1. Care of the Post-Op Foot Surgery Patient By Anne Eby, RN, ONC, BSN Nursing made Incredibly Easy! November/December 2008 2.0 ANCC/AACN contact hours Online: www.nursingcenter.comwww.nursingcenter.com © 2008 by Lippincott Williams & Wilkins. All world rights reserved.

2. Foot Surgery  Includes a variety of procedures: Removal of a growth Amputation of part or all of the foot Elective or emergent procedures for musculoskeletal disorders  Nonsurgical management remains the treatment of choice for chronic foot disorders  When these options fail, surgical treatment may be necessary

3. Anatomy of the Foot  The foot contains: 26 bones 33 joints More than 100 ligaments, tendons, and muscles  Joints and muscles of the foot allow for a wide range of motion  Components prone to injury: Achilles tendon Plantar fascia ligament  Two most commonly discussed arteries: Dorsalis pedis Posterior tibial

4. Anatomy of the Foot

5. Common Foot Deformities  Bunions—a local painful swelling caused by misalignment of a joint  Clawfoot—an abnormally high arch and a fixed equinus deformity of the forefoot; Charcot foot deformity is a common cause  Clubfoot—one or both of the feet turn inward; effects 1 in 1,000 newborns  Flatfoot—progressive disorder in which the arch of the foot is diminished; four times more likely in women; causes: congenital abnormalities, injury, muscle fatigue, obesity, hypertension, diabetes, or arthritis

6. Common Foot Deformities  Hammer toe—flexion deformity of the interphalangeal joint  Heel pain—usually related to inflammation of the plantar fascia or entrapment of the medial calcaneal nerve or the first branch of the lateral plantar nerve  Morton’s neuroma—swelling of the third branch of the median plantar nerve caused by ischemia of the nerve from compression or trauma

7. Picturing Common Foot Deformities

8. A Closer Look at Charcot foot

9. Treatment  Bunions X-rays to determine the extent of deformity Ranges from no treatment to orthoses or night splints  Clawfoot Exercises and bracing  Clubfoot Managed exclusively with the Ponseti technique, which involves stretching the foot, casting, and tenotomy, followed by wearing braces

10. Treatment  Flatfoot Exercises and orthoses, surgery if necessary  Hammer toe Wearing open-toed sandals and performing manipulation exercises; osteotomy may be required  Heel pain Corticosteroid injections, taping,and casting; surgery when conservative treatment fails after 6 to 12 months  Morton’s neuroma Inner soles and metatarsal pads to balance foot posture, local hydrocortisone injections

11. Post-Operative Care  Depends on type of injury and procedure  Nursing care focuses on: Promoting tissue perfusion Pain management Preventing complications Improving mobility

12. Promoting Tissue Perfusion  Assess the neurovascular status of the affected extremity every 1 to 2 hours for the first 24 hours, including: Color Edema Temperature Pain Capillary refill time Sensation Pulses Motion

13. Indicators of Neurovascular Dysfunction  Circulation Pale, cyanotic, or mottled color Cool temperature Capillary refill time of more than 3 seconds  Motion Weakness Paralysis  Sensation Paresthesia Unrelenting pain Pain on passive stretch Absence of feeling

14. Pain Management  Related to inflammation  Elevation and ice  Oral or I.V. pain medications  Assess your patient’s pain by asking her to identify its location, describe its quality, and rate its intensity

15. Preventing Complications  Most significant are infection and deep vein thrombosis  Prophylactic antibiotics  Pin care (if applicable) with stringent standard precautions  Early mobilization, compression devices, and anticoagulants as appropriate

16. Improving Mobility  Weight bearing as tolerated/ordered  Use of assistive devices, such as crutches or a walker  Patient teaching in safe use of these devices

17. Teaching Crutch Maneuvering Techniques  To sit down Grasp the crutches at the hand pieces for control Bend forward slightly while assuming a sitting position Place your affected leg forward to prevent weigh bearing and flexion  To stand up Move forward to the edge of the chair with your strong leg slightly under the seat Place both crutches in your hand on the side of the affected leg Push down on the hand piece while raising your body to a standing position

18. Teaching Crutch Maneuvering Techniques  To go down stairs Walk forward as far as possible on the step Advance the crutches to the lower step, advancing your weaker leg first and then the stronger one  To go up stairs Advance your stronger leg first up to the next step. Advance the crutches and then the affected leg A helpful memory device for your patient is: Up with the good, down with the bad

19. Tripod Position for the Basic Crutch Stance

20. Self Care After Foot Surgery  Signs and symptoms to report Change in sensation Inability to move your toes Toes or foot cool to the touch Color changes  Pain management Elevate your foot to heart level Apply ice as prescribed Use analgesics as prescribed Report unrelieved pain  Mobility Use assistive devices safely Comply with prescribed weight-bearing limits Wear a special protective shoe over the dressing  Wound care Keep the dressing or cast clean and dry Report signs of infection, such as pain, drainage, or fever, immediately Follow the prescribed antibiotic regimen Keep your appointment with the surgeon for the initial dressing change