CH. 61 Caring for Clients Requiring Orthopedic Treatment

A client with a right tibial fracture is being discharged home after having a cast applied. What instruction should the nurse provide in relationship to the client's cast care?

"Keep your right leg elevated above heart level." Explanation: The leg should be elevated to promote venous return and prevent edema. The cast shouldn't be covered while drying because this will cause heat buildup and prevent air circulation. No foreign object should be inserted inside the cast because of the risk of cutting the skin and causing an infection. A foul smell from a cast is never normal and may indicate an infection.

An older adult patient had a hip replacement. When should the patient begin with assisted ambulation with a walker?

- 24 hours Explanation: Following hip arthroplasty (total hip replacement), patients begin ambulation with the assistance of a walker or crutches within a day after surgery.

Define a Cast Window & describe it

- An open wound so healthcare workers can see through the wound to see what i s going on - Client reports discomfort - Wound requires regular dressing change

Which would be an inappropriate initial pain relief measure for the client with a cast?

- Application of a new cast Explanation: Most pain can be relieved by: - elevating the casted part of the bod - applying cold packs as prescribed - administering analgesics

A nurse is caring for a client who is in skeletal traction. To prevent the complication of skin breakdown in a client with skeletal traction, what action should be included in the plan of care?

- Assess the pin insertion site every 8 hours. Explanation: The pin insertion site should be assessed every 8 hours for inflammation and infection. Loose cover dressings should be applied to pin sites, not occlusive The client should be encouraged to use the overhead trapeze to shift weight for repositioning. Isometric exercises should be done 10 times an hour while awake

Which cleansing solution is the most effective for use in completing pin site care?

- Chlorhexidine Explanation: Chlorhexidine solution is recommended as the most effective cleansing solution; however, water and saline are alternate choices. Hydrogen peroxide and betadine solutions have been used, but they are believed to be cytotoxic to osteoblasts and may actually damage healthy tissue.

A client is reporting pain following orthopedic surgery. Which intervention will help relieve pain?

- Elevate the affected extremity and use cold applications. Explanation: Elevating the affected extremity and using cold applications reduce swelling. Deep breathing and coughing helps with maintenance of effective respiratory rate and depth. ROM exercises maintain full ROM of unaffected joints. Antiembolism stockings help prevent deep vein thrombosis (DVT).

What is your First concern for orthopedic surgeries?

- HEMMORHAGE

A nurse is caring for a client after stabilization of a radial fracture. Which actions by the nurse would be appropriate for the client following arm casting?

- Handle the cast with the palms of hands - Circulate room air with a portable fan - Petal and smooth the edges of the cast Explanation: The nurse performs actions to facilitate drying of the cast. Portable fans can be used to dry the cast. Pressure on the cast should be avoided so handle the cast with palms of hands. The nurse can petal and smooth edges of the cast for rough spots. The use of a cloth-covered pillow for elevation is better than a plastic-covered one because the plastic will retain heat and hinder drying of the cast. The cast should be exposed to air to facilitate drying, not covered with a sheet.

Which type of cast encloses the trunk and a lower extremity?

- Hip spica Explanation: A hip spica cast encloses the trunk and a lower extremity. A body cast encloses the trunk. A long-leg cast extends from the junction of the upper and middle third of the thigh to the base of the toes. A short-leg cast extends from below the knee to the base of the toes.

What is your second biggest concern for orthopedics surgeries?

- INFECTION Look for: Redness Edema Ecchymosis Discharge Approximation

What is the purpose of Splints?

- Immobilize and support an injured body part in a functional position

A nurse is planning the care of a client who has undergone orthopedic surgery. What main goal should guide the nurse's choice of interventions?

- Improving the client's level of function Explanation: Improving function is the overarching goal after orthopedic surgery.

To reduce the incidence of complications in a client in traction, which intervention should be included in the care plan?

- Increase fiber intake. Explanation: Immobility increases the incidence of constipation. Increasing fiber intake will reduce GI complications. The weights in traction should never be removed. Inactivity results in fewer calories being burned. Increasing calories would be counterproductive. Reducing fluids will increase the likelihood of constipation.

The nursing care plan for a client in traction specifies regular assessments for venous thromboembolism (VTE). When assessing a client's lower limbs, what sign or symptom is suggestive of deep vein thrombosis (DVT)?

- Increased warmth of the calf Explanation: Signs of DVT include increased warmth, redness, swelling, and calf tenderness. These findings are promptly reported to the health care provider for definitive evaluation and therapy. Signs and symptoms of a DVT do not include a decreased circumference of the calf, a loss of sensation in the calf, or a pale-appearing calf.

Which is a benefit of a continuous passive motion (CPM) device when applied after knee surgery?

- It promotes healing by increasing circulation and movement of the knee joint. Explanation: A CPM device applied after knee surgery promotes healing by increasing circulation and movement of the knee joint.

The nurse assesses a client after total right hip arthroplasty and observes a shortening of the extremity. The client reports severe pain in the right side of the groin. What is the priority action of the nurse?

- Notify the health care provider. Explanation: If any clinical manifestations of dislocation of the prosthesis occur, including acute groin pain in the affected hip or shortening of the affected extremity, the nurse (or the client, if at home) must immediately notify the surgeon, because the hip must be reduced and stabilized promptly so that the leg does not sustain circulatory and nerve damage. After closed reduction, the hip may be stabilized with Buck's traction or a brace to prevent recurrent dislocation. As the muscles and joint capsule heal, the chance of dislocation diminishes. Stresses to the new hip joint should be avoided for the first 8 to 12 weeks, when the risk of dislocation is greatest.

Which orthopedic surgery is done to correct and align a fracture after surgical dissection and exposure of the fracture?

- Open reduction Explanation: An open reduction is the correction and alignment of the fracture after surgical dissection and exposure of the fracture. Arthrodesis is immobilizing fusion of a joint. A joint arthroplasty or replacement is the replacement of joint surfaces with metal or synthetic materials. A total joint arthroplasty is the replacement of both the articular surfaces within a joint with metal or synthetic materials.

A nurse is caring for a client who is recovering in the hospital following orthopedic surgery. The nurse is performing frequent assessments for signs and symptoms of infection in the knowledge that the client faces a high risk of what infectious complication?

- Osteomyelitis Explanation: Infection is a risk after any surgery, but it is of particular concern for the postoperative orthopedic client because of the risk of osteomyelitis.

The nurse is caring for a patient who had a total hip replacement. What lethal postoperative complication should the nurse closely monitor for?

- Pulmonary embolism Explanation: Patients having orthopedic surgery are particularly at risk for venous thromboembolism, including deep vein thrombosis and pulmonary embolism

A client's left leg is in skeletal traction with a Thomas leg splint and Pearson attachment. Which intervention should the nurse include in this client's care plan?

- Teach the client how to prevent problems caused by immobility. Explanation: By teaching the client about prevention measures, the nurse can help prevent problems caused by immobility, such as hypostatic pneumonia, muscle contracture, and atrophy. The nurse applies traction straps for skin traction — not skeletal traction. For a client in skeletal traction, the nurse should assess the affected limb, rather than assess the level of consciousness. Removing skeletal traction is the physician's responsibility — not the nurse's.

Which statement describes external fixation?

- The surgeon inserts metal pins into the bone or bones from outside the skin surface and then attaches a compression device to the pins. Explanation: In external fixation, the surgeon inserts metal pins into the bone or bones from outside the skin surface and then attaches a compression device to the pins. In internal fixation, the surgeon secures the bone with metal screws, plates, rods, nails, or pins. A cast or other mode of immobilization is applied. In closed reduction, the bone is restored to its normal position by external manipulation. In open reduction, the bone is surgically exposed and realigned.

Orthopedic Surgery - Joint Dysfunction Correction (Box 61-4), List the 3 types

1. Arthroplasty; arthrodesis aka a Total knee replacement - Know for exam!!! 2. Osteotomy; hemiarthroplasty 3. Total arthroplasty

Orthopedic Surgery - Open Reduction + Internal Fixation, list the 3 types

1. Buck's extension 2. Nails; intramedullary rod 3. Internal fixation devices

Knee Replacement - How often should joint be flexed? - What's the goal? - Flexion for knee + hip?

1. Clients with knee replacements have the amount of flexion and the frequency of use increased daily while hospitalized. 2. The goal is for the client to have the ability to bend the knee 90° by discharge. 3. The amount of flexion for clients with hip replacements should never exceed 30° in a CPM machine.

List the Types of Casts

1. Cylinder 2. Body 3. Hip spica Others (see Box 61-1)

What are the 3 Positioning Precautions for a Hip Replacement?

1. Have legs abducted with pillows or abductor cushion and extended because the opposite positions of adduction and flexion beyond 90°can dislocate the prosthetic femoral head from the acetabulum 2. Sit in an elevated chair or on a seat raised by pillows, so that the flexion remains less than 90° 3. See Box 61-5

What are the main 4 Preoperative Nursing Management (see Nursing Guidelines 61-4)

1. Obtain complete history 2. Assess complications from previous treatment 3. Assist in reducing pain, risk of infection, and increasing mobility 4. Help control anxiety and understand instructions

What are the 3 purposes of Braces?

1. Provide support 2. Control movement 3. Prevent additional injury - Provide client and family education

What are the 6 main Client and Family Teachings? (Table 61-1)

1. Support system after discharge 2. Explore the kinds of assistance needed 3. Modifications needed in the home environment 4. Information about home care 5. Referral to a home health care agency 6. Printed discharge instructions - Activity, PT, symptoms to report

Reducing Fractures: Name & describe the 5 types of Traction Management

1. Traction (Box 61-3 and Nursing Guidelines 62-1) 2. Closed reduction - Externally manipulate the bone to get it in alignment 3. Open reduction - Bone is shattered, surgery + internal fixation (works hand in hand with internal 4. Internal fixation - Surgery, open with metal plates, pins, screws & close back up 5. External fixation (Nursing Guidelines 61-3) - Surgery, with metal plates & pins on the outside + compressive device to pins

What are the 4 cases that a Bivalve cast is used? How is it removed, and what are the Nursing Management guidelines?

1. With swollen arm or limb 2. When being weaned from a cast 3. When sharp radiograph is needed 4. As a splint - Cast Removal: - Nursing Management (Nursing Guidelines 61-1)

A client has had a brace prescribed to facilitate recovery from a knee injury. What are the potential therapeutic benefits of a brace?

Braces (i.e., orthoses) are used to provide support, control movement, and prevent additional injury. They are not used to immobilize body parts or to facilitate bone remodeling.

By the time of discharge from the hospital, a client with a knee replacement should bend the knee how many degrees? A. 30° B. 45° C. 60° D. 90°

D. 90° Rationale: The goal is for the client to have the ability to bend the knee 90° by discharge.

When do you break Traction?

NEVER BREAK TRACTION unless: - Life threatening event - realign it - Replace it - Fix it

What is the point of a cast?

To Stabilize & Immobilize

Define Bivalve cast

- Two halves cast that are removable to try and relieve pressure while maintain immobilization

The nurse is helping to set up Buck's traction on an orthopedic client. How often should the nurse assess circulation to the affected leg?

- Within 30 minutes, then every 1 to 2 hours Explanation: After skin traction is applied, the nurse assesses circulation of the foot or hand within 15 to 30 minutes and then every 1 to 2 hours.

A client reports swelling and severe pain in the right wrist. After examination and radiographs negate a fracture, what would the physician likely prescribe as treatment?

- splint Explanation: - The client would use a splint when a musculoskeletal condition does not require rigid immobilization, causes a large degree of swelling, or requires special skin treatment.

Which device is designed specifically to initially support and immobilize a body part in a desired position until swelling subsides?

- Splint Explanation: A splint may be applied to a fractured extremity initially until swelling subsides. A brace is an externally applied device to support a body part, control movement, and prevent injury. A CPM device is an instrument that moves a body part to promote healing and circulation. A trapeze is an overhead device to promote client mobility in bed.

A nurse is caring for a client who has had a plaster arm cast applied. Immediately after application, the nurse should provide what teaching to the client?

- The cast will only have full strength when dry. Explanation: A cast requires approximately 24 to 72 hours to dry, and until dry, it does not have full strength While drying, the cast should not be placed on a hard surface The cast will exude heat while it dries and should not be wrapped.

A client in the emergency department is being treated for a wrist fracture. The client asks why a splint is being applied instead of a cast. What is the best response by the nurse?

- "A splint is applied when more swelling is expected at the site of injury." Explanation: Splints are noncircumferential and will not compromise circulation when swelling is expected. A splint is applied to support and immobilize the injured joint. A fracture will swell as part of the inflammation process. The client would not have to stay longer if a fiberglass cast is applied. Fiberglass cast dry in approximately 30 minutes. An orthopedic doctor is not needed to apply the cast. Many nurses and technicians are trained in proper application of a cast. Some fractures may not be treated with a cast but it would not be appropriate to answer with this response because it does not reflect the actual reason for a splint being applied.

The nurse is teaching the client on bed rest to perform quadriceps setting exercises. Which instruction should the nurse give the client?

- "Bend the knees." Explanation: To perform quadriceps setting exercises, the client lies in the supine (face up) position with legs extended, and pushes the knees into the bed while contracting the anterior thigh muscles. The client does not lie prone (face down), contract the buttocks, or bend the knees.

A client is admitted to the orthopedic unit in skeletal traction for a fractured proximal femur. Which explanation should the nurse give the client about skeletal traction?

- "Traction involves passing a pin through the bone." Explanation: In skeletal traction, a metal pin or wire is passed through the bone and traction is then applied using ropes and weights attached to the pins. Skeletal traction is used when greater weight (11 to 18 kg [25 to 40 lb]) is needed to achieve the therapeutic effect. Skin traction, not skeletal traction, stabilizes the fracture until surgery is performed and uses a boot or Velcro to attach the ropes and weights to the leg

A patient had a total hip replacement. What recommended leg position should the nurse ensure is maintained to prevent prosthesis dislocation?

- Abduction Explanation: The nurse educates the patient about protective positioning, which includes maintaining abduction and avoiding internal and external rotation, hyperextension, and acute flexion.

While assessing a client who has had knee replacement surgery, the nurse notes that the client has developed a hematoma at the surgical site. The affected leg has a decreased pedal pulse. What would be the priority nursing diagnosis for this client?

- Risk for Ineffective Peripheral Tissue Perfusion Explanation: The hematoma may cause an interruption of tissue perfusion. There is also an associated risk for infection because of the hematoma, but impaired perfusion is a more acute threat. Unilateral neglect and impaired sensation are lower priorities than tissue perfusion.

An elderly client's hip joint is immobilized prior to surgery to correct a femoral head fracture. What is the nurse's priority assessment?

- Signs of neurovascular compromise Explanation: Because impaired circulation can cause permanent damage, neurovascular assessment of the affected leg is always a priority assessment. Leg shortening and internal or external rotation are common findings with a fractured hip. Pain, especially on movement, is also common after a hip fracture.

A client has a compound fracture of the right femur. Due to the nature of the fracture, open reduction will be used to align the femur. What other rationale requires the use of open reduction? - All options are correct. - Wound débridement is necessary. - Fracture causes wide bone separation. - Fracture involves several, small pieces of bone.

- All options are correct. Explanation: Open reduction is required when soft tissue, such as nerves or blood vessels, is caught between the ends of the broken pieces of bone: - the bone has a wide separation - comminuted fractures are present - patella and other joints are fractured - open fractures are evident - wound débridement is necessary - internal fixation is needed.

Amputation - What is the Etiology?

- Amputation rationale

Which would be consistent as a component of self-care activities for the client with a cast?

- Cushion rough edges of the cast with tape Explanation: - The client can cushion rough edges with tape to prevent skin irritation - Cast should be kept dry, but do not cover it with plastic or rubber because this causes condensation, which dampens the cast and skin - Casted extremity is to be elevated to heart level frequently; a dependent position will increase swelling. A client should not use any object to scratch under the cast

A client with a fractured ankle is having a fiberglass cast applied. The client starts yelling, "My leg is burning, take it off." What action by the nurse is most appropriate?

- Explain that the sensation being felt is normal and will not burn the client. Explanation: A fiberglass cast will give off heat when applied. The reaction is a normal, temporary sensation. Heat given off during the application phase of the cast does not burn the skin. By explaining these principles to the client, the nurse can alleviate any anxiety associated with the application of the cast. Because this is a known reaction to the application of the fiberglass cast, it is not necessary to remove the cast. Holding the client may cause more harm to the injury. Antianxiety medications are generally not needed when applying a cast.

True or False When a limb is placed in a cast, the joint is set straight to assure bone alignment.

- False Rationale: When a limb is placed in a cast, the cast is applied from the joint above the break to the joint below the break. The joint is slightly flexed to decrease joint stiffness.

The nurse is caring for a patient postoperatively following orthopedic surgery. The nurse assesses an oxygen saturation of 89%, confusion, and a rash on the upper torso. What does the nurse suspect is occurring with this patient?

- Fat emboli syndrome Explanation: Fat embolism syndrome (FES) (see Chapter 43) may occur with orthopedic surgery. The nurse must be alert to any signs and symptoms that may suggest the development of FES. These may include: - respiratory distress - onset of delirium or any acute change in level of consciousness - development of unusual skin rashes, especially a papular rash on the upper torso.

Describe Cast Composition & how to apply it

- Fiberglass; plaster of paris - Alignment and support of the fractured area - Cast material feels warm during application - Support drying cast on pillows How to Apply a Cast: - See Box 61-2

A patient in pelvic traction needs circulatory status assessed. How should the nurse assess for a positive Homans' sign?

- Have the patient extend each leg and dorsiflex each foot to determine if pain or tenderness is present in the lower leg. Explanation: The nurse should assess for pain on passive flexion of each foot, which could indicate deep vein thrombosis.

A client with a fractured femur is in balanced suspension traction. The client needs to be repositioned toward the head of the bed. During repositioning, what should the nurse do?

- Maintain consistent traction tension while repositioning. Explanation: Traction is used to reduce the fracture and must be maintained at all times, including during repositioning

A client with a short arm cast is suspected to have compartment syndrome. What actions should the nurse include in the plan of care? Select all that apply. - Elevate the arm above the heart. - Prepare to remove the cast. - Provide support to the injured extremity. - Assess neurovascular status every 8 hours. - Apply ice to extremity.

- Prepare to remove the cast. - Provide support to the injured extremity Explanation: The nurse should anticipate immediate removal of the cast and provide support to the injured extremity Neurovascular status should be assessed more frequently than every 8 hours (1-2 hrs) If the client's neurovascular status is not improving, then a fasciotomy may be needed. Waiting 8 hours to assess neurovascular status may cause permanent damage to the extremity. To promote arterial blood flow, the arm should be elevated to the heart level, not above Ice should not be used, as it could further decrease blood flow to the extremity

The nurse is caring for a client who underwent a total hip replacement yesterday. What should the nurse do to prevent dislocation of the new prosthesis?

- Protect the affected leg from internal rotation. Explanation: Abduction of the hip helps to prevent dislocation of a new hip joint. Rotation and adduction should be avoided While the hip may be flexed slightly, it shouldn't exceed 90 degrees and maintenance of flexion isn't necessary. The client may not be capable of safe independent repositioning at this early stage of recovery.

A nurse is caring for a client who has a leg cast. The nurse observes the client using a pencil to scratch the skin under the edge of the cast. How should the nurse respond to this observation?

- Provide a fan to blow cool air into the cast to relieve itching. Explanation: The client may receive relief from itching by using a fan or hair dryer to blow cool air into the cast. Scratching should be discouraged using a pencil or a sterile tongue depressor because of the risk for skin breakdown or damage to the cast. Benzodiazepines would not be given for this purpose.

A nurse is giving instructions to a client who's going home with a leg cast. Which teaching point is most critical?

- Reporting signs of impaired circulation Explanation: Although all of these points are important, reporting signs of impaired circulation is the most critical. Signs of impaired circulation must be reported to the health care provider immediately to prevent permanent damage. The client should learn to use crutches properly to avoid nerve damage. The client may exercise above and below the cast, as the health care provider orders. The client should be told not to walk on the cast without the health care provider's permission.

Which is not a guideline for avoiding hip dislocation after replacement surgery.

- The hip may be flexed to put on clothing such as pants, stockings, socks, or shoes. Explanation: Guidelines for avoiding hip dislocation after replacement surgery specify that the hip should not be flexed to put on clothing such as pants, stockings, socks, or shoes. Clients should keep the knees apart at all times, put a pillow between the legs when sleeping, and never cross the legs when seated.

True or False? Braces provide support, control movement, and prevent additional injury.

- True Braces provide support, control movement, and prevent additional injury for long-term use. They are made of various materials and are custom fit to the client. Scrupulous skin care is vital to maintain skin integrity.

A 91-year-old client is slated for orthopedic surgery and the nurse is integrating gerontologic considerations into the client's plan of care. What intervention is most justified in the care of this client?

- Use of a pressure-relieving mattress Explanation: Older adults have a heightened risk of skin breakdown; use of a pressure-reducing mattress addresses this risk. Older adults do not necessarily need TPN and the Foley catheter should be discontinued as soon as possible to prevent urinary tract infections. Prophylactic antibiotics are not a standard infection prevention measure.

The client who has had an arm amputated is assigned to nursing care. What potential complications should the nurse closely monitor for in the late postoperative period of the client?

- chronic osteomyelitis and causalgia Explanation: In the postoperative course, the nurse should monitor for potential complications such as chronic osteomyelitis (after persistent infection) or, rarely, a burning pain or causalgia, the cause of which is unknown.

Arthrodesis is:

- fusion of a joint (most often the wrist or knee) for stabilization and pain relief. Explanation: Arthrodesis is fusion of a joint (most often the wrist or knee) for stabilization and pain relief. Arthroplasty is TOTAL reconstruction or replacement of a joint (most often the knee or hip) with an artificial joint to restore function and relieve pain. Hemiarthroplasty is the replacement of ONE of the articular surfaces in a joint, such as the femoral head but not the acetabulum. Osteotomy is the cutting and removal of a WEDGE of bone (most often the tibia or femur) to change the bone's alignment, thereby improving function and relieving pain.

A variety of complications can occur after a leg amputation. Which is not a possibility in the immediate postoperative period?

- osteomyelitis Explanation: Chronic osteomyelitis may occur after persistent infection in the late postoperative period. Hematoma, hemorrhage, and infection are potential complications in the immediate postoperative period.

List the 6 Postoperative Nursing Management

1. Required demonstrations 2. Post-surgery devices 3. Reduce risk for excessive bleeding 4. Review primary provider's orders - Flexion of CPM devices and movement 5. Help reduce pain and inflammation 6. Prevent postoperative complications 7. Increase Protein to promote wound healing (except in kideney failuree) 8. Promote fiber to move bowels from cause of opioids 9. Encourage movement to move secretions

Amputation - What are the 8 Medical and Surgical Managements?

1. Treatment for disorder influencing healing 2. Level at which limb is amputated 3. Amputation methods: open (guillotine); closed (flap) 4. Arm amputation 5. Leg amputation - Attachment of temporary prosthesis to plaster shell - Custom-made conventional prosthesis 6. Phantom limb; phantom pain - Potential phenomenon - Physiologic response 7. Rehabilitation - Factors influencing amputee success - Maintain realistic expectations 8. Nursing Management See Evidence-Based Practice 61-1