การพยาบาลผู้ป่วย Orthopedic

4/3/2020

101

Treatment

» Surgery

⋄ Discectomy/
Diskectomy

⋄ Laminectomy

101

102

Nursing care

» Low back pain related to log-rolling
disorders of the spine
structure.

» Activity Intolerance related
to abnormal of bone & joint
structure.

102

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4/3/2020

Nursing care of Orthopedic patients

: Fracture & Treatment

Asst. Prof. Dr. Saranya Chularee o Fracture
Institute of nursing, o Cast
Suranaree University of Technology o Traction
o Fixation (internal & External)
o Amputation
o Walk with orthopedic devices

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104

Fracture of bone

Common type of fracture

» Transverse fracture
» Oblique fracture
» Comminuted fracture
» Impacted fracture
» Spiral fracture
» Greenstick fracture

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Pathology

Stages of normal fracture Potential complications of fracture include:
healing include:
» Life-threatening systemic fat embolus, which most
» Inflammation commonly develops within 24 to 72 hours after
» Cellular proliferation fracture.
» Callus formation
» Callus ossification » Compartment syndrome, which is a condition
» Mature one remodeling involving increased pressure and constriction of
nerves and vessels within an atomic compartment.

» Nonunion of the fracture side

» Arterial damage during treatment

» Infection and possibly sepsis

» Hemorrhage, possibly leading to shock Stages

105 106

Investigate 53

» HX: injury
» PE:

⋄ Inspection: wound, ecchymosis, deformity,
movement

⋄ Palpation: Rang of motion (ROM), stability;
adduction, flexion, extension, external
rotation, internal rotation, circumduction

» Lab:
⋄ CBC, UA
⋄ X-ray: AP-Lateral

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107

Treatment

» Upper extremities
» Lower extremities

107 108

Upper extremities 54

» Fracture neck of humerus
⋄ u-slab

» Fracture shaft of humerus
⋄ hanging cast 4 wk, complication: radial n. palsy -
wrist drop.

» Fracture of humeral supracondylar
⋄ Closed reduction (CF) & long arm cast 3 wk
⋄ If can’t CF → Open Reduction & Internal Fixation
(ORIF) c plate & screw. complication: medial n.
palsy – numbness.

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Upper extremities 4/3/2020

» Fracture of humeral condylar 109
⋄ ORIF c plate & screw c long arm slab
110
» Fracture of shaft of radius
⋄ CF c Long arm cast (LAC) 55
⋄ If can’t CF → ORIF c P&S

» Colles’ fracture (Fracture radius & dorsal
dislocated)
⋄ CF c short arm cast (SAC)

» Smith’s fracture (Reverse colles’ fracture)
⋄ ORIF c Buttress plate

109

Upper extremities

» Galeazzi fracture (Fracture of distal radius c
dislocated distal radioulnar joint (DRUJ)
⋄ CFc Long arm cast (LAC) /
⋄ If can’t CF → ORIF c P&S

» Montaggia fracture (Fracture of the proximal
ulnar c dislocation of radial head)
⋄ CFc LAC /
⋄ If can’t CF → ORIF c P&S c LAC

» Chauffeur’s fracture (Fracture of the radial
styloid process)
⋄ SAC

110

Upper extremities 4/3/2020

» Fracture both bone of forearm 111
⋄ ORIF c P & S
112
» Fracture of the carpal or carpus
⋄ SAC 56

» Fracture of tibia
⋄ long leg cast → patellar tendon
bearing cast c partial weight bearing
/ traction
⋄ ORIF c P & S / intramedllary nail
⋄ External fixation

111

Lower extremities

» Fracture of the femur
⋄ Stress fracture และ Impacted fracture
⋄ Skeletal traction / Hip spica cast /
⋄ ORIFc Jewett nail /Angle blade plate
⋄ Comminuted fx
⋄ Moore’s endoprosthesis

» Fracture Trochanteric
⋄ Traction c slight abduction /
⋄ ORIF c Jewett nail, Angle blade plate /
condylar blade plate

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Lower extremities 113
114
» Fracture shaft of femur
⋄ Skeletal traction / 57
⋄ ORIFc internal fixation

» Supracondylar fracture
⋄ Skeletal traction /
⋄ ORIFc internal fixation

» Fracture of patella
⋄ Cylinder cast /
⋄ ORIFc wiring Cylinder cast

113

Lower extremities

» Fracture of fibular
⋄ CF c LLC c non weight baring /
⋄ ORIFc P & S /
⋄ Skeletal traction c Bohler Braun frame →
ORIFc P & S c SLC

» Fracture of the ankle
⋄ Joan’s bandage c SLC/
⋄ ORIFc P & S /
⋄ triple arthrodesisc SLC

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115

Open fracture

» A fracture is ‘open’ when there is a
direct communication between the
fracture site and the external
environment.

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Classification of Open Fractures

The Gustilo-Anderson classification can be used to classify open
fractures (OF)
» Type 1: <1cm wound and clean
» Type 2: 1-10cm wound and clean
» Type 3

⋄ Type 3A: >10cm wound and high-energy, but with adequate
soft tissue coverage: managed by orthopedics alone

⋄ Type 3B: >10cm wound and high-energy, but with inadequate
soft tissue coverage: requires plastics input

⋄ Type 3C: All injuries with vascular injury: requires vascular input

116

58

Treatment 4/3/2020

» Antibiotic (ATB) 117
» Tetanus toxin (TT) + Tetanus anti-toxoid (TAT)
» Irrigate + Debridement 59
» Cast / Traction / External fixation
» Amputation
» Primary closure
» Re - Debridement

117

Nursing care

» Prevent infection

⋄ Cover any breaks in the skin with clean or sterile
dressing.

» Provide care during client transfer.

⋄ Immobilize a fractured extremity with splint in the
position of the deformity before moving the client

⋄ Avoid strengthening the injured body part if a joint is
involved.

⋄ Support the affected body part above and below
fracture site when moving the client.

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4/3/2020

Nursing care of Orthopedic patients

: Fracture & Treatment

Asst. Prof. Dr. Saranya Chularee o Fracture
Institute of nursing, o Cast
Suranaree University of Technology o Traction
o Fixation (internal & External)
o Amputation
o Walk with orthopedic devices

119

120

Nursing care with Cast or
splint immobilization

Advantage of cast

» Temporarily resting the broken bone
» To reduce pain and help heal easily
» To prevent disability
» Move faster
» Helps that organ perform its functions better

120

60

Types of cast 4/3/2020

Type Uses for 121

Short arm cast Forearm or wrist 122
(SAC) fractures.
61
Long arm cast Upper arm, elbow, or
(LAC) forearm fractures.

Arm cylinder cast To hold the elbow muscles
(ACC) and tendons in place after
a dislocation or surgery.

Hanging cast Fracture humerus

121

Types of cast

Type Uses for

Short leg cast (SLC) Lower leg fractures, severe
ankle sprains and strains, or
Long leg cast (LLC) fractures.

Femur or fibular fractures.

Leg cylinder cast Knee, or lower leg
(LCC)
fractures, knee dislocations,

or after surgery on the leg
or knee area.

Patellar tendon Fracture Tibia
baring (PTB) cast

122

Types of cast 4/3/2020

Type Uses for 123

Body cast or - Fracture or dislocate of 124
body jacket or T7-L2
Plaster jacket 62
Minerva cast - Fracture or dislocate of
C1-T6
Calot cast - Fracture or dislocate of
neck & body

123

Types of cast

Type Uses for

Figure of 8 cast Fracture or dislocation of
clavicle

Hip spica cast

1. Unilateral hip

spica cast Thigh fractures.

2. One and one-

half hip spica cast

3. Bilateral long

leg hip spica cast Pelvis, hip, or thigh

fractures.

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Nursing care

» Prevent & monitor » Compartment syndrome
complications:
➢ Compartment syndrome » a condition in which the perfusion
➢ Venous thromboembolism pressure falls below the tissue
➢ Pressure sore/ pressure pressure in a closed anatomic
injury space, with subsequent
compromise of circulation and
function of the tissues.

Ekwall,A., Carlberg, E., Palmberg, G. & Sloberg, R. (2018). An audit of complications of fiberglass cast and hybrid cast for fractures of the foot,
ankle and forearm in a Swedish emergency department. International Journal of Orthopedic Trauma Nursing. 21, 32-34. doi: 10.1016/j.ijotn.2018.05.005

125

126

Compartment syndrome

» A condition in which the perfusion
pressure falls below the tissue
pressure in a closed anatomic space,
with subsequent compromise of
circulation and function of the
tissues.

» Observe sign of CS with the 6 Ps:
⋄ pain,
⋄ pallor,
⋄ polar,
⋄ paresthesia,
⋄ pulselessness & paralysis.

Parvizi, J & Kim, G.K. (2010). Charter 55 Compartment syndrome in High Yield Orthopedics. Pp 112-113. doi https://doi.org/10.1016/B978-1-4160-0236-9.00066-3

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Compartment syndrome

» Range of motion exercises every 30 minutes.
» Take oxygen saturation levels every 30 minutes and monitor the

advancement using the oxygen saturation monitor.
» Lower sodium intake to reduce swelling.
» Switching between hot and cold packs every 20 minutes (cold

packs reduce swelling, but also impair the blood flow, hot
compress stimulate blood flow).
» Keep organ (with cast) elevated at heart level (this will help
maintain arterial pressure, which is the pressure blood flows
through arteries in the body).

127

Pressure ulcer / injury

Pressure ulcer stages:
» Deep tissue injury (new stage):

⋄ Purple or maroon localized area of intact skin or blood-
filled blister resulting from pressure damage of
underlying soft tissue.

» Stage I:

⋄ Epidermis is intact.
⋄ Non-branch able erythema of intact skin.

Discolouration of the skin, warmth, edema, induration
or hardness may also be used as indicators, particularly
on individuals with darker skin.

» Stage II:

⋄ Partial-thickness skin loss involving epidermis, dermis,
or both. The ulcer is superficial and presents clinically
as an abrasion or blister.

12»8

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» Stage III:

⋄ Full-thickness skin loss involving damage to or necrosis
of subcutaneous tissue that may extend down to, but
not through, underlying fascia.

⋄ Slough may be present; may include undermining and
tunneling.

» Stage IV:

⋄ Extensive destruction, tissue necrosis or damage to
muscle, bone or supporting structures, with or without
full-thickness skin loss.

⋄ Undermining and tunneling may develop.

» Unstageable:

⋄ Full-thickness tissue loss in which actual depth of ulcer
is completely obstructed by slough or eschar in the
wound bed.

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Nursing care

» Assess the specific risk factors for pressure ulcer: age,
history of preexisting chronic diseases, nutritional status,
fecal and urinary incontinence, environmental moisture.

» SSIET (S-SI-ET) bundle*

⋄ S-Surface: use of equipment to reduce pressure.
⋄ S-Skin: maintain proper hydration of the skin.
⋄ I-Incontinence: prevent incontinence
⋄ E-Encourage: encourage nutrition
⋄ T-Turn position

*กาญจนา รุ่งแสงจนั ทร์, วรรณิภา สายหลา่ และจฒุ าพร ประสงั สิต. (2558). เพมิ่ ประสทิ ธิภาพการดแู ลผ้ปู ่วยด้วย SSIET bundle. เอกสารประกอบการประชมุ ประจาปี 2558
การก้าวส่อู งค์กรพยาบาลที่มีประสิทธิภาพสงู วนั ที่ 8-9 ธนั วาคม 2558

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4/3/2020

Nursing care of Orthopedic patients

: Fracture & Treatment

Asst. Prof. Dr. Saranya Chularee o Fracture
Institute of nursing, o Cast
Suranaree University of Technology o Traction
o Fixation (internal & External)
o Amputation
o Walk with orthopedic devices

131

132

Nursing care with Traction

» Traction is an orthopedic treatment that involves
placing tension on a limb, bone or muscle group using
various weight and pulley systems.

» Traction is applied to:
⋄ Decrease muscle spasms
⋄ Reduce, align, and immobilize fractures (e.g. femur
fractures that cannot be immobilized in a cast).
⋄ Correct or prevent deformity
⋄ Increase space between joint surfaces

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Principles of traction

» Counter traction
» Friction
» Line of pull
» Continuous
» Position

133

Types of traction

» Skin traction involves weight applied and held to the skin with

a splint (e.g. Buck’s traction, pelvic traction)

» Skeletal traction involves weight applied and attached to

metal inserted into bone (e.g. pins, wires, tongs).
⋄ Skull traction is one types of skeletal traction.

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4/3/2020

Skin traction

Indication Contraindication

⋄ Management of femoral ⋄ Abrasion & lacerations of
shaft fx. In older and skin in the area to which
hefty children. traction is to be applied

⋄ Temporary management ⋄ Disturbance in blood
of femoral neck fx. & circulation (Varicose vein)
intertrochanteric fx.
⋄ Dermatitis

135

Skin traction

» Complications of skin traction

⋄ Allergic reaction to adhesive.
⋄ Excoriation of skin on slipping.
⋄ Pressure sore.
⋄ Common peroneal nerve palsy.

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Skeletal traction

Indication Contraindication

⋄ For those cases in which ⋄ Same as skin traction.
skin traction is
contraindication. Complications

⋄ Fracture femur. ⋄ Introduction of infection
⋄ Displaced Fracture of into the bone.

pelvis. ⋄ Incorrect placement of
⋄ Fracture / Dislocation of the pin or wire.

C-Spine. ⋄ Ligament damage.
⋄ Damage to epiphyseal

growth (children).

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Common Traction

Buck’s traction Russel’s traction

138

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Common Traction

Bohler-Braun frame traction

139

Common Traction

Bryant’s traction Suspension traction

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Gardner – wells tong traction

141

Nursing care

» Assess the skin, especially bony prominences for breakdown.
» Perform neurovascular status (6Ps) assessments, and

document as ordered.
» Regularly check the condition of the traction equipment:

ropes, pulleys, and weights.
» For the client in skeletal traction, assess the pin site for signs

and symptoms of infection.

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4/3/2020

Nursing care of Orthopedic patients

: Fracture & Treatment

Asst. Prof. Dr. Saranya Chularee o Fracture
Institute of nursing, o Cast
Suranaree University of Technology o Traction
o Fixation (internal & External)
o Amputation
o Walk with orthopedic devices

143

144

Nursing care with Traction

Internal fixation External fixation

» An open reduction » An external fixation is the
and Internal fixation method of fixing the fracture
(ORIF) is the method with a cluster of pins
to fix severely broken connected to external
bones. It’s only used environment.
for serious
fracture that can’t be
treated with a cast or
splint.

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Internal fixation

Advantages Disadvantages

» Allow early mobility of the » Infection & non-union
patient out of the bed.
Complications
» Joint do not get stiff and
muscle function remain » Infection
good. » Non-union.
» Implant failure
» Complication with » Refracture
confinement of the
patient to bed are avoid.

145

Internal fixation

Indication Contraindication

» Displacement intra-articular » Osteomyelitis or high risk.
fracture. » Osteoporosis.
» Severe comminuted
» Instability fracture that
cannot be controlled by fracture
closed method.

» Associated neurovascular
injury.

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147

External fixation

Indication Contraindication

» Open fracture c severe » Osteomyelitis or high risk.
soft tissue injury.
» Osteoporosis.
» Closed fracture with soft
tissue compromise. » Severe comminuted
fracture
» Fixation of pelvic fracture.

» Stabilize long bone &
periarticular fracture in
multiple trauma pt.

» Infected fracture.

147

External fixation

Complications

» Pin tract infection
» Pin loosing or breakage
» Neurovascular damage
» Delayed union & mal-union

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Nursing care

Preoperative care

» Patient education
» Initial assessment for post operative stability and

complications following devices placement.

Postoperative care

» Assessment of neurovascular status (6Ps)
» Positioning or moving patient to prevent skin breakdown.
» Elevate extremity to reduce swelling
» Providing pin site care.
» Encourage mobility with crutches or walkers

149

Nursing care of Orthopedic patients

: Fracture & Treatment

Asst. Prof. Dr. Saranya Chularee o Fracture
Institute of nursing, o Cast
Suranaree University of Technology o Traction
o Fixation (internal & External)
o Amputation
o Walk with orthopedic devices

150

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151

Nursing care with Amputation

» Amputation of limbs, is the result of trauma,
peripheral vascular disease, tumors and
congenital disorders.

» Amputation refers to the surgical/ traumatic
removal of the limb.

» Amputee refers to person who have the
amputation.

» Stump is the part of extremities that is left
after most of it has been removed.

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Indication of amputation

⋄ Injury/trauma
⋄ Vascular disease
⋄ Acute infection
⋄ Congenital
⋄ Peripheral nerve injury
⋄ Benign tumor/malignant tumor

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Types of amputation

» Upper extremities;

⋄ Below elbow amputation (B.E. amputation)
⋄ Above elbow amputation (A.E. amputation)
⋄ Shoulder disarticulation (S.D.)

» Lower extremities;

⋄ Syme’s amputation
⋄ Below knee amputation (B.K. amputation)
⋄ Knee disarticulation
⋄ Above knee amputation (A.K. amputation)
⋄ Hip disarticulation
⋄ Hind quarter/hemipelvectomy

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Nursing care

Impaired Physical Mobility related to right leg amputation.
» Preoperative patient’s education:

⋄ Reasoning for operation (elective surgery).
⋄ pain assessment and phantom limb sensation.
⋄ Turning position.
⋄ Exercise.

» Postoperative care

⋄ Assess the functional level of mobility, ROM,
muscle strength, the need for assistive devices,
safety of the environment.

155

Nursing care

» Prevention of flexion contracture

⋄ Keep limbs in functional alignment with one or more of
the following: pillows (elevate stump only 24-48 hr.
postoperative).

⋄ Rewrap stump immediately with an elastic bandage.
⋄ Turn and position the patient every 2 hours or as needed

(prone position is recommended).
⋄ Assist with specified ROM exercises for both the affected

and unaffected limbs beginning early in the postoperative
stage.
⋄ Encourage active and isometric exercises for the upper
torso and unaffected limbs.

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» Establish measures to prevent skin breakdown and
thrombophlebitis from prolonged immobility.

» Note for progressing thrombophlebitis

⋄ Calf pain
⋄ Homan’s sign
⋄ Redness
⋄ Localized swelling,
⋄ A rise in temperature.

157

Nursing care of Orthopedic patients

: Fracture & Treatment

Asst. Prof. Dr. Saranya Chularee o Fracture
Institute of nursing, o Cast
Suranaree University of Technology o Traction
o Fixation (internal & External)
o Amputation
o Walk with orthopedic devices

158

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159

Walking with Orthopedic devices

» Crutches
» Walkers
» Cane

159

Crutches

Axillary crutch Platform crutches
Forearm crutches
160
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4-Point gait with crutches 161

ชนนิษฎ์ ลมิ่ สกลุ . (). อปุ กรณ์ชว่ ยเดนิ . ภาควชิ าศลั ยศาสตร์ออร์โธปิดกิ ส์กายภาพบาบดั คณะแพทย์ศาสตร์ มหาวทิ ยาลยั สงขลานครินทร์.
https://meded.psu.ac.th/binlaApp/class05/388_571_2/Walking_aids/index.html

161

3-Point gait with crutches

Partial weight bearing

Non-weight bearing

ชนนษิ ฎ์ ลิ่มสกลุ . (). อปุ กรณ์ชว่ ยเดนิ . ภาควิชาศลั ยศาสตร์ออร์โธปิดกิ ส์กายภาพบาบดั คณะแพทย์ศาสตร์ มหาวิทยาลยั สงขลานครินทร์.
https://meded.psu.ac.th/binlaApp/class05/388_571_2/Walking_aids/index.html

162

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163

Swing gait with crutches

» swing - to gait Non
» swing - through gait weight baring

Weight baring Partial
weight baring

163

Swing through gait

ชนนษิ ฎ์ ลิม่ สกลุ . (). อปุ กรณ์ชว่ ยเดนิ . ภาควิชาศลั ยศาสตร์ออร์โธปิดกิ ส์กายภาพบาบดั คณะแพทย์ศาสตร์ มหาวทิ ยาลยั สงขลานครินทร์.
https://meded.psu.ac.th/binlaApp/class05/388_571_2/Walking_aids/index.html

164

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165

Walkers

Weight baring Non weight baring

Partial weight baring

165

Walkers

166

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167

Cane

167 cane

Standard cane Wide-based cane

ชนนษิ ฎ์ ล่ิมสกลุ . (). อปุ กรณ์ชว่ ยเดนิ . ภาควิชาศลั ยศาสตร์ออร์โธปิดกิ ส์กายภาพบาบดั คณะแพทย์ศาสตร์ มหาวทิ ยาลยั สงขลานครินทร์.
https://meded.psu.ac.th/binlaApp/class05/388_571_2/Walking_aids/index.html

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4/3/2020

cane

ชนนษิ ฎ์ ล่มิ สกลุ . (). อปุ กรณ์ชว่ ยเดนิ . ภาควิชาศลั ยศาสตร์ออร์โธปิดกิ ส์กายภาพบาบดั คณะแพทย์ศาสตร์ มหาวิทยาลยั สงขลานครินทร์. 170
https://meded.psu.ac.th/binlaApp/class05/388_571_2/Walking_aids/index.html

169

Cane

170

85