Nursing Care Plan Sample: Post-Operative Hip Replacement

Model Answer

Patient Scenario

Mrs T, a 68-year-old retired teacher, returned to the orthopaedic ward four hours ago following an elective right total hip replacement under spinal anaesthesia, performed for osteoarthritis. She has a background of hypertension and a body mass index of 31. Post-operative observations show blood pressure 118/76 mmHg, heart rate 88 bpm, respiratory rate 16 breaths per minute, oxygen saturation 96% on 2 L/min oxygen, and temperature 36.8°C. She reports pain scored 6/10 at the surgical site despite regular analgesia, has a wound drain in situ with 40 mL of serosanguinous output, and is not yet able to feel or move her toes fully due to residual spinal block. She is nil by mouth pending confirmation of return of sensation, has a urinary catheter in situ, and is anxious about “never walking properly again”.

Mrs T’s regular medications include amlodipine 5mg once daily for hypertension and, since surgery, prescribed post-operative analgesia comprising regular paracetamol, a non-steroidal anti-inflammatory where not contraindicated, and oxycodone for breakthrough pain, alongside low-molecular-weight heparin for thromboprophylaxis. She has no known drug allergies. She underwent a pre-operative assessment that identified no significant anaesthetic risk factors beyond her body mass index, and surgery was uncomplicated with an estimated blood loss within expected limits. On return to the ward, her surgical dressing was clean, dry and intact, the wound drain was secured and swinging appropriately, and the operative leg was correctly positioned with an abduction wedge in line with the surgical team’s post-operative instructions. Mrs T lives with her husband in a two-storey house with the main bedroom upstairs, which is a relevant consideration for discharge and occupational therapy planning given the temporary mobility restrictions imposed by hip precautions.

Assessment

Assessment used a structured Airway, Breathing, Circulation, Disability, Exposure (A–E) approach on return from theatre, followed by the ADPIE nursing process for ongoing post-operative care (NMC, 2018).

Airway/Breathing: patent airway, respiratory rate 16, saturations 96% on supplemental oxygen, chest clear on auscultation. Circulation: blood pressure and heart rate stable within normal post-spinal parameters, wound drain output within expected range, no visible bleeding through dressing. Disability: alert and orientated, pain scored 6/10 on a numerical rating scale, residual reduced sensation and motor power in the operative leg consistent with resolving spinal block. Exposure: dressing dry and intact, no pyrexia, right leg maintained in neutral rotation with an abduction wedge to reduce dislocation risk. NEWS2 score calculated at 1, appropriate for routine post-operative monitoring frequency (Royal College of Physicians, 2017).

Further assessment covered venous thromboembolism (VTE) risk (assessed as high given surgery type, BMI and reduced mobility), skin integrity (heels and sacrum at risk during immobility), elimination (catheterised, urine clear), and psychological state (anxiety about mobility and long-term recovery, consistent with common concerns after hip arthroplasty) (NICE NG89, 2018).

A Malnutrition Universal Screening Tool (MUST) score of 0 was recorded, and Mrs T was tolerating clear fluids with a plan to progress her diet as tolerated once bowel sounds returned following the spinal anaesthetic. Pressure area assessment using the Waterlow tool placed her at moderate risk owing to reduced mobility, her raised body mass index and the effects of spinal anaesthesia on sensation, prompting two-hourly repositioning and heel protection in addition to the wound and hip-specific interventions detailed below. Pain was assessed using a numerical rating scale supplemented by observation of non-verbal cues, given that residual spinal block can occasionally mask the full extent of discomfort, and reassessment was scheduled at regular intervals rather than relying on a single admission score.

A falls risk assessment was also completed, scoring Mrs T as high risk in the immediate post-operative period owing to the combined effects of residual spinal anaesthesia, analgesia, unfamiliar surroundings and reduced sensation in the operative leg, prompting bed-rail use, a low-height bed where available, and a clear instruction not to attempt to stand unassisted until sensation and power had been confirmed as fully returned.

Nursing Diagnoses

1. Acute pain related to surgical trauma to the hip joint, evidenced by a self-reported pain score of 6/10 despite analgesia (actual problem, high priority).

2. Risk of venous thromboembolism related to major lower-limb surgery and reduced mobility (risk problem, high priority).

3. Risk of prosthetic joint dislocation related to recent hip arthroplasty (risk problem, high priority).

4. Impaired physical mobility related to surgical pain and residual spinal anaesthesia, evidenced by reduced sensation and motor power in the right leg (actual problem, medium priority).

Pain was prioritised first because effective analgesia is a prerequisite for safe, timely mobilisation, which in turn underpins the reduction of both VTE and dislocation risk; the four diagnoses are therefore best understood as interdependent rather than sequential, with good pain control acting as an enabler for the other goals rather than a competing priority. VTE prevention and dislocation prevention were ranked jointly at high priority given that both carry potentially serious, time-critical consequences if missed, whereas impaired mobility, while clinically significant, was judged medium priority because it is expected to resolve as sensation returns and pain is controlled (NICE NG89, 2018; British Orthopaedic Association, 2019).

The Care Plan

Each SMART goal below is paired with interventions reflecting current national guidance on perioperative care, venous thromboembolism prevention and post-arthroplasty precautions, together with a rationale explaining the underlying evidence, and an evaluation criterion stated in observable, measurable terms so that progress can be tracked objectively across the multidisciplinary team, in keeping with the NMC’s expectation of clear, accountable documentation (NMC, 2018).

Evaluation and Review

Evaluation was carried out at each set of post-operative observations and formally reviewed at 24 and 48 hours, comparing pain scores, VTE risk indicators, hip precaution adherence and mobility progress against the goals set. Where pain remained above target despite multimodal analgesia, escalation to the acute pain team was specified rather than simple repetition of the existing regimen. Discharge planning began early, involving physiotherapy and occupational therapy assessment of the home environment, provision of mobility aids, and reinforcement of hip precautions for the recommended post-operative period, supporting Mrs T’s safe return home (NMC, 2018).

By 24 hours, sensation and motor power had fully returned to the right leg, allowing Mrs T to mobilise a short distance with a Zimmer frame and one assistant under physiotherapy supervision, with her pain controlled at 2–3/10 on regular multimodal analgesia. The wound drain was removed on day one once output had reduced to below the local threshold, and the surgical dressing remained clean, dry and intact throughout. Repeat observations showed no clinical signs of deep vein thrombosis, and thromboprophylaxis was continued as prescribed with no bleeding complications. Mrs T correctly repeated back her hip precautions unprompted during a physiotherapy session on day two, demonstrating safe technique for standing and transferring, which confirmed that the dislocation-prevention goal had been met for the acute inpatient phase. At the multidisciplinary discharge planning meeting on day three, attended by the ward nurse, physiotherapist, occupational therapist and Mrs T’s husband, it was agreed that a temporary equipment package (raised toilet seat, perching stool and grab rails) would be delivered before discharge, and that Mrs T would sleep downstairs on a temporary bed for the first two weeks to avoid stair use while hip precautions remained in place. A community physiotherapy follow-up was arranged for one week post-discharge, and Mrs T was given written and verbal information on recognising early warning signs of infection or dislocation and who to contact if concerned. This staged, criteria-led evaluation demonstrates how the nursing process functions cyclically: each reassessment against the original SMART goals directly shaped the discharge plan, rather than discharge being planned as a separate, disconnected step (Roper, Logan and Tierney, 2000; NMC, 2018).

A further reflective point from this case concerns the balance between promoting independence and maintaining safety in the early post-operative period. Mrs T’s anxiety about “never walking properly again” could, if unaddressed, have led either to reluctant, hesitant mobilisation that slowed recovery, or to over-cautious behaviour that increased deconditioning risk. Structuring mobilisation as a series of small, clearly explained, physiotherapy-supervised steps, each tied to an observable success criterion, allowed Mrs T to rebuild confidence incrementally rather than being asked to trust a process she did not yet understand. This approach reflects a person-centred application of the hip precaution guidance, treating adherence not as a rule to be enforced but as a shared goal that Mrs T could see working in practice, consistent with the NMC’s expectation that nurses work in partnership with people to support their own health and to make informed decisions about their care (NMC, 2018; British Orthopaedic Association, 2019).

References

British Orthopaedic Association (2019) Primary Total Hip Replacement: A Guide to Good Practice. London: BOA.
National Institute for Health and Care Excellence (2015) Hip Fracture in Adults (QS87). London: NICE.
National Institute for Health and Care Excellence (2018) Venous Thromboembolism in Over 16s: Reducing the Risk (NG89). London: NICE.
National Institute for Health and Care Excellence (2020) Perioperative Care in Adults (NG180). London: NICE.
Nursing and Midwifery Council (2018) The Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates. London: NMC.
Royal College of Anaesthetists (2021) Guidelines for the Provision of Anaesthesia Services for Perioperative Pain. London: RCoA.
Royal College of Physicians (2017) National Early Warning Score (NEWS) 2. London: RCP.