Collaborative Approach for Assessment, Planning and Care of Adult Patient with Total Knee Replacement Surgery

This essay critically appraises one collaborative approach implemented for the assessment, planning and care of an adult patient with total knee replacement surgery. It demonstrates the significance of observation data to inform clinical judgment and decision making process. It also provides a critical insight into the effectiveness of personal skills to enhance collaborative practice in clinical setting.

Running head: POST GRAD NURSING
Post grad nursing
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The purpose of the essay is to critically appraise one collaborative approach
implemented for the assessment, planning and care of an adult patient with total knee
replacement surgery. The essay is centred on the case scenario of a 65 year women
who had to undergo total knee replacement surgery because of pain in the knees and
diagnosis of osteoarthritis. The knowledge of bioscience is used to inform the rationale,
effectiveness of nursing intervention and team work strategies for the care of the
patient. With the use observation data of the patient, the essay demonstrates the
significance of such data to inform clinical judgment and decision making process. The
evaluation of skills used to prioritise clinical assessment and identify best evidence
based intervention to manage deterioration has been provided. It also provides a critical
insight into the effectiveness of personal skills to enhance collaborative practice in
clinical setting.
Team work in health care is defined as the process in which two or more people
interact with a common purpose and work together towards a common goal. It employs
the practice of team collaboration to deliver care (Frasier et al. 2017). Team
collaboration is the process of sharing work responsibility and working cooperatively to
engage in problem solving and decision making process for the care of patient (Barton
2009). Effective collaboration between medical staffs such as nurse, clinicians and other
health care professionals lead to improvement in decision making and nurse’s
satisfaction with job (Lancaster et al. 2015). Effective team is characterized by respect,
trust and collaboration and it has been shown to improve patient outcomes and reduce
adverse event. Effective team collaboration reduces extra workload (Bosch and Mansell
2015). Although collaboration is associated with many positive outcomes for nurse and
patient, however team collaboration is a complex process which is dependent on the
joint responsibility of the health care team (Irajpour et al. 2012). To make the most of
the contribution of diverse team members, inculcating good knowledge and values
related to collaborative practice among nurses and other medical staffs are essential. In
the context of surgical setting, teamwork is particularly important for a surgical team to
promote efficiency, quality of care and safety. As the anaesthesiology and surgical
department are in pressure to avoid negative outcomes during surgery, team

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collaboration significantly improves performance in a high risk environment (Frasier et
al. 2017).
The critical appraisal of the nursing assessment and care planning is being done
for Mrs. Foxton, a 65 year women, who had to undergo total knee replacement surgery.
A hypothetical name has been given to the client because of NMC’s ethical code of
conduct for nurses which mentions that respecting people’s right to privacy and
confidentiality is necessary for nurse (Nursing and Midwifery Council 2015). Mrs. Foxton
came to the emergency department following symptoms of pain in the knee joints and
difficulty in walking. The physical examination of the patient revealed poor knee joint
strength and knee cartridge wear as the main reason for such symptoms. Due to this
condition, Mrs. Foxton required to be operated for a total knee replacement.
Osteoarthritis and being overweight are the most common causes for a total knee
replacement surgery (Silverwood et al. 2015). Osteoarthritis is associated with symptom
of swollen joints, stiffness in the joints and deteriorating pain during joint movement and
Mrs. Foxton was also suffering from similar symptoms.
Osteoarthritis is a clinical condition most commonly found in elderly patients and
it is the major contributor of disability in the old care. Several other factors like weight,
previous knee trauma and obesity predicts the risk of developing knee osteoarthritis
(Leyland et al. 2016). Heidari (2015) argues that osteoarthritis develops because of the
interplay between systemic and local factors. Knee mal-alignment and mechanical
loading of the joint increase the risk of developing osteoarthritis. The onset and
progression of the condition is also influenced by production of leptin from the
osteopblast and chondrocytes cell. Leptin is one of the hormones released from fats
cells in adipose tissues. Leptin plays a role in the inflammatory response and this
indicates it’s contribution in the development of knee osteoarthritis (Yan et al 2018).
Vuolteenaho et al. (2012) has proved that high level of leptin is found in patients with
osteoarthritis compared to healthy patients. Along with leptins, cytokines, proteolytic
enzymes and biomechanical factors increases synovial inflammatory process and
disrupts the pathway that is needed to restore the integrity of the degraded matrix
(Heidari 2015). Hence, the main rationale for conducting TKR surgery for patients with

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osteoarthritis is that it significantly reduces pain and improves functioning of affected
patients.
Managing and planning care of the adult patient with acute and long term
conditions require updated knowledge and skills related to disease pathophysiology,
clinical management and care planning process. Clinical assessment is an important
process in nursing practice as it provides the guidance to plan appropriate evidence
based interventions for patients in the event of clinical deterioration (Lewis et al. 2016).
Before proceeding with the TKR surgery, clinical assessment of Mrs. Foxton was done
to identify signs of clinical deterioration, assess medical history and identify other signs
of complication. The main rational for examination of patient history is to identify any
medical problem in patient that needs to be corrected prior to the surgery (Zhu et al.
2015). The patient history data for Mrs. Foxton revealed hypertension and diabetes as
other existing health issues for patient. The importance of obtaining such data was that
it helped to identify pre-operative risk factors for the patient. Diabetes and hypertension
both are two conditions that can significantly affect recovery of patient and also increase
risk during surgery. In this circumstance, a nurse plays a role in assessment of all cause
and risk behind problem in patient. Regular assessment of such patient is important to
control any kind of deterioration and take the right clinical judgment for the health and
well-being of critically ill patients. Furthermore, transmission of this information to the
surgical team supports the team to engage in critical discussion regarding the best
treatment option for patient (Ignatavicius and Workman 2015).
Vaidya, Arora and Mathesul (2013) stated that deformities and activity limitation
due to osteoarthritis can compound diabetes and hypertension. The patient history
assessment process helped to take necessary precautions to reduce peri-operative risk
for Mrs. Foxton. For example, after examination of blood sugar level and BP value,
optimizing gylcaemic control became one major nursing care priority. This helped to
reduce the likelihood of joint infection and other complication after surgery. Godshaw et
al. (2018) argues that preoperative A1C levels predict postoperative glucose levels.
A1C level reflects blood sugar level over the past two or three months and this test
helps to diagnose diabetes and predict whether blood sugar level is in control or not.

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The evidence by Pruzansky et al. (2014) explains that patient data related to
preoperative medical history and laboratory results can help to identify modifiable risk
factors before total knee arthroplasty and reduce surgical site infections after knee
arthroplaasty. Hence, blood glucose level data help to implement necessary intervention
to control elevated sugar levels for Mrs. Foxton before undergoing total knee
replacement.
According to Yost et al. (2015), qualified nurse should have the right decision
making skills to effectively use patient’s information and provide safe and quality care.
The wider the experience and knowledge base of the nurse, the wider range of cues
they can collect to promote clinical decision making process. To collect other cues
affecting patient’s recovery, examination of vital signs, onset and duration of symptoms,
location and severity of pain and gait assessment for Mrs. Foxton was also prioritized.
The main rational for such assessment was to determine the severity of knee arthritis
and identify other clinical issues for patient. The Vital stats results showed BP of 140/90,
pulse rate of 120 beats per minute and respiratory rate of 20 breaths per minute. Gait of
patient was affected because of osteoarthritis and pain assessment revealed high
severity of pain. Hence, management of hypertension, diabetes and pain became a
priority as these were identified as major sign of deterioration for patient.
The nursing skills related to inter-professional collaboration played a major role in
prioritising intervention to manage clinical deterioration for Mrs. Foxter. After achieving
glycaemic control before surgery, management of pain was prioritized first in the
anaesthesia room to control adverse events during the surgery of patient in the theatre.
As a nurse, the most effective steps that is needed during the event of clinical
deterioration is to immediately report of any medical risk for patient to all involved
medical staffs (Mok et al. 2015). Surgical nurses share the assessment results with all
involved clinical staffs such as the clinician, surgeon and the anaesthetist. The team
huddle before the surgery made everyone aware about their role during the surgery and
the necessary pharmacological management process that would be necessary for Mrs.
Foxton. Collaboration and information transfer with the surgical team was important as it
made each member’s aware about care priorities and necessary interventions needed

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for the safety of the patient. In case of Mrs. Foxton, normal checklist was used to
transfer information to all staffs. Use of standardized communication through checklist,
proformas and technology facilitates inter-professional team to improve the information
transfer process and positively affect clinical and patient outcomes. This is supported by
the study by Pugel et al. (2015) which revealed that the WHO surgical safety checklist
can help to prevent communication failure during team collaboration and reduce
complications for patients. The checklist has the team briefing component and operating
room briefing significantly improves collaboration process among care providers.
The advantage of the collaborative approach of informing all team member’s
regarding surgical risk factor for Mrs. Foxton was that it helped to implement necessary
pharmacological intervention for the optimal management of patient. For Mrs. Foxton,
one of the priorities in the theatre was to maintain stable state of patient during the
surgery. As per the instruction of surgeon, the nurse had prepared the medications for
patient beforehand. Anaesthetic nurses experience in surgical setting help them to
administer medication efficiently without any errors. Shahrokhi, Ebrahimpour and
Ghodousi (2013) supports this by showing that inappropriate work environment and
insufficient nurse experience increase the chance of medication errors and having
experience nursing staff in surgical care minimizes the likelihood of medication errors.
Propofol was first provided for sedation and Nitrogen gas for maintain sedation. The
surgical nurse was very attentive to follow all instructions regarding medication
administrations and any allergies for the patient
To reduce pain, Fentanyl was provided to patient during the surgery. According
to the evidence by Fragemann et al. (2012), optimal care of patients suffering from
acute pain requires systematic and inter-professional collaboration between all team
members. However, challenges may be encountered when dependent relationship
exists between team members. This occurs because of hierarchical difference and lack
of suitable clinical practice environment for collaboration. Wilson et al. (2016) supported
this by stating that complexity and pace of clinical environment, hierarchical team
membership and disparities in understanding related to communication aspects creates
challenges in team collaboration process. However, these issues were not faced while

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collaborating with other medical staffs during the surgery because of good team work
culture and appropriate environment for charting and documenting patient’s information.
Such interventions could be implemented on time because of the team huddle before
the surgery. However, team huddle is discouraged by many surgeons because of
interruptions and delays in the surgery process. In contrast, the evidence by Jain et al.
(2015) revealed that daily preoperative huddle or briefing can significantly contribute to
safety benefits for surgeons by reducing number of delays. Instead of completely
discouraging the team huddle procedure in surgical setting, surgeons can look to adapt
tactics that can reduce the time involved in taking huddle for each case.
Throughout the care and management of Mrs. Foxton during the TKR surgery,
surgical checklist played a major role in cross checking items and ensuring safety of
patient. The role of the anaesthetic nurse is critical in the surgical team as they
administer medication to patient, inform patients regarding the use and side-effects of
medication and handover patient’s information to the ward nurses. They also play a role
in giving assurance to patient that they are their advocates and they are responsible for
the comfort and safety of patient. According to Choi (2015), nurse’s role during the
preoperative phase is that of advocacy, who identifies the patient’s needs and risk
factors that may affect surgical outcomes. Rutherford, Flin and Mitchell (2012) argue
that anaesthetists nurse assists anaesthetists and operating practitioners. They become
a part of the surgical team and they are one who prepares the patient for the surgery.
The surgical nurse role of informing patient about the purpose and outcome of surgery
and giving assurance regarding the safety of patient ensured that Mrs. Foxton was not
anxious while entering into the operating theatre.
During the collaboration process with the surgical team in the operating room, the
nurse used the checklist to refer to medications that could not be given to Foxton.
However, the nurse was disturbed when she realized that by the time she realized the
need to provide antibiotics to Foxton, the patient was already anesthetized. This created
some tension in the theatre room. At this point, I realized the flaws in the use of surgical
checklist while working as a team. Jain et al. (2015) argues that WHO safety checklist is
not relevant to be used in orthopaedic procedures. The author its use because the

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checklist is completed in superficial manner because of other urgent clinical work and
others express that many urgent actions surface at the wrong time. This might be a
reason that other team members were not using the checklist. My surgeon realized my
worries and gave a sign that the information from checklist would not affected surgical
outcome as all clinical priorities has already been decided during the huddle. Hence,
she proceeded with the other responsibilities during intra-operative care which was to
monitor patient’s vital signs, medication and follows orders of the surgeons and the
anaesthesiologist. The surgeon’s action is commendable as according to research
evidence, maintenance of correct environment in operating room along with care of
patient are the main goals of intra-operative care (Kravchenko 2017). The experience
also reveals the advantage of team huddle and surgical staffs understanding regarding
collaborative practice to improve the quality of surgical procedures in operating room
(Baik et al. 2018).
Apart from anaesthetist nurse, other team members who were coordinating with
the surgeon during the surgery included registered nurse, surgical technicians and s
scrub nurse. The circulating technique provided the surgical gown to the team and was
involved in delivering all supplies or equipment that was needed during the surgery. He
was also documenting the surgery. On the other hand, the registered acted as assistant
for the surgeon and assist them during the surgery. Among all the team members, the
anaesthetist nurse was the one who was unfamiliar part of the team as she joined
recently in the surgical team. This resulted in few delayed actions as the nurse missed
following all the steps needed to safely administer anaesthesia and monitor patient
during surgery. The anaesthetist nurse provided single analgesic although the team
followed multimodal analgesia technique. However, with the inspection of surgeon
regarding the role of each team member during the huddle, the surgeon corrected the
nurse and informed regarding the use of multimodal analgesia with the use of peripheral
nerve block, periarticular injection and analgesia. Turnbull et al. (2017) supported the
use of multimodal analgesia during surgery by explaining that it improve preoperative
pain and minimize the need for systemic narcotic consumption. This is also crucial for
speedy recovery of patient.

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The experience of the surgical team and the use of excellent team collaboration
skills favoured getting positive surgical outcomes for Mrs. Foxton. No abnormal blood
loss was observed during the surgery and fluctuations in vital sign were also well-
managed. The prompt response and action of the surgical team and the procedure
adopted to establish role clarity for individual members also enabled getting favourable
outcome for the patient. Maruthappu et al. (2016) supports the fact that cumulative
experience of the team members and familiarity with the team members promotes
operative efficiency. Team collaboration also helped to decrease operative time. Arana
et al. (2017) argues that inter-professional collaboration is not a new concept within
health care, however appropriate time allocation is necessary to engage in team
collaboration and improve the continuum of care. While implementing team meeting, it
is essential for the team to be flexible and have trust in each other’s role to effectively to
successfully manage any adverse events.
By the discussion related to critical appraisal of collaborative work practices
implemented during preoperative and peri-operative phase for a patient undergoing total
knee replacement surgery, it can be concluded that team collaboration is an important
pathway that enables surgical team to achieve positive outcomes and promote recovery
for patient. While providing care to Mrs. Foxton, nursing assessment skills and use of
observational data helped to prioritize care for patient before surgery. As the patient
was identified to be hypertensive and a patient with diabetes, important nursing
interventions were implemented in collaboration with the surgical team to prepare the
patient for the surgery. Secondly, the team huddle and the use of WHO safety checklist
favoured identifying specific treatment consideration for patient and take all steps to
avoid negative peri-operative outcomes. The process of establishing clarity, team
huddle before the surgery, transmission of vital patient information to the team at
regular intervals and the multi-disciplinary assessment process helped to minimize
negative surgical outcome for patient.

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