Nursing Interventions
RELIEVING PAIN
Physical, pharmacologic, and psychological strategies to control pain are useful in the preoperative period. Specific strategies are tailored to the individual patient. Discomfort is decreased with immobilization of a fractured bone or an injured, inflamed joint. Elevation of an edematous extremity promotes venous return and reduces associated discomfort. Ice, if prescribed, relieves swelling and directly reduces discomfort by diminishing nerve stimulation. Analgesics are frequently prescribed to control the acute pain of musculoskeletal injury and associated muscle spasm. During the immediate preoperative period, the nurse needs to discuss and coordinate the administration of analgesic medications with the anesthesiologist and surgeon. Alternative methods of pain control (eg, distraction, focusing, guided imagery, quiet environment, backrubs) may be used to decrease pain perception.
MAINTAINING ADEQUATE NEUROVASCULAR FUNCTION
Trauma, edema, or immobilization devices may interrupt tissue perfusion. The nurse must frequently assess neurovascular status (ie, color, temperature, capillary refill, pulses, edema, pain, sensation, motion) of the extremity and document the findings. If circulation is compromised, the nurse institutes measures to restore adequate circulation. These include promptly notifying the physician, elevating the extremity, and releasing constricting wraps or casts as prescribed.
PROMOTING HEALTH
The nurse assists the patient in activities that promote health during the perioperative period. The nurse assesses nutritional status and hydration. The preoperative fasting regimen is usually tolerated well. If the patient has diabetes, is elderly and frail, or is the victim of multiple trauma, special fluid and nutritional provisions may be necessary. The nurse monitors fluid intake, urinary output, urinalysis findings, and complaints of burning on urination. At times, patients may limit their fluid intake to minimize the use of a bedpan. A small fracture pan may be more comfortable for the patient to use.
An indwelling catheter should be used only when absolutely necessary to minimize the risk of urinary tract infection. Urinary tract infection must be addressed before surgery. Coughing, deep breathing, and use of the incentive spirometer are practiced preoperatively for improved respiratory function during the postoperative period. Preoperative teaching facilitates postoperative compliance. Smoking should be stopped during the preoperative period to facilitate optimal respiratory function. The nurse provides skin care, paying special attention to pressure points. It is important to institute the use of pressure-reducing surfaces (i.e., special mattresses) before surgery for patients at high risk for skin breakdown.
To minimize the risk for infection, the nurse meticulously and gently cleans the skin with soap and water on the day before surgery. If the surgery is elective, the orthopedic surgeon may instruct the patient to use a germicidal soap for several days before hospitalization. The nurse discusses with the patient and the family the need for assistance with ADLs and the therapeutic regimen during convalescence so that adequate support is available when the patient is discharged. Modification of the home environment may be necessary to accommodate the altered mobility of the patient after surgery. Referral to the social worker and the case manager may be needed to ensure a smooth transition to home care.
IMPROVING MOBILITY
Preoperatively, the patient’s mobility may be impaired by pain, swelling, and immobilizing devices (eg, splints, casts, traction). The nurse should elevate and adequately support edematous extremities with pillows. It is important to control pain before an injured part is moved by administering medication in time for it to take effect and by supporting the injured part when it is moved. The nurse encourages movement within the limits of therapeutic immobility. The patient should perform active range-of-motion exercises of uninvolved joints, and, unless contraindicated, the nurse teaches gluteal-setting and quadriceps-setting isometric exercises to maintain the muscles needed for ambulation. The patient who will be using assistive devices postoperatively may exercise to strengthen the upper extremities and shoulders. If the use of assistive devices (eg, crutches, walker, wheelchair) is anticipated, the nurse encourages the patient to practice with them preoperatively to facilitate their safe use and to promote earlier independent mobility.
HELPING THE PATIENT MAINTAIN SELF-ESTEEM
Preoperatively, orthopedic patients may need assistance in accepting changes in body image, diminished self-esteem, or inability to perform their roles and responsibilities. The degree of assistance required in this area varies greatly, depending on the events preceding hospitalization, the surgery and rehabilitation planned, and the temporary or permanent nature of the problems. The nurse promotes a trusting relationship for patients to express concerns and anxieties and helps them examine their feelings about changes in self-concept. The nurse clarifies any misconceptions patients may have and helps them work through modifications needed to adapt to alterations in physical capacity and to reestablish positive self-esteem.
Evaluation
EXPECTED PATIENT OUTCOMES
Expected patient outcomes may include:
1. Reports relief of pain
a. Uses multiple approaches to reduce pain
b. States that medication is effective in relieving pain
c. Moves with increasing comfort
2. Exhibits adequate neurovascular function
a. Exhibits normal skin color
b. Has warm skin
c. Has normal capillary refill response
d. Reports normal sensation and demonstrates joint motion
e. Demonstrates reduced swelling
3. Promotes health
a. Eats balanced diet appropriate to meet nutritional needs
b. Maintains adequate hydration
c. Abstains from smoking
d. Practices respiratory exercises
e. Repositions self to relieve skin pressure
f. Engages in strengthening and preventive exercises
g. Plans for assistance during convalescence at home
4. Maximizes mobility within the therapeutic limits
a. Requests assistance when moving
b. Elevates edematous extremity after transfer
c. Uses immobilizing devices and assistive devices as prescribed
5. Expresses positive self-esteem
a. Acknowledges temporary or permanent changes in body image
b. Discusses role performance changes
c. Participates in decisions about care