68 Joint replacement surgery
Diagnostic tests
Various tests are combined with patient history and physical findings to confirm presence of conditions that necessitate joint replacement. X-ray examination is commonly required, and arthroscopy may be useful in confirming extent of joint pathology and in identifying appropriate prosthesis.
Nursing diagnosis:
Risk for peripheral neurovascular dysfunction
| ASSESSMENT/INTERVENTIONS | RATIONALES |
|---|---|
| Assess neurovascular function of the operative leg at regular intervals as prescribed by the surgeon or in accordance with hospital policy. Compare to nonoperative leg and preoperative baseline assessment. Notify health care provider of abnormal findings. | Pressure from the abductor wedge (THA) or a bulky knee dressing (TKA) can interrupt arterial blood flow and compress the peroneal and tibial nerves. These nerves provide movement and sensation to the calf and foot muscles. The peroneal nerve runs superficially by the fibular neck; it is assessed by testing sensation in the first web space between the great and second toes and by having patient dorsiflex the foot. The tibial nerve, a branch of the sciatic nerve, is assessed by testing sensation on the bottom of the foot and by having patient plantar flex the foot. Loss of sensation or movement signals impaired nerve function and must be reported promptly to health care provider. |
| Apply cold therapy as prescribed at operative site. | Swelling increases intracompartmental pressure in the lower leg, potentially interrupting arterial blood flow and compromising nerve function. Ice application is an important early intervention to decrease swelling. |
| Teach patient the potential for neurovascular impairment and importance of promptly reporting alterations in sensation, strength, movement, temperature, and color of operative extremity. | These findings indicate impaired nerve function. Nerve damage can lead to severe disability with footdrop and paresthesias. Patient’s awareness of signs of impairment leads to prompt reporting, enabling health care providers to initiate appropriate treatment in a timely way. |
| Instruct patient to perform prescribed exercises (e.g., ankle pumps, heel slides) at regular intervals. | Exercises stimulate circulation to distal extremity and decrease risk for neurovascular dysfunction. |
Nursing diagnosis:
Ineffective peripheral tissue perfusion (or risk for same)
| ASSESSMENT/INTERVENTIONS | RATIONALES |
|---|---|
| Assess for and promptly report to health care provider patient’s complaints of swelling, warmth, or pain/tenderness along vein tracts in lower extremities. | Close monitoring for these signs of thrombosis is imperative to ensure timely treatment. Patient’s awareness of indicators also contributes to early identification and treatment of potential thrombotic complications. |
| Encourage patient to perform ankle pumps/heel slides at regular intervals. | These exercises cause calf muscle contraction. Muscle contraction increases blood return to the heart and decreases risk for thrombus development. |
| Encourage patient to perform other prescribed exercises and participate fully in physical therapy (PT) program. | Early mobilization decreases risk of thrombus formation. |
| Encourage patient to wear antiembolic stockings, intermittent pneumatic compression devices, or venous foot pump compression devices whenever in bed or chair. | These devices compress leg muscles and promote blood return to the heart, decreasing risk for thrombus development. |
| Instruct patient regarding use of anticoagulants and other VTE prevention modalities. Administer anticoagulants as prescribed and review results of any associated blood tests, ensuring health care provider has been informed of laboratory results. | Because of increased risk of VTE with joint replacement surgery, the surgeon will prescribe anticoagulant therapy. In addition, passive prevention strategies (e.g., sequential compression device) are likely to be implemented. Low molecular-weight heparin (e.g., enoxaparin) or heparin derivative (e.g., fondaparinux) is administered by subcutaneous injection. Oral warfarin also may be used for VTE prevention. The patient should be knowledgeable about risks associated with anticoagulant use in order to report adverse effects in a timely way. Review Risk for Bleeding in “Pulmonary Embolus,” p. 128. |
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