Care of the orthopedic surgical patient

37 Care of the orthopedic surgical patient


Anesthesia:  Local or systemic loss of sensation.

Arthrodesis:  Surgical fixation or fusion of a joint.

Arthroplasty:  Reconstruction of joints for restoration of motion and stability.

Arthroscopy:  Surgical examination of the interior of a joint with the insertion of an optic device (arthroscope) capable of providing an external view of an internal joint area.

Arthrotomy:  Surgical exploration of a joint.

Articulation:  The connection of bones at the joint.

Cineplastic (Kineplastic) Amputation:  An amputation that includes a skin flap built into a muscle; a portion of the prosthetic mechanism is activated by the muscle.

Disarticulation:  Amputation at a joint.

Diskectomy (Discectomy):  Removal of herniated or extruded fragments of an intervertebral disk.

External Fixators:  Equipment used in the management of open fractures with soft tissue damage (provides stabilization for the fracture while it permits treatment of soft tissue damage).

Fasciotomy:  Surgical separation of the fascia (a fibrous membrane that covers, supports, or separates the muscles) for relief of muscle constriction or reduction of fascia contracture.

Harrington Rods:  Equipment used in spinal fixation for scoliosis and for some spinal fractures.

Hemiarthroplasty:  Replacement and resurfacing of the femoral head with a prosthesis.

Internal Fixation:  The stabilization of a reduced fracture with the use of metal screws, plates, nails, and pins.

Joint Replacement:  The substitution of joint surfaces with metal or plastic materials.

Laminectomy:  Removal of the lamina for exposure of the neural elements in the spinal canal or relief of constriction.

Lordosis:  Abnormal anterior convexity of the lower part of the back.

Luque Rods:  Contoured metal rods that are fixed to each segment (vertebrae) in the affected part of the spine.

Meniscectomy:  Surgical removal of the damaged knee joint fibrocartilage.

Open Reduction:  The reduction and alignment of a fracture through surgical dissection and exposure of the fracture.

Osteoporosis:  Diminished amount of calcium in the bone.

Osteotomy:  Surgical cutting of the bone.

Paresthesia:  Numbness and a tingling sensation.

Scoliosis:  Lateral curvature of the spine.

Sequestrectomy:  Surgical removal of necrotic bone.

Spinal Fusion:  A fusion of the cervical, thoracic, or lumbar region of the spine with an iliac or other bone graft that primarily fuses the laminae and sometimes the joints, most often through the posterior approach.

Syme Amputation:  Modified ankle disarticulation (below-the-ankle) amputation of the foot.

Volkmann Contracture:  The final state of unrelieved forearm compartment syndrome; contractures of tendons to wrist and hand.

Orthopedics (or orthopaedics) is a specialty of health care that is concerned with the prevention, diagnosis, and correction of disorders of the musculoskeletal system of the body. Orthopedic surgery is concerned with the treatment of diseases and injuries of the musculoskeletal system, mainly with manipulative and operative methods. Perianesthesia nursing care of the orthopedic patient can be challenging and rigorous. In this highly technologic age, the care needed by the orthopedic patient requires both vigilant general perianesthesia care and a sound knowledge of orthopedic surgical procedures. Familiarity with orthopedic procedures and the anticipated patient outcomes helps the perianesthesia nurse provide high quality postoperative care. The perianesthesia nurse must possess astute nursing observation and assessment skills to ensure a low incidence rate of morbidity in this patient population. The psychosocial challenges are generally more evident within this group because, more commonly, the goal of the surgery is focused on restoring mobility and relieving pain and disability. The nurse must be sensitive to heightened anxieties and empathetic to individual needs.

General perianesthesia care

Specific nursing care related to the patient for orthopedic surgery that begins in the postanesthesia care unit (PACU) includes positioning, neurovascular assessment, care of immobilization devices, wound care, range-of-motion exercises, and observation for complications.


After the initial assessment of the patient is made, attention is turned to positioning. Proper body alignment is important for all these patients and requires a sound knowledge of operative procedure and body mechanics. Individual surgeons generally have specific directives for positioning, but general guidelines apply to all patients. The goal is optimal comfort and safety for the operated limb or area. The upper extremities should be held close to the body; elevation should be achieved without undue pressure on the elbow or shoulder. The lower extremities are in a neutral position, with support provided for the entire length, and heels are off the bed.

Elevation of operative limbs is usually indicated to increase venous return, reduce swelling, and promote comfort. In the elevation of a hand or arm, the hand must be higher than the heart and no pressure should be placed on the elbow. This position can be achieved with the use of a stockinette device for suspension on an intravenous (IV) pole. The stockinette is measured from the elbow to approximately 12 inches beyond the fingertips; a piece is cut double this length. That piece is then folded in half, with the elbow resting in the fold. With safety pins, the sides are closed around the limb to form a tube, while ensuring that the fingers are exposed (for assessment of neurovascular status). With the excess material, a knot is tied and suspended from the IV pole. The elbow should be properly supported. If a pillow is used for elevation, the arm should be allowed slight flexion for maximum comfort and provide additional support for the elbow and shoulder.

Lower extremity elevation is most effective if the toes are above the heart. If the limb is not in an immobilization device, it is kept in a position of extension. This position is achieved by elevating the foot of the bed rather than with the use of pillows. The entire length of the limb should be supported if pillows are used and the heels are kept off the bed.

Shoulder immobilization can be accomplished with a sling or shoulder immobilizer. An airplane splint (a padded and Velcro shoulder orthotic used to position the shoulder in various degrees of abduction; Fig. 37-1) may be applied for rotator cuff repairs and other involved humerus fractures and postoperative shoulder or arm surgery where shoulder position and elbow flexion control are desired. If a sling is used, the patient is instructed to keep the arm close to the chest, with the wrist and elbow supported. All shoulder immobilizers require special care and padding to areas where skin contacts skin.

The patient with a hip pinning is positioned with proper body alignment, and the legs are in a proper neutral position. Care is given to avoid stress to the operative area with exaggerated flexion or rotation. A pillow is placed between the knees during turning to prevent adduction and rotation.

For the patient with a posterior or lateral total hip replacement, proper body alignment is achieved with placement of an abduction pillow between the knees at all times (Box 37-1). Most important with these patients is to avoid flexion and adduction of the newly placed joint. There are four basic positions to be avoided after hip surgery: 1) no flexion of the hip past 90 degrees with respect to the axis of the body; 2) no abduction of the leg past the midline of the body; 3) no combined extension of the hip joint with external rotation of the lower extremity; and 4) no flexion with internal rotation. Use of the abduction pillow helps to prevent the patient from getting into positions that could cause dislocation. The patient who has had an anterior total hip replacement does not require dislocation precautions. Therefore there is no need for an abduction pillow, traction sling, or hip cushion to assist with positioning.1

The perianesthesia nurse should also be familiar with various types of orthopedic equipment that may be used and that can affect positioning. Often, patients with total knee replacement and those with more extensive knee arthrotomy are placed in a continuous passive motion (CPM) machine. The purpose of CPM is to enhance the healing process by providing CPM to the joint, thus increasing circulation and movement. Traction may also be used with various patients to immobilize and align a specific area. The perianesthesia nurse is not usually involved in setting up the traction, but should be aware of some basic principles for maintenance: (1) the traction must be continuous, (2) the patient is centered in bed in good alignment to maintain the line of pull in line with the long bone, (3) weights should hang freely and not resting on the floor or bed, and (4) the pulley ropes should be in alignment and free of knots. One type of traction is depicted in Fig. 37-2.

Neurovascular assessment

Critical to the care of the patient for orthopedic surgery is assessment of the neurovascular status of the operative limb. Any alteration in blood flow to the extremity or nerve compression requires immediate intervention. Assessment is recommended every 30 minutes because problems can occur within 2 to 4 hours. Baseline neurovascular indicators should be noted in the admission nursing assessment. These indicators can be used to establish any deleterious effects from the surgery and to avoid the masking of potential complications. Both the affected and unaffected limbs are assessed.2

The hallmarks of neurovascular changes from constriction and circulatory embarrassment are pain, discoloration (skin that is pale or bluish), decreased mobility, coldness, diminished or absent pulses, altered capillary refilling, and swelling. Pain is common with patients for orthopedic surgery, and the approach to treatment must be individualized. Pain unrelieved with conventional methods, such as elevation and repositioning and the administration of opioids, must be assessed further. Color indicates circulatory compromise.2 Cyanosis suggests venous obstruction; pallor suggests arterial obstruction. Mobility is assessed by determining the range of motion of the fingers or toes and strongly indicates neural compromise. Fingers are flexed, extended, spread, and wiggled. Toes should be dorsiflexed, plantarflexed, and wiggled. An inability to move the fingers or toes, pain on extension of the hand or foot, or coldness of the extremity is indicative of ischemia. Sensation is described as normal, hypesthetic (dulled), paresthetic, or anesthetic. Alteration in sensation suggests nerve compression or circulatory compromise. Limb perfusion is further assessed with the presence of peripheral pulses and capillary refilling. Capillary refilling is assessed with compression of the nail bed, which causes blanching; when the compression is released, color briskly returns. Compromise delays the filling time. With the development of pulse oximetry, a more reliable method of perfusion assessment is available. With placement of the oximeter sensor on a finger or toe of the affected limb, the pulsation is sensed and oxygen saturation is displayed. This method is more reflective of perfusion than capillary refilling and is valuable when pulses cannot be assessed because of the presence of a cast or dressing.

Care of immobilization devices (cast care)

Immediate assessment of the patient after orthopedic surgery in the PACU should include the type of immobilization device applied. The soft knee immobilizer should be checked for proper placement and closure, and the surgical dressing should be checked for drainage. For care that involves traction, refer to the previous section in this chapter on positioning.

The cast is a rigid immobilization device molded to the contours of the part to which it is applied. The cast has a dual purpose: immobilization in a specific position and provision of uniform pressure on the encased soft tissue. The cast should be inspected for visibility of fingers and toes for neurovascular assessment. If the cast is bivalved, the edges should be inspected for roughness to avoid discomfort and potential skin breakdown. When the patient arrives in the PACU, the cast is likely still wet, and special care must be taken to prevent indentations. A wet cast must be handled carefully with the palms of the hand to avoid pressure from fingertips. The cast should be supported on a pillow, and hard flat surfaces should be avoided. Improper handling and flat surfaces can cause indentations that can lead to the development of pressure sores. More frequently, a fiberglass cast is applied with quicker drying properties, but the same general principles still apply.2 In general, a full cast may not be placed on a patient where wound drainage is expected (a temporary splint or cast would be used), but any drainage noted on the cast should be circled, and the time should be noted. This documentation can provide a guide for postoperative blood and fluid loss and can alert the nurse if the drainage appears to be excessive. Note that orthopedic wounds tend to ooze and may bleed more than other surgical wounds.

Observation for complications

Postoperative complications for the patient after orthopedic surgery include deep vein thrombosis, pulmonary embolism, fat embolism syndrome, compartment syndrome, shock, and urinary retention.

Deep vein thrombosis

Prevention of deep vein thrombosis (DVT) is a major concern for patients undergoing orthopedic surgery, especially total joint replacement.3 Other contributing risk factors include age, previous history of DVT or pulmonary embolism (PE), metastatic malignancy, smoking, estrogen or current pregnancy, vein disease, obesity, and genetics (Box 37-2). Thrombosis is the formation of a blood clot associated with three conditions outlined by Virchow in 1846: venous stasis, altered clotting mechanism, and altered vessel wall integrity.4 Immobilization and the insult of the surgical procedure place the orthopedic patient at high risk. DVT refers to the formation of a thrombus within the deep vein, typically the thigh or calf. In reports of total hip arthroplasty before routine prophylaxis, venous thrombosis occurred after total hip replacement in 50% of patients, and fatal pulmonary emboli occurred in 2%.3 Immobilization impairs the leg muscle action needed to move the blood sufficiently, and the surgical procedure injures vessel walls that activate and alter clotting mechanisms. An inflammation process begins within the vessel wall and leads to deep vein thrombosis. The patient usually has pain and tenderness. Signs include swelling and sometimes localized redness. Palpation of the calf reveals firmness or tension of the muscle. A positive Homans sign may be seen, although a positive sign does not accurately diagnose a DVT alone.5 DVT can be difficult to diagnose. Diagnostic tests such as venography, magnetic resonance imaging, or Doppler ultrasound may be indicated.

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Nov 6, 2016 | Posted by in NURSING | Comments Off on Care of the orthopedic surgical patient

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