Orthopaedic Surgery - Pre and Post Operative Management …



Canberra Hospital and Health ServicesClinical ProcedureOrthopaedic Surgery – Pre and Post Operative Management in Adults Contents TOC \h \z \t "Heading 1,1,Heading 2,2" Contents PAGEREF _Toc520714260 \h 1Purpose PAGEREF _Toc520714261 \h 2Scope PAGEREF _Toc520714262 \h 2Section 1 – Standard pre and post operative care for all orthopaedic patients PAGEREF _Toc520714263 \h 2Section 2 – Neurovascular observations for orthopaedic patients PAGEREF _Toc520714264 \h 6Section 3– Care of Patient with Fractured Pelvis PAGEREF _Toc520714265 \h 8Section 4 – Care of a Patient with a Hip Fracture or Fractured Femur PAGEREF _Toc520714266 \h 11Section 5 – Care of patient with upper limb fracture – humerus, radius, ulna or shoulder replacement PAGEREF _Toc520714267 \h 13Section 6 – Care of Patient with Lower Limb Fractures PAGEREF _Toc520714268 \h 14Section 7 – Care of patient having spinal surgery (orthopaedic surgeon) PAGEREF _Toc520714269 \h 15Section 8 –Total Hip Replacement PAGEREF _Toc520714270 \h 16Section 9 – Total Knee Replacement (TKR) PAGEREF _Toc520714271 \h 18Section 10 – Application and management of traction PAGEREF _Toc520714272 \h 19Section 11 – Care and management of pinsites following application of external fixation PAGEREF _Toc520714273 \h 21Section 12 – Use of Knee Joint Continuous Passive Motion Machine (CPM) PAGEREF _Toc520714274 \h 24Implementation PAGEREF _Toc520714275 \h 25Related Policies, Procedures, Guidelines and Legislation PAGEREF _Toc520714276 \h 25References PAGEREF _Toc520714277 \h 26Definition of Terms PAGEREF _Toc520714278 \h 26Search Terms PAGEREF _Toc520714279 \h 27Attachment 1: Guide to assess the motor & sensory function of the Upper Limb Nerves PAGEREF _Toc520714280 \h 28Attachment 2: Guide to assess the motor & sensory function of the Lower Limb Nerves PAGEREF _Toc520714281 \h 29Attachment 3: Guide Vascular integrity PAGEREF _Toc520714282 \h 30PurposeTo provide guidelines for the pre-operative and post-operative management of a patient undergoing surgery for:total hip replacement (THR), total shoulder replacement (TSR) and total knee replacement (TKR) upper limb fractures lower limb fractures fractures of the pelvis orthopaedic spinal surgery.It also provides guidelines for: Application and management of traction Use of knee joint continuous passive motion machineCare and management of pinsites following application of external fixation.ScopeThis document pertains to adult patients admitted for orthopaedic surgery involving joint replacements and major limb fractures at the Canberra Hospital and Health Services (CHHS).This document applies to the following CHHS staff working within their scope of practice:Medical Officers (MO)Registered Nurses (RN) and Enrolled Nurses (EN)Allied Health Professionals Students working under direct supervision.Section 1 – Standard pre and post operative care for all orthopaedic patientsDay of surgery/admission Nursing staff caring for patient are to notify:Ward clerk of patient’s arrival to ward to ensure patient is admitted on the ACT Patient Administration System (ACTPAS) Junior medical staff of patient’s arrival to the ward to medically admit the patientClinical Nurse Consultant (CNC)/Team leader (TL) of patient’s arrivalPharmacy to ensure medications are reviewed and plete nursing admission documentation on arrival in Patient Care and Accountability Plan (PCAP) and if applicable the clinical hip fracture pathway, highlight those patients who have high risks on assessment and implement a management planEnsure vital signs are completed 4 hourly as per CHHS Vital Signs (Adult) and Early Warning Scores procedureEnsure neurovascular observations are completed hourly for 24 hours following an injury or post operatively as per Section 2 Neurovascular observations for orthopaedic patients Ensure the following have been completed:Blood tests including group and screenElectro-cardiograph (ECG) if 50 years or above and/or if requiredIntravenous (IV) fluids charted if requiredRegular medications ordered on medication chartVancomycin resistant enterococci (VRE) and Multi resistant staphylococcus aureus (MRSA) swabs are taken/results available if from a nursing home or another hospital. Ensure Venous Thromboembolism (VTE) prophylaxis is in place including sequential compression device (SCD) and graduated stockings on both limbs if no other injuries present in lower limbsConsider an air mattress for the patient (not suitable for patients with a pelvic fracture)Ensure the patient has fasted from 2400 on day prior to surgery or as per medical orders-refer to Fasting Guidelines-Elective and Emergency Surgery Patients Clinical GuidelineEnsure the patient has showered/washed on the morning of surgery with Microshield Chlorhexidine 2%Ensure the patient takes their essential regular medications on the morning of surgery as outlined by the Medical Officer (MO) or the pre admission clinicEnsure the following has been attended:Consent form for treatment/surgery is valid, the operation site is marked and initialled and the goals of care planning and resuscitation plan have been completed by the RegistrarComplete pre-operative checklist form and ensure all current medication charts, fluid balance charts, IV therapy fluid charts and any hardcopy x-rays go with the patient to theatre/holding bayInform relatives of patients transfer to theatre if applicableEscort the patient to theatre if they meet the requirement for escort as per Patient Escort and Transport within Canberra Hospital campus procedure.Refer patient to members of multidisciplinary team as required e.g. social worker maybe required preoperatively Educate the patient on the importance of pressure injury prevention and document skin integrity each shift as per Pressure Injury Prevention and Management procedure.Day 0 post operation Note: For routine first 24 hours post operative care refer to clinical procedure Post-Operative Handover and Observations (First 24 hours) - Adult Ward Nursing Staff to ensure: Patient bed area has been cleaned ready for admission/transferAll emergency equipment is functioning and available at the patient bed space, including oxygen and suction Patient may have an alternating mattress if high risk for developing pressure injury (not for pelvic fractures)Monitor indwelling urinary catheter (IDC) output hourly for the first 24 hours; aim for urine output to be at least 0.5 mL/kg/hr. If measurement does not meet this then inform the patients MOAdminister regular medications as per patient’s medication chart Assess patient’s pain levels and sedation score when vital signs are completed Administer analgesia within prescribed limit as required based on the pain assessment and sedation level. Encourage regular use of analgesia to promote improved movement and mobility. If the patient is on a Patient Controlled Analgesia (PCA) or Continuous Opioid infusion (COI), ensure patient is reviewed by the Acute Pain Service (APS)Commence aperients to assist in prevention of constipationEnsure post-operative VTE prophylaxis (heparin/clexane) is to be administered 6 hours post completion of surgery unless contraindicated. Refer to the Venous Thromboembolism (VTE) – Adult procedure Ensure thrombo-embolic device stockings (TEDS) /Calf compressors in use unless contraindicated on both limbsPatient may require prophylactic intravenous antibiotics post surgery, check post-operative record and medication chartReinforce wound dressing if required. Do not remove theatre dressings If the patient is at risk of pressure injuries put preventative measures in place according to level of risk assessment including minimum 4 hourly change of position and pressure areas inspected as per Pressure Injury Prevention and Management procedure.Day 1 post operationFor pelvic and hip fracture patient’s only, blood tests for Full Blood Count (FBC) and Electrolyte Urea and Creatinine (EUC) to be taken at 0600 in case a blood transfusion is requiredWhen the first 24 hours post-operative is completed continue to attend vital signs as per Adult vital signs and Early warning scores procedure Neurovascular observations 24 hours post surgery, if stable, are recorded 4 hourly as per Section 2 Neurovascular observations for orthopaedic patients. Continue to assess patient’s pain levels and administer analgesia as prescribed Attend patient hygiene daily. Bed wash or shower depending on patient’s current conditionConsider IDC removal as per medical orders for lower limb surgery. If a patient has not voided for 6 hours a bladder scan should be performed and medical staff informed of the result, as per the Urology – Catheter Insertion and Management, Bladder Irrigation, Nephrectomy and Trans Urethral Prostatectomy (TURP) Procedure. Continue to monitor intravenous therapy and IVC siteAnticoagulation therapy to be administered as ordered: Anticoagulation therapy e.g. Clexane, patient education is to begin Day 1 post operatively as required and to continue every day until discharge. It is essential this is commenced early in admission to reduce delay in discharge. If patients are unable to administer it themselves, they are advised to nominate a family member or friend that will be able to do it for them. This person is then taught by the nurses how to administer a subcutaneous injection. Should a patient have a medical condition rendering them unable to give their own Clexane and they have no family member available then a referral for this is to be made to Discharge Liaison Nurse (DLN) for follow up on discharge.Liaise with physiotherapists in the mobilisation of suitable patients-this will occur according to postoperative instructions. Encourage mobilisation, repositioning and deep breathing and coughing throughout the day Inspect the wound dressing for exudate. If exudate is visible may require a pressure dressing- discuss with MO-do not remove theatre dressing Remove drains as per surgeon’s orders, this usually occurs on day 1Complete Patient Care & Accountability Plan (PCAP) and the hip fracture clinical pathway if applicable for each shift and ensure patient is aware of plans for their careMake referrals to, as required: Social worker Occupational Therapist for loan equipment required on discharge Rehabilitation referral Discharge Liaison Nurse (DLN) to arrange community nursing to manage the wound and organise the removal of staples/sutures after discharge. Staples/sutures can be removed 14 days post surgery. A written order by MO is required for this. Be aware some patients have dissolvable sutures so suture removal will not be required but the suture ends will need to be trimmed to skin level.Day 2 - 4 post operationContinue to attend vital signs as per Adult vital signs and early warning scores’ procedure.Neurovascular observations as per Section 2 Neurovascular observations for orthopaedic patientsContinue to assess and manage post operative pain Ensure bowels and bladder function is returning to normalInspect the wound dressing for exudate. If exudate is visible, the wound may require a pressure dressing therefore discuss with MO. Do not remove theatre dressing. Remove drains as per surgeon’s orders, this is usually done on day 1. A negative pressure wound therapy (NPWT) may have been applied to the wound– in this case the dressing remains in situ for 7 days post operative. To apply dressing, follow the manufactures guidelines or seek advice from Tissue Viability Unit (TVU) nurses. The TVU nurses can be contacted on Pager via the SwitchboardPerform daily skin integrity check, increase level of observation if patient at high risk for a pressure injury. See Pressure Injury Prevention and Management procedure The patient should be mobilising as per physiotherapist’s recommendations and gait aid. They should be becoming increasingly independent as the post op days increase Ensure the pharmacist is aware of discharge date/time and the discharge medications script has been organisedPatient education for anticoagulation therapy continues with the patient being given opportunity to practice administration of Clexane injections. If the patient is unable to self-administer the injections a family member or carer needs to be taught to perform the task.Day of DischargeAnticoagulation education, if required, should be complete. The patient will receive an initial supply of injections from the hospital pharmacy but will also require a script for the 6 weeks duration of the therapy. Provide the patient with a Clexane kit, which includes a sharps container (which can be taken to their General Practitioner (GP) or local ACT Health centre for disposal)Provide the patient with copy of their discharge summary which should include their outpatient clinic appointment date and time Ensure the patient is aware of what action to take should they suspect any complications are developing e.g. wound breakdown, Deep Vein Thrombosis (DVT) breathing difficulties or increase in temperatureThe patient is to be discharged prior to 10.00 a.m. If the patient is ambulant, utilise the discharge lounge for the patient to wait for medications, transport etc.The patient will be supplied with discharge medications from the pharmacy. The discharge medications can be collected by the patient from the pharmacy department or may be delivered to the ward by the pharmacist.Back to Table of ContentsSection 2 – Neurovascular observations for orthopaedic patientsOrthopaedic neurovascular observations are prescribed post injury and following procedures which have the potential to affect motor, sensory and circulatory function. Neurovascular observations are attended to accurately assess the nerve and vascular supply to a limb, thereby identifying early any signs and symptoms that may identify the potential to cause permanent dysfunction, such as Compartment Syndrome.FrequencyNeurovascular observation should be attended to and documented:Hourly for the first 24 hours post injury, surgery, application of Plaster of Paris (POP), backslab or fibre glass cast. If within normal parameters, fourth hourly for 24 hours and if stable and satisfactory then 8 hourly, refer to Plaster and Polyester Cast Management. When a new cast is applied, hourly observations commence againImmediately after application of traction, 30 minutes after application of traction, then hourly for 24 hours. If observations are within normal parameters then 4 hourly for 24 hours, then if within normal parameters and stable 8 hourly until traction removed. When traction is re-bandaged, conduct a full set of Neurovascular observations and then again 30 minutes laterIf unable to palpate either a pedal or tibial pulse, contact the MO as they may need to use a Doppler to find the pedal or tibial pulse.ProcedureExplain and ensure the patient understands the signs and symptoms that need to be reported, including :Increased or change in painPins and needlesNumbness.Attend hand hygiene before touching the patient by either hand washing or using Alcohol Based Hand Rub (ABHR)Ensure patients skin and nails are clear of all skin preparations that may obscure natural skin colour prior to assessmentMaintain the patients privacy while conducting the observationsCarry out vascular and neurological observations of affected limb as per Attachments 1, 2 or 3, use a good light source if observing at night timeAssess the vascular and sensory status of the limb below the level of injuryCompare neurovascular observations with the unaffected limb Use a gentle touch with a finger initially. Increase pressure if sensation not detected. Ask if sensation is normal or decreasedAttend hand hygiene by either hand washing or using ABHR after touching the patientRecord all observations on the Neurovascular Observation ChartImmediately report any abnormal neurovascular observations to the MO and document in the patient’s clinical record.ALERT 1: If the limb is in a Plaster of Paris (POP)/ fibreglass cast, splinted or otherwise partially covered, it may be difficult to carry out a full assessment. In this case, deficits in the other tests, which are possible, should indicate a disruption of nerve or blood supply.ALERT 2: If movement of the joint at or immediately below the injury is prohibited check sensation and vascular status only. Check the movement of the most distal uninvolved joint(s).ALERT 3: The difference of skin tones between light-skinned and dark-skinned people should be taken into account. Any deficits in nerve or blood supply will be noted when compared with the unaffected limb.If Neurological Deficit Noted In Upper Limb:Check if a regional block was given and how long since it was administeredCheck for swelling or oedemaCheck all dressings or splinting along the limb to ensure they are not too tightCheck position of arm if elevated to ensure shoulder is not externally rotated too farCheck for pressure points under the elbow and upper arm especially for radial and ulnar deficitsCheck position of sling knot around the neckCheck technique when using crutches as pressure in the axilla can produce a brachial plexus injuryReport all neurological deficits to a MO for reviewDocument all findings in the patients’ clinical record.The source of upper limb neurological deficits may be anywhere along the nerve pathway. The route of the brachial plexus should be checked for pressure being exerted by external forces.ALERT: If damage to the nerve or blood supply of any limb is not detected within 6 hours permanent dysfunction and deformity occurs due to muscle necrosis.If Neurological Deficit Noted In Lower Limb:Check if a regional block was given and how long since it was administeredCheck for swelling or oedemaCheck all dressings or splinting along the limb to ensure they are not too tightCheck any support used at the knee, to prevent external rotation, is not causing pressure on the kneeCheck hip is not dislocatedReport all neurological deficits to a MO for reviewDocument all findings in the patients’ clinical record.The source of lower limb neurological deficits may be anywhere along the nerve pathway. The route of the lumbosacral plexus should be checked for pressure being exerted by external forces.Additional Considerations for all Limb observations:Take into account environmental factors when assessing skin warmth, e.g. the room temperature, exposure of the limb and use of ice/cold packs to reduce swelling If capillary refill is over 3 second, check for possible peripheral vascular disease.ALERT: Peripheral pulses may still be present in the initial stages of Compartment Syndrome because the pathology takes place at the micro-vascular level.Back to Table of ContentsSection 3– Care of Patient with Fractured PelvisRefer to Section 1 for standard pre and post operative care for all orthopaedic patients.This patient may be admitted under the trauma team and may have other injuries which need to be taken into account and considered when providing nursing care.On admission to wardReceive handover of care at the bedside from Emergency Department staff Alert 1: Transfer the patient with a Jordan frame until written instructions are provided as to how the patient may be moved. Alert 2: Patient should be nursed on a standard mattress to keep their pelvis stabilised.Alert 3: Observe the patient for Haematuria and advise MO immediately if signs or symptoms are present.Alert 4: Acute compartment syndrome, fat emboli syndrome, Venous thromboembolism (VTE) and Pulmonary Embolus (PE) are high risk complications with these injuries therefore it is imperative neurovascular observations and vital signs are recorded as per Section 2.Day of SurgeryDay 0 post operation As per Post Operative Handover and Observations – Adult Patients (First 24 hours) procedure, all observations should be attended in the presence of the Post anaesthetic Care Unit (PACU) nurse to ensure any abnormalities are identified and managed as soon as possible. If the patient does not meet the PACU Discharge Criteria (Refer to Post Anaesthetic Observation Chart), ward staff are to request the patient be reviewed by the anaesthetic registrar or MO and/or returned to PACU for further recovery. If the patient meets the Medical Emergency Team (MET) criteria, activation of MET should occur.In additionNeurovascular observations are required hourly for 24 hours, as per section 2 Neurovascular observations for orthopaedic patients Hourly urine measures need to be conducted for 24 hours, if haematuria is noted seek MO reviewProvide 4 hourly pressure injury prevention including heel protection with silicone heel dressings and leg troughs but not an alternating mattress. Oral analgesia needs to be administered 1 hour prior to pressure area careDepending on the surgery performed the patient may require Jordan frame lifts, or may be able to roll onto unaffected side. Check the patient’s clinical record for the height permitted for the head of the bed to be elevated e.g. 30 degreesPatients with a fractured pelvis are not permitted monkey barsThe patient should have bowel sounds present before commencing oral fluids and a light diet. Diet and oral fluid status should be documented by MOIf an external fixator is fitted, pin sites should be observed for excessive exudate see Section 12 –Care and management of pinsites following application of external fixation for more informationPatient will require oral aperients to encourage normal bowel motions. Regular oral aperients should be prescribed on the medication chart.Day 1 post operationBlood tests for FBC and EUC’s to be taken at 0600hrs in case a blood transfusion is requiredRecord vital signs, neurovascular observations and urine output on fluid balance chart 4 hourly, for 24 hrs MO or nurse to refer patient to Physiotherapy for review and possible bed and chest exercises. Patient may require bedrest for 6 weeks post surgery Patient should receive a sponge in bed, noting skin integrity and receive 4 hourly pressure injury prevention. (Surgeon may order patients to have mechanical SCD’S Calf compressors only)Oral fluids and light diet should be encouraged if patient has bowel sounds presentPinsite care begins day 1. as per Section 12 –Care and management of pinsites following application of external fixation Pinsites are cleaned daily, covered with sterile dressing if sutures/staples in place. If exudate is excessive pinsites may require cleaning twice a day (BD)Postoperative check x-ray attended.Day 2 post operationPatient will be reviewed by medical team and blood tests may be orderedVital signs as per adult vital signs, neurovascular observations if stable are reduced to 8 hourly and IDC measures 4 hourly until IDC removed. Once bowels open and patient able to roll onto side IDC is usually removed at 2400hrs. Some patients will require Jordan frame lifts for some time but IDC can be removed (discuss with medical team).Ongoing careAny sutures/staples are to be removed at 14 days with medical staff instructionsCheck x-rays usually performed at 4 and 6 weeks to assess bone healingPinsite care daily as per Section 12 – Care and Management of Pinsites Daily sponge in bed continues. At 4 weeks on medical staff instruction patients may be allowed to transfer to shower bath as long as pin sites (if present) have no exudate from them Pressure injury prevention care continues throughout hospital stay as per Pressure Injury Prevention and Management procedurePatients analgesia requirements usually decline as pain subsides and is usually controlled by a maintenance doseVTE prophylaxis is paramount to prevent development of DVT /PE’sAny external fixators will be removed as per medical staff instructions in theatre around the 6-8 week post-operative period. Mobilisation of the patient will occur as per medical staff instructionsRefer the patient to social work, occupational therapy and pharmacy for discharge planning as required A period of rehabilitation maybe required in which case the patient will be referred to rehabilitation services ( if the patient has private health insurance they can be referred to a private rehabilitation service provider)Ensure the patient is aware of their limitations for movement and requirements for attending outpatient appointments for follow up. Educate the patient on potential complications and what action to take if any are suspectedThe patient will be discharged when deemed safe by physiotherapist and medical staff Provide the patient with a discharge summary, x-rays (or CD) if required and discharge medications as required. Back to Table of ContentsSection 4 – Care of a Patient with a Hip Fracture or Fractured FemurRefer to Section 1 for standard pre and post operative care for all orthopaedic patients.Note:If the patient is 65 years and over with a hip fracture, in addition to the PCAP, the Hip Fracture Clinical Pathway is required to be followed and completed daily.Pre operationVital signs performed 4 hourly and recorded as per adult vital signs Neurovascular observations hourly for 24 hours as per section 2 Neurovascular observations for orthopaedic patientsElevate limb to heart level to reduce swelling. Patient may benefit from application of ice to assist with reduction of swelling. If concerned that the patient is at risk of poor ventilation/ atelectasis / hospital acquired pneumonia, the patient may benefit from a partial recumbent/ sitting up position with legs elevated. Consult MO if concerned. Alert- Acute compartment syndrome, fat emboli syndrome, Venous thromboembolism (VTE) and Pulmonary Embolus (PE) are high risk complications with these injuries therefore it is imperative neurovascular observations and vital signs are recorded as per Section 2Day 0 post operationAs per Post Operative Handover and Observations – Adult Patients (First 24 hours) procedure, all observations should be attended in the presence of the PACU nurse to ensure any abnormalities are identified and managed as soon as possible. If the patient does not meet the PACU Discharge Criteria (Refer to Post Anaesthesia Observation Chart), ward staff are to request the patient be reviewed by the anaesthetic registrar or MO and/or returned to PACU for further recovery. If the patient meets MET criteria, activation of MET should occur. In addition Ensure it is documented by medical team, in the patients clinical records, if and how the patient is to mobilise and provide 4 hourly pressure injury prevention including heels protected with silicone heel dressings and may be off loaded in leg troughs. The patient may have an alternating mattress if risk assessment deems it necessary The patient is to be rolled onto non affected side for nursing care. The patient may sit up to 90 degrees but will often find it more comfortable to be in a reclined 30-40 degrees position except at meal times or if the patient is at high risk of aspirationA Charnley Pillow is required for hip fracture patients post operatively, these can be sourced from Ward 5A OrthopaedicsThe patient can usually commence on clear fluids and a light diet unless otherwise documented by medical staffThe patient will require oral aperients to encourage normal bowel motions. Regular oral aperients should be prescribed on the medication chart.Day 1 post operationBlood tests for FBC and EUC’s to be taken at 0600hrs in case a blood transfusion is requiredPhysiotherapy review to mobilise patient- Hip Fractures may be on ‘Hip Precautions’Vital signs, neurovascular observations and urine output (if stable) can be measured and recorded 4 hourly, for next 24 hoursCommence Clexane education as patient will require 6 weeks of clexane therapyThe patient can be encouraged to shower with assistance by nursing staff- this is an opportunity to inspect the skin integrity and provide pressure injury prevention Intravenous fluids are to be ceased at the discretion of the medical staffThe patient is encouraged to have analgesia on a regular basis; if the patient has a PCA in place patient will be reviewed by APSPatient will have postoperative check x-ray The patient should be referred to an occupational therapist for assessment of requirements for equipment on discharge and other allied health professionals as required.Day 2 post operationFor patients with hip fractures and who are over 65 years, as per the Hip Fracture Clinical Pathway remove IDC at 2400hrsContinue Clexane education with the patient Patient will be reviewed by medical team and blood tests may be ordered and either a blood or iron transfusion maybe requiredPatient will be reviewed by a physiotherapist and encouraged to increase mobility Patient should be encouraged to sit out of bed for longer periods in the morning and evening.Day 3 post operation and dischargeContinue with care as aboveSurgical dressing may be changed if requiredReferral to rehabilitation facility if patient requires it. Discuss with Medical and Allied Health team. Document referral in clinical recordIf the patient is being discharged to their home consider a referral to the Discharge Liaison Nurse for community nursing for wound care and/or GP for removal of sutures at 14 days post surgery. Provide suture removal device to patient and sharps container for Clexane syringes Ensure the patient is aware of limitations for movement and requirements for attending outpatient clinic appointments for follow up Educate the patient on potential complications and what action to take if any are suspectedProvide discharge summary, x-rays (CD) and discharge medications as required. Back to Table of ContentsSection 5 – Care of patient with upper limb fracture – humerus, radius, ulna or shoulder replacementRefer to Section 1 for standard pre and post operative care for all orthopaedic patients.Ensure vital signs 4 hourly and neurovascular observations hourly for 24 hours as per section 2 neurovascular observations on orthopaedic patientsEquipment:? Patient usually fitted with sling in theatre.Procedure Day 0 post operationAs per Post Operative Handover and Observations – Adult Patients (First 24 hours) procedure, all observations should be attended in the presence of the PACU nurse to ensure any abnormalities are identified and managed as soon as possible. If the patient does not meet the PACU Discharge Criteria (Refer to Post Anaesthesia Observation Chart), ward staff are to request the patient be reviewed by the anaesthetic registrar or MO and/or returned to PACU for further recovery. If the patient meets the MET criteria, activation of MET should occur.In additionElevate arm in sling or rest arm on pillow, depending on type of fracture, to reduce swelling and risk of potential complicationsProvide careful handling using cupped palms to ensure backslab is not damaged in first 48 hours while cast is still dryingGive medications as charted- there maybe prophylactic antibiotics for 24 hours if patient has had an open reduction and internal fixation; there may be extended period of antibiotic therapy required if the fracture was a compound fracturePatient may commence on oral fluids and diet as toleratedThe patient usually rests in bed until the next day.Day 1 post operationDepending on the patients social circumstances the patient may be able to be discharged day 1-2 post surgery or return to residential care when medical staff deem patient medically stable for transfer. Refer the patient to Occupational Therapy for assessment pre discharge.Back to Table of ContentsSection 6 – Care of Patient with Lower Limb FracturesAlert: acute compartment syndrome, fat emboli syndrome and DVT and P/E are high risk complications with these injuries. It is imperative to conduct neurovascular observations and vital signs and report any concerns immediately to the medical officer. Fracture blisters also require a medical review as it may mean that theatre is delayed until the blisters have healed.Day of surgery Refer to Section 1 for standard pre and post operative care for all orthopaedic patients.Day 0 post operation As per Post Operative Handover and Observations – Adult Patients (First 24 hours) procedure, all observations should be attended in the presence of the PACU nurse to ensure any abnormalities are identified and managed as soon as possible. If the patient does not meet the PACU Discharge Criteria (Refer to Post Anaesthetic Observation Chart), ward staff are to request the patient be reviewed by the anaesthetic registrar or MO and/or returned to PACU for further recovery. If the patient meets the MET criteria, activation of MET should occur.Ensure Neurovascular observations are attended hourly for 24 hours as per Section 2 Neurovascular observations on orthopaedic patients. The patient may return from theatre with a Camboot instead of a cast. The Camboot can be opened to perform neurovascular observations.In additionElevate affected limb to heart level to reduce swelling and risk of potential complications. The patient my benefit from the application of ice to reduce the swellingProvide careful handling using cupped palms to ensure the back slab, if present, is not damaged in first 48 hours while cast is still dryingGive medications as charted- there will be prophylactic antibiotics for 24 hours if patient has had an open reduction and internal fixation; there may be extended period of antibiotic therapy required if the fracture was a compound fracture Commence Clexane education as patient may require 6 weeks Clexane therapy if non weight bearingThe patient may commence on oral fluids and diet as toleratedThe patient usually rests in bed until the next day.Day 1 post operationContinue to elevate limb when not mobilisingCheck for wound ooze if the patient has a removable boot e.g., aircast splint or Camboot. Check skin integrity and for signs of pressure injury or fracture blisters. If there are signs of fracture blisters a medical review is requiredContinue Clexane education The patient, if medically stable and deemed safe for discharge by physiotherapy may be discharged home (or to residential care) if social circumstances permit. This may occur on day 1 post operation but more likely on day 2Ensure the patient is aware of limitations for movement and requirements for attending outpatient clinic appointments for follow upEducate patient on potential complications and what action to take if any are suspectedProvide the patient with a discharge summary, x-rays (CD) and discharge medications as requiredDressing change may take place day 3 if patient still in hospital otherwise this will occur at the first outpatient clinic appointment at 2 weeks post surgery.Back to Table of ContentsSection 7 – Care of patient having spinal surgery (orthopaedic surgeon)Pre operative careVital signs performed 4 hourly and recorded as per adult vital signs Neurovascular observations performed and recorded 4 hourly until patient goes to theatre.Refer to Section 1 for standard pre and post operative care for all orthopaedic patients.Day 0 Post operation As per Post Operative Handover and Observations – Adult Patients (First 24 hours) procedure, all observations should be attended in the presence of the PACU nurse to ensure any abnormalities are identified and managed as soon as possible. If the patient does not meet the PACU Discharge Criteria (Refer to Post Anaesthesia Observation Chart), ward staff are to request the patient be reviewed by the anaesthetic registrar or medical officer and/or returned to PACU for further recovery. If the patient meets the MET criteria, activation of MET should occur.Day 1 post operationContinue care as per Post operative Handover and Observations - Adult Patient (First 24 hours) procedure.Mobilisation must occur within physiotherapy service hours (0830- 1700) or with nursing staff during weekends and after hours Weight bear as tolerated (WBAT) unless documented otherwise in patient’s clinical notesIt is not necessary to mobilise these post spinal surgery patients on frames. The patients need to limit the duration of sitting out of bed to 10-30 minutes each time as toleratedRoutine spinal bracing (Sacro Cinch brace) is worn for 2 weeks post- operationThe patient should be transferred via log rolling techniqueThe patient is to be given two handouts with emphasis on care of the back post-operatively and transverses abdominus (TA) strengthening exercises (supplied by physiotherapists). Inspect wound dressing for exudate; if drain in place follow postoperative instructions for removal. Day 2 post operation and ongoingContinue to mobilise the patient for increasing periods of timeVital signs are to be performed as per vital signs and early warning scores procedure, neurovascular observations if stable are reduced in frequency as per Section 2 Neurovascular observations of orthopaedic patientsObserve wound site once per shift and document findingsPatient discharge is decided upon by the treating physiotherapist and multidisciplinary team when the patient demonstrates safety with mobility, transfers and activities of daily living (ADL’s) in the ward environment. Back to Table of ContentsSection 8 –Total Hip ReplacementRefer to Section 1 for standard pre and post operative care for all orthopaedic patients.Day 0 post operation As per Post Operative Handover and Observations – Adult Patients (First 24 hours) procedure, all observations should be attended in the presence of the PACU nurse to ensure any abnormalities are identified and managed as soon as possible. If the patient does not meet the PACU Discharge Criteria (Refer to Post Anaesthesia Observation Chart), ward staff are to request the patient be reviewed by the anaesthetic registrar or MO and/or returned to PACU for further recovery. If the patient meets the MET criteria, activation of MET should occur.In additionNeurovascular observations as per Section 2 Neurovascular observations in an Orthopaedic patient Provide a Charnley pillow to maintain limb alignment. Charnley pillows can be sourced from Ward 5A Orthopaedics. Educate the patient on hip precautions to reduce the risk of dislocation occurringWhen moving the patient roll patient onto unaffected side, ensuring affected leg is supported and does not cross the midlineDay 1 post operationContinue care as per Post operative handover and Observations adult patients (first 24 hours)procedureIV therapy is usually ceased day 1 and intravenous cannula (IVC) removed when antibiotics completed. Most patients will be able to return to normal diet and fluidsEnsure that the patient is aware that discharge from hospital for this procedure is routinely day 5 post operation (providing no complications occur).Patient may stay up to 7 days if bilateral joint replacements are performedEnsure patient has Day 1 x-ray performed (escort if required)Referrals to: PhysiotherapistOccupational Therapist for equipment loan required on dischargeSocial worker if requiredRehabilitation facility if required (private if has health insurance)Discharge Liaison Nurse (DLN) to arrange community nursing to manage the wound and organise the removal of staples/sutures on discharge if patient not returning to an outpatient clinic. Staples/sutures can be removed 14 days. A written order by MO is required for this. Be aware some patients have dissolvable sutures so suture removal will not be required.Day 2 - 4 post operationContinue to attend to vital signs as per Adult vital signs and early warning scores procedureNeurovascular observations as per Section 2 neurovascular observations in the orthopaedic patientThe patient is expected to be showering with less assistance from nursing staff than the previous day’s requirements. Promote independence as much as possible according to the patient’s pre-admission level of functioningEnsure the patients bowels and bladder are returning to normal functionObserve surgical site dressing and change on day 3 The patient should be mobilising as per physiotherapist’s recommendations. They should be becoming increasingly independent as the post operation days increase Ensure the pharmacist is aware of discharge and discharge medications organised.Day 5 post operation (expected day of discharge)Routinely Day 5 is the day of discharge for elective THR patientsPatients are to be independently mobilising and deemed safe to discharge from: physiotherapy, occupational therapy and also social work (if applicable). Safety for discharge should be documented in the clinical record Change patient’s dressing prior to discharge, and provide patient with staple remover (for the community nurses) if required. If NPWT dressing is in place, the dressing may need to be changed to a standard post operative film dressingComplete skin integrity check prior to discharge. If pressure injury/skin tears present ensure documentation complete and information provided if patient transferring to another facility. If patient is going home but requires ongoing care for these wounds refer to DLN for community nursing follow up. Back to Table of ContentsSection 9 – Total Knee Replacement (TKR)Refer to Section 1 for standard pre and post operative care for all orthopaedic patients.Day 0 post operation Equipment: Patient may have an alternating mattress if assessed there is a need for it. Alert: Patients having had Total Knee Replacement do not have a pillow under their leg. If patient is at risk of a heel pressure injury, provide a Mepilex foam heel dressing for protection and increase change of position frequency as well as educating the patient.As per Post Operative Handover and Observations – Adult Patients (First 24 hours) procedure, all observations should be attended in the presence of the PACU nurse to ensure any abnormalities are identified and managed as soon as possible. If the patient does not meet the PACU Discharge Criteria (Refer to Post Anaesthesia Observation Chart), ward staff are to request the patient be reviewed by the anaesthetic registrar or MO and/or returned to PACU for further recovery. If the patient meets the MET criteria, activation of MET should occur.In additionNeurovascular observations as per Section 2 Neurovascular observations for Orthopaedic patients.Day 1 post operationPost operative bloods to be taken at 0600. Remember to check the blood test results and to notify the MO of any abnormalities, as to facilitate early blood transfusion if deemed necessaryContinue care as per Post operative handover and Observations adult patients (first 24 hours) procedureWhen first 24 hours is completed, continue to attend vital signs as per Vital signs and Early warning scores procedure Neurovascular observations after 24 hours if stable are recorded 4 hourly as per Section 2 Neurovascular observations for orthopaedic patientsEnsure that patient is aware that discharge from hospital for this procedure is routinely day 5 post operatively (providing no complications occur).Patients may stay up to 7 days stay if bilateral joint replacements are performedReferrals to: PhysiotherapistOccupational Therapist for equipment loan required on dischargeSocial worker if requiredRehabilitation facility if required (private if has health insurance)Discharge Liaison Nurse (DLN) to arrange community nursing to manage the wound and organise the removal of staples/sutures on discharge if patient not returning to an outpatient clinic. Staples/sutures can be removed 14 days. Day 2 - 4 post operationContinue to attend vital signs as per Adult vital signs and early warning scores procedure Neurovascular observations as per Section 2 Neurovascular Observations for Orthopaedic PatientsThe patient is expected to be showering with less assistance from nursing staff than the previous day’s requirements. Promote independence as much as possible according to their pre-admission level of functioningEncourage mobilisation. The patient should be mobilising as per physiotherapist’s recommendations. They should be becoming increasingly independent as the post operation days increaseEnsure the pharmacist is aware of discharge and discharge medications organised.Day 5 post operation (expected day of discharge)Routinely Day 5 is the day of discharge for elective TKR patientsPatients are to be independently mobilising and deemed safe to discharge from: medical team, physiotherapy, occupational therapy and also social work (if applicable). Safety for discharge should be documented in the Clinical recordChange patient’s dressing prior to discharge, and provide patient with staple remover (for the community nurses) if required. If NPWT dressing is in place, the dressing may need to be changed to a standard post operative film dressing.Back to Table of ContentsSection 10 – Application and management of tractionEquipment required: non adhesive skin extensions (discard white bandage that comes in pack)tensocrepe (pink) bandage (1 or 2 depending on limb size)elastoplast tape for securing cord endsweight baggoose neck or end of bed H configuration.Note: Non adhesive Bucks traction is applied where possible as per medical orders.This traction is usually applied for a patient with the diagnosis of a fractured acetabulum or fractured hip/femur with patient experiencing considerable spasm, or to maintain an alignment of the fracture.Alert 1: Traction should never be removed from the patient without manual traction being applied unless there is a written order by medical staff. This may occur for procedures such as MRI or CT scan.ProcedureAttend hand hygiene before touching the patient by either hand washing or using AHBREnsure the patient has privacy during the procedure Ensure patient is comfortable and offer pain reliefObtain patients consent to apply tractionObtain the type & weight of traction ordered & documented by the medical officer in the patients clinical recordExplain the traction equipment, the procedure & the rationale for use to the patientAscertain where the site of injury isCheck skin on injured limb for wounds, abrasions, rashes and skin integrity. Areas of skin damage will require protective dressing and wounds dressed appropriately prior to traction application. The Achilles tendon area is at risk of skin damage due to slippage of bandages. Silicone foam heel will provide protection Check and record baseline neurovascular observations (Refer to Section 2, Neurovascular observations for orthopaedic patients)Prepare the bed space and equipment. A second person will be required to apply manual traction to the limb at the heel and support the limb while skin extensions are bandaged in placeAssist transfer of patient to appropriate traction bed, using appropriate Manual Handling Device(s) (Refer to Manual Handling Policy)ALERT 2: Adhesive skin traction is no longer used.ALERT 3: Any problems with skin integrity, which will affect the safety of the patient in traction, should be reported to the Medical Officer prior to application of traction.Position the patient centrally in bed to ensure the line of pull will be correctly establishedBandage skin extensions in place. Foam should be over malleolus and end of extensions should be a fist away from patient’s heel to allow enough planter flexion by the patient without interfering with the traction. Secure bandage by 3 wraps just above ankle to commence with and then in a figure 8 to within 1cm below tibial tuberosity Rest affected limb on pillow or heel trough to ensure heel is off loadedAttach one cord to the weight bag and over the pulley. Secure 2nd cord to main cord with adhesive tape (pulley can accommodate one cord only). Gently release manual traction once weight bag is in place Apply counter traction by elevating the foot of the bed 20 to 30 degrees. Ensure weight bag is off the floorSecure knots by taping the loose end to the main body of the rope. Taping the actual knot will make observation and adjustments difficultPerform neurovascular observations (Refer to Section 2 Neurovascular Observations for Orthopaedic Patients):ImmediatelyThen 30 minutes laterThen hourly for 24 hours after initial traction application. Re-bandage the traction whenever slippage of the skin extension is noted, otherwise this can lead to skin integrity damage under the bandagesNeurovascular observations are also performed 30 minutes after traction is re-bandaged (Refer to Section 2, Neurovascular Observations for Orthopaedic Patients policy)Teach and encourage the patient to perform exercises to maintain full range of movement of unaffected limbsAttend hand hygiene after touching the patient by either hand washing or using ABHRAny wound care requirements need to be documented on the General Wound Assessment Form and Wound Assessment and Management PlanReport any concerns to the MO. Ongoing care Check the patient’s skin condition daily by washing the skin and reapplying the skin extensions. No moisturiser is applied to the skin as this will increase the slippage of the bandagesPerform neurovascular observations as per Section 2 to ensure no adverse effects each shift (Refer to Section 2, Neurovascular Observations for Orthopaedic Patients)Each shift check the traction set-up to ensure effectiveness and safety, maintaining the line and magnitude of the traction pull and ensuring the correct weight is maintained. Weight bag needs to be clear of floor at all times.Back to Table of ContentsSection 11 – Care and management of pinsites following application of external fixation Equipment requiredAlcohol based hand rub Basic dressing packNormal salineGauze swabsClean glovesSterile glovesPersonal Protective Equipment (PPE) including safety goggles / shieldAntibiotic ointment (optional)Split foam dressing (optional)Silver dressing (and secondary dressing) if requiredOxygen tubing (optional)Wound swab (optional)Safety pin (if clamps in place)Clinical waste receptacleGeneral waste receptacle.ProcedureThe initial post-op dressing remains intact for 24 hours post insertion of the pins, after which pin site dressing/s are attended daily. If pinsite exudate is excessive twice daily pinsite care is required.For patient comfort and early assessment of potential problems, it is recommended that the wound be inspected within 24 hours and on a daily basis. All pin sites should be redressed after 24 hours as there is likely to be exudates in the first week. Pinsite infections can result in osteomyelitis and delayed fracture healing.External fixation is prescribed and applied by the medical officer. External skeletal pins are used for external fixation or for skeletal traction. External fixators will be used when the fracture is comminuted (many fragments) and/or compound (open) involving a wound, which connects directly with the fracture site.Attending Pin Site DressingEnsure patient has been offered analgesia prior to attending pin site dressingsAttend hand hygiene before touching the patient by either hand washing or using ABHRExplain the procedure and obtain patient consent as per consent and treatment policyEnsure the patient has privacy during the procedureDon clean gloves and goggles/shieldRemove old dressing or sponges; warmed normal saline solution may be needed if dressing/sponges have adhered to pins (if umbilical clamps are in place from theatre these can be removed using a safety pin)Discard waste into a clinical waste receptacleRemove glovesAttend hand hygiene by either hand washing or using ABHRALERT 1: Aseptic technique must be rigorously maintained at all times with pin site care.Follow principles outlines in the Aseptic technique procedureAssemble clean dressing equipment on cleaned dressing trolleyDiscard packaging in general waste receptacleAttend hand hygiene by either hand washing or using ABHR Don Sterile glovesObserve general circulation of the limbALERT 2: Alcohol and iodine based solutions should be avoided for cleaning pins due to accelerated corrosion of the metal and skin staining. Alcohol is damaging to the capillary bed when it drips into the wound. Hydrogen peroxide should be avoided as it is damaging to tissue.Remove any crusts that may have formed around the pins using gauze and warm normal salineRationale: Gentle removal of the crusts allows visualisation of the wound and encourages free drainage of exudate, which may harbour infection if allowed to collect below the skinLeave the wound to dry after cleaning, or dry with a clean gauze Rationale: Moisture encourages colonisation If exudates is present a foam dressing is cut and applied around the pin. If sutures/staples are present a film dressing is used around the pinsites until the staples/sutures are removed at 14 daysObserve the wound daily for redness, inflammation, odour, excess or purulent oozeProvide the patient with education to observe and report these signsDiscard waste in clinical waste receptacleRemove glovesAttend hand hygiene be either hand washing or using ABHRDocument the procedure and findings in the patients Clinical Care Plan, Clinical Record and Wound Assessment Chart see Wound Management Procedure. Important considerations and wound observationsWhere serous ooze persists or pus is present, a wound swab is taken and the MO notified (Refer to Wound Management Procedure)Observe the pin site for over-granulation of the skin growing up the pin site or tenting of the skin around the pin Where over-granulation has occurred or exudate is present, place a trimmed split foam dressing over the pin site Rationale: This applies a small amount of pressure on the surrounding tissue to prevent further tentingWhere there is increased tenderness or pain, redness, inflammation, odour, excessive exudate or pus at the pin site alert the MOObserve the pin for any movement and ensure pin attachments are secureOxygen tubing is applied to the pin points extending from the main frame to protect the linen and blankets of the patient’s bedEducate the patient on the importance of good pin site care and if they can perform the procedure teach them to do so Refer to DLN prior to discharge for community nursing follow upNote: if the pin sites are dry and there is no exudate the patient is able to shower normally. The external fixator can be left unprotected whilst showering provided there are no other dressings or wounds.Document the procedure and findings in the PCAP and the patient’s clinical record. If further wound care is required document on General Wound Assessment Chart and Wound Assessment and Management Plan and refer to the Tissue Viability Unit (TVU) nurses if concerned or support is required. Note: if localised signs of infection are evident, silver dressings can be utilised for 2 weeks and then reviewed. Consult the TVU nurses for advice.Back to Table of ContentsSection 12 – Use of Knee Joint Continuous Passive Motion Machine (CPM)Physiotherapists are required to ‘Fit’ a continuous passive motion (CPM) as a component of post-operative care to patients in the recovery or ward environment. Adult and adolescent patient with leg length suitable for this machine are covered by this procedure. Allied Health Assistants or Nursing staff that assist with this process must also comply with this procedure but are not expected to ‘fit’ a CPM.It is the responsibility of the physiotherapist applying the CPM to ensure they are following occupational health and safety guidelines; to ensure a clean CPM is applied, two staff members are used for application and to inform the physiotherapy assistant of the cleaning of the machine post use. It is the responsibility of the physiotherapy assistant to clean/store/ return the CPM to level 5 physiotherapy store room.ProcedureCPM provides regular movement to the knee using an external motorised device which passively moves the joint through a set arc of motion.CPM is utilised to stimulate the formation of synovial fluid which nourishes articular cartilage. The prevention of both the intra-articular adhesions and extra-articular contractures helps to maintain the range of movement (ROM) of the joint. In addition the application of CPM can prevent excess post operative swelling and reduce post operative pain. Machines and covers are stored in level 5 physiotherapy room.ApplicationSet the straps on the machine (the physiotherapist will demonstrate)Educate the patient on the role of the CPMEmphasise the importance of complying with the active exercise regime as well as the CPMPosition the patient correctly:supine or ? sitting only so as not to restrict knee Range of Movement (ROM) affected leg in slight abductionMeasure length of the lower leg from: knee joint to bottom of heel and knee joint to ischial tuberosity(this can be with a tape measure or eyeball and corrected on the patient)Adjust the machine to these lengthsCheck the machine is in full extension for application of the patient’s legPlace padding over the straps and then place the leg on machine Assistance may be necessary unless the patient can complete a straight leg raise(SLR)Assistance should be used to lift the CPM off the trolley onto patient’s bedCheck the position of the leg: patients knee joint must align with hinge and avoid limb rotation i.e. knee and toes should point to the ceilingRolled towels may need to be used to support leg in the correct position Adjust settings: speed (2-3), ROM ( as tolerated or ordered) NOTE: 3 is the maximum speed that should be used on the CPM Supply the patient with the control switchStart the machine and wait until maximum knee flexion has been achieved-assess painBlock the machine to avoid movement in the bed e.g. against foot of the bed or wedge bolster between machine and bed endPrescription of frequency and duration is determined on an individual basis following discussion with the medical team and senior orthopaedic physiotherapistOnce a CPM has been fitted for the individual patient by the physiotherapist it may be reapplied or removed by either an AHA or NurseRoutine use of the CPM is prescribed for manipulation under anaesthetic (MUA).Back to Table of ContentsImplementation This procedure will be available on the CHHS Policy Register.New staff in each division will require education as part of their orientation from those designated/responsible for orientation to their areas. Medical staff will orientate other medical staff to the procedure.Back to Table of ContentsRelated Policies, Procedures, Guidelines and LegislationPoliciesPatient Identification and Procedure Matching PolicyWork Health and Safety Management (WHSMS), sub section 7.7 Hazardous Manual Tasks and Office ErgonomicsNursing and Midwifery Continuing Competence Policy ProceduresFalls and Prevention Management ProcedureVenous Thromboembolism (VTE) Prevention Procedure Pressure Injury Prevention and Management ProcedureClinical Handover ProcedureWound Management ProcedureACT Health Patient Identification and Procedure Matching Procedure Patient Identification - Pathology Specimen Labelling ProcedureAcute Pain Management Techniques ProcedureVital Signs and Early Warning Scores ProcedurePost-operative Handover and observations-Adult patients (first 24 hours) ProcedureHealthcare Associated Infections ProcedureLegislationHealth Records (Privacy and Access) Act 1997Human Rights Act 2004Work Health and Safety Act 2011Back to Table of ContentsReferencesACT Health (2008) The Canberra Hospital, Acute Care Practice Manual, External Skeletal Pin: Site Care ?. The Joanna Briggs Institute.Maher A., Salmond S., Pellino, T., (2002) Orthopaedic Nursing, 3rd Edition W BSaunders, Philadelphia, pp 177-180.Dutton, M., (2004) Orthopaedic Examination, Evaluation and Intervention, 1stEdition, McGraw-Hill, Dow.Joanne Briggs Institute, TCH Manual, Neurovascular Assessment, Evidence Summary, March 2006Joanna Briggs Institute, TCH Manual, Observations: Neurovascular, Evidence Summary, February 2009 HYPERLINK \l "Contents" Back to Table of ContentsDefinition of Terms Comminuted fracture: a fracture in many fragmentsMRI – Magnetic Resonance ImagingCT – Computed Tomography scanSearch Terms Orthopaedic, Total Hip replacement, THR, Femur, Fracture, Total shoulder, TSR, Total knee, TKR, Limb fractures, Ankle, Tibia, Fibula, pelvis, traction, Knee Joint, Continuous Passive Motion Machine, CPM, Pinsites, External fixation, Skeletal, Camboot, AircastBack to Table of ContentsDisclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.Policy Team ONLY to complete the following:Date AmendedSection AmendedDivisional ApprovalFinal Approval 20 Jun 18Complete ReviewDaniel Wood, ED SOHCHHS Policy CommitteeThis document supersedes the following: Document NumberDocument NameTCH11:014Traction - Pin Site Care And Management Following Application Of External Fixation, Ilizarov Fixator And Skeletal Pins UsedTCH11:013Traction - Application And ManagementTCH11:010Neurovascular Observations For Orthopaedic PatientsTCH11:009Mobilisation Of Patients With Lower Limb Injuries Or Post Lower Limb SurgeryAttachment 1: Guide to assess the motor & sensory function of the Upper Limb NervesCircumflex, Ulnar, Radial, MedianNerveFunctionMotorNormalAbnormalSensoryNORMALABNORMALCIRCUMFLEX Supplies deltoid muscle Actively abduct arm at the shoulder: Can perform movements. Chart as full/Unable to perform movements due to pain, numbness or limited movement. Check if passive movement causes severe pain. Chart as decreased or absent – Call medical officerTouch over the deltoid area: Can feel touch the same as unaffected limb. Chart as full/Decreased or lack of sensation. Chart as decreased or absent. Call medical officerMUSCULOCUTANEOUS Supplies biceps and brachioradialis muscleActively flex arm at the elbow:touch radial side of the forearm:ULNAR Supplies ulnar side flexor muscles and hand's intrinsic muscles. Actively abduct (spread) all the fingers. Touch on pad of little finger: RADIAL Supplies extensor muscles of the arm. Actively dorsiflex the hand. If in Plaster- actively hyperextend the thumb and fingers Sensory- touch on the back of the hand between the thumb and index finger (thenar space)MEDIANSupplies the forearm flexor muscles especially to the thumb.Oppose (touch) thumb to all fingers of the handTouch index finger: Attachment 2: Guide to assess the motor & sensory function of the Lower Limb NervesSciatic, Femoral, Peroneal, TibialNerveFunctionMotorNormalAbnormalSensoryNormalAbnormalSCIATIC supplies the hamstring muscles and their divisionsThigh injury - actively flex of the kneeTibial injury- actively plantarflex the ankle. Actively evert and dorsiflex the footButtock or thigh injury - actively move foot and toesCan perform movements. Chart as full/Unable to perform movements due to pain or numbness. Check if passive movement causes severe pain. Chart as decreased or absent. Call medical OfficerButtock or thigh injury - touch all surfaces of the footThigh injury- touch all surfaces of the footTibial injury- touch lateral aspect of the calf, heel and sole of the footCan feel touch the same as unaffected limb. Chart as full/Decreased or lack of sensation. Chart as decreased or absent. Call medical OfficerFEMORAL supplies quadriceps femoriActively extends knee:Touch medial aspect of foot:PERONEAL supplies the peroneal and anterior tibial muscles.Actively dorsiflex ankle. If in POP- actively extend toes at metatarsal and phalangeal jointsTouch in the first webbed space between the big and second toesTIBIAL supplies gastrocnemius and soleus muscles, and the toes' flexorsActively plantarflex the ankles and toes. If in POP - actively plantar-flex toesTouch on the medial and lateral surface of the sole of the foot:Attachment 3: Guide Vascular integrityCHECKNORMALABNORMALColourSkin colour distal to injurySkin colour should be the same as unaffected limb. Chart as natural (for darker skin tones) or pink. Skin different colour to unaffected limb. White or pale indicates inadequate arterial supply. Blue indicates inadequate venous return. Chart as red, white or grey (pale) or blue. Urgent medical reviewWarmth Skin warmth distal to the injurySkin warmth should be the same as unaffected limb. Chart as warm or coolSkin different temperature to unaffected limb. Cold indicates inadequate arterial supply. Hot indicates inadequate venous return. Chart as hot or cold.Urgent medical reviewCapillary returnSqueeze the fleshy pad of a finger or toe for 2 to 3 seconds. Release pressure and observe time taken for colour to returnColour should return in 2 to 3 seconds. Chart time taken for colour to return Colour takes longer than 3 seconds to return. Chart time taken for colour to returnUrgent medical reviewPeripheral pulse Peripheral pulse distal to injuryPulse should be the same strength as pulse on unaffected limb. Chart as presentDiminished or no pulse palpable. Pulse may still be present with Compartment Syndrome. Chart as diminished or absent. Urgent medical reviewSwellingCompare size of limb with unaffected limb:Limb is the same size as unaffected limb. Chart as nilLimb enlarged compared with unaffected limb. Chart as increased, decreased or unchanged. Where swelling is abnormal it is a good practice point to observe swelling on patient handover so incoming staff are aware of the degree of swelling Urgent medical review ................
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