Total Hip Replacement: Pathophysiology, Evidence-based Care, And Patient Holistic Needs Essay.

Anatomical Perspective of Total Hip Replacement

Choose ONE of the following case studies for your assignment in which the nursing process will be applied.

Case Study 1: Total Hip Arthroplasty

Mrs Rose Halpern, a 62-year-old, underwent a right total hip arthroplasty. She has a history of osteoarthritis and obesity. The pain in her hip was making it extremely difficult to mobilise and attend to her everyday activities prior to the surgery.

Social and spiritual history: Rose is a widow and has one son (24 years old) who lives with her on the third floor of a block of units. Rose works as a receptionist primary school. She practices Judaism and normally attends worship services at the synagogue on Saturdays. It is now day 1 post-operatively, she has two bellovac drains in-situ. The wound area is covered by an island opsite dressing. Urinary catheter output has been satisfactory. Vital signs are stable, IV therapy and PCA are insitu. Intravenous antibiotic cover has been prescribed. Mrs. Halpern is reluctant to move due to pain.

Discuss a holistic nursing care plan for her current nursing care and in preparation for discharge in 5 days’ time. The surgeon indicates she will need a further 4 weeks off work and may also require physiotherapy as an outpatient.

Case Study 2: Total Abdominal Hysterectomy

Mrs. Angela Cruz, a 51-year-old, underwent a total abdominal hysterectomy and bi-lateral salpingo-oophorectomy following recent symptoms of indigestion, pelvic bloating and abnormal bowel habits. A CT guided biopsy confirmed ovarian cancer and surgery was recommended within 7 days.

Social and spiritual history: Married to Erik for 25 years. They have two children aged 14 and 16 years old. The Cruz family have recently immigrated to Australia from the Philippines. Angela and her family speak Tagalog and minimal English. Erik is an accountant and Angela is a stay
at home mum. They are practicing Roman Catholics and attend church weekly. The Cruz family’s extended relatives are in the Philippines.

It is now the morning of day 1 post-operatively. Urinary catheter output has been satisfactory. Vital signs are stable. She has been showing non-verbal signs of pain by her facial expressions. Her wound has clips in-situ and is covered with a clear comfeel dressing. IV therapy and PCA remain insitu.

Discuss a holistic nursing care plan for her current nursing care and in preparation for discharge in 5 days’ time. The surgeon indicates she will need chemotherapy in the near future. Assignment instructions: As the nurse looking after Mrs Rose Halpern (case study 1) or Mrs. Angela Cruz (case study 2), you are required to discuss relevant nursing care management in a 2000-word essay.
 

Total Hip replacement refers to a surgical procedure which hip joint replacement is done and replaced with a prosthetic implant. Often the medical condition requires surgical process performed as hemi replacement. Total hip replacement entails the replacement of both femoral head and acetabulum. Currently, this medical procedure offers the most satisfying and short and long term operation with statists estimating that about 58% of the total hip replacements last about 25 years (Evans et al., 2019). Total hip replacement processes are used widely for the treatment of joint failure related to osteoarthritis. The key aim of the procedure is to offer relief of pain and improve hip function. Its consideration is undertaken when there is a failure of other therapist management.

Thus this essay reflects on a patient case assessment regarding total hip arthroplasty with underlying osteoarthritis. The patient case study involves a female aged 62 years and currently has undergone tight total hip arthroplasty and presents with a history of obesity and osteoarthritis. The path physiology, evidenced-based care, and patient holistic needs have been analyzed.

The anatomical perspective of Total hip replacements shows that hip is one of the body targets and important joint area. It has ball and socket capabilities. Acetbulum forms the socket reflecting a large part of the pelvis bone. The surface of the ball and socket are covered with cartilage which cushions the ends of the bones and enables it to move easily. The synovial membrane surrounds the joint hip. In normal cases, the synovial membrane lubricates the cartilage and removes the friction during hip movement. During total hip replacement, the damaged femur is totally removed and a replaced with metal stem.

The femoral head is replaced and fits into the socket and the acetabular pelvis region. The ball and the socket offer a design view with poly axial movement. The femur is gripped tightly by the acetabulum. The femur head and acetubulum are covered with hyaline cartilage (Gremeaux et al., 2008). Worn out of the cartcilage coases pain and stiffens as the bone remains exposed. Replacement of these tissues is geared towards the reduction of pain and stiffness.

Total hip replacement is performed frequently and selectively. Osteoporosis and osteomalacia have been the most significant factors leading to the high incidence of hip fractions. This is illustrated by the patient state of osteoporosis and obesity; further worsened by patient age status as risks increases as age rises. 

Symptoms and Diagnosis of Total Hip Replacement

Primary and secondary osteoarthritis have shown bilateral symmetry. Traditional osteoarthritis is often observed to case articular cartilage occurring on the synovial joints. Inflammations occurring causes noninflammatory arthritis which is observed on cytokines and metalloproteinases released to the joints. Early osteoarthritis causes swelling of the cartilage and increases synthesis of proteoglycans which indicate effort of chondrocytes to repair the cartilage damage. Progression of osteoarthritis leads to great loss of joint space which contrasts with inflammatory arthritis. Cartilage erosion of the osteoarthritis progresses until the underlying bone is exposed. This increases the stress on the biomedical strength of the bone. The etiological pain on the joints, especially on weight-bearing regions on the hip, can cause significant challenge to the patient (Kraeutler et al., 2017).

The occurrence of osteoarthritis is often is low and occur over a long duration of time. This leads to patient less activeness and more susceptible to morbidities thus decreasing physical activity.  Pain occurs on the initial morbidity sources with primary symptoms being deep joint pain. There is an occurrence of reduced movement and physical activity and relive can be sought from rests and response to simple analgesics. The joints can become unstable with osteoarthritis progression thus pain become more prominent. Physical examination depicts joints movements’ difficulty. Physical examination limits itself on the pain joints affected regions. The progression of the disease takes place in three stages, the breakdown of cartilage, fibrillation and breakdown of products (Krasnokutsky et al., 2017.

Joint pain presents a prevalent musculoskeletal condition in osteoarthritis. Evidenced-based care entails application of pharmacology therapy which begins with administration of analgesics and nonsteroidal anti-inflammatory drugs. This entails patient education, weight loss, physical therapy, and joint mobility and muscle strength. Evidence indicates that total joint replacement is a successful mode of therapy applied when joint pain functional ability is observed (Anandacoomarasamy & March 2010).

Clinical manifestations

Common preoperative assessment of the patient indicates the inability to walk and vague pain and difficulty in weight bearing, (Batra et al., 2008). The further occurrence of osteoarthritis enhances sensible recitations leading to lack of neutral anatomical position. This links to increase pain and difficult to walk.

The common clinical features for surgery displaced by the patient shows loss of mobility and increased pain. The common indication which is displayed b the patient entails obesity and osteoarthritis history.

The key diagnostic procedure in total hip replacement is based on symptoms assessments. Pain, loss of mobility and functional impairments are key. In other cases, the differential diagnosis can be undertaken as spine pain do not have any connection of the hip joint itself (Chan et al., 2016). 

Types of Surgery in Total Hip Replacement

Evidence based treatment care

Evidence based treatment of care is surgical approaches. The types of surgery take place in the form of anterior, anteriolateral approach, posteriolateral approach among other approaches of surgery (Oliveira et al., 2015). Various surgical processes for total hip replacement often assume anterio, lateral and posterior approach. These key approaches are essential in determining the soft tissue amount damage and this is essential in determining the key precautions in undertaking the total hip procedure.

The posterior approach is the most preferable mode of surgery (Chechik et al., 2013). This approach offers femur visualization and acetubulum and abductor muscle group is spared (Oldenrijk et al., 2010). The anterior approach offers less invasive and damaging muscles and capsules, nerves, and ligaments (Oldenrijk et al., 2010). Other studies undertaken have indicated that better rehabilitation process and functional outcome (Petis et al., 2015). The associated lower risks of dislocation of anterior approach compared to the posterior approach, mobilization is undertaken early and full weight is attained during the early days of postoperative discharge (Alecci et al., 2011).

The use of minimally invasive surgery is a common medical practice approach globally. Its benefits revolved around quick recovery periods and lowered postoperative pain (Iglesias,  Gentile & Vanoli, 2017).

Nursing process care

Nursing care process entails the use of clinical judgment to balance epistemology between individual interpretation and research-based evidence incorporating n critical thinking and play a key role in categorizing patients and their urgent course of action. The nursing process details a care plan for patients based on their needs. Care plan details key component of assessment, diagnosis, expected outcomes, interventions, rationale and evaluations (Baron, 2017).

The relevance of the nursing care process is essential as a guide in offering care in the dynamic world. The increasing aging corresponds to urgent patients care to cater to these emerging needs. Aging carries tremendous problems and poses the ultimate guide of spotting life-threatening diseases. The traditional roles of nurses are currently changing to suit the needs of the patients (Kim, 2018).

Holistic care plan

Postoperative care process aims at addressing the functional needs of the patient and to increase the strength ability and motion process. This is transformed through the nursing care process aim to get the patient in a functional state. Due to the underlying preoperative pathology, the patient may present with muscle atrophy and strength loss especially due to gluteus mass and quadriceps muscles. As much as surgery often corrects the joint problems, the patient will require post-operative rehabilitation, management of Nursing care plan for total hip replacement entail various care process which is key during the preparatory stage of discharge. The key nursing care plans include impaired mobility, risks for peripheral neurovascular dysfunction and acute pain. 

Nursing Care Process in Total Hip Replacement

Research illustrates that weakness of hip abductor for the patient is a risks factor for joint instability and loosing of the prosthetic (Alecci et al., 2011). Early rehabilitee program for a total hip replacement will focus on mobility, flexibility, and strength and pain reduction.  Establishing early rehabilitation programs as an outpatient is crucial for the patient to allow early mobilization and to improve the confidence of the patient after post operative activities of the daily living.

Early physiotherapy process is initiated by improvement of strength, the speed of gait post hip replacement and prevention of complications such as thromboembolic disease. Further physiotherapy leads to increased patients mobility and offers education on exercise and necessary precaution after hospitalization discharge (Coulter et al., 2013). Further physiotherapy process enhances ad maximize patients functionality which is linked to a greater chance of early discharge and lower cost of care (Robertson et al., 2015). Promotion of relief, offering rehabilitation and integration of the patient into daily activities of living is essential. These provide an improved and better quality of life through integration into social life (Alecci et al., 2011).

Initiation of bed exercise on the patient is vital in lowering the effects of edema, improving cardiac function and increasing positive motion and strength of the muscles. This allows for psychological assessment and physical state of the patient 52. Early initiation of weight bearing has key benefits on the bone tissue quality and improvement on the fixation of the prosthesis and lowers incidence of loosening.  

Acute pain

Patient acute pain signals the inability to move and emotional exercise arising from the tissue damage in sudden or slow onset in any intensity ranging from mild to severe. The pain occasioned by the patients can be linked to total hip replacement surgery procedure. This is evidenced by pain reported by the patients limiting the ability to move. Patient desired outcomes relate to control of pain and resting and relaxation skills.

Patient assessment on pain intensity using n a scale of 0-10 noting down the time is key. The underlying rationale in this case entails previous of vital signs intervention for effective care process. Further, maintaining of propeor position of the extremity is vital for the patient whch enhances the reduction of spams and undue tension and prosthesis and surrounding tissues.  Provision of comfort measures such as back rub and frequent repositioning and encourage stress management techniques and providing therapeutic touch, this is key in reducing the tension of the muscle and promoting a sense of control and enhance coping abilities in the management of pain. Administration of drugs such as narcotics, muscle relaxants and analgesiscs is key for the patient. This will aid in reducing muscle spasm and tension which ensures the overall contribution of tension. (Chechi et al., 2013).

Postoperative Care Process for Total Hip Replacement

Risk of peripheral Neurovascular dysfunction

This is associated with compromised patient state and often occasioned by the decreased sensation of the patient, numbness, and tingling. The desired patient outcomes are evidenced by sensation and movements within short limits. This will demonstrate adequate tissue perfusion.

Key nursing intervention entails evaluation of palpation on both sides which ensures capillary refill and maintenance of color and temperature. Relevant rationale entail undertaking this process is related to diminished refill time, further comparing with unoperated limb offers clues on the neurovascular problem generalization. Enhancing stabilization and the patient is in the correct position and no undue pressure being exerted. This can be indicative of hematoma formation which potentiates through neurovascular compromise. Undertaking observation intervention of continued bleeding and oozing of a site and mucous membrane is key for the pateint. Depression of clotting mechanism and sensitivity to anti coagulants often result in bleeding occurrences which can lead to low blood level.  (Chechi et al.,2013). 

Impaired physical mobility

Impaired physical mobility leads to limited independence and purposeful movement of the body. This is evidenced by the patient inability to engage in movement, pain occurrence and decreased level of wound strength. The desired patient outcomes are to maintain a functional position and for the patient to display function and strength. Maintenance of affected joint in a prescribed position and aligning well in bed, key rationale entail ensuring stabilization and reduces the risks of injury during the recovery phase of the analgesics. Aiding the patient in a range of motion exercise is fundamental. Degenerative joint disease can lead to loss of joint function during movements due to restricted movements.

Holistic care needs

Holistic Assesment of the patient social, physical emotional, psychological, cultural and emotional needs is essential.  The patient social state will change significantly as she will be nursing the wound and having bed rest for the next prescribed periods. Arranging with community health care staff to regular visits the patient at home will be essential. Involving the patient next of kin is essential for the patient. The patient next of kin offers a feeling of safety and security for the patient.

Patient spiritual needs will be enhanced and facilitated the process, through the process of engaging with for the concerned spiritual leader for the patient, which will ensure that special care is taken thus offering great satisfaction. Cultural needs of the patient will entail assessment on his preferred and disliked culture practices which facilitate the growth process, hence incorporating this holistic aspect in the patient will be crucial in facilitating a faster healing process. Thus improving overall outcomes recovery

Conclusion

The total hip replacement procedure is a crucial step in managing the case study, one patient. Engaging in the nursing care process is critical. Care process in this perspective involves the use of various nursing strategies which are goal oriented. This essay has reflected on three key nursing diagnoses being faced by the patient. Its management is essential so as to provide improved care process.  Further incorporating a holistic approach of care is key for the patient. 

References

Alecci, V., Valente, M., Crucil, M., Minerva, M., Pellegrino, C. M., & Sabbadini, D. D. (2011). Comparison of primary total hip replacements performed with a direct anterior approach versus the standard lateral approach: perioperative findings. Journal of Orthopaedics and Traumatology, 12(3), 123-129.

Anandacoomarasamy, A., & March, L. (2010). Current evidence for osteoarthritis treatments. Therapeutic advances in musculoskeletal disease, 2(1), 17-28.

Baron, K. A. (2017). Changing to Concept-Based Curricula: The Process for Nurse Educators. The open nursing journal, 11, 277.

Batra, S., Batra, M., McMurtrie, A., & Sinha, A. K. (2008). Rapidly destructive osteoarthritis of the hip joint: a case series. Journal of orthopaedic surgery and research, 3(1), 3.

Chan, G., Bezuidenhout, L., Walker, L., & Rowan, R. (2016). The Impact on Life questionnaire: validation for elective surgery prioritisation in New Zealand prioritisation criteria in orthopaedic surgery. The New Zealand Medical Journal (Online), 129(1432), 26.

Chechik, O., Khashan, M., Lador, R., Salai, M., & Amar, E. (2013). Surgical approach and prosthesis fixation in hip arthroplasty world wide. Archives of orthopaedic and trauma surgery, 133(11), 1595-1600.

Coulter, C. L., Scarvell, J. M., Neeman, T. M., & Smith, P. N. (2013). Physiotherapist-directed rehabilitation exercises in the outpatient or home setting improve strength, gait speed and cadence after elective total hip replacement: a systematic review. Journal of physiotherapy, 59(4), 219-226.

Evans, J. T., Evans, J. P., Walker, R. W., Blom, A. W., Whitehouse, M. R., & Sayers, A. (2019). How long does a hip replacement last? A systematic review and meta-analysis of case series and national registry reports with more than 15 years of follow-up. The Lancet, 393(10172), 647-654.

Gremeaux, V., Renault, J., Pardon, L., Deley, G., Lepers, R., & Casillas, J. M. (2008). Low-frequency electric muscle stimulation combined with physical therapy after total hip arthroplasty for hip osteoarthritis in elderly patients: a randomized controlled trial. Archives of physical medicine and rehabilitation, 89(12), 2265-2273.

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Krasnokutsky, S., Oshinsky, C., Attur, M., Ma, S., Zhou, H., Zheng, F., ... & Regatte, R. (2017). Serum Urate Levels Predict Joint Space Narrowing in Non?Gout Patients With Medial Knee Osteoarthritis. Arthritis & rheumatology, 69(6), 1213-1220.

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