Module 9: Fractures and Joint Replacement Flashcards
Risk Factors for Fractures
Age (older)
Athleticism/Athletic Injury
Diet
Gender - women more so than men
Genetics
Traumas
Co-morbidities
What sort of diets cause increased risk for fractures
poor vitamin D and calcium intake
Excessive alcohol intake
How do the genders compare for fracture risk
1 out of 2 women while 1 out of 4 men
What sort of co morbidities leave you at higher risk for fracture
HIV
Bone cancer
osteoporosis
Hyper and hypothyroidism (hyper revs up bone activity and hypo may relate more so to meds they take)
Almost any ___ is at risk for fracture
age
Why, despite falling often and getting hurt do infants and preschoolers get less fractures
they have softer bones that do no break as easily
How does alcohol use cause more fracture risk
- calories taken in this way do now have many vitamins for strong bones
- it impairs judgment and causes clumsiness
Why are women at higher risk for fracture than men
they are smaller on average and have a lower bone density than men
4 Types of Fracture Etiologies
Segmental
Displaced
Non-displaced
Pathological
Segmental Fracture
large fragments separate from the main bone
Displaced Fracture
Separated, not aligned
so the broken bone is broken and moved out of normal alignment
can also be segmental or not
Non-displaced fracture
separated but aligned fracture
bone is broken but outline is still the same, the line of fracture is there but the bone did not move out of place after
Pathological Fracture
a fracture as a result of non traumatic forces (frequently underlying illness)
could be something like a cough with a condition like cancer causing a fracture
Fractures are defined by what two things?
Bone (Incomplete or Complete)
Skin (Closed or Open)
What does it mean if the fracture is incomplete?
the fracture line only goes through part of the bone
What does it mean if the fracture is complete
the fracture line goes through the entire bone
What does it mean if the fracture is Simple or Closed
the skin remained closed and intact
What does it mean if the fracture is Compound or Open
skin is open with a greater infection risk
Different types of fracture lines/”Styles”
Transverse
Oblique
Spiral
Comminuted
Segmental
Avulsed
Impacted
Torus
Greenstick
Transverse Fracture
a fracture perpendicular across the bone
Oblique Fracture
an angled line of fracture across the bone
Spiral Fracture
A fracture that has a non straight non neat angle that is more jagged and twisted across the bone
occurs from twisting force
Comminuted Fracture
fracture where there are multiple pieces (looks like shattered glass)
Segmental (Line) Fracture
when a tendon or ligament pulls a piece of the fracture away so you end up with 2 areas of fracture leaving a piece that you could hypothetically pull away
Avulsed Fracture
A fracture where you could hypothetically pull a piece away but there is only one line of fracture
Impacted Fracture
when two piece of fracture (the shard and the bone) are driven together
Torus Fracture
Torus is greek for “Bulging”
it is like if you pushed on each end of the bone until it buckles and now bulged somewhere along the bone
has no distinct fracture line
Greenstick Fracture
a bone that gets bent and has an incomplete/partial fracture line that only goes partway through the bone
What are the 2 most common childhood fractures
Torus
Greenstick
Usually torus and greenstick fractures are not seen after what ages?
10 for torus
12 for greenstick
FOOSH
Falling on outstretched hand
What is the most common cause of the Torus fracture
FOOSH
Diagnostic Tests for Fractures
X Ray
CT Scan/MRI if occult
Bone scan
How can an X Ray help ID a fracture
it is good for outlining the bone (not perfect), and is quick
How can a CT Scan or MRI help ID a fracture
X rays can miss angles and tissues so this will make sure the fractures as seen from angles or tissues are seen
not the first choice though
How can a bone scan help with fractures
the body is injected with a tracer to mark inflammation and problem areas
it can then determine fracture complications like delayed healing and infection
only done if there is one of the complications suspected
What are some things we look for on general assessment of a suspected fracture
deformity (depends if displaced)
edema (can take time)
pain
crepitus
spasms
ecchymosis
loss of function
abnormal ROM
circulatory compromise
not all of these are seen all the time, different people have different results
What can hurt worse than the fracture at times
spasms
it is when the muscles around and near the fractures change and pull in from inflammation
What is our biggest concern on a fracture general assessment
circulatory compromise
if this is impinged than it could make a problem below the area - ex: in the forearm if there is compromise it could cause problems in the hand
We always worry about what is ____/____ the fracture
beyond/distal-to
What are the three early neurovascular assessment concerns for a fracture
Pain
Paresthesia
Pallor
What are the three late neurovascular assessment concerns for a fracture
Polar
Paralysis
Pulses
Early Pain in fractures is …
unrelieved with medication or repositioning/elevation
What does Polar mean
cool or cold fingers and toes
compare bilaterally like everything else
How does Paresthesia compare to Paralysis
paresthesia is early numbness, tingling, pins and needles sensations
paralysis is an inability to move those toes and finger
What are Pulses like in late fractures
doppler only pulse or no pulse felt distal to the injury
need to compare to a baseline tho
How might you check pallor with a fracture
check cap refill (>3 sec) and for bluish fingers and toes distal to the fracture
How are treatments for fractures determined
by type and location
2 Types of fracture treatment
External immobilization
internal immobilization
External Immobilization
for more stable fractures
casts, splints, traction
Internal Immobilization
For less stable fractures or if more conservative treatment fails or immobilization risk is greater than surgical risk
skeletal traction, external fixator, internal fixation (ORIF), bone grafting
Medullary Nail
a large nail that goes through the center of a bone a (the core) and can connect something like a segmental fracture back together
What happens to the hardware used in internal immobilization after healing?
no one goes in and removes it, it stays there
may get a card for metal detectors
Cast
external immobilization
a rigid external immobilizing device
use determined by underlying condition
immobilizes the proximal and distal joints too around the fracture to prevent damage and movement
Uses for Casts
Immobilize a reduced fracture
correct a deformity (like congenital hip dysplasia)
apply uniform pressure to soft tissues (to prevent skin breakdwon)
support to stabilize a joint
Reduced Fracture
one where the pieces have been put back into place and now need immobilization to hold them there and heal
Materials for Casts
- Fiberglass - lightweight, durable, waterproof
2. Plaster - heavier, break apart when wet, require 24+ hours to dry
What to assess about a patient when using a cast
how is the skin
check neurovascular status below area of injury (temp, cap refill, movement)
is there edema and swelling present or no (if pressing on the area may need to loosen or redo cast)
What to assess about the cast itself
is it dry
is it intact
are there no rough edges, if so then pad them
What to educate a patient on before applying the cast
purpose and goals of the cast
expectations for the casting process (like the heat the plaster gives off while hardening)
not to scratch or stick anything under the cast
cushion rough edges
discuss what they can and cannot do with it (activity and mobility options)
What to educate a patient on after applying a cast
control of edema and pain
exercises to do
safe use of assistive devices
S/S to report
What S/S should be reported with a cast
persistent pain or swelling
changes in sensation, movement, skin color, or temperature
signs of infection like burning or itching at pressure areas
burning or itching at pressure areas from it digging in
Common pressure areas that a cast can harm if not padded or careful?
Ulna and Radial Styloid (the wrist bones)
Olecranon and Lateral Epicondyle (Elbow bones)
Lateral malleolus (ankle bone)
tibial tuberosity (knee bone)
What should be monitored for in a leg cast?
peroneal nerve damage that can cause foot drop
this leads to problems walking so we must monitor for different feelings in the calf or foot
Body and Spica Cast
cast that encases the trunk and portions of 1 or 2 extremities
tricky to put on
perineal opening must be large enough for hygiene and voiding
What kind of person may get a spica cast
children born with malformed hips
casting the legs apart can help the hip joint heal in a healthy way
Cast Syndrome
something that can happen in any cast that encases any of the trunk or abdomen
it causes claustrophobia and anxiety from compressing the mesenteric nerve
can talk someone through it and it is sort of like a panic attack
What kinda of cast has the greatest likelihood to cause cast syndrome
an abdominal or trunk cast and the higher up it is the more risk there is
What nerve can lead to foot drop if not monitored for
Peroneal nerve
What nerve can lead to cast syndrome if not monitored for
mesenteric nerve
Traction
external immobilization
means “Pull” - it pulls on the area and you want to maintain this pull to keep things in alignment so they can heal properly
this is mostly to align and immobilize and keep pieces where they need to be in complicated fractures that cannot be fixed normally
Purpose of Traction
Reduce muscle spasms (reduces strain from fracture pieces wiggling)
Reduce, align, and immobilize fractures
Reduce deformity
Increase space between opposing forced
short term intervention (skin) or treatment (skeletal)
Skin traction is a ___ ___ intervention
short term (can be used while waiting surgery)
skeletal traction can be used as ___
treatment (can be weeks or days)
Types of Traction
Manual (AKA: Skin)
Skeletal
Manual (Skin) Traction
used before surgery
can be intermittent
weight limit maximums
ex: a leg in a foam boot with nothing going in, there is a free weight pulling on it and the only thing touching skin is the boot
can even be done intermittently or on going
Skeletal Traction
continuous traction
pins are screwed through bones
a treatment
more internal and external immobilization (pins in bone but come outside the body
It is important to never let what happen with traction
never let the weight hit the floor (that would mean there is no pull)
External Fixators
external traction that does have things going into bones or skin
it can look like a steel cage with pins going into a leg or a device going into the foot or arm that hangs out like a large metal bar
pins go in proximal and distal to the fracture site
nurses never adjust or place there and people can go home with these
What is a big concern with external fixators and skeletal traction
the pins leave open areas for infection
If there is already a lot of open areas and injury, a person may get an external fixator, and what is the benefit then for the nurse
they can assess healing better in that case as they can see it
Nursing Responsibilities regarding traction
- Hydration/nutrition, back rubs, float heels, reposition, avoid shearing damage (skin)
- minimize calf pressure (peroneal nerve)
- monitor pulses and sensation (circulation)
- position feet to avoid plantar flexion, inversion, or eversion (proper body alignment) - we want them pointed up not rotated or down
- pin care (infection)
What is the goal of pin care
prevent infection of skin/soft tissue/bone
Pin care is specific to…
skeletal traction and external fixators
What should be done for pin care initially (first 48 hours)
insertion sites may be covered by a sterile non stick dressing - do not give access too much and check too much
inspect pins every shift for infection
teach patient to perform this care at home
What should occur later in pin care?
use betadine (water/saline solution) to clean once a shift or 2 times daily AS ORDERED/PER POLICY
inspect pin sites every shift for infection
teach patient to perform this care at home
___ may occur and is normal during pin care
crusting (do not scrub it off just gently clean the area)
Always clean pin sites or any open area __ to __
inner to outer
Open Reduction and Internal Fixation
surgical procedure to repair bones using internal hardware
open reduction involves opening the area to internally fix it via pins and stuff
Open Reduction and Internal Fixation is sometimes seen in charts as what
ORIF
ORIF Nursing Responsibilities include what things
Routine post op care
administer IV antibiotics as ordered (not usually on them longer than 3 days unless there is infection)
wound care as ordered (minimal, nothing crazy)
elevate extremity (if possible and PER ORDERS) - may help edema but a surgeon may not want you doing that
monitor for signs of infection
assess for safety
assess neurovascular status frequently
Why is wound care more minimal with ORIF
because the more you touch the surgical area the higher the infection chance is
6 Complications that can occur from a Fracture
Compartment Syndrome
Fat Emboli
DVT
Osteomyelitis
Avascular Necrosis/Non-union
Localized infection at the pin site
Compartment Syndrome
A fracture is relieved, but reperfusion occurs which leads to rapid swelling –> this leads to increased pressure in the muscle compartments –> this leads to compression of nerves and blood vessels
the muscle will swell and push out on compartments causing nerves and blood vessels to squeeze and shrink - it will look red and angry
Fascia
fibrous tissue that keeps things separate in the body compartments
How is Compartment Syndrome diagnosed
you must measure the pressure that is inside (a nurse does not do that)
What may be a huge red flag for compartment syndrome
the human response of pain in the area that does not change regardless of what you do to alleviate it and may even get worse
Compartment syndrome is a ___ situation if acute
emergency
What things can occur in 4-6 hours if compartment syndrome is left unaddressed?
- Necrosis
- Neuromuscular Damage
- Death in severe cases
What is the device that measures pressure for compartment syndrome, and why is it not used much?
The intra compartmental pressure monitor
it can measure pressure through insertion but if someone is suspected to have compartment syndrome they are almost always brought immediately to the OR
What is the first step to being able to do nursing interventions for compartment syndrome?
First - be aware of the risk profile and clinical picture
What nursing interventions can be done for the following 3 human responses as it relates to compartment syndrome:
- Pain
- Edema
- Anxiety
- analgesic administered as ordered
- elevate extremity (helps swelling a little
- educate/answer questions
Despite it not doing much necessarily, what is still done in nursing interventions for compartment syndrome?
We still address and attempt to treat pain
Medical Treatments for Compartment Syndrome
- Control and reduce swelling through elevation of the extremity
- Release any restrictive dressings/casts to relieve pressure
- Fasciotomy
Fasciotomy
Cutting open of the fascia - the tissue dividing compartments
a very dramatic response to compartment syndrome but sometimes needed - high risk for infection
the cut is kept open and only loosely sutured (retention suture) to allow pressure to not be that much
it is covered with moist sterile dressings for 3-5 days
What nursing responsibilities for Pain should be done following a fasciotomy
- analgesics ordered
2. elevate extremity
What nursing responsibilities for Risk for Infection should be done following a fasciotomy
- maintain moist, sterile dressing (3-5 days)
- monitor incision
- monitor labs (WBCs)
- monitor VS (pulse and temp)
- give antibiotics as ordered
What nursing responsibilities for Post op Status should be done following a fasiotomy
- diet for healing (protein and vitamin C diet)
9. routine post op care
Fat Emboli Syndrome (FES)
A fat embolism (not a blood clot) - anything can move as an embolism
these fat globules cannot just be grabbed and pulled out
What is the only treatment for FES?
there is no treatment - it is all supportive - the only way to treat this is through PREVENTION
What is the profile of someone who may get FES?
Young someone with juicy bone marrow out of a long bone)
Casted (instead of ORIF)
Closed Fracture
Long bone/hip fracture
Necrosis of bone marrow
Trauma
Preventative Care for FES
recognize profile and increased risk
Maintenance of adequate oxygenation and ventilation
stable hemodynamics
hydration and nutrition
early ambulation
prophylaxis of stress related GI bleeding
monitor labs, VS, and ABGs
When is FES usually seen/when does it clinically present
24-72 hours post fracture/trauma
What is the clinical presentation like for FES
Respiratory Compromise
Cerebral Dysfunction
Petechiae!
75% of FES leads to respiratory compromise, and 10% progress to…
respiratory failure
How does respiratory compromise present in FES
Tachypnea, Dyspnea, Cyanosis (late sign)
Elevated Temperature
Decreased Hct
Hypoxemia hours before onset of reps. complaints
How does cerebral dysfunction present in FES
acute confusion
rigidity
drowsiness
convulsions
coma
Petechiae
blockages in small vessels leading to small pin point hemorrhages that appear usually in the upper torso and maybe the eye(s)
When do Petechiae appear in FES
within 24-36 hours and disappears within a week
How does petechiae present in FES
nonpalpable petechial rash in the chest, axilla, neck
reddened conjunctiva
How to diagnose FES
- Take the clinical picture and risk factors
- Rule out alternative pathologies like increased ICP, PE, Pneumonia, etc
- Blood gases
- Chest x ray
What will blood gases show in FES
hypoxia with a paO2 <60 mmHg
AND
Hypocapnia with respiratory alkalosis (if hyperventilating)
What will a CXR show in FES
fluffy white shadows
Neurological + Respiratory + Petechiae = ____
FES
Schonfeld’s Criteria
Not used by nurses
A chart used by medical students and doctors to check for estimation risk of whether someone has FES
It looks at Petechiae, CXR changes, hypoxia, fever, tachycardia and tachypnea
A score greater than 5 has a high probability of it being a fat emboli and petechiae instantly scores 5
What should a nurse do as part of their responsibilities and interventions for FES
Telemetry (monitor heart rhythm as this is an early warning sign of emboli in coronary circulation)
Ventilation via face mask or mechanical ventilator (maintain resp system)
Nutrition (TPN or feeding tube if needed)
Adequate hydration (IV fluids)
Foley Catheter (Accurate I&O)
SCDSs(prevent venous stasis in lower extremities)
Air mattress for good skin care
good eye care (keep moist)
ongoing diagnostics (track progress)
DVT
Deep vein thrombosis
a common complication of trauma, surgery, or disability that can progress to a PE SO we focus on prevention rather than treatment of this
swelling is normally in one calf and it is unilateral
What is the most common complication following trauma, surgery, or disability?
DVT
Another name for DVT
VTE - Venous Thromboembolism
What are some prevention measures for DVT
OOB
leg and ankle exercises
adequate hydration
How to treat (1) pain, (2) swelling, and (3) decreased pedal pulse in DVT?
- Analgesia
- Assess pulses pain and swelling
- Report to PCP
Why would Pedal Pulse decrease in DVT
Pulses are minor in DVT since its a venous issue not arterial
however there could be so much swelling that pulses are blocked off
If you suspect a DVT clot…
check bilaterally
Osteomyelitis
Inflammation of the bone because of penetrating organisms
What is the most common penetrating organism for Osteomyelitis
Staphylococcus aureus (which is normally on our skin)
Who is at risk for Osteomyelitis
DM Patients
Patients undergoing orthopedic surgery - placement of prosthesis and other clean orthopedic surgery, management of open fractures, Hx of previous osteomyelitis
How to reduce the risk of osteomyelitis?
Open fractures who receive antibiotics within 6 hours of injury AND prompt surgical treatment
Avoid health care associated osteomyelitis, with careful attention to intravascular and urinary catheters, surgical incisions, and other wounds
S/S of Osteomyelitis
bone pain worse with movement
elevated WBC
elevated temperature
How to diagnose Osteomyelitis
biopsy and culture
Treatments for Osteomyelitis
long term antibiotic therapy (3 MONTHS)
surgery
debridement
amputation
Complications from Osteomyelitis
abscess formation
sepsis
bone deformity
limited ROM
motor and or sensory deficits
Approximately 20-30% of osteomyelitis patients will…
experience recurrence within 2 years, even with appropriate medical and surgical treatment
Nursing Responsibilities and Interventions for Osteomyelitis
Recognize profile and risk factors
Inspection of surgical site and pin sites and note and report any change in COCA or REEDA
Administer antibiotics as ordered
monitor VS and labs
note complaints of worsening pain with movement
maintain “Separation” from potential infectious agents (not in a room with another infectious patient)
What is a major indication for osteomyelitis
pain WHEN MOVING
What are 2 other major complications?
Non Union (Poor Healing)
Avascular Necrosis
Non-union
poor healing of a fracture where bone is not reuniting or healing back together
Diagnosis of Non Union
clinical picture
X Ray
CT or MRI
Treatment for Non Union
internal fixation (surgery)
Bone grafting
Electrical bone stimulation
Avascular Necrosis
Disruption of blood flow to a fracture site leading to bone necrosis
Diagnosis for Avascular Necrosis
clinical picture
X ray
Treatment for Avascular necrosis
repair vascular compromise
surgical joint replacement
What is most often the damaged site for avascular necrosis
A joint like the hip or knee - and this may require a replacement
Joint Replacement
a reconstructive procedure using artificial parts or aftermarket parts
Arthro-
a prefix meaning joint
Arthroscopy
the repair of joint problems through the operating arthroscope or through open joint surgery
Arthroplasty
forming a “new joint”
Hemiarthroplasty
the replacement of ONE of the articular surfaces
hemi = half
Osteotomy
surgical cutting of the bone
-plasty
to form or to make
Prosthesis
artificial substitute for a missing part of the body
can be any missing part
Total Hip Arthroplasty (THA)
total hip replacement (THR)
Total Knee Arthroplasty (TKA)
total knee replacement (TKR)
What parts of the body are frequently replaced?
Hip
Knee
Finger Joints
What parts of the body are replaceable but done so less frequently
shoulder
elbow
wrist
ankle
Who typically gets Replacement Parts
Arthritis (osteo or RA)
Trauma leading to functional joint damage (like certain hip fractures)
congenital deformity leading to functional joint damage
tumors
avascular necrosis
Why replace a joint
- To increase mobility
- To increase us
- To increase joint stability
- To relieve pain
What are the 4 main reasons to replace a joint
Mobility-Functionality-Stability-Comfort
What usually brings people to an orthopedic surgeon
pain
When is a joint replacement done
usually after all other, more conservative therapies for healing and health have failed
What are some of the more conservative therapies done before a joint replacement
PT
medications
joint injections
weight loss
activity modifications
What are the parts of a Hip Prothesis
A metal hip ball that fits into the hip socket and lining
A joint stem that goes into the femur through the middle of it
What can prosthesis components be made of
plastic (polyethylene)
metal (cobalt chrome, titanium)
ceramic (actually a metal oxide)
cement
How is cement used in joint replacement
It is being moved away from and it was used more as a filling compound
it holds the “after market parts” in place
Cement less Hip prothesis
Prosthesis is hammered into more precisely bored holes in the femur and there is a porous coating on it that allows the bone to grow into the nooks and crannies to stabilize
Advantages of Cementless Hip Prosthesis
avoid cement related problems
minimal risk of prosthesis bone bond loss
Disadvantages of Cementless Hip Prosthesis
Risk of bone marrow chunks forced into circulation during shaft placement
Potential need for weight-bearing restriction
Thigh pain (larger prosthesis)
Loosening of fibers from porous coated surface
Requires good circulation to injury site so it may not be appropriate
while this appears more, the advantages outweigh the disadvantages
Cemented Hip Prothesis
the prosthesis is placed into a bored opening in the femur and surrounded by the bone cement
bored opening does not have to be precise here
Advantages of Cemented Hip Prosthesis
Surgical skill deviations
Early weight-bearing
Is smaller, lighter prosthesis
Is cost effective
Disadvantages of Cemented Hip Prosthesis
Cement may cause circulatory interruptions
With age, cement can crack –> bonding loss between prosthesis and bone –> joint instability
How may a knee prosthesis differ from a regular knee?
If the bone is injured the meniscus is gone and the bone on bone contact is painful
so the prosthesis will have a metallic coat over the top leg bone and a prosthetic meniscus in the bottom one
these pieces are smooth and allow for smooth bending and function
may have a pieces to mimic the patella too
Complications of a Joint Replacement
Dislocation/Loosening (Osteolysis) of the artificial joint
Infection at the surgical site
Thromboembolism
Complications from immobility
Long term issues
What are some long term issues/complications of joint replacement
Heterotopic Ossification
Avascular Necrosis
Loosening of the Joint
Heterotopic Ossification
bone growth in odd places
Nursing Goals for Joint Replacement Patients
! - Minimize discomfort/pain
prevent infection at surgical site
prevent and minimize negative consequences of immobility
Prevent dislocation and loosening of the prosthesis
Post Op Nursing Responsibilities for Joint replacements
- VS and Neurovascular checks as ordered
- control Pain
- Monitor the incision
- prevent DVT
- maintain body and limb alignment
- respiratory toilet
- assess skin integrity
- maintain nutrition and hydration
- home health and social service for rehab referrals
How often are VS and Neurovascular checks usually ordered for joint replacements?
every 1-2 hours
Ways to control joint replacement pain
Medications: IV, PO, PCA, nerve block - as needed and before planned activities
Individualized strategies - like repositioning
What to monitor for at the incision site of a joint replacement
Infection
Bleeding
record drainage/drain output
Maintain clean, dry dressings
usually begins occurring around day 5
PCA
patient controlled analgesia
What kind of pain treatment is used a lot and why in joint replacements
nerve blocks
they are local anesthetics with less pain post op, a higher likelihood to progress and participate in therapy, and encourages activity sooner than analgesics
Always give ___ before PT
medications like analgesics
How to prevent DVT
- thrombus preventive therapy (lovenox, coumadin, ASA)
- AE Hose and SCDs
- Activity and weight bearing as allowed by surgeon (OOB ASAP WITH ORDER)
- PROM
Respiratory Toilet
this means cleansing the airways
this is done via C-DB and IS
How to assess joint replacement skin integrity
investigate complaints of itching, burning, redness of boney prominences (especially in the heels)
What are the 3 Early Ps of Neurovascular assessment and concerns for Joint Replacement
Pain
Paresthesia
Pallor
What are the 3 late Ps of neurovascular assessment and concerns for Joint replacement
Polar
Paralysis
Pulses
What is familiar about the 3 early and late Ps of joint replacement?
they are the same as the neurovascular assessment concerns for fractures
What prosthesis dislocates most readily
the hip
What is the human response to dislocation of a hipprosthesis
increased pain, swelling, immobilization
shortening of affected leg
abnormal internal/external rotation
restricted movement
“popping sensation” of affected hip
What is the main way to prevent prosthesis dislocation
PROPER Positioning (but this depends on surgical approach)
ex: maintain abduction for some replacements and sue an abductor pillow
Position depends on…
surgical approach (anterior approach has different instructions that posterior approach)
What are some suggestions other that positioning to prevent dislocation
do not flex hip more than 90 degrees (bending over while sitting in chair)
no internal or external rotation of the affected area
Risk for hip dislocation is greatest…
3 months post op
What are some other risk factors for hip prosthesis dislocation
age
bone loss
RA
cognitive impairment
implant issues
It is important to know what depending on surgical approach?
SPECIFIC precautions straight from the surgeon for hip dislocation
Always give the patient what before discharge?
printed literature with pictures to review
Human response to dislocation of a knee prosthesis
pain or swelling after movement
obvious deformity of the knee
numbness in the foot
no pulse in the foot
less common than hip
Why can a dislocation of a knee or hip be very concerning
it can put pressure on blood vessels
What is the most important nursing intervention to prevent knee dislocation
PROPER POSITIONING:
Maintain the leg in full extension (towel roll under ankle of operative leg)
Reposition towel roll frequently to prevent peroneal nerve damage
What are some devices used in nursing intervention in order to maintain joint function after a knee replacement
- Polar Pack
- Knee Immobilizer
- CPM
Polar Pack
A bio chill cooler
it helps reduce post op swelling
it wraps around the knee and circulates cool ice water to the area to improve inflammation pain and comfort
can be used at home
Knee Immobilizer
foam wrap with a hole in the middle for the patella
rigid back keeps the knee straight and maintains stability
sometimes called POKI (post operative knee immobilizer)
CPM
Continuous Passive motion
Device you put leg in with adjustments that will slowly extend and flex the knee for the patient
they wear them at night in the hospital to improve venous return, prevent joint stiffening and help the knee
What is important to document regarding someone who had a joint replacement?
NOTE AND DOCUMENT DIFFERENCES:
- In time (time of perfusion like cap refill and baselines) on operative limb
- Differences between operative limb and non operative limb
What are some general discharge instructions regarding joint replacements?
There are some restrictions of movement
continue PT as ordered
Medication education and compliance
Education on when to contact PCP/Surgeon
What is a restriction for Hip replacements
you have to follow specific positioning guidelines (surgical approach dependent)
What are the restrictions for knee replacements
- Avoid prolonged kneeling positions
2. no running or involvement in sporting activities requiring high speed running and/or jumping until OK with MD/PT
When should a joint replacement patient call the surgeon/PCP?
Elevated temperature or fever
Drainage from the surgical site
sudden increase in pain
significant changes in range of mobility
gait instability
What sort of medication may the joint replacement patient be on past discharge?
anticoagulants to prevent blood clots
