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Introduction   

Nurses should understand the importance of early postoperative interventions after orthopedic surgery. Understanding and implementing these strategies can help improve patient outcomes, prevent complications, and reduce patient mortality. This course reviews patient planning, initial and ongoing nursing assessments, and incision are and infection prevention interventions that nurses can implement for post-op orthopedic patients. The course will also discuss a multidisciplinary approach to patient care, discharge, and follow-up strategies.

Patient Planning

Prior to any orthopedic surgery, nurses should anticipate the patient’s postsurgical needs and other factors. Although a patient may be mobile before surgery, this is not always the case postoperative, especially for the first 24 hours. Therefore, it’s important for nurses to anticipate environmental factors to improve patient safety and prevent complications.

How the patient recovers after surgery depends on various intrinsic and extrinsic factors, such as the type of orthopedic surgery, the length of the procedure, and the patient’s response to anesthesia and overall health status [2]. Before the patient arrives to the unit, the nurse and charge nurse should select the appropriate mattress and bedframe for the patient. For example, a patient who requires mechanical traction may need an orthopedic traction bed designed for a patient who needs traction therapy. Additionally, if the nurse anticipates the patient may be on bed rest for several hours or days, then they will likely need an alternating pressure mattress that redistributes airflow every so often and helps to prevent pressure injuries from occurring. After selecting the mattress, the nurse should zero the bed’s weight with all necessary pillows and sheets on it.

The nurse should also gather any additional equipment, braces, cushions, and support services for the patient. If the patient has knee surgery, they may need a knee immobilizer or continuous passive motion device, which flexes and extends the knee. For hip surgery patients, a large cushion called a hip abduction pillow is needed to keep the patient’s leg in the correct position and prevent the patient’s inner legs from touching. Upper extremity surgeries may need a shoulder sling or brace that holds the arm in place. Additionally, the nurse should consider other therapies that may be ordered by the surgeon, such as ice packs and materials for dressing changes. After the floor nurse receives a report from the post-anesthesia care unit (PACU) nurse, they may need to set up additional equipment based on the patient’s overall health status. For example, in-wall suction, telemetry monitor, blood pressure machines, oxygen setup, IV pumps, item reachers, and other equipment may be necessary.

Patients are also more prone to falls after surgery [9]. Therefore, the nurse must take proper fall prevention measures as outlined by the organization. Initial fall prevention measures may include applying non-slip socks on the patient and posting fall prevention signs inside and outside the patient’s room to alert staff members. Nurses should also check to make sure the bed alarm is working properly.

Initial and Ongoing Assessment

This section discusses nursing interventions after patient arrival to the unit and additional ongoing assessments that may be required.

Assessing Vital Signs

During the postoperative period, the floor nurse should monitor the patient’s vital signs. Typically, vital signs are taken every 15 minutes for 1 hour, then every 30 minutes for 2 hours, and then every 4 hours for 24 hours [10]. However, the nurse should abide by the surgeon’s orders or follow their unit’s protocols since they can vary. Vital signs to take and record include blood pressure, respiratory rate, heart rate, temperature, oxygen saturation, and the patient’s pain level [16].

When taking the patient’s blood pressure, the nurse should be aware of the patient’s baseline and any blood pressure or heart rate control medications they are taking. Slight deviations in the patient’s blood pressure can indicate the presence of early complications, especially post-operative hypotension [4]. If the patient becomes hypotensive, the nurse should call the surgeon or hospitalist managing the patient immediately. A fluid bolus or other measures may be implemented. Conversely, if the patient becomes hypertensive, the nurse should administer as-needed (PRN) anti-hypertensive medications as ordered, such as IV hydralazine or metoprolol. Oral antihypertensives should be continued after surgery and have administration parameters [17].

The patient’s heart rate may also be elevated after surgery. Tachycardia is a common finding after surgery and has many contributing factors. Factors such as stress, dehydration, and pain can increase a patient’s heart rate. Therefore, the nurse should be knowledgeable about potential contributing factors and address them accordingly. Another factor to consider is the patient’s health history. If they have a history of palpitations, tachycardia, or other conditions that cause tachycardia, a high heart rate may be the baseline for the patient. Tachycardia can also indicate a new underlying pathologic arrhythmia or acute physiological condition [3]. The nurse should notify the provider of any concerns and obtain orders as soon as possible. Many postoperative patients are placed on cardiac telemetry to monitor cardiac arrhythmias.

Respiratory rate and oxygen saturation are additional vital signs to take, assess, and address whenever necessary. The nurse should assess the patient’s respiratory rate and effort. Continued supplemental oxygen is often ordered after surgery. Oftentimes, orders state to wean the oxygen per the patient’s vital signs in hopes they can transition to room air. Respiratory depression, bradypnea, and hypoxemia are common during the postoperative period due to various factors. Administration of opioids, anxiolytics, and muscle relaxants may contribute to respiratory depression [15]. If the patient’s respiratory depression is severe and related to these medications, the nurse should administer the appropriate reversal agent, like naloxone. Alternatively, if a patient is tachypneic with a low oxygen saturation, supplemental oxygen may be needed. Changes to a patient’s respiratory rate and oxygen saturation can also indicate adverse complications, like a pulmonary embolism or developing pneumonia.

In addition, the nurse should assess the patient’s temperature. Several medications during the intraoperative period contribute to temperature alterations. If a patient’s temperature becomes hypothermic, nursing interventions like applying warm blankets or warming devices over the patient must be taken. Hyperthermia is also common after surgery and is typically treated with acetaminophen or other fever-reducing medications as ordered [22]. Additionally, malignant hyperthermia is another potential and serious, life-threatening complication that can develop. Although this condition usually presents in an intraoperative setting shortly after administering anesthetic agents, it can still be present during the postoperative period. Initial clinical signs are hyperthermia, muscle rigidity, arrhythmias, and increased end-tidal CO2 [21]. If the patient develops any of these signs, the nurse notifies the provider and anesthesia immediately. They should plan to administer dantrolene, apply cooling blankets, and transfer the patient to a higher level of care.

Pain is another important vital sign to assess and manage. To assess the patient’s pain, the nurse can utilize various assessment scales. Common pain assessment tools are the verbal rating scale, numeric rating, and visual analog scale. For patients who cannot self-report, observational and behavioral pain scales may be used [6]. Additional information regarding postoperative pain management is discussed below.

Performing Neurovascular Checks

Frequent neurovascular checks should be performed after surgery, especially of the distal area where the orthopedic procedure was performed or the affected extremities. Neurovascular assessments are commonly ordered hourly for the first 24 hours and then every 4 hours thereafter. When performing a neurovascular assessment, the nurse should assess the patient’s pain level, sensation, motor function, and perfusion. Perfusion is assessed by color, temperature, pulse, capillary refill, sensation, and swelling. They should also flex and extend the patient’s affected limb via passive motion. Extreme pain or pain not relieved by analgesic medications may be a sign of compartment syndrome, a surgical emergency.

Any abnormal findings indicate possible neurovascular compromise, and the physician should be notified immediately. Additionally, if there are signs of neurovascular issues, the nurse can provide immediate interventions, such as elevating the limb while maintaining alignment and increasing the frequency of neurovascular checks [30].

Assessing Pain

Patients may have several postoperative medications ordered to manage their pain levels. There are many medications and modalities used to control postoperative pain, including acetaminophen, ketorolac, and opioids. Examples of common opioids are morphine, hydromorphone, tramadol, and codeine. Some of these medications are scheduled, like IV acetaminophen, while others are for mild to moderate (ketorolac) and severe or breakthrough pain (opioids). The nurse should abide by the administration parameters as outlined in the provider’s orders.

As discussed, the nurse uses the appropriate pain assessment tool to determine the patient’s pain level. They should also select the appropriate route of administration if there are several PRN pain medications to choose from [5]. For example, if the patient is able to tolerate food and rates their pain as an 8 out of 10, then oral hydrocodone may be the most appropriate medication to administer. Alternatively, if the patient rates their pain a 4 out of 10 and is NPO (nothing by mouth), then administering IV ketorolac may be the most appropriate. Some individuals may have a patient-controlled analgesia (PCA) pump, where they can push a button to self-administer pain medications. The nurse should verify the medication orders and lockout parameters with another nurse present. Patients on a PCA usually also have corresponding capnography and pulse oximetry monitoring ordered.

Many postoperative orthopedic patients also have nerve blocks, a type of regional anesthesia. This procedure is typically completed prior to surgery and helps control post-operative pain. The perineural catheter continuously administers a local anesthetic (typically ropivacaine or bupivacaine) to the desired nerve and can provide anesthesia to the affected area for around 20 hours. Although a nerve block is targeted at decreasing sensory sensation, it may also have some degree of motor block [12].

If a patient arrives at the unit with a nerve block, the nurse should initially assess the site of catheter insertion and establish the patient’s baseline of sensory and motor function in the affected region. Most continuous nerve blocks have a bulb on the end, where the anesthetic medication is delivered from, and a dial to adjust the dosage. The nurse should verify the administration dosage against the patient’s orders. Additionally, the nurse should perform frequent neurovascular checks on the distal region and assess the patient’s pain level and sensory and motor function.

Again, the frequency of checks is either outlined by the physician’s orders or per the unit and/or hospital protocol. The nurse should also frequently monitor for peripheral nerve block complications, such as hematomas, tissue bruising, and unintended spread of local anesthesia [12]. The nurse should also be aware of the patient’s motor function limitations and provide support or help with repositioning when necessary. For example, if a patient has a brachial plexus nerve block, they will need help moving the arm and should be provided a sling to support the arm and not cause any injury.

Some physicians have additional orders, where the nurse can adjust the dosage of the anesthetic being delivered if the patient is having pain or based on their physical assessment. After the medication has run out of the residual bulb, the nurse or provider will remove the perineural catheter. Note that oral pain medication may need to be administered prior to removal to control the patient’s pain.

Checking for Pressure Injuries

Once the patient arrives at the unit, the nurse should complete a thorough skin assessment with another nurse and document any wounds or suspected pressure injuries, if any. This is especially important for patients who are on strict bedrest after surgery or who have mobility limitations. The nurse should be aware of patient risk factors that increase the likelihood of postoperative pressure injuries, such as age, chronic conditions, duration of surgery, and ability to physically maneuver.

Areas of concern for developing a pressure injury may be the sacrum, heels, or the areas where the orthopedic surgery was performed [14]. For example, a patient with a right hip replacement may be more susceptible to developing a pressure injury on their right leg, buttocks, and heel. The nurse should assess for pressure injuries according to the unit’s policies or physician’s orders.

Monitoring Urinary Output

Nurses should also monitor the patient’s urine output after surgery. They should know the amount of IV fluids the patient received during surgery and estimated blood loss. Depending on the type and length of surgery, the patient may have an indwelling catheter in place prior to unit arrival. The nurse should read the patient’s orders regarding care and removal. For some orthopedic patients, the indwelling catheter is to be removed right after surgery, while for others, it’s to stay inserted for several hours or days. If an indwelling catheter is to remain in place, the nurse should monitor the urinary output and should expect a urine output of at least 1 mL/kg/hour, or some research suggests 200 ml after 2 hours. If a patient has low urinary output, the nurse should suspect potential acute kidney injury and notify the provider immediately [28].

Conversely, the patient may not have a urinary catheter in place. The nurse should encourage the patient to void and measure their output using a commode hat or other measuring device. Postoperative urinary retention is a possibility, so if the patient hasn’t voided after several hours, the nurse should assess the patient and perform a bladder scan. The amount of residual urine in the bladder will help determine if the patient is retaining urine. If there is urinary retention, the nurse should follow the patient’s orders, which usually means a notification to the provider immediately. The provider may order a one-time straight catheter insertion to drain the bladder. Additionally, the nurse can provide several interventions to encourage bladder emptying, such as applying a suprapubic hot pack and promoting early ambulation (if orders permit) [19].

Assessing Bowel Function

Patients are more prone to constipation (most commonly) and other alterations in their bowel habits after surgery. Therefore, it’s important for nurses to monitor and promote the patient’s bowel function. They may encourage early ambulation and a high-fiber and fluid diet if ordered. Additionally, sometimes patients are placed on medications, such as stool softeners, suppositories, or enemas [23]. If the patient is admitted to the hospital unit for an overnight stay or several days, they are typically required to pass a bowel movement before discharge. However, this guideline depends on physician orders and hospital protocol. If the patient is unable to pass gas or have a bowel movement, the nurse should monitor the patient for signs of a possible ileus.

Monitoring Lab Values for Fluid and Electrolyte Imbalances

Postoperative patients, especially those with underlying health conditions, are more likely to have fluid and electrolyte imbalances. Factors such as hormonal mediators, physiological response, blood loss, third spacing, and others can contribute to these imbalances. The nurse should anticipate replacement fluids, such as 0.9% normal saline or lactated ringers, being ordered after surgery. Additionally, sometimes blood products or albumin are ordered for blood loss, adequate tissue perfusion, or anemia [26].

Electrolyte abnormalities are also common postoperatively. If labs were completed prior to surgery, the nurse should review these labs to establish the patient’s baseline. Common electrolyte imbalances after surgery include hyponatremia, hyperchloremia, hypokalemia, and hypomagnesemia. Hypercalcemia, hyperphosphatemia, and hyperkalemia are also possible. Patients may also become hypo- or hyperglycemic [25]. Most commonly, routine labs will be ordered after surgery or the morning thereafter. The nurse should check the most recent lab values and notify the provider of any abnormalities or follow electrolyte replacement protocols (if low) outlined by the orders or hospital protocols.

Nutritional Status

The patient’s nutritional status is another important variable the nurse should monitor after surgery. Diet is dependent on the provider’s orders, although typically, it’s to advance the patient to a regular diet as soon as possible. So, the nurse should first introduce clear liquids, then full liquids, then softer foods, and then a regular diet.

The nurse should also monitor the patient for postoperative nausea and vomiting (PONV), especially during the first 24 hours after surgery. Some relevant patient risk factors of PONV include age of less than 50 years old, females, nonsmoking status, and history of motion sickness or PONV. The amount of anesthesia administered during the procedure can also contribute to this condition. If this PONV occurs, nurses can administer medications like ondansetron, a scopolamine patch, or other prophylactic or as-needed antiemetics [7].

More specifically, orthopedic patients should increase their intake of certain nutrients to aid with healing time and recovery and preserve muscle mass and strength. Some researchers suggest that patients should be encouraged to consume free-form essential amino acids, usually mixed with water, shortly after surgery to prevent muscle atrophy. Patients can then advance to protein beverages and a regular diet. Protein intake post orthopedic surgery should range from 1.6g/kg/day to 3g/kg/day. However, this is dependent on the patient’s nutritional requirements and past medical history.

The nurse should encourage small, frequent meals and promote carbohydrate and protein intake prior to physical therapy or rehabilitation [11]. Additionally, vitamin C and D supplementation reduce the body’s anti-inflammatory effect and support incision healing, respectively. Zinc and calcium supplementation may also be ordered by the provider [20].

Venous Thromboembolism (VTE) Prophylaxis

Prevention of postoperative venous thromboembolism (VTE), such as a deep vein thrombosis (DVT) or pulmonary embolism (PE), is another important variable for the nurse to consider. Pharmacologic and non-pharmacologic measures can be taken to prevent VTE. Non-pharmacologic interventions may include passive motion devices, compression stockings, or sequential compression devices.

The provider typically orders VTE prophylaxis medications based on the patient’s risk stratification, as certain orthopedic procedures and medical conditions place patients at higher risk for developing a VTE. Therefore, non-pharmacological interventions alone do not suffice for prophylaxis. The provider may order antiplatelets (e.g., aspirin), anticoagulants (e.g., warfarin), heparin, low-molecular-weight heparin, or other alternatives or a combination thereof [8]. The nurse should administer these medications accordingly and monitor for possible side effects. If the nurse notices possible signs of a DVT or PE, they should call the provider immediately.

Early Mobilization

Nurses should promote early patient mobilization (within 24 hours) after orthopedic surgery, especially for patients who underwent total hip or knee replacement surgery. According to the enhanced recovery after surgery (ERAS) pathway, early mobilization reduces the likelihood of postoperative complications and hospital length of stay [29].

When ambulating patients with lower extremity or spinal orthopedic surgeries, the nurse must consider assistive devices the patient may need, such as a cane, walker, gait belt, and lift equipment. Some hospital systems require a physical therapist to be present when ambulating the patient for the first time after surgery. Furthermore, nurses should coordinate and communicate with nursing assistant staff and the healthcare team about a patient’s ambulation restrictions and if any assistive devices are required.

Fall Prevention

Patients who undergo orthopedic surgery are more prone to falls, so nurses and members of the healthcare team should take measures to prevent their occurrence. Fall prevention measures such as hourly rounding and fall risk assessments are necessary. Universal fall precautions should be implemented for every patient and include [1]:

• Call light education, use, and make sure it’s within reach
• Keeping patient’s possessions within reach
• Locking hospital bed and wheelchair brakes
• Using lighting
• Keeping floors clean and uncluttered
• Non-slip socks are placed on the patient [1]

Many hospital protocols include the 5 Ps of fall prevention: pain, personal needs, position, placement, and prevention. These should be addressed during patient rounding [1]. Furthermore, orthopedic surgeons should also be involved in fall prevention measures and place specific orders, if possible. They can educate patients on fall prevention safety and environmental measures and order physical and occupational therapy [18].

Incision Care and Infection Prevention

Another vital aspect of post-operative orthopedic nursing management is incision care. Orthopedic surgical dressings are classified as active, passive, and interactive. Since these dressings are typically over bony prominences, providers and nurses must select the appropriate dressing for the patient. Passive dressings include gauze and absorbent pads secured with adhesive tape. While active dressings include film, hydrocolloids, and foam. Interactive dressings have antimicrobial features or can be wound vacuums [27].

When the patient arrives at the unit, the nurse should first inspect the dressing and review the patient’s orders. Depending on the type of dressing, the nurses may slightly lift the dressing to inspect the surgical incision and assess for drainage, erythema, swelling, and other signs. However, this depends on the surgeon’s orders because some surgeons have strict orders not to change or touch the dressing.

The nurse should inspect the type of dressing and if any drainage is seen on the dressing and document any findings in the patient’s chart. Surgical dressings should be checked regularly, and if drainage is present, they may need to mark the area of draining on the dressing with a pen to monitor it closely. Depending on the patient’s orders, the nurse may apply another dressing on top, reinforce it, or change the dressing entirely. If the patient has a wound vacuum, the nurse should ensure the vacuum pressure is set appropriately and matches the physician’s orders. They should also document drainage color and amount in the collection chamber.

The nurse should also follow the surgeon’s incision care instructions. However, these highly vary based on the type of surgery and surgeon’s preferences [13]. Sometimes, surgeons order incision care after the initial 24 hours of surgery. Some orders may include irrigating the wound, applying a wet-to-dry dressing, or changing to a new type of dressing completely. If and when the nurse can inspect the incision, they should look for signs of infection. Signs may include purulent discharge, surrounding erythema or swelling, or abnormal tenderness. The nurse should also monitor the patient for systemic signs of infection, such as fever or tachycardia. If the nurse suspects a surgical wound infection, they should notify the surgeon immediately. Oftentimes, the surgeon will order a wound culture and start the patient on prophylactic antibiotics if they have not already been prescribed [24].

Multidisciplinary Care

Nurses should also recognize that post-op orthopedic patients require care from a multidisciplinary team, especially for patients with an anticipated longer hospital stay. The nurse should coordinate the patient’s care appropriately. Typically, post-op patients will have physical and/or occupational therapy ordered, continuing past discharge. Patients may also have referrals to wound care and nutritional consults to optimize wound healing.

Additional consults may be required depending on the patient’s condition. For example, infectious diseases may be consulted if the patient develops a wound infection. If they develop a cough or heart arrhythmias, pulmonary or cardiology consultations may be ordered respectively.

Patient Discharge Planning and Follow-Up

Patient discharge planning should begin as soon as possible. Over the course of the hospital stay, the patient’s discharge location may change. For example, the patient may have initially thought they would be discharged home, but due to limited mobility, they need to be discharged to a rehabilitation facility instead. When plans for discharge begin or change, the nurse should coordinate patient care with the appropriate case manager.

If a patient is being discharged home, the nurse should help coordinate follow-up appointments and understand the patient’s continued therapies needed. For instance, the patient will require physical therapy (PT) sessions several times weekly; therefore, the nurse and provider should consider whether receiving home PT or driving to a PT office is most appropriate for the patient.

The nurse may also need to help order medical devices or equipment for home use. Often, patients have the necessary equipment before surgery if it is scheduled, but this isn’t always the case. The nurse should ensure the patient has the proper equipment at home, such as braces, walkers, or canes. Furthermore, the nurse should ensure the patient tolerates fluids and food and can take oral pain medications. Nurses should also educate the patient and their family members about home fall prevention strategies, medications, following discharge instructions, and the importance of continued follow-up with the surgeon and other therapies. They should also provide instructions on worsening signs and symptoms and when to call a provider. Some precautionary instructions may include what to do for leg swelling for possible DVT, surgical site infections, or inability to control pain.

Conclusion

Post-operative orthopedic patient care starts before the patient arrives at the unit. Early and appropriate nursing assessment and interventions can prevent complications.

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