6 Total Joint (Knee, Hip) Replacement Nursing Care Plans

Your post-op total joint patient needs four things from you: pain controlled, the incision clean and infection-free, the prosthesis protected from dislocation, and early mobilization to get the joint working again. The big threats are surgical site infection, DVT and PE, and prosthesis slippage. Watch for them while you push mobility.

What are Joint Replacement Surgeries?

Joint replacement (arthroplasty) is indicated for irreversibly damaged joints with loss of function and unrelenting pain, selected fractures, joint instability, and congenital hip disorders. It can be done on any joint except the spine, and hip and knee replacements are the most common. The prosthesis may be metallic, polyethylene, or a combination, fixed with methylmethacrylate cement or as a porous coated implant that encourages bony ingrowth.

Nursing Care Plans and Management

Your goals are to prevent complications, promote mobility, control pain, and teach the patient about the diagnosis, prognosis, and treatment.

Nursing Problem Priorities

1. Manage pain and provide adequate relief.
2. Promote wound healing and prevent infection.
3. Ensure safety and prevent falls and immobility complications.
4. Facilitate early mobilization and rehabilitation.
5. Monitor for DVT and PE and apply preventive measures.
6. Educate on self-care, medications, activity restrictions, and warning signs.

Nursing Assessment

Assess for the following subjective and objective data:

• Pain and discomfort
• Swelling
• Stiffness
• Limited ROM, decreased muscle strength and control
• Bruising and discoloration
• Muscle weakness
• Numbness and tingling around the surgical area
• Difficulty with ADLs

Assess for related factors:

• Inadequate primary defenses (broken skin, exposed joint)
• Inadequate secondary defenses or immunosuppression (long-term corticosteroid use, cancer)
• Invasive procedures, surgical manipulation, implantation of a foreign body
• Decreased mobility
• Pain and musculoskeletal impairment
• Surgery and restrictive therapies
• Mechanical compression (dressing, brace, cast), vascular obstruction, immobilization
• Injuring agents: muscle spasms, the surgical procedure, preexisting chronic joint disease, advanced age, anxiety

Nursing Diagnosis

After a thorough assessment, you form nursing diagnoses that reflect the patient's actual and high-risk problems and guide focused interventions.

Nursing Goals

The client will:

• Achieve timely wound healing, free of purulent drainage or erythema, and stay afebrile.
• Maintain a position of function with no contracture.
• Show increased strength and function of the affected joints and limbs and participate in ADLs and rehab.
• Maintain sensation and movement within normal limits for the situation.
• Demonstrate adequate perfusion: palpable pulses, brisk capillary refill, warm dry skin, normal color.
• Report relief or control of pain.
• Appear relaxed and rest or sleep appropriately.

Nursing Interventions and Actions

1. Preventing Infection Risk and Promoting Infection Control

A prosthetic joint infection can mean removing the prosthesis, so infection control is non-negotiable: aseptic technique, prophylactic antibiotics, surgical site prep, then regular wound assessment, hand hygiene, early mobility, and careful drain and dressing management.

Assess incision color, temperature, and integrity, and note erythema, inflammation, or loss of wound approximation. This tracks healing and flags early infection.

Investigate increased incisional pain and any change in its character. Deep, dull, aching pain in the operative area may signal a developing joint infection.

Monitor temperature and note chills. Early post-op fever is common, but elevation 5 or more days postoperatively or the presence of chills usually needs intervention to head off sepsis, osteomyelitis, tissue necrosis, and prosthetic failure.

Promote good handwashing by staff and patients. It is the single most effective way to prevent infection.

Use strict aseptic technique to reinforce or change dressings and handle drains, and tell the patient not to touch or scratch the incision. Contamination risks a wound infection that could cost the prosthesis.

Maintain patency of drainage devices (Hemovac, Jackson-Pratt) and note drainage characteristics. Draining the joint space prevents blood and secretions from pooling as a bacterial medium. Purulent, odorous drainage signals infection, and continuous incisional drainage may reflect a developing skin tract.

Encourage fluids and a high-protein diet with roughage to support perfusion and supply the nutrients tissue healing needs.

Maintain reverse or protective isolation if appropriate, especially for an elderly, immunosuppressed, or diabetic patient.

Administer antibiotics as indicated. They are used prophylactically in the OR and during the first 24 hr to prevent infection.

2. Improving Physical Mobility and Peripheral Tissue Perfusion

Early mobility restores joint function and prevents stiffness and weakness, while adequate perfusion supports wound healing and guards against pressure injury and DVT. You drive both: get the patient moving, assess circulation, and apply compression or elevation as ordered.

Inspect skin and watch for reddened areas. Keep linens dry and wrinkle-free and massage bony prominences routinely. Protect the operative heel by elevating the whole leg on a pillow and placing the heel on a water glove if the patient reports burning. This prevents skin breakdown.

Investigate a sudden increase in pain, shortening of the limb, or changes in skin color, temperature, and sensation. These suggest prosthesis slippage and need medical evaluation.

Keep the affected joint in the prescribed position and the body in alignment in bed to stabilize the prosthesis and reduce injury while the patient recovers from anesthesia.

Medicate before procedures and activities. Muscle relaxants, narcotics, and analgesics decrease pain and spasm so the patient can participate in therapy.

Turn the patient onto the unoperated side with enough staff, keeping the operated extremity in alignment and supported with pillows or wedges. This prevents hip dislocation and prolonged tissue pressure.

Demonstrate and assist with transfer techniques and mobility aids such as a trapeze and walker. Proper technique supports independence and prevents shearing abrasions and falls.

Determine upper body strength and involve the patient in the exercise program. Lower-extremity replacement means more reliance on the arms for transfers and ambulation devices.

Perform range-of-motion exercises to unaffected joints. Patients with degenerative joint disease lose joint function fast during restricted activity.

Promote a rehab exercise program. For a total hip: quadriceps and gluteal setting, isometrics, leg lifts, dorsiflexion, and plantar flexion of the foot. For a total knee: quadriceps setting, gluteal contraction, flexion and extension, and isometrics. These strengthen muscle, stimulate circulation, and prevent decubitus. Active joint use may hurt but will not injure the joint, and continuous passive motion (CPM) may be started on the knee postoperatively. Other joints get individually designed exercises for the replaced joint.

Observe the limitations for the specific joint: avoid marked flexion or rotation of the hip and flexion or hyperextension of the leg, follow weight-bearing restrictions, and use a knee immobilizer as indicated. Avoid joint stress during the stabilization period to prevent dislocation.

Encourage participation in ADLs to support a sense of control and independence.

Give positive reinforcement for effort to keep the patient engaged in therapy.

Palpate pulses on both sides, evaluate capillary refill, skin color, and temperature, and compare with the non-operated limb. Diminished or absent pulses, delayed refill, pallor, cyanosis, and coldness reflect reduced perfusion, and comparison tells you whether the problem is local or generalized.

Assess motion and sensation in the operated extremity. Increasing pain, numbness, tingling, or inability to flex the foot suggests nerve injury, compromised circulation, or dislocation, and needs immediate intervention.

Test the peroneal nerve by pinch or pinprick in the dorsal web between the first and second toe, and check the ability to dorsiflex the toes. The position and length of the peroneal nerve raise its risk of direct injury or compression from edema or hematoma.

Monitor and record vital signs. Tachycardia and falling BP may reflect hypovolemia or blood loss, or anaphylaxis from absorption of methylmethacrylate into the circulation. This is less common now that porous prosthetics encourage bony ingrowth instead of relying on adhesives.

Monitor the amount and character of dressing and suction drainage, and note swelling in the operative area. This may indicate excessive bleeding and hematoma that can compromise neurovascular status. Drainage after hip replacement may reach 1000 ml in the early postoperative period, affecting circulating volume.

Evaluate for calf tenderness, a positive Homan's sign, and inflammation. Catching a thrombus early may prevent embolus formation.

Watch for continued bleeding, oozing from puncture sites and mucous membranes, or ecchymosis after minimal trauma. Depressed clotting or anticoagulant sensitivity can cause bleeding that affects RBC levels and circulating volume.

Watch for restlessness, confusion, sudden chest pain, dyspnea, tachycardia, fever, and petechiae. Fat emboli can occur, usually in the first 72 hr postoperatively, from surgical trauma and bone manipulation during implantation.

Monitor laboratory studies. See Laboratory and Diagnostic Procedures.

Make sure stabilizing devices (abduction pillow, splint) are positioned correctly and not pressing on skin or tissue, and avoid a pillow or knee gatch under the knees, which can compress nerves and circulation.

Administer anticoagulants and antiplatelet agents as indicated: warfarin sodium (Coumadin), heparin, aspirin, and low-molecular-weight heparin such as enoxaparin (Lovenox), to reduce the risk of thrombophlebitis and pulmonary emboli.

Apply cold or heat as indicated. Ice packs initially limit edema and hematoma; heat later enhances circulation to resolve tissue edema.

Maintain intermittent compression stockings or foot pumps when used to promote venous return and prevent stasis.

Prepare for surgical procedures as indicated, such as hematoma evacuation or prosthesis revision, to correct compromised circulation.

3. Managing Pain and Discomfort

Pain control here is multimodal: analgesics such as opioids or NSAIDs combined with ice or heat, limb elevation, relaxation, and physical therapy.

Assess pain by intensity (0 to 10 scale), duration, and location. This is the basis for judging whether interventions work.

Investigate sudden severe joint pain with muscle spasm and changes in joint mobility, or sudden severe chest pain with dyspnea and restlessness. These can signal prosthesis dislocation or pulmonary embolus and need prompt intervention.

Keep the operated extremity in proper position to reduce spasm and tension on the new prosthesis.

Provide comfort measures (frequent repositioning, back rub), diversion, and stress management such as progressive relaxation, guided imagery, visualization, and meditation, plus Therapeutic Touch as appropriate. These reduce tension and support coping with pain that can persist for a while.

Medicate on a regular schedule and before activities to improve comfort and participation.

Administer narcotics, analgesics, and muscle relaxants as needed, and instruct on and monitor PCA or epidural use. Narcotic infusion, including epidural, may run during the first 24 to 48 hr, with oral analgesics added as the patient progresses. Ketorolac (Toradol) and other NSAIDs are contraindicated while the patient is on enoxaparin (Lovenox).

Apply ice packs as indicated to promote vasoconstriction, reduce bleeding and edema, and lessen discomfort.

Initiate and maintain extremity mobilization: ambulation, physical therapy, exercise, or a CPM device. This increases circulation, minimizes stiffness, and relieves disuse spasms.

4. Initiating Health Teachings and Patient Education

Teach wound care, keeping the incision clean and dry, recognizing infection and complications, activity restrictions, postoperative exercises, and the rehab program that protects joint function.

Identify signs that require medical evaluation: fever and chills, incisional inflammation, unusual wound drainage, calf or upper-thigh pain, or strep throat or dental infection. Bacterial infections need prompt treatment to prevent osteomyelitis and prosthesis failure, which can occur even years later.

Review the disease process, the procedure, and future expectations so the patient can make informed choices.

Encourage alternating rest with activity to conserve energy for healing and prevent fatigue that raises fall and injury risk.

Stress continuing the prescribed exercise and rehab program within tolerance: crutch or cane walking, weight-bearing exercises, stationary bicycling, or swimming. Most patients follow formal rehab, home care, or extended-care therapy. Muscle aching signals too much weight-bearing or activity and a need to cut back.

Instruct on home use of the CPM exercise program, which may continue after discharge. CPM is used in only about 50% of patients at this time.

Review activity limits by joint. For hip or knee, avoid sitting for long periods or in a low chair, toilet seat, or recliner, and avoid jogging, jumping, excessive bending, lifting, twisting, or crossing the legs, to prevent undue stress on the implant. Long-term restrictions depend on the individual and the physician's protocol.

Discuss home safety (removing scatter rugs and unnecessary furniture) and assistive devices (handrails in the tub or toilet, raised toilet seat, cane for long walks) to reduce falls and joint stress.

Review and have the patient or caregiver demonstrate incision and wound care to promote safe self-care.

Review the drug regimen, including anticoagulants and antibiotics for invasive procedures. Prophylaxis may run for a prolonged period after discharge, since procedures causing bacteremia can lead to osteomyelitis and prosthesis failure.

Teach bleeding precautions: a soft toothbrush, electric razor, and avoiding trauma or forceful nose blowing, to reduce therapy-induced bleeding.

Encourage a balanced diet with roughage and adequate fluids to support healing and bowel and bladder function during reduced activity.

5. Administering Medications and Pharmacologic Support

Anticoagulants such as low-molecular-weight heparin (LMWH) or warfarin prevent blood clots and reduce the risk of DVT and PE.

Antibiotics are given prophylactically before and after surgery, IV or orally, to reduce surgical site infections.

Analgesics include opioids (morphine, oxycodone) and non-opioids (acetaminophen, NSAIDs such as ibuprofen) to manage postoperative pain.

6. Monitoring Laboratory and Diagnostic Procedures

Lab studies for hip replacement include hematocrit and coagulation studies, which guide postoperative management and clotting-related interventions.

Hematocrit is usually drawn 24 to 48 hr postoperatively to evaluate blood loss, which can be large given the high vascularity of the hip surgical site. CBC monitoring or a repeat count may also be indicated for patients on enoxaparin (Lovenox).

Coagulation studies evaluate clotting alterations and the effect of anticoagulant or antiplatelet agents. They are not necessary for patients on enoxaparin (Lovenox), though stool occult blood tests may be indicated.