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Nursing care of hip surgery patients
Nursing care of hip surgery patients Lorraine
A Hinsch, RN
The preoperative and postoperative nursing care of hip surgery patients is important to the ultimate functioning of the hip following surgery. I would like to discuss the major aspects of preoperative and postoperative nursing care for four hip operations; nailing, prosthesis, cup arthroplasty and total hip replacement. Different surgical procedures are performed on the hip for a variety of pathological reasons. Each procedure may be usecl f o r one or more conditions. Internal fixation with any one of several types of nails or pins holds a fracture of the head or neck of the femur or a slipped capital femoral epiphysis in correct alignment. An osteotomy of the femur with pin Lorraine A Hinsch, RN, MEd, is an instructor in surgical nursing a t the Jewish Hospital School of Nursing, Cincinnati, Ohio. She is a graduate of the Illinois Masonic Hospital School of Nursing, Chicago, and has a BSN from Loyola University, Chicago, and an MEd from the University of Cincinnati.
550
and/or plate fixation may be selected to compensate for degenerative changes in the hip. A femoral head prosthesis may be inserted to repair a fracture of the head or neck of the femur or to reconstruct a hip deformed by degenerative changes. An arthroplasty with a metallic cup or a total hip replacement may reconstruct a hip joint deformed by degenerative changes or ‘by conditions resulting in dislocation. Preoperative nursing care. Preoperative nursing care will vary according to the pathology as well as the patient’s general physical and emotional state. If the patient suffers a sudden disability, such as a fracture, nursing care should relieve the pain; prevent further damage to soft tissues, nerves and blood vessels; and evaluate the patient’s general condition. Since these patients have not had time to make plans or adjust to the disability, they are often fearful of
AORN Journal, September 1973, Vol18, N o 3
what will happen to them. They require patience, support and understanding. These patients may be placed temporarily in traction. Nursing care of the patient in traction includes maintaining skin integrity, encouraging the patient to perform permitted activities, encouraging adequate food and fluid intake, reducing pain and discomfort, preventing neuromuscuh r complications and maintaining proper body alignment. The foot of the affected leg should be in neutral rotation and supported to prevent foot drop. The full force of the weight of the traction must be constantly maintained. It is also essential to maintain the patient’s position and the position of the leg in traction. Preoperatively most hip surgery patients will have some limitations imposed on them by their disease condition. Depending on the extent d the limitation, preoperative care may include measures to maintain fluid balance and adequate nutrition, elimination, and skin integrity. Procedures involving diagnostic x-rays, labratory tests, local preparation of the operative area and medications must be accurately carried out. Postoperative nursing care. Postoperative nursing care is similar for all types of hip surgery in many respects. During the first and second postoperative days, the nurse should follow this checklist: 1. Take, record, and act on vital Signs.
2. Evaluate the circulation of the affected leg. Check peripheral pulses, and the warmth and color sf the extremity. Observe for numbness or 1 0 s of sensation wbich may indicate pressure on a nerve.
3. Observe the amount and type of drainage on the dressing. When a drain is in place, watch it closely. 4. Encourage coughing and deep breathing to maintain efficient ventilation. 5. Prevent areas of skin breakdown. 6. Maintain fluid intake by keep ing intravenous fluids running properly and/or encourage oral intake of fluids and foods. 7. Take measures to maintain urinary output and bowel elimination. 8. Attempt to keep patient aware of the time, place, people around him and his situation. 9. Encourage the patient to help himself within his limitations and capacities. 10.Ehcourage active and passive movements which will help prevent contractures, especially of the hip, knee, and foot. As the patient progresses, nursing care will include concern with mobilization. The nurse should add to her checklist: 1.Start an exercise program with the patient’s assistance and cmperation. 2. Get the patient into a chair. Move the chair close to the nonoperative side so the patient can pivot on that leg. 3. Encourage the patient in the chair to sit straight. He should keep his knees apart to maintain abduction. At no time may the patient cross his legs. The knees should k flexed and even with the hips. The patient should keep his feet on the floor.
AORN Journal, September 1973, VoE 18, N o 3
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to 554
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4. Prevent weight bearing initially, with few exceptions, on the affected leg. 5. Encourage patient adivities such as hair combing. 6. Provide several short sessions in the chair daily, which are more beneficial than one long session.
The major differences in the care of patients with the various types of hip surgery involve the patient's position in bed and his ambulation schedule. The patient with a hip pin may be in the supine position and turned to either side. When the patient is supine, abduct the affected leg and flex the knee slightly. Place a pillow crosswise under the knee to maintain flexion. The foot can be maintained in a neutral position by preventing external rotation with a trochanteric roll. Lower the head of the bed periodically to prevent hip contractme. When the patient is turned to either side, keep pillows 'between his legs to maintain abduction and to support the extremity. Flex the upper leg and be sure the operative leg is stabilized to prevent uncontrolled movements. Ambulation begins the first or second postoperative day when the patient is permitted up in the chair. He progresses in a few weeks to using crutches or a walker without weight bearing. Partial weight bearing is permitted within three to five months. Total weight bearing occurs after complete union of the fracture in five to eight months. A primary goal of the care of the patient with a femoral head prosthesis is to prevent dislocation of the head of the femur since the hip joint capsule was opened and is weak. The
554
degree of leg rotation and the amount of activity permitted is partially dependent on the surgical approach to the joint. The patient may be in suspension traction or a hip spica cast if the hip is unstable. The following are guidelines for caring for the patient who has neither traction nor cast. When the patient is supine, maintain atduction of the operative leg with extension of the knee. Use two pillows placed lengthwise between the legs for this purpose. Maintain the foot in a neutral position. The head of the bed may be elevated periodically if an anterior approach was used, and' may be elevated to a limited degree if a posterior approach was used. Turn the patient only to the operative side and maintain abduction at all times by keeping pillows between the legs. Stabilize the operative leg and permit abduction of the operative leg to the midline after approximately three weeks. Ambulation begins between five days and six weeks postoperatively when the patient is permitted in the chair. The patient's ambulation progresses as he gradually increases weight bearing. He uses some type of walking aid and then progresses to full-weight bearing in about six months, depending on x-ray evidence of healing. Positioning of a patient with a cup arthroplasty is designed to keep the cup and head of the femur in the acetabulum. Initially, many of these patients are in balanced suspension skeletal traction. When the patient is in supine position maintain the affected leg in abduction with the knee flexed. Keep the leg in the neutral position or
AORN Journal, September 1973, V o l 1 8 , N o 3
slight internal rotation. The iliac crests must be level in this position. The head of the bed may be elevated to the prescribed degree. Do not turn the patient on his side, but move him slightly as ordered without disturbing the traction. Ambulation progresses a t a variable rate. Exercises are begun before the patient gets out of bed, which is about the third week. The patient must regain control of flexion, extension, abduction and adduction of his leg to ambulate, He progresses with gradually increasing weight bearing, but full function may require one year to attain. The patient with a total hip replacement may be in Russell traction for two to five days. Your primary concern when positioning the patient is to prevent dislocation of the prosthesis. When the patient is in the supine position, abduction and neutral rotation of the operative leg is imperative. Pillows or abduction pillows between the legs maintain the abduction. The head of the bed may be slightly elevated. Initially the patient either may not be turned or turned only slightly. The rate of ambulation will vary with the type of prosthesis inserted. The patient usually has gotten out of bed about the fourth or fifth p m t operative day maintaining abduction of the leg. The amount of weight bearing permitted will vary. Some patients may sit in a chair a t that time. Others may not be permitted to flex their hips to 90" until the tenth to fourteenth day. The patient may not cross his legs. He may walk with crutches, cane or walker as desired, but may not flex the leg beyond 90".
Some patients discard the walking aids after four or five weeks while others must retain them for three months. Summary. The ultimate functioning of a hip following surgery is affected by proper positioning and handling of the affected extremity immediately after surgery and by the efforts of the patient during convalesence to walk again. The nurse must properly position the operative leg according to the surgeon's instructions and general positioning guidelines. She is responsible for reminding the patient to maintain proper position. The nurse helps or teaches the patient to move as permitted. She encourages appropriate exercise and generally helps the patient become more mobile as recovery progresses to optimal function.
0 REFERENCES Clayton, M L. "Surgery of the Lower Extremity in Rheumatoid Arthritis," The Journal of Bone and Joint Surgery, October
1963, pp 1526-1527.
Francis, Sr M. "Nursing the Patient with Internal H i p Fixation," American Journal of Nursing, May
1964, pp I l l - I 12. Graves, S, and S Vincent. "Total H i p Replacement is a Family Affair," RN, June 1971, pp 35-41. Kerr, A. Orthopedic Nursing Procedures, 2nd ed. New York: Springer Publishing Co, Inc, 1969, pp
228-319.
Larson, C B, and M Gould. Orfhopedic Nursing. 7th ed. S t Louis: The C V Mosby Co, 1970. pp
68-74,424-432.
Neufeld, A J. "Surgical Treatment of H i p Injuries," American Journal of Nursing. March 1965, pp
80-83. Rockwell, S M. "Total H i p Replacement: the OR Nurses' Role," RN, June 1971, pp 35-41. Turek, S L. Orthopedics-Principles and Their Application. Philadelphia: J B Lippincott Co,
1959. Wiebe,
W B
A M. Orthopedics in Nursing. Philadelphia: Saunders C o , 1961.
AORN Journal, September 1973, V o l 1 8 , N o 3
555
A Hinsch, RN
The preoperative and postoperative nursing care of hip surgery patients is important to the ultimate functioning of the hip following surgery. I would like to discuss the major aspects of preoperative and postoperative nursing care for four hip operations; nailing, prosthesis, cup arthroplasty and total hip replacement. Different surgical procedures are performed on the hip for a variety of pathological reasons. Each procedure may be usecl f o r one or more conditions. Internal fixation with any one of several types of nails or pins holds a fracture of the head or neck of the femur or a slipped capital femoral epiphysis in correct alignment. An osteotomy of the femur with pin Lorraine A Hinsch, RN, MEd, is an instructor in surgical nursing a t the Jewish Hospital School of Nursing, Cincinnati, Ohio. She is a graduate of the Illinois Masonic Hospital School of Nursing, Chicago, and has a BSN from Loyola University, Chicago, and an MEd from the University of Cincinnati.
550
and/or plate fixation may be selected to compensate for degenerative changes in the hip. A femoral head prosthesis may be inserted to repair a fracture of the head or neck of the femur or to reconstruct a hip deformed by degenerative changes. An arthroplasty with a metallic cup or a total hip replacement may reconstruct a hip joint deformed by degenerative changes or ‘by conditions resulting in dislocation. Preoperative nursing care. Preoperative nursing care will vary according to the pathology as well as the patient’s general physical and emotional state. If the patient suffers a sudden disability, such as a fracture, nursing care should relieve the pain; prevent further damage to soft tissues, nerves and blood vessels; and evaluate the patient’s general condition. Since these patients have not had time to make plans or adjust to the disability, they are often fearful of
AORN Journal, September 1973, Vol18, N o 3
what will happen to them. They require patience, support and understanding. These patients may be placed temporarily in traction. Nursing care of the patient in traction includes maintaining skin integrity, encouraging the patient to perform permitted activities, encouraging adequate food and fluid intake, reducing pain and discomfort, preventing neuromuscuh r complications and maintaining proper body alignment. The foot of the affected leg should be in neutral rotation and supported to prevent foot drop. The full force of the weight of the traction must be constantly maintained. It is also essential to maintain the patient’s position and the position of the leg in traction. Preoperatively most hip surgery patients will have some limitations imposed on them by their disease condition. Depending on the extent d the limitation, preoperative care may include measures to maintain fluid balance and adequate nutrition, elimination, and skin integrity. Procedures involving diagnostic x-rays, labratory tests, local preparation of the operative area and medications must be accurately carried out. Postoperative nursing care. Postoperative nursing care is similar for all types of hip surgery in many respects. During the first and second postoperative days, the nurse should follow this checklist: 1. Take, record, and act on vital Signs.
2. Evaluate the circulation of the affected leg. Check peripheral pulses, and the warmth and color sf the extremity. Observe for numbness or 1 0 s of sensation wbich may indicate pressure on a nerve.
3. Observe the amount and type of drainage on the dressing. When a drain is in place, watch it closely. 4. Encourage coughing and deep breathing to maintain efficient ventilation. 5. Prevent areas of skin breakdown. 6. Maintain fluid intake by keep ing intravenous fluids running properly and/or encourage oral intake of fluids and foods. 7. Take measures to maintain urinary output and bowel elimination. 8. Attempt to keep patient aware of the time, place, people around him and his situation. 9. Encourage the patient to help himself within his limitations and capacities. 10.Ehcourage active and passive movements which will help prevent contractures, especially of the hip, knee, and foot. As the patient progresses, nursing care will include concern with mobilization. The nurse should add to her checklist: 1.Start an exercise program with the patient’s assistance and cmperation. 2. Get the patient into a chair. Move the chair close to the nonoperative side so the patient can pivot on that leg. 3. Encourage the patient in the chair to sit straight. He should keep his knees apart to maintain abduction. At no time may the patient cross his legs. The knees should k flexed and even with the hips. The patient should keep his feet on the floor.
AORN Journal, September 1973, VoE 18, N o 3
Cj,
to 554
551
4. Prevent weight bearing initially, with few exceptions, on the affected leg. 5. Encourage patient adivities such as hair combing. 6. Provide several short sessions in the chair daily, which are more beneficial than one long session.
The major differences in the care of patients with the various types of hip surgery involve the patient's position in bed and his ambulation schedule. The patient with a hip pin may be in the supine position and turned to either side. When the patient is supine, abduct the affected leg and flex the knee slightly. Place a pillow crosswise under the knee to maintain flexion. The foot can be maintained in a neutral position by preventing external rotation with a trochanteric roll. Lower the head of the bed periodically to prevent hip contractme. When the patient is turned to either side, keep pillows 'between his legs to maintain abduction and to support the extremity. Flex the upper leg and be sure the operative leg is stabilized to prevent uncontrolled movements. Ambulation begins the first or second postoperative day when the patient is permitted up in the chair. He progresses in a few weeks to using crutches or a walker without weight bearing. Partial weight bearing is permitted within three to five months. Total weight bearing occurs after complete union of the fracture in five to eight months. A primary goal of the care of the patient with a femoral head prosthesis is to prevent dislocation of the head of the femur since the hip joint capsule was opened and is weak. The
554
degree of leg rotation and the amount of activity permitted is partially dependent on the surgical approach to the joint. The patient may be in suspension traction or a hip spica cast if the hip is unstable. The following are guidelines for caring for the patient who has neither traction nor cast. When the patient is supine, maintain atduction of the operative leg with extension of the knee. Use two pillows placed lengthwise between the legs for this purpose. Maintain the foot in a neutral position. The head of the bed may be elevated periodically if an anterior approach was used, and' may be elevated to a limited degree if a posterior approach was used. Turn the patient only to the operative side and maintain abduction at all times by keeping pillows between the legs. Stabilize the operative leg and permit abduction of the operative leg to the midline after approximately three weeks. Ambulation begins between five days and six weeks postoperatively when the patient is permitted in the chair. The patient's ambulation progresses as he gradually increases weight bearing. He uses some type of walking aid and then progresses to full-weight bearing in about six months, depending on x-ray evidence of healing. Positioning of a patient with a cup arthroplasty is designed to keep the cup and head of the femur in the acetabulum. Initially, many of these patients are in balanced suspension skeletal traction. When the patient is in supine position maintain the affected leg in abduction with the knee flexed. Keep the leg in the neutral position or
AORN Journal, September 1973, V o l 1 8 , N o 3
slight internal rotation. The iliac crests must be level in this position. The head of the bed may be elevated to the prescribed degree. Do not turn the patient on his side, but move him slightly as ordered without disturbing the traction. Ambulation progresses a t a variable rate. Exercises are begun before the patient gets out of bed, which is about the third week. The patient must regain control of flexion, extension, abduction and adduction of his leg to ambulate, He progresses with gradually increasing weight bearing, but full function may require one year to attain. The patient with a total hip replacement may be in Russell traction for two to five days. Your primary concern when positioning the patient is to prevent dislocation of the prosthesis. When the patient is in the supine position, abduction and neutral rotation of the operative leg is imperative. Pillows or abduction pillows between the legs maintain the abduction. The head of the bed may be slightly elevated. Initially the patient either may not be turned or turned only slightly. The rate of ambulation will vary with the type of prosthesis inserted. The patient usually has gotten out of bed about the fourth or fifth p m t operative day maintaining abduction of the leg. The amount of weight bearing permitted will vary. Some patients may sit in a chair a t that time. Others may not be permitted to flex their hips to 90" until the tenth to fourteenth day. The patient may not cross his legs. He may walk with crutches, cane or walker as desired, but may not flex the leg beyond 90".
Some patients discard the walking aids after four or five weeks while others must retain them for three months. Summary. The ultimate functioning of a hip following surgery is affected by proper positioning and handling of the affected extremity immediately after surgery and by the efforts of the patient during convalesence to walk again. The nurse must properly position the operative leg according to the surgeon's instructions and general positioning guidelines. She is responsible for reminding the patient to maintain proper position. The nurse helps or teaches the patient to move as permitted. She encourages appropriate exercise and generally helps the patient become more mobile as recovery progresses to optimal function.
0 REFERENCES Clayton, M L. "Surgery of the Lower Extremity in Rheumatoid Arthritis," The Journal of Bone and Joint Surgery, October
1963, pp 1526-1527.
Francis, Sr M. "Nursing the Patient with Internal H i p Fixation," American Journal of Nursing, May
1964, pp I l l - I 12. Graves, S, and S Vincent. "Total H i p Replacement is a Family Affair," RN, June 1971, pp 35-41. Kerr, A. Orthopedic Nursing Procedures, 2nd ed. New York: Springer Publishing Co, Inc, 1969, pp
228-319.
Larson, C B, and M Gould. Orfhopedic Nursing. 7th ed. S t Louis: The C V Mosby Co, 1970. pp
68-74,424-432.
Neufeld, A J. "Surgical Treatment of H i p Injuries," American Journal of Nursing. March 1965, pp
80-83. Rockwell, S M. "Total H i p Replacement: the OR Nurses' Role," RN, June 1971, pp 35-41. Turek, S L. Orthopedics-Principles and Their Application. Philadelphia: J B Lippincott Co,
1959. Wiebe,
W B
A M. Orthopedics in Nursing. Philadelphia: Saunders C o , 1961.
AORN Journal, September 1973, V o l 1 8 , N o 3
555