Common Problems Tca_2

Common Problems TCA #2

TCA #2 Common problems continued A 72 yo female client is admitted to the hospital for a fractured hip, placed in traction and held NPO past midnight awaiting a total hip arthroplasty the following morning. What type of traction will be used? Skin What is the classification of this traction? Straight What is the method for application? Skin How will the patient’s leg be positioned? Straight How will counter traction be provided? Using weight How many pounds of weight will be applied? 5-8 lbs. How often should a neurovascular check be done? Q2 hours During pre-op teaching the nurse makes the patient aware of what 4 major complications post-op a THA? Infection, hemorrhage, DVT, and dislocation 9. How high can the head of the bed be raised post-op? Elevate 60 degrees or less 10. It is important to maintain the hip in what position post-op? Prevent adducting 11. Is an output of 350 ccs in hemovac acceptable for the first 24 hours post-op? Yes, up to 500 is ok 12. How will you minimize hip extension during transfers? Pivot on non-affected extremity 13. What findings may indicate dislocation of prosthesis? Pain, shortening of effected side 14. What 2 positions should always be avoided? Greater than 90 degrees, adducting 1. 2. 3. 4. 5. 6. 7. 8.

Hip – a large weight-bearing ball and socket joint connecting the femur with the pelvis supports three times your body weight when walking. Acetabulum – “cup” or rounded cavity of hip receiving the head of the femur or “ball” Neck of femur – chief blood supply – if get a break in the neck you have disrupted the whole blood supply at that point Femur – longest and strongest bone in the body Greater trochanter Lesser trochanter Pelvic fracture heals rapidly because blood supply has not been altered in the area HIP FRACTURES - Average hospital stay is 5 days - This is the “decade of bone and joints” - Females @↑risk o Osteoporosis – metabolic bone disorder where there is an alteration in the serum calcium levels – can be treated with supplements – but it does present a situation where the bone is coarse and brittle (they take on a honeycomb effect) o Hormonal changes – greater loss of bone mineral density o Smaller bones o Wider pelvis – this is actually less stable than that of a male o Females live longer - Elderly @ risk o Falling frequently o Weak quadriceps muscles o General frailty due to age 1

Common Problems TCA #2

o Conditions that produce ↓ cerebral arterial perfusion (TIA, anemia, emboli, cardiovascular ds, meds effects) Increases RF falls o May have cardiovascular issues, pulmonary, renal, endocrine disorders. Conditions that can lead to cerebral arterial perfusion (stroke, weakness on one side) o Possible back issues or lumbar degeneration – where the extremities are not strong and they cannot walk or stand up and get their balance or gait real well. Estimated that 20% of patients that sustain a hip fracture die within the first year. They die of pneumonia which is one of the hazards of immobility. TYPES - Intracapsular fractures o Fractures of neck of femur – slight degree of external rotation o Can damage the vascular system that supplies the blood to the head and neck of femur o Bone may die – Avascular necrosis o Nonunion or aseptic necrosis is common due to the damaged blood supply - Extracapsular fractures o Fractures of trochanteric (between base of neck and lesser trochanter of femur) & subtrochanteric (break across shaft of bone) (see page 2093) o Have excellent blood supply o Heal rapidly o Extensive soft tissue damage may have occurred at time of injury - fracture may be comminuted (fragment pieces) or unstable o High mortality rate with intertrochanteric hip fractures (between greater and lesser trochanter) – due to elderly patients are poor surgical candidates FYI if you have a patient that falls, do a head to toe assessment on them – you have 24 hours to do an entire head to toe assessment. -

Signs and Symptoms of Hip Fracture o Femoral neck fx  Leg is shortened (can be extremely shortened)  Adducted  Externally rotated (the leg)  Pain in hip and groin or medial side of knee  Unable to move leg without significant increase in pain  Most comfortable w/leg slightly flexed in external rotation  May see an area of ecchymosis or bruising  Specifically with a femoral neck fracture the leg is slightly externally rotated. With an extracapsular fracture it is more significantly shortened and will present with a greater degree of external rotation o Impacted intracapsular femoral neck fx  Moderate discomfort – even with movement  May be able to bear weight  May not demonstrate obvious shortening or rotational changes o Extracapsular femoral fx of trochanteric or subtrochanteric regions 2

Common Problems TCA #2

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    Dx w/x-ray

Extremity is significantly shortened Externally rotated to a greater degree than intracapsular fx Muscle spasms that resist positioning of the extremity in a neutral position Large hematoma or area of ecchymosis

A dislocated hip will internally rotate or adduct. You confirm a hip fracture with an X-ray. ELDERLY CONSIDERATIONS - Hip fx frequent contributor to death after age of 75 – due to pneumonia, sepsis, ↓ability to cope w/other health problems - Many confused during hospitalization – due to stress, unfamiliar surroundings, sleep deprivation, meds, illness - RF for Postop Delirium o >70 o Alcohol abuse o Impaired cognitive status o Poor functional status o Abnormal Na, K, glucose - Other Factors of Confusion o Medications o Anesthesia o Malnutrition o Dehydration o Infection o Mood disturbances o Blood loss o Cerebral ischemia (mild) - Prevent Complications o Assess elderly pt for chronic conditions that require close monitoring  Examine leg for edema – may be due to HF  Check pulses – Pulselessness from arteriosclerotic vascular ds.  Inadequate pulmonary ventilation – chronic respiratory problems o Cough, Deep Breath o Continue home meds (cardiac, anti htn, respiratory meds) o Monitor for these meds also o Pt may be dehydrated – contributes to thromboembolism o Encourage fluids and healthy diet o Bed rest & immobility will cause additional loss of strength – encourage the pt to move all joints except the involved hip and knee o Encourage them to use overhead trapeze to reposition themselves – helps build strength for walking devices MEDICAL MANAGEMENT - Temporary skin traction used to immobilize the extremity – Buck’s traction (most common). o Reduces muscle spasm 3

Common Problems TCA #2

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o Immobilizes – once the extremity is immobilized and they cannot move it then this will decrease the pain a lot o Relieves pain Goal of Surgery – to obtain a satisfactory fixation so that the patient can be mobilized quickly & avoid secondary complications Surgical Treatment o Types  Open reduction of fracture and internal fixation – ORIF (the doctor will go in and make an incision at the hip joint area and will fixate the hip with some type of hardware)  Replacement of the femoral head w/a prosthesis (Hemiarthroplasty) – R/f dislocation  THA – R/f dislocation (Total Hip Arthroplasty) o Surgery carried out as soon as possible o With THA the patient is at risk for dislocation of the prosthesis. With ORIF they just went in and pinned the area so they are not at risk for dislocation. To prevent dislocation use an abductor pillow (A pillow), correct alignment. If you do not have an A pillow place pillows between the legs to make sure that the legs are kept abducted (avoid adduction). Pre-op o Make sure the patient is in favorable condition – will postpone surgery for 2 weeks if patient has infection. o Femoral Neck fractures – may be treated as EMERGENCY – in 12-24 hours after fracture – RF Avascular necrosis o Teach about complications: DVT, Infection, Hemorrhage, Positioning (to prevent dislocation) o Teach about abductor pillow, no crossing legs, bending >90 degrees, no knees above hips - pt can sit on a small pillow – Knees 3-6” apart General or spinal anesthesia used to visualize under x-ray The better the reduction – the better the healing Post-op o Pain meds (come back with a PCA pump) o Prevent complications (the main concerns are DVT and sepsis) o Deep breathing, coughing o Foot flexion q 1-2 hours o Stockings (TED), plexi-pulses to prevent venous stasis o IV antibiotics o I&O, nutrition o Abductor pillow – placed between legs to maintain abduction – should teach this Pre-op o Monitor for dislocation, excessive wound drainage, thromboembolism, infection, heel pressure ulcer o HOB 45 degrees o Knees 3-6” apart o Monitor for pressure on popliteal space  This might happen when sitting up on the side of the bed – do not want to leave them in this position for a long period of time. o Monitor lab values 4

Common Problems TCA #2

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Repositioning o Prescribed by the Dr whether nurse can turn onto affected or unaffected side o Place pillow between legs – turn onto side w/proper alignment Exercise o Use trapeze bar o 1st postop day – transfer to chair w/assistance & begins assisted ambulation o Dr prescribes the amount of weight bearing & rate the patient should progress to full weight bearing o PT works w/transfers, ambulation, walker, crutches Prevention of Dislocation o Leg in abduction o Use abduction pillow or wedge, or 2-3 pillows between legs o Never flex hip >90 degrees o HOB 45 degrees or < o Use Fracture bedpan – flex unaffected hip & use trapeze bar to lift pelvis onto pan o Limited flexion during transfers and sitting o When initially assisted out of bed – abduction pillow between legs o Keep affected hip in extension – pivot on unaffected leg w/assistance o Always protect the hip from: adduction, flexion, internal or external rotation, excessive weight bearing o High-seat chairs, semi-reclining wheelchairs, raise toilet seats o Sitting – hips should be higher than knees – affected leg should not be elevated – may flex the knee o No adduction, internal or external rotation, hyperextension, or acute flexion o Cradle boot – to prevent leg rotation and to support heel off bed - prevent pressure ulcers o Use pillows when supine or side-lying position and when turning o No sleeping on affected side – unless Ok by DR o NO CROSSING LEGS o No bending at waist to put on shoes, socks o Use hip precautions about 4 months after surgery S&S of Dislocation o Increased pain at surgical site o Swelling o Immobilization o Acute groin pain o Shortening of leg o Abnormal external or internal rotation – leg flop o Restricted ability or inability to move leg o “Popping” sensation in hip Monitor Wound Drainage o Fluid and blood drained w/suction device (acceptable amount of blood loss)  1st 8 hrs – <250  1st 24 hrs – 200-500  48 hrs postop - <30cc in 8 hrs – suction device removed o Greater drainage – call DR!!! o Important to make sure bulb is compressed 5

Common Problems TCA #2

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o Check tubing o If needing blood – make sure you get a consent form signed, or make sure there is one Monitor for Infection (due to large wound and soft tissue damage) o May necessitate removal of implant o Hematoma may form in the area – they may have to go back to surgery or they may sometimes at the bedside remove it o Typical post op orders are to D/C the Foley and the hemovac on post op day #2. o They may have urine & stool incontinence – remember where this incision is o May get osteomylitis o High RF Infection  Elderly  Obese  Poorly nourished  Diabetes  RA – rheumatoid arthritis  UTI  Dental abscess  Large hematomas o Prophylactic Antibiotics o Remove catheters and wound suctions as soon as possible o Instruct patient to take prophylactic antibiotics for future surgeries (tooth extraction cystoscopic exam, etc.) o Acute infections – can occur within 3 mos after surgery o Delayed infections – may appear 4-24 mos o Infection 2+ years after surgery – spread of infection through bloodstream from another site (that’s why it is Important to take prophylactic antibx before surgeries) o Give Antibiotics, debridement, or removal of device may be necessary o Sterile dressing changes and strict handwashing o Monitor VS and signs & symptoms of infection (include in teaching) Complications o RF Shock – careful monitoring o RF Infection o RF Hemorrhage  Large incision, proximity to large vessels o RF Neurovascular compromise  Neurovascular deficit due to operative trauma to nerves/blood vessels  Bleeding into tissues is expected  Excessive swelling may be observed  Monitor affected leg  Check pedal pulses, popliteal pulses, check color of toes, capillary refill, swelling, movement of toes, sensation o RF DVT – most common – 5-7 days after surgery  Risk factors – history of DVT, elderly, obesity  Watch for pressure on popliteal space  Encourage fluids – best way to prevent 6

Common Problems TCA #2

Make sure IV is going at the rate it is supposed to Ankle and foot exercises q hour while awake Stockings, compression devices Anticoag meds – Lovenox (check platelet level, don’t want level below 100 and don’t want them on NSAIDs), may also order Fragmin or Arixtra  Assess leg q 4 hours  Ambulate early (key)  Pre-op teach quad setting and calf pumps RF Pulmonary complications  Elderly @ risk  Deep breathing  Change position q 2 hours  Incentive spirometry  Assess breath sounds q 4-8 hours R/F Pneumonia  Increased risk with decreased mobility  Increased risk in the elderly population  Turn cough deep breath  Mobilize early  Incentive spirometry RF Skin breakdown  Elderly @ RF  Tape can cause blisters  Elastic hip spica wrap dressing or elastic tape applied in a vertical fashion may ↓ tape blisters  Pressure ulcers common – due to remaining in same position too long  Proper skin care – heels, back, sacrum, shoulders  Relieve pressure areas  High-density foam, static air, special mattress RF Loss of bladder control  No routine use of indwelling catheter  Removed 1st morning postop  Assess voiding patterns  Encourage liberal fluid intake RF Delayed complications  Infection • Persistent, moderate discomfort in hip • Mildly elevated sedimentation rate  Non-union  Avascular necrosis of femoral head  Fixation device problems    

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Common Problems TCA #2

Post op the patient may have a Stryker drain in place. The advantage of this system is that if they need to have blood replaced (if they lose a certain amount of blood within the initial post op period – roughly 6 to 8 hours, then the patient can be re-infused with their own blood). HEALTH PROMOTION - Osteoporosis screening for pts who have experience hip fractures – prevents future fractures. - Education on diet requirements - Education on lifestyle changes - Exercise to promote bone health - Wear hip protectors – to protect from a fall HOME TEACHING - The major time to worry about dislocation is immediately after surgery up to 6 months after the surgery - Daily exercise – walks, swimming, using a high rocking chair - Remind pt it will take time to strengthen and retrain muscles - Crutches, walker, cane are used for a while - 3 mos – pt should be able to resume ADL - Stair climbing – keep to a minimum for 3-6 mos - Sex – flat on back – for 3-6 mos - For 4 mos – no crossing legs or bending >90 degrees - May need assistance w/shoes, socks, hose - No low chairs (Lazy Boys) - No sitting > 45 min - Frequent changes if traveling for long distances – otherwise avoid - No – tub baths, overexertion, jogging, lifting heavy loads, excessive bending, twisting (shoveling snow, lifting, forceful turning) - Towels or pillows between legs for sleeping - Reducing Pain o Rest o Distraction, relaxation techniques (books, tapes, movies) o Meds (NSAIDS, analgesics o Teach s/e - Keep incision dry, clean – teach dressing changes & S&S of infection - Sutures or staples removed 10-14 days - Sleep w/pillows between legs - Gradual increase in activities - Use elevated toilet set - Use reaching to aid in dressing - Accept assistance for ADL - Teach S&S o Dislocation o DVT o Wound infection o Pulmonary emboli - Regular routine physical exams & screenings 8

Common Problems TCA #2

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Always tell their other doctors when they have another procedure done that they have a prosthesis and they need to be on prophalactic antibiotics before other procedures are done.

Care of Client with A Fractured Hip - Pain - Potential alteration in though process - Potential ineffective coping - Impaired skin integrity - Impaired physical mobility - Impaired home maintenance TRACTION There are two major methods of traction. It will either be by the skin or the skeletal system. If you have skeletal traction employed, you would expect to see some type of hardware, tong, or pin piercing the patient’s skin. If there is skin traction this will not be the case. TRACTION - The application of a pulling force to a part of the body, it must be applied in more than one direction to achieve the desired amount of pull. o For example with the Buck’s traction you have that put on the lower extremity. The pull is at the foot of the bed. The upper pull is handled by the weight of the patient’s body. When in Buck’s traction the patient is lying flat in the bed. If their head is elevated, they will not have a good upper pull. - Used to minimize muscle spasms - To reduce, align, and immobilize fractures - To reduce deformity - To increase space between opposing surfaces – for someone w/lower back pain - Prevent soft tissue damage – a broken bone or slipped disc impinging upon soft tissue &/or nerves - Can be applied in more than 1 direction – when this is done, one of the lines counteracts the other - The effects of traction are evaluated with x-rays - Used for short-term intervention PRINCIPLES - Counter traction MUST be used to achieve effective traction – this is the force acting in opposite direction. - Usually the person’s body weight and bed position adjustments supply the needed counter traction. - Traction must be continuous to be effective - SKELETAL traction is never interrupted - Weights are not removed unless intermittent traction is ordered - The line of pull is always maintained. - Factors affecting the pull o Patient must be in good body alignment in the CENTER of the bed when traction is applied o Ropes must be unobstructed and in wheel groove of the pulley and unfrayed 9

Common Problems TCA #2

o Weights must hang free and not rest on bed or floor o Knots in rope or the footplate must not touch the pulley or foot of bed (tie knots securely) TYPES OF TRACTION - Straight or Running traction – applies the pulling force in a straight line w/body part resting on bed (Buck’s Traction) - Balanced Suspension traction – supports the affected extremity off the bed, and allows for some patient movement without disruption of the line of pull METHODS OF TRACTION - Skin traction - Skeletal traction SKIN TRACTION - Applied to the skin transmitting traction to the musculoskeletal structures to lengthen and exert force directly on the surface of the body and indirectly on the underlying muscles and bones - Used to control muscle spasms and to immobilize an area before surgery - A weight is used to pull on traction tape or a foam boot attached to the skin - Amount of weight applied must not exceed tolerance of skin (duh!) o 4.5 - 7 lbs – extremity (book says 4.5-8) o 10-20 lbs – pelvic traction – depends on pt’s weight - Examples o Cervical head halter (should not feel uncomfortable or be in pain)  Used to treat neck, shoulders, upper arm, fingers pain & numbness  C 4,5,6 – most common area of cervix  Look for pressure points  Teach patient about pressure points  Have to be in a sitting position o Pelvic Belt  To treat back pain  Intermittent pelvic sling which releases back, hip, and leg pain o Buck’s Traction – lower leg (4.5 – 8 lbs)  Used BEFORE surgical fixation (will not get back into Buck’s traction after the surgery is completed)  Inspect skin for abrasions and circulatory problems before applying boot  Clean and dry  To Apply – one nurse elevates and supports the extremity under the patient’s heel and knee while another nurse places the foam boot under the leg, with the heel down into the boot. Velcro straps around the leg.  Traction tape over wrapped w/elastic bandage in a spiral fashion may be used instead of boot  Avoid excessive pressure over malleolus, fibula – prevents ulcers, nerve damage  Pass the rope affixed to the spreader or footplate over pulley fastened to the end of the bed – attach weight – usually 3-5 lbs  NO HOB ↑ - flat – no big pillows under leg either 10

Common Problems TCA #2

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This is an intermittent traction – can take off to inspect and clean skin Complications • Skin breakdown o From irritation by contact of skin w/tape or foam & shearing forces o Elderly @ ↑ Risk o Identify sensitive, fragile skin during the initial assessment o Closely monitor for reaction o Remove boots to inspect skin, ankle, Achilles tendon 3/day – A second nurse is needed to support the extremity during inspection and skin care o Palpate area under traction tape for skin tenderness o Provide back care q 2 hrs – prevents pressure ulcers •

Nerve pressure o From pressure on peripheral nerves o Foot drop if pressure is applied to peroneal nerve at point at which it passes around the neck of the fibula, just below the knee o Question patient about sensation o Have patient move toes, foot o Dorsiflexing the foot – functioning peroneal nerve o Weakness of dorsiflex, or foot movement and inversion of foot – pressure on nerve o Plantar flextion – functioning tibial nerve o Investigate c/o burning sensation under bandages or boot o Call DR!! • Circulatory impairment o S&S - cold skin temp, ↓ pulses, slow cap refill, bluish skin o Assess circulation of foot or hand within 15-30 min after skin traction is applied o Then assess q 1-2 hrs o Active foot exercises q hour while awake • DVT – calf tenderness, swelling, + Homan’s  Interventions • Avoid wrinkling and slipping of the traction bandage • Maintain counter traction • Proper positioning – leg in neutral position • No turning from side to side – can shift position slightly w/assistance SKELETAL TRACTION - Direct pull to the skeletal structures by use of pins or tongs inserted into the bone distal to the fracture - avoiding nerves, BV, muscles, tendons, joints - Applied directly to the bone w/a metal pin or wire (Steinmann pin, Kirschner wire) - Femur, Tibia, Cervical Spine fractures - Tongs applied to head – Gardner-Wells or Vinke tongs – for cervical spine fractures - 15-25 lbs – weights applied initially must overcome the shortening spasms – once muscles relax, the traction weight is reduced 11

Common Problems TCA #2

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skeletal traction used when prolonged or heavy traction required Usually Balanced traction Thomas splint w/Pearson attachment – fractures of femur – over bed frame is used Russell’s – fracture of tibia Dunlop’s – fracture of humerus, forearm, elbow Halo vest – cervical neck problem – neck stays in alignment – can be mobile pg 1930

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Nursing Interventions o Maintain effective traction  Check to see if ropes are in wheel grooves  No fraying of ropes  Weights hang freely  Knots in rope are secure  Evaluate position of patient – slipping down in the bed results in ineffective traction  Never remove weights from skeletal traction – unless a life-threatening situation occurs o Maintain proper body positioning  Maintain alignment of body  Position foot to avoid Foot drop  Foot can be supported w/ortho devices  Counter traction – (example – with cervical traction the weight is at the head of the bed – for increasing counter traction you would raise the head of the bed. If you were using Buck’s traction and you want to increase counter traction above and beyond the weight – you would want to raise the foot of the bed) o Prevent skin breakdown  Check elbows – he may reposition himself w/elbows  Check heels  Encourage trapeze bar for moving  Assess pressure points - Lower extremity traction apparatus, you need to check ischial tuberosity, popliteal space, Achilles tendon, heel, back of head  Provide back care  Keep bed dry, free of crumbs and wrinkles  If pt can’t turn from side to side, nurse can push down on the mattress w/one hand to relieve pressure on the back and bony prominences  Bed linen change – pt raises torso while nurses on both sides of bed roll down and replace the upper mattress sheet - then the patient raises buttocks off mattress, the nurses slide the sheets under the buttocks – then puts the lower section of sheets on  Triple log roll - turn as a unit – 3 people o Monitor neurovascular status  Initially q hour, then q 4 hours  Encourage exercises  Active flexion and extension of ankles  Isometric contraction of calf muscles 10 times an hour – decreases stasis  To prevent nerve pressure 12

Common Problems TCA #2

 Dorsiflexion – if can dorsiflex foot there is an intact peroneal nerve (this is the motor part of the nerve)  Plantar flexion – shows there is intact tibial nerve  Abduction of the little finger & sensation on the ulnar side– there is an intact ulnar nerve o Provide pin site care  Goal – to avoid infection and development of osteomyelitis (infection of the bone)  Pin care 3/day, q 8 hours  Should be no crusts o Promote exercise Cervical Traction - Skin o Helps relieve muscle spasms and nerve compression in the neck, upper arms, and shoulders o The front strap of the cervical head halter fits underneath the chin, while the rear strap fits at base of skill away from earlobes - Skeletal o Stabilizes fracture and displaced vertebrae in the neck and upper thorax preventing injury to spine o Will be lying flat in the bed with this type of traction o Crutchfield, Gardner-Wells, Blackburn, Vinke, and Halo vest Pelvic Traction - Skin – an intermittent pelvic sling that is put on the lower back area and it is done on those that have some lower lumbar pain (lower back, hip and leg pain). They have enough of an issue going on that they need to be put in a sling that will put pull in that area and help to relieve some of that muscle spasm that is going on. This will decrease muscle spasm and increase proper skeletal alignment. They can get in and out of this sling or form of traction. - Skeletal – used for pelvic fracture Suspension Traction - Types of traction where an extremity is extended or floats above the level of the mattress, o Dunlops – used for lower humerus and forearms o Russell’s – used for fracture of the tibia. It is a type of suspension traction. The knee is flexed in a sling o Balanced Suspension (skin) – type of skin traction used for the lower extremities. The lower extremity balances or floats in the traction apparatus. o Balanced Suspension/Thomas Splint with Pearson Attachment (skeletal) – used for the fraction of the femur. The femur is a really strong bone, it is going to take a lot of weight to overcome the pull of the thigh muscle around the bone. One of the reasons to use skeletal traction is that it can _____ more weight THE PATIENT IN TRACTION - Assessment 13

Common Problems TCA #2

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o Consider the psychological & physiologic impact of the musculoskeletal problem, traction device, and immobility o Restricts mobility, independence o Equipment looks threatening, frightening o Monitor anxiety level  Frequent visits by the nurse can reduce feelings of isolation and confinement  Encourage family and friends to visit frequently  Encourage diversional activities o Compare affected extremity to unaffected extremity Complications o Pressure Ulcers o Pneumonia  Auscultate q 4-8 hours  Deep breathing, coughing q 2 hrs  IS o Constipation, Anorexia o Urinary Stasis, Infection o Venous Stasis, DVT

Skeletal traction is used most often for fractures of the femur, cervical spine, humerus or the tibia. A metal pin or wire is inserted into the bone, distal to the fracture. Weights have got to be applied to overcome the spasm of the effected muscle. When the doctor sees that things are improving and the muscles are relaxed, he will order some of the weight taken off. CRUTCH WALKING • Patient Teaching with nurse reinforces education • Several gaits rotate strain on muscles • Bear the weight through the palm of the hands • Check height of crutch • Stand up with tripod position – feet flat with the tip of the crutches 8 – 10 inches out to the side and a little in front o 4 point gait: requires weight bearing on both legs each leg is moved alternately with each opposing crutch so that 3 points of support are on the floor at all times. o 2 point gait: requires at least partial weight bearing on each foot – the client moves a crutch at the same time as the opposing leg so that the crutch movements are similar to arm motion during normal walking o Swing to gait: Feet land at tip of crutches o Swing through: Feet land ahead of crutches o 3 point gait: You will not bear weight on the affected extremity. Never put weight on injured extremity – weight is borne on both crutches and then on the uninvolved leg and the sequence is repeated. • Down Movement: Walk forward as far as possible advance crutch lower step weaker leg first, then stronger leg • Movement Upstairs: Stronger leg 1st, with crutch to step then bring weaker of affected side first 14

Common Problems TCA #2

CAST TYPES • Used for immobilization to aid in healing • Cast wet - handle with palm of hands • 24-48 hours to dry completely – May elevate on pillows o Forearm Cast o Long Arm Cast  Will have some flexion – muscle atrophy o Short Leg cast  NV assessment o Long leg cast  May have heel added to be able to put weight o Body Cast o Full Spica Cast o May see the Spica in the pediatric setting CARE • Elevate • Monitor Drainage • Itch use “cool” blow dryer or take Benedryl • Check pulses • Instruct not to pull padding under cast • Circulate air around promote drying • Isometric exercises EXTERNAL FIXATORS • Pin setting • Used for usually a comminuted fracture or a bad open fracture • Ambulatory or Immobilized with traction bar • Open fracture with soft tissue damage • Clean daily every shift (without osteomyelitis) • ½ / ½ with 4x4, betadine (allergies??), 2x2 with split • Notify MD of any drainage, assess redness, edema • Clear drainage is OK CPM: CONTINOUS PASSIVE MOTION • Used after Total Knee Replacement (Total Knee Arthroplasty) • Can be set from a 0o to a 90o Flexion. • Post op 30-35o flexion, put on in the recovery room • Increase Flexion by 10o each day with no complications • May say extension –10o to make sure it is totally extended as far as it can be • Promote mobility, circulation, healing • Can be painful for the patient to be in if they are not properly medicated for pain • As a nurse it is our job to help get the patient in and out of the CPM machine, but when you take a patient out of the machine make sure that it is in extension. Make sure that you have someone help you support their leg. 15

Common Problems TCA #2

FYI – After Knee Surgery – you do not want them to flex the knee. The biggest issue with the TKA post operatively is lack of mobility and infection. Turning a patient in skeletal traction – we are going to logroll them

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