Nurse Role Grows in Joint Replacement

In 2009, nearly 40 million people, or one in eight Americans, were over the age of 65.1 By 2030, these older adults will make up 19 percent of the population (about 72.1 million people).2

This growing, aging population is one reason joint replacements are on the rise.

“Baby Boomers are aging and individuals are no longer willing to put up with pain and dysfunction as they age,” noted Melissa Verdi BSN, RN, staff nurse for Richard H. Rothman, MD, PhD, at the Rothman Institute in Pennsylvania and New Jersey.

Total hip and knee replacements decrease pain and improve function, which in turn improves the quality of life for arthritic patients. Following surgery, the goal of both the patient and surgeon is to resume daily activities along with low impact sports without pain, remarked Verdi.

Nurses, who are involved in the care of patients with joint replacement from the preoperative period through the recovery phase, have seen their role change throughout the years.


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Joint Replacement Upsurge

According to Jennifer Smith, MSN, RN, APN-C, director of the Orthopedic Program of Excellence at Virtua in Marlton, NJ, two main benefits, namely pain alleviation and mobility restoration, result from joint replacement surgery, allowing people to return to an active lifestyle.

She offered two additional trends contributing to the increase in joint replacements: obesity and more active lifestyles.

For starters, being overweight puts an increased amount of stress on joints over time and the cartilage begins to break down due to years of added stress, Smith explained.

Also, adults are remaining much more physically active later in life; and often they have old knee or hip injuries that contribute to the development of osteoarthritis.

Shivi Dixit, MSN, RN, CMSRN, orthopedic service line manager, St. Joseph Hospital, Orange, CA, mentioned the “Baby Boomer Effect” (a disproportionate number of people hitting retirement age at the same time) as well as an increased awareness of the benefits of the joint replacement as other potential contributors to the increase in joint replacements.

“People in general are living longer and are more active for a longer period of time,” said Dixit.

New procedures, such as the quadriceps tendon sparing knee replacements and anterior approach hip replacements performed at Virtua, enable some patients to be discharged the same day as their surgery. Almost all patients are able to forgo a rehab center, go directly home and be back to work in weeks as opposed to months after surgery.

Greater Nurse Involvement


Smith noted that Virtua appoints a nurse navigator to a patient from the time he or she is scheduled for surgery, guiding the patient through the pre-admission process and educating the patient about what to expect during their hospital stay and recovery process.

“In addition to the care the nurse provides while the patient is in the hospital, homecare and rehab nurses play a key role in the patient’s recovery after they have been discharged from the hospital,” she said.

Dixit remarked that a nurse’s primary preoperative role is to prepare patients for surgery by educating them on their procedure and the care they will be given so they know what to expect during and after surgery.

“One of the core values we live and work by at St. Joseph Hospital is respecting the dignity of our patients, and making sure each patient is properly prepared for their surgery physically, mentally and emotionally,” disclosed Dixit. “The preoperative education also helps to build a personal relationship between our nurses and patients, which in turn helps relieve patient anxiety and makes recovery easier.”

In the past, nurses have had very little involvement with patients preoperatively; now the nurse navigator works to develop a relationship with the patient. Preoperative education has changed the dynamic of care that nurses can provide.

In this information age, patients often come to the hospital well-prepared with questions and a base knowledge of the procedure. The Internet usually plays a key role in the knowledge obtained, acknowledged Dixit.

“Many patients try to reconcile the information learned on the Internet with the information they get in the preoperative education sessions and the nurses need to be equally as prepared to answer any questions and address any concerns the patient may have,” said Dixit.

Changes in Processes & Protocols

Though the basics of the nursing role remain, i.e., clinical, emotional and spiritual care, communication patterns through electronic methods have been a big change for nursing as well as patients to get used to, noted Kanoe Allen, MSN-CNS, RN, PHN, chief nursing officer at Hoag Orthopedic Institute in Irvine, CA.

“Postoperatively, our orthopedic care has advanced dramatically from 10 years ago. Our patients spend a much shorter time in the hospital, with fewer restrictions on movement and are, overall, a very active group,” Allen commented.

Because the length of stay for these types of procedures is getting shorter, nurses have to start working toward discharge planning and mobilization right after surgery. A sooner discharge also means that nurses may only have a few hours instead of days with the patient.

“Most patients are also going directly home instead of a rehab center and because of this, patients and their families must be well-educated prior to discharge,” Smith explained.

Allen believes it is crucial for nurses to keep abreast of all the changes in techniques and care changes through ongoing education. One way that acknowledges the orthopedic nursing expertise is certification, she said. The National Association of Orthopedic Nurses offers a specialty certification, known as Orthopedic Nursing Certified (ONC).

Building a Personal Relationship

Patient education must discuss what to expect during hospitalization as well as when the patient goes home. At Hoag Orthopedic Institute, this takes place during a pre-op class.

“Patients who undergo elective joint replacement may have quite a bit of anxiety,” Allen acknowledged, noting this all must be done in a matter of just a couple of days.


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“Anxiety makes it difficult to retain information, so a lot of reminders may be needed. It is challenging to provide great pain control, ambulate patients, meet their other clinical and psychosocial needs and then provide patient self-care education so they are safe to go home.”


When taking care of patients who have undergone less-invasive operations, the responsibilities of nurses remain more or less the same.

“It is always our duty to ensure that patients are prepared and knowledgeable about their procedure and comfortable through every step of the process,” said Dixit.

The personal relationship that was built during preoperative sessions helps tremendously when patients come out of the operating room and begin postoperative care. At this time, the nursing staff reinforces the information learned before the procedure and ensures the patient understands the importance of dressing changes and symptoms to watch for following discharge.

“At St. Joseph Hospital we strive to deliver perfect care, and ensuring our patients go home with the knowledge needed to heal postoperatively is part of this process,” concluded Dixit.

References for this article can be accessed here.

Beth Puliti is a frequent contributor to ADVANCE.

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