UNIT 2- Management of common

surgical procedures

Contents
NURSING MANAGEMENT OF MUSCULOSKELETAL CONDIITONS REQURING
SURGERY.................................................................................................................................2
Review - Bone Injuries...........................................................................................................2
Fractures.....................................................................................................................................2
Types of Fractures..............................................................................................................3
Common causes of fractures:.............................................................................................6
Clinical Manifestations......................................................................................................6
Diagnosis............................................................................................................................8
Principles of Management:................................................................................................8
EXTERNAL FIXATION....................................................................................................13
Nursing Management Patients Fractures.........................................................................14
Complications..................................................................................................................17
Amputations.............................................................................................................................19
Levels of Amputation.......................................................................................................19
Types of Amputation........................................................................................................20
Diagnostic Tests...............................................................................................................23
Medical Management.......................................................................................................24
Nursing Management.......................................................................................................25
Joint Replacements...................................................................................................................30
Hip Replacement..................................................................................................................30
Nursing Management.......................................................................................................31
Total Knee Replacement......................................................................................................34
Laminectomy (Disc Surgery)...................................................................................................35
Nursing Management.......................................................................................................36
References........................................................................................................................38

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NURSING MANAGEMENT OF MUSCULOSKELETAL CONDIITONS
REQURING SURGERY

Review - Bone Injuries

Common Bone Injuries include

Strains - Strains are an excessive stretching of a muscle or tendon. Management involves

cold and heat applications, exercise with activity limitations, anti-inflammatory medications,
and muscle relaxants. Surgical repair may be required for a severe strain (ruptured muscle
or tendon).

Sprains - Sprains are an excessive stretching of a ligament, usually caused by a twisting

motion, such as in a fall or stepping onto an uneven surface. Sprains are characterized by
pain and swelling. Management involves rest, ice, a compression bandage, and elevation
(RICE) to reduce swelling, as well as joint support. RICE is considered a first-aid treatment,
rather than a cure for soft tissue injuries. Casting may be required for moderate sprains to
allow the tear to heal. Surgery may be necessary for severe ligament damage.

Rotator cuff injuries- The musculotendinous or rotator cuff of the shoulder can sustain a
tear, usually because of trauma. Injury is characterized by shoulder pain and the inability to
maintain abduction of the arm at the shoulder (drop arm test). Management involves
nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy, sling support, and ice-heat
applications. Surgery may be required if medical management is unsuccessful or a complete
tear is present.

Dislocation: Injury of the ligaments surrounding a joint, which leads to displacement or

separating of the articular surfaces of the joint

Subluxation: Incomplete displacement of joint surfaces when forces disrupt the soft tissue
that surrounds the joints

Fractures- See Below

Fractures
A fracture is a complete or incomplete disruption in the continuity of bone structure.

Fractures occur when the bone is subjected to stress greater than it can absorb. Fractures
may be caused by

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  direct blows
 crushing forces
 sudden twisting motions
 extreme muscle contractions

When the bone is broken, adjacent structures may are also affected, resulting in soft tissue
oedema, haemorrhage into the muscles and joints, joint dislocations, ruptured tendons,
severed nerves, and damaged blood vessels.

Types of Fractures
Fractures are classified by their complexity, location, and other features. Some fractures
may be described using more than one term because it may have the features of more than
one type (e.g., an open transverse fracture).

Common Types of Fractures

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A complete fracture involves a break across the entire cross section of the bone and is
frequently displaced (removed from its normal position).

An incomplete fracture (e.g., greenstick fracture) involves a breakthrough only part of the
cross-section of the bone.

A comminuted fracture is one that produces several bone fragments.

A closed fracture (simple fracture) is one that does not cause a break in the skin.

An open fracture (compound, or complex, fracture) is one in which the skin or mucous
membrane wound extends to the fractured bone. Open fractures are graded according to
the following criteria:

 Grade I is a clean wound less than 1 cm long

 Grade II is a larger wound without extensive soft tissue damage
 Grade III is highly contaminated, has extensive soft tissue damage, and is the most
severe.

A Transverse fracture occurs straight across the long axis of the bone

An Oblique fracture occurs at an angle that is not 90 degrees

A Spiral fracture - bone segments are pulled apart because of a twisting motion

Impacted fracture - one fragment is driven into the other, usually because of compression

Greenstick fracture - partial fracture in which only one side of the bone is broken. This is the
fracture in the young bone of children where the break is incomplete, leaving one cortex
intact.

A Pathological fracture: Fracture occurs in diseased bone (such as cancer, osteoporosis),

with no or only minimal trauma.

Stress fracture: occurring at a site in the bone subject to repeated minor stresses over a
period, examples repeatedly jumping up and down or running long distances.

Birth fracture: fracture in the new-born children due to injury during delivery.

Stellate fracture: occurs in the flat bones of the skull and in the patella, where the fracture
lines run in various directions from one point.

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Depressed fracture: occurs in the skull where a segment of bone gets depressed into the
cranium

Avulsion fracture: is an injury to the bone in a location where a tendon or ligament attaches
to the bone. When an avulsion fracture occurs, the tendon or ligament pulls off a piece of
the bone. Avulsion fractures can occur anywhere in the body, but they are more common in
a few specific locations. Often an avulsion fracture occurs when there is a sudden forceful
pull on a tendon while the bone is moving in the opposite direction. Many sports involve a
high impact, lots of twisting, and quick changes in direction. If a person experiences an
injury or impact when they are making these sorts of movements, an avulsion fracture could
occur.

Epiphyseal. An epiphyseal fracture is a fracture located between the expanded end of a long
bone (epiphysis) and the shaft of the bone

Common causes of fractures:

 Falls
 Car accidents
 Direct blow
 Repetitive forces

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  Pathology
 Gunshot

Clinical Manifestations
Pain - Palpation of a fracture that causes pain is accurately called fracture tenderness and is
a sensitive sign of a broken (fractured) bone. The pain is continuous and increases in
severity until the bone fragments are immobilized. Muscle spasms accompany a fracture
and begin within 20 minutes after the injury and result in more intense pain than the patient
reports at the time of injury. The muscle spasms can minimize further movement of the
fracture fragments or can result in further bony fragmentation or malalignment.

Loss of Function - After a fracture, the extremity cannot function properly because normal
function of the muscles depends on the integrity of the bones to which they are attached.
Pain contributes to the loss of function. In addition, abnormal movement (false motion) may
be present. This is motion at a point where there is normally no motion. False motion may
occur at an unstable fracture rather than at a joint when a fractured bone is manipulated.

Deformity - Displacement, angulation, or rotation of the fragments in a fracture of the arm

or leg causes a deformity that is detectable when the limb is compared with the uninjured
extremity. Fracture deformity may occur due to an unstable and/or displaced break in the
bone causing the bone to loss its normal anatomical alignment and shape. When a fracture
heals in an abnormal displaced or angulated shape, a malunion of the bone occurs and can
deform the limb. Fractures of the growth plate can disrupt growth and produce limb
deformity as a child grows.

Shortening - In fractures of long bones, there is actual shortening of the extremity because
of the compression of the fractured bone. Sometimes muscle spasms can cause the distal
and proximal site of the fracture to overlap, causing the extremity to shorten.

Crepitus - When the extremity is gently palpated, a crumbling sensation, called crepitus, can
be felt. It is caused by the rubbing of the bone fragments against each other.

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Localized Oedema and Ecchymosis - occur after a fracture as a result of trauma and
bleeding into the tissues. These signs may not develop for several hours after the injury or
may develop within an hour, depending on the severity of the fracture.

Loss of Pulse. If the fractured bone is interfering with blood circulation, there may be no
pulse distal to (below) the site of the fracture.

Diagnosis
Radiography of bone (Required reading- pg. 1129 to 1131 – Lab Test with Nursing
Implications)

Skeletal x-rays are used to evaluate extremity pain or discomfort due to trauma, bone
abnormalities, or fluid within a joint. Radiography of the bone can be done

 Before plaster to determine site and degree of displacement

 Post Reduction films for insurance of good alignment
 Follow up films to assess healing
 Films Before removal of plaster or fixations to confirm complete healing

Principles of Management:
Aims:

1. Safe life
2. Save the limb
3. Save the function

Emergency management

1. Efficient First Aid: This relieves the pain and prevents complications. If a fracture is
suspected, it is important to immobilize the body part before the patient is moved.
With an open fracture, the wound is covered with a sterile dressing to prevent
contamination of deeper tissues

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 2. Safe transport: This helps to minimize complications in injures to the spine, fracture
of the lower limbs, ribs etc (all fractures should be immobilized immediately ) .

Medical/Surgical Management

Reduction - Fracture reduction (setting) refers to restoration of the fracture fragments to

anatomic alignment and positioning. Either closed reduction or open reduction may be used
to reduce a fracture. The specific method selected depends on the nature of the fracture;
however, the underlying principles are the same. Usually, the physician reduces a fracture
as soon as possible to prevent loss of elasticity from the tissues through infiltration by
oedema or haemorrhage. In most cases, fracture reduction becomes more difficult as the
injury begins to heal.

 Closed Reduction is accomplished by bringing the bone fragments into anatomic

alignment through manipulation and manual traction. The extremity is held in the
aligned position while the physician applies a cast, splint, or other device. Reduction
under anaesthesia with percutaneous pinning may also be used. The immobilizing
device maintains the reduction and stabilizes the extremity for bone healing.

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 Traction (skin or skeletal) may be used until the patient is physiologically stable to
undergo surgical fixation.
 Open Reduction. Through a surgical approach, the fracture fragments are
anatomically aligned. Internal fixation devices (metallic pins, wires, screws, plates,
nails, or rods) may be used to hold the bone fragments in position until solid bone
healing occurs. The procedure is called – Open Reduction and Internal fixation
(ORIF). These devices may be attached to the sides of bone, or they may be inserted
through the bony fragments or directly into the medullary cavity of the bone.

Reduction is often a painful procedure. The patient usually receives

 A local anaesthetic or nerve block to numb the area

 A sedative to make you relaxed but not asleep (usually given through an IV, or
intravenous line)
 General anaesthesia

PERCUTANEOUS PINS

SKIN TRACTION

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 See Handout on Balanced Suspension Skeletal Traction

INTERNAL FIXATION

Internal fixation allows shorter hospital stays, enables patients to return to function earlier,
and reduces the incidence of non-union (improper healing) and malunion (healing in
improper position) of broken bones.

The implants used for internal fixation are made from stainless steel and titanium, which are
durable and strong. If a joint is to be replaced, rather than fixed, these implants can also be
made of cobalt and chrome. Implants are compatible with the body and rarely cause an
allergic reaction.

Internal Fixation Devices

Plates

Plates are like internal splints that hold the broken pieces of bone together. They are
attached to the bone with screws. Plates may be left in place after healing is complete, or
they may be removed.

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In this x-ray, broken bones in a forearm are held in position with plates and screws while
they heal.

Screws

A broken bone in this

patient’s ankle is held in
position with plates and
screws.

Screws are used for internal fixation more often than any other type of implant. Although
the screw is a simple device, there are different designs based on the type of fracture and
how the screw will be used. Screws come in different sizes for use with bones of different
sizes. Screws can be used alone to hold a fracture, as well as with plates, rods, or nails. After
the bone heals, screws may be either left in place or removed.

Nails and Rods

This x-ray shows

a healed shinbone
fracture treated
with
intramedullary
nailing.

In some fractures of the long bones the best way to hold the bone pieces together is by
inserting a rod or nail through the hollow centre of the bone that normally contains some
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marrow. Screws at each end of the rod are used to keep the fracture from shortening or
rotating and hold the rod in place until the fracture has healed. Rods and screws may be left
in the bone after healing is complete. This is the method used to treat most fractures in the
femur and tibia.

Wires/Pins
Wires are often used to pin the bones back together. They are often used to hold together
pieces of bone that are too small to be fixed with screws. In many cases, they are used in
conjunction with other forms of internal fixation, but they can be used alone to treat
fractures of small bones, such as those found in the hand or foot. Wires are usually removed
after a certain amount of time but may be left in permanently for some fractures.

This x-ray shows a child’s elbow fracture that has been put into the correct position and held
in place with two pins. The pins will be removed after healing has begun.

EXTERNAL FIXATION

An external fixator acts as a stabilizing frame to hold the broken bones in proper position. In
an external fixator, metal pins or screws are placed into the bone through small incisions
into the skin and muscle. The pins and screws are attached to a bar outside the skin.
Because pins are inserted into bone, external fixators differ from casts and splints which rely
solely on external support.

External fixation is often used to hold the bones together temporarily when the skin and
muscles have been injured. In many cases, external fixation is used as a temporary
treatment for fractures. Because they are easily applied, external fixators are often put on
when a patient has multiple injuries and is not yet ready for a longer surgery to fix the
fracture. An external fixator provides good, temporary stability until the patient is healthy
enough for the final surgery.

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Other times, an external fixator can be used as the device to stabilize the bone until healing
is complete.

This patient’s fractured thighbone has been stabilized with external fixation. The fixator will
be removed when surgery to repair the fracture can be performed safely.

There may be some inflammation or, less commonly, infection associated with the use of
external fixators. This is typically managed with wound care and/or oral antibiotics.

Nursing Management Patients Fractures

Possible Nursing Diagnosis
 Risk for Trauma: Falls
 Acute Pain
 Risk for Peripheral Neurovascular Dysfunction
 Risk for Impaired Gas Exchange
 Impaired Physical Mobility
 Impaired Skin Integrity
 Risk for Infection
 Deficient Knowledge
 Risk for Injury
 Self-Care Deficit
 Constipation

Goals/desired Outcomes
 Client will maintain stabilization and alignment of fracture(s).
 Client will display callus formation/beginning union at fracture site as appropriate.
 Client will demonstrate body mechanics that promote stability at the fracture site.
 Client will verbalize relief of pain.
 Client will display relaxed manner.

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  Client will demonstrate ability to participate in activities with minimal complaints of
discomfort.
 Client will demonstrate use of relaxation skills and diversional activities as indicated
for individual situation.
 Client will regain/maintain mobility at the highest possible level.
 Client will maintain position of function.
 Client will increase strength/function of affected and compensatory body parts.
 Client will demonstrate techniques that enable resumption of activities.
 Client will achieve timely wound healing, be free of purulent drainage or erythema,
and be afebrile.
 Client will demonstrate optimal performance of activities of daily living.

Closed Fractures

The patient with a closed fracture has no opening in the skin at the fracture site. The
fractured bones may be nondisplaced or slightly displaced, but the skin is intact.

 The nurse instructs the patient regarding the proper methods to control oedema and
pain. (e.g., elevate extremity to heart level; take analgesics as prescribed).
 Teach exercises to maintain the health of unaffected muscles and to increase the
strength of muscles needed for transferring and for using assistive devices such as
crutches, walkers, and special utensils. The patient is also taught how to use assistive
devices safely. Plans can be made to help patients modify the home environment as
needed and to ensure safety, such as removing floor rugs or anything that obstructs
walking paths throughout the house. Patient teaching includes selfcare, medication
information, monitoring for potential complications, how to protect fracture site
from undue stresses, and the need for continuing health care supervision.
 The patient is told to report pain uncontrolled by elevation and analgesics (may be
an indicator of impaired tissue perfusion or compartment syndrome).
 The nurse gives a diet to promote bone healing.
 The nurse demonstrates ability to transfer, use mobility aids and assistive devices
safely.
 Avoid excessive use of injured extremity; observe prescribed weight-bearing limits.
 Report complications promptly to physician (e.g., uncontrolled swelling and pain;
cool, pale fingers or toes; paraesthesia; paralysis; signs of local and systemic
infection; signs of venous thromboembolism; problems with immobilization device,
possible delayed complications of fractures (i.e., delayed union; nonunion; avascular

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 necrosis; reaction to internal fixation device; complex regional pain syndrome
[CRPS], formally called reflex sympathetic dystrophy syndrome; heterotopic
ossification).

Fracture healing and restoration of strength and mobility may take an average maximum
of 6 to 8 weeks, depending on the quality of the patient’s bone tissue. Patients With

Open Fractures

In an open fracture, there is a risk for osteomyelitis, tetanus, and gas gangrene. The
objectives of management are to prevent infection of the wound, soft tissue, and bone
and to promote healing of bone and soft tissue.

 Intravenous (IV) antibiotics are administered immediately upon the patient’s arrival in
the hospital along with tetanus toxoid if needed.
 Wound irrigation and debridement are initiated in the operating room as soon as
possible. The wound is cultured, and bone grafting may be performed to fill in areas of
bone defects.
 The fracture is carefully reduced and stabilized by external fixation and the wound is
usually left open for 5 to 7 days for intermittent irrigation and cleansing. If there is any
damage to blood vessels, soft tissue, muscles, nerves, or tendons, appropriate
treatment is implemented.
 With open fractures, primary wound closure is usually delayed. Heavily contaminated
wounds are left unsutured and dressed with sterile gauze to permit oedema and
wound drainage. Wound irrigation and debridement may be repeated, removing
infected and devitalized tissue, and increasing vascularity in the region. The extremity
is elevated to minimize oedema.
 It is important to assess neurovascular status frequently.
 Temperature is monitored at regular intervals and the patient is monitored for signs of
infection.
 Assess the following:
 Wounds for drainage
 Hemovac for drainage of serosanguineous fluid
 Bowel sounds
 Lung sounds
 Administer medications, such as analgesics, antibiotics, blood thinners per physician’s
orders.
 Arrange for physical and occupational therapy, as ordered.

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  Assist with weight-bearing program, if ordered.
 Encourage early mobilization, coughing, and deep breathing, as appropriate, to help
prevent complications.

In 4 to 8 weeks, bone grafting may be necessary to bridge bone defects and to stimulate
bone healing

 Activity: Exercise of the uninjured leg in bed. This helps prevent blood clots.
 Deep breathing exercises and cough 10 times each hour. This will decrease the risk
for a lung infection. An incentive spirometer can help you take deep breaths.

Complications
Hypovolemic shock resulting from haemorrhage is more frequently noted in trauma
patients with pelvic fractures and in patients with a displaced or open femoral fracture in
which the femoral artery is torn by bone fragments. Treatment of shock consists of
stabilizing the fracture to prevent further haemorrhage, restoring blood volume and
circulation, relieving the patient’s pain, providing proper immobilization, and protecting the
patient from further injury and other complications.

Fat Embolism Syndrome After fracture of long bones or pelvic bones, or crush injuries, fat
emboli may develop. Fat embolism syndrome (FES) occurs most frequently in adults
younger than 40 years of age and in men. It is also more common in patients with multiple
fractures (Stein, Yaekoub, Matta, et al., 2008). Occurs at the time of fracture; fat globules
may diffuse from the marrow into the vascular compartment. The fat globules (ie, emboli)
may occlude the small blood vessels that supply the lungs, brain, kidneys, and other organs.
The onset of symptoms is rapid, typically within 12 to 48 hours of injury (Harvey, 2006), but
may occur up to 10 days after injury (Whiteing, 2008). Clinical Manifestations include
hypoxia, tachypnoea, tachycardia, and pyrexia. The respiratory distress response includes
tachypnoea, dyspnoea, crackles, wheezes, precordial chest pain, cough, large amounts of
thick white sputum, and tachycardia. Cerebral disturbances (due to hypoxia and the lodging
of fat emboli in the brain) are manifested by mental status changes varying from headache
and mild agitation to delirium and coma. Immediate immobilization of fractures including
early surgical fixation, minimal fracture manipulation, and adequate support for fractured
bones during turning and positioning, and maintenance of fluid and electrolyte balance are
measures that may reduce the incidence of fat emboli.

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Compartment Syndrome - Compartment syndrome in an extremity is a limb-threatening
condition. It occurs when there is increased pressure within one of the body's anatomical
compartments resulting in insufficient blood supply to tissue within that space causing
ischemic necrosis if prompt, decisive intervention does not occur. The patient complains of
deep, throbbing, unrelenting pain, which continues to increase despite the administration of
opioids and seems out of proportion to the injury. A hallmark sign is pain that occurs or
intensifies with passive ROM (e.g., pain intensifies with dorsiflexion of the wrist of the
affected extremity).

An anatomic compartment is an area of the body encased by bone or fascia (eg, the fibrous
membrane that covers and separates muscles) that contains muscles, nerves, and blood
vessels. The human body has 46 anatomic compartments, and 36 of these are in the
extremities

Prompt management of acute compartment syndrome is essential. The surgeon needs to be

notified immediately if neurovascular compromise is suspected. Delay in treatment may
result in permanent nerve and muscle damage or even necrosis and amputation

Venous thromboemboli, including PE, are associated with reduced skeletal muscle
contractions and bed rest. PEs may cause death several days to weeks after injury.
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Disseminated intravascular coagulation (DIC) is a systemic disorder that results in
widespread haemorrhage and micro thrombosis with ischemia. Early manifestations of DIC
include unexpected bleeding after surgery, and bleeding from the mucous membranes,
venepuncture sites, and gastrointestinal and urinary tracts.

Delayed union occurs when healing does not occur within the expected time frame for the
location and type of fracture. Delayed union may be associated with distraction (pulling
apart) of bone fragments, systemic or local infection, poor nutrition, or comorbidity (eg,
diabetes mellitus, autoimmune disease). The healing time is prolonged; but the fracture
eventually heals (Whiteing, 2008).

Nonunion results from failure of the ends of a fractured bone to unite

Malunion results from failure of the ends of a fractured bone to unite in normal alignment.
In both instances, the patient complains of persistent discomfort and abnormal movement
at the fracture site

Amputations
An amputation is the removal of a body part, often an extremity.

Causes

Amputation of a lower extremity is often necessary because of

 Progressive peripheral vascular disease due to

 Diabetes mellitus
 Fulminating gas gangrene,
 Trauma (crushing injuries, burns, frostbite, electrical burns, explosions),
 Congenital deformities, chronic osteomyelitis, or malignant tumor.

Of all these causes, peripheral vascular disease (PVD) accounts for most amputations of
lower extremities. PVD is a blood circulation disorder that causes the blood vessels outside
of the heart and brain to narrow, block, or spasm (this topic will be discussed later).

Amputation of an upper extremity occurs less frequently than a lower extremity and is most
often necessary because of either traumatic injury or a malignant tumour.

Amputation is used to relieve symptoms, to improve function, and, most important, to save
or improve the patient’s quality of life

Levels of Amputation
The site of amputation is determined by two factors:

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  Circulation in the part - Muscle and skin perfusion are important for healing.
 Functional usefulness (i.e., meets the requirements for the use of a prosthesis). -
The objective of surgery is to conserve as much extremity length as needed to
preserve function and possibly to achieve a good prosthetic fit. Preservation of joints
is required. Below-knee amputation (BKA) is preferred to above-knee amputation
(AKA) because of the importance of the knee joint and the energy requirements for
walking. When AKAs are performed, all possible length is preserved. Amputations of
toes and portions of the foot can cause changes in gait and balance.

Types of Amputation
Partial foot amputation – this commonly involves the removal of one or more toes. This
amputation will affect walking and balance.

Ankle disarticulation – an amputation of the foot at the ankle, leaving a person still able to
move around without the need for a prosthesis

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Below knee amputations (transtibial) – an amputation of the leg below the knee that
retains the use of the knee joint

Through the knee amputations – the removal of the lower leg and knee joint. The
remaining stump is still able to bear weight as the whole femur is retained

Above knee amputation (transfemoral) - an amputation of the leg above the knee joint

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Hip disarticulation – the removal of the entire limb up to and including the femur. A
variation leaves the upper femur and hip joint for better shape/profile when sitting

Hemipelvectomy (transpelvic) – the removal of the entire limb and the partial removal of
the pelvis

Upper Limb Amputations

Partial hand amputation - amputations can include fingertips and parts of the fingers. The
thumb is the most common single digit loss. The loss of a thumb inhibits the ability to grasp,
manipulate or pick up objects grasping ability. When other fingers are amputated, the hand
can still grasp but with less precision.

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Metacarpal Amputation – this involves the removal of the entire hand with the wrist still
intact

Wrist disarticulation – this form of amputation involves the removal of the hand and the
wrist joint

Below elbow amputation (transradial) – the partial removal of the forearm below the
elbow joint

Elbow disarticulation – the amputation of the forearm at the elbow.

Above elbow amputation (transhumeral) - the removal of the arm above the elbow

Shoulder disarticulation and forequarter amputation is the removal of the entire arm
including the shoulder blade and collar bone.

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A staged amputation may be used when gangrene and infection exist. This is an amputation
that is preformed over the course of several operations, usually to control the spread of the
infection or necrosis.

A guillotine amputation - performed without closure of the skin in an urgent setting. Typical
indications include catastrophic trauma or infection control in the setting of infected
gangrene. The wound is debrided and allowed to drain. Sepsis is treated with systemic
antibiotics. In a few days

Diagnostic Tests
 Radiography of bone (Required reading- pg. 1129 to 1131 – Lab Test with Nursing
Implications)
 Doppler flow studies with duplex ultrasound. Angiography is performed if
revascularization is considered an option (Required reading- pg. 1256 to 1259 – Lab
Test with Nursing Implications)

Medical Management
The objective of treatment - nontender residual limb with healthy skin for prosthetic use.
Healing is enhanced by

 gentle handling of the residual limb

 control of residual limb oedema through rigid or soft compression dressings,
 use of aseptic technique in wound care to avoid infection.

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A closed rigid cast dressing or an elastic residual limb shrinker that covers the residual limb
may be used to provide uniform compression, to support soft tissues, to control pain, and to
prevent joint contractures.

Immediately after surgery, a sterilized residual limb sock is applied to the residual limb.
Padding is placed over pressure-sensitive areas. For the patient with a lower extremity
amputation, the cast may be equipped to attach a temporary prosthetic extension (pylon)
and an artificial foot. This rigid dressing technique is used as a means of creating a socket for
immediate postoperative prosthetic fitting. The length of the prosthesis is tailored to the
individual patient. Early minimal weight bearing on the residual limb with a rigid cast
dressing and a pylon attached produces little discomfort.

The cast is changed in about 10 to 14 days. A fever, severe pain, or a loose-fitting cast may
necessitate earlier replacement.

A removable rigid dressing may be placed over a soft dressing to control oedema, to prevent
joint flexion contracture, and to protect the residual limb from unintentional trauma during
transfer activities.

This rigid dressing is removed several days after surgery for wound inspection and is then
replaced to control oedema. The dressing also facilitates residual limb shaping.

A soft dressing with or without compression may be used if there is significant wound
drainage and frequent inspection of the residual limb is required. An immobilizing splint
may be incorporated in the dressing.

Residual limb wound hematomas are controlled with wound drainage devices to minimize
infection.

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Nursing Management
Nursing Diagnoses

Based on the assessment data, the patient’s major nursing diagnoses may include the
following:

 Acute pain related to amputation

 Risk for Infection related to surgical procedure
 Risk for Ineffective Tissue Perfusion
 Situational Low Self-Esteem
 Disturbed sensory perception: phantom limb pain related to amputation
 Impaired skin integrity related to surgical amputation
 Disturbed body image related to amputation of body part
 Grieving and/or risk for complicated grieving related to loss of body part and
resulting disability
 Self-care deficit: feeding, bathing/hygiene, dressing/ grooming, or toileting, related
to loss of extremity
 Impaired physical mobility related to loss of extremity

Some Goals/Desired Outcome

Expected patient outcomes – The Patient

 Experiences no pain
 Exhibits absence of complications of haemorrhage, infection, or skin breakdown
aUses measures to increase comfort
 Participates in self-care and rehabilitative activities
 Experiences no phantom limb pain / Reports diminished phantom sensations
 Demonstrates improved body image and effective coping
 Acknowledges change in body image
 Resumes role-related
 Focuses on future
 Uses aids and assistive devices to facilitate self-
 Avoids positions contributing to contracture development
 Demonstrates full active ROM

Pre-op Care

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  Before surgery, the nurse must evaluate the neurovascular and functional status of
the extremity through history and physical assessment. If the patient has
experienced a traumatic amputation, the nurse assesses the function and condition
of the residual limb.
 The nurse also assesses the circulatory status and function of the unaffected
extremity.
 If there is infection or gangrene, the patient may have associated enlarged lymph
nodes, fever, and purulent drainage. A culture and sensitivity test is obtained to
determine the appropriate antibiotic therapy.
 The nurse evaluates the patient’s nutritional status and develops a plan for
nutritional care - is essential to promote wound healing. Improve the patient's
nutritional status by encouraging a balanced diet high in vitamins and minerals and
with adequate protein to enhance wound healing. Maintain adequate hydration.
 Any concurrent health problems (e.g., dehydration, anaemia, cardiac insufficiency,
chronic respiratory problems, diabetes mellitus) need to be identified and treated so
that the patient is in the best possible condition to withstand the surgical procedure.
 The assess the use of corticosteroids, anticoagulants, vasoconstrictors, or
vasodilators may influence management and prolong or delay wound healing.
 The nurse assesses the patient’s psychological status. Evaluation of the patient’s
emotional reaction to amputation is important. Grief responses to permanent
alterations in body image, function, and mobility are likely.
 Follow the physician's orders for therapeutic measures used to stabilize any chronic
medical conditions such as diabetes, hypertension, or any other condition that may
interfere with surgery or rehabilitation.
 If ordered, arrange preoperative counselling with the physical therapist. If a
mobilization aid such as a walker or crutches is to be used postoperatively, it is easier
to provide instruction in the preoperative period. The physical therapist will also
inform the patient about his postoperative rehabilitation program.
 If authorized by the physician, schedule a visit from the prosthetic specialist. This
may help to alleviate some of the patient's anxieties about the fitting and wear of
prosthetic devices.

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Postoperative care

Involves routine nursing observation, pain control, positioning and exercise, stump
conditioning, and patient education. Patient education should be done in conjunction with
all nursing interventions.

 Monitor the patient's vital signs closely for changes in pulse or blood pressure that
may indicate haemorrhage under the bulky dressing. A temperature elevation may
indicate the presence of infection.
 Check the stump dressing regularly. Evidence of bloody drainage should be marked
with date and time, and excessive bleeding reported to the physician. Check the
proximal end of the stump dressing for swelling. The dressings are applied to provide
some compression of the stump, but a dressing that is too tight may cause ischemia
at the stump end.
 Observe the patient for pain. Pain medication may be required for several days post-
operatively. Some patients experience a phenomenon known as "phantom pain" or
"phantom sensation" in which they "feel" the lost limb.
 Maintain the prescribed position of the stump. Depending upon the type of
procedure used, the extremity may be in a splint, in traction, or elevated on pillows.
Proper positioning will prevent contracture of the involved muscles.
 Encourage prescribed exercises to preserve the range of motion in the affected limb
and to strengthen the remaining limbs.
 Remove and reapply the bandage. When the wound is healed, the stump must be
conditioned and shaped for the proper fitting of a prosthesis. A special bandaging
technique is used to shrink and mould the stump to a smooth, conical shape. During
the shaping process, the bandage is worn day and night. It is customarily removed
and reapplied twice daily or as ordered by the physician. Different methods are
employed in wrapping the bandage, but the objective is the same: to provide equal,
firm compression to the stump. A criss-cross or spiral pattern is used to avoid
constricting the stump and interfering with circulation.

27 | P a g e
 

 Research shows that amputation poses serious threats to the patient’s psychological
and psychosocial adjustment. Patient who views amputation as life-saving or
reconstructive may be able to accept the new self quickly. Patient with sudden
traumatic amputation or who considers amputation to be the result of a failure in
28 | P a g e
 other treatments is at greater risk for self-concept disturbances. Assessment must be
done to determine patient’s preparation for and view of amputation.
 Allow the patient to vent/express emotions, this helps the patient begin to deal with
the fact and reality of life without a limb.
 Reinforce preoperative information including type and location of amputation, type
of prosthetic fitting if appropriate (immediate, delayed), expected postoperative
course, including pain control and rehabilitation.
 Ascertain individual strengths and identify previous positive coping behaviors.
Helpful to build on strengths that are already available for the patient to use in
coping with the current situation.
 Encourage participation in ADLs. Provide opportunities to view and care for the
stump, using the moment to point out positive signs of healing. This pomotes
independence and enhances feelings of self-worth. Although integration of stump
into body image can take months or even years, looking at the stump and hearing
positive comments (made in a normal, matter-of-fact manner) can help the patient
with this acceptance.
 Encourage and provide for a visit by another amputee, especially one who is
successfully rehabilitating. A peer who has been through a similar experience serves
as a role model and can provide validity to comments and hope for recovery and a
normal future.
 Note withdrawn behaviour, negative self-talk, use of denial, or over concern with
actual and perceived changes. Identifies the stage of grief and the need for
interventions.
 Provide an open environment for the patient to discuss concerns about sexuality.
Promotes sharing of beliefs and values about the sensitive subject and identifies
misconceptions and myths that may interfere with adjustment to the situation.
 Discuss the availability of various resources: psychiatric and sexual counselling,
occupational therapist. May need assistance for these concerns to facilitate optimal
adaptation and rehabilitation.

Joint Replacements
Joint replacements are indicated for irreversibly damaged joints with loss of function and
unremitting pain, selected fractures, joint instability, and congenital hip disorders. Total
Joint Replacement can be performed on any joint except the spine. Hip and knee
replacements are the most common procedures. The prosthesis may be metallic or

29 | P a g e
polyethylene (or a combination) implanted with a methylmethacrylate cement, or it may be
a porous, coated implant that encourages bony ingrowth.

Hip Replacement

In a total hip replacement (also called total hip arthroplasty), the damaged bone and
cartilage is removed and replaced with prosthetic components.

The damaged femoral head is removed and replaced with a metal stem that is placed into
the hollow center of the femur. The femoral stem may be either cemented or "press fit" into
the bone.

A metal or ceramic ball is placed on the upper part of the stem. This ball replaces the
damaged femoral head that was removed.

The damaged cartilage surface of the socket (acetabulum) is removed and replaced with a
metal socket. Screws or cement are sometimes used to hold the socket in place.

A plastic, ceramic, or metal spacer is inserted between the new ball and the socket to allow
for a smooth gliding surface.

Recommendations for surgery are based on a patient's pain and disability, not age. Most
patients who undergo total hip replacement are age 50 to 80, but orthopaedic surgeons
evaluate patients individually.

People who benefit from hip replacement surgery often have:

 Fractured Hip
30 | P a g e
 - Intracapsular (femoral head is broken within the joint capsule). Femoral
head and neck receive decreased blood supply and heal slowly. Skin traction
is applied preoperatively to reduce the fracture and decrease muscle
spasms. Treatment includes not only a total hip replacement. An open
reduction internal fixation (ORIF) with femoral head replacement can also be
done.
- Extracapsular (fracture is outside the joint capsule). Fracture can occur at the
greater trochanter or can be an intertrochanteric fracture. Preoperative
treatment includes balanced suspension or skin traction to relieve muscle
spasms and reduce pain. Surgical treatment includes ORIF with nail plate,
screws, pins, or wires.
 Hip pain that limits everyday activities, such as walking or bending
 Hip pain that continues while resting, either day or night
 Stiffness in a hip that limits the ability to move or lift the leg
 Inadequate pain relief from anti-inflammatory drugs, physical therapy, or walking
supports

Nursing Management
 Risk for Infection
 Impaired Physical Mobility
 Risk for Peripheral Neurovascular Dysfunction
 Acute Pain
 Deficient Knowledge

Some Goals/Desired Outcome

 Client will achieve timely wound healing, be free of purulent drainage or erythema,
and be a Client will maintain a position of function, as evidenced by the absence of
contracture.
 Client will display increased strength and function of affected joint and limb.
Participate in ADLs/rehabilitation program.febrile.
 Client will maintain function as evidenced by sensation, movement within normal
limits (WNL) for the individual situation.
 Client will demonstrate adequate tissue perfusion as evidenced by palpable pulses,
brisk capillary refill, skin warm/dry, and normal color.
 Client will report relieved/controlled of pain.

31 | P a g e
  Client will appear relaxed, able to rest/sleep appropriately.
 Client will demonstrate the use of relaxation skills and diversional activities as
indicated by individual situation.
 Client will verbalize understanding of surgical procedure and prognosis.
 Client will correctly perform necessary procedures and explain the reasons for the
actions

Interventions

 Strict aseptic or clean techniques to reinforce or change dressings and when

handling drains. Instruct patient not to touch or scratch incision. Prevents
contamination and risk of wound infection, which could require removal of the
prosthesis.
 Maintain patency of drainage devices (Hemovac, Jackson Pratt) when present. Note
characteristics of wound drainage. Reduces the risk of infection by preventing the
accumulation of blood and secretions in the joint space (medium for bacterial
growth). Purulent, nonserous, odorous drainage is indicative of infection, and
continuous drainage from incision may reflect developing skin tract, which can
potentiate the infectious process.
 Assess skin/incision colour, temperature, and integrity; note the presence of
erythema or inflammation, loss of wound approximation. Provides information
about the status of the healing process and alerts staff to early signs of infection.
 Investigate reports of increased incisional pain, changes in characteristics of pain.
Deep, dull, aching pain in the operative area may indicate a developing infection in
joint.
 Monitor temperature. Note presence of chills. Although temperature elevations are
common in the early postoperative phase, elevations occurring 5 or more days
postoperatively and/or presence of chills usually requires intervention to prevent
more serious complications, e.g., sepsis, osteomyelitis, tissue necrosis, and
prosthetic failure.
 Encourage fluid intake, high-protein diet with roughage. Maintains fluid and
nutritional balance to support tissue perfusion and provide nutrients necessary for
cellular regeneration and tissue healing.

32 | P a g e
  Maintain reverse or protective isolation, if appropriate. May be done initially to
reduce contact with sources of possible infection, especially in elderly,
immunosuppressed, or diabetic patient.
 Administer antibiotics as indicated. Used prophylactically in the operating room and
first 24 hr to prevent infection.

 Assess reports of pain, noting intensity (scale of 0–10), duration, and location.
Provides information on which to base and monitor the effectiveness of
interventions.
 Maintain a proper position of operated extremity. Reduces muscle spasm and
undue tension on the new prosthesis and surrounding tissues.
 Medicate on a regular schedule and before activities. Reduces muscle tension;
improves comfort and facilitates participation.
 Investigate reports of sudden, severe joint pain with muscle spasms and changes in
joint mobility; sudden, severe chest pain with dyspnoea and restlessness. Early
recognition of developing problems, such as dislocation of the prosthesis or
pulmonary emboli (blood/fat), provides an opportunity for prompt intervention and
prevention of more serious complications.
 Administer narcotics, analgesics, and muscle relaxants as needed. Instruct and
monitor the use of PCA and/or epidural administration. Note: Use of ketorolac
(Toradol) or other NSAIDs is contraindicated when the patient is receiving
enoxaparin (Lovenox) therapy.
 Apply ice packs as indicated. Promotes vasoconstriction to reduce bleeding or tissue
oedema in the surgical area and lessens the perception of discomfort.
 Initiate and maintain extremity mobilization: ambulation, physical therapy, exercise
and/or CPM device. Increases circulation to affected muscles. Minimizes joint
stiffness; relieves muscle spasms related to disuse.
 Turn on the unoperated side using an adequate number of personnel and
maintaining operated extremity in prescribed alignment. Support position with
pillows and/or wedges. Prevents dislocation of hip prosthesis and prolonged skin or
tissue pressure, reducing the risk of tissue ischemia and/or breakdown.
 Ensure that stabilizing devices (abduction pillow, splint device) are in the correct
position and are not exerting undue pressure on the skin and underlying tissue.
Avoid the use of a pillow or knee gatch under knees. Reduces the risk of pressure on
underlying nerves or compromised circulation to extremities.
33 | P a g e
  Demonstrate and assist with transfer techniques and use of mobility aids, e.g.,
trapeze, walker.
 Determine upper body strength as appropriate. Involve in the exercise program.
 Inspect skin, observe for reddened areas. Keep linens dry and wrinkle-free. Massage
skin and bony prominences routinely. Protect operative heel, elevating the whole
length of leg with a pillow and placing the heel on water glove if burning sensation
reported.
 Perform and assist with the range of motion exercises to unaffected joints. Patient
with degenerative joint disease can quickly lose joint function during periods of
restricted activity.
 Palpate pulses on both sides. Evaluate capillary refill and skin color and temperature.
Compare with the non-operated limb. Diminished or absent pulses delayed capillary
refill time, pallor, blanching, cyanosis, and coldness of skin reflect diminished
circulation or perfusion. Comparison with unoperated limb provides clues as to
whether the neurovascular problem is localized or generalized.
 Monitor hematocrit and evaluation studies

Total Knee Replacement

A knee replacement (also called knee arthroplasty) might be more accurately termed a knee
"resurfacing" because only the surface of the bones are actually replaced.

There are four basic steps to a knee replacement procedure.

 Prepare the bone. The damaged cartilage surfaces at the ends of the femur and tibia
are removed along with a small amount of underlying bone.
 Position the metal implants. The removed cartilage and bone is replaced with metal
components that recreate the surface of the joint. These metal parts may be
cemented or "press-fit" into the bone.
 Resurface the patella. The under surface of the patella (kneecap) is cut and
resurfaced with a plastic button. Some surgeons do not resurface the patella,
depending upon the case.
 Insert a spacer. A medical-grade plastic spacer is inserted between the metal
components to create a smooth gliding surface.

34 | P a g e
There are several reasons why knee replacement surgery is recommended. People who
benefit from total knee replacement often have:

 Severe knee pain or stiffness that limits your everyday activities, including walking,
climbing stairs, and getting in and out of chairs. You may find it hard to walk more
than a few blocks without significant pain and you may need to use a cane or walker
 Moderate or severe knee pain while resting, either day or night
 Chronic knee inflammation and swelling that does not improve with rest or
medications
 Knee deformity — a bowing in or out of your knee
 Failure to substantially improve with other treatments such as anti-inflammatory
medications, cortisone injections, lubricating injections, physical therapy, or other
surgeries

More than 90% of people who have total knee replacement surgery experience a dramatic
reduction of knee pain and a significant improvement in the ability to perform common
activities of daily living. But total knee replacement will not allow the person to do more
than you could before you developed arthritis.

Nursing Management – see above for Total Hip Replacement

Laminectomy (Disc Surgery)

Laminectomy is a surgery involves removal of all or part of the lamina (posterior part of the
vertebra) to provide more space for the compressed spinal cord and/or nerve roots to
relieve pressure/pain in the presence of a herniated disc. Also known as decompression
surgery, the procedure may be done with or without fusion of vertebrae. This pressure is
35 | P a g e
commonly caused by bony overgrowths within the spinal canal called bone spurs which can
occur in people who have arthritis in their spines.

Laminectomy is generally used only when more-conservative treatments such as

medication, physical therapy or injections have failed to relieve symptoms. Laminectomy
may also be recommended if symptoms are severe or worsening dramatically.

Nursing Management

Nursing diagnosis

 Impaired Physical Mobility

 Ineffective Tissue Perfusion
 Risk for Trauma
 Ineffective Breathing Pattern
 Acute Pain
 Constipation
 Risk for Urinary Retention
 Deficient Knowledge

Interventions

 Encourage the patient to move his legs, as allowed. Patient participation promotes
independence and sense of control.
 Work closely with the physical therapy department. To ensure a consistent regimen
of leg-and-back-strengthening exercises.
 Schedule activity and procedures with rest periods. Encourage participation in ADLs
within individual limitations. Enhances healing and builds muscle strength and
endurance. Patient participation promotes independence and sense of control.
 Provide and assist with passive and active ROM exercises depending on the surgical
procedure. Strengthens abdominal muscles and flexors of spine; promotes good
body mechanics.
 Assist with activity and progressive ambulation. Until healing occurs, activity is
limited and advanced slowly according to individual tolerance.
 Assess intensity, description, location, radiation of pain, changes in sensation.
Instruct in use of rating scale (0–10).

36 | P a g e
  Encourage patient to assume a position of comfort if indicated. Use logroll for a
position change. Positioning is dictated by physical preference, type of operation
(head of the bed may be slightly elevated after cervical laminectomy). Readjustment
of position aids in relieving muscle fatigue and discomfort. Logrolling avoids tension
in the operative areas, maintains straight spinal alignment, and reduces the risk of
displacing epidural patient-controlled analgesia (PCA) when used.
 Demonstrate and encourage the use of relaxation skills like deep breathing,
visualization.
 Observe and document abdominal distension and auscultate bowel sounds.
Distension and absence of bowel sounds indicate that bowel is not functioning,
possibly because of a sudden loss of parasympathetic enervation of the bowel.
 Use fraction or child-size bedpan until allowed out of bed. Promotes comfort,
reduces muscle tension.
 Provide privacy. Promotes psychological comfort.
 Encourage early ambulation. Stimulates peristalsis, facilitating passage of flatus.
 Begin progressive diet as tolerated. Solid foods are not started until bowel sounds
have returned or flatus has been passed and the danger of ileus formation has
abated.
 Provide a rectal tube, suppositories, and enemas as needed. May be necessary to
relieve abdominal distension, promote the resumption of normal bowel habits.
 Administer laxatives, stool softeners as indicated. Softens stools, promotes normal
bowel habits, and decreases straining.
 Observe and record the amount and time of voiding. Determines whether the
bladder is being emptied and when interventions may be necessary.
 Give plenty of fluids. Maintains kidney function and prevents renal stasis.
 Maintain indwelling catheter as needed. Intermittent or continuous catheterization
may be necessary for several days postoperatively until the swelling is decreased.

References
Closed reduction of a fractured bone: MedlinePlus Medical Encyclopedia. (n.d.). Retrieved from

https://medlineplus.gov/ency/patientinstructions/000521.htm

Cluett, J. (2019, November 9). Avulsion fracture Is an Injury to the Bone Attached to a

Ligament. Retrieved from https://www.verywellhealth.com/avulsion-fracture-2549280

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Fracture Crepitus, Deformity, Motion and Tenderness. (n.d.). Retrieved from

https://www.handsurgeryresource.com/fracture-cdmt

Hinkle, J. L., Cheever, K. H., Brunner, L. S., & Suddarth, D. S. (2014). Brunner & Suddarths

textbook of medical-surgical nursing. Philadelphia: Wolters Kluwer Health, Lippincott

Williams & Wilkins.

Internal fixation devices: MedlinePlus Medical Encyclopedia Image. (n.d.). Retrieved from

https://medlineplus.gov/ency/imagepages/18023.htm

Internal Fixation for Fractures - OrthoInfo - AAOS. (n.d.). Retrieved from

https://orthoinfo.aaos.org/en/treatment/internal-fixation-for-fractures/

Total Knee Replacement - OrthoInfo - AAOS. (n.d.). Retrieved from

https://orthoinfo.aaos.org/en/treatment/total-knee-replacement/

Vera, M., & Vera, M. (2019, September 9). Nursing Care Plan Guide for Fractures: 11 Nursing

Diagnoses. Retrieved from https://nurseslabs.com/8-fracture-nursing-care-plans/10/

Vera, M., & Vera, M. (2019, June 1). 5 Total Joint (Knee, Hip) Replacement Nursing Care

Plans. Retrieved from https://nurseslabs.com/5-total-joint-knee-hip-replacement-nursing-

care-plans/4/

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