Friday, September 3, 2010

Nursing Care Plan | NCP Dislocation; Subluxation

Dislocation and subluxation are terms used to describe the anatomic displacement of a bone from its normal position in the joint. Dislocation is the complete separation of the bone from the articular surfaces of the joint, whereas subluxation is only a partial displacement in the joint. Both dislocations and subluxations refer to the position of the distal bone in relation to its proximal articulation. Although dislocation or subluxation can affect any joint, the most frequently occurring sites are the thumb, elbow, shoulder, wrist, finger, knee, and hip. When dislocation or subluxation is a result of trauma, there are generally associated injuries to the blood vessels, nerves, ligaments, and soft tissues that surround the joint. In addition to the actual damage at the joint, tissue death from circulatory compromise to the distal extremity, or permanent nerve damage from edema, can occur. Avascular necrosis (death of bone cells because of inadequate blood supply) may occur if the bone is torn away from its normal position next to the vascular-rich bony surface.

Dislocations and subluxations can occur as a result of injury or developmental dysplasia of the hip (DDH), previously referred to as congenital hip dysplasia. Sports-related injuries, occupational injuries, and motor vehicle crashes are common causes. DDH can also lead to dislocations and subluxations, and there tends to be an increase in occurrence of DDH within families that have had other children with the condition. In addition, dislocations and subluxations may also be acquired as a result of chronic conditions such as rheumatoid arthritis.

Nursing care plan assessment and physical examination
When the condition is a result of injury, elicit complete details of the injury from the patient, significant others, or the life squad. Note the time of injury, as well as the description, angle of force, and the patient’s immediate sensations. Always ask if the patient felt any numbness immediately after the injury. In an acquired dislocation or subluxation, note a complete history of recent alterations in mobility, pain, or any other changes. For traumatic or acquired displacements, it is important to obtain information about any previous dislocations of this joint or any other joint. DDH can range from a minor instability to total dislocation. In moderate to severe DDH, diagnosis can be made at birth during the physical examination. However, for less severe conditions, symptoms may not occur until the child starts to crawl or walk. Elicit a developmental history from the parents covering the child’s mobility.

With traumatic or acquired dislocation, the immediate clinical manifestations may include severe pain, inability to move the extremity, a change in the length of the extremities, abnormal contour of the joint, and ecchymosis (bruising). The symptoms of subluxation are the same, but usually less severe. Make sure to remove all of the patient’s clothing to observe skin surfaces. Assess joint range of motion unless there is suspected cervical spine injury. In that situation, defer motion until radiographs are completed. Palpate all extremities and note pain, crepitus, instability, and deformity.

Monitor the neurovascular status of the patient with a dislocation before and after reduction or other interventions. Impairment in circulation or neurological deficits may occur during injury, before the reduction, because of pressure from bleeding or edema, and after the reduction, or as a result of interventions. The impairment may occur at the joint, but it may also occur distal to the injury. Serial neurovascular assessment includes critical data related to the 5 Ps: pain, pallor, paralysis, paresthesia, and pulselessness. Normal pulses do not rule out compartment syndrome.

Signs of congenital hip dislocation include asymmetry of gluteal and thigh folds, limited hip abduction, and apparent shortening of the femur with knees in flexion. If the child is beginning to walk, gait abnormalities occur. In the infant, a positive Ortolani-Barlow maneuver is an indication of dislocation. This maneuver involves placing the hands on the knees of the baby with fingers on the upper portion of the femur and abducting the hips while the infant lies on her or his back. Resistance to abduction, or the presence of a click as the femur slips out of the acetabulum, is considered a positive response.

If the dislocation resulted from an injury, the sudden impact may have disrupted the individual’s routines and created certain losses. If dislocation or subluxation is a result of a chronic disease process, the deficit may be a reminder of the deterioration of the body; depression may follow as a result of the decreased mobility or role change. With any congenital or developmental problem, parents may experience anxiety, guilt, or depression.

Nursing care plan primary nursing diagnosis: Pain (acute) related to lack of the continuity of the bone to joint; edema and muscle spasms.

Nursing care plan intervention and treatment plan
If the joint remains unreduced (to reduce is to restore the components of the joint to their usual relationships), the patient is at greater risk for avascular necrosis. The primary goal for therapeutic management is to realign the bones of the joint to their normal anatomic position. With injuries or chronic conditions, the physician will generally use a closed reduction (manually placing the bone into the joint) after giving the patient a sedative or a local or general anesthetic. The decision for a closed reduction depends on the person’s age, condition, and severity of the injury. If the same joint has repeatedly become dislocated or if the condition is severe, an open reduction is required. This procedure requires general anesthesia or an anesthetic block and involves surgical intervention for repositioning the bones and repairing ligaments. Once the proper position has been achieved, the physician may use pins or screws to maintain alignment.

After the open or closed reduction is accomplished, the physician immobilizes the joint to allow for healing through slings, taping, splints, casts, or traction devices. Treatment of subluxation is similar to that of a dislocation, but subluxation generally requires less healing time. Patients require a carefully regulated exercise program to restore the joint to its original range of motion without causing another dislocation.

The goal for treating DDH is the same as other dislocations or subluxations. However, the age of the child and the developmental nature of the condition alter the intervention. Treatment approaches vary, according to the child’s age. Infants under 3 months of age may simply require a triple diapering technique. This procedure abducts (by use of the thick diapers) positioning the femoral head into the acetabulum as the baby grows. Skin traction such as Bryant’s or spilt Russell’s may be used for the baby over 3 months of age. These procedures relocate the femur to the acetabulum while gently stretching the ligaments and muscles around the joint. For the 3- to 6-year-old patient, serial casting (the placement of several casts over time as the child grows or as realignment is required) or open reduction with casting may be needed.

Before reduction of the joint, direct nursing care to relieve pain and protect the joint and extremity from further injury. Maintain proper positioning and alignment to limit further injury. Accompanying soft tissue injuries are treated by RICE therapy: Rest, Ice, Compression bandage, and Elevation with or without immobilization. The patient and family need support to cope with a sudden injury. Allow time each day to listen to concerns, discuss the patient’s progress, and explain upcoming procedures. Older patients may experience depression and loss if the injury has long-term implications about their self-care.

Use social workers and advanced-practice nurses for consultation if the patient’s anxiety or fear is abnormal. Immobilization involving the whole person rather than one extremity requires aggressive prevention of the hazards of immobility. Motivate and educate patients to help them prevent complications. Encourage a balanced diet that contains foods that promote healing, such as those that have protein and vitamin C. Stimulation of the affected area by isometric and isotonic exercises also helps promote healing.

Nursing care plan discharge and home health care guidelines
Be certain that the patient and/or family understands the importance of the prescribed rehabilitation. For children, outline the appropriate activities to maintain growth and development. Demonstrate the adaptations required for patients with casts. Discuss the need to report any changes in pain, numbness, or other signs of neurovascular compromise. Make certain the patient or parents and family understand the signs and symptoms of suture line infections if open reduction has been accomplished and that odors or drainage from a cast should have immediate attention. If antibiotics have been ordered, stress the importance of completing the course as prescribed. Discuss the potential for repeat dislocations and the need for protection during sports or other activities.

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