Complex Care Needs

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Complex Care Needs

 

Introduction

The most common indication in Arthroplasty Orthopaedic Surgery is Osteoarthritis, defined as joint disease particularly usually non inflammatory be degenerative. Certain hip and shoulder (caused mostly due to accidental falls) are also treated by implantation prosthesis. In addition, some bone tumors involving articular surgically said implant. Hip fracture is a condition of epidemic features that affect Women especially senile white. Also add that 9 out of 10 fractures occur in people over 60 years, with the greatest risk of fracture, decrease in bone density. It was also found that the obese individuals suffer these fractures less often than the thin, perhaps because the soft tissues act as a damping mechanism to a fall.

From the nursing, care are essential for the surgical patient (Mrs. Zee) Hip surgery, since the prevention of infection, pain control by administration of medication, etc. A whole range of activities to promote full care assistance, efficient and professional.

 


 

  1. The treatment plan
  • Education and counseling with emphasis on weight reduction and joint protection. or physical media: cryotherapy (cold) and surface heat (heat) in the affected area. or Therapeutic Exercise: passive mobilization and stretching exercises for patients with functional limitations, considering the physical and occupational therapy (exercises in water are effective for patients since they avoid backing affected joints). The mobilization and stretching can be considered together, as the basis of treatment particularly for osteoarthritis of the hip. Improve muscular strength and endurance, protecting the joints, improving gait and reduces pain. These exercises should indicate the specialist in physical medicine and rehabilitation (see reference to second level).
  • Reduction of weight when you are overweight or obese and stay in the lower levels.
  1. Pharmacological management
    • Oral analgesics

All NSAIDs and COX-2 have analgesic in OA, of similar magnitude but vary in their potential gastrointestinal complications, liver or cardio-toxicity. That’s why when you choose the agent and dose, the professional health care should take into account the risk factors individual patient, including age, co morbidities and gastrointestinal evaluation monitor risk factors.

  • Acetaminophen / paracetamol

Recommendation of choice, acetaminophen maximum dose of 4 g daily is effective in analgesia oral initial treatment of moderate pain in patients with OA of the hip and hip, with main effectiveness hip. The initial dose in OA election must be modified according to the patient risk factors (Liver toxicity, particularly with the use of aspirin). In the absence of adequate response or in the presence of severe pain or swelling, alternative therapy should be considered based on efficacy and safety and the medications the patient is taking and co-morbidity, that is, whether paracetamol is insufficient to reduce the pain of people with osteoarthritis, then you should consider the use of opioid analgesics should be considered or replace a NSAIDs for a COX-2 inhibitor. The professional health care should consider prescribing paracetamol to reduce the pain of hip OA regular dose, and base treatment (weight reduction, information, stretching and strengthening).

  • Inflammatory on drugs (NSAIDs )

In patients who have no improvement in reducing the pain and the functional, it must consider the use of NSAID’s post-assessment of risk factors for gastric and renal toxicity (Age 65 years, co morbidity, hypertension, edema), history of peptic ulcer disease, history of gastrointestinal bleeding, use of anticoagulants), as well as appropriate evaluation and monitoring risk factors. The schemes recommended in the following cases s recommended schemes soon the following cases:

  • Reducing pain in OA = NSAID’s, in six weeks to six months

Considerations of patient drug treatment drug treatment considerations risk patients is at risk is a risk:

  • In OA risk In cardiovascular
    • Cardiovascular risk increased gastrointestinal risk (low risk to NSAID’s) Naproxen + = * 200 Mc misoprostol four times / day
    • Increased gastrointestinal risk to cardiovascular risk (high risk NSAID’s) Cox-2 + = * 200 Mc misoprostol four times / day

 

  • Considerations with aspirin (acetyl salicylic acid):
    • If you need to take a low dose of aspirin in OA, the healthcare professional should consider other analgesics before substituting or adding other NSAIDs or COX-2 (with a pump inhibitor protons).
    • All NSAIDs may antagonize the use of aspirin.
    • If gastrointestinal risks of aspirin pretreatment combined with NSAIDs, then it should provide gastrointestinal protection.
  1. Opioids

The use of strong opioids is indicated to manage severe pain of OA, and only in circumstances exceptional. The use of weak opioids and narcotic analgesics may be recommended for the treatment of pain refractory patients with hip and hip OA, where other pharmacological agents have been effective or are contraindicated.

  1. Otrosros

Among other pharmacological agents for the treatment of osteoarthritis are recommended:

  • Tramadol
  • Glucocorticoids or hyaluronate
  • Capsaicin or methyl salicylate
  • Non acetylated salicylate
  1. Topical Analgesics

The use of topical analgesics is cheaper than oral analgesics as these latter have several adverse effects. In hip OA topical analgesics, are cost effective, showing benefits in the short time (<4 weeks), with the adverse effect of local skin irritation. Capsaicin is recommended treatment with base (education, weight reduction, stretching and strengthening exercises). The capsaicin and topical analgesics such as NSAIDs may be effective in adding oral analgesics and anti-inflammatory. Topical rubefacients (trolamine salicylate and copper salicylate) are not recommended for treatment OA.

  1. Technical Help

The walking aids can reduce pain in patients with hip and hip OA. Patients should be provided with instructions for optimal use of cane in the hand contra lateral joint affected or crutches. Walkers with wheels, are recommended in the event that the condition is bilateral. Every patient with hip and hip OA should be oriented on the use of proper footwear. In patients with hip OA with varus or valgus medium / moderate, we recommend the use of hip brace can reduce pain, improve stability and reduce the risk of falling. In patients with hip OA, the use of templates can reduce pain and improve walking. The corrective insoles (lateral wedge), are beneficial for reducing the symptoms of patients with osteoarthritis of the hip and tibia-femoral disorders.

  1. Reference to second level

Symptomatic patients functional class II, III and IV (ARA) with hip osteoarthritis should be referred to rehabilitation services for assessment and prescription of an individualized program for the specialist in physical medicine and rehabilitation based therapeutic modalities such as electrotherapy and therapeutic exercise, in order to reduce pain and improve functional ability.

 


 

  1. Implementing the Plan

Activities

– Introducing patient (Mrs. Zee)rself.

– Provide adequate privacy for the patient (Mrs. Zee) / family.

– Guide the patient (Mrs. Zee) / family.

– Complete documentation of nursing.

– Perform nursing assessment.

– Implement safety precautions, if any.

Nursing throughout the hospitalization process, detects and marks needs objectives, but due to multiple causes, may not be recorded, although the results of the nursing interventions are appropriate, so that patient (Mrs. Zee) can assess and quantify the quality of care. Standardized care plans can be a practical guide, based on external evidence and professional experience (internal evidence), which clarifies the orientation of the care to be in a situation defined previously. Nursing care based on evidence it is useful for:

  • Putting our knowledge to reach provide the best care.
  • Encourage lifelong learning imperative to keep an appropriate degree of professional competence.
  • Promote multidisciplinary work, and identify areas that require investigation.

These guidelines allow the entire nursing work can be reflected and identify process management, being raised from situations care and not just from the prevalent problems.

Physiotherapy starts the morning after surgery. It is very important that patient (Mrs. Zee) receive pain medication 30 minutes before physiotherapy treatment to help patient (Mrs. Zee) fully participate in the exercises. Discuss this with patient (Mrs. Zee)r nurse. How well regain strength and movement depends, in part, to how well continue its program of physiotherapy. This part of their rehabilitation is something patient (Mrs. Zee) should do for patient (Mrs. Zee)rself, not something that someone more for patient (Mrs. Zee). If no complications after surgery, will remain in the hospital for about three or four days. During this time, patient (Mrs. Zee) will receive two therapies times a day from Monday to Friday, once the weekends.

It will provide routine care and physiotherapy as usual on the morning of discharge. Physiotherapy added to patient (Mrs. Zee)r routine therapy the transfers to a car and the bathroom. patient (Mrs. Zee) perform postoperative safety precautions. It is expected that members of the family attend therapy sessions. They will learn how to help with transfers and walking, well as postoperative safety precautions.

The Care Manager will visit again to finalize plans for when patient (Mrs. Zee) are leave the hospital. If patient (Mrs. Zee) have any questions about patient (Mrs. Zee)r health, please post it to patient (Mrs. Zee)r nurse (s) or clarify any concerns on high with Care Manager.

Patient (Mrs. Zee)r physiotherapy program will begin on after surgery. Treatments will given twice daily for about 15 to 30 minutes per session. Patient (Mrs. Zee) start with his bed and move on to do their therapy in the gym the second day after surgery. is a good idea to ask for pain medication before starting his physiotherapy or other activity that may cause pain, such as walking, or getting in and out of bed. As expected inflammation, plan to bring a couple of shoes at least a half size larger than they normally use. This will move patient (Mrs. Zee)r foot with more comfort and safety while walking.

The pain tolerance will be evaluated regularly by nurses, using a visual analog scale (VAS). We then quantify pain by a score of 0 to 10. The anti-pain treatment will be tailored to the patient (Mrs. Zee)’s tolerance

Today the combined figures of chronic patient (Mrs. Zee)s, those with a long-term illness and those with a physical or mental disability resulting in daily care are steadily increasing (but it was me no access to an exact number, most of these figures are grouped by disease or condition). Among these patient (Mrs. Zee)s, more and more people are very savvy, and can recognize their skills on their condition and their needs and expectations are a little different from other patient (Mrs. Zee)s. What then we take care of it? As each of the patient (Mrs. Zee)s that we support, the knowledge of “who is the patient (Mrs. Zee) ‘is a cornerstone of our business for the management of patient (Mrs. Zee) in its entirety. “the essential role of the nurse is to assist the sick or healthy individual to maintain or recovery of health for the performance of tasks which it would carry himself if he had the strength, will, or had the necessary knowledge and to perform these functions to help regain his independence as quickly as possible.

On the morning of discharge, patient (Mrs. Zee) will get routine care and physical therapy which will add car and bathroom transfers to patient (Mrs. Zee)’s routine therapy. The patient (Mrs. Zee) will practice postoperative safety precautions. The family members of patient (Mrs. Zee) are also supposed to attend the therapy sessions. They would get learnt about the assistance with transfers and walking in addition to postoperative safety precautions.

1) The patient (Mrs. Zee)’s family/friends have to take home any flowers or personal items on the day prior to discharge

2) Patient (Mrs. Zee) is required to have already arranged someone to pick him up before discharge time, if he has been discharged home. The patient (Mrs. Zee) will not be capable of driving himself. Patient (Mrs. Zee) should use a pillow for sitting in case the car has a low seat. The front passenger seat ought to be stretched out as much as it can and should be pushed back.

3) Transportation measures would be discussed with the patient (Mrs. Zee) if he has been discharged to a facility.

The nurse will provide the patient (Mrs. Zee) with all the instructions regarding care at home, follow-up appointments and medications at the time of discharge. The patient (Mrs. Zee) should avail this chance to discuss all the concerns with the nurse if there are any.

The patient (Mrs. Zee)’s target is to bring back the normal walking capacity (gait) after the hip replacement surgery without using any walking aide. The surgery itself would not lessen patient (Mrs. Zee)’s need for such devices if he has used any of these prior to the surgery, particularly when the patient (Mrs. Zee) has distress regarding balance or walking safety. It’s usual to have some degree of following walking abnormalities after hip replacement surgery; almost everyone who underwent the surgery demonstrates this abnormality. These walking injuries and abnormalities result in medical appointments for physical therapy care for the correction of these problems following surgery. Mainly, in most common cases, this type of walking trouble occurs when the patient (Mrs. Zee) takes long step with the leg which got operated and takes a short step with the uninvolved leg. The physical therapy is done to put off extension in the surgical hip, which could become a cause of stretching discomfort in groin. Stretching the hip, as stated above, will help in decreasing this groin soreness as the patient (Mrs. Zee) will walk.

Recommendation: Patient (Mrs. Zee) should try and focus on taking short steps on the non operative leg.

Second to that, the other most common walking problem faced by patient (Mrs. Zee) is bending knee too early before the leg usually swings forward during the walking activity. Yet again, most frequently, it is done to prevent extension of the operative hip too far backwards.

Recommendation: Patient (Mrs. Zee) is supposed to keep the heel of the operative leg on the ground for the equal amount of time as the non operative leg.

 

 

 

Bibliography

HCUPnet (2002), Healthcare Cost and Utilization Project. Rockville, MD: Agency for Healthcare Research and Quality

Felson DT, Zhang Y. (1998) An update on the epidemiology of knee and hip osteoarthritis with a view to prevention. Arthritis Rheum; 41:1343-55.

Jordan JM, Linder GF, Renner JB, Fryer JG. (1995) The impact of arthritis in rural populations. Arthritis Care Res; 8:242-50.

Katz JN, Losina E, Barrett J, Phillips CB, Mahomed NN, Lew RA, Guadagnoli E, Harris WH, Poss R, Baron JA. (2001) Association between hospital and surgeon procedure volume and outcomes of total hip replacement in the United States medicare population. J Bone Joint Surg Am; 83-A:1622-9.

Mahomed NN, Barrett JA, Katz JN, Phillips CB, Losina E, Lew RA, Guadagnoli E, Harris WH, Poss R, Baron JA. (2003) Rates and outcomes of primary and revision total hip replacement in the United States medicare population. J Bone Joint Surg Am 2003; 85-A:27-32.

Gore DR, Murray MP, Gardner GM, Mollinger LA. (1986) Comparison of function two years after revision of failed total hip arthroplasty and primary hip arthroplasty. Clin Orthop 1986:168-73.

Stromberg CN, Herberts P, Palmertz B. (1992) Cemented revision hip arthroplasty. A multicenter 5-9-year study of 204 first revisions for loosening. Acta Orthop Scand; 63:111-9.

Katz JN, Phillips CB, Baron JA, Fossel AH, Mahomed NN, Barrett J, Lingard EA, Harris WH, Poss R, Lew RA, Guadagnoli E, Wright EA, Losina E. (2003) Association of hospital and surgeon volume of total hip replacement with functional status and satisfaction three years following surgery. Arthritis Rheum 2003; 48:560-8.

Phillips CB, Barrett JA, Losina E, Mahomed NN, Lingard EA, Guadagnoli E, Baron JA, Harris WH, Poss R, Katz JN. (2003) Incidence rates of dislocation, pulmonary embolism, and deep infection during the first six months after elective total hip replacement. J Bone Joint Surg Am; 85-A:20-6

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