Evidence-Based Nursing Care Plan: Mr. X, Post Knee Replacement

This report presents an evidence-based nursing care plan for a 72-year-old man, Mr. X, who underwent knee replacement surgery and is at high risk of developing pressure ulcers due to immobility and multiple comorbidities, including degenerative joint disease, cirrhosis, congestive heart failure, and COPD. The plan focuses on preventing pressure ulcers, managing pain, and improving the patient's overall well-being. It analyzes the patient's condition, risk factors such as reduced mobility, shear stress, malnutrition, and chronic illnesses, and discusses the pathophysiology of pressure ulcers. The care plan includes interventions such as maintaining aseptic techniques, monitoring skin integrity, providing adequate nutrition, promoting mobility, and preventing falls, all supported by evidence-based practices. The goal is to minimize the severity of pressure ulcers, reduce discomfort, and enhance the patient's health outcomes.

Running head: Nursing care plan
Nursing care plan
Name of the Student
Name of the University
Author Note

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Introduction
Medical workers are challenged to prevent skin damage to peri-operative surroundings
due to prolonged patient immobility, anesthesia impairments of the circulatory functions, and
many surgical populations' pre-existing conditions. These injuries can lead to prolonged
hospitalization, increased medical expenses and prolonged morbidity (Aygör et al. 2014). The
healthcare facility may also face financial and legal consequences for such injuries. Below is the
case-representation of an elderly individual who had undergone knee replacement surgery and
thus, had substantially diminished mobility and bound bed, as a consequence of which he was at
a growing risk of ulcers or bed sores (Coleman et al. 2013). The patient often has multiple
comorbidities and, as a consequence, there were several possible issues found in the individual,
in which bedsores are known to be the most probable issue found in the sense of the significant
health concerns of the individual. In a consequence, the ultimate aim of the nursing care program
is to minimize severity of pressure ulcers, alleviate discomfort and improve general wellbeing
patient. This paper will thus focus on developing evidence based nursing care plan for the old
patient as described in the case study.
Description
Case scenario:
Mr. X, a 72-year-old man with a history of serious left knee arthritis, was treated after a
severe fall and extreme discomfort in his right knee. His medical history included degenerative
joint disease of knees, cirrhosis, congestive heart failure (CHF), interstitial lung disease,
hypertension, atrial fibrillation, s / p pacemaker, and chronic obstructive pulmonary disease
(COPD) with home oxygen. He had current hospitalizations due to mechanical falls followed by

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severe pain in his knees. Upon diagnosis, the patient was admitted that he was an alcoholic and a
smoker was given the surgical alternative of knee replacement. Throughout his hospitalization,
he was given an intra-articular shot of cortisone to his knees and lidoderm patches was given for
pain control. The patient was instead given the surgical alternative of knee replacement. Mr. X
was reassessed by an orthopedic surgeon prior to proceed with the knee replacement surgery.
Preoperative assessment contained an echocardiogram, which revealed an ejection fraction of 40
per cent, and pulmonary function examinations, which indicated a mixture of restricting and
obstructive disorder, with a forced expiratory rate of 2.15 L in 1 second (FEV1). Its serum
albumin amount was < 3.5 g / dL. His advanced age, serum albumin levels, and background of
CHF and COPD put him in the high-risk surgical range. Mr. X was told of the risks but agreed to
continue with the procedure.
Although, the operation was successful, his mobility became restricted. He was on bed
and was unable to move because of the surgery that increased the risk of formation of pressure
ulcer or more commonly called bed sores. Pressure ulcers are common in bedridden elderly
people, particularly those over 65 years of age. Pressure ulcer treatment is especially challenging
for these people, since most of them will have various forms of comorbidities and poor
metabolism (Coleman et al. 2013). The healing cycle is often complex because there are a
variety of extrinsic and endogenous influences related to the production and healing of pressure
ulcers (Cremasco et al. 2013).
Therefore, the potential problem identified in this case scenario is the development of
pressure ulcers or bed sores. Pressure ulcers occur frequently in elderly persons, especially those
over the age of 65. Pressure ulcers are challenging to treat for these patients, as they may have
various kinds of chronic disorders and poor metabolism. The treatment method is often

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complicated because both external and internal influences lead to the production and treatment of
pressure ulcers. This paper will thus focus on developing evidence based nursing care plan for
the old patient as described in the case study above.
Analysis
As it is shown in the case representation, an old patient who has undergone knee
replacement surgery and thus, have a significantly reduced mobility and bed bound, as a result of
which he was at an increasing risk of pressure ulcers or bed sores. The patient also had various
comorbidities and therefore, there were a lot of potential problems identified in the patient, of
which bedsores are considered as the most potential problem identified considering the patient’s
severe health issues. Thus, the overall goal of the nursing care plan is to alleviate symptoms of
pressure ulcer, reduce pain and improve the patient’s overall health condition.
The potential problem identified in this case scenario is the growth of pressure ulcers or
bed sores. This is because the patient has reduced mobility and he is bedbound. Shear stress is
one of the main extrinsic influences in the production of bed sores. Pressure ulcers (PUs) are a
major global health problem (Agrawal and Chauhan 2012). A Pressure ulcer is a localized
damage affecting skin and/or underlying tissue, characteristically attributed to friction or strain
mixed with shear. Pressure Ulcer inflict significant patient discomfort, mentally, psychologically,
and generally impact the individual’s quality of life, and often position patients at elevated risk
of death. Moreover, PUs adds to a healthcare system economic strain. Pressure ulcers can
generally be divided into two different types of elements: external and intrinsic. The first is to
apply mechanical force to the skin and soft tissue over the bones; the latter affects the skin's and
vascular and lymph systems (Raju et al. 2015) (Shuk-Fan et al., 2016). Pressure ulcers often arise
as a function of the intrinsic causes of individuals with illness or serious health and impact older

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people in particular as their metabolic rate declines and the skin becomes more vulnerable.
Malnutrition is often a key element in the production of pressure ulcers. Inadequate protein and
sugar levels have proved to be separate risk factors. Furthermore, vitamin C deficiency or
minerals including zinc and other trace elements may cause the tissue to decay. In fact, people
with arterial illness, hypotension and diabetes are at elevated risk. In earlier studies, elevated skin
and body temperatures can raise suddenness and oxygen demand and render the skin more
vulnerable to degradation and infection (Saghaleini et al. 2018). The dry and growing skin often
reduces tissue's mechanical power resistance. In the other side, as demonstrated in the literature,
chances are higher that pressure ulcers may develop in moist skin than on dry skin. Maceration
of the epidermis quickly allows skin and tissue sloughs to split apart, and friction rises
(Posthauer et al. 2015).
The influence of the force of gravity on the human body implies that there would be
impact forces with the pillow, the wheelchair and other surfaces. There has been a reverse
parabola in time and strain, in which higher shear stress will cause strain harm in shorter time,
while lower shearing stress requires more time to destroy tissue. Immobilization that persists for
longer times leads to the development of pressure ulcers (Aygör et al 2014). Chronic long-term
illnesses expand the effective balance threshold to patients. Chronic illness that persists for a
prolonged period of time may support reduce strength and loss of weight, contributing to greater
exposure to pressure ulcer (Kruger et al 2013). Sarcopenia and fragility arise as metabolic
modifications at the molecular level as well as behavioral shifts marked by decreased muscle
mass, weight loss and physical inactivity. Frailty also leads in abuse, polypharmacy, illness,
geriatric disease, institutionalization and early death. In functionally impaired older population
many factors act synergistically together. Pathogenesis of Pressure Ulcer is an inflammatory and

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hormonal process that includes reduced immune protection, deteriorating blood filling and
degenerative changes. In order for older patients with co-morbidities to prevent development of
Pressure Ulcer functionally impaired a comprehensive approach is required (Briggs et al. 2015).
Disabilities and geriatric syndromes are different conditions that often occur in older
people who influence their daily life (food, clothing, transfer, walking etc) and their quality of
life (distress, pain, lonliness etc) they are also common in people with disabilities.
The patient underwent knee replacement surgery, therefore, he was at an increasing risk
of developed an ulcer with pressure since he was bed bound. He has numerous health disorders,
including degenerative joint disease of knees, cirrhosis, congestive heart failure (CHF),
interstitial lung disease, hypertension, atrial fibrillation, s / p pacemaker, and chronic obstructive
pulmonary disease (COPD). Based on previous research on intrinsic causes, the probability of
pressure ulcer formation is considered high. His appetite was low as he performed surgery and
was in pain, also, his food consumption was severely compromised. He is also a potential smoker
which enhances his risk of pressure ulcer (Nassaji, Askari and Ghorbani 2014). The balance was
still affected and the body was not healed from the surgery. Therefore, he could not turn by
himself. He did not transform himself, however. Nevertheless, inadequate pain control for the
bony prominent parts of his body of his body would potentially contribute to the production of
pressure ulcers (Briggs et al. 2015). Following the application of wound dressing of his surgery
area, cushions were used and repositioning every two hours was carried out to avoid lengthy
pressure on the wound and other bony areas for preventing further pressure ulcer development
(McInnes et al. 2018) (Moore and Webster 2018).
He was also given proper nutrition since a poor nutrition is a risk factor for pressure
ulcer. Proper diet is also one of the main influences in the progress of the treatment of pressure

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ulcer (Posthauer et al. 2015). Researchers also recorded the faster cure of pressure ulcers in
patients with a higher protein intake than in patients with a low caloric protein intake. Other
experiments have also shown that malnutrition raises the frequency of injury diseases, and
decreases collagen deposition and tensile strength throughout cure (LIU and DAI 2011).
Evidence based nursing care plan:
Health preparation and priorities for patients experiencing complete knee replacement
include the avoidance of injuries, the development of voluntary movement, the alleviation of
discomfort and the delivery of diagnostic, prognosis and medical data (Liddle et al. 2014). In
addition to that, the patient has also developed pressure ulcers. Thus, the nursing care plan must
also include the development and implementation of intervention strategies to prevent and
eradicate the potential problem ‘pressure ulcer’.
In order to improve or adjust the dressings and when treating drains, the nurse must use
stringent aseptic or clean techniques. The nurse must instruct patient not to touch incision or
scratch as it prevents contamination and the possibility of infection with wound which may
involve the removal of the prosthesis (Lentz and Luther 2017). The nurse must assess the color,
temperature, and integrity of the skin / incision and note the presence of erythema or
inflammation, approximation loss of wound. The nurse must provide information on the state of
the healing process, and inform health practitioner by detecting any early signs of infection, if
occur. It is also important to investigate indications of heightened incisional pain, changes in
pain products since deep, dull, pain in the operating area may signify a joint infection that
develops. In addition to that, the nurse must promote good protein roughage, fluid consumption
and maintains the liquid and dietary balance to facilitate tissue perfusion and to provide cellular
and tissue repair nutrients. As indicated, the nurse must administer antibiotics to avoid infection

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prophylactically after the first 24 hours of surgery (Norman et al. 2016) (Lee and Moorhead
2014).
Older patients are also at an increasing risk of fall if they want to perform daily activities
on their own (Phelan et al. 2015). Thus, the nurse must also prevent the risk of fall by taking
certain measures. The nurses must determine factors that raise the degree of fall risk. These
indicators help to identify treatments that the individual requires (Khor et al. 2014). Age, illness,
sensory and motor impairment, usage of pharmaceutical drugs and excessive use of mobility aids
are risk factors. The possibility of falling is raised for an individual who is inexperienced with
the positioning of furniture in an environment or who has inadequate house lighting. Thus, it is
required to evaluate the requirement for physical and occupational rehabilitation for patients
through the application of equipment strategies and assistance for transport and ambulatory
services (Sharif et al. 2018).
The patient is at an increasing risk for developing pressure ulcer. Therefore, it is
important to evaluate the nutrition status of the patient, including his weight, and the amount of
serum albumin. The albumin amount of a serious protein deficiency is below 2.5 g / dL. Patients
suffering from pressure ulcer tend to lose big amounts of protein in wound exudates and may
require anabolic species 4000 kcal per day or more. The patient must be evaluated for the
presence of clinical disease experience (i.e., diabetes mellitus, immune deficiency condition, and
systemic and/or cardiovascular condition) along with his poor nutrition, incontinence and
immobility that can increase the risk of pressure ulcer. In order to improve his skin integrity, he
must be given with some moisturizer and ointment so that the skin does not get dried that can
increase the risk of bed sores (Ebi, Hirko and Mijena, 2019).

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It is also important to include family members in the care plan of the patient. Proper
prevention of pressure ulcer includes ongoing risk assessments, taking casual considerations into
account, adopting preventive techniques and choosing suitable pressure reduction tools. If a
individual at risk for pressure injury is detected through an evaluation, prompt action will be
performed (Robineau et al. 2019). Carers and family members are an integral part of the care of
patients and help deter and handle Pressure ulcers by collaboration with the multidisciplinary
team. The possibility of pressure ulcer growth during the patient should be advised and
consequently information should be given to help them identify and lead to designing efficient
and appropriate preventive strategies. It is also important to assess the awareness and willingness
of the patient and caregiver or the families to receive treatment for local injuries. Since patients
are no longer in hospital before pressure ulcers have recovered, local wound treatment
requirements will continue for weeks to months at home. The family members or the caregivers
must be made educated on incontinence management (for example the use of ointments, use of
external catheters and pads) (Cano et al. 2015).
Problem area Nursing Interventions Rationale Evaluation
Knee Replacement
Surgery
Maintain injured joints in the
correct location and
orientation of the body while
in bed.
Provides for the stability
of the prosthesis and
reduces the possibility of
infection after healing
from anesthesia.
The patient’s risk of
injury will be
reduced.
Change on the un operated
side utilizing an appropriate
amount of staff and keeping
the working extremity in the
specified orientation.
This prevents hip
prosthesis from
dislocation and excessive
skin or tissue strain,
decreases the possibility
of tissue ischemia and/or
breakdown.
These risks will be
minimised.
Using strict aseptic or clean
procedures as suggested for
the strengthening or
adjustment of dressings and
for the handling of drains.
Prevents contamination
and the possibility of
wound infection, which
may include the removal
Risk of infection will
be reduced.

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Ask the patient to stop
rubbing or scraping the
incision.
of the prosthesis.
Pain management
due to surgery
Assess pain complaints (scale
0–10), period and location
and consider severity.
It offers details about
how interventions should
be focused and
controlled.
His pain will be
managed.
If required, add ice packs. It promotes
vasoconstriction in the
surgical field to avoid
leakage or tissue oedema
and decreases the
sensation of pain.
His pain will be
managed.
Pressure ulcers of
bed sores
Determine the age of the
individual and the general
skin condition.
Elderly people have a
lower elastic skin, lower
moisture, a lower padding
incidence and an
epidermis thinning, which
makes them more prone
to be affected.
His skin integrity can
be improved by
developing
appropriate
intervention.
Apply a vitamin-rich
emollient to the skin.
It will moisturize the
skin.
The risk of pressure
sores will be reduced.
Patient and family
education
Assess the awareness and
willingness of the patient and
caregiver or the families to
receive treatment for local
injuries.
This is because patients
are no longer in hospital
before pressure ulcers
have recovered, local
wound treatment
requirements will
continue for weeks to
months at home. Also,
the family members or
the caregivers must be
made educated on
incontinence management
(for example the use of
ointments, use of external
catheters and pads).
Patient’s overall
condition will be
improved.
Evaluation
Pressure ulcers are a type of skin-and underlying-tissue inflammation where the area of
the skin under constant pressure for an prolonged time, triggering ischaemia of the tissue, a loss

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of nutrients and a supply of oxygen to the tissue, and tissue necrosis. Perhaps the most fitting
description of the pressure ulcer is continuous pressure that contributes to distortion or distortion
to deformations. Severe ischaemic damage exists in any tissue induced by undue force (either
shear, tension, or a mixture). There are several causes that can lead to the formation of pressure
ulcers; however tissue ischaemia is the most specific route to ulceration. The tissues are capable
of holding a pressure of about 30-32 mm hg on the arterial side for just a brief period of time.
However as the strain rises just marginally beyond this capillary filling level, it induces
microcirculatory occlusion, which in effect starts a downward slide into ischaemia, ulceration
and tissue death. Pressure ulcers may form when a significant volume of pressure is added to the
region of the skin within a brief period of time (Boyko, Longaker and Yang 2018). These may
often arise as less energy is exerted over a prolonged period of time. The tissue distortion
happens either when the soft tissues are stretched and/or sheared between the skin and the
structure, such as a bed or a chair while the individual is seated or standing, or when it is forced
against the body, such as a brace, a prosthesis, a medical instrument or an elastic garment
(Bhattachary and Mishra 2015). As it can be seen in the case study, the patient is at a high risk of
pressure ulcer. Based on literatures, on the underlying factors, the risk of ulcer development of
pressure of the pressure here is known to be high. His appetite was poor, and his food intake was
also significantly impaired. Pressure ulcer growth, including certain disorders that lead to
immobillity, reduction and sensation loss, and even malnutrition, is highly influenced by risk
factors. Extrinsic risk factors include immobilizing on the spinal cord or table for a long period,
as well as poorly equipped human-tissue medical instruments. The possible occurrence of
pressure ulcers was also raised by inherent risk factors such as diabetes, obesity and smoking.
According to a report, because of a immobility mixture and decreased responsiveness, the

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community of people with spinal cord harm (25–66 percent) was more prone to develop a
pressure ulcer (Jaul et al. 2018).
Treatment of pressure ulcer needs a multidisciplinary approach. The paradigm for
multidisciplinary treatment of such complicated patients offers a strong degree of individualized
care from the start, with the importance of thorough preoperative consultation in the clinic being
relevant. In a patient's view, this provides a better appreciation about what is being performed
and gives flexibility to establish trust in the surgical team (Thomson et al. 2017). When actions
are made as a mutual partnership between the patient and various specialists, simple and
attainable goals may be set. A multidisciplinary team involving health professionals from a
various discipline including surgery, occupational therapy, physiotherapy, nutritionist, medicine
and other, provides more incentive to maintain and help the patient through stressful
postoperative program, contributing to better performance and fewer complications (Clarkson et
al. 2019).
References
Agrawal, K. and Chauhan, N., 2012. Pressure ulcers: Back to the basics. Indian Journal of
Plastic Surgery, 45(02), pp.244-254.
Aygör, H.E., Sahin, S., Sözen, E., Baydal, B., Aykar, F.S. and Akçiçek, F., 2014. Features of
pressure ulcers in hospitalized older adults. Advances in skin & wound care, 27(3), pp.122-126.
Bhattacharya, S. and Mishra, R.K., 2015. Pressure ulcers: current understanding and newer
modalities of treatment. Indian Journal of Plastic Surgery, 48(01), pp.004-016.