Joint replacement
Called an arthroplasty, the total or partial replacement of a joint with a synthetic prosthesis restores mobility and stability and relieves pain. In fact, recent improvements in surgical techniques and prosthetic devices have made joint replacement an increasingly common treatment for patients with severe chronic arthritis, degenerative joint disorders, and extensive joint trauma. All joints except the spine can be replaced with a prosthesis; hip and knee replacements are the most common. The benefits of joint replacement include not only improved, pain-free mobility but also an increased sense of independence and self-worth. (See Arthroplasty variations.)
Procedure
The joint replacement procedure is usually an elective procedure and varies slightly depending on the joint and its condition. In a total hip replacement, for instance, the patient is usually placed in a lateral position and given a regional or general anesthetic. The surgeon then makes an incision to expose the hip joint. As necessary, he incises or excises the hip capsule, then dislocates the joint to expose the acetabulum and the head of the femur.
Next, the surgeon reams and shapes the acetabulum to accept the socket part of the ball-and-socket hip prosthesis and secures the device in place. Polymethylmethacrylate adhesive is used to secure the device in place if the prosthesis is cemented. He then repeats this process on the head of the femur for the ball portion of the prosthesis.
After the parts of the prosthesis are in place, the surgeon fits them together to restore the joint. Then he closes the incision in layers and applies a dressing.
Complications
If infection occurs at the implant site, the implant almost always needs to be removed.
Other complications include compromise of the brachial plexus (or other nerves in the surgical site), dislocation or loosening of the prosthesis, heterotrophic ossification (formation of bone in the periprosthetic space), avascular necrosis, and dead bone caused by loss of blood supply. Respiratory complications, such as atelectasis and pneumonia, commonly affect elderly patients because of their decreased activity tolerance.
Serious complications of joint replacement include pulmonary embolism, thromboembolism, hypovolemic shock, and fat embolism. (See Managing fat embolism, page 500.) Pulmonary embolism is the most common cause of postoperative mortality following a joint replacement.
Key nursing diagnoses and patient outcomes
Acute pain related to joint replacement and postoperative swelling. Based on this nursing diagnosis, you’ll establish these patient outcomes. The patient will:
express decreased pain level after therapeutic modalities are instituted (such as analgesics and mild exercise)
increase joint mobility and exercise tolerance.
Risk for injury related to increased chance of fat embolism from intramedullary reaming and seating of prostheses. Based on this nursing diagnosis, you’ll establish these patient outcomes. The patient will:
not develop any signs and symptoms of fat embolism
demonstrate normal neurologic, respiratory, and cardiac function following joint replacement.
Risk for infection related to surgical intervention within the joint space. Based on this nursing diagnosis, you’ll establish these patient outcomes. The patient will:
maintain his temperature and white blood cell count within the normal range following the joint replacement
not demonstrate any signs and symptoms of infection, such as persistent fever, pain, and stiffness and loss of joint range of motion (ROM)
take prophylactic antibiotics before dental or other surgical procedures to decrease the chance of organisms migrating to the joint prostheses.
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