease comfort.
Nursing Diagnoses and Interventions
Chronic Pain Impaired Physical Mobility
Pain is a primary manifestation of OA. As joint tissues degen- As intra-articular cartilage degenerates and joint structures are
erate and changes in joint structure occur, the amount of dis- altered, the client with OA experiences pain, stiffness, and de-
comfort generally increases. The pain associated with OA in- creased range of motion in affected joints. When the spine, large
creases with activity and tends to be relieved with rest. weight-bearing joints of the hips and knees, or the ankles and
Nonpharmacologic comfort measures are appropriate, with feet are affected, physical mobility can be significantly reduced.
mild analgesics used to supplement these as needed.
Assess the range of motion of affected joints. Assessing
Monitor the clients level of pain, including intensity, loca- joint mobility is important as a basis for planning appro-
tion, quality, and aggravating and relieving factors. Accurate priate interventions.
assessment of pain provides a basis for evaluation of the Perform a functional mobility assessment, evaluating the
effect of interventions. clients gait, ability to sit and rise from sitting, ability to step
Teach clients to take prescribed analgesic or anti- into and out of the tub or shower, and negotiation of stairs.
inflammatory medication as needed. Analgesics reduce the The functional assessment provides vital data about the
perception of pain and may decrease muscle spasm as well. clients ability to maintain ADLs.
Anti-inflammatory medication may be ordered to decrease Teach the client active and passive ROM exercises as well as
local inflammatory response in affected joints. isometric, progressive resistance, and low-impact aerobic
Encourage rest of painful joints. The pain of OA is often re- exercises. Active ROM exercises help maintain muscle tone
lieved by joint rest. and mobility of affected joints and prevent contractures.