PDS Case Study

Mrs. Morgan
You are a nurse working on an Orthopedic Unit in a large suburban hospital.
Today you will be doing preoperative assessment and teaching with Mrs. Morgan.
Mrs. Morgan will be admitted next week for a right total hip replacement
(arthroplasty), with epidural anesthesia.
Total hip replacement involves removal of a diseased hip joint and replacement with
a prosthetic joint.

Assessment Data:
• 62 yrs old
• retired shop owner
• widowed with 2 grown children and 5 grandchildren
• history of osteoarthritis for 10 years
• history of bilateral varicose veins
• allergic to meperidine (Demerol)
• recently gave up gardening and other activities due to hip pain

1. Mrs. Morgan has osteoarthritis of her hip. You know that osteoarthritis
involves joint symptoms that are primarily a result of:

A. Erosion of articular cartilage: Erosion can result in some inflammation, but

inflammation is not a significant component of the pathophysiology of
osteoarthritis. Osteoarthritis is also known as noninflammatory arthritis,
and degenerative joint disease. Involved joints most commonly include
the hands (distal interphalangeal joints, proximal interphalangeal joints),
hips, knees, cervical spine, and lumbar spine. Osteoarthritis of the lumbar
spine is a frequent cause of lower back pain. Common risk factors for
osteoarthritis include older age, repetitive joint use (individual variation),
joint trauma, and obesity (knee and hand involvement).

Mrs. Morgan tells you that hip pain from arthritis has been difficult to control with
medications and physical therapy, and has limited her ability to do things she likes,
like walking, gardening, and playing with her grandchildren.
Mr. Morgan also has osteoarthritis in her hands. Arthritic changes in her hands are
not as severe as in her hip. Mrs. Morgan’s left hip is not affected.
Mrs. Morgan has been taking the drug celecoxib (Celebrex) for arthritis. She will
continue using this drug for pain relief in her hands after surgery.

2. Mrs. Morgan is taking celecoxib (Celebrex). Celecoxib (Celebrex) is a COX-2

enzyme inhibitor (and a nonsteroidal anti-inflammatory drug) with analgesic
effects. Many of our patients take this drug. Possible undesirable effects
include: (there are 3 correct answers)
A. Dizziness: Dizziness, fatigue, and drowsiness are side effects of celecoxib
(Celebrex). Mrs. Morgan takes the drug once a day, at night. When she
started taking the drug, she found it made her tired.
 B. Gastrointestinal distress: Anorexia, nausea, indigestion, abdominal pain,
and other GI complaints can occur as side effects of celecoxib (Celebrex)
therapy. Gastrointestinal irritation may contribute to gastric ulceration
and bleeding, although this adverse effect is less likely with celecoxib
(Celebrex) than with other NSAIDS. Mrs. Morgan takes the drug with
dinner, and has found that indigestion is less likely to occur when she
takes the drug with a meal. She knows to check the color of her bowel
movements for signs of bleeding (black, tarry stools).

C. Fluid retention: Fluid retention is reflected in weight gain and peripheral

edema. Mrs. Morgan knows to watch for this, and has never experienced
a problem with fluid retention while on the drug.

NOT CHOSEN:
Confusion
Increased bleeding tendency

After recovery from surgery, Mrs. Morgan should have less pain, and greatly
improved joint function, although she will need to avoid certain movements.

Decreased pain and improved joint function should enable Mrs. Morgan to
participate in many activities that she was unable to participate in because of pain
and limited joint mobility.

3. You talk with Mrs. Morgan about her impending surgery. You feel confident
that Mrs. Morgan is informed regarding her impending surgery when she tells
you that the most common complications of hip replacement surgery include:
(there are 4 correct answers)

A. Wound infection: Is a potential major complication after hip replacement

surgery. Wound infection can result in the need for repeat surgery, which
may be less successful in improving mobility. Typically, antibiotics are
given preoperatively (started just before surgery), and continued for a few
days postoperatively. Invasive procedures are kept to a minimum after
surgery to reduce risk of infection. Invasive lines (IVs) are removed as
quickly as possible, because they increase risk for infection.

B. Dislocation of the prosthetic hip: Is a potential major complication after

hip replacement surgery. Mrs. Morgan will learn about measures to avoid
this complication.

C. Blood clotting in the leg: Deep vein thrombosis (DVT) is a potential major
complication after hip replacement surgery. DVT involves thrombus (clot)
formation, usually in a deep vein in the pelvis or leg. Risk for DVT is
especially increased with orthopedic, abdominal, thoracic, and
genitourinary procedures. Any factor that alters blood flow and results in
venous stasis may contribute to thrombosis. Bed rest and immobility are
 associated with venous stasis. Venous return to the heart is slowed when
activity level decreases. Regardless of the reason for bed rest or
immobility, these always increase risk for DVT. Any surgery that requires
administration of anesthesia and immobilization for more than 45 minutes
increases risk for DVT. Mrs. Morgan has varicose veins (incomplete valves
in leg veins cause venous congestion), which also increase risk for DVT.

D. Bleeding: Bleeding during hip replacement surgery can be significant.

Blood must be available for use during or after surgery. Mrs. Morgan has
been type and cross-matched for blood.

NOT CHOSEN:

Leg paralysis
Peritonitis

4. Preventing the complication deep vein thrombosis (DVT) is critical. If DVT

develops, a clot or part of a clot can break loose from the site of thrombosis,
and travel to the lungs. The potentially-fatal consequence of DVT is called
pulmonary .

A. Embolus: Life-threatening pulmonary embolus (PE) can occur as a result

of deep vein thrombosis (DVT). With DVT, entire thrombi or parts of
thrombi can embolize. Embolization may occur in the first few days after
thrombi develop.

5. Pulmonary embolus may be a result of other causes. After hip replacement

surgery and other major orthopedic surgeries, patients are also at increased
risk for pulmonary embolus due to embolus.

A. Fat: Fat emblolism syndrome (FES) is a possible complication of orthopedic

trauma and major orthopedic surgeries. With FES, fat globules from bone
marrow circulate to the lungs. Air embolism is a possible complication of
intravascular access devices, especially midline catheters and central
venous catheters.

6. To avoid deep vein thrombosis (DVT) postoperatively, you stress the

importance of which of the following with Mrs. Morgan? (there are 2 correct
answers)

A. Drinking plenty of fluids: Dehydration increases the risk for deep vein
thrombosis (DVT). Perioperative fluid losses can lead to dehydration,
despite IV fluid replacement. Mrs. Morgan should be encouraged to drink
plenty of fluids before surgery, and after surgery (once permitted). The
more concentrated the blood, the “thicker” it is and the slower it flows,
and the more readily it will clot. Dehydration (hemoconcentration) is a
hpercoagulable state that may occur with a surgery if fluid volume is not
maintained.
 B. Ambulating as much as permitted: Of great importance in preventing
deep vein thrombosis (DVT) is early ambulation after surgery. When in
bed, Mrs. Morgan should keep moving, and shift positions as permitted,
with assistance as needed. Passive and active exercised are important.
Activity and movement keeps blood flowing, prevents venous stasis, and
will reduce risk for DVT. You encourage Mrs. Morgan to take pain
medication as necessary to make this possible. Pain control with patient-
controlled analgesia (PCA) is common after total hip replacement.

NOT CHOSEN:

Lying still when in bed

Deep breathing

Intermittent pneumatic compression devices also help to prevent deep vein

thrombosis (DVT). These are used alone or in conjunction with graded compression
stockings, to promote venous return to the heart and prevent venous stasis. These
are continues until a postoperative patient is fully ambulatory.

Mrs. Morgan will have intermittent pneumatic compression stockings (sleeves are
sometimes used) applied in the Post-Anesthesia Care Unit, after surgery. You show
her what these look like.

7. Mrs. Morgan has a moderate risk for DVT. For DVT prophylaxis, low-
molecular-weight heparin (enoxaparin), an anticoagulant, will be started after
surgery. You tell Mrs. Morgan that this drug will be given by:

A. Injection: Low-molecular-weight heparin (enoxaparin) is given by

subcutaneous injection. Mrs. Morgan will need two injections a day,
probably for 10 days.

8. After surgery, a variety of exercises will be important. Which of the following

exercises do you teach Mrs. Morgan?

A. Quadriceps setting exercises: Quadriceps setting and gluteal setting

exercises strengthen leg and hip muscles. After total hip replacement,
they help firmly position a new hip prosthesis in place and strengthen
muscles used for walking. To perform these exercises, muscles around the
knees (quadriceps) and in the buttocks (gluteals) are tightened, held
contracted for a few seconds, and then relaxed. Any exercise involving
hip flexion can cause hip dislocation and must not be done.

9. You know that muscle setting exercises are classified as isometric exercises.
They involve active muscle contraction and relaxation without joint
movement.

10.Besides muscle setting exercises, you teach Mrs. Morgan: (there are 3 correct
answers)
 A. Use of an overhead trapeze: Mrs. Morgan will use an overhead trapeze
after surgery. A trapeze will help her position herself and will increase her
upper body strength. It is appropriate to teach Mrs. Morgan about using a
trapeze. Mrs. Morgan should also be taught use of a walker, which she will
probably use during her recovery period.

B. Techniques for turning in bed: Mrs. Morgan needs to know how to

reposition herself after surgery and turn with an abductor pillow in place.
Although surgeries and physician guidelines vary, adduction, flexion, and
extreme internal rotation of the hip (and perhaps external rotation) usually
must be avoided. These movements can cause a new prosthesis to
dislocate. Positioning on the operative side is often avoided.

C. Relaxation techniques: Relaxation techniques can be used to relax

muscles and enhance the analgesic effects of medication. It is
appropriate to teach Mrs. Morgan relaxation techniques.

NOT CHOSEN:

How to adduct her operative hip

To sit in bed at a 90-degree angle

Immediately after total hip replacement surgery, abduction of the newly-implanted

hip prosthesis helps to position it firmly in place. Abduction exercises (moving the
operative hip away from the midline) are taught to Mrs. Morgan.

An abductor pillow is generally used to help maintain abduction postoperatively.

You show Mrs. Morgan how to use an abductor pillow.

11.You also show Mrs. Morgan a fracture bedpan and explain how to use it
postoperatively. Which of the following is appropriate?

A. While keeping the operative leg straight, flexing the other hip and knee,
and pushing with her foot, Mrs. Morgan lifts her hips (using trapeze) then
lowers herself to the bedpan: Flexion of the operative hip must be
avoided immediately after hip replacement surgery. The easiest way for
Mrs. Morgan to get on a bedpan without flexing the operative hip would be
the proposed method.

Mrs. Morgan is admitted the morning of surgery, and surgery is successful and
uneventful. Blood loss is moderate. A posterior incision was used. This involves
spreading of the legs, and slight outward rotation of the operative hip.

Postoperative orders are written:

• Bed rest, abductor pillow in place, avoid hip flexion
• OOB in chair in AM, no weight bearing (NWB) on operative leg
• Stand with walker with PT tomorrow
• Dextrose 5% in water at 75 mL per hour
• Regular diet as tolerated
 • Cefazolin sodium (Ancef) 1 g every 6 hours IVPB x 6 doses
• Wound drain to Hemovac suction
• Intermittent pneumatic compression (IPC)
• Anticouagulation per protocol—low molecular weight heparin

The day after surgery, you are assigned to care for Mrs. Morgan.

Mrs. Morgan is doing well. Pain control is adequate with patient-controlled analgesia
(PCA). IV antibiotics will continue for another 24 hours. Mrs. Morgan is eating and
drinking adequately, and voiding without difficulty.

Mrs. Morgan will get out of bed today, with a physical therapist.

Usually, when a patient first gets out of bed after hip replacement surgery, an
abductor pillow or splint is kept between her legs.

The operative hip is extended, and the person pivots on the nonoperative leg. The
operative hip is protected from adduction, flexion, internal or external rotation, and
excessive weight bearing. High seat chairs should be used. The hips should be
higher than the knees.

12. As you assist Mrs. Morgan with hygiene, you assess her for signs of deep vein
thrombosis (DVT) in her legs. Signs of DVT secondary to surgery generally
become evident after 24 hours. These can include: (there are 4 correct
answers)

A. Tenderness at the calf area: Inflammation associated with DVT generally

causes tenderness at the affected area.

B. Increase in calf girth: With DVT in a lower leg vein, inflammation causes
swelling that can increase calf circumference (girth).

C. Reddened area at the calf area: Inflammation associated with DVT in a

lower leg vein can cause localized redness and warmth at the affected
area.

D. Elevated body temperature: Fever may accompany DVT.

NOT CHOSEN:

Loss of sensation in the leg

Skin pallor at the calf area

You ask Mrs. Morgan about any calf tenderness, and inspect her legs. No signs of
DVT are present.

13.Mrs. Morgan is receiving the low molecular weight heparin, enoxaparin.

Which of the following lab values is monitored?
 A. Platelet count: Treatment with unfractionated heparin or low molecular
weight heparin may cause heparin-induced thrombocytopenia (low
platelet count). Platelet count is checked before and during therapy. No
other lab monitoring is required when low molecular weitgh heparin is
used.

Bleeding is a major complication of anticoagulant therapy, and you know to observe

Mrs. Morgan for signs of bleeding. These include easy bruising (ecchymosis),
melena, bleeding gums, nosebleeds, and excessive bleeding, if it occurs, usually
results in a gradual change in level of consciousness.

Mrs. Morgan has no signs of an increased bleeding tendency at this time.

14.You also assess Mrs. Morgan for signs of dislocation of the prosthetic hip.
Which of the following would suggest dislocation?

A. Inability to move the operative leg: Because the head of the femur us
displaced from its socket when dislocated, movement of the leg would be
difficult, if not impossible, with dislocation. In addition, leg lengths would
appear different. With an anterior dislocation, the operative leg would
appear longer; with a posterior dislocation, the operative leg would appear
shorter. The hip would be abnormally rotated inward or outward. Acute
groin pain might be present. When the hip dislocates, a popping
sensation may be felt/heard.

Mrs. Morgan is able to move her hip, and the operative leg appears to be the same
length as the nonoperative leg. You advise Mrs. Morgan to tell you if the pain in her
leg changes or increases.

15.You review Mrs. Morgan’s care plan, and note assessment findings that
require immediate reporting. Which of the following is correctly included?

A. Numbness in the operative leg: Numbness or tingling in the operative leg

would suggest nerve damage. This assessment finding would need to be
reported immediately.

It is now Mrs. Morgan’s second operative day. Physical therapy has been started
with Mrs. Morgan- supine hip and knee flexion to 45 degrees. Hip flexion will
progress, not to exceed 90 degrees.

In addition, Mrs. Morgan is ambulating with a walker (partial weight bearing). She
will soon be permitted to sit in a chair with a high seat for short periods.

Mrs. Morgan’s Hemovac drain has been removed. Her IV is being discontinued, and
she will be taking pain medication by mouth.

16. You have just started your shift and begin your care of Mrs. Morgan by
completing a thorough assessment. Which of the following outcomes are
expected at this time? (there are 3 correct answers)
 A. Suture line dry and intact: A dry and intact suture line indicates
approximation of wound edges and is expected with normal wound
healing at this time. Mrs. Morgan’s incision line is dry and intact.

B. Verbalizes a reduction in pain: Use of relaxation techniques in conjunction

with analgesics is expected to provide Mrs. Morgan with relief form pain.
A verbal report acknowledging this pain relief is expected. Mrs. Morgan
says she has little pain. She rates pain as a 1 on a scale of 1-10.

C. Vital signs stable: Stable vital signs at preop baseline are expected and
signify absence of hemodynamic and other complications. Mrs. Morgan’s
vital signs are as desired.

NOT CHOSEN:

Bright red wound drainage

Skin of right heel pink/red

Mrs. Morgan will stay with her daughter for several weeks after leaving the hospital.
You will work collaboratively with the case manager to arrange home and
rehabilitative care.

Mrs. Morgan’s daughter has questions about her mother’s postoperative care.

17.Which of the following devices should Mrs. Morgan have at home?

A. Toilet seat extender: A toilet seat extender raises the level of the toilet
seat and would allow Mrs. Morgan to use the toilet without flexing her hip
at a large angle. A physical therapist is arranging for this, and other
needed supplies, such as a walker.

18. What other guidelines should be discussed with Mrs. Morgan and her
daughter regarding Mrs. Morgan’s care at home? (there are 3 correct
answers)

A. Be sure that Mrs. Morgan has antibiotic prophylaxis before any invasive
procedure, including dental work: Introduction of microbes during an
invasive procedure would increase risk for infection of the prosthetic hip.
Antibiotic prophylaxis will decrease this risk.

B. Advise Dr. Harrison if Mrs. Morgan’s joint pain persists as healing

progresses: Continued joint pain, during periods of both activity and rest,
could suggest latent infection of the prosthetic joint. Signs of latent
infection may not appear for months after surgery.

C. Discourage Mrs. Morgan from sitting for extended periods: Sitting for long
periods can cause hip flexion contractures. Ambulation is to be
encouraged. A chair with a high firm seat is preferred for sitting.

NOT CHOSEN:
 Remind Mrs. Morgan to cross her legs when lying in bed
Encourage Mrs. Morgan to bend from the waist when picking up objects

Mrs. Morgan is discharged on her fourth postoperative day. Her recovery has been
uneventful.

She can’t believe how good she feels!

Total hip replacement involves removal of a diseased hip joint and replacement with
a prosthetic joint.

With osteoarthritis, symptoms are primarily a result of erosion of articular joint

cartilage. Erosion can result in some inflammation, but inflammation is not a
significant component of the pathophysiology of osteoarthritis. Osteoarthritis is also
known as noninflammatory arthritis, and degenerative joint disease. Involved joints
most commonly include the hands (distal interphalangeal joints, proximal
interphalangeal joints), hips, knees, cervical spine, and lumbar spine. Osteoarthritis
of the lumbar spine is a frequent cause of lower back pain. Common risk factors for
osteoarthritis include older age, repetitive joint use (individual variation), joint
trauma, and obesity (knee and hand involvement).

Celecoxib (Celebrex) is a COX-2 enzyme inhibitor (and a nonsteroidal anti-

inflammatory drug) with analgesic effects. Dizziness, fatigue, and drowsiness are
side effects of celecoxib (Celebrex). Anorexia, nausea, indigestion, abdominal pain,
and other GI complaints can occur as side effects of celecoxib (Celebrex) therapy.
Gastrointestinal irritation may contribute to gastric ulceration and bleeding,
although this adverse effect is less likely with celecoxib (Celebrex) than with other
NSAIDS. Fluid retention can be a side effect of celecoxib (Celebrex) therapy. Fluid
retention is reflected in weight gain and peripheral edema.

Wound infection is a potential major complication after hip replacement surgery.

Would infection can result in the need for repeat surgery, which may be less
successful in improving mobility. Typically, antibiotics are given preoperatively
(started just before surgery), and continued for a few days postoperatively. Invasive
procedures are kept to a minimum after surgery to reduce risk of infection. Invasive
lines (IVs) are removed as quickly as possible, because they increase risk for
infection.

Deep vein thrombosis (DVT) is a potential major complication after hip replacement
surgery. Deep vein thrombosis (DVT) involves thrombus (clot) formation, usually in a
deep vein in the pelvis or leg. Risk for DVT is especially increased with orthopedic,
abdominal, thoracic, and genitourinary procedures. Any factor that alters blood flow
and results in venous stasis may contribute to thrombosis. Bed rest and immobility
are associated with venous stasis. Venous return to the heart is slowed when
activity level decreases. Regardless of the reason for bed rest or immobility, these
always increase risk of thrombosis. With surgery, imposed immobility and the
depressive effects of anesthetics on circulation increase risk for deep vein
thrombosis (DVT). Any surgery that requires administration of anesthesia and
immobilization for more than 45 minutes increases risk for DVT. Life-threatening
pulmonary embolus (PE) can occur as a result of deep vein thrombosis (DVT). With
DVT, entire thrombi or parts of thrombi can embolize. Embolization may occur in the
first few days after thrombi develop.

Fat embolism syndrome (FES) is a possible complication of orthopedic trauma and

major orthopedic surgeries. It can cause PE. With FES, fat globules from bone
marrow circulate to the lungs. Another cause of PE is air embolism. Air embolism is
a possible complication of intravascular access devices, especially midline catheters
and central venous catheters.

Of great importance in preventing deep vein thrombosis (DVT) is early ambulation

after surgery. Patients should take pain medication as necessary to make this
possible. Pain control with patient-controlled analgesia (PCA) is common after total
hip replacement.

Intermittent pneumatic compression devices also help to prevent deep vein

thrombosis (DVT). These are used alone or in conjunction with graded compression
stockings, to promote venous return to the heart and prevent venous stasis. These
are continued until a postoperative patient is fully ambulatory.

Intermittent pneumatic compression stockings (sleeves are sometimes used) may

be applied in the Post-Anesthesia Care Unit, after surgery. Dislocation of the
prosthetic hip is a potential major complication after hip replacement surgery.
Because the head of the femur is displaced from its socket when dislocated,
movement of the leg would be difficult, if not impossible, with dislocation. In
addition, leg lengths would appear different. With an anterior dislocation, the
operative leg would appear longer; with a posterior dislocation, the operative leg
would appear shorter. The hip would be abnormally rotated inward or outward.
Acute groin pain might be present. When the hip dislocates, a popping sensation
may be felt/heard.

Bleeding after hip replacement surgery can be significant. Blood must be available
for use during or after surgery.

Low-molecular-weight heparin (enoxaparin) is given by subcutaneous injection after

total hip replacement surgery to prevent DVT. Other anticoagulant protocols can be
used. Treatment with unfractionated heparin or low molecular weight heparin may
cause heparin-induced thrombocytopenia (low platelet count). Platelet count is
checked before and during therapy. No other lab monitoring is required when low
molecular weight heparin is used. Bleeding is a major complication of anticoagulant
therapy. The nurse observes for signs of bleeding. These include easy bruising
(ecchymosis), melena, bleeding gums, nosebleeds, and excessive bleeding at IV or
injection sites. Cerebral bleeding, if it occurs, usually results in a gradual change in
level of consciousness.

An overhead trapeze is used after surgery. A trapeze helps the patient position
herself and will increase her upper body strength.

Immediately after surgery, adduction must be AVOIDED. Adduction can cause

dislocation of a new prosthetic hip.

The Fowler's position at a 90-degree angle should be avoided after a total hip
replacement. This position involves severe hip flexion, which can cause dislocation
of a new prosthetic hip. Immediately after total hip replacement surgery, the head
of the bed usually can be at a 45-60 degree angle. Physician guidelines should be
determined.

Relaxation techniques can be used to relax muscles and enhance the analgesic
effects of medication.

Although surgeries and physician guidelines vary, adduction, flexion, and extreme
internal rotation of the hip (and perhaps external rotation) usually must be avoided.
These movements can cause a new prosthesis to dislocate. Positioning on the
operative side is often avoided.

Immediately after total hip replacement surgery, abduction of the newly-implanted

hip prosthesis helps to position it firmly in place. An abductor pillow is generally
used to help maintain abduction postoperatively.

Usually, when a patient first gets out of bed after hip replacement surgery, an
abductor pillow or splint is kept between her legs. The operative hip is kept
extended, and the person pivots on the nonoperative leg. The operative hip is
protected from adduction, flexion, internal or external rotation, and excessive
weight bearing. High seat chairs should be used. The hips should be higher than the
knees.

Numbness or tingling in the operative leg would suggest nerve damage. This
assessment finding would need to be reported immediately.

After hip replacement surgery, a toilet seat extender raises the level of the toilet
seat and allows the patient to use the toilet without flexing her hip at a large angle.
After hip replacement surgery, antibiotic prophylaxis is needed before any invasive
procedure, including dental work, to decrease risk for prosthesis infection.
Continued joint pain, during periods of both activity and rest, could suggest latent
infection of the prosthetic joint. Signs of latent infection may not appear for months
after surgery. Bending at the waist involves severe hip flexion (beyond 90 degrees),
which should be avoided to prevent hip dislocation. Sitting for long periods can
cause hip flexion contractures. Ambulation is to be encouraged. A chair with a high
firm seat is preferred for sitting. Leg crossing must be avoided.