Compartment syndrome: an accumulation of fluid in the muscle compartment, resulting in an increase in pressure that reduces blood flow to the tissues. Can lead to neuromuscular deficit, amputation, and death.

Pathophysiology: inability of the fascia surrounding the muscle group to expand to accommodate the increased volume of fluid —> compartment pressure increases —» venous flow impaired arterial flow continues, increasing capillary pressure —> fluid pushed into the extravascular space —> intracompartment pressure further increased —» prolonged or severe ischemia —> muscle and nerve cells destroyed, contracture, loss of function, necrotic tissue, infection, release of potassium, hydrogen, and myoglobin into bloodstream.
Risk factors:
1. Fractures.
2. Burns.
3. Crushing injuries.
4. Restrictive bandages.
5. Cast.
6. Prolonged lithotomy positioning.
Assessment:
1. Subjective data:
  1. Severe, unrelenting pain, unrelieved by narcotics and associated with passive stretching of muscle.
  2. Paresthesias.
2. Objective data:
  1. Edema; tense skin over limb.
  2. Paralysis.
  3. Decreased or absent peripheral pulses.
  4. Poor capillary refill.
  5. Limb temperature change (colder).
  6. Ankle-arm pressure index (API) decreased; 0.4 indicates ischemia.
  7. Urine output - decreased (developing acute tubular necrosis); reddish-brown color.
Analysis/nursing diagnosis:
1. Pain related to tissue swelling and ischemia.
2. Risk for injury related to neuromuscular deficits.
3. Impaired physical mobility related to contracture and loss of function.
4. Risk for infection related to tissue necrosis.
5. Altered urinary elimination related to acute tubular necrosis from myoglobin accumulation.
6. Body image disturbance related to limb disfigurement.
Nursing care plan/implementation:
1. Goal: recognizes early indications of ischemia.
  1. Assess neurovascular status frequently (qlh): skin temperature, capillary refill, peripheral pulses, mobility, and sensation.
  2. Listen to patient complaints; report suspected complications.
  3. Report nonrelief of pain with narcotics.
  4. Recognize unrelenting pain with passive muscle stretching.
2. Goal: prevent complications.
  1. Elevate injured extremity initially; if ischemia suspected, keep extremity at heart level to prevent compensatory increase in blood flow.
  2. Avoid tight bandages, splints, or casts.
  3. Monitor intravenous infusion for signs of infiltration.
  4. Prepare patient for fasciotomy (incision of skin and fascia to release tight compartment).
Evaluation/outcome criteria:

Relief from pain; normal perfusion restored.
Neurovascular status within normal limits.
Retains function of limb; no contractures or infection.
Compartment pressure returns to normal (20 mm Hg.).
No systemic complications (e.g., normal cardiac and renal function, acid-base balance within normal limits).

Osteoarthritis; joint disorder characterized by degeneration of articular cartilage and formation of bony outgrowths at edges of weight-bearing joints.
1. Pathophysiology: excessive friction combined with risk factors - thinning of articular cartilage, narrowing of joint space, and loss of joint stability; cartilage erodes, producing shallow pits on articular surface and exposing bone in joint space. Bone responds by becoming denser and harder.
2. Risk factors:
  1. Aging (>50).
  2. Rheumatoid arthritis.
  3. Arteriosclerosis.
  4. Obesity.
  5. Trauma.
  6. Family history.
3. Assessment:
  1. Subjective data:
    1. Pain; tender joints.
    2. Fatigability, malaise.
    3. Anorexia.
    4. Cold intolerance.
    5. Extremities: numb, tingling.
  2. Objective data:
    1. Joints:
      1. Enlarge
      2. Stiff, limited movement.
      3. Swelling, redness, and heat around affected joint.
      4. Shiny stretched skin over and around joint.
      5. Subcutaneous nodules.
    2. Weight loss.
    3. Fever.
    4. Crepitation (creaking or grating of joints).
    5. Deformities, contractures.
    6. Cold, clammy extremities.
    7. Lab data: decreased Hgb, elevated WBC.
    8. Diagnostic tests: x-ray, thermography, arthroscopy.
4. Analysis/nursing diagnosis:
  1. Pain related to friction of bones in joints.
  2. Bathing/hygiene self-care deficit related to decreased mobility of involved joints.
  3. Risk for injury related to fatigability.
  4. Impaired physical mobility related to stiff, limited movement.
  5. Impaired home maintenance management related to contractures.
5. Nursing care plan/implementation:
  1. Goal: promote comfort: reduce pain, spasms, inflammation, swelling
    1. Medications as prescribed.
      1. Nonsteroidal anti-inflammatory agents: aspirin (Ecotrin), acetaminophen (Tylenol), ibuprofen (Motrin), indomethacin (Indocin), corticosteroids, nabumetone (Relafen), naproxen (Naprosyn).
      2. Antimalarials: chloroquine (Aralen), hydroxychloroquine (Plaquenil), to relieve symptoms.
    2. Heat to reduce muscle spasms, stiffness.
    3. Cold to reduce swelling and pain.
    4. Prevent contractures:
      1. Exercise.
      2. Bed rest on firm mattress during attacks.
      3. Splints to maintain proper alignment.
    5. Elevate extremity to reduce swelling.
    6. Rest.
    7. Assistive devices to decrease weight bearing of affected joints (canes, walkers).
  2. Goal: health teaching to promote independence.
    1. Encourage self-care with assistive devices for activities of daily living (ADL).
    2. Activity, as tolerated, with ambulationassistive devices.
    3. Scheduled rest periods.
    4. Correct body posture and body mechanics.
  3. Goal: provide for emotional needs.
    1. Accept feelings of frustration regarding long-term debilitating disorder.
    2. Provide diversional activities appropriate for age and physical condition to promote comfort and satisfaction.
6. Evaluation/outcome criteria:
  1. Remains independent as long as possible.
  2. No contractures.
  3. States comfort has improved.
  4. Uses methods that are successful in pain control.

Total hip replacement: femoral head and acetabulum are replaced by a prosthesis, which is cemented into the bone with plastic cement. Performed to replace a joint with limited and painful function due to bony alkalosis and deformity, caused by degenerative joint disease or when vascular supply to femoral head is compromised from a fracture. Goal of the surgery: restore or improve mobilization of hip joint and prevent complications of extended immobilization.

Risk factors:

Rheumatoid arthritis.
Osteoarthritis.
Complications of femoral neck fractures-avascular necrosis and malunion.
Congenital hip disease.

Fractures of the Hip

Risk Factors	Types	Assessment	Surgical Intervention
Osteoporosis Age > 60 Women Caucasian Postmenopausal Immobility/sedentary	Intracapsular (femoral neck; within hip joint and capsule)	Slight trauma Pain, groin and hip Lateral rotation, shortening of leg, Minimal deformity	Total hip replacement
	Extracapsular (outside hip joint; also called intertrochanteric)	Direct trauma Severe pain External rotation, shortening of leg, obvious deformity	Internal fixation with nail (open reduction) Possible total hip replacement
	Sabtrochanteric(below lesser trochanter)	Direct trauma Leg pain near fracture site External rotation, shortening of leg, deformity Presence of hematoma	Internal fixation with nail (open reduction) Closed reduction

Analysis/nursing diagnosis:
1. Risk for injury related to implant surgery.
2. Knowledge deficit regarding joint replacement surgery.
3. Impaired physical mobility related to major hip surgery.
4. Pain related to surgical incision.
5. Risk for impaired skin integrity related to immobility.
Nursing care plan/implementation:
1. Preoperative:
  1. Goal: prevent thrombophlebitis or pulmonary emboli
    1. Antiembolic stockings.
    2. Increase fluid intake.
  2. Goal: prevent infection: antibiotics as ordered, given prophylactically.
  3. Goal: health teaching
    1. Isometric exercises - gluteal, abdominal, and quadricep setting; dorsiflexion and plantarflexion of the feet.
    2. Use of trapeze.
    3. Explain position of operative leg and hip postoperatively to prevent adduction and flexion.
    4. Transfer techniques - bed to chair and chair to crutches; dangle at bedside first time out of bed.
    5. Assist patient with skin scrubs with antibacterial soap.
2. Postoperative:
  1. Goal: prevent respiratory complications.
    1. Turn, cough, and deep breathe.
    2. Incentive spirometry.
  2. Goal: prevent complications of shock or infection.
    1. Check dressings for drainage qlh for first 4 hours; then q4h and pm; may have Hemovac or other drainage tubes inserted in wound to keep dressing dry.
    2. Monitor I&O and vital signs hourly for 4 hours, then q4h and prn.
  3. Goal: prevent contractures, muscle atrophy: initiate exercises as soon as allowed: isometric quadriceps, dorsiflexion and plantarflexion of foot, and flexion and extension of the ankle.
  4. Goal: promote early ambulation and movement.
    1. Use trapeze.
    2. Transfer technique (pivot on unaffected leg); crutches/walker.
    3. Initiate progressive ambulation as ordered; ensure maximum extension of leg when walking.
    4. Administer anticoagulation therapy as ordered prophylactically to prevent thromboemboli.
    5. Recognize early side effects of medications and report appropriately.
  5. Goal: prevent constipation.
    1. Increase fluid intake.
    2. Use fracture bed pan.
  6. Goal: prevent dislocation of prosthesis.
    1. Maintain abduction of the affected joint (prevent external rotation); elevate head of bed, turn according to physician’s order. When turning to unaffected side, turn with abduction pillow between legs to maintain abduction.
    2. Buck’s extension or Russell’s traction may be applied (temporary skin traction).
    3. Plaster booties with an abduction bar may be used.
    4. Wedge Charnley (triangle-shaped) pillow to maintain abduction between knees and lower legs.
    5. Provide periods throughout day when patient lies flat in bed to prevent hip flexion and strengthen hip muscles.
    6. Report signs of dislocation: anteriorly - knee flexes, leg turns outward, leg looks longer than other, femur head may be felt in groin area; posteriorly - leg turns inward, appears shorter than other, greater trochanter elevated.
  7. Goal: promote comfort.
    1. Initiate skin care; monitor pressure points for redness; back care q2h.
    2. Alternating pressure mattress; sheepskin when sitting in chair.
  8. Goal: health teaching.
    1. Exercise program with written list of activity restrictions.
    2. Methods to prevent hip adduction.
    3. Avoid sitting for more than 1 hour: stand, stretch, and walk frequently to prevent hip flexion contractures.
    4. Advise not to exceed 90 degrees of hip flexion (dislocation can occur, particularly with posterior incisions); avoid low chairs.
    5. Teach alternative methods of usual self-care activities to prevent hip dislocation, avoid: bending from waist to tie shoes, sitting up straight in a low chair, using a low toilet seat.
    6. Avoid crossing legs, driving a car for 6 weeks.
    7. Wear support hose for 6 weeks to enhance venous return and avoid thrombus formation.
Evaluation/outcome criteria:
1. Participates in postoperative nursing care plan to prevent complications.
2. Reports pain has decreased.
3. Ambulates with assistive devices.
4. Complications of immobility avoided.
5. Able to resume self-care activities.