1246 UNIT XI / Responses to Altered Musculoskeletal Function
Nursing Care Plan
A Client with Osteoarthritis
Robert Cerulli is a 72-year-old retired com-
mercial fisherman who has experienced arthritic
pain in his hips for the past 10 to 15 years. Over the past year, the
pain in his right hip has become severe, prompting him to seek
medical attention. Significant degenerative changes in both hip
joints are noted on X-ray films. The physician recommends a total
replacement of the right hip, and total replacement of the left hip
to follow in 6 to 12 months. Mr. Cerulli has preoperative teaching
and tests the afternoon prior to his surgery, scheduled for 0800
the following morning.
ASSESSMENT
Christie Phlaugh, RN, completes a nursing history and examina-
tion of Mr. Cerulli on admission. Reviewing his medical record, she
notes that Mr. Cerulli has mild Parkinson’s disease and is taking
carbidopa/levodopa (Sinemet 25-100) four times a day to control
his symptoms. No other chronic medical conditions have been
reported. Mr. Cerulli says he has been essentially healthy his entire
life. He has no known allergies to medications, has never smoked,
and consumes only small amounts of alcohol.
On examination of Mr. Cerulli, Ms. Phlaugh notes that he is alert
and oriented. His vital signs are BP 116/64, P 68 regular, R 18,
T 97.4°F (36.3°C) PO. Peripheral pulses are strong and equal in the
upper extremities, and slightly weaker but equal in the lower ex-
tremities. His feet are cool to touch but have immediate capillary
refill. He has full ROM of his shoulders, elbows, and wrists.The ROM
of both hips is significantly restricted. Hip flexion beyond 90 de-
grees prompts pain on both sides. Both flexion and extension of
the knees are limited slightly.Mr.Cerulli walks with a limp, favoring
his right hip, and has a shuffling gait.
Preoperative laboratory studies including CBC, coagulation
studies,chemistry panel,and urinalysis show a serum creatinine of
1.7 mg/dL and BUN of 30 mg/dL, with no other abnormal values
noted. His ECG and chest X-ray show no apparent pathologies.
Cefazolin (Ancef ) 500 mg is to be administered intravenously at
0600 prior to surgery, and Mr. Cerulli is to shower and shampoo
with antibacterial soap at bedtime. The physical therapist meets
with Mr. Cerulli to evaluate his mobility and begin teaching him
about postoperative weight-bearing restrictions.
DIAGNOSIS (Postoperative)
• Acute pain, related to surgical incision
• Impaired physical mobility, related to activity and weight-
bearing restrictions
• Risk for infection, related to disruption in skin integrity
• Risk for ineffective tissue perfusion, right leg, related to vascular
disruption and edema
EXPECTED OUTCOMES
• Maintain an adequate level of comfort postoperatively as
demonstrated by:
• The ability to move easily within restrictions.
• Compliance with instructions to cough and breathe deeply.
• Verbal expressions of comfort.
• Remain free of adverse consequences of immobility such as
pneumonia, pressure areas, thromboembolism, or contracture.
• Remain free of infection.
• Maintain adequate perfusion of affected leg.
• Remain free of injury postoperatively.
PLANNING AND IMPLEMENTATION
• Assess pain at least hourly during first 24 to 48 hours postoper-
atively, and as needed thereafter.
• Instruct in the use of patient-controlled analgesia (PCA) and
monitor its effectiveness.
• Help change position at least every 2 hours; encourage the use
of the overhead trapeze to shift positions frequently.
• Maintain sequential compression device and antiembolic
stocking as ordered; remove for 1 hour daily.
• Encourage the use of the incentive spirometer hourly for first
24 hours, then at least every 2 hours while awake.
• Assist out of bed three times a day after the first 24 hours.
• Maintain abduction of the right hip with pillows.
• Perform passive ROM exercises of unaffected extremities every
shift.
• Encourage frequent quadriceps-setting exercises and plantar
and dorsiflexion of feet.
• Assess the surgical site frequently; report signs of excess bleed-
ing or inflammation.
• Monitor temperature every 4 hours.
• Assess pulses, color, movement, and sensation of right foot
hourly for the first 24 hours, then every 2 hours for 24 hours,
then every 4 hours.
EVALUATION
Mr. Cerulli returns to the orthopedic unit from the postanesthesia
care unit. He becomes confused and disoriented during the first
36 hours after surgery, but his orientation and thought processes
gradually clear. His family has stayed with him, and he has not ex-
perienced injury or other adverse consequences from his confu-
sion. Otherwise, Mr. Cerulli has had an uneventful postoperative
recovery. Six days after surgery, he is transferred to an extended
care rehabilitation facility for further therapy until he is able to am-
bulate with partial weight bearing on his affected leg. He returns
home 5 weeks after surgery, able to use a walker for ambulation.
Arrangements are made for an overbed trapeze, elevated toilet
seat,and shower chair in his home.A home health nurse and phys-
ical therapist visit Mr. and Mrs. Cerulli weekly for a month follow-
ing his discharge. During this time he gradually resumes full
weight bearing. Mr. Cerulli expresses pleasure with the relief of his
hip pain and says he has no fear of having his left hip replaced in
the future.
Critical Thinking in the Nursing Process
1. Mr.Cerulli’s preoperative laboratory work showed a modest el-
evation in his serum creatinine and BUN. What do these stud-
ies indicate? How might these changes affect nursing respon-
sibilities related to medication administration for Mr. Cerulli?
2. Mr. Cerulli became confused postoperatively. What factors in
his history might have alerted the nurses to this possibility?
How might anesthesia and postoperative analgesics have
contributed to his confusion?
3. Develop a care plan for Mr. Cerulli using the nursing diagno-
sis, Acute confusion.
See Evaluating Your Response in Appendix C.