Nursing care
Total Hip Replacement: the nurse's role, start to finish
Written and reviewed by Dana Whitfield, RN, MSN · 6 min read · Updated September 2026
Short answer
Total hip replacement nursing management centres on preventing dislocation of the new joint. The three rules are no adduction past midline, no flexion past 90 degrees, and no internal rotation. Nurses apply these through positioning, abduction pillows, raised toilet seats, and patient teaching, alongside standard post-op monitoring for bleeding, infection, and venous thromboembolism.
When it is done and why
Total hip replacement, or total hip arthroplasty, replaces a damaged femoral head and acetabulum with prosthetic components. The commonest indication is osteoarthritis causing pain and loss of function that no longer responds to analgesia, weight management, or physiotherapy. Rheumatoid arthritis, avascular necrosis, and femoral neck fracture in older adults are the other main routes to this surgery.
Nurses meet these patients across two very different pathways. An elective patient arrives optimised, often after a pre-assessment clinic weeks earlier, with time to plan mobility aids and home support. A fractured neck of femur patient arrives from the emergency department, frequently frail, sometimes confused, and surgery is scheduled within 24 to 48 hours because delay raises mortality. The nursing priorities shift accordingly: elective care is about preparation, trauma care is about rapid stabilisation and preventing the complications of immobility before the theatre slot even arrives.
Preparing the patient
Pre-operative nursing assessment covers baseline mobility, cognitive status, skin integrity, and cardiovascular and respiratory fitness for anaesthesia. Bloods, an ECG, and a group and save are routine given the blood loss risk of hip surgery. Any active infection, including a urinary tract infection or dental sepsis, must be treated first, because a prosthetic joint infection is far harder to clear than a native joint one.
Teaching starts before the patient goes anywhere near theatre. Show the patient the hip precautions they will need to follow afterwards, ideally with the physiotherapist, so the instructions are not new information delivered through post-anaesthetic fog. Explain the abduction pillow, the raised toilet seat, and why they should not cross their legs. Confirm VTE prophylaxis is prescribed, mark the correct side per local safety checklist, and address anxiety directly, since fear of pain or of falling is a common reason patients disengage from early mobilisation later.
The steps that matter for safety
The single most important safety message for this surgery is the hip precaution set: no adduction past midline, no flexion past 90 degrees, and no internal rotation. These three movements combine to force the femoral head out of the acetabular cup, and posterior dislocation is the complication every subsequent instruction exists to prevent. An abduction pillow between the knees while supine or side-lying keeps the leg from adducting; a raised toilet seat and chair keep hip flexion under 90 degrees; and patients are taught to pivot rather than twist when turning.
These precautions apply from the moment the patient wakes in recovery and continue for a period set by the surgeon, commonly six to twelve weeks, longer with a posterior surgical approach than an anterior one. Every nurse who transfers, positions, or assists this patient needs to know which approach was used and what the precautions are, because a single unsupervised twist to reach a call bell can dislocate a joint that took hours to fix.
During the procedure — the nurse's role
In theatre, the scrub and circulating nurse maintain a sterile field, manage instrument and swab counts, and support positioning, usually lateral decubitus for a posterior approach. Blood loss can be significant, so accurate fluid balance and communication with the anaesthetic team matter throughout. The circulating nurse also confirms the surgical checklist, implant details, and antibiotic prophylaxis timing before incision.
In recovery, the priority is airway, breathing, and circulation as with any post-anaesthetic patient, plus a limb-specific check: peripheral pulses, colour, warmth, and sensation in the operated leg to rule out neurovascular compromise. The operated leg is positioned in abduction with a pillow between the knees from the first moment the patient is repositioned, and staff handling the leg avoid flexing the hip past 90 degrees even while asleep, since the precautions apply before the patient is capable of following them independently.
After: monitoring and complications
Post-operative monitoring covers vital signs, wound drainage, and pain on a standard schedule, but hip-specific complications need active surveillance. Watch for signs of dislocation: sudden severe pain, a shortened or externally rotated leg, and inability to move the limb, which is a surgical emergency requiring immediate reduction. Check the wound for excessive bleeding or discharge, monitor for signs of deep vein thrombosis such as calf swelling or tenderness, and continue prescribed VTE prophylaxis, whether mechanical, pharmacological, or both.
Early mobilisation, usually the day after surgery with physiotherapy, reduces the risk of pneumonia, pressure injury, and thromboembolism, but every transfer must respect the three precautions. Pain control needs to be adequate before physiotherapy sessions rather than chased afterwards, since a patient guarding against pain will move awkwardly and raise the fall and dislocation risk. Older patients are also at risk of post-operative delirium, so orientation, hydration, and early recognition of confusion belong on the same monitoring list as the wound.
Documentation and teaching
Document neurovascular checks, wound status, mobility achieved, and precaution compliance at each assessment, along with pain scores and analgesia given relative to physiotherapy sessions. Any deviation from the precautions, near-fall, or sign suggestive of dislocation needs immediate documentation and escalation, not just a note for the next shift.
Discharge teaching repeats the hip precautions in writing, since patients forget verbal instructions delivered on strong analgesia. Cover sleeping position, safe car transfers, when driving may resume per surgeon guidance, and red flags that warrant a return to hospital: fever, increasing wound pain or discharge, or sudden inability to bear weight. Confirm the patient has the walking aids, home equipment, and follow-up appointment arranged before they leave, since a gap in any of these is a common reason for early readmission.
The next step on this is the same as on everything else here: answer questions and read the rationales. Our med-surg practice questions are the closest set to what this page covers.
One question from the med-surg set
A client with chronic obstructive pulmonary disease has an oxygen saturation of 88% on 2 L/min via nasal cannula and is alert with no distress. What should the nurse do first?
Rationale
In COPD a saturation of 88–92% is the therapeutic target, not an emergency, and this client is alert with no distress. The first action is the independent nursing intervention that is least invasive and most likely to help: sit them up and reassess. Turning the oxygen up to 6 L/min risks blunting the hypoxic drive, and calling rapid response or drawing an ABG escalates ahead of an assessment you have not finished.
Answer: B
Common questions
What are the three hip precautions after total hip replacement?
No adduction past midline, no flexion of the hip past 90 degrees, and no internal rotation of the leg. Together these movements are the ones most likely to force the femoral head out of the socket, so every positioning, transfer, and teaching decision after surgery is built around avoiding them.
How do you position a patient after hip replacement?
Keep the operated leg abducted with a pillow between the knees when supine or side-lying, and avoid flexing the hip past 90 degrees during any repositioning. The unoperated side is usually the safer side to lie on, but confirm the surgical approach and surgeon preference before turning the patient.
What are the signs of hip dislocation after surgery?
Sudden severe pain, a leg that appears shortened and externally or internally rotated, and an inability to move or bear weight on the limb. This is a surgical emergency and needs immediate medical review and imaging.
When can hip precautions be stopped?
Duration is set by the surgeon based on the surgical approach, commonly six to twelve weeks, and is typically longer after a posterior approach than an anterior one. Precautions should never be relaxed on patient report alone; confirm against the discharge plan or surgical follow-up.
Why is early mobilisation encouraged despite the dislocation risk?
Immobility carries its own serious risks, including pneumonia, pressure injury, and venous thromboembolism, so early supervised walking with physiotherapy is standard practice. The precautions make mobilisation safe rather than ruling it out, provided staff and patient both know and follow them during every transfer.
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