Documentation on Total hip replacement

[AllAngelsRN]

Hi all,

I was wondering what would you document on a patient with total hip replacement in day one or 2 post op?

This is a new area to me and I am not sure what kind of assessment and documentation I need to do.

Thanks in advance for any help! :redpinkhe

[PAERRN20]

Here's some questions to help you get started:

What does the surgical incision look like? Any drainage, redness, well approximated edges? What is the patient's pain level? Range of motion? Pulses present? Bowel sounds present? Lung sounds? Has physical therapy been in to assess the patient? Is the patient able to advance their diet? Does the patient need teaching? Any discharge planning needs?

[AllAngelsRN]

Thank you Paerrn20 for your reply!

What I need to know are the specifics for otho! All the other kind of assessments I am aware of and have done them many times. However, what kind of specific assessments related only to Ortho and total/partial hip replacement?

[NeoPediRN]

We usually do q4h neurovascular assessments on the hip, document that the pt maintained hip precautions, that the abductor wedge is in place or that a pillow was utilized to keep the hip aligned when rolling. There isn't much in the way of ortho at all as you can't visualize the replacement and there's usually no external fixation. It's actually more neurovascular as the previous poster mentioned. I usually document CSM, if any edema is present, capillary refill of the toes, and pedal pulses of the affected extremity, as well as documentation on the incision and dressing.

[PAERRN20]

AllAngelsRN- Sorry I didn't see you had SICU experience!!

[missmiamoore]

Hi there..

At our institution we follow hip and knee care paths. On day 1-2, we would be assessing for pain and symptom control, hemodynamic status (hemoglobin and potassium levels), urine output, ambulation (should be 2 assists to sob or chair), bowel sounds and elimination pattern, increasing independence of ADLs, reinforce physio teaching regarding proper use of assistive devices, hip precautions (no crossing legs, flex more than 90 degres, etc), surgical dressing dry and intact. If you look on google under total knee/hip replacement care path, you will find many. Good luck!

[linhi]

Post op total hip you need to document things like dressing changes and wound, pain assessments and interventions, activity levels and tolerance to PT, fall assessments, skin assessments, don't forget bowel and bladder function, does the patient know total hip precautions, and do they have all the equipment they need for discharge. Otherwise just the normal nursing stuff post-op. It's so much fun!