Tibia/Fibular Fractures and Pre-Operative Management
Tibia fractures are the most common long bone fractures, with the fibula being involved in the majority of them, hence the phrase tibia/fibular fractures. Young guys are the most usually reported demographic for the fracture. The fractures are frequently caused by a high-impact force, most typically in sports or car accidents (Al-Hadithy & Panagiotidou, 2012).
Open reduction and fixation is thus a surgical treatment in which the bones are realigned and screwed together to aid healing and return to normal anatomical position. Before such an operation, the nurse will go through a series of processes and exercises to prepare the patient for the surgery. After the surgery, several other measures and guidelines are followed to facilitate a smooth healing process that is sufficiently quick and devoid of complications, ensuring the patient returns to quality, active life.
Pre-Operative Management
Pre-operative care entails all the steps taken and activities performed before the conduction of surgery with the aim of ensuring success by reducing the risk of the surgery and improving the outcomes and recovery eventually (Malley, Kenner, Kim, & Blakeney, 2015).
To begin with, there should be effective education of the patient on matters about the surgery. First of all, the nurse should listen to the patient's concerns and allay fears and any anxiety the patient may express. Such anxiety may stem from a history of previous surgical complications even if unrelated to the current fracture. (Donna D. Ignatavicius, 2015) The nurse then needs to inform the patient of tasks to undertake before surgery and their benefits such as taking medications for prophylaxis and fasting if necessary. The patient also needs to be given instructions about the surgery such as an explanation of what would be done in the surgery, how long it may take, the family would also be informed of where to wait for their patient during the surgery. (Doherty, 2015) In addition to that, the patient needs to be made aware of what to expect and what to do in the post-operative period. Finally, the patient needs to be informed on the type of anesthesia to be used for example whether general or a spinal block as well as being informed of the analgesia options that would be available for pain relief after the operation (Doherty, 2015)
Secondly, in the pre-operative management of the patient accurate and detailed history should be taken, with particular attention to the medical history as it may reveal various aspects that could affect surgery. To begin with, the presence of certain chronic conditions could complicate surgery. Therefore, if the patients had Systemic Lupus Erythematosus (SLE), he would be put on drugs to offset the stress of surgery. Patients with a cardiac disease such as coronary artery disease would also be at risk of anesthesia-related complications. (Donna D. Ignatavicius, 2015) They would thus have to be put on an Electrocardiogram for monitoring during the surgery. Patients who may have a history or risk factors for pulmonary disease may also be predisposed to atelectasis post-anesthesia, therefore if suspected, interventions could be undertaken (Katsura Morihiro, 2015)
The history taken should also seek to find out the presence of factors that may delay healing after surgery. Such may include deficiencies in nutrition, history of steroid use, and diseases of defective metabolism such as Diabetes Mellitus. Where these may be present the nurse would need to ensure that they are considered and adequately addressed before surgery (Donna D. Ignatavicius, 2015)
In addition to that, the nurse should find out the allergy history of the patient, especially allergy to latex, which has been commonly reported to cause anaphylactic shock. (Mali, 2012) Upon identification of such an allergy, materials such as latex-free gloves should be obtained and used for the surgery.
Another important aspect of pre-operative management concerns preparation and availability of materials, medical documents and other requirements for the surgery. To start with are the lab investigations and reports. The nurse needs to make sure that key investigations have been conducted and reports ready before surgery. A full hemogram and hematocrit would be necessary as an evaluation of the patient’s hemodynamic state owing to the bleeding following the fracture as well as the possibility of fat embolism. (George, Dixit, & Gupta, 2013) Coagulation studies would also need to be done with the nurse ensuring that the results for the prothrombin time (PT) and the Activated partial thromboplastin time (aPTT) are ready and available in time. (Donna D. Ignatavicius, 2015) Another important lab test would be a urinalysis test, also used to assess the hemodynamic state of the patient prior to surgery (Donna D. Ignatavicius, 2015)
Additionally, the nurse needs to ensure that the patient’s blood sample is taken and blood grouping and cross match done. He should also ensure that the blood is availed from the blood bank in time for use in the surgery if needed following compromising bleeding from the fracture. This would aid in avoiding any unnecessary delays (Donna D. Ignatavicius, 2015)
Further still, the nurse needs to ensure that relevant documents from imaging are available. These might include X-ray films and their radiological reports, CT-scans and MRI report if there had been an indication for them. The nurse would be required to ensure that the availed documents are updated as well.
The last crucial item of pre-operative care that needs to be attended to is a written consent. This being a legal requirement, it ought not to be overlooked. The patient needs to be explained to about the risks and benefits of the surgery as well as the details of the procedure of open reduction and internal fixation. Upon confirmation of the patient’s understanding, he needs to sign a written consent before the surgery can proceed. The signing of the consent should be as near the time of procedure as possible, and the nurse is usually the witness as the operating surgeon and the patient sign the document (Canterburry District Health Board, 2015)
Post-Operative Management
The post-operative period is the time from when the patient leaves the operating room after surgery to the time that recovery is achieved. The period can be divided into three phases, the immediate post-operative period, the intermediate phase and the convalescent period (Maxey & Magnussum, 2013). The immediate phase mainly focuses on restoration and maintenance of hemostasis for the patient. It also includes aspects of pain management as well as an evaluation of the surgery and measures to detect early and prevent complications from the surgery. The period for this phase is usually the first twenty-four hours, including the time spent in the "post-anesthetic care unit (PACU)". (Doherty, 2015)
Immediately the patient leaves the operating room; he should be taken to the unit, where the nurse should monitor for any immediate complications such as those arising due to anesthesia. The nurse monitors the patient by assessing the various systems such as the respiratory, cardiovascular, and central nervous systems and muscle activity (Serra, et al., 2013). This is done by monitoring the vitals such as temp and heart rate. Other parameters that are usually observed in the assessment are pulses, the level of consciousness and reflexes pain management in this period aims at minimizing or eliminating pain while at the same time cautious of the side- effects that may arise. If the post-operative pain is poorly managed, it could result in the development of complications and a prolonged rehabilitation period. (Garimella & Cellini, 2013) The management is tailored to the patient's need as determined through assessment; mainly through the ten-point method where 1 represents very little pain while 10 is the worst pain (Garimella & Cellini, 2013). The categorization of the pain by the patient thus informs the analgesic to be used. In the case of the fracture of the tibia and fibula, pain is usually relatively severe hence a potent analgesic preferably an opioid would be used. (Garimella & Cellini, 2013)
The intermediate period encompasses the time when the patient is hospitalized awaiting to be discharged. During this period, the nurse should ensure and instruct the patient that the leg should be elevated to prevent edema (Makridis, Tosounidis, & Giannoudis, 2013). It should also remain immobile until it is sufficiently healed to prevent complications such as non-union. The leg could be stabilized by using a brace or a cast which would remain in place for several weeks (Al-Hadithy & Panagiotidou, 2012). During the stay in the hospital still, the nurse should ensure that there is proper care of the surgical wound to prevent infection. It should be inspected, cleaned and disinfected on a regular basis. The dressing of the wound should also be done with clean, sterilized dressing materials. Drainage tubes could also be put to drain away any fluid that may accumulate around the surgical site (Backes, Schepers, & Goslings, 2014). It is important to ensure the wound is well taken care of since it could be a portal of entry for microbes that may cause infection. Besides wound care, infection of the surgical site should be prevented by giving the patient antibiotic medications for prophylaxis. The drugs given should cover a wide spectrum of microbes, keeping in mind that possibility of hospital-acquired infections. (Anderson, Podgorny, & Berrios-torres, 2014)
In addition to that, the nurse should monitor for early diagnosis as well as take initiatives to prevent the development of complications such as compartment syndrome, of which the commonest cause is fractures, especially those of the tibial shaft. (Garner, Taylor, Gausden, & Lyden, 2014) The nurse should, therefore, be on the lookout and regularly examine the patient for the clinical diagnostic signs of pallor, pain, paresthesia, poikilothermia, pulselessness, and paralysis (Garner, Taylor, Gausden, & Lyden, 2014). Another complication that needs to be prevented is thromboembolism. To prevent its occurrence, the nurse should evaluate the patient based on risk factors obtained during the history-taking such as obesity and hypercoagulability. (Acton, 2012) Antithrombotic medications such as heparin should be given if the patient is determined to be at risk. The nurse can monitor for development of thromboembolism by observing clinical signs and symptoms such as calf tenderness and sudden onset pain (Harvey & Megan, 2011).
Finally, the last phase of post-operative care is undertaken from when the patient is discharged from hospital until when full recovery is achieved. It involves activities such as therapy aimed at restoring strength and flexibility of the limb (Doherty, 2015). The patient should also be booked to an outpatient clinic and appointments made to be evaluated for the progress of recovery.
Conclusion
In conclusion, the achievement of the goal of attaining healing and regaining function of the limb in the treatment of the tibia and fibular fractures is dependent on the harmonization and effectiveness of all stages of the patient's management process. The nurse has a critical role in the preparation of the patient for the surgery, which has a bearing on the smoothness and success of the "open reduction and fixation procedure." Upon successful execution of the procedure by the surgeon, the nurse's role in managing the patient post-operatively determines how well and quickly the patient achieves full recovery. A proper understanding of the requirements in each of the stages is therefore important because of the interrelationship with events in one stage being a consequence or in anticipation of occurrences in another stage of patient management.
References
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