Patient Overview
Patient: Mrs EM (pseudonym) | Age: 68 | Procedure: Left total hip replacement (THR) under spinal anaesthesia
PMH: Osteoarthritis (bilateral hips), hypertension, hypothyroidism | Allergies: Penicillin (rash)
Post-Operative Assessment (Day 0 — PACU)
Primary Survey (ABCDE)
A – Airway: Patent, self-maintaining
B – Breathing: RR 16/min, SpO₂ 97% on 2L nasal cannula, clear air entry bilaterally
C – Circulation: HR 82 bpm, BP 128/74 mmHg, CRT <2s, wound drain output 80ml (serosanguinous), Hb 98 g/L (pre-op 124 g/L)
D – Disability: GCS 15/15, AVPU = Alert, pain score 6/10 (NRS)
E – Exposure: Wound dressing intact, no signs of haematoma, left leg in abduction wedge, anti-embolic stockings applied
Priority Nursing Diagnoses
1. Acute Pain
Related to: Surgical tissue trauma, prosthetic joint implantation, spinal anaesthesia regression
As evidenced by: Pain score 6/10 NRS, facial grimacing, guarding of left hip, reluctance to move
2. Risk for Bleeding
Related to: Surgical blood loss, anticoagulant therapy (LMWH prophylaxis)
As evidenced by: Intra-operative blood loss 350ml, post-op Hb 98 g/L, wound drain present
3. Risk for Deep Vein Thrombosis (DVT)
Related to: Prolonged immobility, surgical trauma to pelvic vasculature, hypercoagulable post-operative state
As evidenced by: Risk factors: age, surgery type, reduced mobility (Caprini score: high risk)
4. Impaired Physical Mobility
Related to: Post-operative pain, prescribed movement restrictions (hip precautions), muscle weakness
As evidenced by: Inability to bear weight independently, dependence on frame, Barthel Index reduced to 45/100
Care Plan — Priority 1: Acute Pain
NOC Goal: Patient will report pain ≤ 3/10 NRS within 2 hours of analgesia administration and be able to perform physiotherapy exercises with pain ≤ 4/10 within 24 hours post-operatively.
Interventions:
1. Administer regular multimodal analgesia as prescribed (Paracetamol 1g QDS + Ibuprofen 400mg TDS if no contraindication + Tramadol SR 100mg BD) using the WHO analgesic ladder. Rationale: Multimodal analgesia targets different pain pathways simultaneously, reducing total opioid requirements and associated side effects (NICE NG180, 2020).
2. Assess pain using NRS every 30 minutes for 4 hours post-op, then 2-hourly for 24 hours. Document, report, and titrate analgesia accordingly. Rationale: Frequent reassessment enables timely analgesia adjustment and prevents undertreated pain, which impedes early mobilisation (Scottish Intercollegiate Guidelines Network, 2019).
3. Apply cryotherapy (ice pack wrapped in cloth) to the operative site for 15–20 minutes every 2–3 hours. Rationale: Cold application reduces prostaglandin release, localised oedema, and inflammatory pain (Giaquinto et al., 2020).
4. Position patient in alignment with hip precautions: abduction wedge in place, head of bed ≤45°, avoid internal rotation. Rationale: Maintaining correct anatomical position prevents prosthetic dislocation and reduces pain from mechanical stress (AAOS, 2021).
DVT Prevention Plan
Per NICE NG89 (2018): Enoxaparin 40mg SC daily commenced 6–12 hours post-op for 28 days; anti-embolic stockings; early mobilisation day 1 with physiotherapy; foot and ankle exercises hourly; adequate hydration (≥2L/day). Patient education on VTE signs (calf pain, swelling, warmth) and when to seek urgent review.
