22 terms

Orthopaedic Nursing

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Orthopaedic Nursing
- is a specialty focused on the prevention and treatment of musculoskeletal disorders
- including fractures, joint replacements, complications of fractures, arthritis, and osteoporoisis
Objectives
- list the specialized skills required of an orthopaedic nurse
- to identify assessments required for an orthopaedic nurse
- to identify common orthopaedic conditions
- differentiate early and late signs of various complications related to fractures
Collaborative Care Plans
1. pre-surgical screening:
- anesthesia/pain management
- discharge planning
- education class
- blood conservation
2. hospital
- same day admission as operation
- OR
- postoperative stay (3.7 days)
3. Rehabilitation
- inpatient rehab vs. home
4. 90 days post discharge
Joint Conditions
- osteoarthritis
- rheumatoid arthritis
Osteoarthritis
- a degenerative condition
- affects one in ten Canadians
- cartilage erodes away with wear and tear
- confined to the joints themselves
- symptoms of pain, stiffness, swelling, bone on bone with movement
- Treatment: NSAIDS, weight loss, exercise, heat/cold
Rheumatoid Arthritis
- systemic inflammatory autoimmune disorder
- affects the synovial membrane in joints causing pain and swelling
- can also effect other organs: skin, eyes, lungs, kidneys
- occurs in 0.6% of the population
- Treatment Focus: on symptoms and prevention of joint damage - anti rheumatics, NSAIDS, narcotics and steroids
Treatment for Joint Conditions: General
1. Conservative Treatment
2. Surgical Intervention:
- partial or total joint arthroplasty (hip, knee, shoulder, ankle)
- remove damaged cartilage and replace with artificial device
Potential Complications for Joint Conditions
- infection
- blood clots
- dislocation
- fracture
- nerve injury
- loosening
- revision surgery
Bone Conditions
- osteoporosis
Osteoporosis
- a metabolic bone disease characterized by low bone mass and micro-architectural deterioration of the bone tissue with a resulting increase in fragility fractures
- bone strength = bone density and bone quality
- over the age of 50
- 1 in 4 women
- 1 in 8 men
- 1.4 million Canadians

* Fragility fractures
- one that results from minimal trauma, such as a fall from a standing height or less or no identifiable trauma at all
- usually caused by osteoporosis
- occur a lot in the vertebral spine, hip or wrist (think falls)
- usually not diagnosed

* Risks
- age 65 or older
- vertebral fracture after 40
- family history of osteoporotic fracture
- long term use of glucocorticoid therapy
- medical conditions that inhibit absorption of nutrients
- primary hyperparathyroidism
- tendency to fall
- hypogonadism
- early menopause

* Help Teaching
- maintain adequate protein intake
- avoid excess caffeine (<4 cups coffee/day)
- avoid excess dietary sodium (<2100 mg/day)
- regular exercise, particularly weight bearing exercises
- tailored fall prevention program for those at risk of falls
- calcium and vitamin D +/- biophosphanates

* Interventions
- identify and treat those at high risk
- recognize risk factors that call for osteoporosis screening (BMD)
- assess diet and lifestyle for effect on bone health
- encourage patients to take steps to ensure bone health
- be familiar with treatment options for osteoporosis
Peripheral Neuro Assessment
- assess for adequate nerve function and blood circulation
- distal to an injury, surgical site, cast or restrictive bandage
- begin with unaffected side first
- sensation
- motor function
- pain
Vascular Assessment
- temperature
- colour
- capillary refill
- peripheral pulses (axial, brachial, ulnar, radial, femoral, popliteal, posterior tibialis, dorsalis pedis)
- presence or absence of edema
Complications of Fractures
- Fat embolism Syndrome
- Compartment Syndrome
- Deep Vein Thrombosis/Pulmonary Embolism
- Osteomyletis
Fat Embolism Syndrome (FES)
- the presence of fat globules in the blood stream that pass into the small vessels of the lungs and other sites causing endothelial damage
- the syndrome manifests more in closed fractures of the pelvis or long bone(s)
- occurs within 1-3 days of the injury
- early immobilization of fractures can decrease risk

S&S:
- breathlessness, SOB, hypoxia, fever and tachycardia, petechial rash (chest/arms), thrombocytopenia
- CNS symtoms: headache, drowsiness, confusion, seizures
- renal symptoms: hematuria, anuria, oliguria

Chest X-ray = snow storm appearance

Major criteria for diagnosis:
- respiratory insufficiency
- cerebral involvement
- petechial rash

Minor criteria - other signs and symptoms

Nursing Care
- provide reassurance
- frequent monitoring
- assist with DB&C
- change patient position frequently
- monitor and report ABGs and other blood work
- Provide oxygen as ordered

Treatment
- symptom related and supportive
- oxygen therapy/mechanical ventilation
- fluid replacement
- steroid therapy
- mortality rate: 5-15%
Compartment Syndrome
- a condition in which the circulation and function of tissues within a closed space are compromised by increased pressure within that space reducing blood flow
- causes: increase in contents, decrease in size of compartment
- can occur 1 to 2 hours post trauma (usually within first 48 hours)
- result of severe injury - fractures of the lower arm and lower leg are the most common (tibia), crush injuries, casts etc.

Assessment:
- PAIN (extreme pain despite pain management)
- paresthesias
- skin tense and shiny
- motor weakness
- pulse is often present - a late sign is absent pulse

Dx/Rx
- compartment pressure reading
- remove external pressure: casts or dressing
- surgical fasciotomy

Nursing Care
- assess neurovascular status
- compare and contrast limbs
- encourage finger and toe exercise
- evaluate cast and dressing for tightness
- DO NOT USE ICE
- elevate limb above heart level
- notify MD immediately - a medical emergency
Deep Vein Thrombosis and Pulmonary Embolism
- deep vein thrombosis (DVT) means formation of blood blot in the deep veins of the legs
- if not treated, the blood clots can get larger and/or break off and travel to the lungs
- when this happens it is called a pulmonary embolism
- the chance of dying from a pulmonary embolism is 25%

Precipitating Factors
- injury to deep veins
- immobility
- increased clotting (cancer, pregnancy, age, genetics, hormone replacement, oral contraceptives)

Prevention:
- type of treatment often depends on risk factors
- prophylactic heparin/Coumadin/low molecular weight heparin/ASA
- sequential compression devices/TEDs
- early and frequent mobilization, leg exercises
- any patient in hospital longer than 48 hours should be assessed for DVT risk

S&S PE
- mild: unexplained fever, mild SOB
- moderate: sudden SOB, cough, restlessness, hypoxemia
- severe: pleural pain, friction rub, tachycardia, hypotension, and shock

S&S DVT
- pain
- swelling/edema
- redness
- Homan's sign

Diagnosis/Treatment
- pulmonary angiogram
- ventilation/perfusion scan
CXR (chest x-ray) and CT scan (gold standard for dx PE)
- ECG
- Blood Gases
- Pneumatic compression devices
Osteomyletis
- infection of the bone
- causative agent most often bacterial - staph aureus
- bacteria can spread to the bone from infected skin, muscles or tendons next to the bone, after bone surgery, or spread from another part of the body through blood

Risks:
- infection of the bone
- causative agent most often bacterial - staph aureus
- bacteria can spread to the bone from infected skin, muscles, tendons, next to the bone, after bone surgery, or spread from another part of the body through blood

Diagnosis
- clinical presentation (bone pain, fever, chills, malaise, swelling, warmth)
- X-ray: may not see changes for a few weeks
- Bone biopsy or needle aspiration
- Blood cultures, ESR, CRP, CBC
- Bone scan

Treatment
- acute responds to antibiotics (4 to 6 weeks)
- chronic - usually involves complications
Casts
- casts immobilize the broken bones in correct alignment until healing occurs

Types:
- plaster
- fiberglass

Nursing Interventions:
- neurovascular assessment
- take measures to prevent swelling (elevate, exercise and apply ice, except in case of compartment syndrome)
- notify MD if signs of neurovascular compromise develop - cast may need to be split open
- assess skin: pressure ulcers can develop under and around cast
- assess impact on ADLs
- patient education
Traction
Types:
- skin (bucks): pulling force is applied to soft tissue using a splint and weights (5-8 lbs)
- skeletal: pulling force is applied to bone using surgically implanted pins and weights

Nursing Interventions:
- assess skin - reposition q2h
- bed exercises - prevent muscle atrophy
- assess pin sites for infection
- provide pin care
- administer anticoagulants as ordered
- ensure adequate hydration/nutrition
- monitor for complications of immobility (DVT, pneumonia, urinary stasis, pressure ulcers, constipation)
External Fixation
- a surgical treatment used to stabilize bone and soft tissues at a distance from the operative or injury focus
- they provide unobstructed access to the relevant skeletal and soft tissue structures for their initial assessment and also for secondary interventions needed to restore bony continuity and functional soft tissue cover

Purposes:
- stabilization of severe open fracture
- stabilization of infected non-union's
- correction of extreme malalignments and length discrepancies
- initial stabilization in poly trauma patients
- closed fracture with associated soft tissue injuries
Open Reduction Internal Fixation
- involves the implementation of implants to guide the healing process of a bone, as well as the open reduction, or setting, of the bone itself
- Open reduction: refers to open surgery to set bones, as is necessary for some fractures
- Internal fixation: refers to fixation of screws and/or plates, intramedullary bone nails (femur, tibia, humerus) to enable or facilitate healing

- Rigid fixation prevents micro-motion across lines of fracture to enable healing and prevent infection, which happens when implants such as plates (e.g. dynamic compression plate) are used
- Open Reduction Internal Fixation techniques are often used in cases involving serious fractures such as comminuted or displaced fractures or in cases where the bone would otherwise not heal correctly with casting or splinting alone

Risks and complications include:
- bacterial colonization of the bone
- infection
- stiffness and loss of range of motion
- non-union, or mal-union
- damage to the muscles
- nerve damage and palsy
- arthritis
- tendonitis
- chronic pain associated with plates, screws, and pins
- compartment syndrome
- deformity
- audible popping and snapping
- possible future surgeries to remove the hardware
Closed Reduction Internal Fixation (CRIF)
- is reduction without any open surgery, followed by internal fixation
- it appears to be an acceptable alternative in unstable displaced lateral condylar fractures of the humerus in children, but if fracture displacement after closed reduction exceeds 2 mm, open reduction and internal fixation is recommended
- various techniques of minimally invasive surgery for internal fixation of bones have been reported
- the treatment of fractures of the distal third of the tibia has evolved with the development of improved imaging and surgical techniques