Nursing Case Study on Bilateral Knee Osteoarthritis

This nursing case study focuses on a 63-year-old patient diagnosed with bilateral knee osteoarthritis. It discusses the pathophysiology, risk factors, and post-operative care for knee replacement surgery. The study emphasizes the importance of pain management, wound care, and prevention of complications.

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Nursing case study
Knee replacement
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NURSING CASE STUDY 2
Contents
Contents......................................................................................................................................2
Introduction................................................................................................................................3
BODY........................................................................................................................................3
Conclusion..................................................................................................................................7
References..................................................................................................................................7

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Introduction
This case study is on63-year-old John Grant who has been diagnosed with bilateral
knee osteoarthritis. He has been experiencing progressive pain, predominantly in his right
knee. Since the pain is less responsive tothe counter pain medications (paracetamol 1g four
times daily) he has been consuming, his general practitioner (GP) recommended him for a
right total knee replacement followed by left knee replacement after complete recovery from
first operation.
Total knee replacement is a surgical procedure usually performed for osteoarthritis,
where a diseased knee joint is replaced with prosthetic knee. Osteoarthritis is defined as a
slowly progressing, degenerative joint condition characterized by deterioration of the joint’s
cartilage, inflammation of synovial tissue and weakness in tendon and muscle and this
breakdown of cartilage results in rubbing of bone against each other causing pain, stiffness
and immobility. When both knees are affected by osteoarthritis it is known as bilateral knee
osteoarthritis (Riddle & Stratford, 2013).
This essay will be describing the pathophysiology of bilateral knee osteoarthritis and
risk factors associated with it. Post-operative assessment undertaken by a Registered Nurse
(RN) will be discussed along with nursing care plan to help him recover from the surgery.
Body
Bilateral knee osteoarthritis, diagnosed in John has various risk factors associated
with it such as hypertension (HTN), type 2 diabetes (T2DM), hyperlipidemia, consumption of
alcohol, etc.John has a history of hyperlipidemia which refers to elevated cholesterol
accumulation. This lipid accumulationcan damage the efflux function of cartilage thereby
inducing osteoarthritis. Similarly, HTN results in narrowing of blood vessels and subchondral
ischemia, initiating cartilage degradation, hyperglycemia in T2DM has direct effect on
cartilage and subchondral bone. This erosion or degradation of cartilage can results in
synovial inflammation and production of proteases and proinflammatory cytokines leading to

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the progression of osteoarthritis (Yoshimura et al., 2012; Knapik, Pope, Orr, &
Schram,2018).
As John had a right total knee replacement surgery, he would require skilled nursing
care to completely recover from surgery and experience the benefits of his newly replaced
joint. During the initial postoperative period RN should ensure John is recovering from the
anesthetic effect through the early warning systems of observing the physiological signs such
as heart rate. Any abnormalities observed from the satisfactoryparameterswill be managed
with medical involvement. Pain relief is a major component as this will help him to mobilize
as soon as possible after the surgery. Since he has a history of HTN, depression and pain
therefore if not managed properly it can lead to physical and psychological complications
resulting in slow recovery from surgery (Duivenvoorden, et al, 2013). Considering John’s
age, unrelieved pain can also lead to respiratory complications such as lungs dysfunctions,
hypoxia, etc. RN should administer John with patient-controlled analgesia (PCA) or epidural
opiates for the first 24-48 hours following a step down method using paracetamol with
conventional non-steroidal anti-inflammatory drugs (NSAIDs) (Wylde, Bruce, Beswick,
Elvers, &Gooberman-Hill, 2013).
Another important component of post-operative assessment is the wound care. As per
the hospital policy, John is given proper timely dressing for faster healing. RN should prefer
dressing with semi-permeable film over the fabric adhesive dressing. Semi-permeable film
dressing will help in decreasing the frequency of post-operative skin blistering. This will also
help RN to visualize the wound without disturbing the dressing. If RN observes any sign of
drainage from the wound immediate medical intervention is involved to avoid the risk of
infection or hematoma formation in the joint space. If there is continuous purulent discharge
from the incision, chances of developing skin tract increases that can potentiate infection of
the wound. RN should also regularly check incision color, temperature, presence of
inflammation and loss of wound approximation which will provide evidence about the
healing process of the wound (Jones, Russell, & Huo, 2013; Scuderi, 2018).
In John’s case nursing care priority must be given to alleviate pain and prevent any
complication due to pain.Immediate post-operation will require pain medications prescribed
by the surgeon and PCA administered through IV. Cold therapy to the knee should also be

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given by RN to lessen pain or swelling. RN should monitor the pain intensity, location and
duration based on which they can adjust the dosage of medication. They should regularly
check the discharge from nerve catheter (if present). As John has a history of mild gastro-
esophageal reflux disease (GORD), angina, T2DM, HTN and others, effect of medication
dosage should be carefully observed. Proper positioning of the operated extremity should be
maintained as it would help in decreasing the muscle spasm and excessive pressure on the
new prosthesis and its adjoining tissues. RN should also investigate complains of unexpected,
severe pain, changes in joint mobility or restlessness etc. which can help them in early
recognition of developing problems, giving an opportunity for immediate medical
intervention and prevention from complication. Based on the above observations RN should
apply step down approach and transit medications from IV to oral as necessary. Moreover,
encouraging stress management techniques will help John improve his coping abilities in
managing the pain and discomfort (Specht, Kjaersgaard-Andersen,Kehlet, & Pedersen, 2015).
Nursing care priority should also be given for post-operative compartment syndrome.
It is a serious condition that occurs due to increase in interstitial pressure in closed fascial
compartments resulting in soft tissue necrosis, microvascular compromise and myoneuronal
function impairment. Early diagnosis and surgical decompression is required to release the
pressure in the affected fascial compartments. RN should be aware of the signs and
symptoms indicating to the development of the condition. They should regularly monitor
compartment pressure using devices such as fiberoptic transducer/ camino catheter. The limb
should be positioned so that it is not raised above the level of heart to reduce the chances of
ischaemia, similarly, constrictive bandages should be released to reduce the compartmental
pressure. If RN observes higher pressure in a compartment nearly about 30mmHg, immediate
decompression should be performed by open fasciotomy within 6 to 8 hours which can result
in a good prognosis. Delayed diagnosis leads to severe complications with infection,
contractures, amputation and in extreme conditions death. Therefore, RN should educate John
with the symptoms of the syndrome and ask him to immediately contact the hospital if any of
the symptoms is observed (Park et al., 2014).
Primary wound healing is very significant for the success of total knee replacement.
Wound dehiscence is a major wound healing problem that occur post knee replacement
surgery. As studied the main risk factors associated with post-operative wound healing

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complications are obesity and T2DM. Here in this case study John is known to have T2DM
and this can be a reason for his wound dehiscence. This increases the risk of the wound for
being invaded by pathogenic microorganisms following of which will arise many other
complications.
Nursing interventions are very important to prevent wound dehiscence. The single
most effective way to prevent the risk of infection is to promote proper hand washing by John
and the RN involved in his treatment. Next is to prevent contaminations by using aseptic
techniques and maintaining aseptic conditions when changing the incision dressings and
instruct John not to touch or scratch the incision. Further, care must be taken while using the
drainage devices placed near the operated knee. The drainage devices must be patentedwhich
makes them an authenticated device for use. This reduces the risk of wound complications by
preventing accumulation of blood and secretions in the joint compartments (site for bacterial
growth). RN must always observe the characteristics of wound drainage. If purulent, odorous
drainage is observed, it is indicative of infection. Similarly, continuous drainage from
incision suggests developing skin tract which further leads to wound dehiscence. RN should
check the incision color, temperature, presence of erythema/ inflammation, loss of wound
approximation to conclude about the healing status (Sazegari, Mirzaee, Bahramian, Zafarani,
&Aslani, 2017).
Pain is another indication for developing wound complications (Pope, et al, 2012), in
John’s case RN must carefully investigate the reports of increased incisional pain and
changes in pain characteristics. John must be encouraged to maintain nutritional and fluid
balance which will help in cellular regeneration and tissue healing. Further since he is
diabetic he must be placed in protective isolation which will reduce contact from the possible
sources of infection. Finally if any indication of infection is investigated, RN should
immediately administer antibiotics against the detected microorganism and prevent it from
complications.
Applying Gibb’s Reflective Cycle, John’s post-operative health concern can be
managed by being aware of his previous history of diseases and the complications that can
accompany it. RN must be aware of the wound care practices to bring about more effective
wound management. They need to be more observant of their patients’ wounds and increase

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their skills in nursing research which will help them in wound management. Further, RN
must give moral support to John and improve his confidence level that will help him manage
depression. Finally, when he’s discharged he should be imparted with necessary information
regarding medicines, medical appointments, home nursing and others (“Gibbs-Reflective
Cycle Model (1988)” 2016).
Conclusion
Overall, it can be summarized that John should be kept in observation during post-
operative period for quick and healthy recovery from the surgery. As he has a history of
various health issues utmost care should be taken to avoid any risk of infection. RN must
work efficiently with self-awareness and appropriate work practices. Moral support from his
RN and family members is also required to help him cope depression, creating a safe
environment for him and encouraging him to enjoy the benefits of newly replaced knee.
References
Duivenvoorden, T., Vissers, M. M., Verhaar, J. A. N., Busschbach, J. J. V., Gosens, T.,
Bloem, R. M., ... & Reijman, M. (2013). Anxiety and depressive symptoms before
and after total hip and knee arthroplasty: a prospective multicentre
study. Osteoarthritis and Cartilage, 21(12), 1834-1840.
Gibbs-Reflective Cycle Model (1988). (2016). Retrieved from
https://resources.eln.io/gibbs-reflective-cycle-model-1988/
Jones, R. E., Russell, R. D., &Huo, M. H. (2013). Wound healing in total joint
replacement. The bone & joint journal, 95(11_Supple_A), 144-147.

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Knapik, J. J., Pope, R., Orr, R., & Schram, B. (2018). Osteoarthritis: Pathophysiology,
Prevalence, Risk Factors, and Exercise for Reducing Pain and Disability. Journal of
special operations medicine: a peer reviewed journal for SOF medical
professionals, 18(3), 94-102.
Pope, E., Lara-Corrales, I., Mellerio, J., Martinez, A., Schultz, G., Burrell, R., ... &
Sibbald, G. (2012). A consensus approach to wound care in epidermolysis
bullosa. Journal of the American Academy of Dermatology, 67(5), 904-917.
Park, C. H., Lee, S. H., Kang, D. G., Cho, K. Y., Lee, S. H., & Kim, K. I. (2014).
Compartment Syndrome Following Total Knee Arthroplasty: Clinical Results of Late
Fasciotomy. Knee surgery & related research, 26(3), 177.
Riddle, D. L., & Stratford, P. W. (2013). Unilateral vs bilateral symptomatic knee
osteoarthritis: associations between pain intensity and
function. Rheumatology, 52(12), 2229-2237.
Scuderi, G. R. (2018). Avoiding postoperative wound complications in total joint
arthroplasty. The Journal of arthroplasty, 33(10), 3109-3112.
Specht, K., Kjaersgaard-Andersen, P., Kehlet, H., & Pedersen, B. D. (2015). Nursing in
fast-track total hip and knee arthroplasty: A retrospective study. International journal
of orthopaedic and trauma nursing, 19(3), 121-130.
Sazegari, M. A., Mirzaee, F., Bahramian, F., Zafarani, Z., &Aslani, H. (2017). Wound
dehiscence after total knee arthroplasty. International journal of surgery case reports, 39,
196-198.

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Wylde, V., Bruce, J., Beswick, A., Elvers, K., &Gooberman-Hill, R. (2013). Assessment
of chronic postsurgical pain after knee replacement: a systematic review. Arthritis care &
research, 65(11), 1795-1803.
Yoshimura, N., Muraki, S., Oka, H., Tanaka, S., Kawaguchi, H., Nakamura, K., &Akune,
T. (2012). Accumulation of metabolic risk factors such as overweight, hypertension,
dyslipidaemia, and impaired glucose tolerance raises the risk of occurrence and
progression of knee osteoarthritis: a 3-year follow-up of the ROAD study. Osteoarthritis
and Cartilage, 20(11), 1217-1226.