ORTHOPAEDICS IN THE OPERATING ROOM

1. ORTHOPAEDICS IN THEOPERATING ROOM

2. Objectives Identify nursing care measures during the pre, intra and post-operative periods Familiarize non-surgical orthopaedic nurse with this care

3. Pre-operative Planning Pre-operative coordination Surgeons office Consults as needed Pre-surgical testing Ambulatory/inpatient Patient education Assess patients ability to understand/ communicate Age: pediatric/geriatric Multicultural considerations

4. Pre-operative Planning Hospital/surgeon admission protocols Lab work, x-rays, EKG, blood donation History/physical Advance directives, health care proxy Adaptive devices Explain need, may need to be ordered i.e., lumbar brace

5. Pre-operative Interview M. Kulesa 04

6. Pre-operative Interview Lab work review History and physical Allergies Medications Latex Other Site confirmation- sign your site Consents Medical Blood Surgery Other

7. Question # 1 You are preparing Mrs. H. for a right THA and find that she is allergic to iodine, is an agent found in many radiography dyes and antimicrobial skin preparations. She also notes she is allergic to: a. kiwi b. shellfish c. latex d. bananas

8. Pre-operative Planning Consents Surgery Site Medical Discuss discharge and patient’s goals Referrals to home care, rehab

9. Pulmonary Complications Aspiration NPO Suction Nasogastric tube

10. Anesthesia-related Considerations Pulmonary complications Fluid volume deficit Cardiovascular complications Altered body temperature

11. Fluid Volume Deficit Age considerations IV access Blood loss in suction/lap pads/drapes Urine output

12. Cardiovascular Complications History: identify risk factors Monitoring Medications: pre-op, intra-op, post-op

13. Altered Body Temperature Convection Conduction Radiation Evaporation

14. Altered Body Temperature Hypothermia: monitor temperature Age, condition, open cavity Warming blanket, warm saline irrigation

15. Question # 2 Mrs. H. is taken into the OR, where the room temperature is 67 degrees. The surgical procedure has started. You realize that mild hypothermia appears to increase incisional surgical site infection (SSI) risk by causing decreased delivery of oxygen to the wound space, subsequent impairment of the function of phagocytic leukocytes and: a. vasoconstriction b. coexisting infections at a remote site c. length of peri-operative stay d. vasodilatation

16. Malignant Hyperthermia Trigger All potent inhalation agents Succinylcholine Sequence of event Increased Cytoplasmic Free Calcium Rigidity- may or may not be present Hypermetabolism Cell damage

17. Malignant Hyperthermia Compensatory mechanisms Increased circulating catecholamines Increased cardiac output - may not keep up with O2 demand Increased ventilation - may not keep up with need Temperature rise Secondary systemic manifestations

18. Malignant Hyperthermia Treatment Dantrolene Iced IV saline solutions Ice bags around patient Gastric/rectal ice lavage Lab work Case presentation Hotline number: 1-800-MHHYPER (24 hr)

19. Question # 3 During the next case, your friend is the circulating nurse and her patient is experiencing an MH crisis. Her priorities will be: a. preparing the initial dose of Dantrolene, setting up a warming blanket, drawing blood b. setting up iced gastric and rectal lavage, preparing the initial dose of Dantrolene, getting clean anesthesia tubing c. preparing the initial dose of Dantrolene, drawing blood, setting up iced gastric and rectal lavage, setting up a temperature regulating blanket and ice bags d. leave the OR room to summon you and others for assistance

20. Intra-operative Care Infection control Safety Positioning Equipment for orthopaedic cases Time Out

21. Infection Control IV antibiotics/timing per JCAHO guidelines Traffic control Surgical technique Clip and prep (no shaving) Personal protection devices Implant = “foreign body”

22. Safety Identification Safety straps Counts Electrosurgical unit/grounding pad Sequential stockings Fire and safety

23. Principles of Positioning Surgeon preference Maintain adequate airway Pad all bony prominences Maintain correct body alignment Safety straps Routine maintenance of positioning devices

24. Positions Supine Prone Lateral Semi-fowlers Considerations Age, length of surgery, body weight, nutritional status, medications, chronic disease states

25. Supine Pressure points Length of surgery

26. Prone- Wilson Frame

27. Prone

28. Lateral Pressure points Stability Lateral positioners Axillary roll

29. Semi-Fowlers Pressure points Stability, protection Head and neck Non-operative arm Legs/feet

30. Other Positioning Issues Sheering Friction Pressure

31. Question # 4 Mr. J. is taken to the OR to undergo a cervical spine fusion. During positioning, care is taken to avoid damage to the brachial plexus nerve group by avoiding abduction greater than: a. 30 degrees b. 45 degrees c. 65 degrees d. 90 degrees

32. Question # 5 He is placed in the sitting position; areas especially susceptible to pressure injuries include his: a. clavicle, brachial plexus and illium b. olecranon, greater trochanter and illium c. scapulae, ischial tuberosities and calcaneous d. thoracic vertebrae, sacrum and malleolus

33. Documentation Surgical procedure Implants Prosthesis, bone, etc. Counts Drains, etc.

34. Equipment for Orthopaedic Cases Tourniquet Cuff Settings Casting Microscope Instruments, saws, drills Table, positioning devices Care and maintenance

35. Question # 6 A tourniquet is applied to Mr. T’s left leg during TKA. You know that three concepts that define a tourniquet are: a. compression, circulation, period of time b. constriction, circulation, bloodless field c. circumferential pressure, period of time, extremity d. control, circumferential pressure, bloodless field

36. Post-operative Evaluation Skin/neuro assessment Drains Dressings Post-op devices Shoulder Knee Abduction pillow Brace Halo

37. PACU: Post Anesthesia Care Unit Airway management Aspiration precautions Vital signs Temperature management Pain control

38. PACU: Post Anesthesia Care Unit Nausea management Fluid & electrolyte management Urinary retention Procedure specific Chest tubes External fixator Cast/limb care

39. Question 7: In the PACU, you notice that Mr. T. is showing signs of stridor and appears panic stricken. This is most likely: Bronchospasm Fat emboli An allergic reaction Laryngospasm

40. Post-operative Phase Criteria for discharge Activity level i.e.: NWB, TT, PWB, FWB Medications i.e.: antibiotics, pain, usual meds Diet Incision care, staple removal Referrals PT, OT, Home Care Return to surgeon

41. Post-operative Phase Inpatient Report to the floor Continuation of observation Outpatient Reinforce pre-operative teaching

42. Operative Orthopaedics Preoperative planning Potential complications Infection control Safety positioning

43. Answer # 1 b. shellfish Rationale: Iodine is an agent found in many radiography dues and antimicrobial skin preparations. Patients allergic to iodine may also be allergic to shellfish

44. Answer # 2 a. vasoconstriction Rationale: vasoconstriction decreases blood flow and thus decreases the delivery of oxygen to the wound space

45. Answer # 3 c. preparing the initial dose of Dantrolene, drawing blood, setting up iced gastric and rectal lavage, setting up a temperature regulating blanket and ice bags Rationale: Initiating the medication to counteract the MH crisis is the first priority, followed by other measures to decrease hyperthermia

46. Answer # 4 d. 90 degrees Rationale: 90 degrees or greater abduction will stretch the brachial plexus nerve group leading to wrist drop

47. Answer # 5 c. scapulae, ischial tuberosities and calcaneous Rationale: These are the pressure points when the patient is in the sitting position

48. Answer # 6 a. compression, circulation, period of time Rationale: To avoid neurovascular impairment, the amount of tourniquet compression, circulation and time are key factors that need to be considered during surgery

49. Answer #7 d. laryngospasm Rationale: this condition may be due to pain or secretions, and results in sudden vocal cord closure and feelings of panic