{ "name": "Total Joint (Knee, Hip) Replacement", "slug": "total-joint-replacement", "url": "https://nursingplex.com/care-plans/total-joint-replacement", "category": "Surgery & Perioperative", "summary": "Arthroplasty care with dislocation precautions, VTE prophylaxis and early rehab.", "nursing_diagnoses": [ "Acute pain", "Impaired physical mobility", "Risk for peripheral neurovascular dysfunction" ], "overview": [ "Total joint replacement (arthroplasty) replaces a damaged hip or knee joint with prosthetic components, most often for advanced osteoarthritis that no longer responds to conservative treatment. The goals are pain relief, restored function and joint stability, and modern pathways aim for mobilization within hours of surgery and discharge within one to three days.", "Nursing care centers on three postoperative dangers. The first is dislocation of a hip prosthesis, prevented by strict positioning precautions in the early weeks. The second is venous thromboembolism, since major lower-limb orthopedic surgery is among the highest-risk procedures for deep vein thrombosis and pulmonary embolism. The third is prosthetic joint infection, which is uncommon but devastating, often requiring removal of the implant.", "Rehabilitation is not an afterthought — outcome depends on early, consistent movement. Knee patients need aggressive attention to extension and flexion range in the first weeks because a knee left in flexion contracture will not recover, while hip patients must balance mobility against dislocation precautions determined by the surgical approach." ], "key_facts": [ { "label": "Posterior hip precautions", "text": "No hip flexion beyond 90 degrees, no crossing the legs or adducting past midline, no internal rotation." }, { "label": "Dislocation signs", "text": "Sudden severe pain, shortening of the leg, internal or external rotation, and inability to bear weight." }, { "label": "Knee position", "text": "Never place a pillow under the knee; support the whole leg to preserve extension." }, { "label": "VTE prophylaxis", "text": "Anticoagulation plus mechanical devices and early ambulation, typically continued for weeks after discharge." }, { "label": "Early mobility", "text": "Most protocols start walking with therapy on the day of surgery or the first postoperative day." }, { "label": "Infection prophylaxis", "text": "Dental and invasive procedures may require antibiotic prophylaxis; report any infection anywhere promptly." } ], "nursing_priorities": [ "Control postoperative pain enough to permit early movement and therapy.", "Protect the prosthesis from dislocation through positioning and correct transfer technique.", "Prevent venous thromboembolism with drugs, devices and ambulation.", "Prevent surgical site and prosthetic joint infection.", "Monitor neurovascular status and blood loss in the operative limb.", "Restore mobility, strength and range of motion progressively.", "Prevent falls, skin breakdown, constipation and pulmonary complications.", "Prepare the patient and home for a safe discharge." ], "assessment": { "subjective": [ "Pain location, intensity and response to medication and to activity", "Preoperative function, walking distance, use of aids and home layout", "Numbness, tingling or new sensory change in the operative limb", "Calf pain, chest pain or shortness of breath", "Worry about falling, dependence, or the ability to manage at home" ], "objective": [ "Neurovascular checks distal to the surgery: color, temperature, capillary refill, pulses, sensation and movement", "Dressing and incision for drainage amount and character, approximation, redness and separation", "Drain output volume and color if present; hemoglobin trend", "Leg length, alignment and rotation compared with the other side", "Calf swelling, warmth or asymmetry; respiratory rate and oxygen saturation", "Temperature trend and white cell count", "Range of motion achieved, quadriceps activation and distance walked with therapy", "Skin over the heels, sacrum and under any immobilizer or compression device" ], "related_factors": [ "Surgical incision, bone resection and soft-tissue trauma", "Prosthetic implant with altered joint mechanics and stability", "Immobility, venous stasis and hypercoagulability after surgery", "Advanced age, obesity, diabetes and pre-existing deconditioning", "Anesthesia, opioid analgesia and altered bowel and bladder function" ] }, "goals": [ "The client will report pain at or below the agreed level and participate fully in physical therapy.", "The client will maintain correct alignment with no evidence of prosthesis dislocation.", "The client will remain free of venous thromboembolism, with no calf or chest symptoms.", "The client will have a clean, dry, approximated incision with no signs of infection.", "The client will maintain intact neurovascular status in the operative limb.", "The client will ambulate a safe distance with the prescribed assistive device and correct weight bearing before discharge.", "The client will demonstrate prescribed exercises and state positioning precautions correctly." ], "interventions": [ { "title": "1. Managing pain to enable movement", "points": [ "Use multimodal analgesia — scheduled acetaminophen, an anti-inflammatory when permitted, nerve blocks and short-acting opioids for breakthrough — since opioid-only regimens sedate patients out of therapy.", "Time analgesia 30–45 minutes before physical therapy so the peak effect coincides with the session.", "Apply cold therapy to the joint as ordered to reduce swelling and pain, protecting skin from direct contact.", "Elevate the limb and support it fully during rest, and reposition with the whole leg supported rather than lifting under the knee.", "Reassess after each intervention and distinguish incisional pain from the sudden, severe pain of dislocation or the deep calf pain of thrombosis." ] }, { "title": "2. Preventing hip dislocation", "points": [ "Confirm the surgical approach, because precautions differ: posterior approaches restrict flexion beyond 90 degrees, adduction past midline and internal rotation.", "Keep an abduction pillow or wedge between the legs while in bed and when turning, and turn only to the permitted side with the legs supported.", "Provide a raised toilet seat and a high, firm chair with arms; low soft seating forces flexion past 90 degrees.", "Teach the patient not to bend to reach the feet, not to cross the legs or ankles, and to use a long-handled reacher, sock aid and long shoehorn.", "Recognize dislocation immediately — sudden severe pain, a shortened and rotated leg, and inability to move or bear weight — keep the patient still, support the limb and notify the surgeon at once.", "Instruct on pivoting with the operative leg leading during transfers and never twisting the trunk over a planted foot." ] }, { "title": "3. Knee-specific positioning and range of motion", "points": [ "Never place a pillow directly under the knee; a flexion contracture develops quickly and full extension is difficult to regain.", "Elevate the whole leg on a supported surface to control swelling while keeping the knee straight.", "Encourage ankle pumps, quadriceps sets and straight-leg raises hourly while awake from the first day.", "Support prescribed flexion goals with heel slides and seated knee bends, and record the degrees achieved so progress is objective.", "Use a continuous passive motion device only if ordered and per settings, ensuring skin checks and correct alignment.", "Reinforce that early discomfort during exercise is expected and that skipping sessions costs range that is hard to recover." ] }, { "title": "4. Preventing venous thromboembolism", "points": [ "Administer anticoagulant prophylaxis exactly as prescribed and monitor for bleeding, bruising and hemoglobin drop.", "Apply sequential compression devices or graduated stockings whenever the patient is in bed, ensuring correct sizing and skin checks.", "Get the patient up and walking on the day of surgery or the first postoperative day per protocol, then several times daily.", "Teach ankle pumping and calf exercises hourly while awake and encourage adequate hydration.", "Assess daily for unilateral calf swelling, warmth or pain, and treat sudden dyspnea, pleuritic chest pain, tachycardia or hypoxemia as possible pulmonary embolism requiring immediate response.", "Emphasize that prophylaxis usually continues for several weeks after discharge and must not be stopped early." ] }, { "title": "5. Preventing infection and monitoring the wound", "points": [ "Give preoperative antibiotics within the prescribed window and continue postoperative doses on time.", "Inspect the incision each shift for increasing redness, warmth, separation, or purulent or persistent drainage, and report early.", "Use aseptic technique for dressing changes and keep the dressing dry and intact between changes.", "Monitor temperature trend and white cell count, remembering that low-grade fever in the first 48 hours is often atelectasis rather than infection.", "Manage glucose tightly in diabetic patients, since hyperglycemia sharply raises infection risk.", "Remove urinary catheters as early as possible and encourage incentive spirometry and deep breathing to prevent secondary infection sources.", "Teach lifelong vigilance: report any infection elsewhere in the body promptly because bacteria can seed the prosthesis." ] }, { "title": "6. Neurovascular monitoring and blood loss", "points": [ "Perform neurovascular checks on the operative limb at the ordered frequency and compare directly with the unoperated side.", "Report new numbness, foot drop, inability to dorsiflex, absent pulse or a cool, pale extremity immediately.", "Measure and record drain output and observe the dressing for expanding saturation; report brisk or increasing bloody output.", "Follow hemoglobin trends and assess for symptomatic anemia — tachycardia, dizziness on standing, pallor and fatigue.", "Check for excessive swelling or a tense, painful limb suggesting hematoma or compartment problems." ] }, { "title": "7. Mobility, safety and general recovery", "points": [ "Reinforce the prescribed weight-bearing status at every transfer and confirm the patient can state it themselves.", "Teach correct use of the walker or crutches, including stair technique: up with the strong leg first, down with the operative leg first.", "Keep the environment clear, footwear non-slip, and call light in reach, and assist with the first ambulation after any new analgesic.", "Prevent constipation proactively with fluids, fiber and a stool softener started with the first opioid dose.", "Encourage incentive spirometry, deep breathing and position changes to prevent atelectasis.", "Provide adequate protein and vitamin intake for wound healing and monitor for skin breakdown at pressure points." ] }, { "title": "8. Discharge preparation and home planning", "points": [ "Arrange the home in advance: remove throw rugs and cords, secure a raised toilet seat, shower chair and handrails, and set up a sleeping area that avoids stairs if needed.", "Confirm the patient and caregiver can perform the exercise program and demonstrate safe transfers before discharge.", "Provide a written schedule of anticoagulant, analgesic and antibiotic instructions with clear stop dates.", "Confirm home health or outpatient therapy is booked and the first appointment date is known.", "Review activity restrictions on driving, lifting, kneeling and returning to work with realistic timeframes.", "Give explicit warning signs and the number to call, and confirm the follow-up surgical appointment." ] } ], "patient_teaching": [ "Follow your hip precautions for the full period prescribed: no bending past 90 degrees, no crossing your legs, no turning the leg inward.", "Do not put a pillow under your knee after knee replacement; keep the leg straight when resting and do your exercises every day.", "Take your blood-thinner exactly as prescribed for the full course and report unusual bruising or bleeding.", "Walk several times a day, using your walker or crutches and the weight-bearing limit you were given.", "Call immediately for calf pain or swelling, chest pain or shortness of breath, sudden severe hip or knee pain, or a leg that looks shorter or turned.", "Report fever, chills, or increasing redness, warmth or drainage from your incision.", "Tell every dentist and provider that you have a joint replacement; you may need antibiotics before some procedures.", "Keep all therapy and surgical follow-up appointments — your range of motion depends on the first six weeks." ] }