Care of the Patient with Altered mobility:

Orthopedic surgery and fractures

NURS 3071: Acute Health Challenges
Feb. 26, 2019
Class Outline
0830-0900 Quiz

0900-0910 Review quiz

Concept maps/case study discussion re: surgical

patient

Break (15 minutes)

Lecture/discussion & Wrap up

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Case Study: Surgical Patient
Why do we use cases in the classroom?

Case studies are stories with a teaching/learning objective.

To solve cases, students must collaborate to hypothesize,
problem solve, and determine salient information from a
larger volume of information.

In clinical practice, each patient represents a case.

Therefore, in nursing education, especially at higher levels,
cases are an important way to train your brain to sift
through the information and pull out key info that you need
to act upon.

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Case Study: Surgical Patient
• Case studies link to specific course objectives in NURS
3071. Note: Outcomes 1.1, 3.1, 3.4 link to the case this
week.

• Cases used in class require that you use the nursing

process to support your decisions.

• Cases require that you operate at higher levels of

Bloom’s taxonomy of learning (next slide).

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Bloom’s taxonomy
(Image retrieved from: https://wp0.vanderbilt.edu/cft/guides-sub-pages/blooms-taxonomy/)

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Case Study Review
Altered Mobility:
Lecture/Discussion
Iatrogenic events
• https://globalnews.ca/news/3982276/edmonton-
toddler-iv-complications-emmy-stollery-childrens-
hospital/

• Consider the importance of checking IV site every

hour.
• Parenteral guidelines for medication infusions 
some medications NEED a central line.

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Altered Mobility
• Many causes

• Where to focus?
• Acute care course  think about acute causes of altered mobility.

• Orthopedic injury
• Fits with altered mobility
• Fits with prior learning to date
• Lots of complications to think about

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Objectives of this class
• Develop understanding related to patients with:

• Casts, braces, splints

• Traction (just the basics)
• Total hip replacement
• Total knee replacement
• Amputation
• Complications specific to orthopedic injuries (what do nurses need to
watch for?)
• Consider how iatrogenic injury impacts patient mobility

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Casts
• Used to immobilize part of the body.

• Rigid.

• Major risk factors:

• Compartment syndrome
• Pressure ulcers
• Disuse syndrome

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Compartment syndrome
• Compartment syndrome is an orthopedic emergency!
• Neurovascular vitals
• Colour, sensation, movement
• The 5 P’s
• Pain
• Pallor
• Pulselessness
• Paresthesia
• Paralysis

• Management of compartment syndrome:

• Notify physician immediately.
• Physician will remove cast if there is one.
• Fasciotomy may be required (plenty of photos on-line if you are interested).

• Left untreated:
• Permanent muscle and nerve damage.
• Contractures such as Volkman’s contracture.
• Potential to lose limb due to muscle death.

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Volkman’s contracture
(Image retrieved from: http://physiotherapy-class.blogspot.ca/2009/12/volkmanns-ischemic-contracture.html)

• Caused by ischemia to arm from brachial) artery

obstruction.

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Casts & pressure ulcers
• Improperly fitted casts:
• May cause underlying pressure ulcers, especially over boney
prominences.

• Watch for:
• Complaints of increased pain
• Cast feels warm over an area
• Drainage staining cast

• These signs and symptoms need to be assessed by physician.

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Casts & disuse syndrome
• Cause: muscle atrophy and loss of strength

• Prevention: Isometric exercises

• Quadriceps-setting exercise
• Gluteal-setting exercise

• Inter-professional collaboration:
• What professionals would be important here?

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External fixator
Consider the nursing management

• Used when soft tissue

damage makes a cast an
inappropriate choice.
• Risks?
• What would the nurse
need to know?

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Traction

• What you will most

commonly see:
• Skin traction for patient
awaiting OR.
• Buck’s traction.

• Nursing Considerations

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Total Hip & Total Knee Replacement

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Total Hip: Mobility Considerations
• Keep legs in abduction post-op.
• A wedge pillow often used.

• Hip should never bend >90 degrees.

• Raised toilet seats.
• Think about height of chairs.
• Bed should not be too low when getting patient in and out.
• Can not bend down to put on socks, pants, etc.

• Avoid internal rotation of the leg/hip.

• Do not cross legs!

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Total hip: Mobility considerations
• Failure to adhere to the mobility restrictions after a
total hip can result in dislocation of the prosthetic
hip joint.
• Patient may need to be placed in traction.
• Patient may need to go back to OR for revision.

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Total hip: Recognizing dislocation
• Nurse must be able to recognize dislocation
promptly.
• S&S:
• Increased pain, swelling, immobilization @ surgical site.
• Acute pain, increased discomfort in affected hip.
• Shortening of the leg.
• Abnormal internal or external leg rotation.
• Inability to move the leg at surgical site.
• Reported “popping” sensation

• If this happens notify surgeon immediately!

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Total knee: Mobility considerations
• Expect swelling.
• Cold pack application is commonly ordered.
• Compression bandage post-op.
• Often a surgical drain to remove excess drainage.

• Active flexion of foot every hour.

• Patients ambulate with assistance evening of or day

after surgery.

• When up in chair – elevate leg.

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Mobility limits
• Always think of weight-bearing limits!

• Collaborate with inter-professional team:

• Physiotherapy
• Occupational therapy
• Surgeons

• Does the patient require special equipment?

• Wheelchair
• Walker
• Cane
• Brace
• Splint?

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Assessments to remember
• ABCs
• Same potential complications as other surgeries:
• Atelectasis
• Pneumonia
• DVT/PE
• Infection
• Hemorrhage

• Neurovascular vitals
• Colour, Sensation, Movement

• Pain
• Orthopedic surgery hurts!
• Make sure you have your patient’s pain well controlled to promote mobility.
• Premedicate!

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Assessments to remember
• Wound assessment
• Same principles as other wounds.
• Additional risks if infection occurs  osteomyelitis.

• Skin assessment
• Especially in patients who were involved in trauma  additional soft
tissue injury.
• Was the patient in traction?  increased risk for pressure ulcers.

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Respiratory assessment
• So important to note any respiratory changes!

• PE is a big risk.

• Also…fat embolism syndrome.

• Be alert for skin changes, unusual rash (petechiae)
• Acute confusion/delirium
• Respiratory distress

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Acute Pulmonary Embolism

https://www.youtube.com/watch?v=SzsQWIMYbN8

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Amputation
• Most lower extremity amputations 2nd to PVD.
• Upper extremity usually 2nd to trauma.

• Level selected:
• Goal is to leave as much as possible for a prosthesis.

• Complications:
• Hemorrhage
• Infection
• Skin breakdown
• Phantom limb pain
• Joint contracture

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Amputation
• Nursing considerations
• Be gentle with the limb!
• These patients are often at a high risk for poor wound healing 2nd to their
underlying conditions (i.e. PVD, PAD, DM, infection, etc.)
• Surgeon generally takes the dressing down first after several days.

• Hemorrhage, infection, and skin breakdown are particularly prevelant

risks of amputation surgery.

• Phantom limb pain  may be reduced by keeping active. Anti-seizure

medications are also commonly prescribed (i.e. gabapentin,
pregabalin). For some this can become a chronic pain issue.

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Wrap-up
• Important to have an understanding of:
• Compartment syndrome in the limb, cast as a risk factor.
• Total hip replacement.
• Total knee replacement.
• Caring for a patient with external fixator.
• Risks particular to orthopedic surgeries:
• i.e. osteomyelitis, neurovascular damage, DVT/PE, fat embolism syndrome

• Amputations  focus on the acute care aspects rather than the

rehabilitation phase.
• Major risk factors after an amputation (i.e. hemorrhage, infection, skin
breakdown).

• The role healthcare plays in causing mobility issues.

• Extravasation and the effects this can have on upper limb/hand function.

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