NURSING PROCESS: POSTOPERATIVE CARE OF THE PATIENT UNDERGOING ORTHOPEDIC SURGERY
After orthopedic surgery, the nurse continues the preoperative care plan, modifying it to match the patient’s current postoperative sta-tus. The nurse reassesses the patient’s needs in relation to pain, neurovascular status, health promotion, mobility, and self-esteem. Skeletal trauma and surgery performed on bones, muscles, or joints can produce significant pain, especially during the first 1 or 2 postoperative days. Tissue perfusion must be monitored closely, because edema and bleeding into the tissues can compromise cir-culation and result in compartment syndrome. Inactivity con-tributes to venous stasis and the development of DVT. General anesthesia, analgesia, and immobility can result in altered func-tioning of respiratory, gastrointestinal, and urinary systems.
The nurse notes the prescribed limits on mobility and as-sesses the patient’s understanding of the mobility restrictions. Thenurse discusses the plan of care with the patient and encourages active participation in the plan.
In addition, the nurse assesses and monitors the patient for po-tential problems related to the surgery. Frequent assessment of vital signs, level of consciousness, neurovascular status, wound drainage, breath sounds, bowel sounds, fluid balance, and pain provides the nurse with data that may suggest the possible devel-opment of complications. The nurse reports abnormal findings to the physician promptly.
With major orthopedic surgery, there is a risk of hypovolemic shock because of blood loss. Muscle dissection frequently produces wounds in which hemostasis is poor. Wounds that are closed under tourniquet control may bleed during the postoperative period. The nurse must be alert for signs of hypovolemic shock.
Changes in the patient’s pulse rate, respiratory rate, or color may indicate pulmonary or cardiovascular complications. Atelectasis and pneumonia are common and may be related to preexisting pul-monary disease, deep anesthesia, decreased activity, analgesics, and reduced respiratory reserve due to advanced age or an underlying musculoskeletal disorder (eg, restrictive lung expansion secondary to kyphosis, rheumatoid arthritis, or osteoporosis).
Voiding in unnatural positions may contribute to urinary re-tention. In addition, elderly men usually have some degree of prostate enlargement and may already have difficulty voiding. Therefore, it is important to monitor urinary output.
Temperature elevations within the first 48 hours are frequently related to atelectasis or other respiratory problems. Temperature elevations during the next few days are frequently associated with urinary tract infections. Superficial wound infections take 4 to 6 days to develop. Fever from phlebitis usually occurs during the end of the first week through the second week.
Thromboembolic disease is one of the most common and most dangerous of all complications oc-curring in the postoperative orthopedic patient. Advanced age, venous stasis, lower extremity orthopedic surgery, and immobi-lization are significant risk factors. The nurse assesses the patient daily for calf swelling, tenderness, warmth, redness, and a posi-tive Homans’ sign. The nurse promptly reports abnormal find-ings to the physician.
In addition, fat embolus may occur with ortho-pedic surgery. The nurse must be alert to changes in respiration, behavior, and level of consciousness that suggest the development of fat embolus.
Based on all assessment data, the patient’s major nursing diag-noses after orthopedic surgery may include the following:
· Acute pain related to the surgical procedure, swelling, and immobilization
· Risk for peripheral neurovascular dysfunction related to swelling, constricting devices, or impaired circulation
· Risk for ineffective therapeutic regimen management related to insufficient knowledge or available support and resources
· Impaired physical mobility related to pain, edema, or the presence of an immobilizing device (eg, splint, cast, or brace)
· Risk for situational low self-esteem: disturbed body image or role performance related to impact of musculoskeletal problem
Based on the assessment data, potential complications may in-clude the following:
· Hypovolemic shock
· Atelectasis; pneumonia
· Urinary retention
· Venous stasis and DVT
The major goals for the patient after orthopedic surgery may in-clude relief of pain, adequate neurovascular function, health pro-motion, improved mobility, positive self-esteem, and absence of complications.
After orthopedic surgery, pain can be intense. Edema, hematomas, and muscle spasms contribute to the pain experienced. Some pa-tients report that the pain is less than that experienced preopera-tively, and only moderate amounts of analgesics are needed. The nurse closely monitors the patient’s pain level and response to therapeutic measures and makes every effort to relieve the pain and discomfort.
Multiple pharmacologic approaches to pain management exist. Patient-controlled analgesia (PCA) and epidural analgesia may be prescribed to control the pain. If intramuscular and oral anal-gesics are prescribed on an as-needed basis (PRN), the nurse in-structs the patient to request the analgesic before the pain becomes severe. Alternatively, the nurse can offer the medication at set intervals. The nurse rotates intramuscular injection sites, avoid-ing the operative hip and thigh. The nurse may administer med-ications on a preventive basis within the prescribed intervals if the onset of pain can be predicted (eg, 30 minutes before planned ac-tivity such as transfer or exercise).
In addition to pharmacologic approaches to controlling pain, elevation of the operative extremity and application of cold, if prescribed, help to control edema and pain. Portable suction of the wound decreases fluid accumulation and hematoma forma-tion. The nurse may find that repositioning, relaxation, distrac-tion, and guided imagery help in reducing the patient’s pain.
The nurse should report increasing and uncontrollable pain to the orthopedic surgeon for evaluation. Pain should diminish rapidly after the initial postoperative period. After 2 to 3 days, most patients require only occasional oral analgesia for residual muscle soreness and spasm.
The nurse continues the preoperative plan of care. The nurse monitors the neurovascular status of the involved body part and notifies the physician promptly of any indications of diminished tissue perfusion. The patient is reminded to perform muscle-setting, ankle, and calf-pumping exercises hourly while awake to enhance circulation.
The nurse continues the preoperative plan of care. It is important to encourage the patient to participate in the postoperative treat-ment regimen.well-balanced diet with adequate protein and vitamins is needed for wound healing. The patient progresses to a regular diet as soon as possible. Large amounts of milk should not be given to orthopedic patients who are on bed rest, however, be-cause this adds to the calcium pool in the body and requires that the kidneys excrete more calcium, which increases the risk for urinary calculi.
The nurse monitors the patient for pressure ulcers, which are a threat to any patient who must spend an extended time in bed or who is elderly, malnourished, or unable to move without as-sistance. Turning, washing, and drying the skin and minimiz-ing pressure over bony prominences are necessary to avoid skin breakdown.
Patients are frequently reluctant to move after orthopedic surgery. Preoperative education about the planned postoperative treat-ment regimen promotes patient participation in physical activi-ties. Patients often increase their mobility once they have been reassured that movement within therapeutic limits is beneficial, that the nurse will provide assistance, and that discomfort can be controlled.
Metal pins, screws, rods, and plates used for internal fixation are designed to maintain the position of the bone until ossifi-cation occurs. They are not designed to support the body’s weight, and they can bend, loosen, or break if stressed. The es-timated strength of the bone, the stability of the fracture, re-duction and fixation, and the amount of bone healing are important considerations in determining weight-bearing limits. Although the incision may appear healed, the underlying bone requires more time to repair and regain normal strength. Some orthopedic procedures require weight-bearing restrictions. The or-thopedic surgeon will prescribe the weight-bearing limits and the use of protective devices (orthoses), if necessary, after surgery.
The physical therapist tailors the exercise program to the in-dividual patient’s needs. The goal is the patient’s return to the highest level of function in the shortest time possible. Rehabili-tation involves progressive increases in the patient’s activities and exercises. Assistive devices (crutches, walker) may be used for postoperative mobility. Preoperative practice with assistive de-vices helps the patient use them postoperatively. The nurse makes sure that the patient uses these devices safely.
The nurse continues the preoperative plan of care. The nurse and the patient set realistic goals. Increased self-care activities within the limits of the therapeutic regimen and resumption of roles facilitate recognition of abilities and promote self-esteem, personal identity, and role performance. Acceptance of altered body image is facilitated by support provided by the nurse, family, and others.
Excessive loss of blood during or after surgery can result in shock. The nurse monitors the patient for signs and symptoms of hypo-volemic shock: increased pulse rate, decreased blood pressure, urine output less than 30 mL per hour, restlessness, change in mentation, thirst, decreased hemoglobin and hematocrit. The nurse reports these findings to the orthopedic surgeon and assistsin appropriate management.
The nurse monitors the patient’s breath sounds and encourages deep breathing and coughing exercises. Full expansion of the lungs prevents the accumulation of pulmonary secretions and the development of atelectasis and pneumonia. Incentive spirometry, if prescribed, is encouraged. If signs of respiratory problems de-velop (eg, increased respiratory rate, productive cough, dimin-ished or adventitious breath sounds, fever), the nurse reports the findings to the surgeon.
The nurse closely monitors the patient’s urinary output after surgery. The nurse encourages the patient to void every 3 to 4 hours to prevent urinary retention and bladder distention. It is important to provide privacy during toileting. Because the patient may need to void in an unusual position, the nurse assists the pa-tient with positioning. Fracture bedpans may be more comfortable than other bedpans. Voiding in the side-lying position may be helpful to the male patient. Some male patients can void only if standing, and clarification with the surgeon of the activity pre-scription may be needed before the patient is assisted to a standing position. If the patient is unable to void, intermittent catheteriza-tions may be prescribed until the patient is able to void indepen-dently. Indwelling urinary catheters are to be used only when absolutely necessary and should be removed as soon as possible.
Infection is a risk after any surgery, but it is of particular concern for the postoperative orthopedic patient because of the high risk of osteomyelitis. Osteomyelitis often requires prolonged courses of intravenous antibiotics. At times, the infected bone and pros-thesis or internal fixation device must be surgically removed. Therefore, prophylactic systemic antibiotics are usually prescribed during the perioperative and immediate postoperative period. The nurse assesses the patient’s response to these antibiotics. When changing dressings and emptying wound drainage devices, aseptic technique is essential. The nurse monitors the patient’s vital signs, incision, and drainage. The nurse monitors the patient for signs of urinary tract infection. Prompt assessment for and treatment of infection are essential.
Prevention of DVT requires use of ankle and calf-pumping ex-ercises, elastic compression stockings, and sequential compres-sion devices. Adequate hydration and early mobilization are equally important. Prophylactic warfarin, adjusted-dose heparin, or low-molecular-weight heparin (eg, enoxaparin sodium) may be prescribed. Aspirin has no apparent effect in preventing DVT in the orthopedic patient. The nurse monitors the patient for signs of DVT and promptly reports findings to the physician for management.
The length of stay in the hospital after orthopedic surgery is usu-ally less than 1 week. Convalescence and rehabilitation take place at home or in a nonacute care setting. The nurse teaches the pa-tient and the family to recognize complications that must be re-ported promptly to the orthopedic surgeon.
The patient must understand the prescribed medication regimen. The nurse should demonstrate proper wound care. The patient gradually resumes physical activities and adheres to weight-bearing limits. The pa-tient must be able to perform transfers and to use mobility aids safely. If the patient has a cast or other immobilizing device, fam-ily members should be instructed about how to assist the patient in a way that is safe for the patient and for the family member (eg, using proper body mechanics when lifting the patient). Specific exercises need to be taught and practiced before discharge. The nurse discusses recovery and health promotion, emphasizing a healthy lifestyle and diet.
If special equipment or home modifications are needed for safe care at home, they must be obtained before the patient is dis-charged home. The nurse, physical therapist, and social worker can assist the patient and family in identifying their needs and in getting ready to care for the patient at home.
Frequently, home health nursing and home physical therapy are part of the discharge plan of care. These referrals provide re-sources and help the patient and the family cope with the de-mands of care during convalescence and rehabilitation. The nurse can explore problems that the patient and family identify during the home care visit. The nurse assesses the patient’s progress and monitors for possible complications. Regular medical follow-up care after discharge needs to be arranged (Chart 67-10).
Expected patient outcomes may include:
1) Reports decreased level of pain
a) Uses multiple approaches to reduce pain
b) Uses occasional oral medication to control discomfort
c) Elevates extremity to control edema and discomfort
d) Moves with greater comfort
2) Exhibits adequate neurovascular function
a) Exhibits normal color and temperature of skin
b) Has warm skin
c) Has normal capillary refill response
d) Demonstrates intact sensory and motor function
e) Demonstrates reduced swelling
a) Eats diet appropriate for nutritional needs
b) Maintains adequate hydration
c) Abstains from smoking
d) Practices respiratory exercises
e) Repositions self to relieve pressure on skin
f) Engages in strengthening and preventive exercises
4)Maximizes mobility within the therapeutic limits
a) Requests assistance when moving
b) Elevates edematous extremity after transfer
c) Uses immobilizing devices as prescribed
d) Complies with prescribed weight-bearing limitation
5)Expresses positive self-esteem
a) Discusses temporary or permanent changes in body image
b) Discusses role performances
c) Views self as capable of assuming responsibilities
d) Actively participates in planning care and in the thera-peutic regimen
6)Exhibits absence of complications
a) Does not experience shock
b) Maintains normal vital signs and blood pressure
c) Has clear lung sounds
d) Demonstrates wound healing without signs of infection
e) Does not experience urinary retention
f) Voids clear urine clear
g) Exhibits no signs of DVT