MANAGING THE PATIENT

UNDERGOING ORTHOPEDIC
SURGERY
MANAGING THE PATIENT
UNDERGOING ORTHOPEDIC
SURGERY
 Many patients with musculoskeletal dysfunction undergo surgery to
correct the problem.
 Problems that may be corrected by surgery include:
 Unstabilized fracture
 Deformity

 Joint disease

 Necrotic or infected tissue and tumors

 Frequent surgical procedures include open reduction with internal

fixation (ORIF) and closed reduction with internal fixation (fracture

fragments are not surgically exposed) for fractures; arthroplasty,
meniscectomy, and joint replacement for joint problems; amputation
for severe extremity problems (eg, gangrene, massive trauma); bone
graft for joint stabilization, defect-filing, or stimulation of bone
healing; and tendon transfer for improving motion.
 Joint surgery is one the most frequently performed orthopedic

surgeries.
JOINT REPLACEMENT
 Patients with severe joint pain and disability may undergo joint
replacement.
 Conditions contributing to joint degeneration include osteoarthritis

(degenerative joint disease), rheumatoid arthritis, trauma, and congenital

deformity.
 Some fractures (eg, femoral neck fracture) may cause disruption of the

blood supply and subsequent avascular necrosis; management with joint

replacement may be elected over ORIF.
 Joints frequently replaced include the hip, knee, and finger joints.
 Less frequently, more complex joints (shoulder, elbow, wrist, and ankle)

are replaced.
 The procedure is usually an elective one.
NURSING INTERVENTIONS
 Assessment of the patient and preoperative management
are aimed at having the patient in optimal health at the
time of surgery.
 Preoperatively, it is important to evaluate cardiovascular,

respiratory, renal, and hepatic functions.

 Age, obesity, preoperative leg edema, history of DVT, and

pulmonary embolism.
 Preoperatively, it is important to assess the neurovascular

status of the extremity undergoing joint replacement.

 PREVENTING INFECTION
 Prior to surgery, strict adherence to aseptic

principles and the operating area is controlled

and made s bacteria free as possible.
 Prophylactic antibiotics are administered

perioperatively as a single preoperative or

short perioperative course.
 PROMOTING AMBULATION
 Patient with total hip or total knee replacement begin

ambulation with a walker or crutches within a day after surgery.

 The nurse and the physician therapist assist the patient in

achieving the goal of independent ambulation.

 Patients with cemented prostheses can proceed to weight

bearing as tolerated.
 As the patient is able to tolerate more activity, the nurse

encourages transferring to a chair several times a day for short

periods and walking for progressively greater distances.
TOTAL HIP REPLACEMENT
 Total hip replacement is the replacement of a
severely damaged hip with an artificial joint.
 Indications for this surgery include arthritis

(degenerative joint disease, rheumatoid

arthritis), femoral neck fractures, failure of
previous reconstructive surgeries (failed
prosthesis, osteotomy), and problems resulting
from congenital hip disease.
 NURSING INTERVENTIONS

 The nurse must be aware of and monitor for specific potential

complications associated with total hip replacement.
 Complications that may occur include dislocation of the hip

prosthesis, excessive wound drainage, thromboembolism,

infection, and heel pressure ulcer.
 Other complications monitor include those associated with

immobility, heterotrophic ossification (formation of bone in

the periprosthetic space), avascular necrosis (bone death
caused by loss of blood supply), and loosening of the
prosthesis.
PREVENTING DISLOCATION OF THE HIP PROSTHESIS

 Maintenance of the femoral head component in the acetabular cup is essential.

 The nurse teaches the patient about positioning the leg in the abduction, which

helps to prevent dislocation of the prosthesis.

 The use of an abduction splint, a wedge pillow, or two or three pillows between the

legs keeps the hip in abduction.

 The patient’s hip is never flexed more than 90 degrees.

 To prevent hip flexion, the nurse does not elevate the head of the bed more than 60

degrees.
 For use of the fracture bedpan, the nurse instructs the patient to flex the unaffected

hip and to use the trapeze to lift the pelvis onto the pan.
 Limited flexion is maintained during transfers and when sitting.

 Encourage patient to keep the affected hip in extension, instructing the patient to

pivot in the unaffected leg with assistance by the nurse, who protects the affected
hip from adduction, flexion, internal or external rotation, and excessive weight
bearing.
 MONITORING WOUND DRAINAGE
 Fluid and blood accumulating at the surgical site are usually

drained with a portable suction device.

 PREVENTING DEEP VEIN THROMBOSIS
 Encourage the patient to consume adequate amount of fluids, to

perform ankle and foot exercises hourly while awake, to use

elastic stockings and sequential compression devices as
prescribed, and to transfer out of bed and ambulate with
assistance beginning on the first postoperative day.
 Low-dose of heparin or enoxaparin (Lovenox) is frequently

prescribed as prophylaxis for DVT after hip replacement surgery.

 PREVENTING INFECTION
 PROMOTING HOME AND COMMUNITY-BASED CARE
 Teaching the patient self-care
 Continuing care in the home and community
TOTAL KNEE REPLACEMENT

 Is considered for patients who have been sever

pain and functional disabilities related to joint
surfaces destroyed by arthritis (osteoarthritis,
rheumatoid arthritis, posttraumatic arthritis)
or bleeding into the joint, such as my result
from hemophilia.
NURSING INTERVENTION

 Postoperatively, the knee is dressed with a

compression bandage.
 Ice may be applied to control edema and bleeding.
 Assess the neurovascular status of the leg.
 Encourage patient active flexion of the foot every

hour when the patient is awake.

 Frequently, a continuous passive motion (CPM)

device is used.
ORTHOPEDIC SURGERIES
 OPEN REDUCTION
 The correction and alignment of the fracture after surgical dissection and

exposure of the fracture.

 INTERNAL FIXATION
 The stabilization of the reduced fracture by the use of metal screws, plates,

nails, and pins

 ARTHROPLASTY
 The repair of joint problems through the operating arthroscope (an

instrument that allows the surgeon to operate within a joint without a large
incision) or through open joint surgery.
 HEMIARTHROPLASTY
 The replacement of one of the articular surfaces (eg, in a hip heiarthroplasty,

the femoral head and neck are replaced with a femoral prosthesis – the
acetabulum is not replaced)
 JOINT ARTHROPLASTY OR REPLACEMENT
 The replacement of both articular surfaces within a joint with metal or

synthetic materials.
 MENISCECTOMY
 The excision of damaged joint fibrocartilage.

 AMPUTATION
 The removal of a body part.

 BONE GRAFT
 The placement of bone tissue (autologous or homologous grafts) to promote

healing, to stabilize, or to replace diseased bone.

 TENDON TRANSFER
 The movement of tendon insertion to improve function.

 FASCIOTOMY
 The incision and diversion of the muscle fascia to relieve muscle constriction,

as in compartment syndrome, or to reduce fascia contracture.

 
PERIOPERATIVE TASKS AND RESPONSIBILITIES OF THE NURSE

 PRIOR TO OPERATION:
A careful history and physical examination are perform to exclude the
possibility of other gastrointestinal diseases that may mimic biliary colic,
such as peptic ulcer.
 When the diagnosis of acute cholecystitis is suspected, the patient should
receive nothing by mouth.
 Monitor and regulate IVFs.
 Instruct the patient about the need to avoid smoking and the use of aspirin.
 Let the patient sign an informed consent regarding the surgery.
 The patient is given anesthesia prior to surgery.
 DURING THE OPERATION:
 Monitor vital signs.
 Assist anestzhesiologist during the induction

of anesthesia.
 Ensure adequate oxygenation and hydration.
 AFTER THE OPERATION:
 Assist the patient's vital signs, oxygen saturation level, level of

consciousness, circulation, pain, as well as the status of surgical site and

dressing.
 Help in relieving pain by instructing patient regarding proper positioning.
 Instruct patient regarding deep breathing exercises.
 Provide skin care like cleaning the incision part and providing clean

dressing.
 Instruct patient about prescribed medications.
 Discuss recommended follow-up management with the physician and

surgeon.
 MEDICATIONS
 Non-Steroidal Anti Inflammatory Drugs blocks the COX enzymes and reduce
prostaglandins throughout the body. As a consequence, ongoing inflammation,
pain, and fever are reduced.
 Drug of choice : Diclofenac, Ketorolac, Ibuprofen, Naproxen
 Antibiotics operate by inhibiting crucial life sustaining processes in the organism:

the synthesis of cell wall material the synthesis of DNA, RNA, ribosomes and
proteins.
 Drug of choice : Cefuroxime, Ceftriaxone, Cephalexin
 Narcotics. The main pharmacological action of analgesics is on the cerebrum and

medulla of the central nervous system. Another effect is on the smooth muscle and
glandular secretions of the respiratory and gastro-intestinal tract. The precise
mechanism of action is unknown although the narcotics appear to interact with
specific receptor sites to interfere with pain impulses.
 Drug of choice : Meperidine, Morphine
 Anti-coagulant is a substance that prevents coagulation (clotting) of blood. It

inhibits the actions of the blood clotting factors in the body.

 Drug of choice : Warfarin, Heparin
 PLEXUS BLOCK
 Conduction anaesthesia can be divided into minor

nerve blockade (e.g. ulnar, radial or intercostal),

and major blockade of deeper nerves or trunks
with a wide dermatomal distribution (e.g. brachial
plexus blockade). For each individual agent the
duration of anaesthesia will be determined more
by the total dose of the drug rather than the
volume or concentration of drug used.
 EPIDURAL (EXTRADURAL) BLOCK
 Local anaesthetic solutions are deposited in

the epidural space between the dura mater

and the periosteum lining the vertebral canal.
The epidural space contains adipose tissue,
lymphatics and blood vessels. The injected
local anaesthetic solution produces analgesia
by blocking conduction at the intradural spinal
nerve roots.
 SPINAL ANESTHESIA (SUBARACHNOID BLOCK)
 The introduction of local anaesthetic solutions directly

into the cerebrospinal fluid (CSF) produces spinal

anaesthesia. The local anaesthetics do not have to cross
tissue or diffusion barriers and also the central
attachments of the ventral and dorsal nerve roots are
unmyelinated, which allows rapid uptake of the free base.
There is a faster onset of action and a smaller dose is
required. Spinal anaesthesia produces a similar clinical
effect with a dose approximately ten times smaller than
that needed for extradural anaesthesia.