Nursing Process: The Patient Undergoing Foot Surgery

NURSING PROCESS: THE PATIENT UNDERGOING FOOT SURGERY

Assessment

Surgery of the foot may be necessary because of various condi-tions, including neuromas and foot deformities (bunion, hammer toe, clawfoot). Generally, foot surgery is performed on an outpa-tient basis. Before surgery, the nurse assesses the patient’s ambu-latory ability and balance and the neurovascular status of the foot. Additionally, the nurse considers the availability of assistance at home and the structural characteristics of the home in planning for care during the first few days after surgery. The nurse uses these data, in addition to knowledge of the usual medical management of the condition, to formulate appropriate nursing diagnoses.

Nursing Diagnoses

Based on the assessment data, the nursing diagnoses for the pa-tient undergoing foot surgery may include the following:

·      Risk for ineffective peripheral tissue perfusion: related to swelling

·       Acute pain related to surgery, inflammation, and swelling

·      Impaired physical mobility related to the foot-immobilizing device

·      Risk for infection related to the surgical procedure/surgical incision

Planning and Goals

The goals for the patient may include adequate tissue perfusion, relief of pain, improved mobility, and absence of infection.

Nursing Interventions

PROMOTING TISSUE PERFUSION

Neurovascular assessment of the exposed toes every 1 to 2 hours for the first 24 hours is essential to monitor the function of the nerves and the perfusion of the tissues. If the patient is discharged within several hours after the surgery, the nurse teaches the pa-tient and family how to assess for swelling and neurovascular status (circulation, motion, sensation). Compromised neuro-vascular function can increase the patient’s pain.

RELIEVING PAIN

Pain experienced by patients who undergo foot surgery is related to inflammation and edema. Formation of a hematoma may con-tribute to the discomfort. To control the swelling, the foot should be elevated on several pillows when the patient is sitting or lying. Intermittent ice packs applied to the surgical area during the first 24 to 48 hours may be prescribed to control swelling and provide some pain relief. As activity increases, the patient may find that dependent positioning of the foot is uncomfortable. Simply ele-vating the foot often relieves the discomfort. Oral analgesics may be used to control the pain. The nurse instructs the patient and family about appropriate use of these medications.

IMPROVING MOBILITY

After surgery, the patient will have a bulky dressing on the foot, protected by a light cast or a special protective boot. Limits for weight bearing on the foot will be prescribed by the surgeon. Some patients are allowed to walk on the heel and progress to weight-bearing as tolerated; other patients are restricted to non– weight-bearing activities. Assistive devices (eg, crutches, walker) may be needed. The choice of the devices depends on the pa-tient’s general condition and balance and on the weight-bearing prescription. Safe use of the assistive devices must be ensured through adequate patient education and practice before dis-charge. Strategies to move around the house safely while using assistive devices are discussed with the patient. As healing pro-gresses, the patient gradually resumes ambulation within pre-scribed limits. The nurse emphasizes adherence to the therapeutic regimen.

PREVENTING INFECTION

Any surgery carries a risk for infection. In addition, percutaneous pins may be used to hold bones in position, and these pins serve as potential sites for infection. Because the foot is on or near the floor, care must be taken to protect it from dirt and moisture. When bathing, the patient can secure a plastic bag over the dress-ing to prevent it from getting wet. Patient instruction concern-ing aseptic wound care and pin care may be necessary.

The nurse teaches the patient to monitor for temperature and infection. Drainage on the dressing, foul odor, or increased pain and swelling could indicate infection. The nurse instructs the pa-tient to promptly report any of these findings to the physician. If prophylactic antibiotics are prescribed, the nurse provides in-struction about their correct use.

PROMOTING HOME AND COMMUNITY-BASED CARE 

Teaching Patients Self-Care

The nurse plans patient teaching for home care, focusing on neuro-vascular status, pain management, mobility, and wound care (Chart 68-6).

Evaluation

EXPECTED PATIENT OUTCOMES

Expected patient outcomes may include:

1)    Maintains peripheral tissue perfusion

a)     Demonstrates normal skin temperature and capillary refill

b)    Exhibits normal sensations

c)     Exhibits acceptable motor function

2)    Obtains pain relief

a)     Elevates foot to control edema

b)    Applies ice to foot as prescribed

c)     Uses oral analgesics as needed and prescribed

d)    Reports decreased pain and increased comfort

3)    Demonstrates increased mobility

a)     Uses assistive devices safely

b)    Resumes weight-bearing gradually as prescribed

c)     Exhibits diminished disability associated with preoper-ative condition

4)    Develops no infection

a)     Reports temperature and pulse within normal limits

b)    Reports no purulent drainage or signs of wound in-flammation

c)     Maintains clean and dry dressing

d)    Takes prophylactic antibiotics as prescribed