The Client with Alterations in Musculoskeletal Function

CHAPTER 12


The Client with Alterations in Musculoskeletal Function



image AMPUTATION


An amputation is the removal of all or part of a limb. Amputation of an upper or lower extremity may be performed to treat conditions such as tumors, uncontrollable infection, or gangrene and may be indicated in situations involving tissue destruction resulting from trauma or thermal injury (e.g., frostbite, electrocution, burns). Most amputations, however, are performed on the lower extremities of persons with severe peripheral vascular disease. In these instances, the ischemic limb is removed to prevent life-threatening infection and/or relieve severe, persistent discomfort. The level of amputation (e.g., above the knee, below the knee) is determined by factors such as the adequacy of circulation in the involved extremity; the client’s age, general health, and anticipated mobility; and the requirements for proper fit and optimal function of the prosthetic device.


The two types of surgical amputations are open and closed. The open type is performed if the client has an infected limb. The wound is left open, treated until the infection resolves, and then closed during a second surgical procedure. An open amputation may also be done if the client has a very high risk for developing a wound or bone infection postoperatively. A closed amputation, which consists of soft tissue flaps sutured over the bone, is the type of amputation that is more frequently performed. The basic techniques for postoperative management of the residual limb after a closed amputation include use of a soft compression dressing or use of a rigid dressing. The technique selected depends on the client’s underlying disease process and physiological status and whether the prosthetic fitting will be immediate, early (usually within 10-30 days), or delayed or is not expected to occur (unplanned).


This care plan focuses on the adult client hospitalized for a planned below-the-knee, closed amputation.* Much of the postoperative information is applicable to clients receiving follow-up care in an extended care facility or home setting.



OUTCOME/DISCHARGE CRITERIA


The client will:



1. Have pain controlled


2. Have evidence of normal healing of the surgical wound


3. Achieve expected level of mobility


4. Have no signs and symptoms of postoperative complications


5. Demonstrate appropriate ways to prevent contractures, increase strength, and improve mobility


6. Demonstrate correct transfer and ambulation techniques and proper use of ambulatory aids


7. Identify ways to maintain health of the remaining lower extremity


8. Demonstrate the ability to care for the residual limb


9. Verbalize how to care for the prosthesis and residual limb if a permanent prosthesis is planned


10. Identify ways to manage phantom limb pain if it occurs


11. State signs and symptoms to report to the health care provider


12. Share feelings and thoughts about the change in body image and effects of the amputation on lifestyle and roles


13. Identify community resources that can assist with home management and adjustment to changes resulting from the amputation


14. Verbalize an understanding of and a plan for adhering to recommended follow-up care including future appointments with health care provider, prosthetist, and physical therapist; medications prescribed; and activity level


For a full, detailed care plan on this topic, go to http://evolve.elsevier.com/Haugen/careplanning/.



FRACTURED HIP WITH INTERNAL FIXATION OR PROSTHESIS INSERTION


A fractured hip is the term used to describe a fracture of the proximal end of the femur. Hip fractures are classified according to the specific location of the fracture. A common classification system divides hip fractures into three types: femoral neck fractures (also referred to as intracapsular fractures), intertrochanteric fractures, and subtrochanteric fractures (the latter two types are sometimes referred to as extracapsular fractures).


A fractured hip is one of the most common orthopedic injuries in the elderly because of the increased incidence of osteoporosis and falls in the elderly population. Although a fractured hip can be treated by traction, the preferred treatment is surgery because it allows earlier mobility.


Surgery involves insertion of a femoral head prosthesis or reduction and internal fixation of the fracture with an intramedullary fixation device, cannulated screws, or a dynamic compression hip screw with a plate assembly. Internal fixation with preservation of the femoral head is the preferred treatment for hip fractures, but the femoral head and neck can be replaced with a prosthetic device (e.g., Austin Moore prosthesis) if an intracapsular fracture has occurred and factors are present that increase the risk for avascular necrosis and/or nonunion. Ideally, surgery is performed within 12 to 24 hours after the injury, especially if the client has a displaced femoral neck. During the preoperative period, traction is usually applied to stabilize and reduce the fracture and reduce muscle spasms and pain.


This care plan focuses on the elderly adult client who is hospitalized for surgical repair of a hip fracture. Much of the postoperative information is applicable to clients receiving follow-up care in an extended care facility or home setting.



OUTCOME/DISCHARGE CRITERIA


The client will:



1. Have evidence of normal healing of the surgical wound


2. Have clear, audible breath sounds throughout lungs


3. Have expected level of mobility


4. Have adequate fracture reduction and healing


5. Have hip pain controlled


6. Have no signs and symptoms of infection or postoperative complications


7. Demonstrate correct transfer and ambulation techniques and proper use of ambulatory aids


8. Demonstrate the ability to correctly perform the prescribed exercises


9. Verbalize an understanding of activity and position restrictions necessary to prevent dislocation of the prosthesis or internal fixation device


10. Identify ways to reduce the risk of falls in the home environment


11. Share thoughts and feelings about the need to transfer to or remain in an extended care or assisted living facility


12. State signs and symptoms to report to the health care provider


13. Identify community resources that can assist with home management and provide transportation


14. Verbalize an understanding of and a plan for adhering to recommended follow-up care including future appointments with health care provider and physical therapist, medications prescribed, activity level, and wound care.






Nursing Diagnosis ACUTE PAIN NDx (HIP)


Definition: Unpleasant sensory and emotional experience arising from actual or potential tissue damage


Related to: fracture of the bone, tissue trauma, and muscle spasms






Nursing Diagnosis RISK FOR PERIPHERAL NEUROVASCULAR DYSFUNCTION NDx (FRACTURED EXTREMITY)


Definition: At risk for disruption in circulation, sensation, or motion of an extremity


Related to:














Nursing Diagnosis RISK FOR PERIPHERAL NEUROVASCULAR DYSFUNCTION NDx (OPERATIVE EXTREMITY)


Definition: At risk for disruption in circulation, sensation, or motion of an extremity


Related to:














Collaborative Diagnosis RISK FOR DISLOCATION OF PROSTHESIS OR INTERNAL FIXATION DEVICE


Definition: Temporary displacement of one or more bones in a joint in which opposing bone surfaces lose contact


Related to:







Collaborative Diagnosis RISK FOR THROMBOEMBOLISM


Definition: Formation in a blood vessel of a clot (thrombus) that breaks loose and is carried by the bloodstream to plug another vessel


Related to:







Collaborative Diagnosis RISK FOR FAT EMBOLISM SYNDROME (FES)


Definition: Systemic fat globules from fractures that are distributed into tissues and organs after a traumatic skeletal injury


Related to: Release of fat globules from the bone marrow and injured surrounding tissue into the bloodstream associated with fracture of a long bone and subsequent surgery on the bone






Collaborative Diagnosis RISK FOR AVASCULAR NECROSIS/DELAYED HEALING OF FRACTURED BONE


Definition: A condition in which poor blood supply to an area of the bone leads to bone death (avascular necrosis) or delayed healing of fractured bone


Related to:








Nursing Diagnosis DEFICIENT KNOWLEDGE NDx, INEFFECTIVE SELF-HEALTH MANAGEMENT NDx, OR INEFFECTIVE HEALTH MAINTENANCE*


Definition: Absence or deficiency of cognitive information related to specific topic; pattern of regulating and integrating into daily living a therapeutic regimen for treatment of illness and the sequelae of illness that is unsatisfactory for meeting specific health goals; inability to identify, manage; and/or seek out help to manage health








Tags:
Feb 11, 2017 | Posted by in NURSING | Comments Off on The Client with Alterations in Musculoskeletal Function

Full access? Get Clinical Tree
Get Clinical Tree app for offline access