Phyllis Turner, R N

Caring for emotional needs of orthopedic trauma patients

Patients with multiple orthopedic in- juries often have physical and emo- tional problems not experienced by other trauma patients. Orthopedic trauma can result in the patient’s loss of independence, loss of control of parts of his life, and occasionally loss of body parts. In addition, decreased mobility can result in physical complications such as thrombophlebitis and embolus formation.

Patients with multiple orthopedic trauma are frequently hospitalized for extended periods and make repeated trips t o the OR for reconstructive

Phyllis Turner, RN, M S N , CCRN, is assistant professor of nursing at Eastern Mennonite Col- lege, Harrisonburg, Va, and a critical care staff nurse at Rockingham Memorial Hospital, Har- risonburg. She is a graduate of Rockingham Memorial Hospital School of Nursing and re- ceived a BSN from Eastern Mennonite College and an MSN from the University of Virginia, Charlottesville.

surgery. As the OR nurse prepares to care for such patients, her assessment should also include the psychological and emotional needs related to the pa- tient’s injuries and limitations.

As nurses, it is relatively easy for us to envision the trauma to the skeletal, central nervous, respiratory, cardio- vascular, and renal systems following a bad automobile accident. But we do not readily think of the trauma sustained in such an accident by the “human sys- tem”-the patient‘s self-esteem, self- worth, and security. We are usually so careful to separate the physical from the psychological that we do not think of these personal attributes as making up a bodily system.

Systems and needs. When one body system is suddenly traumatized, other systems become involved in an effort to cope. Although the traumatized patient usually receives excellent care for the directly affected body systems, prob- lems in other systems may not be recog- nized early, if at all.

Abraham Maslow’s theory of motiva- tion states that our wants, desires, and needs are arranged in a hierarchy of importance. Physiologic needs are most important.

A person who is lacking food, safety, love and esteem would most probably hunger for food more strongly than for anything else. . . .

When the human organism is domi-

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nated by a certain need, “the whole philosophy of the future tends also to change.” Life tends to be defined in terms of this need. “Freedom, love, community feeling, respect, philoso- phy may all be waved aside as fripper- ies that are useless, since they fail to fill the need.”’

The trauma patient seeks to preserve his life by directing all of his energies toward the most basic physical needs.

Physiological needs. Trauma and hospitalization immediately disrupt our biological rhythms. Cardiovascular rhythms are one of the first rhythms affected, resulting in tachycardia, atrial fibrillation, and premature beats in many posttrauma patients. Because the etiology of the arrhythmia (eg, fever, pain, anxiety, hypotension, dehydra- tion, acidosis, and drugs) is covert, the treatment may be as varied as the cause. Yet, how many times do nurses think “atrial fibrillation should be treated with digitalis” instead of “that patient with atrial fibrillation should have someone to talk to,” or “should have a quieter environment,” or “needs his pain medication and a cool drink of water”? One of the first principles of providing nursing care is to assess what the patient needs.

In the posttrauma patient, increased blood pressure, increased heart rate, and increased work load on the heart lead to a decreased oxygenation and blood flow to vital organs. All of these cardiovascular complications may re- sult from stress (physiological and psy- chological).

Nursing therapies t o prevent ar- rhythmias should be aimed at decreas- ing anxiety and allaying fear. In con- ducting her preoperative assessment, the OR nurse can:

approach the patient in a calm, un- hurried manner

0 allow the patient to express feelings of fear and frustration about his

Fig 1

Differential symptoms of anxiety, alcohol,

and acidosis

Symptom breath odor cyanosis tachypnea tachycardia drowsiness feelings of guilt rubor

Anxiety no no Yes Yes no

Yes no

Alcohol Yes no no no maybe

no Yes

Acidosis maybe Yes maybe Yes Yes

no no

condition or impending surgery 0 explain OR procedures, treatments,

and the environment to the patient and, if possible, the family, because fear is contagious.

Despite advances in anesthesiology and surgery, postoperative pulmonary complications continue to be a major source of mortality for the orthopedic trauma patient. For this reason, the OR nurse should be aware of the preopera- tive pulmonary assessment.

This assessment is particularly im- portant for the trauma victim coming to the operating room. A patient may have (1) tachycardia, (2) hyperventilation, (3) inappropriate verbal responses such as laughing or crying, and (4) disorien- tation, These may be signs of respira- tory acidosis, alcohol intoxication, or anxiety (Fig 1). A few moments spent preoperatively in relating to the patient may aid in making a differential diag- nosis that could affect his intraopera- tive care and postoperative recovery.

The patient’s fluid and electrolyte balance is also affected. After trauma, pituitary hormones are released, stimu- lating the adrenals to secrete cortisol and aldosterone, which results in fluid and electrolyte retention. Oliguria may

AORN Journal, October 1982, Vol36, No 4 567

he orthopedic patient T has little means to dissipate anxious energy.

also result from dehydration, dimin- ished cardiac output, shock, renal fail- ure, or the “third space effect” (fluid within the abdomen or in a crushed ex- tremity). Stress reactions also predis- pose the patient to sodium and water retention, potassium loss, and negative nitrogen balance, further compounding his fluid and electrolyte imbalance. In the patient who has not lost a great deal of fluid as a result of the trauma, re- tained sodium and water may cause cardiovascular overload. Potassium loss may predispose the patient to cardiac arrhythmias, muscle weakness, and de- creased neural functioning.

Nursing care for metabolic, fluid, and electrolyte problems should therefore include more than the measurement of intake and output, daily weights, and frequent checks of electrolyte reports. It should also include assessing the pa- tient’s stress level, allaying his fears preoperatively, and taking steps to de- crease his anxiety in the operating room.

Psychological needs. Many of the posttrauma patient’s physical problems have a psychological component OR nurses need to assess. Stress may be defined as an emotional state that is intensified when there is an imbalance between the demands on a person and his capacity to adapt.2 Factors that make this emotional state more intense include heat, cold, infection, mechani- cal trauma, fear, pain, imagined events,

and intense emotional inv~lvement .~ People attempt to cope with stress by avoidance, counteraction, and adapta- tion.

Anxiety is the result of excessive un- channeled energy produced by stress. Most of us dissipate our anxiety by walking, talking, or other physical activities. The hospitalized orthopedic patient, who is frequently in a cast, sling, or traction, has little means of dissipating anxious energy. Figure 2 lists some common hospital stressors and suggests what the nurse can do about them.

Whenever there is a decrease in con- trol of body functions, the feeling of se- curity is lost or at least significantly decreased. Nursing measures that rein- force the patient’s control help increase his sense of autonomy and reduce his overwhelming sense of loss of control.

Sensory deprivation and overload. A critical care environment deprives a pa- tient of meaningful sensory input while exposing him to a continual bombard- ment of unfamiliar stimuli. The only familiar sound may be the ringing of the phone, which can cause frustration be- cause he can’t answer it. Quantity of sensory input alone is not sufficient. When there is no meaningful contact with the outside world, the patient may have difficulty in determining reality. Instead, internal mental events may be taken to be events in the external world. In providing nursing care, the use of

568 AORN Journal, October 1982, Vol36 , No 4

Fig 2

Hospital stressors What the nurse can do 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Overhearing careless remarks

Receiving inadequate explanations, medical jargon Seeing another patient in an emergency

Perceiving a strange, threatening OR environment Being separated from the support of loved ones

Feeling like an organ-filled object: depersonalized, exposed, and vulnerable

Suffering simultaneous sensory deprivation and overload Perceiving the environment as highly charged emotionally Feeling uncertain about the outcome

Feeling powerless; having no control over the outcome

1.

2.

3.

4.

5.

6.

7.

8.

9.

10

Talk to the patient, not over him. If you don’t want him to hear, make sure you’re out of hearing range. Explain everything simply and clearly, even if it is routine. It‘s bound to happen sometime; don’t pretend it didn’t happen. Allow the patient to discuss his feelings. Explain everything, if necessary.

Allow expression of feelings and see that waiting family members are notified after the operation. Talk to the patient about something that doesn’t relate to his trauma; know something about him as a person. Speak to the patient about things familiar to him. Spend time talking slowly with the patient.

Encourage the patient to talk; reinforce accurate information and correct his misconceptions. Allow the patient to make some decisions; encourage him to participate in his postoperative care.

auditory stimuli is important. Informa- tion regarding date, time, and place is particularly important for trauma pa- tients with deviations in their levels of consciousness.

Grief and loss. The orthopedic trauma patient may also have lost a part of his body. Immediately after the loss, he may use denial to cope. He may attempt to deal with the problems associated with the loss by denying the limb is mis- sing. Unless he has another defense, such as a strong problem-solving abil- ity, don’t take away this defense against his fear of the unknown and his fear of facing reality. When the reality of the loss finally begins to make its impact, the patient may attempt to slow down that impact by directing his anger about

loss of the limb, loss of function, or loss of future plans at his family or the health care team. Voicing anger gives the helpless patient a sense of power.

As the orthopedic trauma patient works through the stages of his loss, he may at first identify himself as an in- valid and use his defect as his identity. For example, a man who has experi- enced traumatic amputation of a leg may introduce himself to a nurse coun- selor as “one of the ‘crips”’ from the orthopedic ward. Another patient may psychologically detach himself from his loss. For example, he may give the mis- sing limb a name or refer jokingly to a new prosthesis as “that piece of pine from physiotherapy.” Each patient is using the nursing staff to test reactions

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t o h i s new self. H e is watching to see how nurses respond to the name h e gives himself and h is trauma. H e i s looking for acceptance.

Loss of a limb may be more acute than death of a spouse. The widow buries her loss and healing begins. The amputee, after the crisis i s resolved, must adjust to a life-long reminder of h i s loss and muti lat ion. During rehabil itation, the patient may suddenly realize he i s no longer “sick” but “different.” This may again bring for th the feelings experi- enced during the acute grieving period: anger, hosti l i ty, fear, self-conscious- ness, depression, and guilt.

Conclusion. Patients who have ex- perienced mul t ip le orthopedic t rauma have a mult i tude of fears and anxieties tha t nurses can do something about. By

acting as a monitor and basing her in- terventions on the patient’s changing emotional and physical conditions, the nurse wi l l be caring for all the patient’s needs. 0

Notes 1. Abraham H Maslow, Motivation and Personal-

ity, 2nd ed (New York: Harper and Row, 1970) 37. 2. Ruth L E Murray, “Assessment of psychologic

status in the surgical ICU patient,” The Nursing Clinics of North America 10 (March 1975) 69.

3. Hans Selye, The Stress of Ufe, revised ed (New York: McGraw Hill, 1976) 395.

4. Murray, “Assessment of psychologic status,” 70.

Suggested reading Burrell, L 0; Burrell, 2 L, Jr. Critical Care, 4th ed. St

Hoff, Lee Ann. People in Crisis: Understanding and Louis: C V Mosby, 1982.

Helping. New York: Addison-Wesley, 1978.

Complication rate low for craniofacial cases Despite the complexity and danger of rebuilding grossly deformed faces and skulls, the complication rate for this type of surgery is extremely low, according tb a leading craniofacial surgeon.

up to 90% of the skull and face bones and lifting the brain aside during part of the reconstruction, carries a surprisingly low death rate, reported Toronto surgeon Ian Munro, MD. The associate professor of surgery at the University of Toronto reported the findings during a science writers seminar sponsored by the American Society of Plastic and Reconstructive Surgeons.

In an analysis of 800 operations from six major centers, the death rate was between 0.5% and 1 .O%, he reported. The other three major complications, he said, are blindness, less than 1 YO; brain damage, between 0% and 0.5%; and infection. Dr Munro is also head of the craniofacial division at the Hospital for Sick Children in Toronto.

While the infection rate should go no

The surgery, which may involve breaking

higher than 1 O/O, it can go up to 10% or 15%, depending on the type of operation.

Dr Munro’s team of 20 specialists-the world’s largest-includes ophthalmologists, neurosurgeons, radiologists, orthodontists, and otolaryngologists. The team may perform several operations a week to correct the congenital deformities caused by Crouzon’s disease, Apert’s syndrome, Treacher-Collins syndrome, neurological disorders like neurofibromatosis, and benign and malignant tumors.

The operations also provide new faces and skulls for accident victims. Citing one such case, Dr Munro said his team earlier this year successfully filled in the hole of a four-year-old whose forehead was missing. It had been removed following an infection, which developed after the boy had fallen, piercing his skull with nails.

The hole was more than four inches by six inches. The team used six of the boy’s ribs and some skull bones to mold a structure, which then was covered with his own skin. Dr Munro said the skull will grow normally and that new ribs will grow.

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