ORTHOPAEDICS ORTHOPAEDICS IN THEIN THE

OPERATING ROOMOPERATING ROOM

ObjectivesObjectives Identify nursing care measures during the Identify nursing care measures during the

pre, intra and post-operative periodspre, intra and post-operative periods

Familiarize non-surgical orthopaedic nurse Familiarize non-surgical orthopaedic nurse with this carewith this care

Pre-operative PlanningPre-operative Planning Pre-operative coordinationPre-operative coordination

Surgeons officeSurgeons office Consults as neededConsults as needed Pre-surgical testingPre-surgical testing Ambulatory/inpatientAmbulatory/inpatient

Patient educationPatient education Assess patients ability to understand/ communicateAssess patients ability to understand/ communicate Age: pediatric/geriatricAge: pediatric/geriatric Multicultural considerationsMulticultural considerations

Pre-operative PlanningPre-operative Planning Hospital/surgeon admission protocolsHospital/surgeon admission protocols

Lab work, x-rays, EKG, blood donationLab work, x-rays, EKG, blood donation History/physicalHistory/physical Advance directives, health care proxyAdvance directives, health care proxy

Adaptive devicesAdaptive devices Explain need, may need to be orderedExplain need, may need to be ordered

i.e., lumbar bracei.e., lumbar brace

Pre-operative InterviewPre-operative Interview

M. Kulesa 04

Pre-operative InterviewPre-operative Interview Lab work reviewLab work review History and physicalHistory and physical AllergiesAllergies

MedicationsMedications LatexLatex OtherOther

Site confirmation- Site confirmation- sign your sitesign your site

ConsentsConsents MedicalMedical BloodBlood SurgerySurgery OtherOther

Question # 1Question # 1You are preparing Mrs. H. for a right THA You are preparing Mrs. H. for a right THA and find that she is allergic to iodine, is an and find that she is allergic to iodine, is an agent found in many radiography dyes and agent found in many radiography dyes and antimicrobial skin preparations. She also antimicrobial skin preparations. She also notes she is allergic to:notes she is allergic to:a. kiwia. kiwib. shellfishb. shellfishc. latexc. latexd. bananasd. bananas

Pre-operative PlanningPre-operative Planning ConsentsConsents

SurgerySurgery SiteSite MedicalMedical

Discuss discharge and patient’s goalsDiscuss discharge and patient’s goals Referrals to home care, rehabReferrals to home care, rehab

Pulmonary ComplicationsPulmonary Complications

AspirationAspiration NPONPO SuctionSuction Nasogastric tubeNasogastric tube

Anesthesia-related Anesthesia-related ConsiderationsConsiderations

Pulmonary complicationsPulmonary complications Fluid volume deficitFluid volume deficit Cardiovascular complicationsCardiovascular complications Altered body temperatureAltered body temperature

Fluid Volume DeficitFluid Volume Deficit Age considerations Age considerations IV accessIV access Blood loss in suction/lap pads/drapesBlood loss in suction/lap pads/drapes Urine outputUrine output

Cardiovascular ComplicationsCardiovascular Complications History: identify risk factorsHistory: identify risk factors MonitoringMonitoring Medications: pre-op, intra-op, post-opMedications: pre-op, intra-op, post-op

Altered Body TemperatureAltered Body Temperature ConvectionConvection ConductionConduction Radiation Radiation EvaporationEvaporation

Altered Body TemperatureAltered Body Temperature Hypothermia: monitor temperatureHypothermia: monitor temperature Age, condition, open cavityAge, condition, open cavity Warming blanket, warm saline irrigationWarming blanket, warm saline irrigation

Question # 2 Question # 2 Mrs. H. is taken into the OR, where the room Mrs. H. is taken into the OR, where the room temperature is 67 degrees. The surgical temperature is 67 degrees. The surgical procedure has started. You realize that mild procedure has started. You realize that mild hypothermia appears to increase incisional hypothermia appears to increase incisional surgical site infection (SSI) risk by causing surgical site infection (SSI) risk by causing decreased delivery of oxygen to the wound space, decreased delivery of oxygen to the wound space, subsequent impairment of the function of subsequent impairment of the function of phagocytic leukocytes and:phagocytic leukocytes and:a. vasoconstriction a. vasoconstriction b. coexisting infections at a remote siteb. coexisting infections at a remote sitec. length of peri-operative stayc. length of peri-operative stayd. vasodilatationd. vasodilatation

Malignant HyperthermiaMalignant Hyperthermia TriggerTrigger

All potent inhalation agentsAll potent inhalation agents Succinylcholine Succinylcholine

Sequence of eventSequence of event Increased Cytoplasmic Free CalciumIncreased Cytoplasmic Free Calcium

• Rigidity- may or may not be presentRigidity- may or may not be present HypermetabolismHypermetabolism Cell damageCell damage

Malignant HyperthermiaMalignant Hyperthermia Compensatory mechanismsCompensatory mechanisms

Increased circulating catecholaminesIncreased circulating catecholamines Increased cardiac output - may not keep up with O2 Increased cardiac output - may not keep up with O2

demanddemand Increased ventilation - may not keep up with needIncreased ventilation - may not keep up with need

Temperature rise Temperature rise Secondary systemic manifestationsSecondary systemic manifestations

Malignant HyperthermiaMalignant Hyperthermia TreatmentTreatment

DantroleneDantrolene Iced IV saline solutionsIced IV saline solutions Ice bags around patientIce bags around patient Gastric/rectal ice lavageGastric/rectal ice lavage Lab workLab workCase presentationCase presentationHotline number: 1-800-MHHYPER (24 hr)Hotline number: 1-800-MHHYPER (24 hr)

Question # 3Question # 3 During the next case, your friend is the During the next case, your friend is the

circulating nurse and her patient is experiencing circulating nurse and her patient is experiencing an MH crisis. Her priorities will be:an MH crisis. Her priorities will be:

a. preparing the initial dose of Dantrolene, setting up a warming a. preparing the initial dose of Dantrolene, setting up a warming blanket, drawing bloodblanket, drawing blood

b. setting up iced gastric and rectal lavage, preparing the initial b. setting up iced gastric and rectal lavage, preparing the initial dose of Dantrolene, getting clean anesthesia tubing dose of Dantrolene, getting clean anesthesia tubing

c. preparing the initial dose of Dantrolene, drawing blood, setting c. preparing the initial dose of Dantrolene, drawing blood, setting up iced gastric and rectal lavage, setting up a temperature up iced gastric and rectal lavage, setting up a temperature regulating blanket and ice bagsregulating blanket and ice bags

d. leave the OR room to summon you and others for assistanced. leave the OR room to summon you and others for assistance

Intra-operative CareIntra-operative Care Infection controlInfection control SafetySafety PositioningPositioning Equipment for Equipment for

orthopaedic casesorthopaedic cases Time OutTime Out

Infection ControlInfection Control IV antibiotics/timing per JCAHO guidelinesIV antibiotics/timing per JCAHO guidelines Traffic controlTraffic control Surgical techniqueSurgical technique Clip and prep (no shaving)Clip and prep (no shaving) Personal protection devicesPersonal protection devices Implant = “foreign body”Implant = “foreign body”

SafetySafety IdentificationIdentification Safety strapsSafety straps Counts Counts Electrosurgical Electrosurgical

unit/grounding padunit/grounding pad Sequential Sequential

stockingsstockings Fire and safetyFire and safety

Principles of PositioningPrinciples of Positioning Surgeon preferenceSurgeon preference Maintain adequate airwayMaintain adequate airway Pad all bony prominencesPad all bony prominences Maintain correct body alignmentMaintain correct body alignment Safety strapsSafety straps Routine maintenance of positioning Routine maintenance of positioning

devicesdevices

PositionsPositions SupineSupine ProneProne LateralLateral Semi-fowlersSemi-fowlers ConsiderationsConsiderations

Age, length of surgery, body weight, Age, length of surgery, body weight, nutritional status, medications, chronic nutritional status, medications, chronic disease states disease states

SupineSupine Pressure pointsPressure points Length of surgeryLength of surgery

Prone- Wilson FrameProne- Wilson Frame

ProneProne

LateralLateral Pressure pointsPressure points StabilityStability Lateral positionersLateral positioners Axillary rollAxillary roll

Semi-FowlersSemi-Fowlers Pressure pointsPressure points Stability, protectionStability, protection

Head and neckHead and neck Non-operative armNon-operative arm Legs/feetLegs/feet

Other Positioning IssuesOther Positioning Issues Sheering Sheering FrictionFriction PressurePressure

Question # 4Question # 4Mr. J. is taken to the OR to undergo a Mr. J. is taken to the OR to undergo a cervical spine fusion. During positioning, cervical spine fusion. During positioning, care is taken to avoid damage to the care is taken to avoid damage to the brachial plexus nerve group by avoiding brachial plexus nerve group by avoiding abduction greater than:abduction greater than: a. 30 degreesa. 30 degrees b. 45 degreesb. 45 degrees c. 65 degreesc. 65 degrees d. 90 degreesd. 90 degrees

Question # 5 Question # 5 He is placed in the sitting position; areas He is placed in the sitting position; areas especially susceptible to pressure injuries especially susceptible to pressure injuries include his:include his: a. clavicle, brachial plexus and illiuma. clavicle, brachial plexus and illium b. olecranon, greater trochanter and illiumb. olecranon, greater trochanter and illium c. scapulae, ischial tuberosities and c. scapulae, ischial tuberosities and

calcaneouscalcaneous d. thoracic vertebrae, sacrum and d. thoracic vertebrae, sacrum and

malleolusmalleolus

Documentation Documentation Surgical procedureSurgical procedure ImplantsImplants

Prosthesis, bone, etc.Prosthesis, bone, etc. Counts Counts Drains, etc.Drains, etc.

Equipment for Orthopaedic CasesEquipment for Orthopaedic Cases

TourniquetTourniquet CuffCuff SettingsSettings

CastingCasting MicroscopeMicroscope Instruments, saws, drillsInstruments, saws, drills Table, positioning devicesTable, positioning devices Care and maintenanceCare and maintenance

Question # 6Question # 6

A tourniquet is applied to Mr. T’s left leg A tourniquet is applied to Mr. T’s left leg during TKA. You know that three concepts during TKA. You know that three concepts that define a tourniquet are:that define a tourniquet are: a. compression, circulation, period of timea. compression, circulation, period of time b. constriction, circulation, bloodless fieldb. constriction, circulation, bloodless field c. circumferential pressure, period of c. circumferential pressure, period of

time, extremitytime, extremity d. control, circumferential pressure, d. control, circumferential pressure,

bloodless fieldbloodless field

Post-operative EvaluationPost-operative Evaluation Skin/neuro assessmentSkin/neuro assessment DrainsDrains DressingsDressings Post-op devicesPost-op devices

ShoulderShoulder KneeKnee Abduction pillowAbduction pillow BraceBrace Halo Halo

PACU: Post Anesthesia PACU: Post Anesthesia Care UnitCare Unit

Airway managementAirway management Aspiration precautionsAspiration precautions Vital signsVital signs Temperature managementTemperature management Pain controlPain control

PACU: Post Anesthesia PACU: Post Anesthesia Care UnitCare Unit

Nausea managementNausea management Fluid & electrolyte managementFluid & electrolyte management Urinary retentionUrinary retention Procedure specificProcedure specific

Chest tubesChest tubes External fixatorExternal fixator Cast/limb careCast/limb care

Question 7:Question 7:

In the PACU, you notice that Mr. T. is showing signs of stridor and appears panic stricken. This is most likely:

a. Bronchospasm

b. Fat emboli

c. An allergic reaction

d. Laryngospasm

Post-operative PhasePost-operative Phase Criteria for discharge

Activity level i.e.: NWB, TT, PWB, FWB Medications i.e.: antibiotics, pain, usual meds Diet Incision care, staple removal Referrals PT, OT, Home Care Return to surgeon

Post-operative PhasePost-operative Phase InpatientInpatient

Report to the floorReport to the floor Continuation of observationContinuation of observation

OutpatientOutpatient Reinforce pre-operative teachingReinforce pre-operative teaching

Operative OrthopaedicsOperative Orthopaedics

Preoperative planningPreoperative planning

Potential complicationsPotential complications

Infection controlInfection control

SafetySafety

positioningpositioning

Answer # 1Answer # 1

b. shellfish

Rationale: Iodine is an agent found in many radiography dues and antimicrobial skin preparations. Patients allergic to iodine may also be allergic to shellfish

Answer # 2 Answer # 2

a. vasoconstriction

Rationale: vasoconstriction decreases blood flow and thus decreases the delivery of oxygen to the wound space

Answer # 3 Answer # 3

c. preparing the initial dose of Dantrolene, c. preparing the initial dose of Dantrolene, drawing blood, setting up iced gastric and drawing blood, setting up iced gastric and rectal lavage, setting up a temperature rectal lavage, setting up a temperature regulating blanket and ice bagsregulating blanket and ice bags

Rationale:Rationale: Initiating the medication to Initiating the medication to counteract the MH crisis is the first priority, counteract the MH crisis is the first priority, followed by other measures to decrease followed by other measures to decrease hyperthermiahyperthermia

Answer # 4Answer # 4

d. 90 degreesd. 90 degrees

Rationale:Rationale: 90 degrees or greater abduction will stretch the 90 degrees or greater abduction will stretch the

brachial plexus nerve group leading to wrist brachial plexus nerve group leading to wrist dropdrop

Answer # 5 Answer # 5

c. scapulae, ischial tuberosities and c. scapulae, ischial tuberosities and calcaneouscalcaneous

Rationale:Rationale: These are the pressure points These are the pressure points when the patient is in the sitting positionwhen the patient is in the sitting position

Answer # 6Answer # 6

a. compression, circulation, period of timea. compression, circulation, period of time

Rationale:Rationale: To avoid neurovascular To avoid neurovascular impairment, the amount of tourniquet impairment, the amount of tourniquet compression, circulation and time are key compression, circulation and time are key factors that need to be considered during factors that need to be considered during surgerysurgery

Answer #7Answer #7

d. laryngospasmd. laryngospasm

Rationale:Rationale: this condition may be due to pain this condition may be due to pain or secretions, and results in sudden vocal or secretions, and results in sudden vocal cord closure and feelings of paniccord closure and feelings of panic