MED SURGE - Musculoskeletal

Terms in this set (121)

The nursing activities and nursing management needed for this patient prior to surgery are as follows:
The nurse should check vital signs and pulse oximetry, lung and cardiac sounds, and do a pain assessment frequently.
The nurse should also check basic lab work results such as hemoglobin and hematocrit, platelets, white blood cell count, glucose and electrolyte levels.
It is important to check that a chest x-ray, ECG, and history and physical exam have been done pre-operatively.
The consent must be signed and witnessed; this may need to be done by the wife if the patient has received pain medications. The nurse may need to consult hospital policies and procedures or the risk manager in this instance. The best case scenario is that the patient signs before the pre-operative medication or pain medication is administered.
A check of allergy status should be repeated, along with the presence of advance directives, including code status, living will and healthcare power of attorney. These documents should be brought to the hospital and put on the patient's chart.
The patient must be maintained on complete bed rest and NPO status.
Circulation, movement, and sensation of both legs must be assessed at least every 2 hours, and a baseline established.
IV antibiotics will be ordered and administered along with PRN pain medications.
The nurse should begin patient teaching by asking the patient to return-demonstrate deep breathing, gluteal setting exercises, along with the use of incentive spirometry and trapeze equipment.
Dentures and valuables must be removed and stored safely.
d) "The amputation is usually performed at the lowest spot possible on the leg that will heal the best. Perhaps we should call your doctor to explain it to you again before you sign the consent."
Explanation:
The site of amputation is determined by two factors: circulation in the part and whether it meets the criteria for the use of a prosthesis. Preserving the knee joint will make for easier ambulation with less energy expenditure than if the amputation is above the knee. If the amputation is performed right above the area of discoloration and infection, there is a danger that the residual limb or stump will still have poor circulation. This will make using a prosthesis difficult or ultimately impossible. An informed consent mandates that the patient realizes the extent of the surgery; any other information concerning the procedure or preoperative questions must also be fully understood. The nurse is witnessing a signature and verifying that the patient is satisfied with the explanation given by the physician.

The nurse can teach the patient within established parameters and use therapeutic communication techniques designed to elicit whether the patient understands what the physician has said.

The nurse should not belittle or berate the paitent for "forgetting" to ask all of the questions when the doctor was present. Often, the physician has verbally explained all of the pertinent information to the patient, but presurgical anxiety may make the patient forget what was discussed.

The nurse should not force the patient to sign the consent because it is convenient. A consent signed under duress would not be legal.
Maintain careful handling of the residual limb. If the ace wrap or outer wrapping comes off, make sure it is rewrapped as soon as possible to prevent edema. If edema develops, the prosthesis may not fit. The patient should notify his physician immediately. The nurse may ask for a return demonstration of the leg wrapping procedure by the wife or caretaker to ensure that it is done correctly.
Adjustments will be made to his prosthesis to accommodate the changes in residual limb size that are expected within the first six months to a year after the amputation.
Discuss phantom pain and ways to minimize it. Suggest activity, distraction, and kneading/massage of the residual limb. The patient's doctor may prescribe local anesthetics such as Lidocaine patches or TENS (transcutaneous electrical nerve stimulation). It is important to stress that the phantom sensations will eventually decrease.
Emphasize that any antibiotics ordered at discharge must be completely finished.Sometimes patients try to cut costs or forget to finish their prescriptions. This can set the stage for resistant infections and potentially jeopardize the capability for the residual limb to support a prosthesis.
Reinforce that he should not sit for long periods as this can lead to flexion contracture of the affected leg. Also, he should continue his hip and knee exercises to strengthen his muscles and develop the necessary endurance involved in ambulation with a prosthesis.
Help the patient and family to identify any hazards or obstacles in their home, which may be problematic when he is moving within that environment. They should be modified or removed before the patient returns home.
Identify support groups within the community that the patient may find helpful and wish to attend. This might be the American Diabetic Association and/or an amputee support group.
Infection: Since the wound was infected prior to surgery and it had begun to spread to the rest of the body, it is very important for the nurse to monitor the incision site as well as vital signs and lab reports which might indicate infection. Besides the WBC count, an increase in bands on the differential is very important to note.
Hemorrhage: Bleeding from the wound may occur suddenly as the result of a loosened suture. Often, this can be a massive bleed and a tourniquet is prominently displayed at the bedside for use in this situation. The dressing and incision site should be monitored for oozing and increased sero-sanguineous drainage.
Hazards of immobility:
1. Respiratory: any older, post-surgical patient is at risk for atelectasis and pneumonia. Mr. Leung has appropriately utilized his incentive spirometer, coughing, and deep breathing activities to avoid these complications. Pulse oximetry and vital signs have been monitored so that any respiratory problems can be assessed and managed before they become dangerous.
2. Circulatory problems can cause peripheral clots which could result in a pulmonary embolus. Mr. Leung has continued his movement exercises. The physician has also ordered anti-coagulant medications to decrease the viscosity of his blood and prevent the development of clots.
3. Skin breakdown is a risk over any bony prominence as well as over the residual limb. Mr. Leung has been instructed and helped to move from side-to-side at least every two hours. He should wash and dry the prosthesis articulation area of his residual limb daily, and monitor it for any suspicious skin abnormalities. Usually, some sort of absorbent sock will be applied between the skin and the prosthesis.
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