Operating Department Practice for Hip Replacement Surgery - Essay Example

? Operating Department Practice for Hip Replacement Surgery Operating department practitioners or ODPs are important part of multidisciplinary team involving surgery of a patient. They are those health care providers who are mainly involved in the planning and delivery of the perioperative care of patients. In the anesthetic stage, ODPs prepare the drugs and equipment needed for administration of anesthesia. This includes checking and preparing the anesthetic machines, intravenous fluids and drugs and airway instruments like laryngeal masks and endotracheal tubes. ODPs also communicate about shifting the patient in the anesthetic room and verifiy pre-operative check list about medical illnesses and allergies. They assist the anesthesist with anesthesia and stay through the surgery to maintain anesthesia. In the surgical stage, ODPs assist the surgeon during the surgery and hence scrub themselves and wear sterile gown and gloves. They are accountable for all the instruments and swabs used for the surgery. They may also act as circulation nurse to hand over extra materials to the sterilised personnel. In the recovery stage, the ODPs check the patient, manage airway, monitor vital signs, administer prescribed drugs, help patient recover from anesthesia and address to the needs of the patient until discharge to ward. Thus, ODPs have a major role to play in the surgical assessment, procedure and recovery of the patient (Nettina, 2006). In this essay, the role of ODPs in the management of a hip replacement client will be discussed through critical evaluation of literature. 65 year old Maria is a known patient of osteoarthritis of the right hip joint (name changed for confidentiality reasons). In view of distressing pain and decreased mobility because of the pain, she was posted for total hip replacement surgery. Hip replacement is a common procedure in orthopedic operation rooms. It is also known as arthroplasty. It can be total arthroplasty or hemiarthroplasty. In the former procedure, replacement of both the femoral and acetabular articular surfaces is done. This may involve either replacement of both the femoral head and neck or replacement of only the surface of the femoral head. The former is known as conventional total hip arthroplasty and the latter is known as resurfacing total hip arthroplasty. In both the procedures, replacement of the acetabulum is done. In hemiarthroplasty, replacement of the femoral head's articular surface is done without any alteration of the articular surface of the acetabulum. Replacement of the hip joint can be done with several materials including ceramic, metal and polyethylene. Fixation of the arthroplasty can be done with materials like polymethylmethacrylate cement and screw fixation (Jacobson, 2009). Osteoarthritis is the most common indication for total hip arthroplasty in which the articular surfaces of both the acetabulum and femur is affected. On the other hand, hemiarthroplasty is done in avascular necrosis of the femoral head and displaced fracture of the femoral neck which is at increased risk of developing avascular necrosis (Jacobson, 2009). Hip joint is a ball and socket joint. The ball is formed by the head of the femur and the socket by the acetabulum, a part of the pelvis. The ends of both these bones are covered by cartilages to facilitate smooth movement. The cartilage gets damaged by arthritis which makes the joints painful and stiff (Bromhead, 2007). The components of arthroplasty for acetabulum are ceramic, cobalt-chromium metal and polyethylene. Femoral components include ceramic, metal or metal femoral stem (Jacobson, 2009). There is some evidence that use of larger femoral head component with metal-on-metal total hip arthroplasty has decreased risk of dislocation (Jacobson, 2009). The most commonly used combination for total hip arthroplasty is cobalt-chromium alloy metal femoral head that is articulated with a polythelene cup. The most common complication associated with this is wear of polyethylene followed by inflammation and osteolysis (Macfarlane et al, 2009). The main purpose of replacement of the hip joint is to cause relief of distressing pain and to improve the mobility of the patient (Bromhead, 2007). Perioperative nursing is a very important aspect of hip replacement surgery. Planned perioperative nursing is crucial to promote comfort, enhance recovery, establish rehabilitation and prevent complications. According to Van Herck et al (2010), "Joint arthroplasty clinical pathways address pre-admission education, pre-admission exercises, pre-admission assessment and testing, admission and surgical procedure, postoperative rehabilitation, minimal manipulation, symptoms management, thrombosis prophylaxis, discharge management, primary caregiver involvement, home-based physiotherapy and continuous follow-up." These pathways improve the process and also the outcomes related to finance. However, it is unclear whether these pathways have positive outcomes on team and also services. Preoperative nursing mainly involves evaluation of the patient, preparation of the patient for surgery and education of the patient (Johansson, 2010). During evaluation of the patient, the goals of the surgery must be established. For example, some patients may want to regain employment, while others may want to get involved in sports or other activities. Establishing the goal will ascertain as to what extent the surgery needs to be performed. Other aspects of evaluation are investigations like complete blood picture, blood urea, serum creatinine and electrolytes, erythrocyte sedimentation rate, clotting factors, chest X-ray and electrocardiogram. Patient should be educated about pain management, tubes and drains if any, use of bedpan, use of ankle-pumps for prevention of deep vein thrombosis and methods to eat in lying down position. Teaching pain coping abilities and providing pain management information in preoperative period helps good management of pain in the post-operative period. Nurses must educate the patient and provide proper information because proper education can help the patient maintain optimum independence and good quality of life. Lamontagne et al (2003) conducted a randomised controlled trial to evaluate the effects of patient education on postoperative pain and found that effective coping instructions and provision of concrete-objective information causes decrease in postoperative pain. Patients with arthroplasty will require some blood transfusion during surgery. Since most of the times, arthroplasty is a planned procedure atleast weeks ahead, autologous blood transfusion can be planned and the patient can donate 1unit of blood every week for 2 to 3 weeks to store blood. Other aspects which need importance in the preoperative period are preparation for bone grafting, HIV and hepatitis B testing, keeping post-op equipment needs like commode and walker ready, insurance issues, remodelling of home environment, discharge planning and social services management after reaching home. Patients undergoing hip replacement surgery are mainly elderly patients and are likely to have associated problems like ischemic heart disease, hypertension, renal impairment and chronic obstructive pulmonary disease. Thus, identification of risk factors is essential to ascertain whether the patient is fit for surgery. It is often difficult to assess the cardiopulmonary reserve of these patients because of the limitation of exercise intolerance by hip disease. The patient may be taking certain drugs like clopidogrel, warfarin and aspirin which have implications for administering regional anesthesia. Enquiry must be made about antibiotic allergies. Other important factors which influence the anesthesia choice must be taken into consideration. Some such factors include weight of the patient, shape of the back, choice of the patient and whether the patient will tolerate being awake (Bromhead, 2007). Body mass index is an important preoperative assessment factor, because; increased index can lead to joint stress (Bromhead, 2007). The surgical team will consist of the patient, surgeons, anesthesiologist, circulating nurse, scrub nurse and scrub technicians. The circulating nurse will coordinate various activities of the surgical team and will evaluate and monitor the working condition of the operating room and equipment. Other responsibilities of circulating nurse are verification of consent, monitoring of aseptic technique and documentation of events in the operating room. Scrub nurse is one who is specially trained to work with surgeons in the operating room (Wisegeek, 2009). The responsibilities of scrub nurse are setting up of sterile tables, preparation of sutures, equipment and ligatures, anticipation and keeping ready of equipment and items, counting of needles, instruments and sponges before closure and labeling and transfer of specimens. Intraoperative nursing during surgery is a critical function of perioperative nurses. Perioperative nurses function to enhance comfort of the patient, assist surgeons in the surgery and monitor the patient to prevent complications. Perioperative nurses also coordinate various aspects of the surgery like taking hand-over from the ward, arranging the equipment and drugs required for the patient, coordinating with the laboratory personnel and blood bank and such other issues. Other responsibilities include insertion of urinary catheter, securing of intravenous line and prophylactic administration of antibiotics. Once the patient is shifted to the operating room, the patient must be placed on the operating positioning frame which is sufficiently positioned and padded to prevent nerve impingement and pressure. Padding can be done with pillows, foam, blankets and arm boards. Positioning of the patient is very important to ensure optimal exposures, safety, and also to prevent certain complications like neuropathies, pressure injuries and cardiovascular and respiratory compromises. Transferring the patient to operating table and positioning the procedure must be dictated by standard protocols of the hospital. Total hip arthroplasty can be done under regional, general or epidural anesthesia and often, a combination of these is used (Neville et al, 2011). There is no difference in mortality between the techniques. However, there is some evidence that regional anesthesia has significant advantages over general anesthesia (Bromhead, 2007). The patient was given regional anesthesia. There is evidence that blockade of the central neuraxial system provides not only excellent intraoperative anesthesia, but also prolongs analgesia in the post-operative period. However, in peripheral nerve blockade, the operative limb gets targeted analgesia and at the same time avoids the undesirable side effects of central neuraxial blockade. Continuous peripheral nerve blockade provides longer postoperative analgesia of the operative limb. Other advantages of regional anesthesia in hip replacement surgery are low complication rate, improved rehabilitation and decreased length of stay in the hospital. Disadvantages include inherent block failure rate, operating theater delay, requirement of skilled personnel, ultra sound expense equipment, misconceptions about the procedure and finally perceived risk of increased liability (Macfarlane et al, 2009). According to a systematic review by Macfarlane et al (2009), regional anesthesia reduced morphine consumption, postoperative pain and nausea and vomiting when compared to systemic analgesia; however, no benefit was not noted in terms of reduction of hospital stay and rehabilitation. Other advantages of regional anesthesia are decreased blood loss during surgery, thus decreasing the need for blood transfusion, decreasing operative site bleeding, thus improving cement bonding, decreased incidence of deep vein thrombosis and pulmonary embolism and lower cost (Bromhead, 2007). General anesthesia is beneficial to those who cannot lie flat. Since arthroplasty may take several hours to be completed and the risk of postoperative infection is high, high standards must be maintained for sterility. Prophylactic antibiotics must be given and accurate gauze count must be maintained. During the course of surgery, the patient must be monitored for blood loss and fluid requirements and blood and fluids must be provided appropriately. Hypotension must be vigilantly prevented in arthroplasty patients. Other aspects to be monitored during surgery are vital signs, urine output and drain output. Cell saver may be employed to replace lost blood. Other intraoperative complications which need to be watched are hypoventilation, cardiac dysarrhythmia, malignant hyperthermia and hypothermia (Nettina, 2006). The main complications of hip arthroplasty are dislocation, fracture of the implant, mechanical loosening, heterotopic bone formation, infection and particle disease (Jacobson, 2009). Because of the side effects, the patient requires antibiotics for a longer duration of time and the implants may need to be removed. Other complications of arthroplasty are cement reactions which can lead to bone cement implantation syndrome, fat embolism and direct toxic effects of cement (Bromhead, 2007). The main acute needs of the patient in the post operative period are pain relief and mobility. Postoperative nursing is the crux of management of arthroplasty patient. Following joint arthroplasty, care of the patient can become complex because of the physiological changes that can occur. Also, because the patient has artificial hip, he/she has to get used to it. Critical thinking is very essential for post-operative assessment of the patient. The assessment must include vital signs, level of consiousness, pain, range of mobility and comfort level. In the immediate postoperative period, frequent monitoring of vital signs is essential to detect hypotension and tachycardia. Measures like ankle pumps and elastic stockings must be taken to prevent deep vein thrombosis. The patients must be turned frequently to prevent bedsores and also to aid in pulmonary hygiene. The biggest concern for the patient in the postoperative period is pain. Post operative pain of hip arthroplasty is manageable. This symptom must be monitored frequently on a 0-10 scale. Non-steroidal anti-inflammatory drugs and patient-controlled analgesia pump may be employed to relieve pain (Smith-Miller et al, 2009). In the initial phase, respiratory depression needs to be monitored with the help of pulse oximetry. The WHO's Pain Relief Ladder is a useful guide to prescribe medications for pain (WHO, 2009) (Refer Fig.2). This ladder consists of 3 steps of pain from below to up. The lowest is the step of mild pain. Mild pain is that pain which is self-limited and may or may not require treatment. The next step is the moderate pain. This pain is worse than mild pain and it affects functions of the individual. The presence of pain cannot be ignored. This pain goes away with treatment and seldom reappears. The uppermost step is that of severe pain. This pain interferes with most of the daily living activities. The individual may need treatment for many weeks, months or even years. According to this guide, the first drugs which must be recommended for pain are non-opioids like paracetamol and non-steroidal anti-inflammatory drugs or NSAIDs like aspirin and ibuprofen (Alkhenizan et al, 2004). Then if necessary, the treatment must be stepped up to mild opioids like codeine and then to strong opioids like morphine, hydrocodone, oxycodone, methadone, hydromorphone and fentanyl until the patient is relieved of pain. Drugs given to relieve pain must be given every 3-6 hours, round the clock. According to the WHO, the 'ladder approach' treatment allows a patient to get the right drug with the right dose at the right time in the most effective manner and at the least possible cost (WHO, 2009). This ladder has been declared useful even by SIGN (SIGN, 2008) . Other aspects which need to be taken care in the postoperative period are stress ulcers, nausea, sleep, constipation, itching, relaxation, physical therapy, brace application, logrolling and ambulation. The range of motion must be determined by asking the patient about joint stiffness, limited movement, swelling, pain and unequal movement. The patient may be advised rest, use of hip supports and walking aides, physical therapy and appropriate rehabilitative exercises. Patients with tolerable pain must be asked to remain as active as possible. Comfortable motion of hip is regained in about 6 weeks time and strength training can be initiated since then. Since then, low impact exercises like walking and swimming can be performed. Thus, ODPs play a major role in perioperative nursing of a patient posted for hip arthroplasty. References Bromhead, H. (2007). Total Hip Replacement. Retrieved on 7th March, 2010 from http://www.frca.co.uk/SectionContents.aspx?sectionid=177 Jacobson, J.A. (2009). Hip replacement. Emedicine from WebMD. Retrieved on 7th March, 2010 from C:\Users\Ravulapati\Documents\hip replacement\398669-overview.htm Johansson, K., Katajisto, J., and Salantera, S. (2010). Pre-admission education in surgical rheumatology nursing: towards greater patient empowerment. J Clin Nurs., (21-22), 2980-8. LaMontagne, L., Hepworth, J. T., Salisbury, M.H., Cohen, F. (2003). Effects of Coping Instruction in Reducing Young Adolescents' Pain after Major Spinal Surgery. Orthopaedic Nursing, 22(6), 398- 403. Macfarlane, A.J.R., Prasad, G.A., Chan, V.W.S and Brull, R. (2009). Does Regional Anaesthesia Improve Outcome after Total Hip Arthroplasty? A Systematic Review. Br. J. Anaesth., 103 (3), 335-345. Munro, C.A. (2009). The perioperative nurse's role in table-enhanced anterior total hip arthroplasty. AORN J., 90(1), 53-68. Nettina. S.M. (2006). Manual of Nursing Practice. 8th edition. London: Lippincott Williams and Wilkins. Neville, D.A., Dvorkin, M., Chittenden, M.E., and Fromm, L. (2011). The new era of total hip replacement surgery. OR Nurse 2011, 2(10), 18- 25. Smith-Miller, C.A., Harlos, L., Roszell, S.S., Bechtel, G.A. (2009). A comparison of patient pain responses and medication regimens after hip/knee replacement. Orthop Nurs., 28(5), 242-9. Scottish Intercollegiate Guidelines network (SIGN). (2008). Control of pain in adults with cancer. Retrieved on 7th March, 2010 from http://www.sign.ac.uk/pdf/SIGN106.pdf Van Herck, P., Vanhaecht, K., Deneckere, S., et al. (2010). Key interventions and outcomes in joint arthroplasty clinical pathways: a systematic review. J Eval Clin Pract.,16(1), 39-49. WHO. (2009). WHO's pain ladder. Retrieved on 7th March, 2010 from http://www.who.int/cancer/palliative/painladder/en/print.html Read More