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HIPSTERS

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Claire Sogocio

on 31 October 2013

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Transcript of HIPSTERS

HIPSTERS

Variance in Mobility: Osteoporosis, Osteoarthritis & Total Hip Replacement
Post-Op
THE VARIABLES
PRE-OPERATIVE
CRISIS
Defined by Gerald Caplan as "when a person faces an obstacle to important life goals, that is for a time, insurmountable through the utilization of customary methods of problem solving" (Austin & Boyd, 2010)
QUESTION & ANSWER
Osteoporosis
Total Hip Replacement
Physiological
Spiritual
Socio-cultural
Professional, Legal & Ethical Issues
Pre-op Teaching
CARE PLAN #1
Post Op Nursing Care
Mobility
Q?
What are the important goals of pre-op assessement?
Q?
What is the definition of
osteoarthritis
?
Q?
What are some nursing interventions for osteoarthritis/total hip replacement?
Based on Jim Harvey's speech structures
By: Claire S., Erin C., Jemma S., Sarah G., Maggie F., Melissa V.
Osteoarthritis
Definition:
Definition
Total Hip Replacement
CASE STUDY
Meet Arthur...
Psychological
Developmental
GROUP WORK
IDENTIFYING VARIABLES
Social Justice and Environmental Health Determinants
References
Austin, W. & Boyd, M. (2010). Psychiatric & mental health nursing for Canadian practice
(2nd ed.). Philadelphia, PA: LWW
Black, J.M. & Hawks, J.H. (2009). Medical-Surgical Nursing: Clinical Management for Positive
Outcomes (8th ed.). St. Louis, Missouri: Saunders.
Cluett, J. (2010) Are you ready for hip replacement surgery? Signs you need, or don’t need a
hip replacement. Retrieved from http://orthopedics.about.com/cs/hipreplacement/a/signs.htm
College of Registered Psychiatric Nurses of British Columbia (2013). Consent. CRNPBC Code
and standards. Retrieved from https://www.crpnbc.ca/wp-content/uploads/2011/02/2013-04-30-Consent-Formatted.pdf
College of Registered Psychiatric Nurses of British Columbia (2013). Documentation.
CRNPBC Code and standards. Retrieved from https://www.crpnbc.ca/wp-content/uploads/2011/02/2013-04-30-Documentation-Formatted.pdf
Douglas College Department of Psychiatric Nursing (2011). Neuman systems model
workbook (6th ed.). New Westminster, B.C.: Author.
Douglas College Department of Psychiatric Nursing (2013). Psychiatric nursing department
conceptual framework assessment guides. New Westminster, B.C: Author.
Eustice, C. (2008). Total hip replacement – what you need to know. Retrieved from http:/
osteoarthritis.about.com/od/osteoarthritistreatments/a/hipreplacement.htm
Fraser Health Authority. (2009). Fall prevention for staff. [Brochure]. New Westminster,
BC: Author.
Fraser Health Authority. (2012). Mobilizing the elderly is everyone’s responsibility.
[Brochure]. New Westminster, BC: Author.
HealthLink BC (2011). Food Sources of calcium and vitamin D. HealthLink BC File #68e,
March 2011. Retrieved from http://www.healthlinkbc.ca/healthfiles/hfile68e.stm
Jarvis, C. (2009). Physical examination and health assessment – pocket companion (1st C
ed.). St Louis, MO: Saunders.

http://www.interactive-biology.com/wp-content/uploads/2012/07/Osteoarthritis-Hip-Joint-1024x998. jpg
http://drbell.typepad.com/.a/6a01156ecadc3a970c01539224d879970b-800w i
http://www.nlm.nih.gov/medlineplus/images/hipreplacement. jpg
CASE STUDY
Arthur is a 71-year-old widower who has a history of osteoporosis and osteoarthritis. His mobility in his left hip joint has been gradually deteriorating and has now significantly reduced. This is affecting his ability to walk, and it is causing him daily pain, for which he is taking Tylenol.
It has been suggested that Arthur considers a hip replacement procedure, but Arthur is concerned about the invasive surgery because he worries that he will not be able to take care of himself. He does not want to be a burden on his daughter who is busy with her job and taking care of her children. Arthur would like to stay in his own home, and is anxious about losing his independence.
Arthur has been drinking a little more alcohol than usual to help him cope with the pain and to help him get to sleep at night. Arthur has lost touch with most of his friends, as his wife used to arrange their social activities. He has also stopped going to church because he feels that God let him down when his wife passed away.
A Universal Experince...
A!
- Obtaining History
--> allergies
--> ensuring consent form is properly filled out
- Reducing patient anxiety
A!
Osteoarthritis
: a mechanical bone disorder that is characterized by compromised bone strength predisposing to an increased risk of fracture
A!
Education & Encouragement of preventative measures
Protective measures to prevent fracture (fall prevention)
--> Hip protectors, Steady ambulation/proper use of aids, non-slip materials on floors

Why should Arthur have a hip replacement?
-Healthy people tend to recover better than people who are not healthy
-Problematic joints can lead to other medical problems
- Painful joints can cause patients to become sedentary
- Sedentary individuals are at risk for gaining weight, which can lead to the development of cardiovascular problems
-Arthur will have a decrease in pain, increase in mobility, be able to perform activities of daily living, and have improved quality of life



Informed Consent

Disclosure
- providing the appropriate information to the patient (risks of treatment, alternative treatment options, associated facts and risk factors, treatment outcome, risks of not having the treatment
Capacity
- patient's ability to understand the relevant information and appreciate the consequences of the decision
Voluntariness
- patient's right to come to a decision without force, coercion or manipulation from others
When these 3 components are met, the patient is able to provide informed consent for medical treatment (Kozier & Erb, 2010).
CONSENT
is the voluntary agreement to some act or purpose made by a capable individual.
The conditions for consent include
:
According to the CRPNBC,
"Registered Psychiatric Nurses (RPNs) have both legal and ethical obligations regarding consent for proposed care, treatment and research".
1) The client or substitute decision-maker being adequately informed
2) The client or substitite decision-maker being capable of giving or refusing consent,
3) There being no concern, fraud or misrepresentation.
The Principles of Consent
-
Determine
if the client is capable of giving consent.
-Respect
client's rights to make decisions about the management of their own health care
-
Provide
information in a timely and appropriate manner, taking into account the individual's abilities, age, culture, language and preferences
-
Provide
clients with the information to decide about proposed health care
-
Respect
the right of clients to seek further information or anotheropinion, and to
involve
others in the decision-making and consent process
-
Respect
the right of client to refuse or withdraw consent at any times, even if the refusal will result in death, provided they are capable of doing so and there is no legislation that removes that right.
-It is
not appropriate to

take responsibility
for obtaining consent
for care or treatment provided by another healthcare professional
- RPNs who participate in the delivery of treatment by other health professionals
verify
that consent has been given for the proposed health care, and
help
clients understand the information provided by others

College of Registered Psychiatric Nurses of B.C. (2013)

Signs that you're ready for a HIP REPLACEMENT!
- Hip/groin pain that disrupts sleep
- Pain that limits activities of daily living
- Pain that limits activities that give pleasure
- Other treatments have not provided relief
Factors to Consider
Overall Health
- the ability to tolerate anesthesia, surgery, and the recovery process
Strength
- able to rehabilitate, and use mobility devices for recovery
Knowledge
- the person's understanding of procedure
RISK FACTORS

- Family history
- Age (Over 55)
- Gender (Women)
- Previous injury to the joint
- Obesity
- Overuse (Repetitive actions of the joint)
- Poor posture

MEDICATIONS & TREATMENT
Black and Hawks (2009) states the the goals for medical management of osteoarthritis include 1) pain management with improvement or maintenance of mobility, 2) functional independence, and 3) maintenance of quality of life.

- Acetaminophen (Tylenol)
- NSAID's (Ibuprofen, Naproxen, Celecoxib, etc.)
- Corticosteroid injections
- Opioids

- Osteotomy
- Arthrodesis
- Total joint arthroplasty (replacement)
OSTEOARTHRITIS
CLINICAL MANIFESTATIONS
Most of the time osteoporosis isn’t discovered until after a fracture has happened, often a vertebral compression fracture (which causes shortened stature and dorsal kyphosis). Clinical manifestations of osteoporosis can include:
- Decreased bone density
- Progressive vertebral deformities
- Changes in dentition
- Frequent fractures

However, these manifestations don’t occur until the damage has already been done, so it is crucial to prevent the loss of peak bone mass (highest bone mass attained).
RISK FACTORS
MEDICATIONS & TREATMENTS

- Low bone mass
- Personal history of fracture as an adult
- History of fragility fracture in a first-degree relative
- Low body weight (less than about 128 pounds)
- Current cigarette smoking
- Use of corticosteroid therapy for more than 3 months
- Estrogen deficiency
- Inadequate physical activity
- Lifelong, low intake of dietary calcium
OSTEOPOROSIS
Medical management of osteoporosis focuses on preventative measures individuals can take to decrease the chance of bone loss and fragility fractures, however pharmacological interventions can be used when preventative measures aren't enough:
- Bisphosphonates (eg. Fosamax)
- Selective estrogen receptor modulators (SERMS’s) (eg. Raloxifene)
- Hormone therapy (eg. estrogen/progesterone)
- Calcitonin
- Calcium and vitamin D supplements
QUIZ!
Intrapersonal Stressors
-Osteoarthritis
- Pain (chronic)
- Lack of Sleep
- Decreased Mobility
- Increased Alcohol use
Physiological
Intra
personal Stressors
- Anxiety regarding upcoming surgery
- Anxiety about his loss of independence
- Anxiety about being a burden to daughter
Extra
personal Stressors
- Lack of emotional support system
- Loneliness
Psychological
Intra
personal Stressors
- Lack of purpose and meaning
- Doubting faith
Inter
personal Stressors
- Does not want to be a burden to daughter
Spiritual
Intra
personal Stressors
- Isolation --> Lives alone
- Lacks supportive friendships
Extra
personal Stressors
- Worried about maintaining home
- Worried about caring for self post surgery
Developmental
Intra
personal Stressors
What will it mean to have to rely on someone?
Inter
personal Stressors
Lack of social support
Extra
personal Stressors
Loss of daily routine
Socio-Cultural
http://i.telegraph.co.uk/multimedia/archive/02531/pensioner_2531319b. jpg
Douglas College Department of Psychiatric Nursing (2013). Psychiatric nursing department conceptual framework assessment guides. New Westminster, B.C: Author.
The Consent Process
RPNs must
know and understand their agency policies
on consent and follow them. Effective communication is essential to ensure that the client’s own health care decisions are understood, expressed and respected by everyone involved. Strengthen the communication process by giving explanations in ways best understood by the client and by using a combination of strategies. These might include :
1) Give verbal explanations.
2) Use visual aids and handouts.
3) Ask clients for feedback about what they understand.
4) Ask clients if they have any questions.
5) Engage family or friends who are supporting the client to help the client understand.
6) Use plain language and age-appropriate terminology.
7) Use the services of a qualified interpreter if a language barrier exists.

College of Registered Psychiatric Nurses of B.C. (2013)



Also known as degenerative joint disease. It is a chronic, progressive process in which new tissue is produced in response to joint insults and cartilage degeneration, and is the most commonly seen type of arthritis. It can be classified as either idiopathic or secondary.
Osteoporosis is a metabolic bone disorder that is characterized by compromised bone strength predisposing to an increased risk of fracture.
Obtaining Consent
- This is a
legal requirement
- Treating a patient
without obtaining consent
can lead to
battery or negligence charges
- Obtaining informed consent for medical and surgical treatments is the
responsibility of the physician performing the care

Psychiatric Nurse's Role
This is the surgical replacement of the hip joint with an artificial prosthesis that aims to improve the individuals pain and mobility.
It is one the most widely performed orthopedic procedures, and approx. 70% of those cases are due to osteoarthritis - it is indicated when conservative treatments fail (i.e. weight reduction, rest + exercise balance, NSAID’s, etc), severe pain, and a significant decrease in the functionality of the client.

COMPLICATIONS
- Deep vein thrombosis and pulmonary embolism
- Dislocation
- Infection

- There are
no laws
prohibiting the nurse from being part of the information giving process
but this is not the nurse's role
- It is often the nurse’s role to
witness the giving of informed consent
and
confirm that the client was informed and did understand the information

College of Registered Psychiatric Nurses of B.C. (2013)
NURSING INTERVENTIONS
Education is the main point of intervention when caring for an individual with osteoarthritis; important areas to educate the client on are:
- Pain management (multi-modular approach)
- Rest-activity balance
- Nutrition and weight-loss
- Self-care strategies
- Education and encouragement of preventative measure
- Increase calcium intake (dairy products, soy products, tofu, sardines, etc)
- Increase vitamin D intake (fortified products, fish, liver, and egg yolk, etc)
- Weight-bearing exercises
- Pain control
- Protective measures to prevent fractures (fall prevention)
- Hip protectors
- Steady ambulation/proper use of aids
- Non-slip materials on floors

NURSING INTERVENTIONS
What are the
positive
and
negative
determinants in Arthur's life?
DETERMINANTS
1) Housing
2) Education
3) Healthcare
4) Daughter
5) Friend
- Age
- Social exclusion since wife's death
- Social Safety nets: friends are also increasing in age
- Fear of being a burden on family & friends
- Lack of knowledge
- Food insecurity
- Limited Income
POSITIVE
NEGATIVE
CLINICAL MANIFESTATIONS
- Worsening pain
- Limitation of movement
- Crepitus (grating, crackling, or popping sounds)
- Stiffness that increases with activity and decreases with rest
- Possible joint enlargement

Osteoarthritis can be confirmed through radiographic imaging that shows changes to the joint and bone - this includes the presence of osteophytes and a narrowed joint space caused by erosion of the cartilage.

What can we,
As Psychiatric Nurses do?
1) Know the services in the community
where you live or work
2) Encourage clients to reach out to
family and friends for support, if possible
3) Be aware of client's preference
4) Be aware of client's other medical issues and be aware of all their variables
Effectively Teaching Older Adults
1) Vision
2) Hearing
3) Energy Level & Attention
4) Information Processing
& Memory
Hip Precautions
EXERCISES
CARE PLAN
CARE PLAN #2
CARE PLAN #3

When your patient returns to your unit:
- Reposition patient
- Check ABC’s
- Reinforce pre op teaching ie: deep breathing and coughing 5-10X/hour
-
Neurovascular assessment
- Fall precautions
- multi-modular approach to pharmacological intervention

Reference: Black & Hawks (2009)


(Black & Hawks, 2009)
(Black & Hawks, 2009)
(Black & Hawk, 2009)
(Osteoporosis Canada, 2013)
(Black & Hawks, 2009)
(HealthLinkBC, 2011)
(Black & Hawks, 2009)
(Black & Hawks, 2009)
(Black & Hawks, 2009)
(Black & Hawks, 2009)
(Black & Hawks, 2009)
(Siopack & Jergesen, 1995)
What areas are important to include when educating a client with osteoarthritis in regards to mangement of their diagnosis?
The incidence of dislocation is highest in the first year after arthroplasty (1-4%). 50%-70% of dislocations occur within the first 5 weeks to 3 months postoperatively (Werner & Brown, 2012). Precautions must be followed for 3 months unless otherwise specified by the surgeon. Hip replacement dislocations occur when the ball of the ball-and-socket replacement comes out of the socket.
The DO NOTs!
Post-op Total Hip Replacement
Do Not...
- Bend forward more than 90 degrees
- Raise knee higher than hip
- Twist
- Sit on surface lower than knee
- Cross legs
- Rotate operated leg inwardly

Increase blood circulation
to your legs and feet
Prevent the
risk of blood clots
Strengthen
muscle and
improve
movement of replaced hip

· Ankle pumps & Rotations

Q15-20 minutes

and can begin immediately after surgery.
· Quad Sets
Tighten knee muscles by pressing knee down onto the bed. Hold for 6 seconds, Relax, then Do with other leg.


10x every hour.
GOAL...
More Exercises....
· Hip Abduction
Keep legs on the bed, move operated leg no further than 18 inches away from other leg. Return to starting position. Be sure to keep knee and toe pointing to the ceiling when doing exercise and
Do not raise leg off bed
.
Frequency patient specific.
· Short Arc Quad
Place rolled towel (6inches high) under knee of operate leg. Keep thigh resting on towel, and slowly straighten knee. Hold for 3 seconds. Slowly lower leg & Relax.
Frequency patient specific.
Advanced – Home exercise (if PT recommends)
http://www.eorthopod.com/sites/default/files/images/hip_artificial_precautions_ intro01.jpg
answer
http://picayune.uclick.com/comics/crwiz/2008/crwiz081203. gif
(Black & Hawks, 2009)
(National Institutes of Health, 2010)
(National Institutes of Health, 2010)
Variance in emotions (
high anxiety and fearfulness of operation
) related to
deficiency in knowledge
Goal:
Client will
have
reduced anxiety
in regards to the surgery
Interventions:
Nurse will…
- Ensure
client is fully educated
by health care team of pre, intra, and post-operative care
- Ensure
client is fully aware
of secondary complications to surgery ie. Nausea, constipation, sedation, lowered respiration, pain, decreased movement
-
Answer all questions
and
clarify any misconceptions
that the client may have
- If necessary,
refer client
to supporting members of health staff
for further clarification
As evidenced by...
- Patient expressing
doubts
of having surgery
- Restlessness
- Patient frequently
asking questions
Pain Managment (multi-modular approach)
Rest
Activity Balance
Nutrition and Weight Loss
Self-care Strategies

Variance in mobility (
impaired physical mobility
) related to
post-op hip precautions
Goal:
Client will

begin ambulating
with all the necessary aids
post-op day 1-2
Interventions:
Nurse will...
- Obtain assistive devices required for activity at beginning of shift
e.g. walkers, non-slip socks etc
- Educate/Remind client about risks of hip dislocation if precautions are not followed at beginnning of shift
*Bend your operated hip beyond a 90 degree angle
*Turn your operated leg inward
*Cross your operated leg
*Raise your knee higher than your hip while sitting
*Twist your torso inward

DO NOTs!
- Treat pain with PRN before activity, ensuring client is not overly sedated
-
Assess
whether the cause for impairment is physical (pain) or psychological (fear) and aid accordingly
- Monitor and record client’s ability to tolerate activty
*Pulse, blood pressure, dyspnea or shortness of breath, pallor, rate of respirations, dizziness, weakness, pain before, during and after exercise
- Teach client ROM exercises for client to strengthen limbs and joints while in bed
*Ankle pumps. do 10 sets 6x day
*Quad sets. Do 10 sets 4x day
*Short quad arc. Do 10sets 3xday
Variance in neurosensory (
pt. reporting left pelvic pain rating 8/10
) r/t
total hip replacement surgery
As evidenced by...
– Patient self-report
- Grimacing
- Frequent use of PRN medication
Goal:
Patient will

report decrease in pain rating to be 3-4/10
on the pain scale
Interventions:
Nurse will...
-
Assess
the surgical site and its surrounding areas at
beginning of shift, Q2H and PRN
- Reposition left hip to a ­­­­­comfortable position to increase blood flow, promote venous return and decrease pain
Q2H
- Ice the area
Q20min on & Q20min off
and
re-assess
- Mobilize patient once
QAM & QPM
to promote circulation and decrease pain
- Pharmacological:
multimodular approach
as ordered or PRN
Assessments
Neurovacular Checks
* Pain^
* Poikilothermia (coolness)
* Pallor (colour)
* Pulse (femoral, popliteal, posterior tibial, dorsalis pedis)
* Paresthesia^ (numbness is an early indicator of paralysis)
* Paralysis (loss of muscle function)
6 P's
^ early indicator of compartment syndrome
CWMS
* Colour
* Warmth
* Movement
* Sensation
Edema (note if it's pitting, what level?)

Kozier, B., Erb, G., Berman, A., Snyder, S., Bouchal, S., … Buck, M. (2010). Fundamentals of Canadian nursing (2nd Ed.). Toronto, Ontario: Person Canada.
Mayo Clinic (2011). Hip replacement. Retrieved from http://www.mayoclinic.com/health/hip-replacement/MY00235/DSECTION=why-its-done
National Institutes of Health (2010). Hip replacement – physical therapy. Retrieved from http://www.nlm.nih.gov/medlineplus/tutorials/hipreplacementphysicaltherapy/pt039105.pdf
Osteoarthritis Service Integration Society (n.d.). Before, during and after hip and knee replacement surgery: a patient’s Guide. Retrieved from http://vch.eduhealth.ca/PDFs/FB/FB.130.B393.pdf
Osteoporosis Canada (2013). Drug treatments. Retrieved from http://www.osteoporosis.ca/osteoporosis-and-you/drug-treatments/
Siopack, J.S. & Jergesen, H.E. (1995). Total hip replacement. West J Med, 162:243-249. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1022709/pdf/westjmed00055-0049.pdf
Werner, B., Brown, T. (2012) Instability after total hip arthroplasty. World Journal of Orthopedics, 3(8), 122-130.

(Black & Hawks, 2009)
(Black & Hawks, 2009)
(Black & Hawks, 2009)
(Black & Hawks, 2009)
(Black & Hawks, 2009)
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