Joint replacements are indicated for irreversibly damaged joints with loss of function and

unremitting pain, selected fractures, joint instability and congenital hip disorders. Total Joint
Replacement can be performed on any joint except the spine. Hip and knee replacements are the
most common procedures. The prosthesis may be metallic or polyethylene (or a combination)
implanted with a methylmethacrylate cement, or it may be a porous, coated implant that encourages
bony ingrowth.
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Nursing Care Plans

Here are 5 nursing care plans for patients undergoing Total Joint Replacements.
Diagnostic Studies

X-rays: May reveal destruction of articular cartilage, bony demineralization, fractures, softtissue swelling; narrowing of joint space, joint subluxations or deformity.

Bone scan, CT/MRI: Determine extent of degeneration and rule out malignancy.

Nursing Priorities
1.

Prevent complications.

2.

Promote optimal mobility.

3.

Alleviate pain.

4.

Provide information about diagnosis, prognosis, and treatment needs.

Discharge Goals
1.

Complications prevented/minimized.

2.

Mobility increased.

3.

Pain relieved/controlled.

4.

Diagnosis, prognosis, and therapeutic regimen understood.

5.

Plan in place to meet needs after discharge.

1. Risk for Infection

Risk factors may include

Inadequate primary defenses (broken skin, exposure of joint)

Inadequate secondary defenses/immunosuppression (long-term corticosteroid use, cancer)

Invasive procedures; surgical manipulation; implantation of foreign body

Decreased mobility

Possibly evidenced by

Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as the problem
has not occurred and nursing interventions are directed at prevention.

Desired Outcomes

Achieve timely wound healing, be free of purulent drainage or erythema, and be afebrile.

Nursing Interventions

Rationale

Promote good hand washing by staff and

Hand washing is the single most effective way

patient.

to prevent infection.

Use strict aseptic or clean techniques as

Prevents contamination and risk of wound

indicated to reinforce or change dressings and

infection, which could require removal of

when handling drains. Instruct patient not to

prosthesis.

touch or scratch incision.

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Maintain patency of drainage devices

Reduces risk of infection by preventing

(Hemovac, Jackson Pratt) when present. Note

accumulation of blood and secretions in the

characteristics of wound drainage.

joint space (medium for bacterial growth).

Purulent, nonserous, odorous drainage is
indicative of infection, and continuous drainage
from incision may reflect developing skin tract,
which can potentiate infectious process.

Assess skin/incision color, temperature, and

Provides information about status of healing

integrity; note presence of erythema or

process and alerts staff to early signs of

inflammation, loss of wound approximation.

infection.

Investigate reports of increased incisional pain,

Deep, dull, aching pain in operative area may

changes in characteristics of pain.

indicate developing infection in joint. Note:

Infection is devastating, because joint cannot
be saved once infection sets in, and prosthetic
loss will occur.

Monitor temperature. Note presence of chills.

Although temperature elevations are common

in early postoperative phase, elevations
occurring 5 or more days postoperatively
and/or presence of chills usually requires
intervention to prevent more serious
complications, e.g., sepsis, osteomyelitis,
tissue necrosis, and prosthetic failure.

Encourage fluid intake, high-protein diet with

Maintains fluid and nutritional balance to

roughage.

support tissue perfusion and provide nutrients

necessary for cellular regeneration and tissue

Nursing Interventions

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healing.
Maintain reverse or protective isolation, if

May be done initially to reduce contact with

appropriate.

sources of possible infection, especially in

elderly, immunosuppressed, or diabetic
patient.

Administer antibiotics as indicated.

Used prophylactically in the operating room

and first 24 hr to prevent infection.

2. Impaired Physical Mobility

May be related to

Pain and discomfort, musculoskeletal impairment

Surgery/restrictive therapies

Possibly evidenced by

Reluctance to attempt movement, difficulty purposefully moving within the physical

environment

Reports of pain/discomfort on movement

Limited ROM; decreased muscle strength/control

Desired Outcomes

Maintain position of function, as evidenced by absence of contracture.

Display increased strength and function of affected joint and limb. Participate in
ADLs/rehabilitation program.

Nursing Interventions

Rationale

Maintain affected joint in prescribed position

Provides for stabilization of prosthesis and

and body in alignment when in bed.

reduces risk of injury during recovery from

effects of anesthesia.

Medicate before procedures and activities.

Muscle relaxants, narcotics, analgesics

decrease pain, reduce muscle tension and/or
spasm, and facilitate participation in therapy.

Turn on unoperated side using adequate

Prevents dislocation of hip prosthesis and

number of personnel and maintaining operated

prolonged skin or tissue pressure, reducing

extremity in prescribed alignment. Support

risk of tissue ischemia and/or breakdown.

position with pillows and/or wedges.

Demonstrate and assist with transfer

Facilitates self-care and patients

techniques and use of mobility aids, e.g.,

independence. Proper transfer techniques

trapeze, walker.

prevent shearing abrasions of skin and falls.

Determine upper body strength as appropriate.

Replacement of lower extremity joint requires

Involve in exercise program.

increased use of upper extremities for transfer

activities and use of ambulation devices.

Inspect skin, observe for reddened areas.

Prevents skin breakdown and eases irritation.

Keep linens dry and wrinkle-free. Massage

skin and bony prominences routinely. Protect
operative heel, elevating whole length of leg
with pillow and placing heel on water glove if
burning sensation reported.
Perform and assist with range of motion

Patient with degenerative joint disease can

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exercises to unaffected joints.

quickly lose joint function during periods of

restricted activity.

Promote participation in rehabilitative exercise program:

Total hip: Quadriceps and gluteal muscle

Strengthens muscle groups, increasing muscle

setting, isometrics, leg lifts, dorsiflexion,

tone and mass; stimulates circulation; prevents

plantar flexion of the foot; Total knee:

decubitus. Active use of the joint may be

Quadriceps setting, gluteal contraction,

painful but will not injure the joint. Continuous

flexion/extension exercises, isometrics;

passive motion (CPM) exercise may be

initiated on the knee joint postoperatively.

Other joints: Exercises are individually

Meets specific needs of the replaced joint.

designed toes and knee movements; arm and

unaffected fingers (for finger-joint
replacement), exercise fingers and/or wrist of
affected arm (for shoulder replacement).
Observe appropriate limitations based on

Joint stress is to be avoided at all times during

specific joint; avoid marked flexion and/or

stabilization period to prevent dislocation of

rotation of hip and flexion or hyperextension of

new prosthesis.

leg; adhere to weight-bearing restrictions; wear

knee immobilizer as indicated.
Investigate sudden increase in pain and

Indicative of slippage of prosthesis, requiring

shortening of limb, as well as changes in skin

medical evaluation and/or intervention.

color, temperature, and sensation.

Encourage participation in ADLs.

Enhances self-esteem; promotes sense of

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control and independence.

Provide positive reinforcement for efforts.

Promotes a positive attitude and encourages

involvement in therapy.

3. Risk for Peripheral Neurovascular Dysfunction

Risk factors may include

Orthopedic surgery; mechanical compression (e.g., dressing, brace, cast), vascular

obstruction, immobilization

Possibly evidenced by

Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as the problem
has not occurred and nursing interventions are directed at prevention.

Desired Outcomes

Maintain function as evidenced by sensation, movement within normal limits (WNL) for
individual situation.

Demonstrate adequate tissue perfusion as evidenced by palpable pulses, brisk capillary

refill, skin warm/dry, and normal color.

Nursing Interventions

Rationale

Palpate pulses on both sides. Evaluate

Diminished or absent pulses, delayed capillary

capillary refill and skin color and temperature.

refill time, pallor, blanching, cyanosis, and

Compare with non-operated limb.

coldness of skin reflect diminished circulation

or perfusion. Comparison with unoperated limb
provides clues as to whether neurovascular

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problem is localized or generalized.

Assess motion and sensation of operated

Increasing pain, numbness or tingling, inability

extremity.

to perform expected movements (flex foot)

suggest nerve injury, compromised circulation,
or dislocation of prosthesis, requiring
immediate intervention.

Test sensation of peroneal nerve by pinch or

Position and length of peroneal nerve increase

pinprick in the dorsal web between first and

risk of direct injury or compression by tissue

second toe, and assess ability to dorsiflex toes

edema or hematoma.

after joint replacement.

Monitor vital signs.

Tachycardia and decreasing BP may reflect

response to hypovolemia or blood loss or
suggest anaphylaxis related to absorption of
methyl methacrylate into systemic circulation.
Note: This occurs less often because of the
advent of prosthetics with a porous layer that
fosters ingrowth of bone instead of total
reliance on adhesives to internally fix the
device.

Monitor amount and characteristics of drainage

May indicate excessive bleeding and

on dressings and from suction device. Note

hematoma formation, which can potentiate

swelling in operative area.

neurovascular compromise. Note: Drainage

following hip replacement may reach 1000 cc
in early postoperative period, potentially

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affecting circulating volume.

Ensure that stabilizing devices (abduction

Reduces risk of pressure on underlying nerves

pillow, splint device) are in correct position and

or compromised circulation to extremities.

are not exerting undue pressure on skin and

underlying tissue. Avoid use of pillow or knee
gatch under knees.
Evaluate for calf tenderness, positive Homans

Early identification of thrombus development

sign, and inflammation.

and intervention may prevent embolus

formation.

Observe for signs of continued bleeding,

Depression of clotting mechanisms and/or

oozing from puncture sites and mucous

sensitivity to anticoagulants may result in

membranes, or ecchymosis following minimal

bleeding episodes that can affect red blood cell

trauma.

(RBC) level and circulating volume.

Observe for restlessness, confusion, sudden

Fat emboli can occur (usually in first 72 hr

chest pain, dyspnea, tachycardia, fever,

postoperatively) because of surgical trauma

development of petechiae

and manipulation of bone during implantation

of prosthesis.

Monitor laboratory studies:

Hct

Usually done 2448 hr postoperatively for

evaluation of blood loss, which can be quite
large because of high vascularity of surgical
site in hip replacement. Note: Monitoring of
CBC or repeated count may also be indicated

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for patients receiving enoxaparin (Lovenox).

Coagulation studies.

Evaluates presence or degree of alteration in

clotting mechanisms and effects of
anticoagulant and/or antiplatelet agents when
used. Note: Not necessary for patients
receiving enoxaparin (Lovenox); however,
stool occult blood tests may be indicated.

Administer medications as indicated: warfarin

Anticoagulants and/or antiplatelet agents may

sodium (Coumadin), heparin, aspirin, low-

be used to reduce risk of thrombophlebitis and

molecular-weight heparin, e.g., enoxaparin

pulmonary emboli.

(Lovenox).
Apply cold or heat as indicated.

Ice packs are used initially to limit edema

and/or hematoma formation. Heat may then be
used to enhance circulation, facilitating
resolution of tissue edema.

Maintain intermittent compression stocking or

Promotes venous return and prevents venous

foot pumps when used.

stasis, reducing risk of thrombus formation.

Prepare for surgical procedure as indicated.

Evacuation of hematoma or revision of

prosthesis may be required to correct
compromised circulation.

4. Acute Pain
May be related to

Injuring agents: biological, physical/psychological (e.g., muscle spasms, surgical procedure,

preexisting chronic joint diseases, elderly age, anxiety)

Possibly evidenced by

Reports of pain; distraction/guarding behaviors

Narrowed focus/self-focusing

Alteration in muscle tone; autonomic responses

Desired Outcomes

Report pain relieved/controlled.

Appear relaxed, able to rest/sleep appropriately.

Demonstrate use of relaxation skills and diversional activities as indicated by individual

situation.

Nursing Interventions

Rationale

Assess reports of pain, noting intensity (scale

Provides information on which to base and

of 010), duration, and location.

monitor effectiveness of interventions.

Maintain proper position of operated extremity.

Reduces muscle spasm and undue tension on

new prosthesis and surrounding tissues.

Provide comfort measures (frequent

Reduces muscle tension, refocuses attention,

repositioning, back rub) and diversional

promotes sense of control, and may enhance

activities. Encourage stress management

coping abilities in the management of

techniques (progressive relaxation, guided

discomfort or pain, which can persist for an

imagery, visualization, meditation). Provide

extended period.

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Therapeutic Touch as appropriate.

Medicate on a regular schedule and before

Reduces muscle tension; improves comfort,

activities.

and facilitates participation.

Investigate reports of sudden, severe joint pain

Early recognition of developing problems, such

with muscle spasms and changes in joint

as dislocation of prosthesis or pulmonary

mobility; sudden, severe chest pain with

emboli (blood/fat), provides opportunity for

dyspnea and restlessness.

prompt intervention and prevention of more

serious complications.

Administer narcotics, analgesics, and muscle

Relieves surgical pain and reduces muscle

relaxants as needed. Instruct and monitor use

tensions and spasm, which contributes to

of PCA and/or epidural administration.

overall discomfort. Narcotic infusion (including

epidural) may be given during first 2448 hr,
with oral analgesics added to pain
management program as patient progresses.
Note: Use of ketorolac (Toradol) or other
NSAIDs is contraindicated when patient is
receiving enoxaparin (Lovenox) therapy.

Apply ice packs as indicated.

Promotes vasoconstriction to reduce bleeding

or tissue edema in surgical area and lessens
perception of discomfort.

Initiate and maintain extremity mobilization:

Increases circulation to affected muscles.

ambulation, physical therapy, exerciser and/or

Minimizes joint stiffness; relieves muscle

CPM device.

spasms related to disuse.

5. Knowledge Deficit

May be related to

Lack of exposure/recall

Information misinterpretation

Possibly evidenced by

Questions/request for information, statement of misconception

Inaccurate follow-through of instructions, development of preventable complications

Desired Outcomes

Verbalize understanding of surgical procedure and prognosis.

Correctly perform necessary procedures and explain reasons for the actions.

Nursing Interventions

Rationale

Review disease process, surgical procedure,

Provides knowledge base from which patient

and future expectations.

can make informed choices.

Encourage alternating rest periods with

Conserves energy for healing and prevents

activity.

undue fatigue, which can increase risk of injury

or falls.

Stress importance of continuing prescribed

Increases muscle strength and joint mobility.

exercise and/or rehabilitation program within

Most patients will be involved in formal

patients tolerance: crutch, cane walking,

rehabilitation and/or outpatient home care

weight-bearing exercises, stationary bicycling,

programs or be followed in extended-care

or swimming.

facilities by physical therapists. Muscle aching

indicates too much weight bearing or activity,

Nursing Interventions

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signaling a need to cut back.

Instruct in home use of CPM exercise

CPM therapy may be continued for some

program.

patients after discharge. Note: CPM therapy is

used in only about 50% of patients at this time.

Review activity limitations, depending on joint

Prevents undue stress on implant. Long-term

replaced, for hip/knee sitting for long periods or

restrictions depend on individual situation or

in low chair/ toilet seat/ recliner, jogging,

physicians protocol.

jumping, excessive bending, lifting, twisting or

crossing legs.
Discuss need for safe environment in home

Reduces risk of falls and excessive stress on

(removing scatter rugs and unnecessary

joints.

furniture) and use of assistive devices

(handrails in tub or toilet, raised toilet seat,
cane for long walks).
Review and have patient or caregiver

Promotes independence in self-care, reducing

demonstrate incisional/wound care.

risk of complications.

Identify signs and symptoms requiring medical

Bacterial infections require prompt treatment to

evaluation, e.g., fever and chills, incisional

prevent progression to osteomyelitis in the

inflammation, unusual wound drainage, pain in

operative area and prosthesis failure, which

calf or upper thigh, or development ofstrep

could occur at any time, even years later.

throat or dental infections.

Review drug regimen: anticoagulants or

Prophylactic therapy may be necessary for a

antibiotics for invasive procedures.

prolonged period after discharge to limit risk of

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thromboemboli or infection. Procedures known

to cause bacteremia can result in osteomyelitis
and prosthesis failure.
Notify of bleeding precautions. Instruct use of

Reduces risk of therapy-induced bleeding

soft toothbrush, electric razors, avoidance of

and/or hemorrhage.

trauma or forceful blowing of the nose.

Encourage intake of balanced diet, including

Enhances healing and feeling of general well-

roughage and adequate fluids.

being. Promotes bowel and bladder function

during period of altered activity.

Other Possible Nursing Care Plans

Trauma, risk forbalancing difficulties/altered gait, weakness, lack of safety precautions,

hazards associated with use of assistive devices.

Self-Care deficit/Home Maintenance, impairedmusculoskeletal impairment, decreased

strength/endurance, pain in operative site or other joints.