Orthopaedic Nursing
An orthopaedic nurse is a specialty nurse trained in orthopaedic
problems such as fractures and is an expert in neurovascular
status monitoring, traction, casting and continuous motion
therapy. More than 350,000 hip fractures occur in the United
States every year (Watters, 2006). Nurses' skills, interventions,
attitudes, communication and continuity of care constitute the
essential components of orthopaedic nurse care .
Patient
satisfaction measures assist nurses in the evaluation of
effectiveness of their practice and assist the process of
improvement of established orthopaedic practice methods (Wu
et.al, 2000). Technical advances in the field of orthopaedics like
Radiography, Computed Tomography, and Magnetic Resonance
Imaging have not only led to improved diagnosis and
evaluation of orthopaedic diagnosis but also innovative
treatment options like Vertebroplasty, Bupivacaine Infiltration,
Total Disc Replacement Arthroplasty, Unicompartmental Knee
Arthroplasty, The Titanium Rib, Toe-to-Hand Transplantation
Surgery, The Scandinavian Total Ankle Replacement (STAR),
Mechanical Devices for Lateral Transfers and Kyphoplasty.
Thus, orthopaedic nurse should have the essential training and
skills in the latest innovations in the field.
Nursing Skills and Interventions
Nursing intervention begins with the assessment of the patient
after a traumatic event, determination of the mechanism of
injury, assessment of the injured or fracture site, confirmation
of the exact injury, identification of potential complications, and
assessment of the patient's social and professional status to
identify potential problems that might affect treatment and challenge and are important as a cause for morbidity and
mortality (Kobziff, 2006).Fractures of the forearm in an adult
may involve the ulna, the radius, or both and it is better to xray
the entire upper extremity in most upper-limb injuries
(Altizer, 2003).
Spinal cord injuries are devastating events, and
they are particularly tragic when they affect children or
adolescents (Vogel et.al, 2004).Nurses should provide
interventions preoperatively, intraoperatively, and
postoperatively to avoid potential complications (Harvey,
2005).Preoperative interventions include a thorough
assessment of the patient history and screen for hypertension
or other problems in order to avoid possible intraoperative and
postoperative complications. Intraoperative interventions
include insertion of a urinary catheter, prophylactic
administration of antibiotics and inflammation of tourniquets.
Postoperative care is equally important at the surgery itself. An
effective postoperative nurse care can decrease the patient's
pain and decrease vasospasm in replantation surgeries (
Michalko and Bentz, 2002 ).
Compartment syndrome is a
common complication in fracture, sprain, or orthopaedic
surgery. Early identification of the symptoms can prevent the
loss of a limb (Altizer, 2004).Pulse oximetry provides one of the
best objective ways to monitor arterial blood flow. Patient
monitoring is done hourly during the first 24 hours and then
every 2 hours during the second 24-hour period after a
surgery. This intense monitoring frequently is done in the ICU.
Antibiotic chemotherapy is usually recommended for 5 days,
but is always determined by the wound intensity. Bed rest
minimizes vasospasm. Intake of chocolate, caffeine, and
nicotine in any form is strictly prohibited in the postoperative
period to avoid induction of vasospasm that could impede
blood flow. Patient-controlled analgesia (PCA) has been
recommended for pain relief with relatively few side effects.
But, IV PCA has been shown to cause respiratory depression
(Brubakken and Shippee, 2004). Continuous low-dose
infiltration of a local anesthetic into the postoperative wound
incision for a 48-hour period has been shown to diminish the
need for narcotics or other analgesics to reduce postoperative
pain (Pulido et.al, 2002). The use of a mechanical device for
the lateral transfer has been shown to give comfort to the
patients (Pellino et.al, 2006).
Though most patients treated
with casts do not have any significant orthopaedic problems, it
is important to emphasize cast care instructions to young
patients and their parents to alleviate itching, such as blowing
cool air under the cast to reduce the risk of serious infectious
complications (Carmichael, 2006).Tracking outcomes of
interventions provides a systematic method of monitoring
effectiveness and efficiency. The nurse should evaluate and
choose appropriate measurement tools, and understand the
clinical meaning of measurements to successfully employ these
instruments (Resnik and Dobrykowski, 2005).
Nurse attitudes
Attitudes of nurses caring for orthopaedic patients affect the
quality of care provided. A recent research on positive and
negative attitudes of such nurses has shown that knowledge
deficits shape most of the negative attitudes (Mary et.al,
2000). The cultural background of nurses also has an influence
on the attitudes and there are reports of nurse's disagreements
with patient's self-report, especially in pain assessment (Harper
et.al, 2007).
Communication
Patient education is a critical component of orthopaedic nursing
that requires nurse communication to maintain optimum
independence and quality of life (Oldaker, 1992).
A randomized controlled trial study with sixty six young
adolescents to evaluate the effects of coping instruction and
concrete-objective information on adolescents' postoperative
pain and focus on potential applications of these interventions
for orthopaedic nursing practice has shown that nurse
interventions that direct adolescent patients' attention to
learning coping strategies reduce the postoperative pain in
such patients (LaMontagne et.al, 2003). The gender, age and
health condition also influences the communication. For
example, it is difficult to communicate to or assess an old
patient whose 'hearing capacity would be at a reasonably low
level or whose perception has diminished due to aging. Nonverbal
verbal communications do occur in nurse-patient
communication. (Wilma, 1999).
Continuity of care
It may take several months of intense physical or occupational
therapy for the patients to regain optimal function, especially
after complicated orthopaedic surgical procedures like toe-tohand
transplants. In such surgical procedures progressive joint
mobilization, usually begins on the seventh to tenth
postoperative day and Progressive resistive exercises are
begun 4 weeks later to increase strength.
A recent conference
convened to explore the strengths and weakness of the current
continuum of care, develop recommendations for addressing
problems in the system, and devise strategies for implementing
the recommendations has brought out recommendations in four
broad categories: Communication/Continuum of Care,
Reimbursement, Prevention/Education, and Research
Initiatives. A study examining the risk factors for falls and the
effectiveness of physical therapy interventions to decrease the
risk of falls in a community dwelling population has shown that
an appropriately designed physical therapy intervention in the
form of an exercise program can decrease the risk for falls
among a community-dwelling aging population identified as
having an increased risk of falls (Robinson et.al, 2002).
Massage therapy has been shown to be safe and effective for
orthopaedic patients with low back problems and potentially
beneficial for patients with other orthopaedic problems.
Massage therapy appears to be safe, to have high patient
satisfaction, and to reduce pain and dysfunction (Dryden et.al,
2004).
Conclusion
There is a critical need to incorporate the use of latest
technological innovations like guided imagery (Antall and
Kresevic, 2004) and bone morphogenetic proteins (Boden,
2005) into all nursing curricula to improve the skills,
interventions, communication and attitudes of orthopaedic
nurses so that nurses can develop the expertise to act as
patient educators and advocates in the use of these
interventions. Early identification of the care problem is vital in
orthopaedic nursing.
References
-- Carmichael, Kelly D.; Goucher, Nicholas R. (2006).
Orthopaedic Essentials. Orthopaedic Nursing. 25(2):137-
139.
-- Carol V. Harvey (2005). Spinal Surgery Patient Care.
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-- Cindy Pfeiff (2006). The Scandinavian Total Ankle
Replacement (STAR). Orthopaedic Nursing.25 (1):30 -
33.
-- Courtney, Mary, Tong, Shilu, Walsh, Anne (2000).
Acute-care nurses' attitudes towards older patients: A
literature review. International Journal of Nursing
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-- Elwin R. Tilson et .al (2006). An Overview of
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Resonance Imaging in the Diagnosis of Lumbar Spine
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-- Harper, Phil, Ersser, Steven and Gobbi, Mary (2007)
How military nurses rationalize their postoperative pain
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-- Heather Chong (2004). Innovations: The Titanium Rib:
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-- Jim Hanna et.al (2007). Kyphoplasty: A Treatment for
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-- Julie Hummer-Bellmyer (2002). The Collaborative Role
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-- LaMontagne, Lynda; Hepworth, Joseph T.; Salisbury,
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-- Linda Altizer (2003). Forearm and Humeral Fractures.
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-- Lydia Kobziff (2006). Traumatic Pelvic Fractures.
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-- Mary E. Hagle et.al (2004). Respiratory Depression in
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-- Mary Faut Rodts (2004). Total Disc Replacement
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-- Maryann Godshall (2006). Toe-to-Hand Transplantation
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