Case Study-Gianna : Replacement Surgery

Discuss about the Case study for Gianna of Replacement Surgery .

 

Gianna was suffering from osteoporosis and had to undergo total hip replacement surgery due to fracture of the hip. The hip is the largest weight-bearing ball and socket type joint present at the juncture of leg and pelvis. The ligament attached to the joint is lubricated by synovial fluid and provides stability to the joint. Synovial fluid allows flexing of joints without getting weared away and allows movement without pain. The problem in the hip may be caused by osteoporosis, fracture, dislocation, bursitis and bone tumor. The regulation of pro-inflammatory pathway and the homeostatic mechanism fails in patient with severe osteolysis (Gallo et al., 2013).

Osteoporosis is a medical condition in which the density and quality of bone are reduced. Bone becomes porous, brittle and fragile due to loss of tissue due to hormonal change or deficiency of Vitamin D. The primary reasons for which a person develops osteoporosis includes high rate of bone loss at the time of achieving peak bone mass and poor acquisition of bone mass during maturity. This mechanism may be influenced by environmental and genetic factors (Armas & Recker, 2012). 50% of bone mass accumulates during pubertal development, and other additional accumulation takes place in the adult maturity period. As peak bone mass is achieved during the maturity period of life, some may have a problem in accumulation due to genetic factors. The genes responsible for osteoporosis are genes for estrogen receptor, transforming growth factor β, collagen and apolipoprotein E (Ralston & de Crombrugghe, 2006). Bone loss is also triggered by environmental factors like nutrition, behavior, and medications. Vitamin D aids in calcium absorption and facilitates development of bone mineral. A person who has taken low dose of calcium in childhood is vulnerable to fracture in later part of his/her life. Behavioral activities like smoking and alcohol consumption also accelerated bone loss and have an effect on peak bone mass development (Drake et al., 2015).

Fractured joints can be treated by hip replacement surgery or hip arthroplasty. The type of surgery depends on the patient’s age, level of physical mobility, location of fracture, mental strength and condition of hip and joint. Internal fixation is done by using devices like rods, plates, screws and pins to hold the bone in place. This treatment is given when fractures occur in the extracapsular or intracapsular region of hip joint (Müller et al., 2012). Hemiarthroplasty is suggested in older patients who have already lost their mobility prior to fracture and when fractures occur inside the socket of the hip joint (Olsen et al., 2014). Total hip replacement surgery is also a treatment procedure required in those patients whose hip joint has been damaged by osteoarthritis and rheumatoid arthritis. The purpose of this treatment is to relieve pain, improve the function of hip and increase mobility. Total hip replacement surgery involves replacing acetabulum with an artificial prosthesis and replacing the proximal femur with the artificial stem to enhance mobility in patients (Ellman & Levine, 2013).

According to the case study Gianna Rossi was a seventy nine years old lady who have undergone a total hip replacement or arthroplasty since x-ray has revealed a fracture on her left leg which resulted from osteoporosis. Post her surgery she was shifted to the “post anesthetic recovery room (PARU).” At this stage she was almost unconscious and on wakening up she was under tremendous pain. The surgery and the anesthesia have effected three physiological functions of Gianna.

First of all the ventilation was affected due o her anesthesia followed by her surgery. Her signs reflect that her respiration was 10 and the oxygen saturation was 93%. Most often general anesthetics modifies the rate of breathing in individual. According to Rozé et al. (2015), opioid as an anesthetic has impact on the control of respiration rate. In terms of Gianna, the use of opioid as an anesthetic lowered the respiration in her. The use of Morphine due to her pain aced as a pain suppressor through the process of respiratory depression.

Before the discharge from the “Post anaesthetic recovery room (PARU)” her signs reflected her pulse as 110, temperature as 36 degree centigrade and blood pressure as 95 / 50. Moreover, her blood loss during her surgery was estimated as 1700mls. The effect of opioid and anesthetic during surgery has many affects on the circulation process as well. The use of opioid or anesthetic makes the heart rate either fast or slow. In this case Gianna’s pulse rate increased above the normal value, that is 110 after the surgery. As stated by Brennan (2013), Morphine which is an opioid was used to relief her pain due to operation might cause fluctuations in her heart rate. Moreover, due to the blood loss during the surgery the blood pressure of the patient resulted in lowering of the blood pressure. In case of Gianna the blood pressure accounted to 95 /50. Use of opioid may develop postural hypotension or severe fall of the pressure on lying position or sitting up.

At first  Gianna was administered for two hours, she was given oxygen for 6L per minute with the help of Hudson mask. The main features shown by her at that time are: the temperature of her body was thirty six degree centigrade, her pulse rate was 110, blood pressure 95 / 50 , respiration was 10 and oxygen saturation of her body was 93%. A foam abduction pillow was provided to her between her legs. When she woke up she was not in her full consciousness. But she was still complaining about the pain. In order to relief her from the pain she was administered with 5 mg of Morphine which was beneficial to her.

Due to the consumption of Morphine she slept for some more time. After Morphine was monitored to Gianna she was transferred to the orthopedic ward. According to Whitehead et al. (2015), the main use of any anaesthetic is to depress the central nervous system. In case of Gianna, the hip replacement surgery required generalized anaesthesia which ultimately made her unconscious complete by affection the sense organs. Addition to this the use of Morphine after Gianna got back her consciousness, lead to dizziness and hallucination. This made her feel sleep again. Opioids have multiple inhibitory affects in terms of the cerebral activity. Opioids are usually believed to augment sleep but there is little evidence to support this belief. In case of Gianna use of anaesthic, loss of blood during surgery and use of Morphine has resulted in abnormalities with regards to ventilation, circulation and consciousness. The result of vital sign assessment showed that it is the affect of the surgery and anesthetic drug on patient (Whitehead et al., 2015).

Gianna has undergone hip replacement surgery following fracture of her left hip. After hip replacement surgery she was shifted to the PARU. At that time Gianna was sleepy and difficult to arouse. A redivac drain and indwelling urinary catheter were fixed to the patient in situ. At that point, her pulse rate was a little high and blood pressure was extremely low. She had acute pain then. After transfer to the orthopedic ward, she was eating well, but she required assistance with her daily activities (ADLs). The patient was worried about her loss of independence post the surgery. Currently, she is mobilizing using a four-wheeled walker, and her pain is managed by medications like Paracetamol and Tramadol.

The discharge plan of the patient is based on her current condition of pain and morbidity present post surgery. The discharge plan for Gianna are as follows:

Gianna needs to put the dry dressing on hip incision once or twice a day. It will help to clean the drainage that occurs from wound. If the drainage continues even after dressing, Gianna must immediately pay a follow up visit. Till the dry dressing is in place, Gianna cannot apply ointment in the incision area for about 6-7 weeks (Choi et al., 2016).

Make sure that the stitches are in place and patient should get it removed by medical staff after two weeks of discharge (Garson et al., 2014).

Support or wheelchair is necessary for Gianna for six weeks after discharge even if she can mobilize. This will minimize the risk of falling and allow the bone to grow into replaced components of the hip (Choi et al., 2016).

It is necessary for Gianna to put a pillow between her leg while sleeping for the first six weeks. It would be better if Gianna sleeps on her right side as she had undergone hip replacement surgery on her left side (Garson et al., 2014).

While taking shower Gianna must pat dry the surgery wounds after bath and avoid soaking it in bath tub for one-two months. Gianna should also not take bath during for 4 days after discharge (Garson et al., 2014).

To manage her medication, Tramadol and Paracetamol medication has been prescribed to Gianna. It will help manage her pain. However,  Vazzana et al., (2015) suggest avoiding this medicine if Gianna suffers from breathing problems or if she uses narcotic drugs. It has been found that there maximum chance of seizure due to this medication in those patients who has epilepsy disorder or those who takes medicine for migraine, muscle spasm, and depression. Gianna might also suffer breathing problems, so she must discontinue this medication in she faced this kind of difficulty.

Gianna is advised not to drive and wear compression stockings to prevent the blood clot.

It is also necessary for Gianna to consult a physiotherapist and attend his sessions to learn to manage daily life activities independently at home. Physical therapy Controlled exercise and physical therapy will be beneficial to strengthen hip muscles and prevent contractures. This session will also help Gianna to learn management of activities post surgery (Westby et al., 2014).

Armas, L. A., & Recker, R. R. (2012). Pathophysiology of osteoporosis: new mechanistic insights. Endocrinology and metabolism clinics of North America, 41(3), 475-486.

Brennan, M. J. (2013). The effect of opioid therapy on endocrine function.The American journal of medicine, 126(3), S12-S18.

Choi, J., Jacelon, C. S., & Kalmakis, K. A. (2016). Web‐based, Pictograph‐formatted Discharge Instructions for Low‐literacy Older Adult after Hip‐replacement Surgery: Findings of End‐user Evaluation of the Website.Rehabilitation Nursing.

Drake, M. T., Clarke, B. L., & Lewiecki, E. M. (2015). The pathophysiology and treatment of osteoporosis. Clinical therapeutics, 37(8), 1837-1850.

Ellman, M. B., & Levine, B. R. (2013). Fracture of the modular femoral neck component in total hip arthroplasty. The Journal of arthroplasty, 28(1), 196-e1.

Gallo, J., Goodman, S. B., Konttinen, Y. T., & Raska, M. (2013). Particle disease: biologic mechanisms of periprosthetic osteolysis in total hip arthroplasty. Innate immunity, 19(2), 213-224.

Garson, L., Schwarzkopf, R., Vakharia, S., Alexander, B., Stead, S., Cannesson, M., & Kain, Z. (2014). Implementation of a total joint replacement-focused perioperative surgical home: a management case report. Anesthesia & Analgesia, 118(5), 1081-1089.

Müller, M. E., Bandi, W., Bloch, H. R., Allgöwer, M., Willenegger, H., Mumenthaler, A., ... & Weber, B. G. (2012). Technique of internal fixation of fractures. Springer Science & Business Media.

Olsen, F., Kotyra, M., Houltz, E., & Ricksten, S. E. (2014). Bone cement implantation syndrome in cemented hemiarthroplasty for femoral neck fracture: incidence, risk factors, and effect on outcome. British journal of anaesthesia, 113(5), 800-806.

Ralston, S. H., & de Crombrugghe, B. (2006). Genetic regulation of bone mass and susceptibility to osteoporosis. Genes & development, 20(18), 2492-2506.

Rozé, H., Germain, A., Perrier, V., Dewitte, A., Joannes-Boyau, O., Fleureau, C., & Ouattara, A. (2015). Effect of flumazenil on diaphragm electrical activation during weaning from mechanical ventilation after acute respiratory distress syndrome. British journal of anaesthesia, 114(2), 269-275.

Vazzana, M., Andreani, T., Fangueiro, J., Faggio, C., Silva, C., Santini, A., ... & Souto, E. B. (2015). Tramadol hydrochloride: pharmacokinetics, pharmacodynamics, adverse side effects, co-administration of drugs and new drug delivery systems. Biomedicine & Pharmacotherapy, 70, 234-238.

Westby, M. D., Brittain, A., & Backman, C. L. (2014). Expert consensus on best practices for post–acute rehabilitation after total hip and knee arthroplasty: a Canada and United States Delphi study. Arthritis care & research, 66(3), 411-423.

Whitehead, R. A., Schwarz, S. K., Asiri, Y. I., Fung, T., Puil, E., & MacLeod, B. A. (2015). The efficacy and safety of the novel peripheral analgesic isovaline as an adjuvant to propofol for general anesthesia and conscious sedation: a proof-of-principle study in mice. Anesthesia & Analgesia, 121(6), 1481-1487