NURSING PROCESS: THE PATIENT UNDERGOING SURGERY OF THE HAND OR WRIST
Surgery of the hand or wrist, unless related to major trauma, is generally an ambulatory surgery procedure. Before surgery, the nurse assesses the patient’s level and type of discomfort and lim-itations in function caused by the ganglion, carpal tunnel syn-drome, Dupuytren’s contracture, or other condition of the hand.
Based on the assessment data, the nursing diagnoses for the pa-tient undergoing surgery of the hand or wrist may include the following:
· Risk for peripheral neurovascular dysfunction related to sur-gical procedure
· Acute pain related to inflammation and swelling
· Self-care deficit: bathing/hygiene, dressing/grooming, feed-ing, and/or toileting related to bandaged hands
· Risk for infection related to surgical procedure
The goals of the patient may include relief of pain, improved self-care, and absence of infection.
Neurovascular assessment of the exposed fingers every hour for the first 24 hours is essential for monitoring function of the nerves and perfusion of the hand. The nurse compares the af-fected hand with the unaffected hand and the postoperative sta-tus with the documented preoperative status. The nurse asks the patient to describe the sensations in the hands and to demonstrate finger mobility. With tendon repairs and nerve, vascular, or skin grafts, motor function is tested only if prescribed. The nurse as-sesses the temperature of the affected hand. Dressings are to be supportive but nonconstrictive. Pain uncontrolled by analgesics suggests compromised neurovascular functioning.
Pain may be related to surgery, edema, hematoma formation, or restrictive bandages. To control swelling that may increase the pa-tient’s pain and discomfort, the nurse elevates the hand to heart level with pillows. When higher elevation is prescribed, an ele-vating sling may be attached to a pole used in intravenous (IV) therapies or to an overhead frame. If the patient is ambulatory, the arm is elevated in a conventional sling with the hand at heart level.
Intermittent ice packs to the surgical area during the first 24 to 48 hours may be prescribed to control swelling. Unless con-traindicated, active extension and flexion of the fingers to pro-mote circulation are encouraged, even though movement is limited by the bulky dressing.
Generally, the pain and discomfort can be controlled by oral analgesics. The nurse evaluates the patient’s response to analgesics and to other pain-control measures. Patient education concern-ing analgesics is important.
During the first few days after surgery, the patient needs assis-tance with ADLs because one hand is bandaged and independent self-care is impaired. The patient may need to arrange for assis-tance with feeding, bathing and hygiene, dressing, grooming, and toileting. Within a few days, the patient develops skills in one-handed ADLs and is usually able to function with minimal assis-tance and use of assistive devices. The nurse encourages use of the involved hand, unless contraindicated, within the limits of dis-comfort. As rehabilitation progresses, the patient resumes use of the injured hand. Physical or occupational therapy–directed ex-ercises may be prescribed. The nurse emphasizes adherence to the therapeutic regimen.
As with all surgery, there is a risk for infection. The nurse teaches the patient to monitor temperature and signs and symptoms that suggest an infection. It also is important to instruct the patient to keep the dressing clean and dry and to report any drainage, foul odor, or increased pain and swelling. Patient education includes aseptic wound care as well as education related to prescribed pro-phylactic antibiotics.
After the patient has undergone hand surgery, the nurse teaches the patient how to monitor neurovascular status and the signs of complications that need to be reported to the surgeon (eg, pares-thesia, paralysis, uncontrolled pain, coolness of fingers, extreme swelling, excessive bleeding, purulent drainage, fever). The nurse discusses prescribed medications with the patient. In addition, the nurse teaches the patient to elevate the hand above the elbow and to apply ice (if prescribed) to control swelling. Unless con-traindicated, the nurse encourages extension and flexion exercises of the fingers to promote circulation. The use of assistive devices is encouraged if they would be helpful in promoting accomplish-ment of ADLs. For bathing, the nurse instructs the patient to keep the dressing dry by covering it with a secured plastic bag. Generally, the wound is not redressed until the patient’s follow-up visit with the surgeon (Chart 68-5).
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) Achieves pain relief
a) Reports increased comfort
b) Controls edema through elevation of the hand
c) Experiences no discomfort with movement
3) Demonstrates independent self-care
a) Secures assistance with ADLs during first few days post-operatively
b) Adapts to one-handed ADLs
c) Uses injured hand within its functional capability
4) Demonstrates absence of wound infection
a) Complies with treatment protocol and prevention strategies
b) Reports temperature and pulse within normal limits
c) Experiences no purulent wound drainage
d) Experiences no wound inflammation
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