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

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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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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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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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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