Effect of the clinical nursing pathway on clinical symptoms, hip joint function, and nursing satisfaction in male patients with artificial hip arthroplasty

The purpose of this study is to explore the effect of clinical nursing pathway on the clinical symptoms, hip function and nursing satisfaction of male patients who undergo artificial hip replacement. A total of 102 male patients who had artificial hip arthroplasty and were admitted to the West China Hospital of Sichuan University were recruited. Participants were randomly divided into the study group (given clinical nursing pathway) and the control group (given routine nursing intervention). The hospitalization time, treatment cost, symptom checklist, nursing satisfaction and hip function score of the two groups were observed and compared. The hospitalization time and treatment cost of the study group were significantly lesser than those of the control group ( p < 0.05). Both groups showed significant improvement in the scores of the symptom checklist, but the study group had significantly lower scores than the control group. Similarly, on the day of discharge, there was no significant difference in hip joint function scores between the two groups of patients. However, 30 days after surgery, the hip joint function scores of both groups of patients was remarkably improved ( p < 0.05), yet, this improvement is significantly higher in the study group. The nursing satisfaction of the study group was higher than that of the control group, and the difference was significant ( p < 0.05). The total incidence of complications in the study group was lower than the control group (5.88%, vs. 23.53%, p < 0.05). The clinical nursing pathway could effectively improve the clinical symptoms of male patients undergoing artificial hip arthroplasty, promote the recovery of hip joint function, and significantly improve the clinical nursing satisfaction. Therefore, it is one of the reliable schemes in the clinical practice of patients undergoing artificial hip arthroplasty.


Introduction
The incidence of osteonecrosis of femoral head in the elderly is rising, and is closely linked with the increasing aging of the population [1, 2]. Although, the overall incidence of agerelated fracture is lower in men than in women. Yet, recently there is significant increase in the number of hip fractures especially in men. At the same time, the age at first hip fracture is lower in men than in women but, the mortality rate of men is twice as high as that of women. Similarly, men affected by the condition tend to have lesser quality of life and more serious sequelae as compared to women. Thus, research on femoral head necrosis especially in elderly men is necessary. Clinical studies have shown that at present, the most effective treatment for osteonecrosis of the femoral head is artificial hip arthroplasty. However, following the surgery, a long time bed rest is needed for the patient's recovery [3][4][5]. Therefore, postoperative nursing care is particularly important for the overall success of the procedure. Targeted scientific nursing interventions are of great significance in the consolidation of postoperative effects and postoperative recovery in men undergoing artificial hip arthroplasty [6][7][8]. With the active summarization of clinical experience, clinical nursing pathway was implemented in male patients with artificial hip arthroplasty and remarkable results were achieved in our hospital. Hence, the purpose of this study is to explore the effect of clinical nursing pathway on clinical symptoms, hip joint function and nursing satisfaction in male patients with artificial hip arthroplasty.

General data
A total of 102 male patients with artificial hip arthroplasty were admitted to the West China Hospital of Sichuan University. They were randomly and evenly divided into the study group and the control group. Each group has 51 male patients. There were no significant differences in the clinical data between the two groups. This open prospective randomized controlled study was reviewed and approved by the hospital ethics committee and all patients have signed an informed consent form.
Inclusion criteria: (1) Patients met the clinical diagnostic criteria for osteonecrosis of the femoral head; (2) Patients were with new closed fractures; (3) Patients met the indications for surgery; (4) Patients or their family members signed an informed consent form.

Methods
All patients were treated with conventional artificial hip arthroplasty. After treatment, the control group was given routine nursing interventions, while the study group was given a clinical nursing pathway.
As for the control group, patients were given routine nursing interventions, as follows: (1) Health Education: in addition to routine health education, the interventions for health education were refined. For example, patients and their family members were provided withe information regarding the surgery and preoperative dietary abstinence time; encouraged to perform pulmonary respiratory function exercise before surgery; informed about postoperative functional exercise methods and precautions; and issued with relevant handbooks to introduce disease-related contents. (2) Nutritional management: checked patients for the presence of hypoproteinemia on the day of admission; Albumin supplementation for hypoproteinemic patients; Work with dietitian for addressing the issues related to malnourished patients. (3) Intraoperative thermal preservation: temperature monitoring was performed throughout, and patients were managed with a variety of insulation measures to prevent intraoperative hypothermia. (4) Pain management: assessed the pain levels of patients; Intervene in patients with pain and optimize perioperative analgesia protocols under the guidance of anesthesiologists. (5) Respiratory exercises: preoperative guidance is provided to instruct patients on respiratory exercises. After the surgical anesthesia wears off, patients were encouraged to begin exercising in bed and were motivated to get out of bed early. Patients were given instructions on functional exercises and provided with explanations of precautions to be taken.
As for the study group, established clinical nursing pathway was given as follows: Before hospital admission, (1) the patient's personal information was recorded. The patients and their family members were introduced with fundamental state, and they were made to be familiar with the hospital environment; (2) the patient's condition including psychological was evaluated; (3) guidance about the bedridden defecation and urination was given to the patients; (4) based on the patient's personal needs, a comfortable treatment environment was created and the patient was guided to quickly adapt to the environment of hospitalization; (5) the patients and their family members received comprehensive and meticulous introduction of the basic principles of disease occurrence and clinical treatment principles and were informed about the necessity of surgical treatment so that they could actively cooperate in carrying out clinical treatment; (6) the patients were guided to scientifically cooperate with clinical staff to implement various preoperative examinations and related treatments.
Two or three days after hospital admission, (1) the sleep state during hospitalization was assessed, and targeted guidance based on the individual situation was implemented to adjust the biological clock and ensure the quality of sleep, and if necessary, drug intervention was given in accordance with the doctor's instructions; (2) the patients were told to change their position regularly; the environmental health was examined and the patients were taught with sputum excretion in a right way; the frequency of daily rounds was more than 5 times; (3) the patient's psychological state was monitored so that psychological counseling and health education could be given timely when problems occur; the patients and their family members were helped with the establishment of confidence.
24 hours before surgery, (1) the patient's psychological state was evaluated and targeted psychological interventions were given to patients with serious anxiety and depression. The patients and their family members were comprehensively informed with surgical process so that they could build confidence, fully understand the surgical process, and cooperate with the surgical operation; (2) the patients were critically supervised not to eat or drink 6 hours before surgery; the preoperative examination and intestinal lavage were completed as well as the skin preparation.
On the day of the surgery and within 24 hours after surgery, (1) the preoperative preparations were completed in the morning and the patients were sent to the operating room according to the schedules of the day; (2) the patient's vital signs were closely monitored after surgery. Also, the state of postoperative indwelling catheter was monitored according to the patient's specific conditions; (3) the patient's postoperative psychological state was timely assessed and targeted psychological interventions were given based on the assessment results so that the postoperative anxiety and depression could be ameliorated in time.
From the fourth day to the day of hospital discharge, (1) a soft cushion was used at the pressure points because of the long-term bed rest to avoid the occurrence of pressure sores; (2) early postoperative limb training (both active and passive training) was carried out to prevent the occurrence of deep vein thrombosis in the lower limbs; (3) the patient's postoperative recovery was evaluated; (4) the patients were provided with guidance about off-bed activities at a frequency of 3 to 4 times/day according to their situation. Furthermore, an activity intensity of 5 to 10 minutes/time as well as targeted nursing interventions if pains occur was given to them; (5) dietary care was given. Specifically, a light diet is e maintained in accordance with the personal eating habits and tastes. Easily digested food and food with high-fiber and/or high protein were encouraged. Besides, the patients were encouraged to drink enough water every day to prevent the occurrence of constipation.
From the fourth day to the day of hospital discharge, (1) the patients were guided with gradual increased exercise intensity of the affected limb and hip joint. Strengthening in the isometric contraction of quadriceps, ankle rotation, and active exercises of flexion and extension were emphasized; (2) trainings of curvature movement of the hip and knee were conducted according to the patient's individual situation. The patient was required to exercise at an angle greater than 90 degrees and a frequency of 3 to 5 times/day and a duration of 15 min/time; (3) activities such as sitting up by the bed, standing with walkers and walking slowly were carried out according to the patient's recovery of athletic ability; (4) the patient's postoperative rehabilitation was comprehensively evaluated. Patients were informed with the relevant precautions for postoperative rehabilitation.
Regarding postoperative follow-up visit, a telephone calls once a week were conducted regularly. During the calls, patients and their families were requested to answer various questions that arose during the postoperative rehabilitation after discharge in a timely manner.

Comparison of interventions between the two groups
See Table 1.

Study endpoints
The primary endpoint of this study is the Harris Hip Score while the secondary endpoints are nursing satisfaction and selfassessment questionnaire scores for symptoms. SPSS 22.0 software (IBM, Armonk, NY, USA) was used for data analyses. The quantitative data and enumeration data were represented as mean ± standard deviation (x ± s) and proportion (%) respectively. Furthermore, test of associations were conducted using t-test for the quantitative data and Chisquare test for the enumeration data. A p value less than 0.05 was considered statistically significant.

Comparison of clinical data between two groups
There was no statistically significant difference in clinical data between the two groups of patients. See Table 2.

Comparisons of the hospital course between the two groups
Patients in the study group showed shorter stay in hospital and lesser cost of treatment than those in the control group. The difference was statistically significant (p < 0.05). See Table 3.

Comparisons of the symptom (SCL-90) between the two groups
Before the intervention, there was no significant difference in the scores of the self-rating symptom scales between the two groups. After the intervention, the scores of the selfrating symptom scales in both groups improved significantly. Interestingly, the scores of the self-rating symptom scales of the patients in the study group were significantly lower than those of the Control group (all p < 0.05). See Table 4.

Comparison of the hip joint function between the two groups
The hip joint function of patients was not significantly different between the two groups on the day of hospital discharge. However, there was remarkable improvement at 30 days postoperative with higher scores observed in the study group. The difference was statistically significant (p < 0.05). See Table 5.

Comparison of patient satisfaction and incidence of complications between two groups
The nursing satisfaction in the study group was higher than that in the control group. Also, the overall incidence of complications in the study group was lower than that in the control group, with a significant difference (p < 0.05). Refer to Table 6.

Discussion
At present, artificial hip arthroplasty is considered as one of the effective treatments for osteonecrosis of the femoral head [9, 10]. The procedure replaces the patient's own injured joints TA B L E 1. Comparison of the interventions between the two groups.

Contents
Control group with the artificial hip joints made of specific materials to exert the joint-related functions. However, due to the requirement of a relatively long period of bed rest after surgery, patients are prone to a variety of complications, including infection, pressure sores, venous thrombosis, etc. Clinical studies believe that the application of targeted scientific nursing interventions is able to accelerate the patient's postoperative rehabilitation after artificial hip arthroplasty [11,12], and it is of great importance in the promotion of surgical effect and improvement in the patient's postoperative living quality [13][14][15].
The clinical nursing pathway is more advanced than the traditional nursing model, which originated from developed countries such as Europe, the United States and Japan in the 1880s. In 2009, with the support of national ministries and commissions, the promotion of clinical pathways is gradually becoming popular. With the active summarization of clinical experience and the combination with the actual situation of the patients with artificial hip arthroplasty in our hospital [16,17], clinical nursing pathway was implemented in the clinical nursing practice, and impressive results were achieved. Clinical nursing pathway is a targeted nursing pathway established on the basis of the specific characteristics of each department in the clinic [18]. In this study, the clinical nursing pathway was centered on the characteristics of the perioperative period in male patients with artificial hip arthroplasty. Based on the clinical nursing theory and the specific practical experience of our hospital, the detailed and targeted nursing plan was formulated. The plan has the chronological order of patient admission to the hospital as the coordinate axis and the content of specific nursing intervention as the vertical coordinate.
Regarding the detailed nursing plans, targeted contents of the nursing interventions were designed according to the characteristics of stage of hospitalization for every patient. Before surgery, to help patients build confidence and alleviate anxiety and depression caused by fear of surgery, emphasis is placed on the nursing of mental health and sleep. It is well known that psychological stress could lead worsen physiological indicators. Similarly, sleep disturbance may occur in patients with more severe disease condition, and it may increase the risk of complications of anesthesia during surgery. Therefore, improving the quality of sleep in patients could improve the chances of positive outcome of the surgery [19,20]. After surgery, how to prevent the incidence of related complications should be seriously considered in the nursing process. Be-TA B L E 4. Comparisons of the symptoms between the two groups (Score,x ± s).

Indicators
Study group (n = 51) cause a long-term bed rest is usually required after surgery in the patients that undergo artificial hip arthroplasty, the indicators relevant to the patient's hemorheology are prone to be decreased. Therefore, patients need to increase the frequency of in vitro changes. Also, blood circulation in locally compressed tissues should be increased in the patients. This can be achieved through the application of several maletargeted interventions in order to reduce the risk of associated adverse complications. During the process of postoperative rehabilitation, the individual's level of physical activity, the condition of injury, surgery and recovery should be integrally considered in the key points of nursing care. If permitted, the patients should be encouraged to actively do bed exercise and take a walk in order to promote early recovery of exercise performance [21,22].
The present study showed that patients in the study group had significantly shorter stay in hospital, less treatment cost, less score of symptom check after interventions, better hip joint function, higher nursing satisfaction, and lower incidence of side effects than those in the control group, and the difference was statistically significant (p < 0.05). Consistent with the previous reports (both local and international) these results indicate that the clinical nursing pathway has a considerable advantage in the clinical nursing practice for patients with artificial hip arthroplasty [23][24][25]. However, in practical setting, it is also important to note that treatment and care should be strictly carried out according to the scheduled timetable. Time management methods should be utilized to effectively allocate hospital resources. Proactive communication with relevant departments should be established to ensure that all examinations are completed on time and that test results are reported on the same day. Only by doing so can we ensure the effective implementation of the clinical care pathway.
A major limitation of this study is that only male patients undergoing total hip arthroplasty in our hospital were recruited. As a next step, we will examine the specific effects and enhancement directions of clinical nursing practice pathways in a broader scope in order to provide a more comprehensive, scientific, and accurate foundation for clinical nursing practice.

Conclusions
The adoption of clinical care pathways has been shown to effectively improve clinical symptoms and promote the recovery of hip joint function in male patients undergoing total hip arthroplasty. In addition, it significantly enhances the satisfaction with clinical care and stands as a reliable approach in the practical management of patients undergoing total hip arthroplasty. However, future research should focus on assessing the specific effects and improvement directions of applying clinical care pathways.

AVA ILABILITY OF DATA AND MATERIALS
The authors declare that all data supporting the findings of this study are available within the paper and any raw data can be obtained from the corresponding author upon request.

A UTHOR CONTRIBUTIONS
LTB and XYL-designed the study and carried them out; LTB, XYL, YL, JYL, XL and QL-supervised the data collection, analyzed the data, interpreted the data; LTB and XYLprepared the manuscript for publication and reviewed the draft of the manuscript. All authors have read and approved the manuscript.

E T H I CS A PPR OVA L AN D CONS E N T TO PA RT ICI PAT E
Ethical approval was obtained from the Ethics Committee of West China Hospital (Approval no. 2021/268). Written informed consent was obtained from a legally authorized representative for anonymized patient information to be published in this article.

AC K NOW LED G ME N T
Not applicable.

F U ND ING
This research received no external funding.

CO NFL ICT OF IN T ERE ST
The authors declare no conflict of interest.