Evidence-based nursing care of a patient treated with the Ilizarov method for lower limb length inequality

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INTRODUCTION
Lower limb inequality is a major dysfunction.When the discrepancy is bigger than 5 cm, the condition poses a threat to the statics and dynamics of the locomotor system.In such cases several therapeutic options are available including epiphysiodesis surgery, shortening of the longer leg, or lengthening of the shorter leg [1].The most popular method of the lower limb inequality treatment is the Ilizarov method, which is surgical lengthening of the limb based on the principle of distraction osteogenesis, with the apparatus elements inserted to the bone by osteotomy [2].The process of bone lengthening with the Ilizarov method involves the phenomenon of tissue regeneration in which slowly stretched and lengthened tissues increase their metabolic activity.The new bone tissue formed at the site of osteotomy is a regenerate and the process of its formation is distraction osteogenesis [3].The bone lengthening phase starts approximately 5-7 days after the apparatus attachment and gradual adjustments of the bolts so the bone fragments at the site of osteotomy are slowly moved away of each other.Duration of this phase depends on the response of the soft tissues, pain experienced by the patient and emotional condition of the patient [4].The rate of the tissue stretching in the femoral bone is 1 mm per 24 hours.Therefore ¼ of the bolt turn is performed every 6 hours, with 4 turning cycles, 0.25 mm each, including night break.This rate is optimal for making the most of the regenerative potential of the bone tissue, while reducing the risk of blood vessel, muscle, nerve or join damage [5].The next phase of the therapy is stabilization.The formed regenerate is being remodelled until complete bone fusion and restoration of the cortical bone are achieved.During this phase the patient should exercise a lot with weight bearing of the operated limb to strengthen the newly formed bone segment.This treatment method enables walking in the apparatus with full weight bearing of the operated leg [5].

AIM
The aim of the study was to recognize nursing problems and present selected elements of nursing care of a patient with lower limb inequality treated with the Ilizarov method.

MATERIALS AND METHODS
The work was based on the individual case study method, using research techniques: interview, observation, measurement, and analysis of nursing documentation.The research tools were: a guide for collecting data about the patient, a numerical scale for assessing pain intensity (NRS), a scale for assessing the risk of wound infection WAR, Beck's Depression Rating Scale (BDI).The collection of empirical data was carried out during 3 days of care between 8 a. m. and 6 p. m. in the Orthopedics and Traumatology Department of the Infant Jesus Clinical Hospital in Warsaw, in June 2019.Oral consent of the head of the department and written consent of the patient's parents were obtained for the study.The patient himself consented to the study.The diagnoses were formulated in a traditional way, based on the concepts of making nursing diagnoses developed in the Polish environment, referring to the patient's bio-psycho-social state, by J. Górajek-Jóźwik [6].The effects of the activities were assessed by direct observation of the patient's health condition and using the NRS, WAR, and BDI scales.

Description of the patient's health problem
The patient was born with his right lower limb shorter than left one.He was diagnosed with post-inflammatory varus deformity of the right hip and shortening of the right femur.The study started on the day of the surgery aiming to lengthen the right femur which was 10 cm shorter versus the left one.The Ilizarov apparatus was fixed on the operated limb and the sites of rods and wires insertion were protected with dressings.After the surgery the patient was placed on a mattress with a cut-out for the Ilizarov apparatus and the position of the operated limb was regularly monitored.The patient reported pain in the operated limb, with the NRS score of 7.He complained of sleep problems due to unnatural position for night rest forced by the stabilizer.Loss of appetite caused by persistent pain in the lengthened limb was also observed.Analgesics from the class of opioids were administered as prescribed by the surgeon and the dose of the antithrombotic agent was increased because of the platelet count elevation.Observation of the stabilizer was continued and dressings on the postoperative wounds were controlled.There was some oedema and serous exudate, a sample of which was collected for microbiological examination.Temperature and blood supply to the operated limb were monitored.Isometric exercises, passive and active exercises including exercises with the leg suspended in a Balkan frame were started.The patient was in depressed mood and felt sadness.He did not want to talk because of recurrent pain and perspective of long-term treatment with accompanying disability (BDI score of 10).During the next few days verticalization attempts were made but the patient did not want to get involved in the rehabilitation process because of pain in his limb (NRS score of 5).When pain relief was achieved, the patient took up the rehabilitation and his mood kept on improving along with increased physical activity.

Diagnosis 1 Pain in the operated limb associated with skin incision and deep tissue damage (NRS score of 7)
Nursing interventions 1-Pain assessment on the Numeric Rating Scale.2-Disability facilities including the special mattress with a cut-out for the Ilizarov apparatus ring to help the patient take a comfortable position and unweight the leg.3-Participation in the analgesic pharmacotherapy according to the medication chart prescribed by the surgeon and assessment of its therapeutic effects.4-Careful nursing -providing gentle hygiene care.5-Showing support and empathy to the patient.
Outcome: The undertaken interventions resulted in pain reduction from NRS score of 7 to 3.
Evidence-based nursing care of a patient treated with the Ilizarov method for lower limb length inequality

Diagnosis 2 Depressed mood and feeling of sadness due to the perspective of long-term treatment and accompanying disability (BDI score of 10)
Nursing interventions 1-Recognition of factors that contribute to the depressed mood (immobilization, long hospital stay).2-Building a therapeutic relationship with the patient by focusing attention on the patient, active listening, talking.3-Encouraging the patient to get involved in the development of treatment and nursing plan, e.g.deciding on the timing of nursing procedures, preferences about food intake etc. 4-Encouraging the patient to ask questions about his health.5-Instructing the patient about relaxation techniques.6-Providing access to books, crossword puzzles, computer games, TV.
Outcome: The undertaken interventions resulted in improvement of the patient's mood (BDI score of 3)

Diagnosis 3 Risk of soft tissue infection as a result of the presence of metal implants (WAR score of 3)
Nursing interventions 1-Prophylactic antibiotic use according to the medication chart.2-Regular control of dressings at the sites of bolts and wires insertion.3-Collecting wound exudate for microbiological examination.4-Everyday observation of the skin around the wires and bolts for local signs of infection (pain, redness, swelling, pus).5-Everyday observation of the patient for systemic signs of infection (fever, shivers, bacteraemia).6-Using an aseptic technique when changing wound dressings.7-Adherence to hand hygiene and sanitary regime by health professionals and patients.8-Education of the patient and his family about risk factors and prevention of infections.
Outcome: Postoperative wounds were not infected, and the only problems observed were swelling and serous exudate.

Diagnosis 4 Risk of venous thromboembolism as a result of the limb immobilization
Nursing interventions 1-Administration of antithrombotic drugs according to the medication chart.2-Observation of the patient for signs and symptoms suggestive of thromboembolic events (heat, swelling, redness, tenderness of the limb).3-Early rehabilitation and mobilization.4-Monitoring of the limb temperature.5-Measurements of the limb swelling.6-Education of the patient's caregiver about handling of the prefilled syringes with antithrombotic agent.
Outcome: Thromboembolic events were not observed.

DISCUSSION
Pain in the operated limb caused by tissue damage due to wires and bolts inserted into the bone is the key nursing problem in this patient.The nature of the procedure and the treatment method chosen contribute to severe intensity of pain.Alleviation of pain is of key importance for effective rehabilitation [4].The pain was rated 7 on the Numerical Rating Scale.As recommended by treatment guidelines, pharmacotherapy was administered according to the individual medication chart.This approach can provide pain relief in most paediatric patients [7].Reduction of pain severity can also be achieved with disability facilities that minimize pain by decreasing pressure and stabilizing the body [8].Pain threshold can also be raised by appropriate environment for sleep and rest, in which signs and symptoms of any disease can be reduced [8].Also psychological interventions are shown to reduce pain in children and adolescents [9].The applied treatment method, which generated a lot of limitations and the perspective of long term therapy, contributed to the feeling of sadness and depression in the adolescent patient.There are reports in literature that long duration of treatment, persistent pain and being dependent on other people may lead to depression, anxiety, low mood, and lack of acceptance for the disease and its treatment methods.Emotional distress and helplessness are the main causes of depression [10].The patient was assessed with Beck Depression Inventory (BDI), and was rated 10 (the score of 11 or higher means moderate depression).Therefore, monitoring factors that contribute to depressed mood was found reasonable.An important aspect of care is building a relationship with the patient by paying attention to him, active listening, talking.This kind of support is likely to reduce the patient's feeling of helplessness [9].Active participation in the development of treatment plan, including decisions on timing of nursing procedures, can increase the patient's self-confidence [9].Appropriate time management and access to entertainment can also improve the patient's well-being [8].The applied method of treatment is associated with an increased risk of postoperative wound infection [5].The inserted wires damage the tissues and the skin around them is stretched and tensed.The WAR score was 3, which suggested that the risk of wound infection was increased.Preventive measures that help in early detection of infection and timely treatment initiation include appropriate selection of dressings, monitoring of dressing moisture, everyday observation of the skin around the wires and bolts, and adherence to the aseptic technique [8,11,12].Hand washing, using alcohol-based disinfectants (60-80% concentration), wearing gloves for any contact with blood, mucous membranes, secretions, discharges or damaged skin, using safety glasses and medical gowns when needed are of key importance for reduction of infections [9].In case of infection it is important to identify etiological factors of the infection, which is possible with microbiologic diagnostic procedures including the wound exudate culture [13].More than a half of wound infections develop at home after the patient's discharge from hospital.Therefore, education of the patient and his family as well antibiotic prophylaxis was very important [9,14].
The Ilizarov apparatus considerably limits the range of movements of the operated limb, which, in turn, increases the risk of thromboembolic events.Antithrombotic treatment protects against deep vein thrombosis in hospitalized patients with reduced mobility [8].Early mobilization

Opieka pielęgniarska oparta na dowodach naukowych nad pacjentem leczonym metodą Ilizarowa wskutek nierówności kończyn dolnych
and rehabilitation is of great importance, because immobilization is one of the most important risk factors for thromboembolic events.Initiation of exercises and activation of the patient prevents the development of blood clots while monitoring of the operated limb temperature and measurement of its swelling and pain allow for early detection of thrombosis [9].It is advisable to instruct the patient's caregiver how to handle the prefilled syringes with antithrombotic agents, because supporting the therapeutic process with educational activities should provide significant health benefits [15].

CONCLUSIONS
1.The applied treatment method with the Ilizarov apparatus predisposes the patient to the post-operative pain of considerable severity, post-operative wound infections; thromboembolic events, limited range of movements in the operated limb, depression and lack of motivation to continue the therapeutic process.2. The use of evidence-based nursing interventions is the only way to take the most effective actions that guarantee beneficial changes in the patient's health.3.There is a need to present the issue of nursing care in this area due to the small number of Polish publications.