Perioperative Patient Pathway Handbook Orthopaedic Surgery

Orthopaedic is a Greek word, which means straight and rearing of children. First used by Nicholas Andry in 1741 in the title of his book which deals with prevention and correction of deformities in children (Bowen, 2003). Orthopaedic surgery is a surgical Subspecialty, which involves restoration of the normal function of the Musculoskeletal System by medical, surgical and physical means. The specialty of Orthopaedic surgery has an extremely broad scope but the emphasis is placed equally on the surgical intervention, prevention and correction of deformities. The complexity of Orthopaedic Surgery requires high degree of skills and competence with all the staff involved including facilities to ensure efficient patient care and safety, thus preventing Perioperative morbidity and mortality.

The aim of this essay is to present a Perioperative Patient Pathway Handbook that will describe the different stages that orthopaedic patient will go through the Perioperative period. I will also address what makes orthopaedic patients different from the other surgical patients including nursing issues and concerns that present to the patients and the nurse.

PERIOPERATIVE PERIOD Orthopaedic patients come for surgery with specific musculoskeletal problems which may include unstable fractures, deformities, joint diseases, necrotic or infected tissues and tumours, amongst which joint surgeries are the most common and frequently performed (French, 2005). Patients may come in a varying health status but the goals remain the same such as restoring normal function by surgical intervention, early mobilisation, prevention of disabilities while providing stability and managing pain. Like any other surgeries, orthopaedic patients go through the same stages of Perioperative period. Using the nursing process of assessment, nursing diagnosis, intervention and evaluation, specific and individualized Perioperative nursing care is provided to the patient in each period. PREOPERATIVE PHASE Preoperative phase begins when orthopaedic surgeons confirm on the surgical intervention and ends when the patient is handed over to the theatre. During this

stage date of surgery is anticipated, consent is obtained, medical and nursing assessments are done, including routine investigation to establish over all health status of the patient. Anaesthetic assessment, consultation with occupational and physiotherapist, pre-operative education is also done. Other areas of preoperative assessment, patient and nursing activities are similar to those for any other patient undergoing surgery. The nursing objectives include relief of pain, maintaining adequate neurovascular function, health promotion, improve mobility and help the patient in having a positive self-esteem (French, 2005).

Medical and Nursing assessment Patient assessment includes hydration status, medication history, and possible infection. Hydration can be assessed clinically by looking at skin, mucous membrane, vital signs, urinary output, and laboratory values. Adequate hydration reduces blood viscosity, venous stasis and ensures adequate urine flow thereby preventing urinary stasis and associated bladder infection. Patients who receive corticosteroid medication for chronic illness such as rheumatoid arthritis, pulmonary disease, multiple sclerosis, should continue their regular medication in the Perioperative period to prevent any adrenal insufficiency from suppressed adrenal function (French, 2005). Other medication such as anticoagulants, cardiovascular drugs, oral hypoglycaemic agents and insulin should be discussed with the surgeon and anaesthetist to ensure adequate management. Any pre-existing infection such as respiratory, urinary tract infection, dental and skin problems must be resolved prior to elective surgery to prevent occurrence of osteomyelitis (French, 2005).

Relieving pain Assessment and utilizing medical and nursing intervention such as physical, pharmacological and psychological method can be useful and should be designed to individual patient needs. Immobilization and elevation of fractured bone or inflamed joint and oedematous extremity, increases venous return and reduces associated discomfort. Cold compress diminishes nerve stimulation, relieves swelling and improves patient comfort.

Maintaining adequate neurovascular function - Trauma, Oedema, or immobilization device may interrupt tissue perfusion. Preoperative nurse must assess neurovascular status frequently such as colour, temperature, capillary refill, pulse, oedema, pain, sensation and movement of the extremity (Appendix 3). This baseline neurovascular status preoperatively acts as reference for continuous evaluation during the postoperative period. Any abnormal findings and initiation of appropriate intervention should be reported and documented (Australian College of Operating Room NursesACORN S5, 2004).

Promoting health Preoperative nurse assesses patient nutritional status and hydration. Patient who is diabetic, geriatric, very young, and trauma patients may need special fluid and nutritional management. Monitoring of fluid intake and urine output should be documented. Indwelling catheter should be used only if absolutely necessary to minimize the risk of urinary infection (French, 2005). Coughing, deep breathing exercise and the use of incentive Spiro meter should be taught and initiated preoperatively to prevent respiratory complication during postoperative period. Assessment of pressure sores and skin breakdown should be done and proper nursing intervention should be initiated. Patient must have antimicrobial wash prior to theatre to minimize the risk of infection.

Improving mobility Patients mobility maybe impaired by swelling and immobilizing devices such as splint, cast, and traction. Oedematous extremities need to be elevated and adequate support should be provided including pain relief to reduce patient discomfort. Patients who might require assistive devices in the postoperative period such as crutches, walking frames, and wheelchair are encourage to practice with it preoperatively to facilitate its safe and effective use and promote earlier independent mobility. Encouragement of movement within the limit of therapeutic mobility and teaching active exercises of uninvolved joints such as gluteal-settings, quadriceps-settings, and isometric exercise to maintain muscles needed for ambulation and exercises, should be done preoperatively, unless it is contraindicated (French, 2005).

Helping the patient maintains self-esteem Orthopaedic patients who have diminished self-esteem may require assistance in accepting changes in body image or inability to perform their roles and responsibility. Preoperative nurse assesses the degree of help needed, promotes trusting relationship that encourages the patient to express their concerns. Clarification of any misconception and helping them to adapt to any alteration in physical capacity is one of the vital role of preoperative nurse.

Consent Surgical consent is one the major concern in orthopaedic due to the incidents of performing an operation to the wrong patient or wrong extremity. Marking the right limb or part of the body during the process of obtaining consent and confirmation with the patient prior to surgery reduces the chance of performing an operation to the wrong patient or wrong limb. A time out procedure is one of the policies, which verifies the patient consent prior to anaesthetizing patient on the table (Appendix 1).

Anaesthetic assessment Depending on the patients age, medical condition and type of surgical procedures, patients maybe seen by the anaesthetist on the day of operation or a few days before the surgery. Regardless of the type of anaesthetic and analgesic plan to be given, discussion and consent is to be obtained with the patient prior to procedure.

Consultation with occupational and physical therapist - Preoperative nurse facilitates patient consultation with occupational and physiotherapist prior to operation. Discharge plan, rehabilitation activities, and cares should be discussed to clarify any concerns and anticipate needs or issues that will affect patient and family throughout the Perioperative period.

Admission Orthopaedic patients can be admitted directly from Emergency department to operating theatre, day care procedure unit or from the wards. Patients who are admitted from emergency department most often need an

immediate operation, which shortens the preoperative assessment and preparation of the patient prior to surgery. Preoperative nurse should utilize all possible source of information to obtain nursing and medical history. Collaboration from all involved staffs is vital to establish patient over all health status. Confirmation of allergy, fasting status, and obtaining legal consent are among the immediate concern of Preoperative nurse during this stage (ACORN S11, 2004).

INTRAOPERATIVE PHASE This stage begins with the admission of the patient in the holding bay and ends with the transport of patient to the post anaesthetic care unit. The focus of patients care includes patient safety, prevention of infection, monitoring and prevention of surgical and anaesthetic complication and safety handling of orthopaedic equipment, instruments and devices. Intraoperative nurses are composed of Instrument nurse, Circulating nurse, and Anaesthetic nurse, ensures that the following consideration, nursing and patient activities are performed prior to patient arrival and during intraoperative period;

Patient admission to theatre- Patient is admitted in theatre using routine theatre checklist form and final check from the ward (Appendix 2). Intraoperative nurse ensures that x-ray film and report is with the patient

since it can be a reference during operation. When checking consent upon admission, site of operation must be marked and should match with the written consent and the same to be confirmed with the patient (ACORN S11, 2004). Any discrepancies should be sorted prior to patient admission to theatre. Since hypothermia is one of the major concerns of patient during operation, pre warming of patient should start from the holding bay where patient is being kept upon admission. Providing a warming device is a good start especially for a very young, old and sick patient.

Intraoperative environment preparation - It includes safety measures, cleaning, temperature, movement and airflow control inside the theatre (ACORN S8, 2004). Limited number of staff and less movement inside the theatre during the procedure reduces the risk of infection. High cleaning of the theatre is a good practice prior to a major joint surgery such as hip, knee and shoulder. Intraoperative nurses are responsible for routine safety measures for the patient and the other staffs. Since some orthopaedic equipment and tools require electrical supply and other source of power to operate, proper connection, safe lead and cables should be assured. Airflow control is critical during orthopaedic procedure to prevent introduction of micro-organism to the surgical site, which can be reduced by laminar airflow system (Warner Jr, 1198). Room temperature is maintained as to the patient comforts.

Anaesthetic preparation - Central neuraxial block is commonly used because it reduces the incidence of thromboembolism, Deep Vein Thrombosis, reduces blood loss during operation and provides effective analgesia postoperatively. Peripheral nerve blocks are also beneficial in minor surgeries (Morgan, Mikhail & Murray, 2006). Major orthopaedic operation such as hip arthroplasties and bilateral knee replacement may require invasive monitoring device such as pulmonary artery, central venous and arterial blood pressure monitoring (Sharrock and Savarese, 2000). Intensive monitoring devices, availability of blood products, blood transfusion set and fluid warmer including blood salvaging equipments should be prepared if blood loss is anticipated during the surgery. Anaesthetic nurse should collaborate with the anaesthetist in planning and anticipating patient needs during administration of anaesthetic (ACORN NR1, 2004). Routine anaesthetic preparation should be done including

availability of emergency equipment in the event of failure of local or regional anaesthetic or in case of unanticipated complication. If patient remains awake during operation, noise should be kept to minimal and patient psychological and emotional assurance should be provided throughout the surgical period.

Patient positioning Positions such as Lateral decubitus, sitting or prone are being used during orthopaedic surgery which can cause air embolism, stretch or malposition of joints, direct pressure, and compression of vein or

arteries (Sharrock and Savarese, 2000). In prevention of those complications, Intraoperative nurses must ensure that care and consideration is observed on patients neurovascular function, chest expansion, pressure sore, privacy, safety, comfort, airway access, intravenous lines, monitors, and patients maintenance of proper body alignment during positioning. The surgeon is responsible for selecting the patients position ensuring adequate exposure of operative site, which depends on the type of procedure, site of the operation or injury and the anaesthetic consideration. The Intraoperative nurses and staff must be oriented and knowledgeable with the function and safety use of all orthopaedic devices including orthopaedic bed, fracture table, supports and attachments for holding or supporting the body and extremities during positioning (Bowen, 2003). An extensive assessment of patient condition will help the Intraoperative nurse to formulate a nursing care plan for safe movement and positioning of the patient on the table and should be communicated to all involved staff (ACORN S15, 2004). Prevention of further injury of patients who have co-existing disease such as rheumatoid arthritis and osteoporosis which limits their movements during positioning should be ensured.

Surgical prep One of the major concerns in orthopaedic surgery is the prevention of infection. Prevention on further injury on trauma patient in application of prep solution to the membrane or injured soft tissues during

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skin prep and movement should be avoided. Scrub prep starts with using soap and water to remove superficial oil and skin debris, followed by a povidone iodine preparation to scrub the surgical area. Prep solution pooled beneath the patient and tourniquet can cause skin burns and therefore any excess solution should be allowed to dry, prior to draping. Cross contamination must be prevented when prepping multiple extremities such as in bone graft. Consideration of patient allergy to any skin prep or scrub solution should be identified prior to application. Intraoperative nurse knowledge of aseptic technique, the ability to organize and prioritize the activities is paramount in proper preparation of surgical site (ACORN S21, 2004).

Draping - Extremities are covered with a cloth or water resistant impervious stockinet. During arthroscopy and wound irrigation large amount of fluids are required, impervious sheets are useful to prevent contamination of the operative site and flooding of the whole surgical site. Prefabricated disposable with fenestration for the upper and lower extremity are also useful. Antimicrobial incise drapes can be used to isolate the surrounding areas from incisional site. These drapes contain iodophor-impregnated adhesives that slowly release iodine during the procedure, inhibiting proliferation of organism from the patient skin. Intraoperative nurse ensure that the patient is not allergic to iodophor prior to use (Bowen, 2003).

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Protective measures - Orthopaedic procedures are usually a bloody operation and large amounts of fluids are used for irrigation of wound. Intraoperative nurse should exercise caution and barriers such as protective mask with face shield, eyewear, and boots (ACORN S9, 2004). Double gloving is required to prevent any inadvertent punctures or cuts from the sharp bone edges and sharp instruments.

Equipment and supplies Orthopaedic operating room require a variety of special equipment and accessories. Intraoperative nurse is responsible in routine preparation and insuring the availability of orthopaedic instruments and supplies such as prosthesis, nitrogen-battery and electrical powered equipment, video system, pneumatic tourniquet, x-ray equipment, laser and special orthopaedic table (ACORN NR4, 2004). Intraoperative nurse also anticipate equipments and supplies needed during immediate postoperative period such as knee braces, abduction pillows, arm slings, traction weights, shoulder immobilizers, orthopaedic bed, etc. Manufacturer pamphlets with illustration and direction on equipment use and sterilization should be available during the procedure for references.

Powered surgical instruments - Variable speed saw, drills and reamers are used during orthopaedic surgeries. Understanding of its safe use is mandatory including safety control which should be engaged when passing the instrument to the surgeon to prevent any inadvertent activation.

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Instrument nurse should not allow powered instrument to rest on the patient when not in use (ACORN NR4, 2004).

Radiographic interventions Portable x-ray or fluoroscopy machines are needed to allow the team to review the procedure such as confirming fractures, reduction or as guide during intramedullary reaming of the humerus, femur or tibia. The Intraoperative nurse is responsible for communicating to the radiographer the procedure, aseptic technique, and traffic flow inside the operating theatre. All staff in proximity of the x-ray machine must wear x-ray protective device or lead gown including thyroid shields. The staff should be monitored of radiation exposure. Intraoperative nurse ensures that protective devices are provided to the patient and the same should be documented in the nursing records (Bowen, 2003).

Pneumatic tourniquet Intraoperative nurse and staff must be familiar with its safe use and assessment of the patient, including contraindication such as compartment, McArdee syndrome, hypertension, and other vascular problems should be confirmed prior to its use (Bowen, 2003). Intraoperative staff ensures that inflation pressures are established based on the systolic blood pressure, age of the patient and circumference of the extremity. Intraoperative nurse records the accurate time and location of tourniquet including the set pressures in the notes. Since it can cause irreversible ischemia and neurovascular damage, the Perioperative nurse is responsible in

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assessing and evaluating the extremity after removal of tourniquet and documenting or reporting any abnormal findings (Murphy and Hahn, 2000). Anaesthetist should be informed prior to inflation of tourniquet since initial inflation pressure must be about 100 mm Hg over systolic blood pressure and prophylactic antibiotic is given prior to inflation. Intraoperative nurse should warn the surgeon of overuse of tourniquet time, since it can cause lifethreatening complications, such as hemodynamic changes, pain, metabolic alterations, arterial thromboembolism, and pulmonary embolism to facilitate appropriate measures to be taken (Morgan, Mikhail & Murray, 2006). Bone cement implantation syndrome Bone cement or

polymethylmetacrylate is frequently used for joint arthroplasties. The cement interdigitate within the interstices of cancellous bone and strongly binds the prosthetic device to the patient bone (Morgan, Mikhail & Murray, 2006). The liquid monomer is highly flammable requiring the operating room to be properly ventilated. Precaution should be exercise during mixing of the two components to prevent exposure as it causes irritation of respiratory tract, eyes, and possibly liver (Bowen, 2003). Special hood and mixing device should be use to minimize staff exposure to the fumes. Wearing second pair of gloves and not wearing any contact lenses are helpful to prevent fumes from permeating and irritating the skin and the eyes (Murphy & Hahn, 2000). Bone cement also causes a life threatening complication to the patient such as transient hypotension, cardiac arrest, cerebral vascular accident, pulmonary embolism and hypersensitivity reaction. Since some of the

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complication occur during insertion of prosthesis, collaboration with the anaesthetist before application of bone cement is essential to facilitate patient vigilant monitoring (Morgan, Mikhail & Murray, 2006).

Intraoperative haemorrhage - Intraoperative haemorrhage is one of life threatening complication of major orthopaedic surgery such as total hip replacement (Sharrock and Savarese, 2000). Intraoperative nurse must anticipate and prepare for all necessary equipment and supplies such as blood transfusion set, fluid warmer and availability of blood products including blood salvaging devices if needed. Clinical monitoring on the blood pressure, heart rate, blood loss, urine output, and patient temperature remains beneficial.

Prophylactic antibiotic - Intraoperative nurse should remind the surgeon or anaesthetist for administration of antibiotics immediately before surgery for patient who will have permanent implants, use of polymethylmetacrylate and when wound contamination is suspected (Warner Jr, 1998).

POSTOPERATIVE PHASE This stage begins with the transport of patient into the recovery room until safe handing over of the patient to the ward or may extend up to the patients complete recovery and rehabilitation. Intraoperative nurse routinely gives systematic hand

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over to the recovery room nurse, all the necessary information that can influence the management plan in the postoperative care of the patient. During immediate postoperative period, the focus of patient care includes routine assessment, maintenance of basic airway, breathing and circulation, prevention and monitoring of surgical and anaesthetic complication, prevention of infection, patient comfort, and safety (Howard, 2004). Re-assessment of pain, neurovascular status, health promotion, mobility and self-esteem are among the primary concerns of postoperative nurses. Following immediate postoperative period, nursing and patient activities also include reinforcement of education, occupational and physiotherapist care and discharge planning (French, 2005). Upon discharge of patient from theatre, Postoperative nurse continues the preoperative care plan, by modifying it according to the individual patient needs. Pain - Oedema, hematoma, and muscle spasm causes pain after surgery. The nurse must closely monitor the patients level of pain and response to the intervention (NR6 ACORN, 2004). Multiple pharmacological approaches to pain such as Patient controlled analgesia (PCA), neuraxial analgesia and peripheral nerve blocks are commonly used (Morgan, Mikhail & Murray, 2006). Oral analgesia and other routes of PRN (if necessary) medications have to be given round the clock, before the pain becomes severe and prior to any planned activity. Oedema and pain can be relieved with cold compress and limb elevation, unless contraindicated. Maintaining the patency of surgical drains can prevent fluid accumulation and hematoma formation. Repositioning, relaxation, distraction and guided imagery are also useful.

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Any increasing pain in spite of interventions could be an early manifestation of compartment syndrome.

Maintaining adequate Neurovascular function - The assessment and monitoring of the neurovascular function of the patient should be continued throughout postoperative period. The nurse should be aware that if neuraxial and peripheral anaesthetic was performed on the patient, sensation and movement may not be present on the affected side postoperatively, masking some symptoms and signs of neurovascular complication. Assisting patients to perform muscle setting, ankle and calf-pumping exercises every hour enhances circulation (French, 2005). Any abnormal finding should be documented and reported promptly and immediate intervention should be initiated.

Postoperative bleeding Poor haemostatic technique and wounds that are closed under tourniquet control during surgery post a high risk of bleeding postoperatively. Monitoring of wound, dressing and amount, colour and discharge from drains remains beneficial. Postoperative nurses must be vigilant in recognising early signs and symptoms of bleeding to prevent hypovolaemic shock (French, 2005). .

Prevention of respiratory complication Pre-existing pulmonary disease, deep anaesthesia, decreased activity, analgesia, and reduced respiratory reserved due to ageing and underlying musculoskeletal disease that could

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restrict lung expansion can cause pneumonia and atelectasis postoperatively. During immediate postoperative period, postoperative nurses should encourage the patient for, deep breathing and coughing exercise, including use of incentive Spirometer if prescribed thereby ensuring full expansion of lungs to prevent accumulation of pulmonary secretions and associated lung complications. Fat embolism syndrome is one of the causes of mortality and morbidity in orthopaedic postoperative patients. It usually occurs within 72 hours after long bone or pelvic operations (Morgan, Mikhail & Murray, 2006) with the triad of dyspnea, confusion and petechiae, thus monitoring, recording and immediate reporting of the above symptoms is vital during this period including respiratory rate, rhythm, and oxygen saturation.

Prevention of urinary retention Voiding in unnatural position and existing prostate problems in ageing patient contribute to bladder distension and urinary retention (French, 2005). Encouraging patient to void by offering bedpan or urinal remains useful during immediate postoperative period, or if unable to void, intermittent catheterization might be beneficial. Indwelling catheter must be the last resort and should be removed as soon as possible to reduce the risk of urinary infection.

Infection Osteomyelitis is high risk in orthopaedic patients, which requires prolonged and massive antibiotic therapy. If the infection starts the infected bone and prosthesis or internal fixation device has to be removed, which

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delays healing, hospitalization and rehabilitation of the patient. Perioperative nurse ensures and initiates that prescribed antibiotics cover the patient throughout the Perioperative period, including monitoring of patients response to antibiotic therapy (French, 2005). Postoperative nurse maintains aseptic technique when handling patients wound and monitors any symptoms and signs of wound infection (ACORN S9, 2004).

Venous stasis and Deep Vein Thrombosis Patients immobility contributes to venous stasis and development of DVT. Application of intermittent calf pumping exercises, elastic compression stockings, sequential compression devices, adequate hydration and early ambulation prevent these complications (Morgan, Mikhail & Murray, 2006). Postoperative nurse ensures that prophylactic drugs such as clexane is given, monitors and reports any symptoms to facilitate early intervention.

Early mobilization - Metal pins, screw, rods, and plates used for internal fixation are designed to maintain the position of the bone until ossification occurs and not to support the body weight thereby it can be loosened or break if stressed. Postoperative nurse assistance, reassurance and effective pain control are vital in increasing patients mobility within their therapeutic limits. The physiotherapist designs the exercises based on the individual patient needs, with the goal of restoring normal function as soon as possible (French, 2005).

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Maintaining health The patients should progress to a regular diet as soon as possible. Providing food rich in protein and vitamins aids in proper wound healing. Large amount of milk is contraindicated to orthopaedic patient who are bedridden, to avoid any calcium accumulation in the body which may increase work load of the kidneys to excrete calcium, increasing the risk of urinary calculi (French, 2005). Prolonged bed rest, immobilization, aging and malnourishment predispose the patients to pressure sores and skin breakdown. Frequent turning, walking and keeping the skin dry and clean prevents such complication.

Maintaining self-esteem - Psychological and emotional support for patient and the family members is vital to accept any altered image postoperatively. Postoperative nurse must discuss realistic goals in increasing self-care and activities within the set therapeutic limits (French, 2005).

Discharge and Continuing care In collaborating with physiotherapist, occupational therapist, and social worker, the nurse anticipates the patient and family needs prior to discharge including special equipments and home modification if required. Referral and consultation with community nursing and home therapy, is required for continuity of patient care and resources during the rehabilitation period. Postoperative nurse educate the patient and the family to recognize any complications that necessitate prompt action and reporting including, prescribed medication, wound care, prescribed

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therapeutic physical activities, weight bearing limits and proper use of mobility aids (French, 2005).

CONCLUSION Orthopaedic patients require unique Perioperative care that challenges competent skills of the Perioperative nurse. The knowledge of anatomy, physiology, principles of bone fixation and healing, and keeping up with the advancement in equipment and hardware ensure continuous understanding of the care required for orthopaedic patients. Working within the framework of nursing process, guides the Perioperative nurse in providing safe and efficient cares. Collaboration with Perioperative staff involved in patient care is vital to ensure continuity of care, rehabilitation and complete recovery.

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References:

Australian College of Operating Room Nurses, 2004, Postanaesthesia Recovery Nurse, ACORN, Adelaide, NR6, pp.1-10

Australian College of Operating Room Nurses, 2004, Skin Preparation of the patient, ACORN, Adelaide, S21, pp.1-4

Australian College of Operating Room Nurses, 2004, Anaesthetic Nurse, ACORN, Adelaide, NR1, pp1-6

Australian College of Operating Room Nurses, 2004, Positioning the Patient for Surgery, ACORN, Adelaide, S15, pp.1-4

Australian College of Operating Room Nurses, 2004, Legal Implications, ACORN, Adelaide, S11, pp.1-3

Australian College of Operating Room Nurses, 2004 Infection Prevention, ACORN, Adelaide, S9, pp.1-8

Australian College of Operating Room Nurses, 2004, Documentation ACORN, Adelaide, S5, pp. 1-3

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Australian

College of Operating

Room Nurses, 2004, Environmental

Management, ACORN S8, pp. 1-7

Australian College of Operating Room Nurses, 2004, Instrument Nurse ACORN NR4, pp. 1-5

Bowen B. 2003, Chapter 22, Orthopaedic Surgery in Alexanders Care of the Patient in Surgery, 12th edition, Rothrock JC. Smith D. & McEwen DM. (editors), Mosby, Missouri, pp. 817-930

French J. 2005, chapter 67 Musculoskeletal Care Modalities in Smeltzer and Bares Textbook of Medical-Surgical Nursing, Farrell M. (editor), 1st Australian and New Zealand edition, Lippincott William & Wilkins Pty Ltd. Philadelphia, pp. 2039-2053

Howard L. 2004, Chapter 49, Orthopedic Surgery in PeriAnesthesia Nursing Core Curriculum PREOPERATIVE, PHASE 1 and PHASE 11 PACU NURSING, DeFazio Quinn DM and Schick L. (editors) Saunders, St. Louis Missouri, pp.1049-1087

Morgan GE, Mikhail M, & Murray M, 2006, Clinical Anesthesiology, 4th edition, McGraw Hill, New York, pp.849-860

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Murphy M. and Hahn G. 2003, Orthopaedic Surgery in Patient Care during Operative and Invasive Procedure, Phippens ML. and Wells MP. (Editors), W.B. Saunders, Pennsylvania, pp.502-567

Sharrock N.E. and Savarese J.J. 2000, Chapter 60, Anesthesia for Orthopedic Surgery in Anesthesia, Miller R.D. (editor), 5th edition, volume 2, Churchill Livingstone, Philadelphia Pennsylvania, pp.2118-2135

Warner Jr W.C. 1998, Chapter 13, General Principle of infection in Operative Orthopaedic, Canale S.T. (editor), 9th edition, volume 1, Mosby, St. Louis, Missouri, pp.563-572

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Appendix 1

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Appendix 2

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Appendix 3

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Appendix 4

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Appendix 5

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