Shoulder immobilization can be accomplished with a sling or shoulder immobilizer. An airplane splint (a padded and Velcro shoulder orthotic used to position the shoulder in various degrees of abduction; Fig. 37-1) may be applied for rotator cuff repairs and other involved humerus fractures and postoperative shoulder or arm surgery where shoulder position and elbow flexion control are desired. If a sling is used, the patient is instructed to keep the arm close to the chest, with the wrist and elbow supported. All shoulder immobilizers require special care and padding to areas where skin contacts skin.

FIG. 37-1 Airplane splint.

(From Coppard BM, Lohman H: Introduction to splinting: a clinical-reasoning and problem solving approach, ed 2, St. Louis, 2001, Mosby.)

The patient with a hip pinning is positioned with proper body alignment, and the legs are in a proper neutral position. Care is given to avoid stress to the operative area with exaggerated flexion or rotation. A pillow is placed between the knees during turning to prevent adduction and rotation.

For the patient with a posterior or lateral total hip replacement, proper body alignment is achieved with placement of an abduction pillow between the knees at all times (Box 37-1). Most important with these patients is to avoid flexion and adduction of the newly placed joint. There are four basic positions to be avoided after hip surgery: 1) no flexion of the hip past 90 degrees with respect to the axis of the body; 2) no abduction of the leg past the midline of the body; 3) no combined extension of the hip joint with external rotation of the lower extremity; and 4) no flexion with internal rotation. Use of the abduction pillow helps to prevent the patient from getting into positions that could cause dislocation. The patient who has had an anterior total hip replacement does not require dislocation precautions. Therefore there is no need for an abduction pillow, traction sling, or hip cushion to assist with positioning.¹

BOX 37-1 Surgical Approaches for Total Hip Arthroplasty

The approaches for total hip arthroplasty vary in the invasiveness of the hip musculature: (1) the posterior approach, (2) the lateral or transgluteal approach, (3) the anterolateral approach, and (4) the anterior approach.

1. The posterior approach (i.e., Kocher-Langenbeck approach) splits the gluteus maximus muscle and detaches the posterior external rotator muscles (i.e., the piriformis, obturator internus and externus, superior and inferior gemellus).

2. The lateral or transgluteal approach (i.e., Harding approach) splits the gluteus medius muscle and detaches the gluteus minimus and the anterior third of the gluteus medius muscles from the femur.

3. The anterolateral approach (i.e., Watson-Jones approach) is performed posterior to the tensor fascia lata and anterior to the gluteus medius and splits the hip deltoid muscle, which consists of the gluteus maximus and tensor fascia lata muscles.

4. The anterior approach (i.e., short Smith-Petersen and Hueter approach) does not split or detach muscles. This approach is performed over the tensor fascia lata, inside the tensor sheath, anterior and medial to the tensor fascia lata, and lateral to the sartorius and rectus femoris muscles.

(From Munro CA: The perioperative nurse’s role in table-enhanced anterior total hip arthroplasty, AORN J 90:54, 2009. Illustration by Kurt Jones.)

The perianesthesia nurse should also be familiar with various types of orthopedic equipment that may be used and that can affect positioning. Often, patients with total knee replacement and those with more extensive knee arthrotomy are placed in a continuous passive motion (CPM) machine. The purpose of CPM is to enhance the healing process by providing CPM to the joint, thus increasing circulation and movement. Traction may also be used with various patients to immobilize and align a specific area. The perianesthesia nurse is not usually involved in setting up the traction, but should be aware of some basic principles for maintenance: (1) the traction must be continuous, (2) the patient is centered in bed in good alignment to maintain the line of pull in line with the long bone, (3) weights should hang freely and not resting on the floor or bed, and (4) the pulley ropes should be in alignment and free of knots. One type of traction is depicted in Fig. 37-2.

FIG. 37-2 Russell skin traction (single) with overhead frame and trapeze.

Neurovascular assessment

Critical to the care of the patient for orthopedic surgery is assessment of the neurovascular status of the operative limb. Any alteration in blood flow to the extremity or nerve compression requires immediate intervention. Assessment is recommended every 30 minutes because problems can occur within 2 to 4 hours. Baseline neurovascular indicators should be noted in the admission nursing assessment. These indicators can be used to establish any deleterious effects from the surgery and to avoid the masking of potential complications. Both the affected and unaffected limbs are assessed.²

The hallmarks of neurovascular changes from constriction and circulatory embarrassment are pain, discoloration (skin that is pale or bluish), decreased mobility, coldness, diminished or absent pulses, altered capillary refilling, and swelling. Pain is common with patients for orthopedic surgery, and the approach to treatment must be individualized. Pain unrelieved with conventional methods, such as elevation and repositioning and the administration of opioids, must be assessed further. Color indicates circulatory compromise.² Cyanosis suggests venous obstruction; pallor suggests arterial obstruction. Mobility is assessed by determining the range of motion of the fingers or toes and strongly indicates neural compromise. Fingers are flexed, extended, spread, and wiggled. Toes should be dorsiflexed, plantarflexed, and wiggled. An inability to move the fingers or toes, pain on extension of the hand or foot, or coldness of the extremity is indicative of ischemia. Sensation is described as normal, hypesthetic (dulled), paresthetic, or anesthetic. Alteration in sensation suggests nerve compression or circulatory compromise. Limb perfusion is further assessed with the presence of peripheral pulses and capillary refilling. Capillary refilling is assessed with compression of the nail bed, which causes blanching; when the compression is released, color briskly returns. Compromise delays the filling time. With the development of pulse oximetry, a more reliable method of perfusion assessment is available. With placement of the oximeter sensor on a finger or toe of the affected limb, the pulsation is sensed and oxygen saturation is displayed. This method is more reflective of perfusion than capillary refilling and is valuable when pulses cannot be assessed because of the presence of a cast or dressing.

Care of immobilization devices (cast care)

Immediate assessment of the patient after orthopedic surgery in the PACU should include the type of immobilization device applied. The soft knee immobilizer should be checked for proper placement and closure, and the surgical dressing should be checked for drainage. For care that involves traction, refer to the previous section in this chapter on positioning.

The cast is a rigid immobilization device molded to the contours of the part to which it is applied. The cast has a dual purpose: immobilization in a specific position and provision of uniform pressure on the encased soft tissue. The cast should be inspected for visibility of fingers and toes for neurovascular assessment. If the cast is bivalved, the edges should be inspected for roughness to avoid discomfort and potential skin breakdown. When the patient arrives in the PACU, the cast is likely still wet, and special care must be taken to prevent indentations. A wet cast must be handled carefully with the palms of the hand to avoid pressure from fingertips. The cast should be supported on a pillow, and hard flat surfaces should be avoided. Improper handling and flat surfaces can cause indentations that can lead to the development of pressure sores. More frequently, a fiberglass cast is applied with quicker drying properties, but the same general principles still apply.² In general, a full cast may not be placed on a patient where wound drainage is expected (a temporary splint or cast would be used), but any drainage noted on the cast should be circled, and the time should be noted. This documentation can provide a guide for postoperative blood and fluid loss and can alert the nurse if the drainage appears to be excessive. Note that orthopedic wounds tend to ooze and may bleed more than other surgical wounds.

Wound care

All surgical dressings should be checked for drainage and closure. Patients with orthopedic surgery are highly susceptible to infection; therefore strict asepsis is required when changing dressings or handling drains. Drains may be placed in the wound to minimize blood accumulation and the possibility of infection. Care must be taken to attend these drains and maintain suction.

A patient with total joint replacement may commonly have a large amount of blood loss in the immediate postoperative period. This loss can be as great as 250 to 300 mL in the first hour. With advances in technology and the implementation of minimally invasive techniques, blood loss of even 150 mL in the first hour could be significant and may require surgeon notification. The retrieval of this blood for reinfusion (autotransfusion), when coupled with preoperative autologous blood donation, has substantially reduced the need for homologous transfusions. Autotransfusion is accomplished with the use of self-contained disposable systems that are designed for easy setup and safe use.

Range-of-motion exercises

Range-of-motion exercises can be initiated in the PACU as soon as the patient is alert and cooperative. Flexion, extension, and rotation of joints distal to the operative area assist in stimulating circulation and strengthening muscles. Quad tightening exercises, if permitted by the physician, may also be helpful. Prevention of venous stasis decreases the incidence rate of thromboembolism, and early movement of joints promotes healing and stabilization.

Observation for complications

Postoperative complications for the patient after orthopedic surgery include deep vein thrombosis, pulmonary embolism, fat embolism syndrome, compartment syndrome, shock, and urinary retention.

Deep vein thrombosis

Prevention of deep vein thrombosis (DVT) is a major concern for patients undergoing orthopedic surgery, especially total joint replacement.³ Other contributing risk factors include age, previous history of DVT or pulmonary embolism (PE), metastatic malignancy, smoking, estrogen or current pregnancy, vein disease, obesity, and genetics (Box 37-2). Thrombosis is the formation of a blood clot associated with three conditions outlined by Virchow in 1846: venous stasis, altered clotting mechanism, and altered vessel wall integrity.⁴ Immobilization and the insult of the surgical procedure place the orthopedic patient at high risk. DVT refers to the formation of a thrombus within the deep vein, typically the thigh or calf. In reports of total hip arthroplasty before routine prophylaxis, venous thrombosis occurred after total hip replacement in 50% of patients, and fatal pulmonary emboli occurred in 2%.³ Immobilization impairs the leg muscle action needed to move the blood sufficiently, and the surgical procedure injures vessel walls that activate and alter clotting mechanisms. An inflammation process begins within the vessel wall and leads to deep vein thrombosis. The patient usually has pain and tenderness. Signs include swelling and sometimes localized redness. Palpation of the calf reveals firmness or tension of the muscle. A positive Homans sign may be seen, although a positive sign does not accurately diagnose a DVT alone.⁵ DVT can be difficult to diagnose. Diagnostic tests such as venography, magnetic resonance imaging, or Doppler ultrasound may be indicated.

BOX 37-2 Risk Factors for Venous Thromboembolic Disease

Clinical Risk Factors	Hemostatic Abnormalities (Hypercoagulable States)
Advanced age	Antithrombin III deficiency
Fracture of pelvis, hip, femur, or tibia	Protein C deficiency
Paralysis or prolonged immobility	Protein S deficiency
Prior venous thromboembolic disease	Dysfibrinogenemia
Operation involving abdomen, pelvis, or lower extremities	Lupus anticoagulant and antiphospholipid antibodies
Obesity	Myeloproliferative disorder
Congestive heart failure	Heparin-induced thrombocytopenia
Myocardial infarction	Disorders of plasminogen and plasminogen activation
Stroke

Adapted from Anderson FA, Spencer FA: Risk factors for venous thromboembolism, Circulation 107:S19, 2003; Lieberman JR, Hsu WK: Current concepts review: prevention of venous thromboembolic disease after total hip and knee arthroplasty, J Bone Joint Surg 87A:2097, 2005.

Prevention of DVT includes providing adequate hydration, early mobility, and exercise and applying compression elastic stockings and external compression devices to enhance venous flow. Rehabilitation beginning the first day after surgery will help to prevent venous complications. The pneumatic stockings (alternating–pressure gradient stockings) automatically provide a consistent compression-decompression system and are used in patients having many surgical procedures, including total hip replacement and spinal surgery. Surgeon’s preference typically dictates the choice of postoperative anticoagulant therapy for patients at high risk, such as those with total joint replacements. The ideal agent for pharmacologic prevention of DVT has not been determined.³ Most hospitals use a detailed DVT prophylaxis screening tool or protocol to assess each patient’s individual need for anticoagulation therapy and thromboprophylaxis. All health care facilities who are accredited by The Joint Commission must comply with National Patient Safety Goal 03.05.01 to “take extra care with patients who take medication to thin their blood.”⁶

(From Canale ST, Beaty JH: Campbell’s operative orthopaedics, ed 11, Philadelphia, 2008, Mosby.)

Shock

Because of the highly vascular composition of bone and secondary injury to the soft tissue, hemorrhage is always a potential risk after trauma and orthopedic surgery. Vigilant observation of the operative area and blood pressure and pulse alerts the perianesthesia nurse to any impending danger. Immediate nursing measures include keeping the patient warm and flat in bed, monitoring vital signs, and replacing fluid volume. The surgeon is notified immediately, and more definitive treatment is initiated (see Chapter 54).

Urinary retention

Urinary retention refers to the inability to void despite the urge or desire. This condition can occur in adult patients on whom hip or back surgery has been performed. The retention may be the result of spinal anesthesia or possibly the inability to void in the supine position. These patients should be monitored for bladder distention and pain in the lower abdomen. The surgeon should be notified if distention occurs or if the patient is unable to void within 8 hours after the surgery is completed. It is common practice in many perianesthesia units to use a bladder ultrasound to assess bladder volume, urinary retention, and postvoiding residual volume in postoperative patients.

Perianesthesia care after hand surgery

Hand surgeries have become highly specialized, and there are numerous procedures including carpal tunnel release, excision of ganglions, fractures of carpal bones, or digit reimplantation.⁸ There are several anesthesia options for patients undergoing hand surgery. Regional blocks to selectively block sensory functions of specific nerves are frequently used; these include digital blocks, wrist blocks, IV regional blocks, and axillary blocks. Therefore, many times patients with hand surgery bypass PACU Phase I and are admitted directly to PACU Phase II. Large bulky dressings may be in place on the hand and forearm. Ace wraps or elastic bandages for application of pressure may also be in place outside the dressing. The hand should be elevated above the level of the heart at all times to prevent edema and hemorrhage. The hand may be placed on pillows on the chest of the patient or suspended from the bed frame or IV pole with a stockinette. The elbow should be supported with a pillow. Support under the shoulder and wrist aids in decreasing pressure to the elbow. If a drain is present, it should be checked to ensure that it is activated, or it may be connected to a vacuum blood tube. The drain is placed to minimize the bleeding into the wound and to reduce the possibility of infection. Drains should be checked every 1 or 2 hours to maintain a proper vacuum, and the output should be recorded on the intake and output records. The tips of the fingers should be visible, and the neurovascular status should be assessed every 30 minutes for signs of change. If a regional block is used for anesthesia, the perianesthesia nurse must be aware that the patient’s sensation and movement might not fully return for several hours after surgery and extremities must be protected from injury. Baseline neurovascular indicators should be noted in the admission nursing assessment and can be used to establish any deleterious effects from the surgery.

Perianesthesia care after arm and forearm surgery

Postanesthesia care of the patient who is recovering from arm and forearm surgery centers on elevating the extremity, observing for excessive bleeding, and monitoring for neurovascular changes. The radial pulse should be taken every 30 minutes and compared with that of the unaffected limb. If pulses cannot be assessed because of a dressing or cast, the pulse oximeter sensor should be placed on a finger of the affected arm; the pulsation reflects perfusion to the limb. Any decrease in intensity of the pulse or in bilateral strength of the hand, any excessive bleeding, and any changes in neurovascular status should be reported to the surgeon. Symptoms of excessive pain, weakness, or decreased sensation, especially on passive extension of the fingers, usually indicate compartment syndrome, which constitutes an orthopedic emergency. Patients should be encouraged to perform active range-of-motion exercises with the wrists and hands. The perianesthesia nurse should keep in mind that peripheral nerve blocks are frequently used as primary anesthesia or for prolonged postoperative analgesia for these types of surgeries. Patients should be aware that they will have temporary loss of motor function and sensation from these blocks, and protective precautions must be taken.

Perianesthesia care after shoulder surgery

Shoulder surgery can include arthroscopy, arthrotomy, rotator cuff repair, or total shoulder joint replacement. The patient may be admitted to the PACU with a bulky pressure dressing in place along with a sling-style shoulder immobilizer. The immobilizer should not interfere with chest expansion, because this inhibits adequate respiratory exchange. The surgical dressing should be inspected for bleeding because the shoulder is a vascular area in which hemorrhage is difficult to manage.

Inspection should include checking to see whether any skin surface is in contact with another. If this situation occurs, a protective pad should be inserted between the two skin surfaces. The radial pulse should be monitored, because flexion of the arm in the immobilizer can reduce blood flow to the hand. The immobilizer should be checked for areas that might be causing pressure to the shoulder and arm. The elbow and wrist should be supported to prevent any undue pressure to the ulnar and radial nerves. Again, neurovascular observations are a critical part of the postanesthesia assessment of these patients. The patient should be encouraged to perform active range-of-motion exercises with the hand. Ice packs or cryotherapy may be ordered to decrease edema and pain. Management of pain can include intraoperative intraarticular injection of local anesthetic, interscalene block, opioids, and or nonsteroidal antiinflammatory drugs (NSAIDs).² Some surgery patients benefit greatly from peripheral nerve block for prolonged postoperative analgesia (see Chapter 25 for further information on regional anesthesia).

Perianesthesia care after hip or femoral surgery

Total joint replacement or arthroplasty may be indicated in patients with painful debilitating arthritis that has failed to respond to conservative treatment over a period of time. It may also be indicated for patients with degenerative joint disease, rheumatoid arthritis, or avascular necrosis. A hip arthroplasty is a replacement of damaged or arthritic surfaces of the hip joint with materials to restore the integrity of the hip joint. The materials can be metal, plastic, or ceramic. The joint is replaced with a ball that is solidly fixed to a stem inserted into the femur and a cup that is fixed to the acetabulum, or socket. The implants are designed to create a new smoothly functioning joint that prevents painful bone-on-bone contact. A minimally invasive surgical technique is available for hip replacement. The minimally invasive technique reduces the incision from 6 to 8 inches to 3 to 4 inches and reduces the extent of soft tissue disruption in the hip. The decreased trauma to the muscles, ligaments, and tendons results in less postoperative pain. Other advantages of the minimally invasive hip replacement include shorter hospital stays, earlier mobilization, quicker rehabilitation, less blood loss, and a faster return to productivity and normal activities. The anterior approach is becoming more widely used for hip replacement because it does not split or detach muscles (see Box 37-1).¹ Advantages to the anterior approach include less postoperative pain, shorter length of stay, a single and small incision, no postoperative dislocation precautions because of decreased risk of dislocation, and immediate weight bearing on the leg.¹

A hemiarthroplasty resurfaces the femoral head and is often used for displaced femoral fractures. Hip fractures include femoral neck fractures, intertrochanteric fractures, and subtrochanteric fractures. These types of fractures generally require open reduction with internal fixation. They occur in women more frequently than in men, mainly because of osteoporosis. Efforts should always be made to get these patients to surgery as soon as possible to avoid complications related to immobility, pressure, thrombophlebitis, or pulmonary compromise. Femur fractures are also frequently seen in trauma patients and will also require open reduction with internal fixation.

When the patient who has had hip or femoral surgery is admitted to the PACU, nursing assessment should include pulmonary and neurovascular function, body alignment, and the amount and type of bleeding from the surgical incision. Because of long bone trauma and the often advanced age of this group of patients, these patients represent the highest risk group for postoperative orthopedic complications. Many of these patients receive spinal anesthesia and the perianesthesia nurse must monitor the level of spinal blockade close and be alert for hypotension associated with spinal anesthesia (see Chapter 25 for further information on spinal anesthesia).

Preexisting medical conditions and the effects of anesthetic agents may compromise respiratory function. Coughing and deep breathing, sustained maximal inspirations, and position changes, when possible, are of utmost importance. The incentive spirometer can be used to facilitate good lung expansion. Any change in pulmonary dynamics should be reported to the anesthesia provider.

Because swelling at the operative site can reduce blood flow to the feet, neurologic signs along with pulses of the affected foot should be monitored and compared with those of the unaffected foot. The dorsalis pedis pulse can be palpated on the dorsum of the foot and lateral to the extensor tendon of the great toe. The posterior tibial pulse can be palpated just behind and slightly below the medial malleolus of the ankle. The extremity is elevated where indicated.

The body should be aligned as normally as possible. The legs and feet are maintained in a neutral position, elevated as indicated, and supported to avoid rotations of and pressure on the heels. Traction may be applied and has been discussed previously in this chapter. These patients may have antiembolism hose, sequential compression devices, or abduction pillows in place and should be observed for peroneal nerve compression. Compression can occur where the peroneal nerve crosses the knee at the head of the fibula. Decreased sensation over the dorsum of the foot, tingling, extremity weakness, and an inability to bring the foot up are indicative signs of this injury, which is a common cause of foot drop. The patient should be encouraged to perform active range-of-motion exercises of the ankle to enhance venous return.

The patient with posterior total hip replacement has an abduction pillow placed between the knees at all times. This position must be maintained to avoid adduction and internal rotation of the newly placed joint. The patient should not be allowed to flex the hips at a greater than 30- to 40-degree angle or to adduct the leg of the affected side. The muscle groups are weakened, and dislocation of the joint is a potential risk. If turning is necessary, the patient may be turned to the unoperated side no more than 45 degrees, with hip abduction maintained and total leg support provided. The head of the bed can be elevated no more than 45 degrees. The patient who has had an anterior total hip replacement does not require an abduction pillow, traction sling, or hip cushion to assist with positioning.¹ Many of these patients use a walker and begin ambulation the same day of surgery.

An autotransfusion system or other drain with suction, such as a Hemovac, may be inserted at the operative site to facilitate the removal of blood; the color and amount should be inspected frequently. Autotransfusion is a technique that salvages red blood cells lost by the patient at the wound site and re-infuses that blood into the same patient. Autotransfusion may be used if the patient is expected to lose enough blood during the perioperative period to require transfusion and can reduce or eliminate the need for allogeneic transfusion. The patient may also receive autologous blood that was provided by the patient before surgery.⁹ The perianesthesia nurse should know how to operate any device that is used for drainage or autotransfusion and the hospital policies and procedures that apply (Fig. 37-4). If drainage systems are in use, the nurse should monitor the drainage and notify the surgeon for excessive volume or bright red blood.

FIG. 37-4 OrthoPAT orthopedic perioperative autotransfusion system.

(Used with permission of Haemonetics Corporation, Braintree, Mass.)

Perianesthesia care after knee surgery

Total knee arthroplasty is a surgical procedure to replace the worn surfaces of the knee. This goal of this surgery is to relieve the patient’s complaints of chronic knee pain and instability. The replacement implants are designed to create a new, smoothly functioning joint that prevents painful bone-on-bone contact. Many different types of designs and materials are currently used in total knee replacement surgery, nearly all of which consist of three components: the femoral component (made of a highly polished strong metal), the tibial component (made of a durable plastic often held in a metal tray), and the patellar component (also plastic). Surgeons may elect to replace all or part of the knee, depending on the patient’s condition and the extent of the arthritis affecting the knee (Fig. 37-5).³ In patients with only limited knee arthritis, surgeons may choose to perform a unicompartmental or partial knee replacement. Unlike total knee replacement that involves removal of all the knee joint surfaces, a unicompartmental knee replacement replaces only one side of the knee joint. Usually knee osteoarthritis occurs first in the medial compartment of the knee, because this side of the knee bears the most weight. If the knee is otherwise healthy, a unicompartmental approach allows the outer compartment and the ligaments to remain intact, which may help the joint bend better and function more naturally. The partial knee replacement is done through a small incision, with minimal trauma to surrounding tissue. Many patients leave the hospital on the same day of or on the day after the surgery. Patients also have less postoperative pain, earlier mobilization, and less blood loss, which results in a faster return to activities of daily living. The total knee replacement is performed more frequently than the unicompartmental knee and involves replacing the opposing femorotibial joint and the patellofemoral joint.

FIG. 37-5 Knee implant components. Up to three bone surfaces may be replaced in a total knee replacement: 1) The lower ends of the femur. The metal femoral component curves around the end of the femur (thighbone). It is grooved so the kneecap can move up and down smoothly against the bone as the knee bends and straightens. 2) The top surface of the tibia. The tibial component is typically a flat metal platform with a cushion of strong, durable plastic, called polyethylene. Some designs do not have the metal portion and attach the polyethylene directly to the bone. For additional stability, the metal portion of the component may have a stem that inserts into the center of the tibia bone. 3) The back surface of the patella. The patellar component is a dome-shaped piece of polyethylene that duplicates the shape of the patella (kneecap).

(Modified with permission from OrthoInfo © American Academy of Orthopaedic Surgeons, available at http://orthoinfo.aaos.org.)

Postanesthesia care of the patient who has had surgery of the knee involves observation for complications and proper knee positioning. After knee surgery, the patient may arrive in the PACU with a bulky compression dressing in place. Ice over the surgical site may be ordered to provide comfort and minimize swelling. The leg should be elevated and positioned in full extension, which can be facilitated by elevation at the ankle so that maximum extension of the leg can be accomplished. Assessments of neurovascular status should be performed frequently. Any decrease in sensation over the dorsum of the foot should be noted because it can represent compression of the peroneal nerve where it crosses the fibula at the knee. The surgeon should be notified if any neurologic or circulatory change is found, because early detection and correction prevent permanent nerve deficit or ischemic muscular injury. If the patient received a spinal anesthetic, the nurse cannot initially assess the patient’s motor function. One of the most significant complications after total knee arthroplasty is the development of DVT, possibly resulting in a PE ³ (see the previous discussion of DVT and PE).

These patients should be encouraged to flex, extend, and rotate the ankles as soon as possible to improve circulation. Knee-strengthening exercises can also be started in the PACU. Isometric exercises and quadriceps sets aid in healing the muscle and providing stability to the joint. Isometrics involve a 6-second contraction of the entire leg followed by relaxation. The quadriceps sets require contraction of the quadriceps muscle while pressing the knee to the bed for 5 to 10 seconds and then relaxation.

The patient with total knee replacement and the patient who has undergone extensive arthrotomy knee repair are sometimes placed in a CPM machine (Fig. 37-6). This device provides a safe method of elevation, comfort, and continuous range-of-motion to the operative knee. The CPM promotes healing by increasing circulation and movement of the knee joint. The machine should be inspected to ensure proper positioning of the limb. The flexion and extension settings of the machine should be determined by the physician and are generally 0 to 30 degrees at slow speed initially.

FIG. 37-6 OptiFlex Knee continuous passive motion machine with bed mount.

(Courtesy Chattanooga Group, Hixson, Tenn.)

Extensive knee procedures may have large amounts of drainage. An autotransfusion device or Hemovac drain may be present to facilitate removal of drainage from the wound. The Hemovac drain is emptied and reactivated as necessary. Drainage amounts of 250 to 300 mL in 1 to 2 hours are not uncommon. See the section on Hip Replacement Surgery for a discussion of autotransfusion.

Arthroscopic examination of the knee is done to facilitate minor repairs and the diagnosis of more extensive damage to the knee. In general, fewer postoperative complications occur because this procedure is less invasive. However, neurovascular assessment remains an important part of the postanesthesia care of these patients.

Perianesthesia care after foot surgery

The patient who has had a surgical procedure performed on the foot has either a cast or a bandage over the operative site. The amount and color of bleeding should be noted. Neurovascular signs should be monitored every 30 minutes. The exremity should be elevated above the level of the heart, with pillows supporting the entire length of the leg.

Perianesthesia care after spinal surgery

Several types of spinal procedures exist. The important features of the postoperative assessment relate mostly to the surgical area of the spine. Patients who have had a cervical procedure should be monitored for neurologic signs of the upper extremities. Symptoms such as weakness and radiating pain should be reported to the surgeon. Patients in halo traction should be monitored for any deficiency in the sixth cranial (abducent) nerve. Any decrease in the lateral movement of the eye is indicative of injury to the abducent nerve.

If the surgical procedure involves C3, C4, or C5, respiratory movements should be monitored because the diaphragm muscle is innervated by the spinal outflow from these vertebrae. The patient with this nerve deficit has a lack of diaphragmatic excursion and shortness of breath and uses the intercostal and accessory muscles in breathing. If these symptoms appear, oxygen should be administered and assistance in ventilation may be necessary.

An ileus can develop in patients who have had midthoracic or lower spinal surgery. This complication is signaled by abdominal distention, diminished or absent bowel sounds, and tympany on percussion of the abdomen. The usual treatment is to withhold oral food and fluids and to decompress the stomach with a nasogastric tube.

Patients who have had lumbar or sacral spinal surgery should be observed for loss of strength in the lower extremities and bladder distention. Bladder distention may be indicated by diaphoresis, hypertension, tachycardia, tachypnea, and a feeling of distress. If the patient has a catheter in place, it should be irrigated to remove any obstruction. If the patient has no urinary catheter and cannot urinate, the surgeon should be notified.

Patients with progressive curvature of the spine (scoliosis) may undergo a Harrington or Luque rod insertion for correction or stabilization of the spine. The procedure entails a spinal fusion followed by rod placement. The postanesthesia assessment entails those features included in the assessment of the patient after thoracic and lumbosacral spine surgery.

Patients who have surgery on the spine should also be observed for bleeding from the site of the operation. The patient should be turned from side to side to help reduce stasis of fluids in the lungs. The technique for turning the spinal patient is called log rolling.² All parts of the patient’s body should move in unison. To facilitate this action, a pillow is placed between the patient’s knees, and the knee opposite the side the patient is turned to should be flexed. The use of a draw sheet can also help to facilitate turning in one smooth motion. Pillows should be placed to support the length of the back and buttocks along with the pillow between the patient’s knees. This method of turning the patient puts the least amount of pressure on the spine. With the advent of microdisk surgery, disturbance to the stability of the spine is minimal, and these patients are generally allowed activity as desired and often go home on the first postoperative day.

All spinal surgery patients with restricted movement should be wearing antiembolism or pneumatic stockings, and ankle pumping and rotation should be encouraged to decrease the stasis of blood in the lower extremities. The patient should be encouraged to use the incentive spirometer every hour to reduce the stasis of fluids in the lungs. Neurovascular evaluation is performed every 30 minutes to assess any improvements or deficiencies. Pain is a relative experience for the patient after spinal surgery. In many instances, the relief from nerve compression pain is so dramatic that the operative site pain is minimized. In other instances, the pain from spinal fusion is often difficult to manage. As discussed previously in this chapter, the pain experience must be individualized and treated appropriately. The perianesthesia nurse’s goal is to help the patient perceive the pain as something that can be controlled rather than a fearful unrelenting burden.

Perianesthesia care after limb amputation

Patients who have had an amputation of the leg are admitted to the PACU with a dressing or a cast applied to the extremity. A cast is used to provide uniform pressure to the soft tissue, to control swelling, and to position the limb to avoid contracture (see cast care discussed previously in this chapter in the section on immobilization devices). To prevent hip contracture, elevation of the lower extremity with a soft compression dressing should be achieved by elevating the foot of the bed rather than using a pillow.² The patient with an amputation of the arm usually has a bulky compression dressing in place. The dressing should be assessed for drainage. The extremity should be elevated, and ice can be applied to reduce postoperative edema and discomfort. Opioids should be given for pain control. Phantom limb pain should be assessed and treated with appropriate pharmacologic agents. Adequate treatment is important to reduce the risk of chronic phantom pain syndrome.²

Postoperative pain management for the patient after orthopedic surgery

Orthopedic pain can be severe because of the significant muscle and skeletal tissue repair or reconstruction.¹⁰ Pain management is vital in allowing the orthopedic patient to participate in early ambulation and physical therapy; both are key components of recovery.¹⁰ Pain management for the orthopedic patient involves conventional pain protocols and can include the insertion of an epidural catheter or use of a patient-controlled analgesia pump (see Chapter 31). The patient-controlled analgesia pump administers a predetermined intravenous dose of the prescribed pain medication. The pump can be set to allow a continuous infusion of analgesic and bolus administration when the patient finds it necessary. Nonopioid analgesics such as acetaminophen, aspirin, and NSAIDs can also be used, with the possibility of gastrointestinal irritation, renal and hepatic toxic effects, and the inhibition of platelet aggregation kept in mind. Opioids such as hydromorphone, morphine, and fentanyl can be administered via IV drip, epidurally, or intrathecally to promote analgesia. Increasingly, orthopedic surgeons are using single-use systems that provide continuous delivery of local anesthetic through a small catheter inserted directly into the surgical site to decrease postoperative pain. The catheter is secured at the operative site with the dressing and with tape. Frequently, the patient is discharged home with this type of pain management. Also of note is the increased use of peripheral nerve blocks for postoperative pain management. These blocks are well tolerated by the patient and greatly increase patient satisfaction. A multimodal approach to pain management allows the lowest effective dose of each medication (opioids, NSAIDs, local anesthetics) to be administered, resulting in less side effects.¹⁰ Anticonvulsants can also be used and can produce an opioid dose-sparing effect and improve pain control.¹⁰

The perianesthesia nurse must collaborate with the surgeon and the anesthesia provider to determine an individualized plan of care to provide the patient with appropriate and effective pain management (Box 37-3).

BOX 37-3 Management of Postoperative Orthopaedic Pain: Summary of Key Points

• Screen all patients preoperatively for underlying chronic (persistent) pain.

• If present, assess pain control and medication use.

• Contact primary care provider if pain is poorly controlled.

• With the exception of nonselective NSAIDs, continue pain medications; switch from a nonselective NSAID to a COX-2 selective NSAID or a nonselective NSAID with minimal antiplatelet effect.

• Anticipate higher opioid requirements in patients who are taking regular daily doses of opioids preoperatively.

• Establish comfort-function goals with patients preoperatively whenever possible.

• Teach the use of equipment that will be used postoperatively, such as IV PCA pumps, during the preoperative interview whenever possible.

• Ensure multimodal analgesia regardless of primary mode of therapy. The following applies to any treatment plan.

• Unless they are contraindicated, acetaminophen (oral or rectal) and an NSAID (oral, rectal, or IV) should be administered preoperatively or as soon as possible in the PACU.

• Consider a COX-2 selective NSAID after fracture or procedures requiring bone healing.

• Consider adding an anticonvulsant for neuropathic pain or difficult-to-control pain.

• Administer IV opioid doses to patients who have pain on admission to the PACU until a safe and satisfactory level of comfort is achieved.

• Opioid analgesics

• Give scheduled, around-the-clock doses for continuous pain.

• Consider a long-acting formulation for moderate-to-severe pain if an oral opioid is appropriate.

• Establish a protocol for RN administration of IV opioid range orders.

• Avoid IM administration of opioids because of unreliable and variable absorption; it is not recommended for any type of pain management.

• PCA

• Patient must understand relationships between pain, taking pain medication, and pain relief and be cognitively and physically able to use the PCA equipment.

• Ensure that the patient is relatively comfortable before initiating PCA therapy.

• For IV PCA, use basal rates with caution in opioid-naive patients.

• Oral PCA is appropriate for treatment of intermittent or breakthrough pain in patients who can take oral medications and are cognitively and physically able to use the PCA equipment.

• Iontophoretic transdermal fentanyl PCA is indicated for pain that is expected to be moderate to severe for approximately 24 hours.

• Intrathecal anesthesia or analgesia is administered by single bolus dose technique; therefore it has short duration and is used most often as part of a multimodal plan.

• Epidural analgesia

• Administered by single or intermittent bolus doses and continuous infusion only or with PCA capability (PCEA).

• Cautious timing of epidural catheter placement and removal and anticoagulant dosing is crucial to prevent epidural hematoma.

• Continuous local anesthetic (block) infusions

• Wound infusion: catheter inserted into or next to surgical site.

• Perineural infusion: catheter inserted near peripheral nerves or nerve plexus.

• May be administered with PCA capability.

• Disposable pumps are used for administration in outpatient setting.

• Provide opioid analgesic as needed for breakthrough pain.

• Patient or family member may be taught to remove catheter at end of therapy.

NSAID, Nonsteroidal antiinflammatory drug; COX, cyclooxygenase; IV, intravenous; PCA, patient-controlled analgesia; PACU, postanesthesia care unit; PCEA, patient-controlled epidural analgesia; RN, registered nurse; IM, intramuscular.

Evidence-Based Practice

Wong and colleagues conducted a study to examine the effectiveness of pain management educational intervention on level of pain, anxiety, and self-efficacy among patients who had musculoskeletal trauma and subsequent orthopedic surgery. Patients were assigned to either a control group (usual care) or experimental group (usual care plus educational intervention). The educational intervention was 30 minutes long and included information about pain, coping strategies, and breathing relaxation exercises. The experimental group had significantly lower levels of pain, less anxiety, and better perceived self-efficacy during hospitalization. The experimental group requested significantly more analgesics on day 2 only. There were no significant differences on length of hospitalization. When evaluated at 3 months, there were significantly lower anxiety levels among those in the experimental group.

Implications for practice

Patients may benefit from an educational intervention that focuses on relieving pain and anxiety and improving self-efficacy. Self-efficacy interventions such as seeking pain relief and practicing breathing relaxation techniques could result in decreased anxiety and pain. This educational intervention could be part of routine care for musculoskeletal trauma patients before surgery. Similar interventions could be applied to other patients who require orthopedic surgery.

Source: Wong EM, et al: Effectiveness of an educational intervention on levels of pain, anxiety, and self-efficacy for patients with musculoskeletal trauma, J Adv Nurs 66:1120–1121, 2010.