What hip precautions should be included in a total hip replacement care plan?

For a posterior approach total hip arthroplasty, standard hip precautions include: no hip flexion beyond 90 degrees, no adduction past midline (do not cross legs), no internal rotation of the operative leg, use an abduction pillow between the legs when in bed, sit on elevated surfaces (raised toilet seat, elevated chair), use a long-handled reacher to avoid bending, and avoid low chairs or sofas. These precautions are typically maintained for 6-12 weeks post-operatively. Anterior approach procedures may have fewer restrictions, so it is essential to confirm precautions with the surgeon.

How is DVT prevented after hip replacement surgery?

DVT prevention after hip replacement includes pharmacological prophylaxis (typically low-molecular-weight heparin such as enoxaparin, direct oral anticoagulants like rivaroxaban, or aspirin depending on surgeon preference), mechanical prophylaxis (sequential compression devices and/or graduated compression stockings), early mobilization (out of bed on POD 0 or POD 1), ankle pumps and quadriceps sets every 1-2 hours while awake, adequate hydration, and monitoring for signs and symptoms of DVT (calf pain, swelling, warmth, redness, positive Homans sign).

When should a patient be able to walk after hip replacement?

With modern enhanced recovery after surgery (ERAS) protocols, many patients are assisted to stand and take a few steps on the day of surgery (POD 0) or the morning of POD 1 with physical therapy. Progressive ambulation goals include walking 50-100 feet with a walker by POD 1, increasing distance daily, and demonstrating safe stair navigation before discharge. Most patients are discharged home within 1-3 days and continue outpatient physical therapy for 6-12 weeks.

Hip Replacement (Total Hip Arthroplasty) Nursing Care Plan Example

Total hip arthroplasty (THA) is one of the most commonly performed orthopedic surgeries, typically indicated for severe osteoarthritis, avascular necrosis, or hip fracture. Nursing care in the post-operative period focuses on pain management, mobility restoration, DVT prevention, surgical site monitoring, and patient education on hip precautions. This example outlines a comprehensive care plan using NANDA-I diagnoses, NIC interventions, and NOC outcomes.

Condition Overview

Total hip arthroplasty involves replacing the damaged femoral head and acetabulum with prosthetic components. The procedure may use a posterior, lateral, or anterior surgical approach, each with different implications for post-operative precautions and rehabilitation. The posterior approach is most common and requires strict hip precautions to prevent posterior dislocation: no flexion beyond 90 degrees, no adduction past midline, and no internal rotation of the operative leg. The anterior approach offers fewer post-operative restrictions but has its own surgical considerations.

Modern enhanced recovery after surgery (ERAS) protocols have significantly reduced hospital stays, with many patients going home within 1-3 days. These protocols emphasize multimodal pain management (minimizing opioid use), early mobilization (often day-of-surgery ambulation), early nutrition, and VTE prophylaxis. Nurses play a central role in implementing ERAS protocols, monitoring for post-operative complications, and preparing patients for safe discharge and home recovery.

Typical Patient Presentation

The typical post-operative THA patient arrives on the orthopedic unit from the PACU with a surgical dressing over the operative hip, possibly with a wound drain (Hemovac or Jackson-Pratt). Initial assessment reveals pain at the surgical site (often 5-8/10 in the immediate post-operative period), limited mobility of the operative extremity, and varying degrees of sensation depending on the anesthesia type (general versus spinal). The patient may have an indwelling urinary catheter, sequential compression devices (SCDs) on both lower extremities, and an abduction pillow between the legs.

Vital signs may show mild tachycardia and blood pressure changes related to anesthesia recovery, blood loss, and pain. Hemoglobin may drop from pre-operative baseline due to intraoperative blood loss. The nurse must assess neurovascular status of the operative extremity (the 5 P's: pain, pulse, pallor, paresthesia, paralysis), surgical dressing integrity, drain output, and the patient's ability to perform ankle pumps and quadriceps sets.

Sample Assessment Scenario

Patient:Dorothy S., 68-year-old female, POD 1 following right total hip arthroplasty (posterior approach) for severe osteoarthritis. Spinal anesthesia with sedation. PMH: Osteoarthritis, hypertension, osteoporosis, GERD. Medications: amlodipine 5 mg daily, alendronate 70 mg weekly, omeprazole 20 mg daily. Post-operative orders include enoxaparin 40 mg subQ daily for DVT prophylaxis, multimodal pain regimen (acetaminophen 1g q8h scheduled, celecoxib 200 mg BID, oxycodone 5 mg q4h PRN), and physical therapy BID starting POD 1. Current assessment: Pain 6/10 at right hip, worse with movement. JP drain in place, 120 mL serosanguinous output in past 8 hours. Surgical dressing clean, dry, and intact. Neurovascular check: toes warm and pink, brisk capillary refill, pedal pulse palpable, sensation intact, able to dorsiflex and plantarflex right foot. Abduction pillow in place. SCDs on bilateral lower extremities. Foley catheter draining clear yellow urine. She is anxious about getting out of bed for the first time and states, "I'm afraid I'll fall or pop something out." Braden Scale: 16. Morse Fall Scale: 55.

NANDA-I Nursing Diagnoses

1. Acute Pain (00132)

Definition: An unpleasant sensory and emotional experience associated with actual or potential tissue damage, with sudden or slow onset of any intensity from mild to severe, with an anticipated or predictable end.

Related factors: Physical injury agent (surgical incision, tissue manipulation, bone resection).

Evidence: Reports pain 6/10 at right hip, pain worsened by movement, facial grimacing during repositioning.

2. Impaired Physical Mobility (00085)

Definition: Limitation in independent, purposeful physical movement of the body or of one or more extremities.

Related factors: Musculoskeletal impairment (surgical procedure), pain, prescribed movement restrictions (hip precautions), decreased muscle strength.

Evidence: POD 1, has not yet ambulated, hip precautions limiting range of motion, unable to bear full weight independently, requires assistance for bed mobility.

3. Risk for Peripheral Neurovascular Dysfunction (00086)

Definition: Susceptibility to disruption in the circulation, sensation, or motion of an extremity.

Risk factors: Orthopedic surgery with prosthetic implant, potential for compartment syndrome, venous stasis, immobility, anticoagulation therapy.

4. Risk for Injury (00035)

Definition:Susceptibility to physical damage due to environmental conditions interacting with the individual's adaptive and defensive resources.

Risk factors: Post-operative status, altered mobility, Morse Fall Scale 55 (high risk), hip precaution requirements, anxiety about mobilization, potential for prosthetic dislocation if precautions not maintained.

NIC Interventions

For Acute Pain

Pain Management (1400): Assess pain every 4 hours and PRN using numeric rating scale. Administer multimodal analgesia on schedule: acetaminophen 1g q8h (scheduled), celecoxib 200 mg BID (scheduled), oxycodone 5 mg q4h PRN for breakthrough pain. Apply ice to operative hip for 20 minutes every 2 hours. Premedicate 30-45 minutes before physical therapy sessions and ambulation. Teach non-pharmacological techniques: guided imagery, deep breathing, distraction. Position for comfort while maintaining hip precautions. Elevate head of bed no more than 60 degrees (to maintain less than 90 degrees hip flexion). Evaluate pain response 30-60 minutes post-intervention.
Analgesic Administration (2210): Monitor for opioid side effects (sedation, respiratory depression, nausea, constipation). Assess sedation level using Pasero Opioid-Induced Sedation Scale before each opioid dose. Initiate bowel regimen prophylactically (docusate sodium + sennosides). Taper opioid use as pain decreases, transitioning to non-opioid alternatives.

For Impaired Physical Mobility

Exercise Therapy: Ambulation (0221): Collaborate with physical therapy for first ambulation on POD 1. Reinforce weight-bearing status as ordered (typically weight-bearing as tolerated for cemented prosthesis). Assist to sitting position at bedside first, assessing for orthostatic hypotension. Progress to standing with walker, then ambulation. Goal: 50-100 feet with walker by end of POD 1, increasing daily. Ensure non-skid footwear. Keep walker and call bell within reach at all times.
Exercise Therapy: Joint Mobility (0224): Instruct and supervise ankle pumps (10 repetitions every 1-2 hours while awake). Teach quadriceps sets and gluteal squeezes. Reinforce hip precautions at every interaction: no flexion past 90 degrees, no crossing legs, no internal rotation. Use abduction pillow when in bed. Demonstrate proper technique for getting in and out of bed (operative side trailing). Post hip precaution reminders at bedside and in the bathroom.

For Risk for Peripheral Neurovascular Dysfunction

Circulatory Care (4070):Perform neurovascular checks every 2 hours for first 24 hours, then every 4 hours (5 P's assessment). Maintain SCDs on bilateral lower extremities when in bed. Administer enoxaparin 40 mg subQ daily as ordered. Monitor Hemovac drain output (report if exceeding 200 mL/hr or sudden increase in output). Monitor hemoglobin — transfuse per order if below threshold (typically Hgb less than 7 g/dL or symptomatic anemia). Assess for signs of DVT every shift: calf tenderness, swelling, warmth, redness, positive Homans sign (though clinical reliability is debated). Assess for signs of pulmonary embolism: sudden dyspnea, chest pain, tachycardia, anxiety.
Embolus Precautions (4110): Encourage active ankle dorsiflexion and plantar flexion exercises. Promote early and progressive ambulation. Ensure adequate hydration. Avoid placing pillows under the knees (impedes venous return). Educate patient on the importance of maintaining SCDs when in bed and the rationale for anticoagulation.

For Risk for Injury

Fall Prevention (6490): Implement fall precautions per Morse Fall Scale score of 55 (high risk). Keep bed in lowest position with brakes locked. Ensure call bell within reach at all times. Assist with all transfers and ambulation. Provide adequate lighting. Remove environmental hazards (cords, wet floors). Non-skid footwear for all ambulation. Toileting schedule to reduce urgency-related falls.
Positioning (0840): Maintain abduction pillow between legs when supine and during turning. Turn only to the non-operative side with pillow between legs. Use elevated toilet seat and raised chair. Instruct patient to avoid bending to pick up items — provide long-handled reacher. Reinforce hip precautions before every position change.

NOC Outcomes

Pain Level (2102)

Target: Pain reduced to 4/10 or less at rest by POD 2
Indicator: Patient able to participate in physical therapy sessions with pain controlled
Indicator: Opioid use decreasing by POD 2-3 with transition to non-opioid regimen

Mobility (0208)

Target: Ambulates 200+ feet with walker by POD 2
Indicator: Demonstrates safe transfers (bed to chair, chair to standing) independently
Indicator: Navigates 3-4 stairs with rail and walker before discharge
Indicator: Maintains hip precautions without prompting during all activities

Tissue Perfusion: Peripheral (0407)

Target: Neurovascular checks remain intact throughout hospitalization
Indicator: No signs or symptoms of DVT or PE during admission
Indicator: Hemoglobin stable or trending upward by discharge

Fall Prevention Behavior (1909)

Target: No falls during hospitalization
Indicator: Patient uses call bell before ambulating
Indicator: Patient verbalizes understanding of fall prevention measures

Discharge Planning Considerations

Discharge readiness after THA requires the patient to demonstrate safe ambulation with an assistive device, independent or safely assisted transfers, stair navigation (if applicable to home environment), adherence to hip precautions, adequate pain control on oral medications, no signs of surgical site infection or DVT, stable hemoglobin, and understanding of the home exercise program. Arrange outpatient physical therapy (typically 2-3 times per week for 6-12 weeks). Ensure home safety assessment is complete: remove throw rugs, install grab bars in the bathroom, arrange for raised toilet seat and shower chair. Confirm the patient has enoxaparin syringes or prescribed oral anticoagulant for DVT prophylaxis (typically 2-6 weeks post-operatively). Schedule follow-up with the orthopedic surgeon at 2 weeks for wound check and staple removal.

Building Your Own Hip Replacement Care Plan

Every THA patient has unique surgical variables (approach, fixation type, weight-bearing status), comorbidities, functional baseline, and discharge destination that shape the care plan. The diagnoses and interventions above represent a common framework for a straightforward posterior approach THA with cemented prosthesis.

CarePlanHQ creates individualized post-operative hip replacement care plans from your patient assessment data. Enter the surgical details, mobility status, pain level, and comorbidities to receive a complete NANDA-I care plan with interventions, outcomes, and a downloadable PDF.