NCM 112 RLE Surgical PBL

Prepared by: April E. Loro, RN, MN

Osteoporosis

 Defined as systemic skeletal disorder characterized by

compromised bone strength predisposing to an increased risk of
fracture
 Decrease in bone mass/ density
 Occurs when the creation of new bone doesn’t keep up with the
loss of old bone.
 Male: 30%/Female: 70%

 Risk Factors
Non Modifiable

Advanced age
Gender: Female (Post Menopausal)
White/ Asian Race
Low Peak Bone Mass
Family History
Personal History of Fracture
Low Body Mass Index(BMI)

Modifiable

Smoking, Nicotine and alcohol consumption

Inadequate calcium intake
Inadequate Vitamin D
Low Body Weight (BMI <21kg/m2
Estrogen Deficiency
Hypogonadism
Chronic Glucocorticoid treatment (Steroids)

 Signs and Symptoms

Typically there are no symptoms in the early stage
of bone loss but once your bone have been weakened by
osteoporosis you might have manifested the following:
 Back pain by a fracture or collapse vertebra
 Loss of height over time
 Stooped posture
 A bone that breaks much more easily than expected

Diagnostics

1. DEXA SCAN (DUAL-ENERGY X-RAY ABSORPTIOMETRY)

Often used to diagnose or assess your risk of
osteoporosis
Measures bone density
Normal Values: > 1.0
- 1.0 to -2.5 Osteopenia
- 2.5 below Osteoporosis

2. BONE MINERAL DENSITY TEST (BONE DENSITY TEST

Painless and quick. It estimates how dense or thick your

bones are by using X-rays.
Measure how much calcium and minerals are in a part of
your bone.

3. CALCIUM LEVELS
Calcium (serum) 8.6-10.3 mg/dL
Calcium (ionized) 4.4-5.2 mg/dL

Medical Management

1. Alendronate Sodium( Fosamax)

 Used to prevent and treat certain types of bone loss
(osteoporosis) in adults.
 take 30 minutes before breakfast with full glass of
water
 Sit upright for 30 minutes
2. Regular check of calcium and phosphorus level
3. Calcitonin
derives from its ability to inhibit osteoclasts and
increase renal excretion of calcium.
4. Hormonal Replacement Therapy - Estrogen

Hip Fracture

 A break in the upper portion of the femur (thighbone).

 Mostly occur in elderly patients whose bones have
become weakened by osteoporosis.
 Medical complications such as bed sores, blood clots,
and pneumonia. In very old patients, prolonged bed
rest can also lead to disorientation, which makes
rehabilitation and recovery much more difficult.
Ecchymosis -bruising due to injury of subcutaneous tissue
Extracapsular proximal femur fractures
 Also known as INTERTROCHANTERIC FRACTURES

PHYSICAL EXAMINATION
 The patient with a displaced intertrochanteric femur
fracture will typically present the following:
 Inability to ambulate following the fall
 Pain in the groin, lateral hip and/or buttocks
 Have a shortened and externally rotated lower
extremity.
 Neurovascular status should be carefully documented;
however neurovascular injuries are rare in isolated
intertrochanteric fractures.

Surgical Management

OPEN REDUCTION AND INTERNAL FIXATION

“Open reduction” means a surgeon makes an incision to re-
align the bone.
“Internal fixation” means the bones are held together
with hardware like metal pins, plates, rods, or screws.
After the bone heals, this hardware isn’t removed.

A. Pre-Operative Care
1. Secure Consent for the procedure
 as well as for the administration of Anesthesia
(General or Spinal Anesthesia)
2. Physical Examination and Obtaining Madical History
3. Blood Test and other laboratory Reports
4. Abdominal Preparation
 NPO post midnight or 8-10 hours prior to the scheduled
surgery
5. Pre operative medication as prescribed
6 . Completion of Pre-operative checklist
 Latest VS prior to endorsing to OR nurse

Buck’s Extension (Traction)

 Used to treat fractures, to realign broken bones, to

correct contractures or deformities, and for knee
immobilization.
 Skin traction in the lower leg used to immobilize
fracture of the femur before surgical fixation.
 Provides for straight pull through a single pulley
attached to a crossbar at the foot of the bed.
 The patient is usually not allowed to turn and must
remain flat on his back.

Nursing Considerations
1. Check alignment of the leg to maintain a straight line
of pull from the rope attached to the spreader bar to the
pulley mounted on the foot of the bed.

2. Check the extremities for color (pallor, cyanosis),

numbness, edema, signs of infection, and pain. Look for
areas of skin breakdown or pressure sores on all skin
surfaces.

3. Check the bandage wrappings and tape or moleskin

strips to be sure that they are adhering properly and
have not slipped downward.

4. Report immediately if any part of the wrappings or

traction apparatus appears to be out of place.

Role of the Nurse in Caring for Patients in Traction

1. The nurse shall not apply or set up skeletal or
cervical traction.
2. The nurse shall not remove, add, or lift up on weight
when the patient is in traction for the treatment of
fractures.
3. The Nurse may remove or add weights to balance
suspension (slings), which is used with skeletal
traction.
4. The nurse shall not release a patient from traction
for the purpose of transfer to and from bed, stretcher,
or procedure tables. The nurse shall notify the
physician, so the physician may come and remove traction
for transfer and to replace traction.
5. The nurse shall provide pin care per physician order.

Common Immediately After Surgery

 Constipation/ Urinary Retention- Bowel Protocol and
fluids
 Slight drainage of incision
 Drop in hemoglobin -typically 2 gm. drop.
 Hypo bowel sounds - Light food until (+) Bowel Sounds
 Swelling in affected extremity
 Nausea/ Vomiting
 Occassional low grade fever

B. Post Operative Care

1. Pain management
Opioids (Fentanyl, Naloxone, Meperidine,Morphine)
as prescribed
Watch out for: Constipation
Drowsiness
Nausea and vomiting

2. Venous thromboembolism Prevention

TEDs (Thrombo Embolus Deterrent

Stocking)
 Used for non ambulatory patients
 The thickest part of the leg
receives the most
pressure
 Reduce the risk of developing a
deep vein thrombosis
or blood clot in lower leg after
surgery.

Do Not
1. Roll down your stockings while wearing them as they
will form a tight band around your leg and restrict the
blood flow to your leg.

2. Apply ointments, oils, lanolin to your legs as these

products will damage the elastic fibres of the stockings.

3. Wear wet stockings

4. Cross your legs when sitting or lying down.

DVT Symptoms

 Assymetry
 Slight Unilateral Edema
 Tenderness or intermittent pain, usually not help with
medication
 Dull ache that worsen with walking
 Calf warm to touch

Pulmonary Embolism

 Restlessness
 Labored Breathing,
Tachypnea
 Decreased Oxygen Saturation
 Leg Swelling
 Bluish Skin
 Swollen Neck Veins

Sequential Compression Device

 Also know as Intermittent
Pneumatic Compression (IPC)
Device
 Is a method of DVT
prevention that improves
blood flow
in the legs.
 SCD’s are shaped like “sleeves” that wrap around the
legs and inflate with air one at a time. This imitates
walking and helps prevent blood clots.

Nursing Consideration

Contraindicated in DVT, compartment syndrome, extremity

deformity, and an open infected wound of the extremity.
Physicians or licensed independent practitioners (LIP)
must order SCD therapy. The SCD therapy order is based on
a completed physician or LIP VTE risk assessment
(mandatory for all acutely admitted patients).

 Nurses will measure the patient for correct fit of SCD

sleeves.
 Follow manufacturer recommendations to determine size
correctly. One size does not fit all.
 Knee-High sleeves, pressure starts at the ankle and
moves toward the knee; pressure is approximately 45 mm
Hg at the ankle and 35 mm Hg at the knee.
 Thigh-high sleeves-pressure at the thigh is 30 mm Hg.
 Use a tape measure to obtain accurate measurements.
 The nurse should be able to place two fingers between
the SCD sleeve and the patient’s leg.
 Resize the sleeve(s) if an obvious change in leg
diameter has occurred due to edema or third-spacing.

Assess for:
1. presence and level of pain
2. pallor
3. palpable or Doppler pulses
4. paresthesia (“pins and needles” sensation)
5. paralysis (weakness or lack of movement)
6. skin abnormalities under the sleeve
7. pain associated with movement or touch
8. increasing edema of the extremity
9. signs or symptoms of possible blood clots to
extremity: swelling, redness, pain.

3. Wound Care

 Assess for redness, swelling, drainage and odor

 Watch out for fever
 Administer antibiotics as prescribed
 Daily wound dressing

4. Delirium prevention
 Occurs in a quarter of patients without baseline
dementia, and over half of dementia patients who
experience a hip fracture.

 Fall Prevention and Rehabilitation

 An important part of post hip fracture care.

 Home Assessment (Safety)
 Provide Bedside Commodes
 Assessment of vision and referral
 Medication review and modification
 The ultimate goal is to restore their ability to walk
as well as they were able to do before the fracture.
 For people who are recovering from a leg injury or
surgery, using a cane that is the correct height is
important. A cane that is too long or too short can cause
low back pain, poor posture, and instability. The cane
should be held on the side opposite the injured leg.
 At the Hospital post procedure:
 The patient will be asked 48-72 hours to get out of
bed and walk 2-3 times a day to help with blood flow
 The patient will be taught on how to do exercises
that help with strength and range of motion
 The patient will be taught on how to use devices such
as wheelchair and crutches.