Iraqi J Pharm Sci, Vol.21(1) 2012 Total hip replacement home – care 39 Assessment of Patients’ Knowledge Toward Total Hip Replacement Home – Care Suad .J. Mohamed * ,1 and Abdullah .E. Mecheser** *Nursing College, University of Baghdad ,Baghdad, Iraq. ** Medical & Health Technical College,Baghdad, Iraq. Abstract To assess the total hip replacement patients’ knowledge of home – care regarding pain management, medication therapy, wound care, mobility limitation and complications may occur in the post hip replacement surgery, and to assess relationship between some variables such as, age level of education, sex & marital status with home- care knowledge. A descriptive study was used to assess the hip-replacement patient home-knowledge, a purposive sampling of (60) hip-replaced –patients were selected from Gazy Alhariri Hospital (central of surgical profession ) and Alwasity Hospital ( plastic surgery) , the questionnaire obtains two parts , part one, which included socio-demographical characteristics of the sample and part 2 , which included hip-replacement home-care knowledge , reliability and validity of the questionnaire were determined . Data were collected through the use of the questionnaire, at the hip application of the interview techniques and review of the hip replacement surgery rehabilitation review literature. Data were analyzed through descriptive and inferential data approach.The result of the study presented that the majority of the study sample were group at age (25- 35) years old, female married, housewife with (50%) of patients were at level of primary school education. They were lacking knowledge toward pain management at home and wound care , also discharged with very minimum information and rehabilitation training instruction toward practicing assistive walking and activity device or preventing potential complication such as infection and dislocation , Besides the study revealed a significant relationship between total- hip replacement knowledge toward complication may be occurred and level of education ,which revealed that the educated hip- replaced patients can managing and preventing the complication may occurred better than those not educated.Establishing a special rehabilitation unit in the ward to provide the patients with a rehabilitation program for training , also to provide them with a booklet or pamphlet illustrating all formations the patient may need at home. Key words: Total – hip replacement , patients’ knowledge of pain , patients’-knowledge of potential complication , patients' knowledge toward wound , patients’ knowledge of mobility. تقويم معرفت انمرظى نهعنايت انمنزنيت بعد عمهيت استبدال مفصم انورك *سعاد جاسم محمد ،1 **هللا عيادة مجيسر و عبد * وٍُت اٌخّزَض ،خاِعت بغذاد ، بغذاد ، اٌعزاق. ** وٍُت اٌخمُٕاث اٌصحُت واٌطبُت ، بغذاد ، اٌعزاق. الخالصة ٕاَت إٌّشٌُت بعذ عٍُّت اسخبذاي ِفصً اٌىرن اٌىاًِ ، فُّا َخعٍك باٌعٕاَت باألٌُ واٌعالج ُُ ِعٍىِاث اٌّزضً ٌٍعمُح اٌعاللت بُٓ بعض اٌّخغُزاث ِثً حمُُُ ووذٌه اٌذوائٍ واٌعٕاَت بدزذ اٌعٍُّت وححذَذاث اٌحزوت و اٌّضاعفاث اٌخٍ ححذد بعذ اٌعٍُّت ، . دراست وصفُت غُز احخّاٌُت ٌخمُُُ ِعٍىِاث ِزضً اسخبذاي ُت إٌّشٌٌٍعٕاَت واٌدٕس بّعٍىِاث اٌّزَض اٌعّز واٌّسخىي اٌثمافٍ ( ِزَض حُ إخزاء عٍُّت اسخبذاي ِفصً اٌىرن ٌهُ فٍ ِسخشفً اٌشهُذ غاسٌ 06)إٌّشٌُت وشٍّج اٌعُٕت ِفصً اٌىرن باٌعٕاَت حخضّٓ اداة االسخبُاْ ِٓ خشئُٓ:اٌحزَزٌ اٌّزوشٌ ٌٍدزاحاث اٌخخصصُت وِسخشفً اٌىاسطٍ ٌٍدزاحاث اٌخدٍُُّت ،و اٌدشء األوي: اٌّعٍىِاث اٌذَّىغزافُت ٌٍعُٕت. اٌدشء اٌثأٍ: ِعٍىِاث ِزضً اسخبذاي ِفصً اٌىرن اٌىاًِ ٌٍعٕاَت إٌّشٌُت. عض األدبُاث وحُ ححذَذ صذق األداة وخّع اٌبُأاث خالي اسخّارة اسخبُاْ عٓ طزَك اٌّمابٍت اٌّباشزة ِٓ لبً اٌباحذ ووذٌه ِزاخعت ب اٌخٍ حخص عٍُّاث اسخبذاي ِفصً اٌىرن وحأهٍُه، وحُ ححًٍُ اٌبُأاث ِٓ خالي اإلحصاء اٌخحٍٍٍُ واالسخذالي . سٕت، ٔساء ِخشوخاث ورباث بُىث . 52-52ِٓ اٌّدّىعت اٌعّزَت أظهزث اٌذراست أْ ِعظُ اٌّزضً اٌّشاروُٓ فٍ اٌعُٕت هُ %( ِٓ اٌّزضً واْ ِسخىاهُ اٌثمافٍ هى اٌذراست االبخذائُت فمظ ، اظهزث اٌذراست أَضا هٕاٌه ٔمص فٍ ِعٍىِاث اٌّزضً 26واْ) ٌّّارسه حأهٍه شفً بّعٍىِاث لٍٍُت خذا ٔحى اٌعٕاَت عٕذ حذود األٌُ فٍ إٌّشي ووذٌه اٌعٕاَت باٌدزذ، وَخُ خزوج اٌّزَض ِٓ اٌّسخ ٌخهاباث وعذَ حّىضع اٌّفصً فٍ ِىأت، ووذٌه اظهزث اٌحزوت وِٕع حذود ِضاعفاث خطزة واالاٌّشٍ وإرشاداث اسخعّاي ِسأذ اٌذراست عاللت لىَت بُٓ اٌّسخىي اٌثمافٍ ٌٍّزَض وِٕع حذود ِضاعفاث ٌّزضً اسخبذاي ِفصً اٌىرن اٌىاًِ. ّارسه إٌشاطاث ُز بزٔاِح حأهٍٍُ ٌٍّزَض ٌٍخذرَب عًٍ ِأوصً اٌباحثىْ أشاء وحذة حاهٍُُت ِخخصصت فٍ ٔفس اٌزدهت ٌخىف اٌّعٍىِاث اٌخاصت اٌخٍ حخعٍك واٌفعاٌُاث اٌُىُِت اٌخٍ َحخاخها اٌّزَض فٍ إٌّشي ووذٌه حىفُز وخُب َخضّٓ وً إٌشاطاث و . باٌخّارَٓ اٌحزوُت ٌُىىْ دًٌُ عًّ ٌه عٕذ اٌخزوج انكهماث انمفتاحيت : تبديم كامم انمفصم ، معرفت انمريط باألنم ، معرفت انمريط نمعاعفاث انمرض اندقيقت ، معرفت انمريط .بانجروح، معرفت انمريط بانحركت 1 Corresponding author E- mail : suad_jassim@yahoo.com Received : 9/8/2011 Accepted : 21/2/2012 Iraqi J Pharm Sci, Vol.21(1) 2012 Total hip replacement home – care 40 Introduction Total- hip replacement provides significant relief of pain and improvement of function, it is the replacement of severely damaged hip with an artificial joint, indication for this surgery include arthritis, femoral neck fracture , expulsive trauma and problem resulting from congenital –hip disease (1 - 15 ) . Hip replacement, have been an offer to patients with painful hip-joints for almost 50 years, millions of patients worldwide have benefited from this surgery and regained pain free, active lives (6,14) Home as health setting, optimal management in the home occurs when a person can independently maintain a growth – promoting environment, the home is comfortable and safe, and a person perform self-care and hygiene tasks, interacts with others and engages in activities (9) .With maintaining femoral head component in acetabullar cup (2) .Rehabilitation program and precautions necessary to protect newly implanted hip and to prevent problem called dislocation, these instructions and precautions given as sessions after surgery related to how to use a walker in walking and keeping a good alignment and balance in a usual time 2-4 weeks with cane and 4-6 weeks unassisted (2,12) .Home care considerations include ongoing assessment of management , maintaining for infection , and prevention of deep vein thrombosis (DVT). not all patients will qualify for home nursing visit, the incision may be closed with metal staples ,which are removed at the surgeon's clinic, because of the high risk of DVT, prothrombin times will be determined weekly are commonly used to map the care of clients after total hip replacement because of the consistent postoperative needs of these population (4,8) . Infection of all the surgical complication , is then most difficult to address .It can get into the hip joint by a variety of means ,may be transferred in top blood from skin at the time of operation or by the patients circulation (blood born contamination) , so in order to prevent infection the patient should takes a certain precautions, such as intra venous antibiotics (7) , an operations will be required to put things right , or may hip-joint opened and irrigated to remove infection after 6-weeks.Outpatient physiotherapy treatment is tailored to patients need and speed recovery , usually about 6 - 7 physiotherapy sessions will be arranged over on 8 weeks period in participating walking on a regular basis and build-up a strength thigh and hip muscles (9) . Methodology A descriptive design study was carried out to assess the patients knowledge toward hip replacement home-care knowledge A purposive (non- probability) sampling of 60 patients on discharged from Alhariri hospital and Alwasity hospital A questionnaire, interview form was designed by investigator to measure the variables underlying the present study, which is consisted of two part: *. Part one: demographical sheet, consisted of 6 items; as following Age, gender, employment, marital status, level of education, and appliance aids used by patient.  Part two: is composed of 4 sections, which are knowledge section to present the patients home care knowledge.  First section: patient knowledge of pain managment at home, which consisted of 5 items, scored as 3 for always, 2 for sometimes and 1 for never.  Second section, wound care patient knowledge which consisted of 5 items, scored as 3 for always, 2 for sometimes and 1 for never.  Third section: Patients’ knowledge in mobility limitation and also scored 3, 2, 1 consisted of 8 items.  Forth section: patients’ knowledge regarding potential complication, consisted of 4 items and also scored 3, 2, 1 for always, sometimes, and never respectively with 2 as cutting of point. Data was collected by the researchers through the use of the designed questionnaire interview technique to patients on discharge the data collection was carried out from 1/October /2010 to 1/July/2011.The researcher took a long time to collect the data due to the rare cases and the surgery take place once a week.The validity of the questionnaire was determined for clarity, relevancy and adequacy. Results Distribution of the sample according to the occupation. Iraqi J Pharm Sci, Vol.21(1) 2012 Total hip replacement home – care 41 Table 1: Demographical characteristics of the sample. % F Item 33.3 21.7 10 25 10 20 13 6 15 6 25-35 35-45 46-55 56-65 66 - or above Age 100 60 Total 46.7 53.3 28 32 Male Female Gender 100 60 Total 33.3 20 46.7 20 12 28 -employed -retired -housewife Job 100 60 Total 80 3.3 16.7 48 2 10 -Married -single Widowed- Marital status 100 60 Total 50 33.3 16.7 30 20 10 -primary school -secondary school -college Level of education 100 60 Total F = frequency. This table indicated that the majority of the sample 33.3% were of (25.35) years age and employed,80% of them married, the level of education was primary school is 50% . Table 2: Distribution of patients' knowledge of pain management at home MS* Never Sometimes Always Item No. Methods to reduce pain 2.6 0 20 40 Taking bed-rest and maintaining alignment on-pain experience at operative site 1 2.9 9 35 16 Practicing destruction and relaxation technique periodically 2 2.6 2 48 10 Administrating medication when experience pain by care giver. 3 1.9 40 18 2 Identify the action and doses of medication non-steroidal, anti-inflammatory and opioid drugs. 4 2.3 30 18 12 Recognizing medication side-effect such as nausea, vomiting ,and constipation 5 *MS: main score This table showed the highest main score ( 2.9)on relaxation technique periodically and lowest main of score( 1.9) to identify the action and dose of medication that indicates lacking of knowledge related to treatment. Iraqi J Pharm Sci, Vol.21(1) 2012 Total hip replacement home – care 42 Table 3 : Distribution of patients' knowledge toward wound management at home. MS Never Sometimes Always Item No. 2.16 20 10 30 Keeping a wound incision clean and dry , until staple removed 1 1.5 30 6 14 Changing wound dressing in a sterile technique 2 1.5 38 16 6 Recognizing wound infection signs such as (redness, swelling, and drainage from incision) 3 2.2 12 26 22 Fellow-up that wound suture is removed in fourteen days in out-patient clinic 4 3.8 2 3 28 Taking antibiotic in time to avoid infection 5 This table showed highest main of score( 3.8) toward taking antibiotic in time while lowest main of score (1.5) to item recognizing wound infection . Table 4: Patients' knowledge of mobility-limitation. MS Never Sometimes Always Item No. 1.3 34 8 16 Demonstrate safe use of assistive devices crutches ,walker ,and wheel chair 1 3.2 16 24 22 Demonstrate, how to stand without flexing leg actually 2 2.2 18 12 30 Recognizing the weight bearing limits especially on praying 3 2.1 12 28 20 Recognizing avoidance of low seated chair and crossing legs in sitting 4 2.9 14 28 18 Sleeping with abduction pillow , between legs to maintain alignment 5 1.9 18 34 10 Participating in gradual activities and prescribed exercise regimen 6 1.9 36 10 10 Accepting assistance in ADL,(clothing, bathing himself) 7 1.7 26 24 10 Demonstrating how to change position frequently 8 This table showed highest main of score( 2.9) in sleeping with abduction below between the legs while lowest main of score(1.3) to item demonstrating safe use of assistive devices crutches, walker and wheelchair. Iraqi J Pharm Sci, Vol.21(1) 2012 Total hip replacement home – care 43 Table 5 : Distribution of patients' knowledge toward mobility limitation according to some demographical characteristics. Sig. * DF X2 total Never Sometimes Always AGE No. 0.278 12 14.354 23 5 7 11 30-34 1 7 2 3 2 35-40 2 7 3 3 1 41-45 3 6 - 4 2 46-50 4 6 2 3 1 51-55 5 11 7 3 1 56-60 &above 6 60 19 23 18 Total *D.F=degree of freedom This table indicated no significant relation between age group and patient knowledge at home toward activity and mobility limitation . Table 6 : Patients’ knowledge of potential complication- at home. MS Never Sometimes Always Item No. 1.6 48 6 6 Identifies dislocation prosthesis signs; increase in pain, shortening of leg, inability to move leg. Feeling of popping sensation in operative hip's site. 1 1.2 50 10 0 Identifies deep-vein thrombosis signs; swelling calf pain. 2 1.6 32 16 12 Identifies wound infection signs ,swelling ,pain, fever, purulent drainage from the wound incision 3 This table showed low main of score (1.6) to potential complication which indicating lacking of knowledge and information related to management of complication at home. Table 7: The relation between the patients' knowledge of complication after hip-replacement at home and level of education . Sig. DF X2 total Never Sometimes Always Item No. S 4 2.75 29 9 13 7 Primary school 1 S 4 2.74 14 3 5 6 Secondary school 2 S 1 - 17 7 5 5 college 3 S 0.001 60 19 23 18 Total This table reveals significant relation between level of education and patients' knowledge toward complication may occur after total hip-replacement at home , which indicating hip- replaced educated patients able to manage the complication that may occur Iraqi J Pharm Sci, Vol.21(1) 2012 Total hip replacement home – care 44 Discussion The current study showed that , the majority of the study sample were at age of 25-35 year,(table-1), this finding is not compatible with( Smeltzer & Bare) (1) who stated that total hip- replacement patients usually 60 years of age or older, and has unremitting pain or irreversibly damage hip joint . Also the table revealed that 53.3% of the Sample were female,46.7% they were housewife , married 80%,and 50% with primary level of education . Concerning the patient-knowledge toward pain management at home, (table -2) the result of the study showed high mean score (2.9). Toward practicing destruction and relaxation technique periodically and (2.6) on taking bed- rest and maintaining alignment on experience pain, while low mean of score (1.9), identifying the action of a serious medication taken.These findings indicating a lack of knowledge of hip-replaced patients in managing pain at home, and also revealed that no discharge instruction was provided to them. It was stated that among patients undergoing hip replacement procedure ,pain is one of the five most undesirable complication .Unrelieved pain can adversely affect the individual's ability to perform basic daily activities as well as increase of stay and rehabilitation (2 ,3) .One of the most important aspect to prevent postoperative infection is the knowledge of wound-care at home, (table-3) showed highest mian of score (3.8) on taking antibiotics in time, While lowest mian of score (1.5) for two serious item ,first for recognizing wound infection signs, second on changing dressing in a sterile technique , which also indicating lack of discharge knowledge and information given to patients at hospital.This result supported by( White) (7,13) , following a Total Hip Replacement, the client is at increased risk for joint infection that may lead to the development of osteomylitis, also stated, the client will remain free from wound infection, as evidenced by normal temperature and white blood cells count (WBC), absence of purulent drainage from the wound and absence of redness or inflammation at the surgical site.Practicing walking at home is the important aspect for hip-replacement patients as shown in (table - 4) which indicating highest mean of score (3.2) to item of demonstrating, how to stand without flexing leg acutely, while lowest mean of score (1.3) to item of demonstrating safe use of assistive devices crutches, walkers and wheels chairs, this result revealed, that hip replacement patient discharged from hospital without any training programs or practicing the assistive devices provided to them for safety activity at home. This result supported by( Micheals) (5, 11 ,15) who presented that many assistive devices have been developed to make activities easier and less stressful for joints and muscles, these devices will be helpful at home or work. Also stated ( 6-7) physiotherapy sessions will be arranged over an 8 weeks period, the most important to do ,is how to walk on a regular basis and build up the strength in thigh and hip muscles , how to keep legs and knees apart, and avoid exercise flexion at the hip joint .The list of complication following total hip replacement was extensive ( table - 6) showed that all mean of score for the three items of complication ,was(1.6)and(1.2) which indicating poor information and instruction were given related to complication may occurred at home ,that may keep them to be at high risk for these complication (8,10) supporting this result, who stated that home care consideration include ongoing assessment of pain management ,monitoring for infection and prevention of deep vein thrombosis. The patient should be instructed to obtain prophylactic antibiotics prior to any surgical procedures .No significant relation between the sample age group and patients knowledge toward mobility limitation at home (table 5) ,while significant relation between level of education and patients knowledge toward managing complication at home, which revealed that hip replacement educated patients can managing the complication at home (table7). Conclusion The study presents that the majority of the sample were lacking knowledge related to pain management at home and wound care, also discharged with very minimum information and rehabilitation training instruction toward practicing assistive walking device and preventing potential complication such as infection and dislocation. Recommendation 1. Establishing a special rehabilitation unit at the ward to provide a Program of training on assistive device instructed to patient apply to them before discharge to prevent complication of dislocation which is a very serious one. 2. Provide the discharge patient with a pan phlet6 of all need instruction with figures illustrating to them all information they may need at home relating to activity and sleeping or medication Iraqi J Pharm Sci, Vol.21(1) 2012 Total hip replacement home – care 45 References 1. Smeltzer C. and Bare B. "Brunner& Suddarth text bock of medical-surgical nursing "10 th . Edition, Lippincott and Wilkins company, Philadelphia, 2004; p.782. 2. Cluett J, '' Hip Replacement Rehabilitation & Recovery". About.com. orthopedics , 2010 ;Feb(6) ,p.25-26. 3. BergesI ,et al;" Perceived pain and satisfaction with medical rehabilitation", Clinical rehabilitation.2006; August 20(8);724-730 4. Jonethan. P" Mobility Assessment of patients with the total hip replacement Hospital Research" ,Joint Reconstruction Center , sep 02, 2010; 521-528. 5. Micheals J, " Total Hip Replacement Postoperative Instruction " Department of orthopedics, Georgetown university Medical center,2003;(9), 115-119. 6. Lawrence T," Hip Replacement Surgery ',Journal of Advanced Nursing ,2010 ;(12), 28-32 7. White.l, "Fundation of nursing" 2 nd . Philadelphia, 2005; p.171-173. 8. Black J ," medical –surgical Nursing, clinical Management for positive outcome", W.B. Saunders Philadelphia comp, 2001 ;p557 9. Sammour.S "Adult Health Nursing, Theory and practice" 1 st . edition, Oman, 2008; p. 31-45 10. Lewis J ,'' Medical-Surgical Nursing , Assessment and Management of Clinical problem'', Mosby company, 2007 ; Philadelphia , p1662 11. Hoist, Matthew. "Concerns over Metal on Metal Hip Implants" , The New York Times, March (3), 2010 ;p. 655-661 12. Huston,G. "Medical Device Alert: All metal-on-metal (MoM) hip replacements" ,Medicines and Healthcare , products Regulatory Agency. 22 April 2010. MDA / 2010;p. 1132-37 13. Stevan A," Arthritis Physical and Occupational Therapy " Australian Orthopedic Association National Joint Replacement Registry Annual Report. Adelaide: AOA; 2008 ;(18),p. 431-438 . 14. Barbara B , "The effect of pain on health related quality of life" , Conference Coverage, American Academy of Orthopedic Surgeons (AAOS), March 3, Annual Meeting of Arthroplasty,2009;p. 753 -759. 15. Jackson JL, "Predictors of Patient satisfaction with Medical Rehabilitation ",American Journal of Physical Medicine& Rehabilitation , 2003;(82) , 1123-1123 . http://www.mhra.gov.uk/Publications/Safetywarnings/MedicalDeviceAlerts/CON079157 http://www.mhra.gov.uk/Publications/Safetywarnings/MedicalDeviceAlerts/CON079157 http://www.medscape.com/viewarticle/588980 http://www.medscape.com/viewarticle/588980