Transcript Chapter 46 Nursing Care of Patients with Musculoskeletal and

N124IN
Spring 2013
Used
for:
• Connective tissue diseases where joints are
severely deteriorated
• Long-term steroid therapy
• Avascular necrosis
 Inadequate blood supply causes bone tissue
death
Goal:
• Alleviate severe chronic pain
• Improve capability to perform ADLs
 Replacement
of any synovial joint can
occur
 Arthroplasty
 Replacement devices/prostheses
• Made of: metal, ceramic, plastic, combination
• Hold in place: cement, patient bone
• Bone substitutes (biologics)
 Used when bone isn’t able to support replacement
devices
• Bone glues/fillers, bone stimulants
 Assist in better support for prosthetics
2-piece
device
• Acetabular cup that’s placed into pelvic
acetabulum
• Femoral part that’s placed into femur
 Replaces femoral head/neck
Cemented THR
average life span: 10
years
Noncemented prostheses: can last
longer
 Preoperative
Care
• Case manager
• Ensure patient has caregiver available to help
patient after surgery
• Standard preoperative care
• Baseline assessments
 Neurovascular status of extremity
 Pain
 Mobility
• IV
 Prophylactic antibiotics
 Preoperative
Care, cont.
• Education
 Surgery
 Postoperative expectations
• Meet with physical therapist
 Learn exercises for postoperatively
 Learn how to walk with walker/crutches
• Total joint education programs, if present
• Autologous blood donation
• Typically admitted morning of surgery
 Length of stay is usually 2-5 days
 Joint camp programs
Postoperative Care
• Interdisciplinary
• Patient moves into chair night of surgery
or next morning
 No adduction or hyperflexion of surgical hip!
• Weight bearing dependent upon
prosthesis type
 Cemented: as tolerated or full weight bearing
 Uncemented: toe-touch, partial weight bearing,
or featherweight bearing
 Postoperative
Care, cont.
• Pain management
 Initially: epidural analgesia, patient-controlled analgesia
(PCA), analgesic injections
 After first day: oral analgesic
 Proper positioning
• Early ambulation
 Walker, crutches
 Cane
• Hip flexion restriction
 Educate patients to not bend forward
• Interventions to prevent complications
 Postoperative
Complications: Hip
Dislocation
• Can be a partial dislocation (subluxation) or total
dislocation
• When femoral component dislodges from acetabular
cup
• Audible “pop” and then pain
 Surgical leg shortens and possibly rotates
• Nursing considerations
 Keep patient in bed
 Inform surgeon stat
 Give analgesics until surgery
Postoperative
Complications: Hip
Dislocation, cont.
• Prevention
 After PACU, keep patient in supine position with
slightly elevated head of bed
 Use methods to prevent leg adduction
 Trapezoid-shaped abduction pillow, splint, wedge,
bed pillows
 When turning patient, avoid hip adduction
 Prevent hyperflexion
 Use fracture pan when patient is on bedrest and
needs to void
 Postoperative
Complications: Skin
Breakdown
• Turn patient at least q 2 hours
• Keep heels off bed
• Prophylactic DuoDERM dressings
• Heel protectors
• Incontinence
 Keep clean/dry
 Help patient to toilet every 2 hours
 Use protective barrier cream
• Diet, hydration
 Postoperative
Complications: Infection
• Prophylactic IV antibiotic preoperatively
 Can also give intraoperatively and postoperatively
for 24 hrs
• Aseptic wound care at incision, drain sites
• Assess for infection signs/symptoms
 Redness, swelling, warmth, odor, pain, drainage that
is yellow/green/brown
 Temperature
 Confusion (elderly)
• Antibiotics often placed into wound during
surgery
 Beads, part of cement mixture, irrigating solution
 Postoperative
Complications: Bleeding
• Surgical drain (Hemovac, Jackson-Pratt)
 Empty q 8-12 hours or per orders
• Assess dressing for bleeding; reinforce if necessary
• Blood transfusion
 On day 2-3, hemoglobin/hematocrit may decline
• Replace blood
 Collect shed blood postoperatively into reservoir via
suction
 Filter, reinfuse within 6 hrs
• Assess for signs of blood loss and shock
Postoperative
Complications:
Neurovascular Compromise
• Neurovascular checks
 Circulation (color, warmth, pulses)
 Sensation
 Movement
 Postoperative
Complications:
Thromboembolitic Complications
• DVT, pulmonary embolus risk
• Preventions:
 Thigh-high elastic stockings
 Sequential compression devices (SCDs)
 Anticoagulant medications




Subcutaneous low molecular weight heparin (Lovenox)
Oral warfarin (Coumadin)
Heparin
Assess partial thromboplastin times (heparin), International
normalized ration/prothrombin time (warfarin)
 Leg exercises
Rehabilitation
• Home with rehabilitation, subacute care
unit, rehabilitation unit, nursing home
• Rehab continues after discharge until
patient can ambulate and perform selfcare independently
Education
• Hip precautions
 Prevent dislocation
 Keep legs abducted
 Place pillows between legs when sleeping
 Bend at waist (not more than 90 degrees)
 Push straight up off chair or bed when
getting up and don’t lean forward
 Use walker if needed
 Use equipment to help put on socks/shoes
Total
replacement
• 3 components
 Femoral, tibial, patellar button
Similar
to care of patient with THR
• After surgery, drain and bulky dressing in
place
• Assess for bleeding
• Standard postoperative care
• Work to prevent complications similar to
those for total hip replacement
 Continuous
passive motion (CPM) machine
• Physician orders degree of flexion and speed
• Can be applied by nurse, physical therapist,
technician
• Used intermittently (8-12 hours/day) or
continuously when patient is in bed
• Purpose: Keeps joint mobile
• Nursing care
 Position joint over machine’s flexion area
 Use padding, especially at proximal end
 Make sure speed/angle settings are correct and monitor
them per protocol
 Assess toleration of speed/angle
Body
part removal
• Surgical
 Caused by disease
• Traumatic
 Caused by accident
Surgical
Amputation
• Primary indication: ischemia related to
peripheral vascular disease in elderly
• Can also be done for:
 Bone tumors
 Thermal injuries (frostbite, electric shock)
 Crushing injuries
 Congenital problems
 Infections
Traumatic Amputation
• Accident-related
 Industrial machinery, motor vehicles, lawn mowers,
chain saws, snow blowers
• Replantation may occur
 Amputated part is typically healthy
 Prehospital care of part:
 Wrap in cool, slightly moist cloth
 Put in sealed plastic bag
 Can submerge bag in cold water until hospital
 Microscope used in reattachment procedure
 Nerves, vessels, muscle reattached
 Amputation levels
• Lower Extremity
 Small toes: little problem
 Great toe: more of problem because it alters balance and
gait
 Midfoot: preferred over below-the-knee for PVD
 Syme amputation: most of foot removed, ankle left intact for
walking and weight bearing
 Lower leg: below-the-knee preferred over above-the-knee
for joint function preservation
 Hip disarticulation: hip joint removal
 Hemipelvectomy: part of pelvis removal
 Hemicorporectomy: hemipelvectomy and translumbar
amputation
 Removes almost half of body
 Bowel and urinary diversion surgeries (ostomies) required
Levels
of Amputation, cont.
• Upper Extremity
 More often result from trauma
 Upper extremities needed for ADLs
 Will more than likely have a greater impact
on individual than a lower extremity
amputation
 Replacement with prosthesis early is
important
Levels
Of Amputation, cont.
• Below-the-knee (BKA)
• Above-the-knee (AKA)
• Below-the-elbow (BEA)
• Above-the-elbow (AEA)
 Preoperative Care
• Elective amputations
 Education
 Prosthesis fitting
 Adjustment to loss
 Review postoperative and rehab care
• Traumatic amputations
 No preparation for changes
 Meet physical needs
 Address psychological and emotional concerns
• Assess reaction to having amputation
• Identify support systems and coping
mechanisms
Postoperative
Care
• Standard post operative care
• Interventions to prevent complications
(hemorrhage, infection)
• Pain control
• Mobility/Ambulation
• Prosthesis care
• Lifestyle adaptation
Postoperative
Care: Prevention of
Hemorrhage
• Large pressure dressing is placed on
patient after surgery
 Secured with elastic wrap
• Palpate most distal pulse between
heart and amputated body part
 Assess strength
 Compare with other extremity
 Postoperative
Care: Prevention of
Hemorrhage, cont.
• Assess dressing for bloody drainage
 Circle, date, time drainage and assess for enlargement
 Inform surgeon if bleeding continues
• Keep tourniquet available in case of hemorrhage
• After dressing is removed:
 Assess for perfusion to skin flap at end of stump
 Light-skinned patient: skin should be pink
 Dark-skinned patient: skin should not be discolored
 Stump should be warm, not hot
Postoperative
Care: Prevention of
Infection
• Assess wound for signs of infection
• Assess temperature
• Traumatic amputations have infection
risk due to injury’s nature and exposure
to environmental pathogens
 Postoperative Care: Pain control
• Incisional pain
• Phantom limb pain
 Severe pain where body part was
 Described as: intense burning, crushing sensation, or
cramping
 Can be triggered by: touching stump, fatigue,
emotional stress, pressure changes, weather changes
 Treat pain with meds and complementary therapies




Knifelike pain: anticonvulsants
Burning sensations: beta-blocking agents
Nerve pain: gabapentin, amitriptyline
Complementary therapies: biofeedback, massage, imagery,
hypnosis, acupuncture, acupressure, distraction
 Postoperative
Care: Mobility/Ambulation
• Prevent swelling
 Cold application
 Elevate limb for 24 hrs or less
• Assess limb periodically to make sure it lies
completely flat
• Have patient avoid flexion positions
 Lying prone assists in preventing contractures (30
minutes, 4 times a day)
• Rehabilitation (sub-acute unit, extended care
facility, ambulatory basis)
• Trapeze bar
Postoperative
Care: Prosthesis care
• Prepare residual limb for prosthesis
• Wrap residual limb q 8 hours with elastic
wrap in figure-of-eight pattern
 With each wrapping, do neurovascular checks and
assess for infection and tissue integrity alterations
 Start with distal portion and move proximally until
bandage secures to most proximal joint
 Bandage needs to be tighter at distal end
Postoperative
Care: Prosthesis care,
cont.
• Perform and educate patient on prosthesis
care
 Use mild soap and water to clean prosthesis socket
 Dry it after
 Regularly clean inserts and liners
 To keep socks in place, use garters
 Grease parts per instructions
 When shoes wear out, replace them with shoes that
are same height and type
 Postoperative
Care: Lifestyle adaptation
• If necessary, job analysis may be performed
• Most patients can return to work after surgery
• Many individuals who have amputations can
bowl, ski, hike, etc.
• Assess family support
• Assist patient with setting realistic expectations
• If patient did not get prosthesis, may need to
have home adaptations for wheelchair
 http://www.youtube.com/watch?v=UQo7
QOz_EO0
 http://www.youtube.com/watch?v=njJUc
TbR2SY&feature=related