Question about hip surgery and dressing change positioning

[Thunda]

I was on the floor this week in clinical, we had a Pt. who had a left total hip done 2 days prior. Apparently on this floor, the surgeon has historically done the first dressing change, the surgeon who did this one is new to the hospital and wanted the nurses to do the change. When asked what kind of dressing he wanted on it, the MD stated "I don't care so long as it's sterile" (duh).

The nurse I was following seemed a little unsure of what to put on it but made due. The Pt was ambulatory and able to move around in bed. When setting up for the dressing change the Nurse did not have the pt roll over onto the right side so she had complete access to the wound, the pt held onto the ortho bar over the bed rotating the buttock up enough so the nurse could get at the tape in contact with the bed, thus making it impossible to create a sterile field for the dressing change.

Am I being the annoying nursing student in having a problem with what seemed to be a non-sterile setting for this change. The patient did not have the abduction pillow available to put between the knees so they could roll completely onto the right side, thus keeping the wound away from the bedding.

-Is it dangerous for a Hip fx pt to not roll on the non-surgical side without that pillow between the knees/legs (could the hip pop out?)

Thanks for the response!

[Double-Helix, BSN, RN]

Yes, it's dangerous for a patient post-hip surgery to adduct the affected leg without a pillow supporting the leg. The operative leg should not cross the midline. The tendons and ligaments that support the hip joint are loose and weak from surgery. Doing so can cause the head of the femur to slip out of the hip socket.

Patients like this are on 'hip precautions' which you should learn about in school. It means they cannot roll to the side without something between the knees, they cannot cross their legs, they cannot sit with their hips lower than their knees (in a low chair, or even in a wheelchair with the feet elevated).

ETA: That being said, you don't need a special pillow. Any pillow(s) that are firm and supportive enough to prevent adduction of the hip will suffice. It's important to try to maintain a sterile field, and taking an extra minute to track down a couple of pillows is well worth the risk of infection.

[netglow, ASN, RN]

Also fresh post op with "tree" pillow you need two assist for that roll and support during that dressing change, yo must keep things in line and help prevent the patient from auto assisting with hips. Your RN needed to send you to get that pillow if needed before moving the patient. Also no big mystery on dressing change. You take a peek at what's there and go get more of same.

But, I'll note that she still needed orders...

[nurseprnRN, BSN, RN]

What, now nurses don't know how to look at a post-op wound and decide how to dress it without a specific physician order? Lordy. You must be, umm, pulling my leg.

I would expect that 24 hours post op the bulky pressure dressing from the OR (for traditional hip replacement) doesn't need to be replaced. A nonstick dressing covered with a clear breathable dressing should be just fine after cleaning the area with saline and patting dry. Since normal epithelium seals in about 18 hours, unless you see open wet areas, a clean dressing change is all you need. Otherwise, or if the surgeon wants it sterile (appropriate if there's a drain in place, e.g.), I would expect a RN to know how to apply a sterile dressing, and I would expect an experienced ortho nurse to know about proper positioning. If you can do it without turning the patient, do it. If you can't, turn him and position the leg properly. How hard is that?

[SaoirseRN]

Each of our orthopedic surgeons have specific protocols for their dressings, which we access on our intranet so we have their specifications, but the nurses are still expected to do the dressings and really, a standard hip dressing isn't difficult.

Pillow aside, if the wound was not touching the bedding, and nothing that touched the wound directly touched the bedding, how did she compromise the wound?

[Aurora77]

The positioning sounds awkward. Get a pillow and have the patient roll over just enough so that you can get to the dressing. Depending on how long it's been from the surgery you may not need to do a sterile dressing change. Maybe the nurse was new and that's why she didn't know what to put on there?