Four Days After a Hip Replacement, at 0300
Mr. Boone, 80, is four days out from a right total hip replacement. His care plan reads: weight bearing as tolerated with a walker, one staff assist, no hip flexion past 90 degrees, no crossing legs, no turning the right leg inward, up for all meals. At 0300 he calls you: 'I need to use the bathroom. The call light takes forever, I'll just walk myself.' Yesterday, while walking with you, he mentioned his right calf was sore; you noticed it looked slightly swollen. He is alert and oriented, and there is no lift equipment in the room.
1. It is 0300. What do you do about his plan to walk to the bathroom alone?
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A flat 'no' through a doorway means he gets up alone the moment you leave. Offer an alternative and stay with him.
- Offer the urinal or bedpan first, matter-of-factly, with privacy.
- If he wants the toilet, take him - walker in front, gait belt on, lights on, non-skid footwear, one staff assist as ordered. Never pull him up by the arms; use the gait belt.
- Do not let him walk alone 'just this once.' He is four days post-op with a new hip, night-time, possibly on pain medication - this is the highest-risk walk of the day.
- If he refuses help and starts to get up anyway, get a second staff member rather than physically blocking him.
- Report the call-light delay to the nurse so the underlying complaint gets addressed - but that conversation does not change tonight's answer.
- Document the request, what you offered, what he accepted.
Judgement point: 'weight bearing as tolerated' means he can bear weight, not that he can do it unsupervised.
2. What do you do with the sore, slightly swollen right calf you noticed yesterday?
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- Report it before the next walk - the nurse decides whether he ambulates and how much, not you.
- Look at it and describe it objectively: compare both calves, note warmth, redness, swelling, and whether it hurts when he moves his foot - and write down what you saw.
- Do not massage the calf. A painful, swollen calf after hip surgery raises the question of a deep vein clot, and massage is exactly what you do not do to a possible clot.
- Do not apply heat, and do not tell him it's normal soreness or that it will pass. Reassuring someone out of reporting is how a clot becomes a pulmonary embolism.
- Do not encourage extra exercise on that leg until the nurse has assessed it.
- Stay within scope: you detect and describe; the nurse interprets and decides.
The judgement: 'he had surgery, of course he's sore' is the reasoning that misses a clot.
3. During the assisted walk, what do you do to protect the new hip - and what do you deliberately let him do himself?
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Protect the hip:
- Walker in front, gait belt on, you on his operated side.
- No bending past 90 degrees - raise the toilet seat, bring the walker close, and pick up anything he drops yourself instead of letting him reach down.
- No crossing the legs and no turning the right leg inward - when he pivots, cue him to step around rather than twist; when he is in bed, keep the abduction pillow between his legs if ordered, and do not turn him by pulling the leg.
- Move at his pace, stop if he reports pain or dizziness, and let him sit if he needs to.
Deliberately let him do: grip the walker, push up from the armrests, stand, balance, steer, and pivot with your cueing. Restorative care is him doing the work with the right amount of help - do too much for him and he loses strength, but stand by ready to steady him.
Report any pain, giving-way, or change from what he did yesterday to the nurse.