Arthroplasty nursing: caring for patients after hip and knee replacement

Total joint arthroplasty — hip and knee replacement — is one of the most common elective surgical procedures in the United States, with more than one million total hip arthroplasties (THA) and total knee arthroplasties (TKA) performed annually. Nursing care in the perioperative and postoperative phases directly determines outcomes: preventing dislocation, detecting neurovascular compromise early, preventing deep vein thrombosis, managing pain effectively, and getting patients safely mobile as soon as possible.

This guide covers the complete nursing scope for THA and TKA: preoperative assessment, immediate postoperative management, hip precautions, knee-specific care, DVT prophylaxis, complication recognition, discharge planning, and NCLEX high-yield content. The most urgent nursing responsibility in arthroplasty care is neurovascular assessment — any sign of compromise requires immediate escalation.

Preoperative nursing assessment

The preoperative nursing assessment for total joint arthroplasty establishes the clinical baseline against which all postoperative assessments are compared. A postoperative neurovascular finding that looks abnormal may be normal for a specific patient — only if you have a baseline can you make that determination.

Baseline neurovascular assessment — the 6 Ps

The 6 Ps framework provides the structure for every neurovascular assessment before and after arthroplasty surgery. Each P targets a specific component of vascular and neurological integrity:

Pain — Assess quality, location, and severity using a standardized scale such as the numeric rating scale (NRS, 0–10) or the faces pain scale. For arthroplasty patients, preoperative pain at the joint is expected; document this carefully so postoperative pain in unexpected locations (calf, compartment, distal extremity) is recognized as new and significant.

Pallor — Compare skin color bilaterally. Inspect the toes and dorsum of the foot for the hip patient; toes and dorsum of the foot for the knee patient. Pallor or mottling distal to the operative site indicates compromised arterial flow.

Pulselessness — Palpate pedal pulses bilaterally: posterior tibial pulse (behind the medial malleolus) and dorsalis pedis pulse (dorsal foot, lateral to the first metatarsal tendon). Document pulse quality using a standard scale: 0 = absent, 1+ = diminished, 2+ = normal, 3+ = bounding. If pulses are not palpable preoperatively, document this finding and notify the surgical team — a postoperative absent pulse in a patient with preoperative absent pulses requires a different response than a new-onset absent pulse.

Paresthesia — Ask the patient to describe sensation in their toes and foot. Common descriptors of nerve compromise include numbness, tingling, burning, or “pins and needles.” Note which dermatome is affected — this can suggest which nerve is involved.

Paralysis — Assess motor function. For lower extremity arthroplasty: ask the patient to dorsiflex and plantarflex the foot (“pull your toes toward your nose, now push down like a gas pedal”), and assess great toe extension. Compare bilaterally. Note that regional nerve blocks used for postoperative analgesia — such as femoral nerve blocks or adductor canal blocks — will temporarily reduce motor function on the operative side; document block status and expected duration.

Poikilothermia (also called poikilothermia or “temperature change”) — Assess skin temperature in the extremity distal to the surgical site by touch. A cool or cold extremity relative to the contralateral side suggests reduced perfusion. Use the dorsum of your hand, which is more sensitive to temperature differences than the palm.

Document all 6 Ps bilaterally and report the baseline in the preoperative nursing note.

Additional preoperative assessments

Skin integrity assessment — Inspect the skin overlying the operative joint, the entire extremity, and any pressure-prone surfaces (sacrum, heels). Document existing wounds, bruising, skin tears, or rashes. Any active skin infection at or near the surgical site is typically a contraindication to surgery and must be reported immediately.

Cardiovascular and respiratory baseline — Record baseline vital signs including pulse oximetry. Patients undergoing arthroplasty are often older adults with comorbidities (hypertension, atrial fibrillation, COPD) — these baselines become critical reference points postoperatively.

Functional baseline — Assess preoperative mobility level, assistive device use, and home environment (stairs, bathroom location, living alone). This information directly informs discharge planning.

Preoperative teaching

Preoperative teaching substantially reduces postoperative anxiety, improves adherence to precautions, and shortens recovery time. Cover the following with the patient and any caregivers who will support recovery at home:

Hip precautions (THA posterior approach) — If the patient is having a posterior approach THA, introduce the three precautions before surgery: no hip flexion greater than 90°, no adduction past the midline, and no internal rotation of the operative leg. Demonstrate what these restrictions look like in daily activities (getting out of a chair, getting dressed, using the toilet).

Rehabilitation expectations — Most arthroplasty patients will stand and attempt ambulation on the day of surgery or the first postoperative day, guided by physical therapy. Emphasize that early mobility is protective — it reduces DVT risk, reduces deconditioning, and accelerates joint recovery.

Pain management — Explain the multimodal approach: regional nerve blocks will reduce early postoperative pain but will wear off over 12–24 hours. After the block resolves, oral analgesics (acetaminophen, NSAIDs if appropriate, short-course opioids) will be used. Encourage the patient to request pain medication before therapy sessions rather than waiting until pain is severe. For more detail on using pain scales effectively, see our guide to pain assessment nursing.

Anticoagulation plan — Patients will receive anticoagulation after surgery to prevent DVT and PE. Explain the medication name, how long they will take it, and the importance of not missing doses. Review signs of bleeding to report. See anticoagulation nursing for the broader anticoagulation care framework.

Bowel and NPO status — Standard NPO guidance applies (clear liquids until 2 hours preoperatively, solid food until 6–8 hours preoperatively per current ERAS protocols). Some institutions use bowel prep; others do not — follow institutional protocol.

Medication reconciliation — Review all medications with the patient and the surgical team. Key medication holds before arthroplasty surgery:

• Anticoagulants (warfarin, direct oral anticoagulants): hold timing varies — warfarin typically 5 days, DOACs 24–48 hours depending on renal function; confirm with surgeon and anesthesia
• NSAIDs (ibuprofen, naproxen): typically hold 5–7 days preoperatively to reduce bleeding risk
• Steroids (long-term prednisone users): do not abruptly discontinue — adrenal insufficiency risk; surgical team will manage stress dosing
• Metformin: often held day of surgery due to contrast and anesthesia risk; confirm with prescriber
• Herbal supplements (fish oil, ginkgo, garlic): many increase bleeding risk; hold 1–2 weeks preoperatively

Surgical site marking — The surgeon or a designee marks the operative site before the patient enters the OR as part of the Universal Protocol (Joint Commission). The nurse confirms the mark matches the consent and the patient’s verbal confirmation during the preprocedure time-out.

Postoperative nursing care — immediate (PACU and first 24 hours)

The immediate postoperative period carries the highest risk for life-threatening and limb-threatening complications. Systematic assessment, frequent reassessment, and prompt escalation define safe care in this phase. For an overview of the full PACU nursing framework, see PACU nursing.

Airway, vital signs, and level of consciousness

On arrival to PACU, verify a patent airway, adequate respiratory rate (>8 and <24 breaths/minute), and SpO2 ≥94% (or at the patient’s personal baseline). Patients recovering from spinal anesthesia are at risk for sympathetic blockade effects including hypotension and bradycardia; monitor vital signs every 15 minutes in the immediate PACU phase. Patients receiving opioids via PCA are at risk for respiratory depression — monitor level of consciousness alongside respiratory rate and SpO2.

Hypothermia is a common perioperative complication — patients undergoing lengthy joint replacement procedures often arrive in PACU with core temperatures below 36°C. Use active warming measures (warm blankets, forced-air warming blanket) and monitor temperature at arrival and every 30 minutes until normothermic.

Neurovascular assessment — postoperative frequency and parameters

Perform a full 6 Ps neurovascular assessment every 1–2 hours for the first 12–24 postoperative hours, then per protocol (typically every 4 hours while hospitalized). Compare every finding to the preoperative bilateral baseline.

What is abnormal — escalation criteria:

A special note on compartment syndrome — Compartment syndrome is the most time-critical complication after lower extremity arthroplasty. It occurs when pressure within the muscle compartment exceeds perfusion pressure, causing ischemia. The classic signal is pain disproportionate to the injury — pain that is far more severe than expected, often with a feeling of tightness, and not relieved by repositioning. Critically, compartment syndrome pain worsens with passive stretch of the muscles in the affected compartment. The affected compartment will feel tense and firm on palpation. Compartment syndrome is a surgical emergency — fasciotomy must occur within hours. Remove any constrictive dressings, do not elevate the limb above heart level (elevation reduces arterial inflow to a compromised compartment), and notify the surgeon immediately.

Wound assessment

Assess the wound dressing at arrival in PACU and at each subsequent assessment:

Drainage — Some serosanguineous drainage on the dressing in the first 24 hours is expected. Document the size of any stain on the dressing with a circle and time stamp so you can monitor for expansion. Assess hemovac or Jackson-Pratt drain output if present (many arthroplasty surgeons no longer routinely use drains, but practice varies). Report output exceeding the surgeon’s specified threshold (often >200–300 mL in the first few hours). Signs of excessive bleeding: large expanding stain, drainage saturating multiple dressings, hemodynamic instability (tachycardia, hypotension).

Dressing integrity — Maintain the original surgical dressing intact for the first 24–48 hours unless there is a specific reason to change it (saturation, suspected infection, surgeon order). Inspect visible dressing margins for integrity.

Pain management — multimodal approach

Effective pain management after arthroplasty is not just about comfort — it enables early mobilization, which in turn reduces DVT risk and improves outcomes. The multimodal approach uses several different mechanisms simultaneously to achieve adequate analgesia while minimizing opioid dose:

Peripheral nerve blocks — Most arthroplasty patients receive a regional block preoperatively or intraoperatively. For THA, this may include a fascia iliaca block or lumbar plexus block. For TKA, the adductor canal block (ACB) is now strongly preferred over the femoral nerve block because the ACB spares quadriceps motor function, enabling safer early ambulation. Nerve blocks provide excellent analgesia for 12–24 hours. After the block wears off, patients commonly experience a “rebound pain” episode as sensation returns — anticipate this and ensure oral analgesics are prescribed and available.

Scheduled acetaminophen — Typically 650–1000 mg every 6–8 hours; provides baseline analgesia without opioid side effects. Do not omit scheduled doses even when the patient’s pain is controlled by the nerve block.

NSAIDs (if not contraindicated) — Ketorolac IV in the early postoperative period, followed by oral celecoxib or ibuprofen. NSAIDs are not appropriate for patients with renal impairment, peptic ulcer disease, or significant cardiovascular risk — assess before administering.

Opioids — Short-acting oral opioids (oxycodone, hydrocodone) for breakthrough pain. PCA (patient-controlled analgesia) may be used if oral intake is not yet possible. Minimize opioid dose by maximizing non-opioid coverage.

Timing for therapy — Administer analgesics 30–45 minutes before physical therapy sessions. Pain that is not controlled before therapy will limit participation and slow recovery. Use a validated pain scale (see pain assessment nursing) to guide administration decisions.

Positioning

Correct positioning is critical, particularly for THA, where improper positioning can cause prosthetic dislocation.

THA — posterior approach — Elevate head of bed no more than 60–70° (some surgeons allow 90° — confirm order). Maintain abduction pillow between the legs when the patient is supine to prevent adduction. When turning the patient to the side, the surgeon will specify which position is permitted — many surgeons allow turning to the operative side with an abduction pillow, but not the non-operative side.

THA — anterior approach — Fewer positioning restrictions than the posterior approach; however, extension and external rotation are restricted rather than flexion and adduction. Confirm specific restrictions with the surgeon.

TKA — Elevate the operative leg with a pillow placed under the calf (not directly under the knee, which causes flexion contracture risk). Avoid prolonged knee flexion in the early postoperative period. Ice packs to the knee reduce swelling and pain — apply with a cloth barrier to prevent skin injury; use per institutional protocol.

IV fluids and urinary catheter management

Maintain IV access and fluid resuscitation per protocol until the patient is tolerating oral fluids. Patients receiving spinal anesthesia commonly have urinary retention due to sympathetic blockade; an indwelling catheter placed perioperatively is common practice. Per CAUTI prevention guidelines, remove the catheter as early as possible — typically on the first postoperative morning. Monitor for urinary retention after catheter removal (see urinary catheterization nursing).

First mobility — when and how

Early mobilization is one of the most evidence-supported interventions in arthroplasty recovery. In most Enhanced Recovery After Surgery (ERAS) protocols, patients are out of bed on the day of surgery — this is the current standard of care, not an exception.

Process for first ambulation:

1. Confirm weight-bearing status from surgeon orders (most are WBAT, but toe-touch weight bearing or non-weight bearing occurs in specific situations)
2. Ensure analgesics have been administered and are taking effect
3. Physical therapy leads the session — nurse assists and monitors
4. Have a gait belt available; use an assistive device (walker for most arthroplasty patients)
5. Monitor vital signs before, during, and after ambulation — orthostatic hypotension is common in the first 24 hours
6. For THA patients: apply hip precautions throughout transfer — instruct the patient on the sequence before moving

For a detailed guide to transfer techniques and safe ambulation, see ambulation and transfer nursing.

Hip precautions — total hip arthroplasty (posterior approach)

Hip precautions are activity restrictions designed to prevent prosthetic dislocation in the early postoperative period before the joint capsule heals and the muscles surrounding the hip recover strength. They are specific to the posterior approach, which cuts through the posterior capsule and short external rotator muscles — the structures most important for posterior stability.

The anterior approach does not violate the posterior structures, so classic posterior hip precautions do not apply. However, anterior approach patients may have restrictions on extension and external rotation — confirm with the surgeon.

The three precautions

Precaution 1: No hip flexion greater than 90°

The hip joint must not be flexed past a right angle between the trunk and thigh. Exceeding 90° forces the femoral head posteriorly, where the posterior capsule was divided — the path of least resistance for dislocation.

ADLs that violate this precaution:

• Sitting in low chairs or soft sofas (knees higher than hips)
• Bending forward to pick up objects from the floor
• Reaching for items at foot level (shoes, socks)
• Leaning forward to use a standard toilet

Adaptations:

• Use a raised toilet seat (adds 4–6 inches to toilet height, keeping hips above knee level)
• Use a chair with arm rests to assist standing; sit in high-backed chairs rather than low sofas
• Use a long-handled reacher/grabber to retrieve items without bending
• Use a long-handled shoehorn and slip-on shoes (no bending to tie laces)
• Dress by pulling the operative leg toward you using a dressing stick, not by bending forward

Precaution 2: No adduction past the midline

The operative leg must not cross the centerline of the body. Adduction combined with internal rotation is the most common mechanism of posterior dislocation.

ADLs that violate this precaution:

• Crossing the operative leg over the other leg (especially sitting cross-legged)
• Rolling onto the non-operative side in bed without an abduction pillow

Adaptations:

• Place an abduction pillow between the knees when in bed or supine
• When transferring, keep the operative leg ahead and to the side
• When getting into a car, use the “back-seat technique” — back up to the seat, keep knees apart, and lower into a reclined seat

Precaution 3: No internal rotation

The operative leg must not turn inward (toes pointing toward midline). Internal rotation winds the femoral neck against the posterior capsule repair and is the third component of the dislocation mechanism.

ADLs that violate this precaution:

• Sitting with feet pigeon-toed
• Rolling onto the operative side with the foot dropping inward
• Being lifted by pulling on the operative leg

Adaptations:

• Remind patient: when standing, operative foot should point straight ahead or slightly outward
• When in bed, may place a small roll laterally against the leg to prevent foot drop inward

Equipment required for THA (posterior approach) patients

Duration of precautions

Hip precautions typically remain in effect for 6–12 weeks postoperatively. Duration is surgeon-specific and depends on surgical technique, implant design, and individual patient healing. Many newer implant designs and surgical techniques have led some surgeons to use a shorter precaution period (6 weeks) or “hip-aware” programs rather than formal precautions. Always follow the specific surgeon’s orders — document and teach the exact restrictions ordered, not a generic protocol.

Knee-specific postoperative care — total knee arthroplasty

The goals of TKA postoperative care differ from THA: there are no dislocation precautions, but the focus shifts to achieving adequate range of motion early, controlling swelling and pain, and restoring quadriceps strength. Poor early ROM is difficult to recover once scar tissue forms — the window for maximal ROM gains is approximately the first 6–8 weeks.

Knee flexion goals by day

Document knee flexion and extension measurements at each PT session as part of the nursing record. Extension should approach 0° (full extension); a flexion contracture — inability to fully extend the knee — is a more difficult problem than limited flexion.

Continuous passive motion (CPM) machine

The CPM machine is a motorized device that passively cycles the knee through flexion and extension while the patient is at rest. It was widely used in arthroplasty recovery programs for decades. However, the evidence base has shifted: multiple RCTs and meta-analyses have found that CPM does not meaningfully improve long-term ROM outcomes compared to standard physical therapy and exercise. Current practice at many institutions has moved away from routine CPM use; some centers no longer use it at all.

Where CPM is still used, nursing responsibilities include:

• Verify machine settings match the surgeon’s orders (starting degrees of flexion and extension, speed, duration of daily use)
• Apply leg cradle correctly — knee must be centered in the device; improper positioning causes pressure injury on the heel and popliteal fossa
• Set CPM so the heel does not drag, which increases shear risk
• Assess skin integrity under the device at each check
• Remove for neurovascular assessments, toilet, ambulation
• Document daily degree settings and patient tolerance

Immobilizer vs CPM decision

If CPM is not used, a knee immobilizer may be applied to maintain extension during rest. The immobilizer should be removed for ROM exercises, ambulation, and skin assessment. Prolonged immobilization in flexion is contraindicated — it leads to flexion contracture.

Ice therapy and elevation protocol

Ice and elevation are standard post-TKA nursing interventions with strong support:

Elevation — Elevate the operative leg with pillows placed under the calf, keeping the knee extended. Avoid placing pillows directly under the knee in a flexed position (this risks flexion contracture and reduces venous return). The goal is heels slightly above the level of the heart for the first 24–48 hours to reduce edema.

Ice — Apply ice packs (covered with a cloth barrier to prevent frostbite) to the lateral and medial aspects of the knee for 20 minutes every 2 hours, or per institutional protocol. Ice reduces postoperative edema and provides meaningful supplemental analgesia, reducing opioid requirements. Cryotherapy units (mechanized ice compression devices) are used at some institutions and provide more consistent temperature and pressure.

Patellar tracking and knee alignment assessment

Assess the knee for patellar tracking at each nursing assessment. Patellar maltracking — where the patella moves laterally rather than tracking in the trochlear groove — can occur after TKA and causes persistent anterior knee pain. Clinical signs include anterior knee pain with quadriceps activation, a visible lateral tilt of the patella, and “catching” or crepitus with movement. This is a clinical finding to document and report to the surgical team; it does not require emergency intervention but should be assessed during the acute phase.

For a review of range of motion assessment and documentation, see range of motion nursing.

DVT and PE prophylaxis after arthroplasty

Total joint arthroplasty carries one of the highest DVT risks of any elective surgical procedure. Immobility, venous stasis from tourniquet use (especially in TKA), and hypercoagulable state from surgical trauma all contribute. Without prophylaxis, symptomatic DVT rates after TKA approach 40–60%. Rigorous prophylaxis has reduced this substantially but not eliminated the risk.

For a comprehensive DVT nursing guide, see DVT nursing.

Assessing for DVT — what to look for (and what not to rely on)

Homan’s sign — do not use as a reliable indicator. Homan’s sign (dorsiflexion of the foot eliciting calf pain) has poor sensitivity and specificity for DVT. It is positive in fewer than half of confirmed DVTs and is positive in many patients without DVT. Current clinical guidelines do not recommend Homan’s sign as a DVT screening tool. Its continued use in clinical exams may reflect its historical prominence — NCLEX and nursing exams still test knowledge of it, but as an unreliable finding.

What to assess instead:

• Unilateral calf swelling — Compare calf circumference bilaterally; document in centimeters. Any increase in the operative leg’s calf girth should be reported.
• Calf pain at rest and with palpation — Posterior calf tenderness on palpation is a more specific finding than Homan’s sign.
• Warmth and erythema — Localized heat and redness over the calf or thigh, distinct from expected wound-site inflammation.
• Increasing leg edema — Progressive swelling that extends above the calf into the thigh.

Monitoring for PE — escalation criteria:

PE can occur acutely (within days) or sub-acutely (up to several weeks post-discharge). Signs and symptoms requiring immediate escalation include:

• Sudden dyspnea or shortness of breath
• Tachycardia (new or worsening)
• Pleuritic chest pain (sharp, worse with inspiration)
• Hemoptysis
• Anxiety or sense of impending doom
• Hypoxemia — SpO2 drop from baseline
• Hypotension and syncope (massive PE)

Any suspected PE requires immediate notification of the physician, supplemental oxygen, IV access, and preparation for imaging (CT pulmonary angiogram is the diagnostic standard). See DVT nursing for the full PE assessment framework.

Complications after arthroplasty — recognition and nursing response

Discharge planning and patient education

Effective discharge planning begins at admission and intensifies in the 24–48 hours before discharge. The arthroplasty patient leaving the hospital will be managing a healing surgical wound, a new joint prosthesis, an anticoagulation regimen, a rehabilitation program, and activity restrictions — often at home with limited support. Discharge teaching must be specific, confirm patient understanding, and document that the patient can verbalize each component.

Weight bearing status and activity by week

Wound care instructions for home

• Keep the wound clean and dry until the staples/sutures are removed (typically 10–14 days postoperatively)
• Showering is permitted once the surgeon clears it — do not submerge in a bath, pool, or hot tub until the wound is fully closed
• Staple/suture removal at the first postoperative visit (confirm appointment before discharge)
• Signs of wound infection to report immediately: increasing redness, warmth, swelling around the wound; discharge that becomes purulent or malodorous; fever above 38.5°C (101.3°F); the wound opening or separating

For comprehensive wound care principles, see wound care nursing.

DVT warning signs — urgent symptoms requiring immediate action

Teach the patient to call 911 or go to the ED immediately for:

• Sudden shortness of breath or difficulty breathing
• Chest pain, especially with breathing
• Rapid heart rate
• Coughing up blood
• Feeling faint or collapse

Teach the patient to call the surgeon’s office (urgent — same day) for:

• New calf pain, swelling, or redness in either leg
• Increasing leg swelling beyond expected postoperative swelling
• Missed anticoagulation doses

Hip precautions equipment — home setup checklist (THA posterior approach)

Confirm before discharge that the patient has obtained or has a plan to obtain:

• Raised toilet seat installed and patient has demonstrated use
• Long-handled reacher, shoehorn, and sock aid in hand
• Shower chair if bathing in a shower; tub transfer bench if using a tub (with surgeon approval after wound closure)
• Walker with correct height adjustment
• Abduction pillow for sleeping

Occupational therapy evaluation and discharge equipment prescription should be part of every THA posterior approach discharge — if OT has not assessed the patient, notify the case manager.

Return to driving

• TKA: Most patients may return to driving 4–6 weeks after right knee replacement; left knee patients with automatic transmission may return sooner (confirm with surgeon). Driving requires the ability to perform an emergency stop — this is the clinical criterion, not an arbitrary time point.
• THA: Most patients may return to driving at 4–6 weeks; varies by approach (anterior approach patients may clear sooner) and which side was operated on. Left hip, automatic transmission — sooner. Right hip — 6 weeks minimum in most protocols.

The surgeon provides final clearance for driving.

When to call the surgeon vs go to the ED

NCLEX high-yield points

20 NCLEX tips for arthroplasty nursing

20 NCLEX practice scenarios

Clinical sources and references

• American Academy of Orthopaedic Surgeons (AAOS). Management of Osteoarthritis of the Hip and Management of Osteoarthritis of the Knee — evidence-based clinical practice guidelines.
• Bottros J, et al. “Total hip arthroplasty: postoperative care and rehabilitation.” Orthopedic Clinics of North America — posterior approach precautions and dislocation risk.
• Chughtai M, et al. “Anterior approach total hip arthroplasty.” Journal of the American Academy of Orthopaedic Surgeons — anterior vs posterior approach comparison.
• Kauppila AM, et al. “Continuous passive motion versus conventional physical therapy” — meta-analysis on CPM efficacy after TKA.
• Meneghini RM, et al. “ERAS (Enhanced Recovery After Surgery) protocols in total joint arthroplasty” — evidence for early mobilization and multimodal analgesia.
• National Blood Clot Alliance / American Academy of Orthopaedic Surgeons. Joint guidelines on VTE prophylaxis after total joint replacement.
• Pelt CE, et al. “Fat embolism syndrome following total joint arthroplasty.” JAAOS — timing, presentation, and management.
• StatPearls (NCBI). “Total Hip Arthroplasty” — NBK507800; “Compartment Syndrome” — NBK448124; “Deep Vein Thrombosis” — NBK507709.
• Wylde V, et al. “Systematic review of multimodal pain management in arthroplasty” — analgesic timing and nerve block evidence.