c

c
c
c

Perioperative
Review on
OPEN
REDUCTION
INTERNAL
FIXATION

Submitted to:
Llywelyn I. Cortez Rn.
Submitted by:
Jay Ian C. Reterba
Bsn3
13D
c
c
c
c

Table of Contents
I.Introduction ...3
II.Definition of terms4
III.Anatomy and pyshiology ...5
IV.Surgical procedure ...............7
V.Instruments9
VI. Perioperative Tasks and Responsibilities of the nurse ..18
VII.NCP.21
VIII.DRUGS.....24
IX.Reference/Bibliography..27c
c
c
c
c
c
c
c
c
c
c
c
c
c
c
c
c
c
c
c
c
c
c
c
2 c2
2
c
c

A fracture is the (local) separation of an object or material into two, or more, pieces
under the action of stress.

The word
  is often applied to bones of living creatures, or to crystals or crystalline
materials, such as gemstones or metal. Sometimes, in crystalline materials, individual crystals
fracture without the body actually separating into two or more pieces. Depending on the
substance which is fractured, a fracture reduces strength (most substances) or inhibits
transmission of light (optical crystals).

Fracture is any break in the continuity of bone. In some cases, a bone may fracture
without visibly breaking. Fractures occur when the bone is subjected to stress greater than it
can absorb. It can be caused by a direct blow, crushing force, sudden twisting motion, or even
extreme muscle contraction. When the bone is broken, adjacent structures are also affected,
resulting in soft tissue edema, hemorrhage into the muscles and joints, joint dislocations,
ruptured tendons, severed nerves, and damaged blood vessels. Body organs may be injured by
the force that caused the fracture or by the fracture fragments. And according to the physician
the kind of fracture that my PT experience is comminuted fracture that the bone splinters at the
site of impact, and smaller bone fragments lie between the two main fragments. c
Femur is the largest and strongest bone and has a good blood supply. Because of this and its
protective surrounding muscle, the shaft requires a large amount of force to fracture. Once a
fracture does occur, this same protective musculature usually is the cause of displacement,
which commonly occurs with femoral shaft fractures. Orthopedic surgeons often encounter
femur fractures because these fractures most often result from high-energy trauma, one must
have a high index of suspension for complications or other injuries like vehicular accident that
experience by my PT While a variety of treatment options exist for a fracture that is associated
to injury.
22
 c
c c

Biceps- a biceps muscle, esp. the one at the front of the upper arm.

Break- to fracture a bone of (some part of the body)

Cartilage- a firm, elastic, flexible type of connective tissue of a translucent whitish or yellowish
color; gristle.

Crushing- to press or squeeze with a force that destroys or deforms.

Crystalline- of or like crystal; clear; transparent.

Femur - the largest and strongest bone and has a good blood supply

Fracture - (local) separation of an object or material into two, or more, pieces under the action of
stress.

Fragments- to collapse or break into fragments; disintegrate:

Twisting- to turn sharply or wrench out of place; sprain:

222 c

In human anatomy, the femur is the longest and largest bone. Along with the temporal
bone of the skull, it is one of the two strongest bones in the body. The average adult male femur
is 48 centimeters (18.9 in) in length and 2.34 cm (0.92 in) in diameter and can support up to 30
times the weight of an adult.[1] It forms part of the hip joint (at the acetabulum) and part of the
knee joint, which is located above. There are four eminences, or protuberances, in the human
femur: the head, the greater trochanter, the lesser trochanter, and the lower extremity. They
appear at various times from just before birth to about age 14. Initially, they are joined to the
main body of the femur with cartilage, which gradually becomes ossified until the protuberances
become an integral part of the femur bone, usually in early adulthood.

The shaft of femur is cylindrical with a rough line on its posterior surface (linea aspera).

The intercondylar fossa is present between the condyles at the distal end of the femur. In
addition to the intercondylar eminence on the tibial plateau, there is both an anterior and
posterior intercondylar fossa (area), the sites of anterior cruciate and posterior cruciate ligament
attachment, respectively.
2 cc

Physical trauma
due to vehicular
accident

Break in the
skin

Tissue
damage

Bone cannot
withstand the ouside
body forces
nerve endings that
surrounds bone contain caused
pain fibers Breakage of
bone
these fibers become
irritated when bone is
broken or bruised

series of bleeding
internally and externally

blood is associated to
swelling (edema)

swelling causes pain

Muscles that sussround the injured

area may go into spasm when they
try to hold the broken bone in place

and these spasm

causes further pain

Resulting to Immobilization
of the injured lower
extremity
22cc

Pre-operative antibiotics, +/- interscalene block

General endotracheal anesthesia
Modified beach-chair position. All bony prominences well padded.
Examination under anesthesia of affected shoulder.
Prep and drape in standard sterile fashion. Have a well-padded height adjustable Mayo
stand or shoulder positioner available to hold the arm during the case.
Deltopectoral incision from just medial to AC joint to just lateral to the proximal edge of
the biceps muscle belly.
Identify deltopectoral interval (interval can be found by palpating medial edge of deltoid
insertion into clavicle or finding fat layer in interval surrounding cephalic vein.)
Preserve cephalic vein by ligating any branches to deltoid and taking the cephalic vein
and its surrounding tissues medially.
Incise clavipectoral fascia adjacent to the conjoined tendon up to the coracoacromial
ligament.
Release upper 1/3 of pectoralis tendon if needed for exposure.
Ensure the anterior humeral circumflex vessels are protected and preserved.
Identify the long head of the biceps tendon and ensure that it is preserved thoughtout the
case.
Identify the fracture fragments. The key to identifying the various components is the long
head of the biceps tendon. The lesser tuberosity and subacapularis tendon are medial to
the long head tendon. The greater tuberosity and supraspinatus are lateral. Generally
splinting the rotator interval between the tuberosities provides adequate exposure to the
proximal humerus.
Mobilize the tuberosity fragments. Tag them with suture as needed.
Gently identify the humeral head fragment, being careful to avoid any neurovascular
injury. Confirm that the head fragment is not split or impacted and the cartilage is intact.
Reduce that fragments into anatomic position. The humeral head can usually be
reduced by externally rotation the arm and gentle pushing and rotating the head into its
anatomic position.
The fragments are then anatomically reduced and temporarily fixed using k-wires or
suture. Placing a non-absorbable #5 suture in a figure-8 fashion is often beneficial to
maintain the reduction during plate placement and also serves additional fixation.
Place a proximal humeral plate as selected in the preoperative plan using AO technique
and as instructed in the manuctures technique guide.
Pack allograft bone chips / demineralized bone graft as needed to improve healing.
Repair the rotator interval.
Irrigate.
Close in layers.
 c2   c !cc  c ! c

A  "  retractor (manual) is used to retract deep abdominal or chest incisions. Available in various
widths.

A  ! retractor (manual) is used to retract deep abdominal or chest incisions

An 
"    (manual) is used to retract shallow or superficial incisions. Other names:

#cc.

A  $ cc$$ retractor (manual) is used to retract deep wounds. May be bent to various
shapes.
 c!c c2   
  c%c  - Used to cut suture and supplies. Also known as:   c .

" !c%c ccUsed to cut heavy tissue (fascia, muscle, uterus, and breast). Available in regular
and long sizes.c

% & $c c'(ccUsed to cut delicate tissue. Available in regular and long sizes.

cc

c
c!c !c2   

Ac   is used to clamp blood vessels or tag

sutures. Its jaws may be straight or curved.
Other names:  #ccc  .

A )  is used to clamp small blood vessels.

Its jaws may be straight or curved.

A *  is used to clamp larger vessels and tissue.

Available in short and long sizes.
Other names:    c .
A $  is used to clamp deep blood vessels.
Burlishers have two closed finger rings. Burlishers
with an open finger ring are called tonsil hemostats.
Other names:  ! c c
 #c!c

 .

Kelly, hemostat, mosquito (left to right)

A  c is used to clamp hard-to-reach

vessels and to place sutures behind or around a
vessel. A right angle with a suture attached is called
a "tie on a passer." Other names: %+ .

A   c c, c   applies metal

clips onto blood vessels and ducts which will remain
occluded.
c!c-!c2   
Are used to hold tissue, drapes or sponges.

An  is used to grasp tissue. Available in short

and long sizes. A "Judd-Allis" holds intestinal
tissue; a "heavy allis" holds breast tissue.

A .$  / is used to grasp delicate tissue

(intestine, fallopian tube, ovary). Available in short
and long sizes.

A *   is used to grasp heavy tissue. May also

be used as a clamp. The jaws may be straight or
curved. Other names: Ochsner.
A   c c  / is used to grasp
sponges. Other names: sponge forcep.

A !  is used to hold a peanut.

A . /c , c cis used to hold towels and
drapes in place. Other name: , c .

c
c
c
c
 /c#c $c
 c!c  c
  are
available in various lengths, with or without teeth,
and smooth or serrated jaws.

c
c
c  c
 care used to grasp tissue.
 c
c
c
c
 ./ c
  are used to grasp delicate
tissue, particularly in cardiovascular surgery.

c
c
c
c
c
c
c
c
c
!cpick ups are either smooth: used to grasp
delicate tissue; or with teeth: used to grasp the
skin. Other names: Dura forceps.c

c
c
=
 c
c 



 c 
c

 
c 
cc

cc 
c
2   " c/c!c $  c
c  c


.c

Pre-operative Responsibilities
1. Assist with the preparation of the room for the designated surgical procedure, including
gathering supplies for the procedure.
2. Scrub, dry hands, gown, and glove.
3. Assist person scrubbed in first position with:
a. Setting up back table, mayo, and basins
b. Arrangement of instruments
c. Preparation of suture and needles
d. Preparation and counting sponges
e. Arrangement and preparation of other necessary items
f. Gowning and gloving surgeon and assistants
g. Assist with draping
h. Arrangement of sterile field
Intra-operative Responsibilities
1. During the procedure, progress from double-scrubbed position. Train self to keep eyes on
field, and learn steps of procedure.
2. Begin developing methods of anticipating needs of surgeon and assistant.
3. After closing the skin:
a. Assist with care of instruments and counts if necessary
b. Care of specimen
c. Assist with dressing of wound
Post-operative Responsibilities
1. After the completion of the Procedure:
a. Assist with the gathering of all materials used during the procedure
b. Discard items as necessary being careful to discard sharp items in designated places
c. Return all items to respective area
d. Assist with cleaning of room
e. Clean the materials used properly and arrange them after drying
2. Perform any duties which will speed up the surgical procedure to follow in that room.
22
c

Pre-operative Responsibilities
1. Care for the patient before surgery by:
a. Greeting patient and assist nurse with identification
b. Checking patient's chart, preparation, etc.
2. Prepare the room by:
a. Obtaining instruments, supplies, and equipment for the designated operative procedure
b. Opening unsterile supplies
c. Assisting in gowning
d. Observing breaks in sterile technique
e. Assisting anesthesiologist as necesssary
f. Assisting with skin preparation and positioning
g. Assisting with forming of the sterile field
3. Count the instruments, sharps and sponges before the procedure and confirm with scrub
nurse.
Intra-operative Responsibilities
1. During the Procedure:
a. Remain in room and dispense materials as necessary
b. Observe procedure as closely as possible
c. Begin establishing method of anticipating needs of surgical team
d. Care of specimen as indicated
e. Care of operative records as indicated
2. Before the closing of the organ or peritoneum, count all instruments, sharps and sponges and
confirm with scrub nurse.
3. Inform the surgeon and assistant surgeon of a report of the instruments.
Post-operative Responsibilities
1. Properly document all the necessary information on the patients chart.
2. Assist in the cleaning of the Operation Room as necessary.

c c  0c
A careful history and physical examination are performed to exclude the possibility of
other gastrointestinal diseases that may mimic biliary colic, such as peptic ulcer disease
or reflux esophagitis.
When the diagnosis of acute cholecystitis is suspected the patient should receive
nothing by mouth; however, nasogastric suction usually can be reserved for patients
who are vomiting or have ileus and abdominal distention.
 Intravenous fluids are given to correct volume depletion and any electrolyte imbalances
are measured and corrected. Monitor and regulate IVFs
The nurse instructs the patient about the need to avoid smoking to enhance pulmonary
recovery postoperatively and avoid respiratory complications. It is also important to
instruct the patient to avoid the use of aspirin and other agents that can alter coagulation
and other biochemical process
On of the most important responsibility of the nurse is to let the patient sign an informed
consent regarding the surgery.
The patient is given anaesthesia prior to surgery and the patient is under NPO.
c  c  
Monitoring the vital signs of the patient is one of the responsibilities of the nurse during
the surgery.
Assisting the anesthesia care provider during induction of general anesthesia
Ensuring adequate oxygenation and hydration

c  c  c
After recovery, the nurse places the patient in the low fowlers position. IV fluids may be
given and nasogastric suction may be given to relieve abdominal distention. Water and
other fluids are given in about 24hours, and soft diet is started when bowel sounds
returned.
Placing warm blankets on the patient to enhance comfort and preserve the patient's
body temperature
Assessing the patient's vital signs, oxygen saturation level, level of consciousness,
circulation, pain, IV site, fluid rate, and hydration status, as well as the status of the
surgical site and dressing and all related monitoring equipment
The nurse helps in relieving the pain by instructing the patient regarding proper
positioning.
The nurse helps in improving the respiratory status by instructing the patient regarding
deep breathing exercises.
The nurse also provides skin care like cleaning the incision part and providing clean
dressing following a strict aseptic technique
The nurse instructs the patient about the medications that are prescribed by the
physician
Discussing recommended follow-up management with the physician and the surgeon
22
c
ASSESSMENT SCIENTIFIC PLANNING INTERVENTION RATIONALE EXPECTED
EXPLANATION OUTCOME
S
S>Masakit yung Unpleasant sensory and > Within one Independent: >After one
inopera sa akin, as emotional experience hour of > Offer divertional activities > Heighten ones hour of
verbalized by the arising from actual or appropriate such as reading concentration upon appropriate
patient. potential tissue damage or nursing newspaper or magazines, nonpainful stimuli to nursing
> pain scale of described in terms of such intervention, socialization with others or decrease ones intervention,
7/10 damage; sudden or slow the patients listening radio. awareness and the patients
O >weak in onset of any intensity from pain scale will experience of pain. pain scale
appearance mild to severe with an alleviate from > Monitor vital signs: will alleviate
>guarding anticipated or predictable 7/10 to 3/10. (RR and BP) from 7/10 to
behavior/self- end and duration of less > vital signs usually 3/10 as
protective behavior than 6 months. altered in acute pain evidenced
>limited movement > Instruct deep breathing by:
>grimace upon exercises. a. can
movement move
> to improve
> irritable and freely
pulmonary gas
restless b. verba
exchange or to
maintain respiratory lized
Nursing Diagnosis: function incre
> Provide comfort
Acute pain and ase
measures such as backrub
discomfort related to level
and changing position
surgical incision. of
every 2 hours. > to provide
comf
nonpharmacological
ort
> Provide quiet pain management and
environment and calm to prevent pressure
activities. ulcer

> Encourage adequate > to provide comfort

rest periods. and prevent fatigue
Dependent:
> Administer analgesics as
indicated to maximal > to prevent fatigue
dosage as needed.
 ASSESSMENT SCIENTIFIC PLANNING INTERVENTION RATIONALE EXPECTED
EXPLANATION OUTCOME
S
S> Nanghihina ako >Introduction of spinal > Within 2 to 2

  >After 3
as verbalized by the anesthesia into the 3 hours of > Plan care with rest >To reduce or prevent hour of
patient subarachnoid space at the appropriate periods between activities fatigue. appropriate
lumbar area usually L4 and nursing >Assist in self care >To increase mobility nursing
O >grimace L5 which causes intervention activities, before and to protect or intervention,
>pale and weak in anesthetic effect or the the patient will ambulation prevent patient from the patients
appearance absence of sensation in be able to >Promote comfort injury. demonstrate
>mostly confined on the lower extremities and demonstrate measures and provide for >To enhance ability to increase
bed lower abdomen resulting increase relief of pain. participate in activities. activity
>restless traumatic or activity >Perform ROM exercise intolerance
>limited pathophysiologic damage tolerance. (active assistive). >Inability rapidly
movements to their tissue causing contributes to muscle
>inability to perform body weakness shortening and
ADL changes in periarticular
>Encourage participation and cartilaginous joint
NURSING in self care and divertional structure which
DIAGNOSIS: or recreational activities. contribute to the
>Activity intolerance >Observe and document limitation of motion.
r/t generalize skin integrity at least 3 >To enhance self
weakness times within the shift. concept and sense of
independence.
>Emphasize adequate
intake of fluids at least
1500-2000 ml and >Activity intolerance
nutritious foods such as may lead to pressure
fruits and vegetables ulcer.
>Encourage to maintain
positive attitude; suggest
use of relaxation >Promotes well being
techniques such as deep and maximizes energy
breathing exercise. production.
>Pr
 ASSESMENT SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION
EXPLANATION
S> > Vague, uneasy > Within the 2

  > After the shift,
feeling of shift, the patient >Facilitate development > Trust is necessary before the patient
O>Expressed discomfort or will as a trusting relationship patient and family can feel acknowledged
concerns due to dread acknowledge with patient and family free the open personal feelings and
change in life accompanied by feelings and lines and communication identify healthy
events autonomic identify healthy with hospice team and ways to deal with
> restlessness response. ways to deal >Provide open, address sensitive issues. them.
> worried about with them. nonjudgmental >Promotes and encourage
his condition environment. Use dialogue about feelings
> unpleasant therapeutic and concerns.
thoughts about communication skills.
any event related >Encourage >Patient may feel
to death or dying verbalization of thoughts supported expression of
> feelings of and concerns and accept feelings by understanding
hopelessness expressions of sadness that deep and often
and anger. conflicting emotions are
Nursing >Reinforce teaching normal in this situation.
Diagnosis: regarding disease > Patient/SOs benefit from
Anxiety r/t process and treatments factual information. Honest
change in health and provide information answer promotes trust.
status. as requested. Be honest;
do not give false hope
while providing emotional
support.
 222c

Generic Brand Mech. Action Classification Indication Contraindication Adverse Dosage Nursing Rep.
name Name effect
Atracuriu Tracriu Drugs which may Musculoskele as an adjunct to hypersensitivity to Wheezing 0.4 to
m m enhance the tal agents general anesthesia, to it Hypotension 0.5
Besylate neuromuscular Neuromuscul facilitate endotracheal Use of atracurium Skin Flush mg/kg
blocking action of ar blockers intubation and to besylate from anaphylactic
atracurium nondepolarizi provide skeletal multiple-dose vials or
besylate include: ngRelaxants muscle relaxation containing benzyl anaphylactoi
enflurane; during surgery or alcohol as a d responses
isoflurane; mechanical preservative is
halothane; ventilation. contraindicated in
certain patients with a
antibiotics, known
especially the hypersensitivity to
aminoglycosides benzyl alcohol
and polymyxins;
lithium;
magnesium salts;
procainamide;
and quinidine.

If other muscle
relaxants are
used during the
same procedure,
the possibility of
a synergistic or
antagonist effect
should be
considered
Generic Brand Mech. Action Classification Indication Contraindication Adverse Dosage Nursing Rep.
name Name effect
TRANEXA antifibrinolytic Haemostatics This medication is Severe renal Nausea, 1-1.5 g
MIC ACID Cykloka agent that used for short-term failure, active vomiting,
pron competitively control of bleeding in intravascular diarrhea
inhibits hemophiliacs, clotting, vision
breakdown of including dental thromboembolic changes,
fibrin clots. It extraction procedures. disease, colour dizziness
blocks binding of used for many other vision disorders,
plasminogen and conditions in which subarachnoid
plasmin to fibrin, bleeding control is bleeding.
thereby required such as after
preventing surgery or injury,
haemostatic plug recurrent nosebleeds
dissolution. or abnormal vaginal
bleeding.
21 c
  3.$c
http://66.218.69.11/search/cache?ei=UTF-
8&p=medications+for+post+cholecystectomy&fr=yfp-t-501-
s&u=www.facs.org/public_info/operation/cholesys.pdf&w=medications+medicated+medicati
on+post+cholecystectomy&d=UzolavL9P0uZ&icp=1&.intl=us
http://dcregistry.com/users/cholecystectomy/preoperative.htmlv
http://www.emedmag.com/html/pre/fea/features/021503.asp
http://www.encyclopedia.com/doc/1G1-103379524.html
http://www.healthatoz.com/healthatoz/Atoz/common/standard/transform.jsp?requestURI=/he
althatoz/Atoz/ency/cholecystectomy.jsp
http://www.facebook.com/blackwinter.o14#!/sometwo.hangal?ref=profile
http://www.medscape.com/viewarticle/535569?rss
http://www.scribd.com/doc/11972130/Open-Cholecystectomy-surgical-case-report
http://nursingcrib.com/nursing-notes-reviewer/cleft-lip-and-palate/