Postoperative Day 2 After Total Hip Arthroplasty: Pain, Refusal, and a Swollen Calf
Mrs. K., 72, is on postoperative day 2 after an elective right total hip arthroplasty for osteoarthritis and transferred to inpatient rehabilitation yesterday. She has a history of atrial fibrillation, hypertension, and type 2 diabetes. She is prescribed enoxaparin 40 mg subcutaneously daily, started 12 hours after surgery. This morning her pain is 7/10 in the right hip and she refuses physical therapy, saying it hurts too much to move. She has been hesitant to use the incentive spirometer. On assessment, her right calf is 3 cm larger than the left and warm, heart rate is 112 and regular, respirations 24, SpO2 93% on room air, temperature 37.4 degrees C, blood pressure 128/76. She denies chest pain but says she feels winded and a little lightheaded after walking to the bathroom. She uses a hydromorphone patient-controlled analgesia pump and has not had a bowel movement since surgery.
1. Interpret these findings. What is your priority, and what will you do immediately?
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The combination of unilateral calf swelling that is warm, tachycardia at 112, tachypnea at 24, SpO2 of 93%, and exertional dyspnea is concerning for deep vein thrombosis with possible pulmonary embolism, not just normal postoperative swelling. Homans' sign is unreliable, so do not use it. Immediate actions: keep her at rest, do not massage the leg, notify the provider now, and prepare for duplex ultrasound and possibly D-dimer or CT angiography per order. Give oxygen if SpO2 stays below 90 to 92% and position her semi-Fowler's; monitor heart rate, respiratory rate, SpO2, and mental status. Check the medication administration record, because a missed enoxaparin dose is a risk factor. The priority is respiratory and hemodynamic stability; she is stable enough to remain on the unit but needs urgent evaluation.
2. How do you respond to her refusal of physical therapy and her pain of 7/10?
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Her refusal is clinically meaningful, not noncompliance. Pain of 7/10 before therapy is undertreated, and immobility is itself a DVT and PE risk. Coordinate analgesia: premedicate 30 to 45 minutes before therapy with the prescribed multimodal regimen (scheduled acetaminophen or an NSAID if not contraindicated, plus a PCA bolus) and negotiate a realistic pain goal with her. Do not simply push her through severe pain, which undermines trust and mobility. Meanwhile, with a suspected DVT, hold aggressive therapy until the provider evaluates the leg. Address the constipation, since no bowel movement since surgery plus opioids worsens pain and immobility. Use a gait belt and the prescribed hip precautions: no hip flexion beyond 90 degrees, no adduction past midline, and no internal rotation.
3. Describe safe transfer and hip precautions, and the anticoagulation monitoring you would include.
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Transfer with the operative leg kept in abduction and neutral rotation: use a raised toilet seat, avoid low chairs, and teach the log-roll and a posterior-lateral approach. Precautions are approach-specific: a posterior approach restricts flexion beyond 90 degrees, adduction, and internal rotation, while an anterior approach has different limits, so verify the surgeon's order rather than applying a default. For enoxaparin, monitor for bleeding at injection sites, gums, urine, stool, and any neurologic change; avoid intramuscular injections and NSAIDs without an order, and hold or consult before procedures. Report a falling platelet count or new bruising. Ambulation and ankle pumps help prevent DVT, but not until the suspected DVT is evaluated. Teach her to report calf pain with swelling or sudden shortness of breath immediately after discharge.