ORTHOPAEDICS
IN THE
OPERATING ROOM
Objectives
 Identify
nursing care measures during the
pre, intra and post-operative periods
 Familiarize
non-surgical orthopaedic nurse
with this care
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
Pre-operative Planning
 Hospital/surgeon



Lab work, x-rays, EKG, blood donation
History/physical
Advance directives, health care proxy
 Adaptive

admission protocols
devices
Explain need, may need to be ordered
i.e., lumbar brace
Pre-operative Interview
M. Kulesa 04
Pre-operative Interview

Lab work review
 History and physical
 Allergies



Medications
Latex
Other

Site confirmationsign your site
 Consents




Medical
Blood
Surgery
Other
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
Pre-operative Planning
 Consents



Surgery
Site
Medical
 Discuss

discharge and patient’s goals
Referrals to home care, rehab
Pulmonary Complications
 Aspiration



NPO
Suction
Nasogastric tube
Anesthesia-related
Considerations
 Pulmonary
complications
 Fluid volume deficit
 Cardiovascular complications
 Altered body temperature
Fluid Volume Deficit

Age considerations
 IV access
 Blood loss in suction/lap pads/drapes
 Urine output
Cardiovascular
Complications
 History:
identify risk factors
 Monitoring
 Medications: pre-op, intra-op, post-op
Altered Body Temperature
 Convection
 Conduction
 Radiation
 Evaporation
Altered Body Temperature
 Hypothermia:
monitor temperature
 Age, condition, open cavity
 Warming blanket, warm saline irrigation
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
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
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
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)

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
Intra-operative Care
 Infection
control
 Safety
 Positioning
 Equipment
for
orthopaedic cases
 Time Out
Infection Control
 IV
antibiotics/timing per JCAHO guidelines
 Traffic control
 Surgical technique
 Clip and prep (no shaving)
 Personal protection devices
 Implant = “foreign body”
Safety
 Identification
 Safety
straps
 Counts
 Electrosurgical
unit/grounding pad
 Sequential
stockings
 Fire and safety
Principles of Positioning
 Surgeon
preference
 Maintain adequate airway
 Pad all bony prominences
 Maintain correct body alignment
 Safety straps
 Routine maintenance of positioning
devices
Positions
Supine
Prone
Lateral
Semi-fowlers
Considerations
Age, length of surgery, body weight,
nutritional status, medications, chronic
disease states
Supine
 Pressure
points
 Length of surgery
Prone- Wilson Frame
Prone
Lateral
 Pressure
points
 Stability
 Lateral
positioners
 Axillary roll
Semi-Fowlers
Pressure points
Stability, protection
Head and neck
Non-operative arm
Legs/feet
Other Positioning Issues
 Sheering
 Friction
 Pressure
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
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
Documentation
Surgical procedure
Implants
Prosthesis, bone, etc.
Counts
Drains, etc.
Equipment for Orthopaedic Cases
 Tourniquet
 Cuff
 Settings
 Casting
 Microscope
 Instruments, saws, drills
 Table, positioning devices
 Care and maintenance
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
Post-operative Evaluation
 Skin/neuro assessment
 Drains
 Dressings
 Post-op devices
 Shoulder
 Knee
 Abduction pillow
 Brace
 Halo
PACU: Post Anesthesia
Care Unit
 Airway
management
 Aspiration precautions
 Vital signs
 Temperature management
 Pain control
PACU: Post Anesthesia
Care Unit
Nausea management
Fluid & electrolyte management
Urinary retention
Procedure specific
Chest tubes
External fixator
Cast/limb care
Question 7:
In the PACU, you notice that Mr. T. is
showing signs of stridor and appears
panic stricken. This is most likely:
a. Bronchospasm
b. Fat emboli
c. An allergic reaction
d. Laryngospasm
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
Post-operative Phase
 Inpatient


Report to the floor
Continuation of observation
 Outpatient

Reinforce pre-operative teaching
Operative Orthopaedics
 Preoperative
planning
 Potential
complications
 Infection
control
 Safety

positioning
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
Answer # 2
a. vasoconstriction
Rationale: vasoconstriction
decreases blood flow and thus
decreases the delivery of oxygen to
the wound space
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
Answer # 4
d. 90 degrees
Rationale:
90 degrees or greater abduction will stretch the
brachial plexus nerve group leading to wrist
drop
Answer # 5
c. scapulae, ischial tuberosities and
calcaneous
Rationale: These are the pressure points
when the patient is in the sitting position
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
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