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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
joint

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


Arthroplastyrepair

of a joint.

There are two basic types: (1)


joint replacement and (2) total
hip replacement

Types of orthopedic surgeries contd


Joint

replacement

involves replacement of joint


surfaces with metal or plastic
materials.
Joints frequently replaced include
the hip, knee, and finger joints.

Joint replacement contd. Normal joint

Joint replacement contd.

Joint replacement contd.

Joint replacement contd.

Joint replacement contd.

Joint 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.


Amputationremoval

of a body part

TOTAL HIP REPLACEMENT

DEFINITION
Total

hip replacement is a surgical

procedure whereby the disease cartilage


and a bone of hip joint 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 Piagets diseases.
Certain hip fractures.
Ankylosing spondilytis

PRE-OPERATIVE
CARE

Preoperative Nursing Care


Psychological

care

Assess the clients 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 joint 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 patients 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 patients hip paying attention to
the range of motion in the joints 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 patients bowel to decrease


bacteria load.
Antibiotics are administered 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 clients 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 frequentlyrising


pulse rate, widening pulse pressure, or slowly
falling BP indicate persistent bleeding or
development of a state of shock.
Monitor for hemorrhageorthopedic 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.
Administer

ordered.

I.V. fluids and blood products as

Pain management
Assess

level of pain, intensity and location


Assess the clients level of comfort frequently
Use diversional therapy to reduce pain.
Administer 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 support 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.
Administer 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

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 administer 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 retentionelderly 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 joint 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,
supporting 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,

supportive 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
joint 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 joint.
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
ThromboembolismDVT or PE
Constipation or fecal impaction

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
Support

limbs, do not pull on arms or legs or


lift the legs to prevent more fractures or
deformities.
Position the patient withcare.
Check the patients circulatory, motor, and
sensory abilities.
Provide emergencycareof 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.
Providecarefor client with traction, with cast, or
with open reduction.
Encourage mobility when possible.
Administer 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 joints.

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 patients 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, administered 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