Fred Brown is 72-year old and has been admitted for a right knee replacement.
He has had a history of COPD and depression.
Fred is a frail man and lives alone.
Fred has had his knee surgery today. Fred returned to the ward in the late evening around 2100.
He is being looked after by you, the nurse on night shift.
He has a PCA for pain management and IVI normal saline at 100mls/hour.
Fred’s sedation score has been 1 since his return from theatre. He has Oxygen running at 2L per min via nasal prongs.
He has a vacudrain implanted and a large bandage over his knee.
Task :1. Develop an appropriate nursing approach for the client in the scenario and include relevantassessment, potential problem / issue identification, and interventions(including monitoring) in the case outlined.
These actions should be based in nursing practice evidence and referenced appropriately.a.
Your discussionshould explain why these nursing actions are necessary.
You will need to draw on the literature to help you develop your nursing plans and explain why the proposed care is the best.
The care you provide must be prioritized. It should address both psychosocial and physical needs. Also, it should consider any co-morbidities.
This section is the most important part of your essay. It will be about the patient’s first 24 hours post-surgery.2.
Discuss Fred’s COPD with co-morbidity, and any potential complications that may arise post-operatively.
You should discuss any complications that may arise and the possibility of Fred becoming worse.
Your rationale for intervention and the nurse’s interventions to decrease the risk to the patient are included.3.
Discuss briefly the topic of discharge planning with patient.
Consider the following case scenarios.
Keep this section short.
Answer to Question: NUR2100 Episodes Of Nursing Practice
Introduction and Background
Knee replacement surgery is the procedure that replaces a worn, damaged or diseased part of the knee with an artificial joint.
Knee replacement surgery first became popular in the 1960s. Since then, many surgical techniques have improved.
The total knee replacement procedure has been the most successful in medicine.
The practice of total knee replacement is well-established for over 50 years. However, it was only thirty-five year ago that its complexities began to be appreciated.
The process of applying molds to the femoral cyles, which followed the same pattern as the hip, was used for the initial artificial implants.
The debate continues about whether knee ligaments must be preserved or can they be sacrificed.
Cemented total-knee replacements will be the official criteria for total arthroplasty (TKA), although promising midterm outcomes are being shown with uncemented designs featuring bioactive surfaces. (Cankaya, & Della Valle, 2016)
TKA is indicated by the relief of severe arthritis-related pain.
This means that the pain should not be unbearable.
If the knee problem causes clients to have a reduced quality of their lives, this should be taken into consideration.
Surgery is required to correct a deformity.
The replacement shows a predictable survival, which is negatively affected by the level and intensity of activity.
It is recommended for elderly patients with moderate activity.
Because the expected outcome is superior than patellectomy, severe patellofemoralarthritis rarely warrants the procedure.
If a client has mild arthritis and is experiencing flexing contracture (or valgus laxity), deformity could be an indication that he or she needs to have arthroplasty. (Dunbar, & Richardson, 2012)
TKA is contraindicated in absolute cases if there are severe vascular problems, sepsis at the knee, severe arthrodesis and extensor mechanism dysfunction.
A number of medical conditions can make it difficult to get anesthesia that is safe.
Some other contraindications include skin diseases, neuropathic arthritis, obesity, and history around the knee region. (Hanna Eskander, 2016)
According to anatomy, mobility at the knee joint is classified as having six levels. This includes three flexible translations as well three rotations.
The shape and condition of the articulating coating and the surfaces on the femur, tibia determine the movement.
The anterior and posterior cruciate lateral ligaments are the primary four-based linkage system.
The main function of medial collateral ligaments is to restrict the valgus movement and turning of knee joints. The second function is to regulate external rotation.
The anterior Cruciate ligament protects the distal and anterior displacements of the distal leg on the femur in the period that the knee tends be flexed. Thus, it controls the screw home mechanism of tibia extension.
Clients with degenerative disease of the knee are given some options for operative and efficient procedures during procedural planning.
Sometimes, arthroscopic comprehensive resection is necessary for mild joint diseases. These are those that have mechanical manifestations or persistent, steadfast swellings.
A proximal troibial valgus osteotomy can be done for clients who have medial or greater tibiofemoral compartment disease and a correctable varus in the knee area.
The distal foemoral varus osteotomy is also possible for patients suffering from lateral tibiofemoral cancer. (Hanssen, & Scott, 2012)
To prevent complications, clients undergoing TKA should have a comprehensive preoperative medical exam.
It is crucial to have the preoperative medical evaluation completed in a preadmission clinic prior the day.
Patients who are undergoing surgery need to have a strong functional cardiopulmonary system in order to manage anesthesia as well as the blood loss that may occur during the postoperative period.
A patient must be informed about the risks and potential complications of the procedure and should read the consent carefully.
Preoperative laboratory testing includes the urine investigation, culture, serum electrolytes and full blood count.
Urinalysis can be done to exclude the possibility of a urinary tract infection.
Imaging studies can include radiographic views, such as the patellofemoral and standing anteroposterior views, and the long leg radiographs. Also, there are standing X-rays/radiographs in which the knee is extended/flexed at 45 degrees. (Kane, 2013)
ECG is another preoperative test that can be used for clients with history of heart disease or older patients.
Other imaging modalities that may be of benefit for the assessment of severe bone loss or infection include computed tomography and the indium white cell (WBC), scanner, bone density, and magnetic resonance imaging. (Laskin, 2012)Equipment And Patient Preparation
There are several types of TKA prostheses: medial platforms, rotating platforms, fixed bearers and posterior cruciate ligament (PCL). The substituting PCL is also available.
The procedure can be performed even if the subject is already under general or local anesthesia.
The choice of anesthesia type is made after a discussion with both the patient (and the anesthetists) and some preoperative information by the surgical team.
The patient is placed on an operating table while being supine. After this, there is a preoperative scrub of the leg. (Lee, 2017)
Monitoring and Follow up
These follow-ups depend on the client and surgeon.
One example is a medical-surgical follow-up appointment after 4 weeks, 4 months, 8 months, 8 months and the subsequent years.
You can modify the treatment plan for each patient based on your age, complications, or level of activity.
TKA can usually restore significant knee function. Many patients may return to less contact sports activities.
Many studies have demonstrated a functional score, a 90-95% survival rate and a high level of functionality for prosthetics over 13-16 years.
There is no distinction between PCL retaining or substituting designs.
For cementless designs, a 95& prosthesis survival rates is observed at 11-13years. It does not have the exact same length of follow up. (Mostofi, & Shetty, 2012)Technique
To avoid contamination of the operation site, total knee arthroplasty occurs in a laminarflow operating surgical theater.
Antibiotics, antithrombotic prophylactic medicines and other medications are administered approximately 30-40 min before the incision is made.
The medial parapatellar approach is most commonly used to reach the knee joint. However, some surgeons may use the subvastus and lateral approaches.
Once the osteophytes have been removed, they are then rehabilitated with intra-articular soft tissus.
A sufficient amount of bone is removed to allow the prosthesis to be placed at the appropriate level and plane.
There is some contraction around and around your knee due to preoperative deformity.
They are then carefully released in a gradual, balanced manner around your knee. This allows for efficient knee kinematics. (Parvizi, & Klatt, 2011)
Post-Operative Health Care
The client will be monitored for up to 24 hours following the procedure.
It is crucial to get adequate pain relief through analgesia, and to hydrate properly during high levels of stress.
Analgesia can also be provided by an intraoperative epidural or oral analgesia.
Under the supervision and guidance of physiotherapists it is recommended that the patient perform continuous passive range of movement activities.
Drains are removed and the patient is directed to ambulate on the second day after surgery.
The wound heals in a satisfactory manner and the knee flexion is at least 85-90°.
(Shakespeare, Kinzel (2015)) The patient should be considered safe and supported in the home setting. There should be no complications.
Thromboembolism treatment should be continued at home and maintained for a certain period.
In general, the initial outpatient evaluation takes five to four months. After TKA surgery, approximately one third of all patients will need critical care services. (Rand, 2013)
TKA is not associated with a high mortality rate. However studies show that TKA can reduce the risk of death by reducing the number of preexisting diseases and increasing age.
For minimizing perioperative complications, optimization and early identification of these diseases are crucial.
TKA can cause complications such as infections, aseptic loosening, thromboembolism, and neurovascular and patellofemoral problems.
An additional complication that can occur following surgery is Arthrofibrosis. It is a condition where there is excessive scar tissue. (Schwarzkopf, Chin, Kim, Murphy, & Chen, 2017)
Current empirical studies do no provide clinical recommendations for the TKA outcome.
More information is needed to address the growing demand for discrimination in elective surgery.
The ideal research designs to answer questions concerning the indications for the surgeries are currently randomized trials. Individuals with advanced arthritis are usually randomly assigned to a particular medical management or joint repair.
Further research on the TKA effectiveness and client characteristics that lead to better outcomes is required. This will be done through observational studies. It will address many unanswered questions.
Refer toCankaya, D., & Della Valle, C. (2016).
The Revision Unicompartmental Knee Arthroplasty and Total Knee Arthroplasty has similar blood loss and transfusion rates to primary total knee arthroplasty. However, they are lower than the revision Total Knee Arthroplasty. The Journal Of Arthroplasty, 31(1), 339-341.doi.org/10.1016/j.arth.2015.08.002Dunbar, M., & Richardson, G. (2012).
Cemented Femoral Fixation, Back to the Future. Seminars In Arthroplasty, 23(3), 155-158.doi.org/10.1053/j.sart.2012.06.002Hanna Eskander, H. (2016).
Knee Surgery: Partial and Total Knee Replacement. Orthopedics And Rheumatology Open Access Journal, 3(4).doi.org/10.19080/oroaj.2016.03.555619Hanssen, A., & Scott, W. (2012).
Total knee replacement (1st Edition). Philadelphia, Pa.: Saunders.Kane, R. (2013).
Total knee replacement (1st Edition). Rockville, MD: U.S. Dept.
of Health and Human Services. Agency for Healthcare Research and Quality.Laskin, R. (2012).
Controversies surrounding total knee replacement (1st Edition).
Oxford University Press.Lee, G. (2017).
What’s New in Adult Reconstructive knee Surgery. The Journal Of Bone And Joint Surgery, 99(2), 164-174.doi.org/10.2106/jbjs.16.01124Mostofi, S., & Shetty, R. (2012).
Knee replacement 1st ed.
London: Orthopaedic Associates.Parvizi, J., & Klatt, B. (2011).
(2011). Thorofare, NJ: Slack.Rand, J. (2013).
(2013). Total knee replacement (1st edition).
New York: Raven Press.Schwarzkopf, R., Chin, G., Kim, K., Murphy, D., & Chen, A. (2017).
Is Conversion Total hip arthroplasty comparable to primary total hip arthroplasty in terms of results? The Journal Of Arthroplasty, 32(3), 862-871.doi.org/10.1016/j.arth.2016.08.036Shakespeare, D., & Kinzel, V. (2015).
Rehabilitation after total knee surgery.
The Knee12(3), 185-189.doi.org/10.1016/j.knee.2004.06.007