Acute Care Nursing: Pain Assessment and Wound Care in Knee Replacement Surgery

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This article discusses the importance of pain assessment and wound care in knee replacement surgery. It highlights the nursing priorities and interventions for post-operative pain improvement and prevention of wound dehiscence. The article also emphasizes the role of nursing professionals in ensuring successful recovery from knee replacement surgery.

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ACUTE CARE NURSING 1
Contents
INTRODUCTION.....................................................................................................................................2
MAIN BODY...........................................................................................................................................2
PAIN ASSESSMENT.............................................................................................................................3
WOUND CARE....................................................................................................................................3
TWO NURSING PRIORITIES....................................................................................................................4
POST OPERATIVE PAIN IMPROVEMENT.............................................................................................4
POST-OPERATIVE WOUND DEHISCENCE............................................................................................5
NURSING INTERVENTION FOR WOUND DEHISCENCE IN PRESENT CASE...............................................5
GIBBS REFLECTION.................................................................................................................................7
Soumya Prakash Biswal

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ACUTE CARE NURSING 2
INTRODUCTION
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.
MAIN BODY
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
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ACUTE CARE NURSING 3
be addressed in assessment. The first assessment is pain relief and second assessment is
wound care.
PAIN ASSESSMENT
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).
WOUND CARE
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.
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ACUTE CARE NURSING 4
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).
TWO NURSING PRIORITIES
The two nursing priorities identified for the current patient includes – reducing pain
after one week of surgery and post-operative wound dehiscence.
POST OPERATIVE PAIN IMPROVEMENT
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

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ACUTE CARE NURSING 5
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).
POST-OPERATIVE WOUND DEHISCENCE
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).
.
NURSING INTERVENTION FOR WOUND DEHISCENCE
IN PRESENT CASE
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.
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ACUTE CARE NURSING 6
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.
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ACUTE CARE NURSING 7
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.
GIBBS REFLECTION
Case description
John Grant is a 63 year old patient scheduled for knee replacement surgery due to
osteoarthritis.
Feelings

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ACUTE CARE NURSING 8
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.
Recommendation
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.
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ACUTE CARE NURSING 9
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.
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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
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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:
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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.

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ACUTE CARE NURSING 11
Salmond, S. W., & Echevarria, M. (2017). Healthcare transformation and changing roles for
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Sazegari, M. A., Mirzaee, F., Bahramian, F., Zafarani, Z., & Aslani, H. (2017). Wound
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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
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Weeks, W. B., Schoellkopf, W. J., Ballard, D. J., Kaplan, G. S., James, B., & Weinstein, J. N.
(2017). Episode-of-care characteristics and costs for hip and knee replacement
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