Knee replacement surgery is a major life event and warrants skilled nursing care so that they must recover from the surgical issues. However, knee replacement surgery has complications associated with it both pre-operatively and post operatively. To address the post-operative complications, nursing professionals must have the required skills set to address the issues and must have the analytical knowledge to link the post-operative complications with peri-operative symptoms.
In the present case John grant suffers from bilateral knee osteoarthritis. Osteoarthritis is progressive degenerative musculo-skeletal condition that leads to progressive cartilage loss and remodelling of bone structure. Previously thought to be an outcome of wear and tear current research suggest different reasons ranging from cellular (McCulloch, Litherland and Rai, 2017) to genetic (Peffers, Balaskas and Smagul, 2018) and environmental (Bortoluzzi, Furini & Scire, 2018). The progressive damage of cartilage and bone remodelling occurs due to active chondrocytes response and inflammatory cells that surrounds the tissues. The inflammatory response leads to enzymatic breakdown of collagen and proteoglycans resulting in articular cartilage damage. As a result, subchondral bone gets exposed and causing sclerosis followed by bone remodelling, and formation of bone cysts and osteophytes (Herrero-Beaumont, Roman-Blas, Bruyère, Cooper, Kanis, Maggi, & Reginster, 2017).
Patient undergoing total knee arthroplasty or replacement warrants skilled nursing intervention in order to recover from the anaesthesia and pain. Post-operative nursing management plan can extend from some months to one year or more based on patient’s recovery. In the present scenario, and based on patient condition two main components will be addressed in assessment. The first assessment is pain relief and second assessment is wound care.
Post-surgery, the assessment can involve different rating scales or tools. According to Wylde et al., (2013) post knee replacement surgery pain assessment can be done by single item measures. However use of American Knee Society score is the common approach. From Australian perspective, use of 11 point pain rating scale will be used for assessment of pain. In case pain rating is greater than four, it is indicative of breakthrough pain (Botti, et al, 2014). The frequency should be two hourly when awake and four hourly during sleep. After administration of pain medication, pain assessment should be done after 30 minutes.
Rationale – The patient undergoing total knee replacement surgery suffers from severe pain that can stay upto 2 months. The chronic pain post knee replacement surgery is well documented with most research studies showing persistent pain even after 4 months of knee replacement surgery. The patient has type 2 diabetes and hyperlipidemia that can further worsen vascular complications, thus complicating the pain pathology. Therefore, the patient will be assessed for pain (Rajamäki, Jämsen, Puolakka, Nevalainen, & Moilanen, (2015).
In case of knee replacement surgery, depending on the type of surgery the wound length vary from 10 cm to 30 cm. However, these days minimally invasive procedures reduces the wound area. Immediately after the surgery, the wound area is attached with a drainage pipe in order to collect the body fluids and blood. Post-surgery RN must assess the dressing and in a collaborative approach with surgeon, whether the dressing should be changed or not should be analysed. The assessment will also include amount of drain from wound area.
RATIONALE – To prevent peri-prostehtic infection rate post knee replacement surgery wound care is imperative (Harato, Tanikawa, Morishige, Kaneda, & Niki, 2013). Secondly, the patient has a history of type 2 diabetes that has shown higher prevalence of prosthetic infections when patients have peri-operative diabetes in case of total knee replacement surgery (Kremers et al, 2015). Thus, to prevent any type of future complications that demands removal of implant, leg amputation, muscle flap rotation wound assessment is a must in the present case. Secondly, depression accompanied with other health conditions can further delay wound healing. Thus, as a RN proper wound assessment is necessary (Bernstein et al, 2018).
The two nursing priorities identified for the current patient includes – reducing pain after one week of surgery and post-operative wound dehiscence.
Pain improvement post-surgery is not only a good nursing care approach, but in case of total knee replacement surgery faster recovery from pain will help in faster movement. Based on anaesthesia used and pain score, post-surgery the nursing priority should be determining whether anaesthesia should be patient controlled or epidural opiates for a period of 24-48 hours. Once, the pain reduces it can be reduced from dose perspective using paracetamol and non-steroidal anti-inflammatory drugs. Therefore, the nursing implications for the current approach would be knowing the side effects, benefits and adverse events associated with analgesia (Tedesco et al., 2017). The priority would be on reducing patient dependency on opioid and short term acute post-operative recovery. The first two to three days will be crucial based on the vital signs of patient and other parameters. Nursing professional must assess the vitals of the patient at four hour frequency, and assess the patient pain score. IV medications prescribed and their effects must be monitored along with cold therapy for improvement in patient pain symptoms (Burns et al., 2015).
Wound dehiscence is a common issue reported in surgical ulcer that involves breaking of surgical incision at stitch area. As per the studies, it is a severe complication associated with knee arthroplasty. Success of knee replacement surgery is dependent on primary wound healing. The prevalence rate of wound dehiscence in case of knee replacement surgery vary from 33% to 50%. There are different types of risk factors associated with wound dehiscence involving patient specific factors, post-operative factors, and intra-operative factors. The other risk factor associated with failed wound healing includes peri-operative diabetes, age, vascular disease, diabetes, inadequate nutrition etc. The two most prominent issue that can slow down wound healing includes diabetes and obesity. The patient in the present case has type 2 diabetes that can lead to slow wound healing. Thus, the nursing priority should be controlling factors that can increase the risk of wound dehiscence (Sazegari, Mirzaee, Bahramian, Zafarani, & Aslani, 2017).
Post-operative wound dehiscence is a major complication post knee replacement surgery. Therefore, in the present section nursing interventions are designed for the patient with evidence based rationale.
Nursing Intervention 1 – Following good hand washing technique while addressing patient issues.
Rationale – Since the surgical incision area is highly prone to infection and patient in the present case has type 2 diabetes. In case infection occurs it will take time to heal.
Nursing Intervention 2 – Use of protective equipment’s such as gloves while assessing the wound, or change the dressing. Similarly, aseptic techniques must be followed while addressing drain of the patient. The patient is advocated not to scratch or touch the incision area as this can lead to infection (Hass, Jaekel, & Nesbitt, 2015).
Rationale – This will prevent wound infection that in turn can result in prosthesis removal. The success of total knee replacement surgery depends how well the surgical wound is managed.
Nursing Intervention 3 – Maintaining the drainage devices patency and characteristic of wound drainage must be noted.
Rationale – This will help patient as during sleeping due to anaesthesia effect the drainage device might have displaced. This can cause discomfort or pain to the patient. Secondly, it will prevent accumulation of blood or any other body fluids at medium position. In case of purulent, odorous and non-serous drainage if observed it implicates infection. In case, the drainage is continuous it might enhances the chances of infection (Weeks et al., 2017).
Nursing Intervention 4 – Assessment of skin colour and incision, temperature and integrity. The wound assessment must be focussed on whether erythema or inflammation is present is or not.
Rationale – This will help the nursing professional to find out whether there is any chances of infection or not or any infection has been started or not.
Nursing Intervention 5 – Proper assessment of pain that also includes increased incision pain. Similarly, the characteristics of pain and changes must be noted.
Rationale – In any case deep pain is noted it might indicate of development of joint infection. This is the most crucial factor because once infection occurs at joint area, it can lead to prosthesis removal and joint immobility (Salmond and Echevarria, 2016).
Nursing Intervention 6 – Monitoring vital signs and temperature. Chills are present or not must be assessed.
Rationale – Although a slight increase in temperature post-operatively is evident after knee replacement surgery, if the temperature is persistent after 5 days of surgery it might indicate serious complications. This might be due to sepsis, tissue necrosis, prosthetic failure and osteomyelitis (Iorio et al., 2019).
Nursing intervention 7 – Encouraging patient for fluid intake and fibre intake.
Rationale- Helps in improving wound recovery, nutritional balance and enhance tissue perfusion issues.
Case description
John Grant is a 63 year old patient scheduled for knee replacement surgery due to osteoarthritis.
Feelings
During care plan formulation, my feeling was I am privileged to have the case as it helps in improvement of my nursing skills and competence.
Evaluation
The feelings are expected as this care plan designing provides platform to carry out use of subject knowledge and skills learnt.
Analysis
The case facilitated an environment of knowledge gain, skill enhancement and use of analysis while formulating care plan.
Conclusion
To design a care plan it is imperative to use evidence based article.
In case of future cases evidence based research articles must be used to address knee replacement surgical patients (Hass, Jaeskel and Nesbitt, 2015).
References
Burns, L. C., Ritvo, S. E., Ferguson, M. K., Clarke, H., Seltzer, Z. E., & Katz, J. (2015). Pain catastrophizing as a risk factor for chronic pain after total knee arthroplasty: a systematic review. Journal of pain research, 8, 21.
Bernstein, D. N., Liu, T. C., Winegar, A. L., Jackson, L. W., Darnutzer, J. L., Wulf, K. M., … & Bozic, K. J. (2018). Evaluation of a Preoperative Optimization Protocol for Primary Hip and Knee Arthroplasty Patients. The Journal of arthroplasty, 33(12), 3642-3648.
Bortoluzzi, A., Furini, F., & Scirè, C. A. (2018). Osteoarthritis and its management-Epidemiology, nutritional aspects and environmental factors. Autoimmunity reviews.
Botti, M., Kent, B., Bucknall, T., Duke, M., Johnstone, M. J., Considine, J., … & Cohen, E. (2014). Development of a Management Algorithm for Post-operative Pain (MAPP) after total knee and total hip replacement: study rationale and design. Implementation Science, 9(1), 110.
Harato, K., Tanikawa, H., Morishige, Y., Kaneda, K., & Niki, Y. (2016). What are the important surgical factors affecting the wound healing after primary total knee arthroplasty?. Journal of orthopaedic surgery and research, 11(1), 7.
Hass, S., Jaekel, C., & Nesbitt, B. (2015). Nursing strategies to reduce length of stay for persons undergoing total knee replacement: integrative review of key variables. Journal of nursing care quality, 30(3), 283-288.
Herrero-Beaumont, G., Roman-Blas, J. A., Bruyère, O., Cooper, C., Kanis, J., Maggi, S., … & Reginster, J. Y. (2017). Clinical settings in knee osteoarthritis: Pathophysiology guides treatment. Maturitas, 96, 54-57.
Iorio, R., Clair, A. J., Inneh, I. A., Slover, J. D., Bosco, J. A., & Zuckerman, J. D. (2016). Early results of Medicare’s bundled payment initiative for a 90-day total joint arthroplasty episode of care. The Journal of arthroplasty, 31(2), 343-350.
Kremers, H. M., Lewallen, L. W., Mabry, T. M., Berry, D. J., Berbari, E. F., & Osmon, D. R. (2015). Diabetes mellitus, hyperglycemia, hemoglobin A1C and the risk of prosthetic joint infections in total hip and knee arthroplasty. The Journal of arthroplasty, 30(3), 439-443.
McCulloch, K., Litherland, G. J., & Rai, T. S. (2017). Cellular senescence in osteoarthritis pathology. Aging Cell, 16(2), 210-218.
Peffers, M. J., Balaskas, P., & Smagul, A. (2018). Osteoarthritis year in review 2017: genetics and epigenetics. Osteoarthritis and cartilage, 26(3), 304-311.
Rajamäki, T. J., Jämsen, E., Puolakka, P. A., Nevalainen, P. I., & Moilanen, T. (2015). Diabetes is associated with persistent pain after hip and knee replacement. Acta orthopaedica, 86(5), 586-593.
Salmond, S. W., & Echevarria, M. (2017). Healthcare transformation and changing roles for nursing. Orthopedic nursing, 36(1), 12.
Sazegari, M. A., Mirzaee, F., Bahramian, F., Zafarani, Z., & Aslani, H. (2017). Wound dehiscence after total knee arthroplasty. International journal of surgery case reports, 39, 196-198.
Tedesco, D., Gori, D., Desai, K. R., Asch, S., Carroll, I. R., Curtin, C., … & Hernandez-Boussard, T. (2017). Drug-free interventions to reduce pain or opioid consumption after total knee arthroplasty: a systematic review and meta-analysis. JAMA surgery, 152(10), e172872-e172872.
Wylde, V., Beswick, A., Bruce, J., Blom, A., Howells, N., & Gooberman-Hill, R. (2018). Chronic pain after total knee arthroplasty. EFORT open reviews, 3(8), 461-470.
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