Patient With Total Hip Replacement, Case Study Example

Mrs. HT, the patient, is a 65-year-old Caucasian female of average weight and body size.

Subjective

• Patient has a long history of hypertension, high cholesterol, and lower back pain following a car accident five years ago.
• On medication for high blood pressure and cholesterol, since she was 40 years old, and has a strong family history of both conditions. The patient has no known drug allergies.
• Childhood hx of measles and mumps as well as German measles. As an adult, had diagnoses of uterine fibroids and osteoarthritis. Last mammogram and Pap smear occurred last year, and were normal.
• married 35 years to the same man, a 67-year-old Caucasian male who retired two years ago.  Reports that her marriage is good.She has no children.
• Born in Boston, moved to Chicago to attend college and has remained in the Midwest since then.
• taught elementary school for approximately 35 years in her local school system. Many of the physical activities in which she had to engage as a teacher caused back pain, and standing on her feet for most of the workday for so many years also placed a great deal of strain on her hips, legs, and back.
• Until five years ago, she was able to engage in the full range of activities needed to lead a normal life, and only after her car accident five years ago did her back pain begin to affect her functioning. At that point, she was unable to stand for long periods of time, experienced pain when sitting for more than 30 minutes, and curtailed her activities more and more to the point that she is unable to walk or stand for more than five or 10 minutes at a time. For the last few months, she has been using a cane to reduce the pressure on her legs.
• For several years, the patient has been taking glucosamine chondroitin, to reduce pain and stiffness.
• Client strengths include being motivated to have any procedure that will reduce her pain level, and restore her to a more “normal” existence; intelligence that allows her to participate rationally in decision-making regarding her medical status; a long history of coping with her medical situation and following medical advice to minimize pain and discomfort, i.e., compliance with medical plans; and a supportive husband who attends all appointments with her and will be part of her rehabilitation.

Objective Data

• Patient is a well-nourished female, pulse 98, blood pressure 125/85. Neurological exam within normal limits, patient unable to lift either right or left leg higher than three or four inches from the ground, cannot bend over to touch toes. Her gait reflects a slight limp when she puts weight on her left foot, but is otherwise normal.

Assessment

• Client deficits: back pain, leg pain that reduces ability to walk and sit for reasonable periods of time, hypertension and high cholesterol. This patient is an ideal candidate for total hip replacement surgery.

Plan

• Presurgery, patient education regarding expectations prior to and following operation, including rehabilitation that will involve physical and occupational therapy. Following therapy, three short term goals:

1. Manage pain with medication. This goal was selected because pain plays a significant role in the rehabilitation of people who have total hip replacement, and their ability to recover; if their pain level is too great, they will be unable to engage in the physical and occupational exercises that will restore them to health. The patient should keep a log of pain on a scale of 1 to 10, so that there should be a decrease in the level of pain as reported by the patient on a regular, daily basis. 2. Get out of bed and sit in a chair two or three times a day for 30 minutes, including walking a very short distance to the chair. This will begin to increase strength and normalize gait more quickly. 3. Restore ability to urinate oneself by using a commode or an elevated toilet seat every few hours; this will heighten patient’s sense of dignity and independence and is much less messy and difficult to use than a bed pan, which may leave the patient feeling unclean, humiliated, and dependent.