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NURSING PROCESS: PREOPERATIVE CARE OF THE PATIENT UNDERGOING ORTHOPEDIC SURGERY
Assessment of the patient is focused on hydration status, current medication history, and possible infection. Adequate hydration is an important goal for orthopedic patients. Immobilization and bed rest contribute to DVT, to urinary stasis and associated blad-der infections, and to kidney stone formation. Adequate hydra-tion decreases blood viscosity and venous stasis and ensures adequate urine flow. To determine preoperative hydration status, the nurse assesses the skin and mucous membranes, vital signs, urinary output, and laboratory values.
The medication history provides information for perioperative management. The patient with chronic illness (eg, rheumatoid arthritis, chronic pulmonary disease, multiple sclerosis, allergies) frequently has received corticosteroid medications to control symptoms.
The corticosteroid should be administered preoperatively, intraoperatively, and postoperatively as prescribed to pre-vent the occurrence of adrenal insufficiency from suppressed adrenal function. The patient’s use of other medications, such as anticoagulants, cardiovascular agents, or insulin, needs to be doc-umented and discussed with the surgeon and anesthesiologist to ensure adequate management.
The nurse asks the patient specifically about the occurrence of colds, dental problems, urinary tract infections, and other infec-tions within the 2 weeks before surgery. Osteomyelitis could de-velop through hematologous spread. Permanent disability can result if infection occurs within a bone or joint. Preexisting infec-tions must be resolved before elective orthopedic surgery is per-formed.
Other areas of preoperative assessment are similar to those for any patient undergoing surgery. Intramuscular medications are injected into an uninvolved area, because tissue absorption is bet-ter in nontraumatized tissues.
Based on the nursing assessment data, the patient’s major preop-erative nursing diagnoses related to orthopedic status may include the following:
· Acute pain related to fracture, orthopedic problem, swelling, or inflammation
· Risk for peripheral neurovascular dysfunction related to swelling, constricting devices, or impaired venous return
· Risk for ineffective therapeutic regimen management re-lated to insufficient knowledge or lack of available support and resources
· Impaired physical mobility related to pain, swelling, and possible presence of an immobilization device
· Risk for situational low self-esteem: disturbed body image and/or functional impairment related to impact of musculo-skeletal disorder
The major goals for the patient before orthopedic surgery may in-clude relief of pain, adequate neurovascular function, health pro-motion, improved mobility, and positive self-esteem.
Physical, pharmacologic, and psychological strategies to control pain are useful in the preoperative period. Specific strategies are tailored to the individual patient. Discomfort is decreased with immobilization of a fractured bone or an injured, inflamed joint. Elevation of an edematous extremity promotes venous return and reduces associated discomfort. Ice, if prescribed, relieves swelling and directly reduces discomfort by diminishing nerve stimulation. Analgesics are frequently prescribed to control the acute pain of musculoskeletal injury and associated muscle spasm. During the immediate preoperative period, the nurse needs to discuss and coordinate the administration of analgesic medications with the anesthesiologist and surgeon. Alternative methods of pain control (eg, distraction, focusing, guided im-agery, quiet environment, backrubs) may be used to decrease pain perception.
Trauma, edema, or immobilization devices may interrupt tissue perfusion. The nurse must frequently assess neurovascular status (ie, color, temperature, capillary refill, pulses, edema, pain, sensation, motion) of the extremity and document the findings. If circulation is compromised, the nurse institutes measures to re-store adequate circulation. These include promptly notifying the physician, elevating the extremity, and releasing constricting wraps or casts as prescribed.
The nurse assists the patient in activities that promote health dur-ing the perioperative period. The nurse assesses nutritional status and hydration. The preoperative fasting regimen is usually toler-ated well. If the patient has diabetes, is elderly and frail, or is the victim of multiple trauma, special fluid and nutritional provisions may be necessary.
The nurse monitors fluid intake, urinary output, urinalysis findings, and complaints of burning on urination. At times, patients may limit their fluid intake to minimize the use of a bed-pan. A small fracture pan may be more comfortable for the pa-tient to use. An indwelling catheter should be used only when absolutely necessary to minimize the risk of urinary tract infec-tion. Urinary tract infection must be addressed before surgery.
Coughing, deep breathing, and use of the incentive spirometer are practiced preoperatively for improved respiratory function during the postoperative period. Preoperative teaching facilitates postoperative compliance. Smoking should be stopped during the preoperative period to facilitate optimal respiratory function.
The nurse provides skin care, paying special attention to pres-sure points. It is important to institute the use of pressure-reducing surfaces (i.e., special mattresses) before surgery for patients at high risk for skin breakdown.
To minimize the risk for infection, the nurse meticulously and gently cleans the skin with soap and water on the day before surgery. If the surgery is elective, the orthopedic surgeon may instruct the pa-tient to use a germicidal soap for several days before hospitalization.
The nurse discusses with the patient and the family the need for assistance with ADLs and the therapeutic regimen during convalescence so that adequate support is available when the pa-tient is discharged. Modification of the home environment may be necessary to accommodate the altered mobility of the patient after surgery. Referral to the social worker and the case manager may be needed to ensure a smooth transition to home care.
Preoperatively, the patient’s mobility may be impaired by pain, swelling, and immobilizing devices (eg, splints, casts, traction). The nurse should elevate and adequately support edematous ex-tremities with pillows. It is important to control pain before an in-jured part is moved by administering medication in time for it to take effect and by supporting the injured part when it is moved. The nurse encourages movement within the limits of therapeutic immobility. The patient should perform active range-of-motion exercises of uninvolved joints, and, unless contraindicated, the nurse teaches gluteal-setting and quadriceps-setting isometric exercises to maintain the muscles needed for ambulation (see Chart 67-3). The patient who will be using assistive devices post-operatively may exercise to strengthen the upper extremities and shoulders. If the use of assistive devices (eg, crutches, walker, wheelchair) is anticipated, the nurse encourages the patient to practice with them preoperatively to facilitate their safe use and to promote earlier independent mobility.
Preoperatively, orthopedic patients may need assistance in accept-ing changes in body image, diminished self-esteem, or inability toperform their roles and responsibilities. The degree of assistance re-quired in this area varies greatly, depending on the events preceding hospitalization, the surgery and rehabilitation planned, and the tem-porary or permanent nature of the problems. The nurse promotes a trusting relationship for patients to express concerns and anxieties and helps them examine their feelings about changes in self-concept. The nurse clarifies any misconceptions patients may have and helps them work through modifications needed to adapt to alterations in physical capacity and to reestablish positive self-esteem.
Expected patient outcomes may include:
1) Reports relief of pain
a) Uses multiple approaches to reduce pain
b) States that medication is effective in relieving pain
c) Moves with increasing comfort
2) Exhibits adequate neurovascular function
a) Exhibits normal skin color
b) Has warm skin
c) Has normal capillary refill response
d) Reports normal sensation and demonstrates joint motion
e) Demonstrates reduced swelling
3) Promotes health
a) Eats balanced diet appropriate to meet nutritional needs
b) Maintains adequate hydration
c) Abstains from smoking
d) Practices respiratory exercises
e) Repositions self to relieve skin pressure
f) Engages in strengthening and preventive exercises
g) Plans for assistance during convalescence at home
4) Maximizes mobility within the therapeutic limits
a) Requests assistance when moving
b) Elevates edematous extremity after transfer
c) Uses immobilizing devices and assistive devices as pre-scribed
5) Expresses positive self-esteem
a) Acknowledges temporary or permanent changes in body image
b) Discusses role performance changes
c) Participates in decisions about care
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