Basic Orthopaedic Ax Flashcards
proposed benefits of posterior THJR technique
improved ROM post op
less post op limp
proposed risks of posterior THJR technique
increased rate of dislocation as posterior capsule is disrupted
potential sciatic nerve injury
Proposed benefits of lateral approach
reduced chance of dislocation
Proposed risks of lateral approach
altered gait pattern with incr trendelenberg gait and slower functional recovery
Hip dislocations can be caused by
inadequate adjustment of soft tissue tension at time of surgery leading to instability – decreased femoral offset
shortening of limb with short femoral neck and high acetabular component
malpositioned prosthetic components
steep lateral inclination is associated with superior dislocation
retroverted cup is associated with posterior dislocation
anteverted cup is associated with anterior dislocation.
Sections of Subjective Ax
HPC PMHx PSHx SocHx FnlHx
HPC
Clarification of details obtained from your review of the medical record. Could include details from the operation report or medical admission notes.
Paraphrasing back to the patient what you know from the medical record is a useful tool –e.g. I understand from your notes that you had a TKR yesterday by Dr X and that you have diabetes, smoking Hx of 10/day 20 yrs, and a total shoulder replacement eight years ago. Is this correct?
Do you have any pain (Numeric Analogue Scale (NAS) - Site of pain
At rest (score out of 10: 1 being no pain and 10 the worst pain imaginable)
With movement (score out of 10)
What type of pain is it (sharp, ache, stabbing)?
Is it constant?
Do you have pain in any other areas of your body?
Are the medications helping with the pain?
Do you have any areas of pins and needles or numbness?
Do you have any weakness?
Do you have any shortness of breath? Do you have a productive cough? Are you a smoker, or have you previously smoked?
PMH
Do you have any medical problems?
PSH
Have you had any surgery in the past?
SHx
Do you live alone?
Do you receive any assistance at home?
Do you have any stairs at home? How many? Do you have a rail? Is it sturdy?
Do you have a shower or bath at home?
Do you have any rails or adaptive equipment?
FnlHx
How did you get around before you came into hospital?
Did you use any mobility aids i.e. stick, crutches, frame?
Were you able to shower and dress yourself?
Have you had any falls?
Objective Ax includes
General observation Respiratory Circulation UL/LL Neuro Musculoskeletal Affected body part/s Functional assessment
General Observation
Patient’s position and posture
Attachments and appliances (IV lines, O2, PCA/epidural/wound infusion catheter, IDC, drains, slings, splints, bed brakes)
Respiratory
Respiratory
Observation, palpation, auscultation (R cf L, breath sounds, added sounds)
Cough
resp Rate
Circulation
Capillary refill
Pulses
DVT check including observation for redness and swelling, palpation for temperature and localised tenderness, and Homan’s sign (calf pain on passive dorsiflexion of the ankle)
UL/LLNeurological
Strength
Light touch sensation
Reflexes
MSK
ROM of all unaffected limbs
Affected body parts
Observation
Palpation
Movement including adjacent joints
Strength
Functional Ax
Bed mobility
Transfers
Mobility including assistance required, aid used, distance, weight bearing
Assistance
As a general guide the following definitions are provided for levels of assistance required
Assistance: hands on required
Supervision: verbal cues and gesture may be required
Independent: no manual assistance, verbal cues, or gesture required
Day 1 checklist - bloods
Blood pressure and heart rate
If blood pressure is low and heart rate is high, it may indicate that there is not enough circulatory volume and may indicate low Hb.
Fluid balance
When a patient receives post-operative fluid, it may dilute the “blood”; and Hb levels may drop on day 2 and 3 due to this.
Pre-operative Hb levels:
Important to review this when you have a reading post-op, as large drops can create significant symptoms:
e.g. someone with Hb 147 that drops to 90, may be more symptomatic when compared to someone who starts at 105 and drops to 85, despite the fact that the second person has a lower Hb than the first.
Blood loss intra-operatively
Refer to Barry’s operation record or anaesthetic record to capture this information.
Look for any “cell salvage” techniques performed intra-operatively or in recovery. This is a process whereby the surgical field Blood is collected, filtered, and washed to produce red blood cells for transfusion to the patient. (See picture above and to the right.)
Blood loss post-operatively
Refer to fluid balance summary to see drainage/output.
Physically look at drainage in the collection bags.
Extra tips
After you have approached the patient and gained consent, ensure patient is decently clothed, then pull back all covers to visualise all lines/attachments and position on one side of the bed if possible. This will make it easier when the time comes to mobilise them.
Condensing the number of attachments also makes mobilising the patient easier. Have a discussion with the nursing staff and if attachments are to be removed that day, attempt to time mobilisation in after they have been removed.
Put the attachments onto one pole if possible and ensure there are no kinks in the lines or tubes as this reduces available length.
Physiotherapists must take care when attaching oxygen from the wall to a portable cylinder on the walking aid. Be sure to check the portable cylinder levels before you set off on a walk and realise it is empty.
You may be able to utilise your physiotherapy assistant to check all cylinders in the morning.
Be sure to check all attachments before you mobilise. Examples of what you could pick up include:
drainage bags – connected and not too full? (figure 1.0)
non slip socks or slippers?
IDC – kinked and collection bag too full?
IVT – connected and secured well?
anti-embolic stockings – correct fit and position? (figure 2.0)
benefits of standing mobility check prior to mobilising
Benefits of getting Barry to stand, march, and weight shift by the bedside before mobilising include:
it allows time to recognise signs of latent postural hypotension
it ensures you have all attachments correctly positioned
the patient gains confidence in taking weight on affected limb
it ensures you check the walking aid is at an appropriate height.
strategies for the fainting patient
- incr O2
- bring bed to pt to lay down
if the patient is in the hallway, a chair or commode is a good option
from here they still need to transfer to the bed soon after if they remain faint
“facilitating” the patient to the floor allows them to be stabilised before they transfer back to bed - to transfer from floor to bed, you may use:
sling Hoist (if there are no hip precautions)
Jordan frame on hoist
hover mat
sheet lifter.
