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Mrs Jean Bailey is a 76-year-old lady who has been admitted to the surgical ward post operatively following a left total hip replacement (THR). She has a long-standing history of Osteoarthritis.  She is retired and lives with her husband in a two-storey house.

She is 160cm in height and weighs 45 kg. On return to the ward from theatre her vital signs are: BP 108/59, T 37. 2  P99, R 18, O2 sat - 96% RA. Pain Score 5/10. She has an indwelling catheter insitu and has drained 100 mls of clear urine since return; IV (Peripheral) N/Saline 0.9% infusing in left hand at 100 ml/hr, wound dressing is intact with no drainage on the dressing, but haemovac with 30 mls of haemoserous drainage. O2 running at 2 l/minute via nasal prongs. GCS is 14 she is orientated to time person and place.

Review the case study and complete the following:

Identify and explain the specific risk factors for post-operative complications for Mrs Bailey.

Discuss one potential post-operative complication for Mrs Bailey based on Roper and Tierney’s modified ADL’s: Breathing, diet and fluids, elimination, hygiene, mobility, comfort and rest, skin integrity and psychosocial. Include in your discussion the related aetiology of the  complication. (Note you are only discussing one potential post-operative complication that includes all above mentioned ADLs Eg: Breathing difficulty, mobilisation problem, fragile skin)

Develop a care plan (using the care plan template on Blackboard) to address 4  potential complications for Mrs Bailey.

Analyse the role of the physiotherapist in preventing complications and promoting recovery

Highlight the education required for Mrs Bailey prior to discharge to support her recovery at home.

Risk factors for postoperative complications

Osteoarthritis is a very serious health condition that can lead to total hip replacement surgery. Postoperatively, total hip replacement is associated with complications which usually develops following various risk factors. This paper will identify and explain the risk factors for postoperative complications for the client. The paper will identify and discuss one possible post-operative complication for the client based on various Activities of Daily Living (ADL’s) such as elimination, breathing, hygiene, diet and fluids, comfort and rest, mobility, psychological and skin integrity and their aetiology. The paper will develop a care plan addressing four potential complications with three appropriate nursing assessments, nursing interventions and their rationale. Lastly, the paper will analyze the role of a physiotherapist in the postoperative prevention of complications and prevention of complications and highlight the appropriate education required for the client before discharge to enhance and support quick recovery.

Postoperatively, there is a wide of risk factors that can lead to complications following total hip replacement in a patient. Some of these risk factors include; bleeding, blood clots, infections, fractures, loosening, inflammation and swelling, hip stiffness, hypersensitivity to the bone cement applied and damage to the surrounding tissues and structures of the joint (Belmont et al, 2014, pp 597-604).

Postoperative hemorrhage is associated with the formation of blood clots. This is very dangerous since a portion of the blood clot may break off and move to other body organs such as the heart, lungs and sometimes to the brain. At the legs, the formation of clots leads to the development of Deep Vein Thrombosis (DVT). Clot formation occurs due to thickening of blood making it stick together. Formation of clots is important to prevent excessive hemorrhage but it is very dangerous especially when it forms inside the blood vessels. In the lungs, the presence of a blood clot can lead to pulmonary embolism which is life-threatening because it causes obstruction and blockage of blood flow. After hip replacement, prolonged stay in bed necessitates formation of blood clots because the flow of blood in the deep veins is slowed down (Belmont et al, 2014, pp 597-604).

Another risk factor for postoperative complication in total hip replacement is infections. Infections usually occur at the incision site and extends to the deeper tissues and structures of the new hip (prosthesis). Infections may develop intraoperatively, postoperatively or even after patient discharge. Mostly, postoperative infections are caused by bacteria which might be present in gastrointestinal tract or the skin. Spread of the bacteria into the bloodstream stimulates a rapid immune system response in an effort to kill them (Courtney, Rozell, Melnic, & Lee, 2015, pp 1-4).

The immune response involves inflammatory process which involves production of cytokines and mediators. Failure of the immune system to fight the bacterial pathogens may lead to a serious complication such as sepsis which leads to multi-system dysfunctions. The bacteria get into the body in various ways such as skin cuts or breaks and surgical wounds. Some of the key indicators of infected joint replacement are; increased stiffness and pain, swelling, redness and warmth around the joint, fatigue, wound drainage, fever, night sweats and chills (Belmont et al, 2014, pp 597-604).

Potential postoperative complication

During surgery, fractures might occur on the healthy part of patient’s hip joint. These fractures are usually small and may not be noticed by the physicians/surgeons hence leading to a high risk of development of post-operative infections if they remain unmanaged or untreated. Loosening of the hip joint as a result of failure to solidly fix the bone may lead to pain at pain and other injuries hence predisposing the patient to hemorrhage and infections. Other risk factors for post-operative complications is inflammation and swelling which indicates healing response of the body to the surgery. Increased and rapid leg swelling and calf tenderness are indications of blood clots in blood vessels and can lead to serious post-operative complications (Courtney et al, 2015, pp 1-4).

Hip stiffness is associated with the development of scar tissues around the newly replaced hip hence hindering flexibility leading to joint stiffness. Joint stiffness results in decreased blood supply to the surrounding tissues of the new hip. Postoperatively, there might be allergic reactions to the bone cement applied to ensure adherence of the hip prostheses to the already existing hip bone.  The hypersensitivity reactions may lead to inflammation, swelling, fever and redness of the surrounding tissues resulting to infections and complications such as sepsis and septic shock (Pugely, Martin, Gao, Schweizer, & Callaghan, 2015, pp 47-55)

Additionally, damage to the tissues and structures around the joint during surgery may lead to complications. Some of the soft tissues damaged may be ligaments, muscles and tendons. The damage may sometimes extend to the surrounding nerves, veins and arteries resulting to weakness and reduced sensitivity of the leg (Pugely et al, 2015, pp 47-50).

The potential post-operative complication for this patient could be sepsis/septic shock. This complication impacts various Activities of Daily Living (ADLs) in the patient. These ADLs include diet and fluids, breathing, elimination, comfort and rest, hygiene, skin integrity, mobility and psychological needs. Sepsis is a very serious and life-threatening medical condition which involves response of the body to its own organs and tissues following infection injuries (Singer et al, 2016, pp 801-810).

Sepsis involves production and release of cytokines by the body’s immune system during inflammatory responses following bacterial or viral invasion. The inflammatory response in sepsis/septic shock results in increased permeability of capillaries, massive vasodilation and reduced systemic vascular resistance hence leading to hypotension. Consequently, hypotension results to reduced perfusion of body tissues leading to tissue hypoxia which causes septic shock. During the inflammatory process in sepsis in response to infections, formation of microthrombi obstructs arterial vessels hence decreasing the blood flow to body tissues (Cawcutt, & Peters, 2014, pp 1572-1578)

Decreased tissue perfusion and hypoxia (tissue ischemia) leads to multi-organ dysfunction and failure. Some of the organs affected include; heart, brain, lung, kidneys and liver. Decreased tissue perfusion leads to decreased supply of blood to the kidneys hence causing oliguria due to kidney dysfunctions. Decreased gastrointestinal supply of oxygen and blood leads to hypomotility which then leads to constipation, swallowing difficulties (dysphagia) and reduced appetite resulting to impaired elimination patterns of the patient. This also leads to difficulties in breathing, dyspnea and tachypnea as a compensatory mechanism for reduced oxygen supply to the alveolar (De Backer, Orbegozo Cortes, Donadello, & Vincent, 2014, pp 73-79).

Develop a care plan

It can be triggered by bacteria, fungi or viruses. Post-operative sepsis in hip replacement is associated with various factors such as spread of bacteria from the skin or the gastrointestinal tract to the surgical site and other body parts. The bacterial multiplies at the site causing severe which consequently triggers body’s immune response leading to sepsis (De Backer et al, 2014, pp 73-79).

Postoperatively, the body produces some fluids in response to the surgical operation. The fluids collect in body parts like pelvic or abdominal cavities where important body organs such as urinary bladder, stomach, kidneys, gut, chest and womb are located. In these organs, the produced fluids provide a favorable environment for bacterial replication and spread leading to development of sepsis. Inability of the patient to sufficiently move and take sufficient breath may cause development of pneumonia hence impairing the breathing aspect of patient’s ADLs. Following the prolonged history of the patient’s condition (osteoarthritis), her nutritional state has been tampered with (De Backer et al, 2014, pp 73-79).

Postoperatively, the patient might have reduced appetite due to sepsis leading to impaired dietary and fluid intake and output. Impaired nutritional state results to poor and delayed wound healing hence making it more vulnerable to bacterial infections. In major operations such as hip replacement involves use of special drips, drainage tubes and monitoring lines place into her body. Despite that they are inserted in a clean and sterile environment, they break the skin and prolonged use increases the risk of development of infections since they have broken the protective bacteria of the patient (Seymour, & Rosengart, 2015, pp 708-717).

Hypoperfusion of brain in septic shock leads to alteration in patient’s mental status resulting in depression, confusion and anxiety. This impairs the psychological functioning of the patient. Septic shock presents with weakness and fatigue leading to reduced patient mobility since she requires bed rest and relaxation. Prolonged bed-stay has a greater risk of development of pressure sores following tissue ischemia. As a result of impaired mobility, the patient’s hygiene is impaired because she is strong enough to maintain her own hygiene (oral care, cleaning, washing). At this stage, she might need total nursing care and assistance in performance of her daily Activities of Living (ADLs) (Hotchkiss et al, 2016, pp 16045).

ADL

Nursing Assessment

Nursing Intervention

Rationale

Breathing-

Patient has potential for post-operative pulmonary embolism

Mobility-

Patient has a potential for Deep Vein Thrombosis (DVT)

Fluids-

Patient has a potential bleeding (haemorrhage) and hematoma.

Vital signs one hourly-Blood pressure, respirations, pulse rate.

One hourly-Breathing patterns, use of accessory muscles and lung sounds

Daily-Skin colour, mucous membranes and nail beds.

Administer oxygen via nasal prongs/facial mask at a rate of 2L/minute.

Positioning the patient in a Semi-Fowler’s Position with the head of the bed elevated at angle of 45 degrees.

Encouraging bed rest and relaxation.

Supplemental oxygen helps in maintaining partial pressure of Oxygen (PaO2) at an acceptable concentration (more than 90%) hence increasing oxygen supply for body metabolism (Kremers et al, 2015, pp 1386).

Semi-Fowler’s position and elevating the head of the bed increases thoracic capacity, promotes lung expansion and full diaphragmatic descent (Adam, Osborne, & Welch, 2017, pp 50- 78). 

Bed rest and relaxation decreases consumption and demand for oxygen by the body during acute respiratory distress (Adam et al, 2017, pp 50-78). 

One hourly-respiratory rhythm and rate and use of accessory muscles.

One hourly-Pulse rate,

Blood Pressure, skin turgor and oral mucous membranes,

Two hourly- fluid intake and output and fluid status

Administering oxygen therapy as per instructions.

Observing the patient for generalized cyanosis and duskiness on the lips, earlobes, buccal membranes and tongue.

Immobilizing the patient and initiating bed rest.  reduce risk of clot mobilization

Oxygen therapy ensures maintenance of adequate tissue perfusion (Messas, Wahl, & Pernod, 2016, pp 42-50).

Generalized cyanosis and duskiness suggests systemic hypoxemia hence necessitating implementation of effective remedy measures (Messas et al, 2016, pp 42-50).

Bed rest and immobilization reduces risk of clot formation and mobilization (Messas et al, 2016, pp 42-50).

One hourly-Vital Signs-Blood pressure and pulse rate.

24-hourly-fluid intake and output.

Daily-Mucous membrane and skin for signs of hematoma formation, bruising, oozing of blood and petechiae.

Careful use of sharp objects such as scissors or razor.

Administering intravenous fluids such as Normal Saline.

Administering anticoagulants such as heparin or Warfarin.

Careful use of cutting objects reduces tissue trauma and risk for bleeding (Stambough, Nunley, Curry, Steger-May, & Clohisy, 2015, pp 521-526).

Fluid therapy ensures body rehydration and replacement of electrolytes (Stambough et al, 2015, pp 521-526).

Anticoagulants prevent formation of blood clots which may lead to other complications like pulmonary embolism (Stambough et al, 2015, pp 521-526).

Psychological-

Patient has potential for post-operative delirium

Hourly- Vitals- Blood pressure, Oxygen saturation, temperature, pulse rate and respirations.

Hourly-Glasgow Coma Scale

Daily-Mental Status Examination (MSE)

Administering prescribed post-operative antibiotics.

Assessing the patient for level of consciousness, functioning and orientation using appropriate tools and equipment. Implementing effective measures to prevent patient deterioration.

Ensuring that the patient is well groomed and kempt noting psychomotor, attention, mood, affect, insight and judgement.

Antibiotics helps in reducing the side effects for delirium (Kratz, Heinrich, Schlaub, & Diefenbacher, 2015, pp 289).

Accurate and thorough patient assessment is important in reduction of side effects of delirium (Seymour, & Rosengart, 2015, pp 708-717).

Non-pharmacological strategies are important in management of delirium (Seymour, & Rosengart, 2015, pp 708-717).

A physiotherapist may help the patient in performance of appropriate physical exercises to speed recovery. He or she is responsible for recommending mobility and strengthening exercises to help the patient learn on use of walking aids like cane, walker or crutches. Physical exercises enhance easy and increased blood supply to the various body tissues. The physiotherapist has a role in addressing patient’s functional needs and improvement of her range of motion and muscle strength before discharge (Lowe, Davies, Sackley, & Barker, 2015, pp 252-265).

The physiotherapist should also ensure adequate restoration of patient’s mobility and flexibility and reduction of pain. Physiotherapy is useful in maximizing patient’s level of functioning and ensures reintegration of the ADLs. Additionally, the physiotherapist has a role in educating the patient about precautions and physical exercises necessary to her during hospitalization and even after she is discharged from the unit (Smith, & Sackley, 2016, pp 228).

Analyzing the role of the physiotherapist

The patient should be educated on adherence to pain medications and other prescribed antibiotics, avoiding driving until instructed to do so by the doctor and do slight physical exercises such as moving around to relieve night discomfort. The patient should be educated on regular checking of the incision for swelling, redness, drainage or tenderness and washing her hands before touching the area (McDonald, Page, Beringer, Wasiak, & Sprowson, 2014, 45-60).

Other important aspects that the patient should be educated about are; adequate and balanced nutrition, not to sit for more than 30 minutes at a time, not to cross her legs or lean forward, use of elevated seats when in the toilet, seeking medical attention in case abnormalities, safe movement using the walking aids without bending the left hip, making follow-up appointments and being in safe environment that is well lit and free of safety hazards (Van Citters et al, 2014, pp 1619-1635).

Conclusion

Osteoarthritis is a very serious health condition that leads to total hip replacement surgery. Post-operatively, the risk of factors complications includes; blood clots, infections, tissue damage, hypersensitivity, fractures, inflammation and swelling. Sepsis/septic shock is one of the postoperative complications that results from infections. It impacts on patient’s ADLs such as breathing, hygiene, diet and fluids, mobility, skin integrity, psychological needs, comfort and rest and elimination. Following hip replacement surgery, a physiotherapist plays an important role in prevention of complications and promotion of patient recovery. Before discharge, it is important to enlighten and educate the patient on effective management of the new prosthesis to ensure home recovery and prevent any potential complications that may arise due to poor home management techniques.

References

Adam, S., Osborne, S., & Welch, J. (Eds.). (2017). Critical care nursing: science and practice. Oxford University Press., pp.50-78

Belmont, P. J., E’Stephan, J. G., Romano, D., Bader, J. O., Nelson, K. J., & Schoenfeld, A. J. (2014). Risk factors for complications and in-hospital mortality following hip fractures: a study using the National Trauma Data Bank. Archives of orthopaedic and trauma surgery, 134(5), 597-604.

Cawcutt, K. A., & Peters, S. G. (2014, November). Severe sepsis and septic shock: clinical overview and update on management. In Mayo Clinic Proceedings (Vol. 89, No. 11, pp. 1572-1578). Elsevier.

Courtney, P. M., Rozell, J. C., Melnic, C. M., & Lee, G. C. (2015). Who should not undergo short stay hip and knee arthroplasty? Risk factors associated with major medical complications following primary total joint arthroplasty. The Journal of arthroplasty, 30(9), 1-4.

De Backer, D., Orbegozo Cortes, D., Donadello, K., & Vincent, J. L. (2014). Pathophysiology of microcirculatory dysfunction and the pathogenesis of septic shock. Virulence, 5(1), 73-79.

Hotchkiss, R. S., Moldawer, L. L., Opal, S. M., Reinhart, K., Turnbull, I. R., & Vincent, J. L. (2016). Sepsis and septic shock. Nature reviews Disease primers, 2, 16045.

Kratz, T., Heinrich, M., Schlaub, E., & Diefenbacher, A. (2015). Preventing postoperative delirium: a prospective intervention with psychogeriatric liaison on surgical wards in a general hospital. Deutsches Ärzteblatt International, 112(17), 289.

Lowe, C. J. M., Davies, L., Sackley, C. M., & Barker, K. L. (2015). Effectiveness of land-based physiotherapy exercise following hospital discharge following hip arthroplasty for osteoarthritis: an updated systematic review. Physiotherapy, 101(3), 252-265.

McDonald, S., Page, M. J., Beringer, K., Wasiak, J., & Sprowson, A. (2014). Preoperative education for hip or knee replacement. Cochrane Database of Systematic Reviews, (5), 45-60

Messas, E., Wahl, D., & Pernod, G. (2016). Management of deep-vein thrombosis: a 2015 update. Journal des maladies vasculaires, 41(1), 42-50.

Pugely, A. J., Martin, C. T., Gao, Y., Schweizer, M. L., & Callaghan, J. J. (2015). The incidence of and risk factors for 30-day surgical site infections following primary and revision total joint arthroplasty. The Journal of arthroplasty, 30(9), 47-50.

Seymour, C. W., & Rosengart, M. R. (2015). Septic shock: advances in diagnosis and treatment. jama, 314(7), 708-717.

Singer, M., Deutschman, C. S., Seymour, C. W., Shankar-Hari, M., Annane, D., Bauer, M., ... & Hotchkiss, R. S. (2016). The third international consensus definitions for sepsis and septic shock (Sepsis-3). Jama, 315(8), 801-810.

Smith, T. O., & Sackley, C. M. (2016). UK survey of occupational therapist’s and physiotherapist’s experiences and attitudes towards hip replacement precautions and equipment. BMC musculoskeletal disorders, 17(1), 228

Stambough, J. B., Nunley, R. M., Curry, M. C., Steger-May, K., & Clohisy, J. C. (2015). Rapid recovery protocols for primary total hip arthroplasty can safely reduce length of stay without increasing readmissions. The Journal of arthroplasty, 30(4), 521-526.

Van Citters, A. D., Fahlman, C., Goldmann, D. A., Lieberman, J. R., Koenig, K. M., DiGioia, A. M., ... & Nelson, E. C. (2014). Developing a pathway for high-value, patient-centered total joint arthroplasty. Clinical Orthopaedics and Related Research®, 472(5), 1619-1635.

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