• A rigid, external immobilizing device
• Uses
– Immobilize a reduced fracture
– Correct a deformity
– Apply uniform pressure to soft
... [Show More] tissues
– Support and stabilize weakened joints
• Materials: nonplaster (fiberglass), plaster of Paris
• Contoured splints of plaster or pliable thermoplastic materials may be used for:
• Braces (i.e., orthoses) are custom fitted to various parts of the body and are used to:
What is a cast?
• Before application
• Monitoring of neurovascular status and for potential complications
• Treat lacerations and abrasions before cast, brace, splint
• Provide information about the purpose of treatment
• Prepare patient for application by explaining procedure
• Assessing for neurovascular changes using “6 Ps”
• Monitoring and treating pain
Is the following statement true or false?
A patient’s unrelieved pain should be reported to the physician 30 minutes after administered pain medication
A patient’s unrelieved pain must be immediately reported to the physician to avoid possible paralysis and necrosis
• Compartment syndrome:
• Dx: Clinical assessment of 6 Ps; pain is the early indicator
• Treatment: Notify physician, cast may be removed, and emergency fasciotomy may be necessary
• Pressure ulcer: caused by inappropriately applied cast
– Lower extremities most susceptible
– Patient reports painful “hotspot” and tightness
– Dx: May cut window in the cast for inspection and access
– Treatment: dressing applied over exposed skin
• Disuse Syndrome: muscle atrophy and loss of strength
– Treatment: Isometric exercises, muscle setting exercises
• Impact of injury to physiologic functioning (ADL, IADL)
• Activity, exercise, rest
• Medications
• Techniques for cast drying
• Controlling of swelling and pain
• Care of minor skin irritation
– Pad rough edges with tape or moleskin
– Blow with hair dryer to relieve itching
– Do not stick foreign objects into the cast
• Unrelieved itching may need antihistamine
• Signs and symptoms to report:
– Persistent pain or swelling,
– Changes in sensation, movement, skin color or temperature
– Signs of infection or pressure areas
• Required follow-up care
• Cast removal and after care
• Used to manage open fractures with soft tissue damage
• Provide support for complicated or comminuted fractures
• Patient requires reassurance because of appearance of device
• Discomfort is usually minimal, and early mobility may be anticipated with these devices
• Elevate to reduce edema
• Monitor for signs and symptoms of complications, including infection
• Pin care
• Patient education
Is the following statement true or false?
The nurse never adjusts the clamps on the external fixator frame
True
The nurse never adjusts the clamps on the external fixator frame. It is the physician’s responsibility to do so
• The application of pulling force to a part of the body
• Purposes
– Reduce muscle spasms
– Reduce, align, and immobilize fractures
– Reduce deformity
– Increase space between opposing forces
• Used as a short-term intervention until other modalities are possible
• All traction needs to be applied in two directions. The lines of pull are “vectors of force.” The result of the pulling force is between the two lines of the vectors of force
• Whenever traction is applied, a counterforce must be applied. Frequently, the patient’s body weight and positioning in bed supply the counterforce
• Traction must be continuous to reduce and immobilize fractures
• Skeletal traction is never interrupted
• Weights are not removed unless intermittent traction is prescribed
• Any factor that reduces pull must be eliminated
• Ropes must be unobstructed, and weights must hang freely
• Knots or the footplate must not touch the foot of the bed
• Skin traction
– Buck extension traction
– Cervical head halter
– Pelvic traction
• Skeletal traction
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Balanced Skeletal Traction with Thomas Leg Splint
Is the following statement true or false?
The nurse must never remove weights from skeletal traction unless a life-threatening situation occurs
True
The nurse must never remove weights from skeletal traction unless a life-threatening situation occurs. Removal of the weights completely defeats their purpose and may result in injury to the patient
Nursing Interventions for the Patient in Skin Traction
• Proper application and maintenance of traction
• Monitor for complications of skin breakdown, nerve damage, and circulatory impairment
– Inspect skin at least three times a day
– Palpate traction tapes to assess for tenderness
– Assess sensation and movement
– Assess pulses, color, capillary refill, and temperature of fingers or toes
– Assess for indicators of DVT
– Assess for indicators of infection
• Evaluate traction apparatus and patient position
• Maintain alignment of body
• Report pain promptly
• Trapeze to help with movement
• Assess pressure points in skin every 8 hours
• Regular shifting of position
• Special mattresses or other pressure reduction devices
• Perform active foot exercises and leg exercises every hour
• Elastic hose, pneumatic compression hose, or anticoagulant therapy may be prescribed
• Pin care
• Exercises to maintain muscle tone and strength
Nursing Management of Patients in Traction
• Assessing anxiety
• Assisting with self-care
• Monitor and manage complications
– Pressure ulcer
– Atelectasis and pneumonia
– Constipation
– Anorexia
– Urinary stasis
– Infection
– DVT
How often must the nurse inspect the traction pin site for signs of inflammation and evidence of infection?
A. Every 8 hours
B. Every 12 hours
C. Every 16 hours
D. Every 24 hours
A. 8 hours
The nurse must inspect the traction pin site for signs of inflammation and evidence of infection at least every 8 hours
Joint Replacements
• Used to treat severe joint pain and disability and for repair and management of joint fractures or joint necrosis
• Frequently replaced joints include the hip, knee, and fingers
• Joints including the shoulder, elbow, wrist, and ankle may also be replaced
Needs of Patients With Hip Replacement Surgery
• Preventing Dislocation of Hip Prosthesis
– Correct positioning using splint, wedge, pillows
– Keep hip in abduction when turning, adduction when transferring
– Limited flexing of the hip; <90 degrees
• Mobility and ambulation
– Patients usually begin ambulation within 1 day after surgery using walker or crutches
– Weight bearing as prescribed by the physician
• Drain use postoperatively
– Assess for bleeding and fluid accumulation
– 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
Needs of Patients With Hip Replacement Surgery
• Prevention of infection
– Remove drain within 24 to 48 hours
– Strict hygiene practices
– At risk for up to 24 months
– Prophylactic antibiotic may be given
• Prevention of DVT and Fat embolus
– Appropriate prophylaxis,
– Instituting preventive measures, and
– Monitoring the patient closely for clinical signs of the development of DVT and PE
• Patient education and rehabilitation
DVT vs Fat Embolus vs Embolus
• Thrombus
• Embolus
• Fat Embolus
• Postoperatively
– Compression bandage on knee
– Assess neurovascular status every 2 to 4 hours
– Monitor for complications; VTE, infection, bleeding
• Wound suction drain
– Removed in 24 to 48 hours
– Antibiotics prophylactically
– Autotransfusion of extensive bleeding
• Continuous passive motion (CPM)
– Promote range of motion, circulation, and healing
– Prevent scar tissue in knee
– Placed in device immediately after surgery
• Physical therapy
– Strength and ROM
– Assistive devices
– Ambulate first post op day
• Acute rehab
– 1 to 2 weeks
– Total recovery 6 weeks
CPM Device
Nursing Process: The Care of the Patient Undergoing Orthopedic Surgery—Assessment,
Preoperative
• Routine preoperative assessment
• Hydration status
• Medication history
• Possible infection
– Ask specifically about colds, dental problems, urinary tract infections, infections within 1 to 2 weeks
• Knowledge
• Support and coping
Nursing Process: The Care of the Patient Undergoing Orthopedic Surgery—Assessment, Postoperative
• Pain
• Vital signs, including respirations and breath sounds
• LOC
• Neurovascular status and tissue perfusion
• Signs and symptoms of bleeding: wound drainage
• Mobility and understanding of mobility restrictions
• Bowel sounds and bowel elimination
• Urinary output
• Signs and symptoms of complications: DVT or infection
Nursing Process: The Care of the Patient Undergoing Orthopedic Surgery—Diagnoses
• Acute pain
• Risk for peripheral neurovascular dysfunction
• Risk for ineffective therapeutic regimen management
• Impaired physical mobility
• Risk for situational low self-esteem and disturbed body image
Nursing Process: The Care of the Patient Undergoing Orthopedic Surgery—Planning
• relief of pain,
• adequate neurovascular function,
• health promotion and wound healing,
• improved mobility, and
• positive self-esteem
• the absence of complications
• Administration of medications
– Patient-controlled analgesia (PCA)
– Medicate before planned activity and ambulation
• Use alternative methods of pain relief
– Repositioning, distraction, guided imagery
• Specific individualized strategies to control pain
– Use of ice or cold packs
– Elevation
– Immobilization
• Ankle and calf-pumping exercises
• Measures to ensure adequate nutrition and hydration
• Skin care measures, including frequent turning and positioning
• Follow physical therapy and rehabilitation programs
• Encourage the patient to set realistic goals and perform self-care care within limits of the therapeutic regimen
Collaborative Problems and Potential Complications—Postoperative
• Hypovolemic shock
• Atelectasis
• Pneumonia
• Urinary retention
• Infection
• Thromboembolism: DVT or PE
• Constipation or fecal impaction
Is the following statement true or false?
Phantom limb pain is perceived in the amputated limb
True
Phantom limb pain is perceived in the amputated limb
• Neurovascular status and function of affected extremity or residual limb and of unaffected extremity
• Signs and symptoms of infection
• Nutritional status
• Concurrent health problems
• Psychological status and coping
• Acute pain
• Impaired skin integrity
• Disturbed body image
• Grieving
• Self-care deficit
• Impaired physical mobility
• Major goals include:
– Relief of pain
– Absence of altered sensory perceptions
– Wound healing
– Acceptance of altered body image
– Resolution of grieving processes
– Restoration of physical mobility
– Absence of complications
• Relief of pain
– Administer analgesic or other medications as prescribed
– Changing position
– Putting a light sand bag on residual limb
– Alternative methods of pain relief: distraction, TENS unit
• Promoting wound healing
– Handle limb gently
– Residual limb shaping
• Encourage communication and expression of feelings
• Create an accepting, supportive atmosphere
• Provide support and listen
• Encourage patient to look at, feel, and care for the residual limb
• Help patient set realistic goals
• Help patient resume self-care and independence
• Referral to counselors and support groups
• Amputation may be congenital or traumatic or caused by conditions such as progressive peripheral vascular disease, infection, or malignant tumor
• Amputation is used to relieve symptoms, improve function, and improve quality of life
• The health care team needs to communicate a positive attitude to facilitate acceptance and participation in rehabilitation
Rehabilitation Needs
• Psychological support
• Prostheses fitting and use
• Physical therapy
• Vocational or occupational training and counseling
• Use a multidisciplinary team approach
• Patient teaching
• Proper positioning of limb; avoid abduction, external rotation and flexion
• Turn frequently; prone positioning if possible
• Use of assistive devices
• ROM exercises
• Muscle strengthening exercises
• “Preprosthetic care”; proper bandaging, massage, and “toughening” of the residual limb
• Encourage active participation in care
• Continue support in rehabilitation facility or at home
• Focus on safety and mobility
Collaborative Problems and Potential Complications
• Postoperative hemorrhage
• Infection
• Skin breakdown
• Phantom limb pain
• Joint contracture
• . June Frankel, a 23-year-old patient, presents to the emergency department with a sports-related fracture injury to her right arm and receives a long-arm fiberglass cast.
– What nursing assessment should the nurse provide after the cast has been applied?
– What nursing interventions should the nurse provide?
• Neurovascular status is assessed, including the palpation of distal accessible pulse, temperature of extremity, coloration of extremity, sensation, capillary refill, ability to wiggle fingers, and presence of edema as compared with the opposite extremity. The neurovascular assessment is performed every hour for the first 24 hours. Any change in the neurovascular assessment, including numbness, tingling, loss of sensation, inability to move fingers, pallor, coolness, decreased capillary refill, or pain unrelieved by administration of narcotic analgesic, should be reported to the primary provider immediately
• Vital signs and presence of pain should be assessed. The pain assessment includes quality, radiation, strength of the pain as rated on a pain scale, and the time the pain started and the duration.
• Provide discharge instructions (verbal and written) to patient/family and assess understanding by having the patient/family provide the instructions in their own words. Have the patient/family demonstrate proper usage of a sling and how to elevate the extremity on pillows above the heart and assess the neurovascular status of the affected limb
– Keep the cast dry. Use a plastic bag secured with tape when bathing and keep casted arm out of water. Use a hair dryer on a cool setting to dry the cast if it becomes wet. If the cast does not dry within at least 24 hours, call the physician.
– Elevate the affected limb using the sling or pillow supports, keeping the extremity above the level of the heart to promote circulation and decrease the risk for swelling
– Do not stick anything down into the cast to scratch your skin
– Do not apply lotion or powder into the cast
– Do not bang the cast, cut it, or pull it apart
– Do not wash the cast
– Call the physician immediately if you develop any of the following:
• Tingling, numbness in your arm
• Severe pain unrelieved by the prescribed pain medication
• Feeling that your cast is too tight or becomes too loose
• If your fingers become swollen, cold, turn pale or become blue
• If your cast gets damaged or develops rough edges that irritate your skin
• Foul odor or drainage from the cast
– Instruct the patient on the activity restrictions and follow-up care as directed by the physician
– Instruct the patient on prescribed medications, including side effects to report to the physician
• Sue Newhart, a 55-year-old patient, is admitted to the medical-surgical unit after a total hip arthroplasty due to osteoarthritis.
• What considerations should the nurse follow when positioning the patient in bed after hip surgery?
•
• What nursing interventions should the nurse provide the patient?
• When positioning the patient in the supine position, the nurse should use the abductor splint or pillow support to prevent dislocation of the prosthesis
• When turning the patient, two nurses help the patient; one nurse supports the affected leg, keeping the leg abducted and straight, as the second nurse turns the patient to the unaffected side. The abductor pillow or splint is used. A pillow support is used to keep the leg abducted
• When sitting the patient up in bed, raise the head of the bed 60 degrees or less, as directed by the surgeon to prevent dislocation of the hip prosthesis
• Assess vital signs, incision site, and portable suction drainage device; neurovascular checks on right hip and leg; and pain assessment, as prescribed
• Use fracture pan and instruct the patient to flex the left leg and hip and use the trapeze bar to get onto the bedpan or to get off the bedpan and not to place pressure or flex the right knee and hip in the process
• Keep a draw sheet under the patient from head to feet to use in turning or moving the patient up in the bed, and use the help of two nurses
• Instruct the patient to perform exercises that the physical therapist prescribed to prevent contractures and to promote mobility
• Provide thromboembolism-prevention measures, including the usage of prescribed antiembolism hose, sequential compression device, and low-- molecular-weight heparin such as enoxaparin (Lovenox)
• Instruct the patient to use the incentive spirometer, cough and deep breathe every 2 hours while awake. Report any change in the coloration of sputum and signs of respiratory infection immediately to the physician
• Promote early ambulation as prescribed:
– Monitor for orthostatic hypotension
– Transfer to standing with walker per physical therapist protocol as prescribed by the surgeon
– Ambulate to chair using the walker by advancing the walker, then the operative extremity, and then the nonoperative extremity (Follow weight-bearing restrictions.)
– When sitting in the chair, do not sit for longer than 45 minutes. Flex the hip less than 90 degrees
• Institute hip precautions
– When sitting, keep the knees apart and do not cross the legs
– Avoid bending forward while sitting in a chair
– Avoid low chairs
– Do not flex the hip when putting on clothing articles. Use a long- handled reaching device to help dress
– Use elevated seat cushion in the chair and a raised toilet seat to help prevent over flexion of the hip joint.
– Avoid twisting motions
– Sleep with pillows between legs when in the side-lying position following discharge
– Notify surgeon of sudden pain, popping sensation, or shortening of leg [Show Less]