What is the recommended nursing care plan for a patient with impaired mobility following a post-operative abduction leg injury, with a need to avoid acute flexion?

Nursing Care Plan for Impaired Mobility Related to Post-Operative Hip Abduction Precautions

For patients requiring hip abduction precautions with avoidance of acute flexion (typically post-hip arthroplasty or hip fracture repair), mobilize the patient as soon as hemodynamically stable while maintaining strict positioning protocols, implement DVT prophylaxis immediately, and establish a structured progressive mobility protocol to prevent the life-threatening complications of immobility. 1

Priority 1: Immediate Mobilization with Positioning Precautions

Begin mobilization within 24 hours of surgery while maintaining hip abduction and avoiding flexion >90 degrees, as early mobilization reduces mortality risk by up to 51% in the first 30 days. 1, 2

Specific Positioning Requirements:

• Maintain the affected hip in abduction at all times using an abduction pillow or wedge between the legs 1
• Position joints on the affected side higher than proximal joints to prevent dependent edema and facilitate venous return 1
• Avoid hip flexion beyond 90 degrees, hip adduction past midline, and internal rotation of the affected leg 1, 2
• When repositioning, never pull on the affected limb—use proper body mechanics and assistive devices 1, 2
• Reposition the patient at least every 2 hours to prevent pressure ulcers, maintaining abduction precautions during all turns 1, 2

Progressive Mobility Protocol:

• Day of surgery: Sit at bedside with feet on floor for 2 hours total (in divided sessions), maintaining hip precautions 1, 3
• Postoperative day 1: Out of bed to chair for 6 hours total, begin assisted ambulation with walker if cleared 1, 4
• Monitor the first transfer closely for neurological worsening or orthostatic hypotension 1
• Use short, frequent exercise sessions rather than infrequent long sessions to prevent fatigue 2

Priority 2: Venous Thromboembolism Prevention

Apply intermittent pneumatic compression (IPC) devices within the first 24 hours and maintain until the patient is consistently ambulatory, as DVT and pulmonary embolism account for substantial mortality in immobilized patients. 1, 2

DVT Prophylaxis Protocol:

• Apply bilateral IPC devices immediately upon admission to the unit 2
• Ensure IPC devices remain on except during ambulation and hygiene 1
• Perform bilateral lower extremity neurovascular checks every 4 hours, documenting pulses, capillary refill, sensation, and motor function 5
• Assess for signs of DVT: unilateral leg swelling, warmth, erythema, or calf tenderness 1
• Coordinate with the medical team regarding pharmacological prophylaxis (typically enoxaparin 40 mg subcutaneously daily or unfractionated heparin 5000 units twice daily) 1

Priority 3: Skin Integrity Maintenance

Implement a structured repositioning schedule with skin assessments every 2 hours, as pressure injuries significantly increase length of stay and mortality risk. 1, 2

Pressure Injury Prevention:

• Perform skin assessment using the Braden scale on admission and daily thereafter 2
• Inspect bony prominences on the affected side with each repositioning: sacrum, heels, greater trochanter, lateral malleolus 1, 2
• Use pressure-redistributing surfaces (foam mattress overlay or low-air-loss mattress) for high-risk patients 1
• Elevate heels off the bed surface using pillows or heel protectors 2
• Maintain the affected hip in abduction during all position changes using pillows between the knees 1

Priority 4: Bladder and Bowel Management

Remove indwelling urinary catheter within 48 hours and establish a scheduled toileting program every 2 hours during the day and every 4 hours at night to prevent UTI and constipation. 1, 2

Elimination Management:

• Discontinue Foley catheter by postoperative day 2 unless specific contraindications exist 2
• Offer bedside commode, bedpan, or urinal every 2 hours while awake and every 4 hours overnight 1, 2
• Measure post-void residual if patient voids <100 mL or has signs of retention; initiate intermittent catheterization if residual >100 mL 1
• Encourage high fluid intake during the day (minimum 1500-2000 mL unless contraindicated) and decreased intake after 6 PM 1
• Implement bowel protocol with stool softeners and scheduled laxatives to prevent constipation from immobility and opioid use 1

Priority 5: Fall Prevention

Conduct fall risk assessment using a validated tool on admission and implement environmental modifications, as hip fractures occurring within 7 days post-stroke are associated with poor prognosis. 1, 2

Fall Prevention Strategies:

• Keep call bell within reach at all times and instruct patient to call for assistance before attempting to stand 2
• Maintain bed in lowest position with brakes locked when patient is in bed 2
• Remove clutter from the environment and ensure adequate lighting 2
• Provide properly fitted non-skid footwear before any mobility activity 2
• Use assistive devices (walker with platform attachment if needed) for all ambulation 1, 2
• Never leave the patient unattended during transfers or ambulation until independence is clearly established 1

Priority 6: Pain Management

Administer scheduled analgesics to maintain pain control adequate for participation in mobility activities, as uncontrolled pain is a primary barrier to early mobilization. 1, 6

Pain Control Protocol:

• Assess pain using a numeric rating scale before and after each mobility session 6
• Administer scheduled NSAIDs (if not contraindicated) or acetaminophen for baseline pain control 1
• Provide breakthrough opioid analgesia 30-45 minutes before planned mobility activities 6
• Monitor for opioid-related side effects: sedation, respiratory depression, constipation, urinary retention 1
• Reassess pain 30 minutes after medication administration and adjust plan accordingly 6

Priority 7: Range of Motion and Contracture Prevention

Initiate passive and active-assisted range of motion exercises for all joints on the affected side within the first postoperative days, avoiding movements that violate hip precautions. 1, 5

Range of Motion Protocol:

• Perform ankle pumps and quadriceps sets every hour while awake to prevent DVT and maintain muscle strength 1, 4
• Conduct passive range of motion to the affected hip within precaution limits (abduction, neutral rotation, flexion <90 degrees) three times daily 1
• Encourage active range of motion of the shoulder, elbow, wrist, and hand on the affected side 5
• Never force range of motion beyond the point of resistance or pain 1
• Coordinate with physical therapy for formal assessment and progressive strengthening exercises 2, 6

Priority 8: Nutritional Support

Monitor nutritional intake closely and provide protein-rich supplements, as up to 50% of immobilized patients become malnourished within 2-3 weeks. 1, 2

Nutritional Monitoring:

• Document oral intake at each meal using percentage consumed 1
• Offer protein-rich oral nutritional supplements between meals to maintain adequate protein and energy intake 1
• Coordinate with dietitian for formal nutritional assessment if intake is <50% of meals for 3 consecutive days 2
• Monitor for signs of malnutrition: unintended weight loss, decreased albumin, poor wound healing 2

Priority 9: Psychosocial Assessment

Screen for depression and anxiety within the first week, as psychological complications affect up to one-third of patients with impaired mobility and significantly impact rehabilitation participation. 1, 2

Psychosocial Monitoring:

• Assess for signs of depression: declining to participate in therapy, flat affect, social withdrawal, sleep disturbances 1, 2
• Screen for poststroke fatigue, which affects at least half of patients and negatively impacts rehabilitation 1, 2
• Provide emotional support and encourage family involvement in care 1
• Refer to social work or psychology if depression screening is positive or patient exhibits significant anxiety 2

Critical Monitoring Parameters

Assess for complications of immobility daily: atelectasis, pneumonia, DVT, pulmonary embolism, pressure injuries, urinary retention, and constipation. 1

Daily Assessment Checklist:

• Respiratory status: auscultate lung sounds, assess respiratory rate and effort, encourage incentive spirometry every 2 hours while awake 1
• Cardiovascular status: monitor for tachycardia, hypotension, or signs of DVT/PE 1
• Neurovascular status of affected extremity: pulses, capillary refill, sensation, motor function, temperature 5
• Skin integrity: complete head-to-toe assessment with focus on pressure points 2
• Elimination patterns: document voiding frequency, bowel movements, and any incontinence 1
• Functional status: document distance ambulated, level of assistance required, and patient tolerance 6

Common Pitfalls to Avoid

• Never allow hip flexion >90 degrees during transfers, toileting, or sitting—this violates precautions and risks dislocation 1
• Never pull on the affected limb during repositioning—this can cause subluxation or dislocation 1, 2
• Never delay mobilization waiting for "the patient to feel better"—immobility complications account for 51% of early mortality 1, 2
• Never rely solely on patient report of needing to void—implement scheduled toileting to prevent retention and UTI 1, 2
• Never leave IPC devices off for extended periods—DVT risk remains elevated throughout hospitalization 1, 2