Nursing Care Of Patients Undergoing Orthopedic Surgery 5q3k5e

Nursing care of patients undergoing orthopedic surgery Isaac Amankwaa

Introduction  Orthopedics

is a branch of surgery that deals with conditions of the musculoskeletal system.  Orthopedic surgeons use both surgical and nonsurgical approaches.  Orthopedics cure varied conditions such as degenerative diseases, tumors and musculoskeletal trauma.

Indications for surgery  Unstabilized

fracture

 Deformity  t

disease,

 necrotic  tumors

or infected tissue,

Goals of Orthopedic Surgery Restoring

motion. Stabilizing fractured fragments. Relieving pain. Relieving disability or deformity.

Types of orthopedic Surgeries  Open

reduction

 Closed

reduction

 Internal  Bone

fixation.

graft

Types of orthopedic surgeries contd Arthroplasty—repair

of a t.

There are two basic types: (1) t replacement and (2) total hip replacement

Types of orthopedic surgeries contd t

replacement

◦involves replacement of t surfaces with metal or plastic materials. ◦ts frequently replaced include the hip, knee, and finger ts.

t replacement contd. Normal t

t replacement contd.

t replacement contd.

t replacement contd.

t replacement contd.

t replacement contd.

Types of orthopedic surgeries contd Meniscectomy:

excision of

damaged meniscus (fibrocartilage) of the knee.

Types of orthopedic surgeries contd  Tendon

transfer —movement of tendon

insertion point to improve function.  Fasciotomy

—cutting muscle fascia to

relieve constriction or contracture.  Amputation—removal

of a body part

TOTAL HIP REPLACEMENT

DEFINITION  Total

hip replacement is a surgical

procedure whereby the disease cartilage and a bone of hip t are surgically replaced with artificial materials.  It

is also known as total hip

arthroplasty.

INDICATIONS  Osteoarthritis  Traumatic

arthritis  avascular necrosis  Femoral neck fractures  Failure of previous reconstructive surgery (failed prosthesis, osteotomy).  Bone tumors  Arthritis associated with Piaget’s diseases.  Certain hip fractures.  Ankylosing spondilytis

PRE-OPERATIVE CARE

Preoperative Nursing Care  Psychological

care

◦ Assess the client’s knowledge and understanding of the planned operative procedure. ◦ Provide further explanations and clarification as needed. ◦ Discuss postoperative pain control measures ◦ Patient is introduced to other patients who have undergone such procedures and had come out successfully and also show a video to him or her to know how it is performed and also relive anxiety.

Preoperative Nursing Care  Patient

Teaching

◦ Explain necessary postoperative activity restrictions. ◦ Teach how to use the overhead trapeze for changing positions. ◦ Provide or reinforce teaching of postoperative exercises specific to the t on which surgery is to be performed Teach respiratory hygiene procedures such as the use of incentive spirometry, coughing, and deep breathing.

Preoperative Nursing care  Physiological

care

◦ Perform blood investigation including complete blood count Electrolyte levels, prothrombin time etc. ◦ Check patient’s vital signs and report any abnormal findings such as increased BP to the physician ◦ Hydration, protein, and caloric intake are assessed. The goal is to maximize healing and reduce risk of complications by providing I.V. fluids, vitamins, and nutritional supplements as indicated.

Preoperative Nursing care  Physiological

care ◦ Ensure that requested radiological examinations such as X-rays has been carried out and report filed ◦ Prepare patients skin in accordance with hospital policy ◦ Review of all medications being taken by the patients.  Anti-inflammatory medications including aspirin are discontinued one week prior to surgery because of the effect on platelet function and blood clotting.

Preoperative preparation  Physiological

preparation ◦ Examine patient’s hip paying attention to the range of motion in the ts and the strength of the surrounding muscles. It is done to know if patient is fit enough to undergo the surgery. ◦ Major dental procedures such as tooth extractions and prior dental work should be done before total hip replacement to prevent hematogenous spread

Pre-operative preparation  Physiological

preparation

◦ Urinalysis is done to rule out infection ◦ The skin should not have any skin infections or irritations before the surgery. ◦ The operation site will be shaved, clean and drape with a sterile towel.

Preoperative preparation Physiological

preparation

◦Prepare patient’s bowel to decrease bacteria load. ◦Antibiotics are istered to prevent further infections. ◦Education on weight loss for patient who are obese is highlighted to help minimize the stress on the new hip and decrease the risks of surgery.

Pre-operative preparation Physiological preparation ◦ Check for any indications of infections, severe heart and lung disease or active metabolic disorders such as uncontrolled diabetes ◦ Preoperative exercise program must be reinforced to build muscle and increase flexibility. ◦ Because it involves blood loss, patient planning to undergo the surgery offer their own (autologous) blood to be stored for transfusion during surgery, minimizing risk related to blood transfusion. ◦ Ensure that consent form is duly signed.

Pre-operative preparation  The

patient should practice voiding in bedpan or urinal in recumbent position before surgery. This helps reduce the need for postoperative catheterization.  The patient is acquainted with traction apparatus and the need for splint or cast, as indicated by type of surgery.  Review discharge and rehabilitation options post-surgery.

POST-OPERATIVE CARE

IMMEDIATE POST-OP CARE (WITHIN 24HOURS  Patient

Reception

◦ Receive and put patient on a firm bed and place him/her in a position as prescribed by the surgeon. ◦ Asses the level of consciousness. ◦ The affected area is immobilized and activity limited to protect the operative site and stabilize musculoskeletal structures.

IMMEDIATE POST-OP CARE (WITHIN 24HOURS  Observation

Use ABC format to assess the patient.  Airway: ensure patent airway and suction any mucus in the nostrils; if patient is unconscious, turn patient head to side to prevent tongue from falling back.  Breathing: check the up and down movement of the chest; check respiration rate, rhythm and abnormal sound periodically.  Circulation: check for pulse rate, capillary refill and central cyanosis; assess skin for redness, warmth and coldness; monitor incisional bleeding by emptying and recording suction drainage every 4 hours and assessing the dressing frequently.

Immediate post-operative care  Observation

& initial care

◦ Check vital signs (including temperature) and level of consciousness, every 4 hours or more frequently as indicated. Report significant changes to the physician. ◦ Perform neurovascular checks (color, temperature, pulses and capillary refill, movement, and sensation) on the affected limb hourly for the first 12 to 24 hours, then every 2 to 4 hours. ◦ Swelling caused by edema and bleeding into tissues needs to be controlled. ◦ Connect all tubings such as the urine catheter and check for amount, colour and odour.

Immediate Post-operative nursing  Observation

& Initial care ◦ Hemorrhage and shock, which may result from significant bleeding and poor hemostasis of muscles that occur with orthopedic surgery, are monitored. ◦ Assess the client with a total hip replacement for signs of prosthesis dislocation, including pain in the affected hip or shortening and internal rotation of the affected leg.

Immediate Post-operative nursing  Observation

& Initial care ◦ Assess the client’s level of comfort frequently. Maintain PCA, epidural infusion, or other prescribed analgesia to promote comfort. Adequate pain management promotes healing and mobility. ◦ Maintain intravenous infusion and accurate intake and output records during the initial postoperative period.

SPECIFIC NURSING CARE (post-operatively)

Nursing diagnosis  



  



Risk for Deficient Fluid Volume related to hemorrhage Ineffective Breathing Pattern related to effects of anesthesia, analgesics, and immobility Risk for Peripheral Neurovascular Dysfunction related to swelling Acute Pain related to surgical intervention Risk for Infection related to surgical intervention Impaired Physical Mobility related to immobilization therapy and pain Imbalanced Nutrition: Less Than Body Requirements related to blood loss and the demands of healing

Monitoring for shock and hemorrhage  Evaluate

BP and pulse rates frequently—rising pulse rate, widening pulse pressure, or slowly falling BP indicate persistent bleeding or development of a state of shock.  Monitor for hemorrhage—orthopedic wounds have a tendency to ooze more than other surgical wounds. ◦ Measure suction drainage if used. ◦ Anticipate up to 500 mL of drainage in the first 24 hours, decreasing to less than 30 mL per 8 hours within 48 hours, depending on surgical procedure. ◦ Report increased wound drainage or steady increase in pain of operative area.  ister

ordered.

I.V. fluids and blood products as

Pain management  Assess

level of pain, intensity and location  Assess the client’s level of comfort frequently  Use diversional therapy to reduce pain.  ister analgesics as prescribed.  Institute pain-relief measures, as prescribed, as well as nursing measures as indicated: backrubs, soft light, soft tranquil music.  Use patient-controlled analgesia (PCA) according to standards of care.  Facilitate progression from I.V. medications to by mouth when tolerated.

Wound care and drainage  Reinforce

the dressing as needed. The dressing is usually changed 24 to 48 hours after surgery but may need reinforcement if excess bleeding occurs  Drainage of 200 to 500 mL in the first 24 hours is expected; by 48 hours postoperatively, the total drainage in 8 hours usually decreases to 30 mL or less, and the suction device is then removed.  The nurse promptly notifies the physician of any drainage volumes greater than anticipated.

Wound care and drainage Stitches

or staples will be removed approximately 2 weeks after surgery. Avoid getting the wound wet The wound should be bandaged to prevent irritation from clothing or stockings.

Preventing Infection  Monitor

vital signs for fever, tachycardia, or increased respiratory rate, which may indicate infection.  Examine incision for redness, increased temperature, swelling, and induration.  Note character of drainage.  Evaluate complaints of recurrent or increasing pain.  ister antibiotic therapy as prescribed.  Maintain aseptic technique for dressing changes and wound care.  Potential sources of infection are avoided. If indwelling urinary catheters or portable wound suction devices are used, they are removed as soon as possible to avoid infection.

Preventing dislocation of prosthesis  Maintain

bed rest and prescribed position of the affected extremity using a sling, abduction splint, brace, immobilizer, or other prescribed device.  Prevent hip flexion of greater than 90 degrees  The leg is normally Positioned in abduction to prevent dislocation of the prostheses  Provide a seat riser for the toilet or commode. Use a high-seated chair and a raised toilet seat.  Do not flex hip more than 90°  Avoid internal rotation  Avoid bending forward when seated in a chair.  Avoid bending forward to pick up an object on the floor

Use of an Abduction Pillow to Prevent Hip Dislocation After Total Hip Replacement

4

SIGNS OF DISLOCATION OF A PROSTHESIS  Increased

pain at the surgical site, swelling, and immobilization  Acute groin pain in the affected hip or increased discomfort  Shortening of the leg  Abnormal external or internal rotation  Restricted ability or inability to move the leg  Reported “popping” sensation in the hip

Preventing dvt and improving mobility  The

nurse must institute preventive measures and monitor the patient closely for the development of DVT and PE. Signs of DVT include calf pain, swelling, and tenderness.  Use sequential compression devices or antiembolism stockings as prescribed. These help prevent thromboembolism and pulmonary embolus for the client who must remain immobile following surgery.  Initiate physical therapy and exercises as prescribed

Nutrition 

Watch for signs and symptoms of anemia, especially after fracture of long bones: ◦ ◦ ◦ ◦











Fatigue Shortness of breath Pallor Tachycardia

Monitor hemoglobin and hematocrit levels. Report below-normal results to health care provider. Encourage high-iron diet, and ister blood products and iron supplements as directed. Provide a balanced diet, and increase fluids and fiber to reduce incidence of constipation associated with immobility. Maintain urinary output and prevent infection and calculi by increased fluid intake. Watch for urinary retention—elderly men with some degree of prostatism may have difficulty in voiding.

TEACHING PATIENT OF SELF CARE  The

nurse advises the patient of the importance of the daily exercise program in maintaining the functional motion of the hip t and strengthening the abductor muscles of the hip, and reminds the patient that it will take time to strengthen and retrain the muscles.  Teach patient activities that will minimize the development of complications (eg, turning, ankle pumps, antiembolism stockings, SCDs, coughing, and deep breathing).  Instruct patient on dietary considerations to facilitate healing and minimize development of constipation and renal calculi.

TEACHING PATIENT OF SELF CARE  Assistive

devices (crutches, walker) are used for a time. Stair climbing is permitted as prescribed but is kept to a minimum for 3 to 6 months.  Frequent walks, swimming, and use of a high rocking chair are excellent for hip exercises.  Inform patient of techniques that facilitate moving while minimizing associated discomforts (eg, ing injured area and practicing smooth, gentle position changes).  Encourage long-term follow-up and physical therapy (PT) exercises, as prescribed, to regain maximum functional potential.

Patient teaching 







At no time during the first 4 months should the patient cross the legs or flex the hip more than 90 degrees. Assistance in putting on shoes and socks may be needed. The patient should avoid low chairs and sitting for longer than 45 minutes at a time. These precautions minimize hip flexion and the risks of prosthetic dislocation, hip stiffness, and flexion contracture. Traveling long distances should be avoided unless frequent position changes are possible. Other activities to avoid include tub baths, jogging, lifting heavy loads, and excessive bending and twisting (eg, lifting, shoveling snow, forceful turning).

REHABILITATION  Initially,

ive devices such as walker or crutches are used.  Pain is monitored whiles exercise takes place.  Degree of discomfort is normal. It is often gratifying for the patient to notice, even early on substantial relief from preoperative pain.  Patients are instructed not to strain the hip t with leg lifting or the unusual activities at home.

CONT………..  Specific

techniques of body posturing, sitting and using an elevated toilet seat can be helpful.  They are instructed not to cross the operated lower extremity across the midline of the body (not crossing the leg over the leg) because of the risk of dislocating the replaced t.  They are discouraged from bending at the waist and are instructed to use a pillow between the legs when lying on non-operated site in order to prevent the operated lower extremity from crossing over the midline.

Potential Complications— Postoperative  Hypovolemic

shock

 Atelectasis  Pneumonia  Urinary

retention  Infection  Thromboembolism—DVT or PE  Constipation or fecal impaction

5

OSTEOGENESIS IMPERFECTA

Osteogenesis Imperfecta Also

known as brittle-bone disease. Is a genetic (inherited) disorder characterized by bones that break easily without a specific cause

Etiology Genetic

mutation

Pathophysiology Can

result from autosomal dominant or recessive inheritance. Mutation change occurs in the DNA (the genetic code) within a gene that makes collagen, a major component of the connective tissues in bones, ligaments, teeth, and the white outer tissue of the eyeballs (sclera) The reticulum fails to differentiate into mature collagen or causes abnormal collagen development Leading to immature, coarse bone formation and cortical bone thinning Result in fragile bones that break easily

Signs and Symptoms  Multiple

fractures at birth  Bilaterally bulging skull  Triangular shaped head and face  Prominent eyes  Blue or gray tinted sclera  Pain and bone swelling  Loss of function  Thin, translucent skin  Teeth that breaks easily

Signs and Symptoms  Breathing

problems  Delayed walking  Scoliosis as the child grows  Tinnitus  Hearing loss  Kidney stone  Urinary problems

Diagnostic investigations  Family

history and characteristics features such as blue sclera or deafness.  Complete medical history and physical examination.  Skin biopsy to determine the amount and structure of collagen.  X-ray showing evidence of multiple old and new fractures and skeletal deformities.  Bone Mineral Density (BMD) test

Nursing Interventions 

limbs, do not pull on arms or legs or lift the legs to prevent more fractures or deformities. Position the patient with care. Check the patient’s circulatory, motor, and sensory abilities. Provide emergency care of fractures. Observe for signs of compartment syndrome. Encourage diet high in protein and vitamins to promote healing.

Nursing intervention  Encourage

fluids to prevent constipation, renal calculi, and urinary tract infection.  Provide care for client with traction, with cast, or with open reduction.  Encourage mobility when possible.  ister analgesics as prescribed.  Teach the patient preventive measures.  Monitor hearing needs.  Aggressively teach all upper respiratory infections including

Complications Pressure

ulcer Pneumonia Constipation Urinary stasis Infection

Osteomyelitis

Osteomyelitis  Synonyms

◦Ostitis ◦Osteitis ◦Panostitis ◦osteomyeloperiostitis

Osteomyelitis Definition Osteomyelitis

is the Inflammatory process within the bone with an infectious cause.

It

is defined as bacterial infection of the whole cross-section of the bone including the periosteum

Bone

infections are more difficult to treat

Pathophysiology  Causative

organisms Staphylococcus aureus (most common) Proteus, Pseudomonas species and Escherichia coli.  The organism usually settles in the metaphysis because of the perculiar arrangement of the vessels there.  The infection starts with ◦ Inflammation ◦ Suppuration ◦ Necrosis ◦ New bone formation ◦ resolution 

Pathophysiology  The

initial response to infection is

inflammation  This

is followed by thrombosis and ischemia

with bone necrosis.  Extension

of infection into the medullary

cavity and under the periosteum and may spread into adjacent soft tissues and ts.

Pathophysiology  This

leads to formation of a bone abscess

 The

resulting abscess cavity contains

dead bone tissue (the sequestrum)  Therefore,

the cavity cannot collapse and

heal, as occurs in soft tissue abscesses.

Pathophysiology  New

bone growth (the involucrum)

forms and surrounds the sequestrum.  Although

healing appears to take place, a

chronically infected sequestrum remains and produces recurring abscesses throughout the patient’s life.

Pathophysiology

Clinical Manifestations  Acute

osteomyelitis

◦ chills, high fever, rapid pulse, general malaise ◦ The infected area becomes painful, swollen, and extremely tender. ◦ Pain is constant, pulsating and intensifies with movement

◦ The area is swollen, warm, painful, and tender to

touch

Clinical Manifestations  Chronic

osteomyelitis

◦ Continuously draining sinus ◦ recurrent periods of pain, inflammation, swelling, and drainage.

Classification of osteomyelitis  Classification

according to location

◦ Type I: Medullary osteomyelitis: primary lesion is endosteal ◦ Type II: Superficial osteomyelitis: surface of bone is infected. ◦ Type III: Localized osteomyelitis: bone cortex and osteum infected: ◦ Type IV: Diffuse osteomyelitis: disease spread through bone and soft tissue

Classification of osteomyelitis  Classification

of according to

onset/duration ◦ Acute osteomyelitis  Acute haematogenous osteomyelitis  Acute post traumatic osteomyelitis ◦ Chronic osteomyelitis ◦ Sub-acute or primary chronic osteomyelitis

Assessment and Diagnostic Findings ◦ White blood cell (WBC count) ◦ Erythrocytes sedimentation rate rises with osteomyelitis ◦ Blood culture can identify the pathogen ◦ X-rays may show bone involvement only after the disease has been active for some time ◦ Bone scans can detect early infection

Differential diagnosis  Cellulitis  Acute

suppurative arthritis

 Acute

rheumatism

 Sickle

cell crisis

Treatment  Medical

◦ Cold compression ◦ Broad spectral antibiotics ◦ Splinting of the affected limb ◦ Analgesics ◦ Treat underline cause. E.g. Sickle cell, DM or HIV

Treatment 

Surgical Management

◦ A sequestrectomy (removal of enough involucrum to enable the surgeon to remove the sequestrum) is performed. ◦ In many cases, sufficient bone is removed to convert a deep cavity into a shallow saucer (saucerization). ◦ All dead, infected bone and cartilage must be removed before permanent healing can occur. ◦ A closed suction irrigation system may be used to remove debris.

Complications Lethal

outcome if not promptly treated

Metastatic

infection- serious and

overwhelming sepsis that spread to other sides Suppurative Altered

arthritis

bone growth

Pathologic

fracture

Prevention  Efforts

must be made to prevent infection in orthopedic surgeries  Prophylactic antibiotics, istered to achieve adequate tissue levels at the time of surgery and for 24 hours after surgery, are helpful.  Urinary catheters and drains are removed as soon as possible to decrease the incidence of hematogenous spread of infection.  Aseptic postoperative wound care.  Prompt management of soft tissue infections