Orthopaedic Nursing
An orthopaedic nurse is a specialty nurse trained in orthopaedic problems such as fractures and is an expert in neurovascular status monitoring, traction, casting and continuous motion therapy. More than 350,000 hip fractures occur in the United States every year (Watters, 2006). Nurses' skills, interventions, attitudes, communication and continuity of care constitute the essential components of orthopaedic nurse care .Patient satisfaction measures assist nurses in the evaluation of effectiveness of their practice and assist the process of improvement of established orthopaedic practice methods (Wu et.al, 2000). Technical advances in the field of orthopaedics like Radiography, Computed Tomography, and Magnetic Resonance Imaging  have not only led to improved diagnosis and evaluation of orthopaedic diagnosis but also innovative treatment options like Vertebroplasty, Bupivacaine Infiltration, Total Disc Replacement Arthroplasty, Unicompartmental Knee Arthroplasty, The Titanium Rib, Toe-to-Hand Transplantation Surgery, The Scandinavian Total Ankle Replacement (STAR), Mechanical Devices for Lateral Transfers and Kyphoplasty. Thus, orthopaedic nurse should have the essential training and skills in the latest innovations in the field.

Nursing Skills and Interventions
Nursing intervention begins with the assessment of the patient after a traumatic event, determination of the mechanism of injury, assessment of the injured or fracture site, confirmation of the exact injury, identification of potential complications, and assessment of the patient's social and professional status to identify potential problems that might affect treatment and rehabilitation (Altizer, 2003). Pelvic fractures pose a big challenge and are important as a cause for morbidity and mortality (Kobziff, 2006).Fractures of the forearm in an adult may involve the ulna, the radius, or both and it is better to x-ray the entire upper extremity in most upper-limb injuries (Altizer, 2003). Spinal cord injuries are devastating events, and they are particularly tragic when they affect children or adolescents (Vogel et.al, 2004).Nurses should provide interventions preoperatively, intraoperatively, and postoperatively to avoid potential complications (Harvey, 2005).Preoperative interventions include a thorough assessment of the patient history and screen for hypertension or other problems in order to avoid possible intraoperative and postoperative complications. Intraoperative interventions include insertion of a urinary catheter, prophylactic administration of antibiotics and inflammation of tourniquets. Postoperative care is equally important at the surgery itself. An effective postoperative nurse care can decrease the patient's pain and decrease vasospasm in replantation surgeries ( Michalko and Bentz, 2002 ). Compartment syndrome is a common complication in fracture, sprain, or orthopaedic surgery. Early identification of the symptoms can prevent the loss of a limb (Altizer, 2004).Pulse oximetry provides one of the best objective ways to monitor arterial blood flow. Patient monitoring is done hourly during the first 24 hours and then every 2 hours during the second 24-hour period after a surgery. This intense monitoring frequently is done in the ICU. Antibiotic chemotherapy is usually recommended for 5 days, but is always determined by the wound intensity. Bed rest minimizes vasospasm. Intake of chocolate, caffeine, and nicotine in any form is strictly prohibited in the postoperative period to avoid induction of vasospasm that could impede blood flow. Patient-controlled analgesia (PCA) has been recommended for pain relief with relatively few side effects. But, IV PCA has been shown to cause respiratory depression (Brubakken and Shippee, 2004). Continuous low-dose infiltration of a local anesthetic into the postoperative wound incision for a 48-hour period has been shown to diminish the need for narcotics or other analgesics to reduce postoperative pain (Pulido et.al, 2002). The use of a mechanical device for the lateral transfer has been shown to give comfort to the patients (Pellino et.al, 2006). Though most patients treated with casts do not have any significant orthopaedic problems, it is important to emphasize cast care instructions to young patients and their parents to alleviate itching, such as blowing cool air under the cast to reduce the risk of serious infectious complications (Carmichael, 2006).Tracking outcomes of interventions provides a systematic method of monitoring effectiveness and efficiency. The nurse should evaluate and choose appropriate measurement tools, and understand the clinical meaning of measurements to successfully employ these instruments (Resnik and Dobrykowski, 2005). 

Nurse attitudes
Attitudes of nurses caring for orthopaedic patients affect the quality of care provided. A recent research on positive and negative attitudes of such nurses has shown that knowledge deficits shape most of the negative attitudes (Mary et.al, 2000). The cultural background of nurses also has an influence on the attitudes and there are reports of nurse’s disagreements with patient’s self-report, especially in pain assessment (Harper et.al, 2007).

Communication
Patient education is a critical component of orthopaedic nursing that requires nurse communication to maintain optimum independence and quality of life (Oldaker, 1992).
A randomized controlled trial study with sixty six young adolescents to evaluate the effects of coping instruction and concrete-objective information on adolescents' postoperative pain and focus on potential applications of these interventions for orthopaedic nursing practice has shown that nurse interventions that direct adolescent patients' attention to learning coping strategies reduce the postoperative pain in such patients (LaMontagne et.al, 2003). The gender, age and health condition also influences the communication.  For example, it is difficult to communicate to or assess an old patient whose ‘hearing capacity would be at a reasonably low level or whose perception has diminished due to aging.  Non-verbal communications do occur in nurse–patient communication. (Wilma, 1999).

Continuity of care
It may take several months of intense physical or occupational therapy for the patients to regain optimal function, especially after complicated orthopaedic surgical procedures like toe-to-hand transplants. In such surgical procedures progressive joint mobilization, usually begins on the seventh to tenth postoperative day and Progressive resistive exercises are begun 4 weeks later to increase strength. A recent conference convened to explore the strengths and weakness of the current continuum of care, develop recommendations for addressing problems in the system, and devise strategies for implementing the recommendations has brought out recommendations in four broad categories: Communication/Continuum of Care, Reimbursement, Prevention/Education, and Research Initiatives. A study examining the risk factors for falls and the effectiveness of physical therapy interventions to decrease the risk of falls in a community dwelling population has shown that an appropriately designed physical therapy intervention in the form of an exercise program can decrease the risk for falls among a community-dwelling aging population identified as having an increased risk of falls (Robinson et.al, 2002). Massage therapy has been shown to be safe and effective for orthopaedic patients with low back problems and potentially beneficial for patients with other orthopaedic problems. Massage therapy appears to be safe, to have high patient satisfaction, and to reduce pain and dysfunction (Dryden et.al, 2004).   

Conclusion
There is a critical need to incorporate the use of latest technological innovations like guided imagery (Antall and Kresevic, 2004) and bone morphogenetic proteins (Boden, 2005) into all nursing curricula to improve the skills, interventions, communication and attitudes of orthopaedic nurses so that nurses can develop the expertise to act as patient educators and advocates in the use of these interventions. Early identification of the care problem is vital in orthopaedic nursing.

 

References

• Carmichael, Kelly D.; Goucher, Nicholas R. (2006). Orthopaedic Essentials. Orthopaedic Nursing. 25(2):137-139.
• Carol V. Harvey (2005). Spinal Surgery Patient Care. Orthopaedic Nursing. 24 (6). 426 – 440.
• Cindy Pfeiff (2006). The Scandinavian Total Ankle Replacement (STAR). Orthopaedic Nursing.25 (1):30 – 33.
• Courtney, Mary, Tong, Shilu, Walsh, Anne (2000). Acute-care nurses' attitudes towards older patients: A literature review. International Journal of Nursing Practice. 6(2):62-69.
• Elwin R. Tilson et .al (2006).  An Overview of Radiography, Computed Tomography, and Magnetic Resonance Imaging in the Diagnosis of Lumbar Spine Pathology. Orthopaedic Nursing.25 (6): 415 – 420
• Gloria F. Antall (2004). The Use of Guided Imagery to Manage Pain in an Elderly Orthopaedic Population. Orthopaedic Nursing. 23(5): 335 – 340.
• Harper, Phil, Ersser, Steven and Gobbi, Mary (2007) How military nurses rationalize their postoperative pain assessment decisions. Journal of Advanced Nursing, 59, (6), 601-611.
• Heather Chong (2004). Innovations: The Titanium Rib: Creating Room to Grow. Orthopaedic Nursing. 23(5): 348 – 349.
• Jim Hanna et.al (2007). Kyphoplasty: A Treatment for Osteoporotic Vertebral Compression Fractures. Orthopaedic Nursing.26 (6):342 – 346.
• Julie Hummer-Bellmyer (2002). The Collaborative Role of the Perioperative Nurse Practitioner in Assessing Perioperative Patients. Orthopaedic Nursing. 21(1): 29-44.
• Kathleen A. Gross (2002). Vertebroplasty A New Therapeutic Option. Orthopaedic Nursing. 21(1): 23-29.
• LaMontagne, Lynda; Hepworth, Joseph T.; Salisbury, Michele H.; Cohen, Frances. Effects of Coping Instruction in Reducing Young Adolescents' Pain after Major Spinal Surgery. Orthopaedic Nursing. 22(6):398-403.
• Linda Altizer (2003). Forearm and Humeral Fractures. Orthopaedic Nursing.  22 (4): 266 - 273.
• Lawrence C. Vogel et.al (2004). Unique Issues in Pediatric Spinal Cord Injury. Orthopaedic Nursing. 23(5): 300-308.  
• Lydia Kobziff (2006). Traumatic Pelvic Fractures. Orthopaedic Nursing. 25(4):235 – 241.
• Mary E. Hagle et.al (2004). Respiratory Depression in Adult Patients with Intravenous Patient-Controlled Analgesia. Orthopaedic Nursing. 23(1): 18-27.
• Mary Faut Rodts (2004). Total Disc Replacement Arthroplasty. Orthopaedic Nursing. 23(3): 216-219.
• Maryann Godshall (2006). Toe-to-Hand Transplantation Surgery. Orthopaedic Nursing. 25(1):13 – 19.
• Watters CL, Moran WP (2006). Hip fractures--a joint effort. Orthop Nurs. 25(3):157-65.
• Wilma M.C.M et.al (1999). Non Verbal behaviour in nurse elderly patient communication. Journal of Advanced Nursing 29: 808.
• Wu ML, Courtney M, Berger G (2000). Models of nursing care: a comparative study of patient satisfaction on two orthopaedic wards in Brisbane. Aust J Adv Nurs.; 17(4):29-34.

 

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