Orthopaedic guidelines for Hospital at Night (HAN)

Most night time problems are generic eg. hypotension, breathlessness, pain, low urine output...

The following are more specific and recommended assessment and initial treatment is detailed.

• Post-op pyrexia
• Post-op pain / swelling
• Wound soakage
• Falls
• ? compartment syndrome

When phoning for advice, the following guidelines outline the questions that are likely to be asked and examination required:

1. POST-OP PYREXIA

Pyrexia following an operation is common (up to 50% of post op joint replacements develop a pyrexia of >38˚C in days 0-3)

QUESTIONS:

• When was the surgery?
• When did symptoms begin?
• Are there any symptoms other than pyrexia?
• Does the patient have pre-existing medical conditions that could predispose to fever?
• Were / are there blood products being given?

EXAMINATION:

Should include the usual systemic review and peripheral or central sites that were used for vascular access as well as the wound site. In early post op days the dressing should NOT be removed unless
there is clear spreading cellulitis.

ACTION:

Blood tests, fluid hydration, paracetamol, fan.
Unless a definite source of infection is identified do not start empirical antibiotics.

2. POST OP PAIN / SWELLING

Post op pain and swelling in the operated limb can be common but may indicate a problem.

QUESTIONS:

• What was the operation? (Hand written op note should be found in Orthopaedic Unitary Record).
• Is the pain / swelling increasing?
• Are there any circumferential dressings or a plaster
• Is the limb elevated?
• Have they had appropriate analgesia?

EXAMINATION:

Distal neurovascular status.
Check dressings are not tight dressings.
Wound soakage (see below).

ACTION:

Release tight dressings or split plasters (usually a backslab – can be split along the bandage part – ask a ward nurse for assistance!).
Elevate limb on pillows or a Braun frame (lower limb) or in a roller towel (upper limb) - ask a ward nurse for assistance!
Check drug chart for analgesia and re-prescribe if necessary.
Come back and review in an hour or so.
If no improvement consider compartment syndrome – see below

3. WOUND SOAKAGE

Persistent wound soakage / bleeding within 1st 24 hrs post op

QUESTIONS:

• Is the patient haemodynamically stable?
• Has the wound been redressed?
• What was the operation? (hand written operation note in Orthopaedic Unitary Record)

EXAMINATION:

Obs?
Dressing-what does it look like?

ACTIONS:

Give fluids / check bloods as appropriate.
Ask for dressing to be added to with pressure dressing or further padding.
Try NOT to remove dressing (bleeding may increase).
If no improvement call for senior advice.

4. FALLS

Falls may occur on any ward. The only difference is that these patients may have had an operation!

QUESTIONS

• Has the patient had an operation – if so what? (Check hand written note in Orthopaedic Unitary Record)
• Is there a possibility of a dislocation of a joint replacement?

EXAMINATION

Area of pain.
Abnormal posture of the limb.
ACTIONS:
Analgesia.
If unsure ask for AP and lateral X-Rays of affected part.
If # or dislocation refer to ED doctor.

5. ?COMPARTMENT SYNDROME

Compartment syndrome can occur as a result of trauma to a limb, a crush injury and tight dressings or casts amongst other things. It can occur in upper and lower limbs including hands and feet.

QUESTIONS:

• Does the patient have pain OUT OF PROPORTION TO THAT EXPECTED FOR THEIR INJURY?
• Have they had surgery? (see operation note in Orthopaedic Unitary Record)
• Do they have a cast or dressings on their limb?
• What analgesia have they had?

EXAMINATION:

Swelling?
Tense muscle compartment?
Pain on PASSIVE stretching of muscles (e.g. passive movement of toes)?
Check distal neurovascular status but paraesthesia or lack of pulse is LATE finding.

ACTIONS:

DO NOT highly elevate limb (may reduce perfusion pressure).
Split casts or dressings all the way down to the skin.
Reassess after 30 mins – if no improvement call for senior help.