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Posted: 27 Jul 2010 08:58 AM PDT

Reading time: 4 – 7 minutes

In external fixation, a physician inserts metal pins through skin and muscle layers into the broken bones and affixes them to an adjustable external frame that maintains their proper alignment. (See Types of external fixation.) This procedure is used most commonly to treat open, unstable fractures with extensive soft tissue damage, comminuted closed fractures, and septic, nonunion fractures and to facilitate surgical immobilization of a joint. Specialized types of external fixators may be used to lengthen leg bones or immobilize the cervical spine.

An advantage of external fixation over other immobilization techniques is that it stabilizes the fracture while allowing full visualization and access to open wounds. It also facilitates early ambulation, thus reducing the risk of complications from immobilization.

The Ilizarov fixator is a special type of external fixation device. This device is a combination of rings and tensioned transosseous wires used primarily in limb lengthening, bone transport, and limb salvage. Highly complex, it provides gradual distraction resulting in good-quality bone formation with a minimum of complications.

Equipment

Sterile cotton-tipped applicators â€¢ prescribed antiseptic cleaning solution â€¢ sterile gauze pads â€¢ povidone-iodine solution â€¢ optional: antimicrobial ointment.

Equipment varies with the type of fixator and the type and location of the fracture. Typically, sets of pins, stabilizing rods, and clips are available from manufacturers. Don’t reuse pins.

Preparation of equipment

Make sure the external fixation set includes all the equipment it’s supposed to include and that the equipment has been sterilized according to your facility’s procedure.

Implementation

Explain the procedure to the patient to reduce his anxiety. Assure him that he’ll feel little pain after the fixation device is in place and that he’ll be able to adjust to the apparatus.
Tell the patient that he’ll be able to move about with the apparatus in place, which may help him resume normal activities more quickly.
After the fixation device is in place, perform neurovascular checks every 2 to 4 hours for 24 hours, then every 4 to 8 hours, as appropriate, to assess for possible neurologic damage. Assess color, motion, sensation, digital movement, edema, capillary refill, and pulses of the affected extremity. Compare with the unaffected side.
Apply an ice bag to the surgical site, as ordered, to reduce swelling, relieve pain, and lessen bleeding.
Administer analgesics or narcotics, as ordered, before exercising or mobilizing the affected extremity to promote comfort.
Monitor the patient for pain not relieved by analgesics or narcotics and for burning, tingling, or numbness, which may indicate nerve damage or circulatory impairment.
Elevate the affected extremity, if appropriate, to minimize edema.
Perform pin-site care, as ordered, to prevent infection. Pin-site care varies, but you’ll usually follow guidelines such as these: Use sterile technique; avoid digging at pin sites with the cotton-tipped applicator; if ordered, clean the pin site and surrounding skin with a cotton-tipped applicator dipped in ordered antiseptic solution; if ordered, apply an antimicrobial ointment to the pin sites; apply a loose sterile dressing, or dress with sterile gauze pads soaked in povidone-iodine solution. Perform pin-site care as often as necessary, depending on the amount of drainage.
Also check for redness, tenting of the skin, prolonged or purulent drainage from the pin site, swelling, elevated body or pin-site temperature, and any bowing or bending of pins, which may stress the skin.

For the patient with an Ilizarov fixator

When the device has been placed and preliminary calluses have begun to form at the insertion sites (in 5 to 7 days), gentle distraction is initiated by turning the appropriate screws one-quarter turn (1 mm) every 4 to 6 hours, as ordered.
Teach the patient that he must be consistent in turning the screws every 4 to 6 hours around the clock. Make sure he understands that he must be strongly committed to compliance with the protocol for the procedure to be successful. Because the treatment period may be prolonged (4 to 10 months), discuss with the patient and family members the psychological effects of long-term care.
Don’t administer nonsteroidal anti-inflammatory drugs (NSAIDs) to patients who are being treated with the Ilizarov Fixator. NSAIDs may decrease the necessary inflammation caused by the distraction, resulting in delayed bone formation.

Special considerations

Before discharge, teach the patient and family members how to provide pin-site care. This is a sterile procedure in the hospital, but clean technique can be used at home. Teach them how to recognize signs of pin-site infection.
Tell the patient to keep the affected limb elevated when sitting or lying down.

Complications

Complications of external fixation include:

loosening of pins and loss of fracture stabilization
infection of the pin tract or wound
skin breakdown
nerve damage
muscle impingement.

Ilizarov fixator pin sites are more prone to infection because of the extended treatment period and because of the pins’ movement to accomplish distraction. The pins are also more likely to break because of their small diameter. Also, the large number of pins used increases the patient‘s risk of neurovascular compromise.

Documentation

Assess and document the condition of the pin sites and skin. Document the patient‘s reaction to the apparatus and to ambulation as well as his understanding of teaching instructions.

source : Nursing Procedures, 4th Edition,Lippincott Williams & Wilkins

Related Other Nursing

NCP | Nursing Care Plan Anorexia Nervosa

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NCP | Nursing Care Plan Anorexia Nervosa

Posted: 27 Jul 2010 04:00 AM PDT

Reading time: 9 – 14 minutes

Anorexia NervosaEating DisorderAnorexia nervosa is a disorder characterized by an intense fear of obesity or weight gain and the inability or refusal to maintain body weight at 85% minimum expected for height.

It is generally considered to be a disorder of young women that begins in adolescence or young adulthood. It is becoming more common in males. Anorexia nervosa is marked by severely restricted calorie intake, despite hunger, which leads to malnourishment and serious weight loss.

The patient with anorexia nervosa achieves and maintains massive weight loss by calorie restriction; self-induced vomiting; abuse of cathartics, laxatives, or enemas; and/or excessive exercising. Many patients have severe disturbances in self-concept, self-esteem, and body image and may benefit from a therapeutic approach that involves nutritional consults, individual and family therapy, and medical management of the complicated organ system imbalances that this order brings about.

Patients may be hospitalized briefly during the initial acute phase of treatment, when medical problems require intensive monitoring and complicated therapies. The initial aim of treatment is to stabilize the patient medically and stop weight loss. When medically stable, the patient can be managed in outpatient day treatment or partial hospitalization programs.

Nursing DiagnosisImbalanced Nutrition: Less Than Body Requirements

Common Related Factors	Defining Characteristics
Severe fear of obesitySeverely distorted self-concept, self-esteem, and/or body imageAbsence of physical conditions that would explain weight loss or prevent weight gain	Body weight 15% to 29% or more below ideal weight for heightSelf-restricted calorie intake despite hungerObsession with food, calories, weight, and control issues
Common Expected OutcomesPatient stops losing weight.Patient begins to gain weight.Patient recognizes eating disorder.	NOC OutcomesNutritional Status: Food and Fluid Intake; Weight ControlNIC InterventionsEating Disorders Management; Weight Gain Assistance; Nutritional Therapy

Ongoing Assessment

Actions/Interventions	Rationale
Record the patient's weight and height on intake. Weigh regularly, maintaining standard conditions (i.e., same scale, same time of day, patient wearing similar clothes).	This ensures accurate record of weight changes.

Weigh the patient in a matter-of-fact manner without discussion.	This reduces risk of acting-out behaviors. Weight gain is only one aspect of the total therapeutic program; other critical factors include nutritional adequacy, behaviors related to eating, appropriate use of exercise, and development of a healthy body image.
Obtain weight history, including initial motivation for weight loss or food restrictions.	Clinical anorexia can follow ordinary weight loss dieting.
Conduct a nutritional assessment:	It is critical that the health care provider openly discuss and have an understanding of the complex food and weight-related behaviors of the patient so that appropriate supports can be integrated into the treatment plan.
· Assess the patient's beliefs and fears about food and weight gain	Excessive focus on food and weight can be a maladaptive method of coping with stress.
· Knowledge about nutrition and sources of information	This information provides the basis for an individualized teaching plan about maintaining adequate nutritional intake.
· Behaviors used to reduce calorie intake (dieting), to increase energy output (exercising), and generally to lose weight (vomiting, purging, and laxative abuse)	This provides data on patient thinking and thought distortions.
Assess cardiovascular, metabolic, renal, gastric, hematological, and endocrine system functioning.	Assessment provides data on the severity of malnutrition.
Monitor intake (i.e., daily food plans that track eating trends along with emotional states and triggering events). Record intake and output for the hospitalized patient.	These data help determine the patient's actual caloric intake and eating behaviors.

Therapeutic Interventions

Actions/Interventions	Rationale
Prescribe appropriate nutrition and total calories per day to relieve acute starvation.	A gradual refeeding prescription ensures steady weight gain and reduces risk of medical complications.
Supervise all activities immediately before and after meals; maintain supervision consistency.	This decreases opportunity to engage in compensatory activities to reduce calorie intake.
Provide food and meals without comment.	This helps separate emotional behaviors from eating behaviors.
Set limits on all exercise but allow daily activity.	Preventing all forms of exercise may induce severe anxiety.
Assure the patient that treatment is not designed to produce obesity.	Patients have an overwhelming fear of weight gain and obesity.
Acknowledge any anger, sadness, or feeling of loss that the patient may have toward treatment.	This helps provide external emotional controls that have not yet been internalized by the patient.
Provide supplemental feedings and nutrition as indicated.	Nutritional supplements may be necessary if the patient is malnourished. Tube or parenteral feedings may be necessary if the patient is unable to allow herself or himself oral feedings.

Nursing DiagnosisDisturbed Body Image

Common Related Factors	Defining Characteristics
Difficulty coping with development and maturationInability to achieve unreasonable personal goalsAlexithymia (channeling uncomfortable feelings into behaviors such as self-starvation)	Distorted views of one's body weight and shape for ageNegative feelings about self and bodySelf-loathing (impulsive or obsessive)Intense fear of gaining or not being able to lose weight
Common Expected OutcomesPatient identifies positive thoughts and feelings regarding body and self.Patient identifies a direct means of coping with problems.	NOC OutcomeBody ImageNIC InterventionsSelf-Awareness Enhancement; Body Image Enhancement

Ongoing Assessment

Actions/Interventions	Rationale
Explore the patient's understanding of his or her physical body, especially as it relates to maturation. Assess to what degree the patient's negative body image and negative self-concept are related to overwhelming anxiety.	Patients with anorexia have a distorted body image.
Assess to what degree culture, religion, race, and gender influence the patient's negative views of self.	Cultural and social norms about body size and shape may influence the patient's thinking and feelings about his or her body image.
Determine the family or patient's perceptions regarding psychological and physical changes brought about by anorexia.	These data need to be compared to the patient's thinking prior to the onset of anorexia.
Obtain the patient's assessment of personal strengths and weaknesses.	Patients learn they have the ability to handle day-to-day stress.
Assess the patient's ability to identify "here and now" emotional states and precipitating events that trigger negative behaviors.	The patient may not be aware of the relationship between feelings and eating behaviors.

Therapeutic Interventions

Actions/Interventions	Rationale
Encourage reexamination of positive and negative self-perceptions.	The patient needs to develop a realistic understanding of his or her body image.
Encourage the patient to identify the differences between "real people" and celebrities.	Patients often use media reports of celebrities as a guide for their eating behaviors.
Encourage recognition, expression, and acceptance of unpleasant feelings.	Patients with anorexia have a need for control in multiple areas of their lives. Mastery over food may have become a method for reducing tensions.
Help the patient develop a realistic, acceptable perception of body image and food.	Patients must understand the complex health problems associated with anorexia.
Refer the patient to individual counseling and a support group for eating disorders.	Multiple approaches are needed to achieve long-term changes in behavior. Groups that come together for mutual support and guidance can provide long-term assistance.

Nursing DiagnosisInterrupted Family Processes

Common Related Factor	Defining Characteristics
Developmental attachment and separation crisis and the necessity for family restructuring	Family members unable to relate to each other for mutual growth and maturationFamily system unable to meet the emotional needs of all family membersRigid family functions and rolesFamily does not tolerate individuality and autonomy for all membersFamily fails to accomplish critical developmental tasks
Common Expected OutcomesFamily members develop effective methods of communication.Family members express understanding of shared and individual problems.Family members identify new resources for problem solving.	NOC OutcomesFamily Coping; Family FunctioningNIC InterventionsFamily Integrity Promotion; Family Therapy

Ongoing Assessment

Actions/Interventions	Rationale
Assess interactional patterns used by family:
· Enmeshment	This is a lack of boundaries between family members.
· Overprotectiveness	This is exaggerated concern for the welfare of family members.
· Rigidity	This is an excessive need to maintain status quo.
· Dysfunctional conflict resolution	Child becomes symptomatic in response to unresolved parental conflict.
Explore family views on recurring problems.	It is important to de-emphasize the family's view of the patient as the family problem.
Explore effects of family members' behaviors on one another. Identify interaction patterns.	This demonstrates how patterns produce dependence on family cues for regulation rather than fostering self-regulation.
Enroll the patient and family in counseling.	The family's willingness to participate in the therapeutic process is a strong indicator of how successful the patient will be in reducing symptoms and behavior.
Acknowledge and give feedback to the family's concerns and feelings.	This encourages direct expression of personal feelings.
Assist the adolescent or young adult patient in individuating self from parents. Encourage autonomy as is appropriate for age.	Patients with anorexia and their families may struggle with issues of dependence and independence, as well as control issues.