Medical Surgical Nursing

Introduction to Post-Operative Care in Total Knee Replacement

According to Kim, Shin & Lee(2018), it is very important to monitor the patient after the surgery to ensure fast and successful recovery after the operation. It also helps in reducing hospital stays, reduce the postoperative mortality rates, provide quality care services, and few others. The post-operative care not only includes checking for vital signs of the patient but it also include checking for the dressings, pain assessments, post-anesthesia care team, and many others. In this essay, the following sections will discuss the post-operative care and related aspects of the patient named Gerald Jaworski, a 72 years old man. He has undergone a total knee replacement, had a history of benign prostatic hypertrophy, controlled hypertension, he has administered with a urinary catheter after surgery and prescribed with few medications – ural, ramipril, paracetamol, morphine infusion, and silodosin. Moreover, he has NaCl running at 85 ml/hr.

Patient’s Return to Ward Post-Operatively

There should be at least 2 care providers to support the patient’s head and feet while moving on bed. He should be monitored for important organs like respiratory rate, confusion, altered mental state, sepsis, the quantity of the urine and its color, and tachypnoea or hypotension. The patient should be provided with balance aids like a pillow, a walker, comfortable sleepover, ice packs, and setting of bed levels. He should never be left unattended or alone. He should be provided with liquid diet and after 24 hours a normal diet without spicy food. The patient should be assessed for swellings, and medication reactions if any, catheter hygiene, vital signs like temperature, blood pressure, and skin texture. There should be clear and effective communication with the patient to prevent chances of emotional distress. According to Lentz & Luther (2017), due to hypertension, there is a risk of high blood pressure related to cardiovascular problems, therefore, frequent monitoring of vital signs gives insight about unexpected or related health complications. Due to catheters there are chances of infection and a knee replacement patient cannot move effectively, therefore, hygiene should be maintained to prevent the risk of infections (Pietsch, David &Vergara et al., 2018). The timings of medication administrations should be fixed and scheduled and there should be family involvement as well. Moreover, it is found that there are chances of reoccurrence of prostatic hypertrophy again in the patient’s lifetime so the patient should also be monitored for it.

Patient Assessment and Documentation

According to Olthof, Stevens &Dijkstra et al. (2018), for a post-operative total knee replacement the patient should be assessed for pain including the intrinsic and extrinsic factors – instability, infection, malalignment, soft-tissue impingement, extensive mechanism problems, psychological disorder, stress fracture, and few others. The considerations for assessments include chances of severe pain, catheter infection, post-surgery issues of nausea, stress, abnormal ranges of vital signs, cognitive, behavioral issues and others. These assessments can be done and documented in subjective, objective, assessment, plan (SOAP) framework; and with the help of pain score scales, cognitive assessment tools, and catheter assessment tool can be used for documentation of the catheter-related issues. It is a medical documentation of the patient about his health status or health notes. The patient’s medication administration list should be updated and maintained and the administered medications should be either checked or encircled on the list and this prevents medication errors. The patient should be explained and informed about his medication and related procedures and written consent should be taken as well. It is the right of the patient either to accept or refuses the treatment care services to ensure patient-centered care. Other patient assessments that should be documented in ISBAR or patient’s medical record document are - pulse, wound condition, circulatory status, fluid-balance, level of consciousness, and few others. These assessments help in preventing the post-operative complications of bleeding, shock, urinary retention, wound complications, reaction to anesthesia, and few others (Pal, Chughtai& Sultan et al., 2017).

Two Complications and Management

The two complications are high blood pressure and the other is infection. The patient already had controlled hypertension that might increase or get out of control due to surgery or in post-operative periods, leading to various complications. The patient has a catheter for urinary discharge that might cat as an infection complication. According to Gröndahl, Muurinen&Katajisto et al. (2019), it is found that hypertension is also one of the side effects of surgery that result in poor oxygen supply to the body and an increase in blood pressure. However, it can be managed with the help of low salt in a healthy diet, enough good sleep, medications like thiazide diuretics, loop diuretics, potassium-sparing diuretics, and few others. According to Richards, Hilli&Pentecost et al. (2018), the use of urinary catheters can lead to complications like an infection in the kidney, urinary bladder, urinary tract, and other related complications. These can be managed with the help of avoiding regular replacement of catheter, using 0.5 % chlorhexidine skin preparation for alcohol, maintaining aseptic and sterile conditions, employing educated and trained care providers for catheter management.The catheter not only causes in-site infections but it can also lead to ex-site complications like tenderness, indurations, erythema, mucosal irritation, bacterial adhesion, and purulent discharge. According to Shin & Lee(2018), the nurse should frequently monitor and assess the patient for the complications and report the senior doctors if any progress or deterioration in the health status is observed. As the nurses cannot prescribe the medication to the patient but can ensure that medications are timely taken and storage and disposal are proper. Moreover, the nurse should ensure that there is effective communication among patients and health professionals for the prevention of complications or effective transfer of information about the patient’s health. This is so because high blood pressure can lead to hypertension and hypertension can further lead to dementia, metabolic syndrome, heart failure, heart attack, thickening of blood vessels, and many others. With the help of effective management and nursing care, the complications can be prevented. Moreover, due to anesthesia, there can be damage to cardiovascular systems, pain, nausea, vomiting, and respiratory issues that can be managed effectively with effective multidisciplinary team involvement (Yajnik, Hill&Hunter et al., 2019). According to Berthelsen&Frederiksen(2017), there are few general complications that are faced by the knee replacement patient. These are as follows: persistent pain, stiffness, swelling, deep venous thrombosis, bleeding, wound healing issues, fever, shaking chills, blood clots, infection, and many others. The ranges of complications that are reported after total knee replacement surgery are in the range of 1.65 % to 11.3 % only.

Patient Education

The patient and their family members should be educated about the medical procedure; they should be educated about the unexpected signs and symptoms like unbearable pain, swelling, and others. They should be educated and trained about how to use catheter and hygiene maintenance with the catheter. The family members should be asked to help or assist the patent in his daily physical and other household activities until the complete recovery of the patient. The patient should be educated not to involve in habits of smoking, drinking, and have a healthy diet and exercises as recommend by the physiotherapist for knee recovery. The patient and family members should be asked to make the patient take his medications on time, visit the doctor for regular check-ups, and visit the physiotherapist for knee sessions. The patient and family members should be educated about the importance of frequent checking of vitals and self-management. The patient should be advised to use loose clothing and the patient should be provided with support stockings (Kennedy, Wainwright&Pereira et al., 2017). According to Kennedyet al. (2017), the patient should be asked to use support while going upstairs or downstairs, maintain a healthy weight, no skipping of meals and medicines, do not use cream or lotion in incisions, and few other precautions. The patient may be provided with alert systems as he is an old man so that he does not forget about his medications.

Conclusion on Post-Operative Care in Total Knee Replacement

The patient with total knee replacement suffers from various complications like pain, redness, swelling, and a few others. It is also found that due to surgery the patient might face some health issues like high blood pressure, nausea, vomiting, stress, depression, respiratory, physical problems, and few others. However, if the nursing care and management are effective then the complications can be effectively managed. It should be ensured by the nurse that she/she frequently monitor the patient for the health status and inform the senior doctors about the same. The nurse should also ensure the involvement of a multidisciplinary team and perform effective communication with the patient and family members to educate and train them about the care and treatment plans. The patient should be educated to frequently monitor his vitals and health status. Moreover, there should be an encouragement for self-management as well for effective recovery and long term care services. Thus, nurses are found to play a very important role in delivering safe and effective care to the patient in the post-operative period.

References for Post-Operative Care in Total Knee Replacement

Berthelsen, C. B., &Frederiksen, K. (2017). Orchestrating care through the fast-track perspective: Orthopaedic nurses’ perceptions and experiences of providing individualised nursing care in older patients’ standardised fast-track programmes after total hip or knee replacement. International Journal of Orthopaedic and Trauma Nursing24, 40-49.DOI:10.1016/j.ijotn.2016.04.006

Gröndahl, W., Muurinen, H., Katajisto, J., Suhonen, R., &Leino-Kilpi, H. (2019). Perceived quality of nursing care and patient education: A cross-sectional study of hospitalised surgical patients. BMJ Open9(4), e023108.DOI:10.1136/bmjopen-2018-023108

Kennedy, D., Wainwright, A., Pereira, L., Robarts, S., Dickson, P., Christian, J., & Webster, F. (2017). A qualitative study of patient education needs for hip and knee replacement. BMC Musculoskeletal Disorders18(1), 413. DOI: 10.1186/s12891-017-1769-9

Kim, J., Shin, S., & Lee, M. (2018).Changes in clinical practice environment of nursing students due to comprehensive nursing care services. Journal of Public Health Nursing32(2), 221-234. DOI:10.5932/JKPHN.2018.32.2.221

Lentz, S., & Luther, B. (2017).Nursing care management. Orthopaedic Nursing36(1), 28-33.DOI:10.1097/NOR.0000000000000309

Olthof, M., Stevens, M., Dijkstra, B., Bulstra, S. K., & Van Den Akker-Scheek, I. (2018).Actual and perceived nursing workload and the complexity of patients with total hip arthroplasty. Applied Nursing Research39, 195-199.DOI:10.1016/j.apnr.2017.11.023

Pal, S., Chughtai, M., Sultan, A. A., Khlopas, A., Sodhi, N., George, N. E., &Bhave, A. (2017). Impact of neuromuscular electrical stimulation (NMES) on 90-day episode costs and post-acute care utilization in total knee replacement patients with disuse atrophy. Surgical Technology International31, 384-388. Retrieved from: https://europepmc.org/article/med/29316600

Pietsch, T., David, J., &Vergara, F. (2018).integrative review for patients with bilateral total knee replacement: A call for nursing practice guidelines. Orthopaedic Nursing37(4), 237-243.DOI:10.1097/NOR.0000000000000465

Richards, D. A., Hilli, A., Pentecost, C., Goodwin, V. A., & Frost, J. (2018). Fundamental nursing care: A systematic review of the evidence on the effect of nursing care interventions for nutrition, elimination, mobility and hygiene. Journal of Clinical Nursing27(11-12), 2179-2188.DOI:10.1111/jocn.14150

Shin, Y. S., & Lee, Y. H. (2018).The effects of an early knee joint exercise education program on pain, knee range of motion, and satisfaction in patients after undergoing total knee replacement arthroplasty. Journal of Clinical Nursing Research24(3), 283-292. DOI:10.22650/JKCNR.2018.24.3.283

Yajnik, M., Hill, J. N., Hunter, O. O., Howard, S. K., Kim, T. E., Harrison, T. K., & Mariano, E. R. (2019). Patient education and engagement in postoperative pain management decreases opioid use following knee replacement surgery. Patient Education and Counseling102(2), 383-387. DOI: 10.1016/j.pec.2018.09.001

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