What are the post-operative orders for a patient with a history of hip cancer, status post surgical intervention?

Post-Operative Hip Cancer Orders

For patients post-hip cancer surgery, implement multimodal analgesia with scheduled paracetamol plus NSAIDs/COX-2 inhibitors, supplemental oxygen for 24 hours, early mobilization within hours of surgery, immediate urinary catheter removal, and aggressive nutritional support—all while avoiding routine opioid scheduling in favor of rescue-only dosing. 1, 2

Immediate Post-Operative Analgesia (First 24 Hours)

Scheduled Multimodal Regimen:

• Paracetamol 1g every 6 hours (maximum 4g daily), continued from intra-operative dosing 1
• COX-2 selective inhibitor OR NSAID continued postoperatively on a scheduled basis (not PRN) for anti-inflammatory effect 1
• Opioids strictly as rescue medication only—never scheduled dosing 1, 3

Critical Pitfall: Do not assume treatment failure without proper medication optimization; multimodal analgesia with scheduled paracetamol and NSAIDs should minimize or eliminate opioid requirements 3

Respiratory Management

• Supplemental oxygen for at least 24 hours postoperatively in all elderly patients, as they are at high risk of postoperative hypoxia 1
• Oxygenation and respiratory function improve with mobilization 1

Mobilization Protocol

• Begin mobilization as soon as medically appropriate—ideally within hours of surgery to prevent deep vein thrombosis, which occurs in 58% of hip replacement patients 2
• Early weight-bearing and toe-off exercises reduce thromboembolism risk (clinical DVT prevalence 1-3%, PE 0.5-3%) 2
• Do not delay mobilization due to pain concerns; inadequate pain control that prevents mobilization increases thromboembolism risk more than it protects the surgical site 2

Fluid and Catheter Management

• Remove urinary catheter as soon as possible (ideally within 24 hours) to reduce urinary tract infection risk 1, 2, 4
• Encourage early oral fluid intake rather than routine intravenous fluids, as hypovolemia is common 1, 2
• Avoid leaving catheters "just in case"—this significantly increases infection risk 2, 4

Cognitive Monitoring

• Screen for postoperative cognitive dysfunction, which occurs in 25% of hip fracture patients 1, 2, 4
• Multimodal optimization includes: adequate analgesia, nutrition, hydration, electrolyte balance, appropriate medication, bowel management, and mobilization 1
• Identify and treat complications: chest infection, silent myocardial ischemia, urinary tract infection 1
• Use haloperidol or lorazepam only for short-term symptom control 1
• Avoid cyclizine due to antimuscarinic side effects worsening cognitive dysfunction in elderly patients 1, 2, 4

Nutritional Support

• Assess nutritional status immediately, as up to 60% of hip fracture patients are clinically malnourished on admission 1, 2
• Administer nutritional supplementation and employ dietetic assistants, which may reduce mortality and length of stay 1

Pain Assessment and Monitoring

• Include pain evaluation as part of routine postoperative nursing observations 1
• Maintain nurse-to-patient ratio of 1:4 for hip replacement patients 2
• Regular input from physicians specialized in geriatric medicine is recommended 2

Anticoagulation Considerations

For patients on pre-operative anticoagulation:

• Aspirin: May be withheld during inpatient stay unless indicated for unstable angina or recent/frequent TIAs 1
• Clopidogrel: Generally not stopped, especially with drug-eluting coronary stents; expect marginally greater blood loss but do not delay surgery 1
• Warfarin: Recommence 24 hours after surgery; INR should be <2 for surgery and <1.5 for neuraxial anesthesia 1

Medications to Avoid

• Avoid oral opioids to reduce urinary retention risk 4
• Avoid codeine due to constipating, emetic, and cognitive-impairing effects 4
• Avoid gabapentinoids routinely due to side effects without proven benefit 3
• Avoid femoral nerve blocks, lumbar plexus blocks, or epidural analgesia for ongoing pain management due to adverse effects outweighing benefits 3

Rehabilitation Planning

• Coordinate care with orthogeriatricians, physiotherapists, occupational therapists, social workers, and nursing staff 1
• Consider secondary prevention of falls and osteoporosis in the early postoperative period 1
• Provide printed information describing typical care pathways for patients, carers, and relatives 1