Timby's Introductory Medical-Surgical Nursing Chapter 61 PDF

Timby’s Introductory Medical-Surgical Nursing Chapter 61: Caring for Clients Requiring Orthopedic Treatment Dawn Page RN, MSN Copyright © 2018 Wolters Kluwer Health | Lippincott Williams & Wilkins Objectives ❖ Differentiate types of casts. ❖ Discuss t...

Timby’s Introductory Medical-Surgical Nursing Chapter 61: Caring for Clients Requiring Orthopedic Treatment Dawn Page RN, MSN Copyright © 2018 Wolters Kluwer Health | Lippincott Williams & Wilkins Objectives ❖ Differentiate types of casts. ❖ Discuss the nursing management for a client with a cast. ❖ State the reasons for using splints or braces. ❖ Identify the principles for maintaining traction and describe nursing care for the client in traction. ❖ Differentiate between closed reduction and open reduction and between internal fixation and external fixation. ❖ Describe nursing care for the client with a fracture reduction. ❖ Identify the reasons for performing orthopedic surgery. ❖ Discuss the nursing management for a client undergoing orthopedic surgery. Copyright © 2022 Wolters Kluwer · All Rights Reserved Objectives ❖ Compare minimally invasive joint replacement surgery with conventional joint replacement surgery. ❖ Describe the positioning precautions after a conventional total hip replacement. ❖ Explain the nursing needs of the client undergoing total knee replacement. ❖ Discuss amputation, including reasons it may be performed and appropriate nursing management of the client. Copyright © 2022 Wolters Kluwer · All Rights Reserved Management of Orthopedic Disorders ❖ Musculoskeletal disorders involves the use of casts, splints and braces, traction, and various types of orthopedic surgery. o Casts o Splints o Braces o Traction o Various types of surgery o Amputation Copyright © 2022 Wolters Kluwer · All Rights Reserved Types of Casts A cast is a rigid mold that immobilizes an injured structure while it heals. Used alignment and support of the area ❖ Three main types: o Cylinder cast– encircles arm or leg o Body cast– encircles the trunk o Hip spica – One or both legs and the trunk o Others (see Box 61-1) - Students read the examples ▪ The cast is applied from the joint above the break and to one below it with joint is slightly flexed. ▪ Why? Copyright © 2022 Wolters Kluwer · All Rights Reserved Casts Fiberglass vs. plaster of Paris – Name some differences? Cast Composition: See Box 61-2 applying a cast Cast application: Support drying cast on pillows; monitor material feels for signs of complications; handle with warm during palms of hands; elevate extremity application Wound requires regular dressing casting Cast Windows: change, observation casting Copyright © 2022 Wolters Kluwer · All Rights Reserved Spica cast Figure 61-1 Copyright © 2022 Wolters Kluwer · All Rights Reserved Question #1 Is the following statement true or false? When a limb is placed in a cast, the joint is set straight to assure bone alignment. Copyright © 2022 Wolters Kluwer · All Rights Reserved Answer to Question #1 False Rationale: When a limb is placed in a cast, the cast is applied from the joint above the break to the joint below the break. The joint is slightly flexed to decrease joint stiffness. Copyright © 2022 Wolters Kluwer · All Rights Reserved Casts #2 Bivalve Bivalve: Cut in two As a splint – When being When With swollen can be weaned from a radiograph is arm or limb removed cast needed easily Cast Removal: mechanical cast cutter Noisy and frightening – reassure client its safe Nursing Management See Nursing Guidelines 61-1 Education on skin care, importance of keeping limb supported, progressive exercise; monitor circulation; pain, sensation and ambulation if applicable Copyright © 2022 Wolters Kluwer · All Rights Reserved Client Teaching Two Point ❖Walking with Crutches ❖Walking with walker ❖Walking with cane client teaching Copyright © 2022 Wolters Kluwer · All Rights Reserved Splints and Braces Splints: Immobilize and Does not require ridged immobilization; support an injured body large degree of swelling; or requires special part in a functional skin treatment position when cast is not needed Made from various materials Provide support Braces: More long term Control movement Prevent additional injury Provide client and family education to Nursing Management: provide healing and avoid complications Copyright © 2022 Wolters Kluwer · All Rights Reserved Splints and Braces Copyright © 2022 Wolters Kluwer · All Rights Reserved Braces Copyright © 2022 Wolters Kluwer · All Rights Reserved Shoulder Immobilizer Copyright © 2022 Wolters Kluwer · All Rights Reserved Reducing Fractures and Traction Management ❖ Reducing a fracture involves restoring proper alignment to the injured bone. o Traction: Figure 61-3 ▪ Skin traction and skeletal o Closed Reduction: External manipulation o Open Reduction: Surgically realigned o Internal Fixation o External fixation (Nursing Guidelines Box 61-3) o Cast Copyright © 2022 Wolters Kluwer · All Rights Reserved Traction Traction: Stabilization Method of pulling structures of the of a fracture or injury, musculoskeletal system. to restore tension to Requires countertraction - a force opposite to the surrounding the mechanical pull with patients own weight tissues, muscles, Uses ropes, pulleys, and weights tendons and prevent Can be pulled in different directions contractures. Bucks' traction: Applied to skin without surgery Types: Skeletal Traction: Directly to bone with wires, pins or tongs Copyright © 2022 Wolters Kluwer · All Rights Reserved Examples of Traction Skin Traction Skeletal Traction directly to bone Copyright © 2022 Wolters Kluwer · All Rights Reserved Principles of Effective Traction Box 61-3 Nursing Guidelines 61-2 ❖ Principles of Effective ❖ Nursing Guidelines:61-2 Traction ❖ Assess neurovascular status ❖ Ensure continuous traction frequently ❖ Maintain countertraction ❖ Check traction equipment for ❖ Ensure opposite pull of alignment traction ❖ Monitor for pressure areas ❖ Suspend splints and slings ❖ Observe for foot drop freely ❖ Provide pin care if applicable ❖ Ensure ropes and pulleys move freely ❖ Apply exact amount of wt. ❖ Ensure weights hang freely Copyright © 2022 Wolters Kluwer · All Rights Reserved Orthopedic Interventions ❖ Open Reduction Internal Fixation (ORIF) – Bone is surgically exposed and realigned. o Breaks in multiple places ,combined fractures, bone has wide separation o Internal fixation devices ▪ Nails, screws, intramedullary rods, pins, plates to stabilize fracture ❖ Closed Reduction: o External manipulation -Skin traction or cast or splint applied See page 1123 Copyright © 2022 Wolters Kluwer · All Rights Reserved Orthopedic Surgery #1 External fixation – pins screws outside to bone Pin care: Nursing Guidelines 61-3 - infection prevention Nursing Care for specific fractures: See Table 61-1 Mandible, Clavicle, rib, wrist, hand, finger, spine, leg Joint Dysfunction Correction (Box 61-4) Total Arthroplasty: Joint replacement (Hip or Knee) Arthrodesis: fusion of joint (wrist or knee) Osteotomy: removal of part of a bone Hemiarthroplasty: Partial part of hip Copyright © 2022 Wolters Kluwer · All Rights Reserved External Fixation Internal Fixation Copyright © 2022 Wolters Kluwer · All Rights Reserved Orthopedic Surgery #2 Minimally invasive vs. Arthroplasty: use of arthroscope for joint conventional problems, or joint surfaces replaced instead of the entire joint. joint replacement Preoperative Obtain complete history Nursing Assess complications from previous treatment Assist in reducing pain, risk of infection, and Management increasing mobility (see Nursing Help control anxiety and understand instructions Guidelines 61-4) Education on what to expect Copyright © 2022 Wolters Kluwer · All Rights Reserved Minimally Invasive Joint Replacement Try not to cut Smaller incision – Clients are through muscle and two small incisions generally younger tendons instead of for hip and motivated cutting when possible Resurfacing, a technique in which Using spinal Computer-assisted only warn surfaces anesthesia instead surgery of joint are of general replaced or covered Same day or only overnight stay with PT sooner Copyright © 2022 Wolters Kluwer · All Rights Reserved Nursing Process Orthopedic Surgery Assessment for neurovascular and systemic complications Administering analgesics Providing comfort measures Promoting physical mobility Infection prevention Maintain skin integrity – pin care, pressure ulcers Provide simple and direct explanations and teaching Elevation of extremity and ice to prevent swelling Prevention of DVT Copyright © 2022 Wolters Kluwer · All Rights Reserved  Have legs abducted with pillows or abductor cushion and extended - Positioning because the opposite positions of Positioning Precautions: Hip adduction and flexion beyond 90°can dislocate the prosthetic femoral head Replacement from the acetabulum Sit in an elevated chair or on a seat Sitting raised by pillows, so that the flexion remains less than 90° See Box 61-5 Keep knee apart at all time Alignment Never cross legs Avoid bending over Use raised toilet seat Copyright © 2022 Wolters Kluwer · All Rights Reserved Orthopedic Surgery #3 ❖ Postoperative Nursing Management o Required demonstrations o Post surgery devices (walker, braces) o Reduce risk for excessive bleeding o Review primary provider’s orders ▪ Flexion of CPM devices and movement o Help reduce pain and inflammation o Walking with walker: Teaching on importance of movement o Monitor breathing status (Pulmonary embolism) Copyright © 2022 Wolters Kluwer · All Rights Reserved Postoperative Complications ❖Postoperative Nursing Management o Diaphragmatic breathing o Coughing & Deep breathing o Leg exercises o Turning to side o Getting out of bed o Prevention DVT o Incentive spirometer Copyright © 2022 Wolters Kluwer · All Rights Reserved Pain Assessment Copyright © 2022 Wolters Kluwer · All Rights Reserved Orthopedic Surgery #4 ❖ See Client and Family Teaching 61-1 o Support system after discharge o Explore the kinds of assistance needed o Modifications needed in the home environment o Information about home care o Referral to a home health care agency o Printed discharge instructions ▪ Activity, PT, symptoms to report Copyright © 2022 Wolters Kluwer · All Rights Reserved  Clients with knee replacements have the amount of flexion and the frequency of use increased Knee Replacement daily while hospitalized. The goal is for the client to have the ability to bend the knee 90° by discharge. The amount of flexion for clients with hip replacements should never exceed 30° in a CPM machine. Clients should be up and walking with walker and performing prescribed exercises Copyright © 2022 Wolters Kluwer · All Rights Reserved Question #3 By the time of discharge from the hospital, a client with a knee replacement should bend the knee how many degrees? A) 30° B) 45° C) 60° D) 90° Copyright © 2022 Wolters Kluwer · All Rights Reserved Answer to Question #3 D) 90° Rationale: The goal is for the client to have the ability to bend the knee 90° by discharge. Copyright © 2022 Wolters Kluwer · All Rights Reserved Amputation #1 Etiology: Removal of a Malignant tumors, extensive trauma, life threatening disorders, limb due to: infection Treatment for disorder influencing Medical and Surgical healing Management Level at which limb is amputated Amputation methods: open (guillotine); closed (flap) Monitor for Complications Copyright © 2022 Wolters Kluwer · All Rights Reserved Amputation #2 ❖ Medical and Surgical Management—(cont.) o Arm amputation o Leg amputation: Above or below the knee ▪ Attachment of temporary prosthesis to plaster shell ▪ Custom-made conventional prosthesis Copyright © 2022 Wolters Kluwer · All Rights Reserved Amputation #3 Phantom limb; phantom pain Medical and Potential phenomenon Surgical Physiologic response – Grief counseling Management— Rehabilitation Factors influencing amputee success (cont.) Maintain realistic expectations Nursing See Evidence-Based Practice 61-1 Management Copyright © 2022 Wolters Kluwer · All Rights Reserved  Encourage client with a leg amputation to assume some of their care Monitor for Disuse Syndrome related to altered Nursing Planning mobility and Interventions Provide stump care and bandaging Ensure proper positioning Expect the client with a prosthesis to progress to walking and provide assistive devices Facilitate communication regarding loss of limb Phantom limb pain Proper nutrition to promote healing `stump stump care care stump care Copyright © 2022 Wolters Kluwer · All Rights Reserved Prostheses ❖ Amputees receive prosthesis soon after surgery ❖ Rehab begins as a team approach Copyright © 2022 Wolters Kluwer · All Rights Reserved Case Study, Caring for Clients Requiring Orthopedic Treatment Janice Watts, a 24-year-old female client, is admitted after a motor vehicle crash for a closed reduction of the left fibula and tibia fractures and application of a cylinder plaster cast because of the edema present. The client had previously used crutches and has a pair of crutches. She will be non–weight-bearing. The vital signs are stable. She stated the pain was relieved after the narcotic analgesic was provided 30 minutes earlier and that she is comfortable. The client had suffered a concussion as well and will remain in the hospital for the next 24 hours. The client has no known allergies. She has no previous hospitalizations and does not take any medications. The LVN will need to take care of the client after she has the cast applied in the casting room. a. What nursing management is needed right after a plaster cast has been applied? b. Four hours after the client arrived at the orthopedic floor, she reports that her leg and foot hurts more than before the cast was applied. She rates the pain 10/10 despite having pain medication 30 minutes earlier. She has numbness and tingling in the leg. What is probably happening and what should the LVN do? Copyright © 2022 Wolters Kluwer · All Rights Reserved Questions ??? Copyright © 2022 Wolters Kluwer · All Rights Reserved