COLLABORATIVE DIAGNOSIS: Potential complications

  1. hemorrhage and/or hematoma formation related to surgical trauma to blood vessels (the hip is a very vascular area) and use of anticoagulants or antiplatelet agents before and after surgery;
  2. dislocation of hip prosthesis(es) related to weakness of the hip muscles, improper positioning or movement of the operative extremity, and/or noncompliance with weight-bearing limitations;
  3. thromboembolism related to:
    1. trauma to vein walls during surgery
    2. venous stasis associated with decreased mobility, increased blood viscosity (can result from fluid volume deficit), and pressure exerted on veins by balanced suspension device or abductor wedge
    3. hypercoagulability associated with increased release of tissue thromboplastin into the blood (occurs as a result of surgical trauma) and hemoconcentration and increased blood viscosity (can occur as a result of fluid volume deficit);
  4. fat embolism syndrome (FES) related to release of fat from the bone marrow into the blood associated with trauma to the bone during preparation for and implantation of the hip prosthesis.
Desired Outcome
The client will not experience hemorrhage or hematoma formation as evidenced by:
  1. expected amount of wound drainage
  2. no further decrease in RBC, Hct, and Hb
  3. no significant increase in hip pain
  4. absence of tense swelling in surgical area.
Nursing Actions and Selected Purposes/Rationales
  1. Assess for and report the following:
    1. excessive wound drainage (expected loss is 200-500 ml in the first 24 hours, diminishing to less than 100 ml/24 hours by 48 hours after surgery)
    2. significant decrease in RBC, Hct, and Hb levels
    3. signs and symptoms of hematoma formation (e.g. increased pain and tense swelling in buttock and/or thigh).
  2. Implement measures to reduce operative site bleeding and/or prevent hematoma formation:
    1. maintain pressure dressing over operative site as ordered
    2. keep trochanter roll or sandbag placed firmly against operative site for the first 24-48 hours after surgery to provide additional pressure on surgical site
    3. apply ice pack to operative hip if ordered
    4. maintain patency of wound drainage system if present.
  3. If signs and symptoms of excessive bleeding or hematoma formation occur, prepare client for return to surgery to ligate bleeding vessels and/or drain hematoma if planned.
Desired Outcome
The client will not experience dislocation of the hip prosthesis(es) as evidenced by:
  1. continued resolution of hip pain
  2. ability to maintain operative leg in proper alignment
  3. ability to adhere to expected exercise and ambulation regimen
  4. usual length of operative extremity
  5. normal neurovascular status in operative leg.
Nursing Actions and Selected Purposes/Rationales
  1. Assess for and report signs and symptoms of dislocation of the hip prosthesis(es):
    1. sudden, severe hip pain followed by continued pain and muscle spasms during hip movement
    2. abnormal rotation of operative leg
    3. inability to move or bear weight on operative leg
    4. shortening of operative leg
    5. decline in neurovascular status in operative leg.
  2. Implement measures to prevent dislocation of the prosthesis(es):
    1. maintain bed rest as ordered (may be on bed rest for first 24 hours after surgery)
    2. perform actions to prevent adduction of the operative extremity:
      1. maintain extremity in abducted position using balanced suspension device, an abduction wedge, or 2-3 pillows between legs
      2. remind client to avoid crossing legs
      3. do not move operative extremity past midline
      4. turn client only as ordered and always with pillows between legs
    3. maintain operative extremity in proper alignment
    4. instruct client to avoid extreme internal and external rotation of operative leg
    5. maintain restrictions on head of bed elevation if ordered (some physicians order a 45-60° maximum for first 2-3 days after surgery) to reduce hip flexion
    6. perform actions to prevent extreme (beyond 90°) hip flexion:
      1. instruct client not to lean forward to reach objects on end of bed or on floor or to put on slippers, socks, or shoes
      2. raise the entire bed to client's midthigh level before he/she gets in or out of bed in order to reduce the degree of hip flexion that occurs when client sits on edge of bed
      3. provide a high, firm chair (or elevate sitting surface with pillows) and an elevated toilet seat for client's use to reduce degree of hip flexion when client sits down
      4. do not elevate operative leg when client is sitting in chair
    7. reinforce importance of adhering to recommended weight-bearing restrictions (the amount of weight bearing allowed is based on the type of prostheses inserted; partial weight bearing is usually allowed as soon as ambulation is started)
    8. instruct and assist client to pivot and bear weight on the unoperative leg when transferring from bed to chair and raising self out of chair.
  3. If signs and symptoms of dislocation of the prosthesis(es) occur:
    1. maintain client on bed rest
    2. prepare client for x-rays of the surgical area
    3. prepare client for closed reduction (e.g. traction) or surgical relocation of the prosthesis(es) if planned.
Desired Outcome
The client will not develop a deep vein thrombus or pulmonary embolism (see Standardized Postoperative Care Plan, Diagnosis 20, for outcome criteria).
Nursing Actions and Selected Purposes/Rationales
  1. Refer to Standardized Postoperative Care Plan, Diagnosis 20, for measures related to assessment, prevention, and treatment of a deep vein thrombus and pulmonary embolism.
  2. Implement additional measures to prevent thrombus formation:
    1. make sure that antiembolism stockings are applied correctly and that intermittent pneumatic compression device is correctly applied and functioning properly
    2. assist client with exercises and ambulation as allowed
    3. perform actions to reduce risk of compromising venous return:
      1. make sure elastic wraps or stockings are not too tight
      2. avoid use of knee gatch or pillows under knees
      3. discourage prolonged sitting or standing
      4. make sure that balanced suspension device or straps on abductor wedge do not exert excessive pressure on any area
    4. administer anticoagulants (e.g. low-dose warfarin, low-molecular-weight heparin, danaparoid) or antiplatelet agents (e.g. aspirin) as ordered.
Desired Outcome
The client will not experience fat embolism syndrome as evidenced by:
  1. usual mental status
  2. unlabored respirations at 12-20/minute
  3. absence of petechiae
  4. PaO2 within normal limits.
Nursing Actions and Selected Purposes/Rationales
  1. Assess for and report signs and symptoms of fat embolism syndrome (usually occurs within 72 hours after surgery):
    1. restlessness, apprehension, confusion
    2. sudden onset of dyspnea
    3. tachypnea
    4. elevated pulse and temperature
    5. petechiae on the chest, neck, or axilla
    6. low PaO2 level.
  2. Move operative extremity gently and avoid excessive movement of the extremity during the first few days after surgery to reduce the risk for fat emboli.
  3. If signs and symptoms of fat embolism syndrome occur:
    1. maintain client on bed rest and move operative extremity as little as possible to prevent further emboli
    2. administer oxygen and assist with positive airway pressure techniques (e.g. positive end expiratory pressure) if ordered
    3. prepare client for chest x-ray or lung scan
    4. administer intravenous fluids as ordered to help maintain adequate perfusion to vital organs and prevent shock
    5. administer corticosteroids if ordered to reduce cerebral edema and pulmonary inflammation.