Musculoskeletal Care Modalities

Patient education is essential for optimal outcomes. Nursing care is planned to maximize
the effectiveness of the treatment modalities and to prevent potential complications
associated with each of the interventions.

Patient In A Cast:

Cast- a rigid external immobilizing device that is molded to the contours of the
body

Specific uses of cast:

1. to immobilize a reduced fracture

2. to correct deformity

3. to apply uniform pressure to underlying soft tissue

4. to support and stabilize weakened joints

Generally:

1. cast permits mobilization of the patient while restricting movement of a body part.

2. the joints proximal and distal to the area to be immobilized are included in the cast.

Types of Cast:

1. Arm Casts:

A. Short arm cast – extends from below the elbow to the palmar crease, secured the
base of the thumb.

“thumb spica or gauntlet cast” – if the thumb is included

B. Long arm cast – extends from the upper level of the axillary fold to the proximal
palmar crease

- the elbow is usually is immobilized at the right angle

2. Leg Casts:

A. Short leg cast – extends from below the knee to the base of the toes

- the base is flexed at a right angle in a neutral position

B. Long leg cast - extends from the junction of the upper and middle third of the thigh to
the base of toes

C. Walking cast - a short or long leg cast reinforced for strength

3. Body cast – encircles the trunk

4. Spica Casts:

A. Shoulder spica cast – a body jacket that encloses the trunk and shoulder and elbow

B. Hip spica cast – encloses the trunk and a lower extremity. A double hip spica cast
include both legs

Casting Materials:

Ø Nonplaster
- fiber glass cast
- water-activated polyurethane materials which has the versatility of plaster

- lighter in weight, stronger, water resistant and durable

- consist of an open weave with cool water-activated hardeners that bond and reach the
full rigid strength in minutes

- porous and therefore diminish skin problems

- do not soften when wet (allows hydrotherapy)

- used for nondisplaced fractures with minimal swelling and for long term wear
Ø Plaster

- traditional cast

- rolls of plaster bandage are wet in cool water and applied smoothly to the body

- produces an exothermic reaction

* the nurse should inform the patient about the senstion of increasing warmth so that
the patient does not be alarmed

* the nurse should explain that the cast needs to be exposed to allow maximum
dissipation of the heat and that most casts cool after about 15 minutes

- does not have the full strength until it is dry

- while damp: the cast can be dented

* it must be handled with the palms of the hand and not allowed to rest on hard surfaces
or sharp edges

- requires 24 to 72 hours to dry completely

* when freshly applied, the cast should be exposed to circulating air to dry and should
not be covered with clothing or bed linens.

* a wet plaster cast appears dull and gray, sounds dull on percussion, feels dump and
smells musty

* a dry plaster cast is white and shiny, resonant, odorless and firm

Guidelines For Applying A Cast

Procedure
Support extremity or body part to be
casted
position and maintain part to be casted in
position indicated by the physician during
casting procedure
drape patient
wash and dry part to be casted
place knitted material (eg. Stockinette)
over part to be casted
Rationale
minimizes movement; maintains reduction
and alignment; increases comfort
facilitates casting; reduces incidence of
complications(eg. Malunion, nonunion,
contracture)
avoids undue exposure; protects other body
parts from contact with casting materials
reduces incidence of skin breakdown
protects skin from casting material

Ø apply in smooth and protects skin from pressure

nonconstrictive manner

Ø allow additional material folds over edges of cast when finishing

application, creates smooth, padded edge;
protects skin from abrasion
wrap soft , nonwoven roll padding cast protects the skin from pressure smoothly
and evenly around part

Ø use additional padding protects bony prominences

around bony prominences to protect
superficial nerves (eg. Head of fibula, protects superficial nerves
olecranon process)

apply plaster or nonplaster casting material creates smooth, solid, well-contoured

evenly on bony part cast

Ø choose appropriate width facilitates smooth application

bandage

Ø overlap preceding turn by creates smooth, solid, immobilizing

half the width of the bandage cast

Ø use continuous motion, shapes cast properly for adequate support

maintaining constant contact with bony
part

Ø use additional casting strengthens cast

material (splints) at joints and at points of
anticipated cast stress
“Finish” cast:
protects skin from abrasion
Ø Smooth edges
assures full range of adjacent joint
Ø Trim, reshape with cast
knife or cutter
Remove particles of casting materials from prevents particles from loosening and
skin sliding underneath cast
Support cast during hardening:
casting materials harden in minutes.
Ø handle hardening cast with maximum hardness of nonplaster cast
palms of hands occurs in minutes. Maximum hardness of
plaster cast occurs with drying (24-72
Ø support cast on firm soft hours) depending on environment and
surface thickness cast
 Ø do not rest cast on hard avoid denting of cast of pressure areas
surfaces

Ø avoid pressure on cast

Promote drying of cast: promotes drying

Ø leave cast uncovered and

exposed to air

Ø turn patient every 2 hours

supporting major points

Ø fans may be used to

increase air flow and speed drying

When the cast is dry, the nurse instructs the patient as follows:

1. move about as normally as possible, but avoid excessive use of the injured
extremity and avoid excessive use of the extremity and avoid walking on wet
slippery floors of sidewalks
2. perform prescribed exercises regularly, as scheduled.
3. elevate the casted extremity to heart level frequently to prevent swelling
4. do not attempt to scratch the skin under the cast
5. cushion rough edges of the cast with tape
6. keep the cast dry but do not cover it with plastic or rubber because this may cause
condensation which dampens the cast and skin.
7. report any of the following to the physician:
A. persistent pain
B. swelling that does not respond to elevation
C. changes in sensation
D. decrease ability to move exposed fingers or toes
E. changes in skin color and temperature
F. note odors around the cast, stained areas, warm spots and pressure areas
8. report a broken cast to the physician. Do not attempt to fix it yourself

Specific Cast Management Considerations:

1. Arm Casts
> The unaffected arm must assume all the upper extremity activities
> Frequent rest periods are necessary

NI:
 > to control swelling – elevate the immobilized arm
> a sling may be used when the patient ambulates
> the sling should distribute the supported weight over a large area and not on the
back of the neck to prevent pressure on cervical on spinal nerves
> frequent neurovascular checks to prevent compartment syndrome

Volkmann’s contracture - a form of compartment syndrome. Contracture of the fingers

and wrist occurs as the result of obstructed arterial blood flow to the forearm and hand

2. Leg Casts

NI:
 support the patient leg on pillow to heart level to control swelling
 applies ice packs as prescribed over the fracture site for 1 to 2 days
 taught the patient to elevate the casted leg when seated
 the patient should also assume recumbent position several times a day
with casted leg elevated to promote venous return and control swelling
 assessing the circulation by observing the color, temperature and capillary
refill of the exposed toes
 observing the patient’s ability to move the toes and by asking about the
sensations in the foot
 teach the patient how to transfer and ambulate safely with assistive
devices

NOTE: injury to the peroneal nerve as a result of pressure is a cause of footdrop (the
inability to maintain foot in a normally flexed position), consequently, the patient drags
the foot when ambulatory

3. Body or Spica Cast

Body cast – encase the trunk
Spica Cast – portion of one or two extremities
Hip spica – used for some femoral fractures and after some hip joint surgeries
Shoulder spica cast - used for some humeral neck fractures

NI:
 preparing and positioning the patient
 assisting with skin care and hygiene
 monitoring for cast syndrome
 explaining the procedure
 reassures the patient that several people will provide care during the
application, that support for the injuries area will be adequate
 administration of medications for pain relief and relaxation before the
procedure
  positioning the patient with pillows next each other, because spaces
between pillows allow the damp cast to sag, become weak and possibly
break.
 turning of the patient as a unit toward the uninjured side every 2 hours to
relive pressure
 avoid twisting the patient’s body within the cast
 encouraging the patient to assist in the repositioning, if not contraindicated
 adjusting the pillows to provide support without creating areas of pressure
 inspecting the skin around the edges of the cast frequently for signs of
irritation
 inserting clean dry plastic sheeting under the cast and over the cast edge
before elimination by the patient to protect the cast from soiling.
 Monitoring the patient in a large body cast for potential cast syndrome,
noting bowel sounds every 4-8 hours
 Teaching the family member how to care for the patient
* providing hygiene and skin care
* ensuring proper positioning
* preventing complications
* recognizing symptoms that should be reported to the health care
provider

Cast Syndrome:
- psychological and physiologic responses to confinement

Psychological Components (Claustrophobic Reaction) :

 anxiety behavioral changes
 autonomic responses : increase RR, diaphoresis, dilated pupils, increase
HR, increase BP

Physiologic Cast Syndrome (Superior Mesenteric Artery Syndrome) responses:

 decrease physical activity
 GI motility decreases
 Intestinal gases accumulate
 Intestinal pressure increase
 Ileus may occur
 Abdominal distention
 Abdominal discomfort
 Nausea, vomiting

The Patient in A Cast:

Diagnosis:
 Deficient knowledge related to the treatment regimen
 Acute pain related to the musculoskeletal disorder
  Self-care deficit: bathing/hygiene, feeding, dressing/grooming, or toileting
due to restricted mobility
 Impaired skin integrity related to lacerations and abrasions
 Risk for peripheral neuromuscular dysfunction related to physiologic
responses to injury and compression effect of cast

Major goals:
 knowledge related to the treatment regimen
 pain relief
 improved physical mobility
 achievement of maximum level of self-care
 healing of lacerations and abrasions
 maintenance of adequate neurovascular function and absence of
complications

Nursing Interventions:

> explaining the treatment regimen (promotes active participation in and Adherence
to the
treatment program)

> preparing the patient for the application of the cast by describing the anticipated sights,
sounds and sensations (the patient needs to know what to expect during application
and that the body part will be immobilized after casting)

> relieving pain

* elevating the involved part
* applying cold as prescribed
* administering usual dosages of analgesia
PAIN associated with the disease process – frequently controlled by
immobilization
PAIN due to edema (associated with trauma, surgery, or bleeding into the tissues)
- can be frequently controlled by elevation and if prescribed, intermittent
application of cold
NOTE:
Pain decreases when ulceration occurs
A patient’s unrelieved pain must be immediately reported to the physician to
avoid possible paralysis and necrosis.
The nurse must never ignore complaints of pain from the patient in a cast because
of the possibility of potential prob;lems such as impared tissue perfusion or pressure ulcer
formation

> improving mobility

- toe exercises
> promoting healing of skin abrasions
- nurse cleans the skin and treats it as prescribed
- sterile dressing are used to cover the injured skin
- while the cast is on the nurse observes the patient for systemic signs of infection,
odors from the cast and purulent drainage staining the cast
- “notify the physician if any of these occur”

> maintaining adequate neurovascular function

- swelling and edema are natural responses of the tissue to trauma and surgery
- the nurse monitors circulation, motion and sensation of the affected extremity
- encourage the patient to move fingers or toes hourly when awake to stimulate
circulation

> monitoring and managing complications:

1. compartment syndrome
- oocurs when there is increased tissue perfusion with a limited space that
compromises the circulation and the function of the tissue within the confined area
- the cast must be bivalved, to relieve the pressure
- fasciotomy may be done if pressure is not relieved and circulation is not
resolved
* the nurse closely monitors the patient’s response to conservative and surgical
management of compartment syndrome
*the nurse records neurovascular responses and promptly reports to the physician

2. pressure ulcers
Lower extremity sites most susceptible to pressure ulcers:
Heel
Malleoli
Dorsum of the foot
Head of fibula
Anterior surface of the patella
Upper extremity main pressure sites:
Medial epicondyle of the humerus
Ulnar styloid
> the nurse must monitor the patient a cast for pressure ulcer development and report
findings to the physician

3. Disuse syndrome
> the patient needs to learn to tense or contract muscles without moving the part, while in
a cast
> helps to reduce muscle atrophy and maintain muscle strength
> the nurse teaches the patient with a leg cast to “ push down” the knee and teaches the
patient in an arm cast to to make a fist
> and muscle setting exercises are important exercises in maintaining muscle essentials
for walking
 Muscle setting exercises:

Quadriceps-setting exercise
- position patient supine with leg extended
- instruct patient to push knee back onto the the mattress by contracting the
anterior thigh muscles
- encourage patient to hold the position for 5-10 seconds
- let patient to relax
- have the patient repeat the exercise 10 times each hour when awake

Gluteal-setting exercices
- position the patient supine with the legs extended , if possible
- instruct the patient to contract the muscles of the buttocks
- encourage the patient to hold the contraction for 5-10 seconds
- let the patient relax
- leave the patient repeat the exercise 10 times each hour when awake

Patient with Splints and Braces

Contoured splints of plaster or pliable thermoplastic materials:

- used for conditions that do not require rigid immobilization
- for those in which swelling may be anticipated
- for those that require special skin care
- needs to immobilize and support the body part in a functional position
- must be well padded to prevent pressure, skin abrasion and skin breakdown
- overwrapped with an elastic bandage applied in spinal fushion and with
pressure uniformly distributed so that the circulation is not restricted
Braces (orthoses)
- used to provide support, control movement
- custom fitted to various parts of the body
- may be constructed of plastic materials canvas, leather or metal

NI for patient with Splints and Braces:

1. frequently assessed the neurovascular status and skin integrity of the splinted
extremity
2. providing skin care and makes adjustments for swelling
3. helping the patient learn to apply the brace and to protect the skin from irritation
and breakdown
4. encouraging the patient to wear the brace as prescribed
5. reassures the patient that minor adjustments of the brace by the orthotist will
increase comfort and minimize problems

Patient with an External Fixator

External fixators:
- used to manage open fractures with soft tissue damage
- provide stable support for severe comminuted (crushed or splinted) fractures
while permitting active treatment of damaged to soft tissues
- facilitates patient comfort, early mobility, and active exercise of adjacent
uninvolved joints

NI:
1. preparing the patient psychologically for application of the external fixator
2. reassurance that the discomfort associated with the device is minimal and that
early mobility is anticipated promotes acceptance promotes acceptance of the
device
3. elevating the extremity to reduce swelling
4. monitoring neurovascular status of the extremity every 2-4 hours and assess each
pin site for redness, drainage, tenderness, pain and loosening of the pin
5. the nurse must be alert for potential problems caused by pressure from the device
on the skin, nerves or blood vessels and for the development of compartment
syndrome
6. carries out pin care as prescribed to prevent pin tract infection
NOTE: the nurse never adjust the clamps on the external fixator frame. It is the
physician’s responsibility to do so
7. encouraging isometric and active exercises within the limit of tissue damage.
8. the nurse helps the patient to become mobile within the prescribed weight-
bearing units (non-weight-bearing to full bearing exercise).

Ilizarov external fixator

- a special device used to correct angulation and rotational defects
- to treat nonunion (failure of bone fragments to heal)

9. teach the patient how to adjust the telescoping rods and how to perform skin care
*to report any signs of in site drainage or fever.

Patient in Traction

Traction:
- application of a pulling force to a part of the body

Uses of Traction:
1. to minimize muscle spasms
2. to reduce, align and immobilize fractures
3. to increase space between opposing surfaces
4. used primarily as a short-term intervention until other modalities such as external
or internal fixation are possible
 5. to reduce deformity
6. reduces the risk of disuse syndrome and minimizes the length of hospitalization.

Principles of Effective Traction:

1. traction must be continuous to be effective in reducing and immobilizing fractures
2. skeletal traction is never interrupted
3. weights are not removed unless intermittent traction is prescribed
4. any factor that might reduce the effective pull or alter its resultant line of pull
must be eliminated:
a. the patient must be in good alignment in the center of the bed where
traction is applied
b. ropes must be unobstructed
c. weight must hang free and not rest on the bed or floor
d. knots in the rope or the footplate must not touch the pulley or the foot of
the bed

Types of Traction

1. Straight or nursing traction

- applies the pilling force in line with the body part resting on the bed
2. Balanced suspension traction
- supports the effected extremity off the bed and allowing for some patient
movement without disruption of the line of pull
3. skin traction
4. skeletal traction – directly to the bony skeleton
5. manual traction – applied with the hands

Skin Traction
- used to control muscle spasms and to immobilize an area before surgery
- no more than 2-3.5 kg (4.5 – 8 lb) of traction can be used on an extremity
- 4.5 – 9kg (10- 20 lb) – pelvic traction

Types of Skin Traction

1. Buck’s extension traction
- applied in the lower leg
- used to provide immobility after fractures of the proximal femur before
surgical fixation
2. cervical head halter
3. pelvic belt

NI:
1. nurse inspects the skin for abrasions and circulating disturbances
 2. nurse elevates and support the extremity under the patient’s heel and knee while
another nurse places the foam boot under the leg, with the patient’s heel in the
heel of boot
3. ensuring effective traction:
- avoid wrinkling and slipping of the traction bandage
- maintain counteraction
- proper positioning – keep the leg in a neutral position
- patient should not turn from side to side to prevent bony fragments from
moving against one another

4. Monitoring and managing for potential complications:

Potential Complications:
1. skin breakdown
2. nerve pressure
3. circulating impairment

a. skin breakdown
> monitor the traction of the skin in contact with tape or foam
> remove the foam boots to inspect the skin, the ankle and the Achilles
tendon three times a day. A second nurse is needed to support the extremity
during the inspection and skin care
> palpating the area of the traction tapes daily to detect underlying
tenderness
> provides back care at least 2 hours to prevent pressure ulcers
> uses special mattress overlays to minimize the development of skin
ulcers

b. nerve pressure
> regularly assess sensation and motion
> immediately investigate any complaint of burning sensation under the
traction bandage or boot
> promptly report altered sensation or motor function

Skeletal traction

> applied directly to the bone by use of a metal pin or wire distal ton the
bone fracture, avoiding nerves, blood vessels, muscles, tendons and joints.
> used occasionally to treat fractures of the femur, the tibia and the
cervical spine
> uses 7-12 kg. (15 to 25 lbs.) to achieve therapeutic effect
> allows for some patient movement, and facilitate patient independence
and nursing care while maintaining effective traction.
> orthopedic doctors applies skeletal traction.
Nursing Interventions:

Maintaining effective traction

 the nurse checks the apparatus to see that ropes are in wheel grooves of the
pulleys, that the ropes are not frayed, that the weight hang free and the
knots in the rope are tied securely
 evaluates the patient’s position

NOTE: The nurse must never remove weights from skeletal traction unless a life-
threatening situation occurs. Removal of the weights completely defeats that purpose and
may result in injury to the patient.

> Maintaining Positioning

- Plantar flexion, Inward rotation (inversion), Outward rotation (eversion)
to avoid footdrop
- foot supports

> Preventing skin breakdown

- Nurse should protect the elbows and heels and inspect them for pressure
areas.
- Areas vulnerable to pressure:
* ischial tuberosity
* popliteal space
* Achilles tendon
* Heel
- Nurse must make a special effort to provide back care and to keep the
bed dry and free of crumbs and wrinkles
- monitoring neurovascular status
Nurse assesses the neurovascular status of the immobilized extremity at
least every hour initially and then every 4 hours
- instructing the patient to report any changes in sensation of movement
immediately
- encouraging the patient to do active flexion and extension ankle exercises and
isometric contraction of the calf muscle (calf-pumping exercise) 10 times an
hour while awake to decrease venous stasis
- elastic stockings, compression devices and anticoagulant may be prescribed

> providing pin site care

- to avoid infection to development of osteomyelitis
- keeping the area clean
NOTE: the nurse must inspect the pin site at least every 8 hours for signs of
inflammation and evidence of inspection

> promoting exercise

- pulling up on the trapeze
 - flexing and extending the feet
- ROM and weight resistance exercises for noninvolved joints
- Isometric exercises
NOTE: the nurse must promptly investigate every complaint of discomfort
expressed by the patient in traction

The Patient in Traction:

Diagnosis:

> deficient knowledge related to the treatment regimen

>anxiety related to health status and the traction device
> acute pain related to musculoskeletal disorder
> self care deficit (feeding, bathing, hygiene, dressing, grooming and/or toileting)
related to traction

Potential Complications:

> pressure ulcer

> pneumonia
>constipation
> urinary stasis and infection
>venous stasis with DVT

Nursing Intervention:

>promoting understanding of the treatment regimen

>reducing anxiety
>achieving a maximum level of comfort
>achieving a maximum self-care
>attaining maximum mobility with traction
>monitoring and managing potential complications

Patient Undergoing Orthopedic Surgery

>Joint replacement
Indication:
> Severe joint pain and disability
> Joint degeneration (osteoarthritis, rheumatoid arthritis, trauma,
congenital deformity)

> with joint replacement :

>excellent pain relief is obtained in most patients
 >return of motion and function depends on preoperative soft tissue
condition, soft tissue reactions and general muscle strength

Nursing Intervention:

>evaluate cardiovascular, respiratory, renal and hepatic function

>assessing the neurovascular status of the extremity undergoing joint replacement
>preventing infection
-any infection 2-4 weeks before planned surgery may result in postponement of
surgery
-preoperative skin preparation frequently begins 1 or 2 days before the surgery
-prophylactic antibiotics are administered perioperatively
-culture of joint during surgery

>promoting ambulation
- a day after surgery, patients with total hip and total knee replacement begin
ambulation with a walker or crutches
-specific weight- bearing limits on the prosthesis are determined by the physician
and are based on the patient’s condition
-encouraging transfer to a chair several times a day for short periods and walking
for a progressively greater distance

Total Hip Replacement:

Indication:
> severely damaged hip
> degenerative joint disease
> rheumatoid arthritis
>femoral neck fractures
>failure of previous reconstructive surgeries
> congenital hip disease
>usually the patient is 60 years of age and older and has unremitting pain or
irreversibly damaged hip joints.

Nursing Intervention

> Preventing dislocation of the hip prosthesis

-teaching the patient about positioning the leg in abduction
-keep the operative hip in abduction
> Method for avoiding displacement includes the following:
-keep the knees apart at all times
-put a pillow between the legs when sleeping
-never cross the leg when seated
-avoid bending forward when seated in a chair
-avoid bending forward to pick up an object on the floor
 -hip should not bend more than 90 degrees; use a high-sealed chair and a
raised toilet seat
-do not flex the hip to put on clothing such as parts, stockings, socks or
shoes
-affected leg should not turn inward

>Indicators of dislocation:

-increased pain at the surgical site, swelling and immobilization

-acute groin pain in affected hip or increased discomfort
-shortening of leg
-abnormal external or internal rotation
-restricted ability or inability to move leg
-reported “popping” sensation in hip

>Monitoring wound drainage

-200 to 500 ml in the first 24 hours- is expected by 48 hours post
operatively
-Decrease to 30ml less- drainage in 8 hours

>preventing DVT
-encouraging the patient to consume adequate amount of fluids
-encouraging to perform ankle and foot exercise hourly while awake
-encouraging to use elastic stockings and sequential compression dences
as prescribed

>low-dose heparin or enoxaparin (Lorenox)

>preventing infection
-prophylactic antibiotics are prescribed

>teaching the patient self-care

-report once of the daily exercise
-frequent walks, swimming, and use of a high rocking chair (excellent hip
exercise)
-sexual activities should be carried out with the patient in the dependent
position (flat on back) for 3 to 6 hrs. to avoid excessive adduction and
flexion of the new hip
-patient should avoid low chairs and sitting for longer than 45 minutes
-traveling long distance should be avoided unless frequent position
changes are possible
-other activities include:
-tub baths
-over exertion
-jogging
-lifting heavy loads
 -excessive bending and twisting

Total Knee Replacement:

Indications:
>patients who have severe pain and functional disabilities related to joint surfaces
destroyed by arthritis (osteoarthritis, rheumatoid arthritis, post-traumatic arthritis)

>bleeding into the joint

ex. Result from hemophilia

Nursing Intervention:

>Post-op:
-knee is dressed with a compression bandage
-ice may be applied to control edema and bleeding
-assessing neurovascular status of the leg
-encouraging active flexion of the foot every hour when the patient is
awake
-200-400 ml- drainage during the first 24hours after surgery and
diminishes to less than 25ml by 48 hours

CPM device
>increase circulation and range of motion of the knee joint
>10o of extension
>50o of flexion
>90o of flexion with full extension by discharge

>assisting the patient to get out of bed on every or the day after the surgery
>the physician prescribes weight-bearing limits
>progressive ambulation using assistive devices and within the prescribed weight-
bearing limits, begins in the day after surgery.

Pre-op Nursing Care of the Patient undergoing orthopedic surgery:

>relieving pain
-elevation of the edematous extremities
-ice, if prescribed
-analgesics
>monitoring adequate neurovascular function
-frequently assessing neurovascular status (color, temperature, capillary
refill, pulses, edema, pain, sensation, motion) of the extremity

>promoting health
-assessing nutritional status of hydration
 -monitoring I&O, urinalysis findings, and complaint in burning sensation
on urination
-coughing, deep breathing and use of the incentive spirometer are
practiced
-smoking should be stopped to facilitate optimal respiratory function
-providing skin care
-discussing with the patient an the family the need for assistance with
ADLS

>improving mobility
-elevating and adequately supporting edematous extremities with pillow
-encouraging movements within the limits of therapeutic immobility
-ROM exercises of involved joints performed by the patient unless
contraindicated
-performing isometric exercises to maintain the muscle need for
ambulation

>helping the patient maintains self-esteem

-assisting the patient in accepting changes in body image, diminished self-
esteem or inability to perform their roles and responsibilities
-promoting trusting relationship
-clarifying any misconceptions patients may have and helping them work
through modifications needed and adapt to alterations in physical
capacities and to reestablish positive self-esteem

Post-op Nursing Care of the Patient Undergoing Orthopedic Surgery:

>relieving pain
-pain controlled analgesic (PCA)
-epidural anesthesia
-IM and oral anesthesia are prescribed, PRN
-instructing the patient to request analgesic before the pain becomes severe
-elevating the operative extremity and application of cold compress if
prescribed
-repositioning, relaxation, distraction and guided imagery, helps in
reducing the patient’s pain

>maintaining adequate neurovascular function

-reminding the patient to perform muscle setting ankle and calf-pumping
exercises hourly while awake to enhance circulation

>maintaining health
-well balanced diet with adequate protein and vitamins (necessary for
wound healing)
 -large amounts of milk should not be given to orthopedic patients who are
in bed rest (adds calcium pool in the body and requires that kidney excrete
more calcium, increasing the risk for urinary calculi)

>monitoring for pressure ulcers

-preventing skin breakdown
-thinning
-washing and drying skin and maintaining pressure over bony
prominences

>improving physical mobility

-the orthopedic surgeon will prescribe the weight-bearing limits and
the use of protective devices
-the physical therapist tailors exercise program to the individual
patients needs

>maintaining self-esteem
-setting realistic goals

>monitoring and managing potential complications:

1. Hypovolemic Shock
a. Monitoring the patient for signs and symptoms of shock
i. Increased PR, decreases BP, urine output (UO)
<30ml/hr restlessness, change in mentation, thirst,
decreased Hgb amd hematocrit
2. Atelectasis and Pneumonia
a. Monitoring breath sounds
b. Encouraging deep breathing and coughing exercises
c. Incentive spirometry if prescribed
d. Signs of respiratory distress
i. Increased RR, productive cough, diminished
adventitious breath sounds, fever
3. Urinary retention
a. Closely monitoring of urinary output (UO)
b. Encouraging the patient to void 3 to 4 min.
c. Provide privacy during toileting
d. Intermittent catheterization- if the patient is unable to void until
patient is able to void
e. Indwelling urinary catheter- are to be used only when
absolutely recessing and should be removed as soon as possible

>infection
-prophylactic systemic antibiotics are usually prescribed
-aseptic technique is essential when doing the dressing
 -VS and signs of sepsis monitoring, UTI monitoring

>nervous stasis and DVT

-DVT- use of ankle and calf-pumping exercises, elastic compression
stockings and sequential compression devices
-adequate hydration and early mobilization
-prophylactic warfarin, adjusted dose heparin or low-molecular
weight heparin (e.g. enoxaparin sodium)

-monitoring signs for DVT and prompting reports findings to the

physician for management