A Case Study of Post-Surgical Care: Total Knee Replacement

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Table of Contents
INTRODUCTION...........................................................................................................................................2
PART A.........................................................................................................................................................3
PRE-OPRATIVE ASSESSMENT...................................................................................................................3
POST OPERATIVE ASSESSMENT AND CARE..............................................................................................4
PART B.........................................................................................................................................................4
PART C.........................................................................................................................................................6
CONCLUSION...............................................................................................................................................7
REFERENCES................................................................................................................................................8
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INTRODUCTION
Nursing care plays a vital role in operative procedures (Parratte et al., 2010). Be it pre-operative or post-
operative conditions. Nursing interventions need to focus upon the principles of surgery, should know
about all the co-morbidities which the patient can face after surgery and assess and implement various
principles to prevent further clinical issues. The nursing interventions aimed at reducing the hospital
stay of the patients and also make it comfortable for them (Beswick et al., 2012).
The assignment will comprise of the clinical reasoning and also will provide a strategy for post-surgical
care of the patient. Apart from this the impact of co-morbidities on the health of the individual and the
effect of anesthesia on the recovery pattern of the patient. Later the discharge planning will be
discussed concerning the total knee replacement. The people who have undergone total knee
replacement follow a different protocol of discharge and so it is to be discussed in the following essay
(Parratte et al., 2010).
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PART A
Mr. Frank Wright is a 76-year-old man who is married and is a retired architect by profession. He has
two children and a wife who is suffering from dementia. Recently Mr. Wright has been admitted to the
hospital for a total knee replacement of his right leg.
Total knee replacement also known as total knee arthroplasty is a surgical procedure where the
individual’s knee is replaced by the artificial articulating surfaces (Beswick et al., 2012). The procedure is
done in people who are generally old-aged, obese, have last grade of osteoarthritis, etc ( Parratte et al.,
2010). Osteoarthritis is a condition where due to the process of aging osteophytes develop and damage
the articulating surfaces of the joint. Thus resulting in micro wear and tear of the joint and causing
immense pain on movements (Parratte et al., 2010). Patients complain of pain while walking from rest,
in the morning and while prolonged sitting. Severe cases show a history of locking of the knee joint in a
position (Parratte et al., 2010). These cases require operative procedures for the management of the
condition (Beswick et al., 2012).
Before the surgery, a pre-operative assessment of Mr. Wright was done to evaluate co-morbidities if
any. The assessment included a detailed study of the vital signs, all the blood tests, urine tests, medical
history, recent medications, social history, and family history to know whether the condition is genetic
or not.
PRE-OPERATIVE ASSESSMENT
The pre-operative assessment included following details- weight-92kgs, height- 170cm, blood pressure-
140/95 mmHg, heart rate-86 beats per minute, respiratory rate-18 breaths per minute,
temperature36.8, the study of urine was found- normal.
The patient was found to have hypercholesterolemia, hypertension, osteoporosis which affected both
the knees and hips and obstructive sleep apnea which was diagnosed recently in the sleep study
performed in Mach 2019.
Mr. Wright was addicted to smoking and used to smoke ten cigarettes a day. And sometimes used to
take alcohol also. Current medication Simvastatin 40mg nocte, Atenolol 50mg daily and Ranitidine
150mg BD.
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The familial history of Mr. Wright showed that his father died due to heart failure and mother died due
to pancreatic cancer. These details will help to plan out a proper plan of care for Mr. Wright and will also
help in preventing further postoperative complications.
After the surgery, Mr. Wright was kept under the intensive care unit from where he was shifted to the
ward at 11:00 pm where the night shift nurses looked after him further.
POSTOPERATIVE ASSESSMENT AND CARE
After shifting Mr. Wright to the ward the nurse who was on the night duty took charge of him and made
further post-operative assessments to monitor the condition of Mr. Wright. The post-operative
assessments made by the nurse in the first 24 hours were as follows:
Blood pressure was- 100/54, heart rate- 106, respiratory rate- 12 beats per minute, oxygen saturation-
95%, FiO2- 2 liters of oxygen via nasal prongs, the temperature measured under axilla-37.60C. The score
of sedation was found to be 1-2, vacudrain in situ- 50ml in a bag, estimated blood loss in operation
theatre was found to be- 200ml.
Medications which were to be given to Mr. Wright were Simvastatin 40mg nocte, regular paracetamol
IG QID, Captopril 50mgBD, Ranitidine 150mg BD, Aspirin 100mg, Morphine PCA 1 mg bolus: 5-minute
lockout, intravenous infusion sodium chloride 0.9% 100 ml/hour.
Apart from this the first 24 hours are critical and need to be managed properly such as- com feel, crepe
bandage which is to be de-bulked at day one. Apply cryotherapy as tolerated. Diet should be normal.
The patient should be made to wear stockings to prevent deep vein thrombosis. Aspirin is given 100 mg
daily to reduce pain.
PART B
Mr. Wright has co-morbidities such as- hypertension, hypercholesterolemia and sleep apnea. For this,
he might be prone to develop a risk of heart failure, myocardial infarction, and breathlessness. These
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three potential issues may cause harm to the life of Mr. Wright. Hypertension may result in heart failure
and may prove to be fatal for life if not treated on-spot (Randerath et al., 2009). Hypercholesterolemia is
the condition where the viscosity of blood increases thereby making clots in the vessels and leading to
myocardial infarction (Sachdeva et al., 2010). Obstructive sleep apnea is a condition where a person
stops breathing while in deep sleep thus leading to breathlessness and decreased concentration of
oxygen in the body (Randerath et al., 2009).
To have control of such conditions the nurse must keep an atrial defibrillator to give emergency
treatment in case of heart failure (Goodman et al., 2017). In the case of myocardial infarction, the blood-
thinning agents must be given so that the clot is dissolved quickly without causing much damage
(Mancia et al., 2013). And there must be a mechanical ventilator near the patient to provide first-aid
care in case of sleep apnea (Sachdeva et al., 2010).
The history of Mr. Wright showed some of his bad habits which might hinder the recovery process and
may lead to some co-morbidities. Mr. Wright was a chronic smoker and used to smoke around 10
cigarettes a day. And even sometimes he used to drink alcohol. Some researchers suggest that nicotine
in the cigarette increases the viscosity of blood thereby causing the chances of myocardial infarction
(Kaplan et al., 2010).
Hypercholesterolemia can hinder the process of healing of the tissues (Sachdeva et al., 2010).
Obstructive sleep apnea may worsen under general anesthesia and may block the respiratory passage
thereby blocking the pathway through the tongue. In such a condition when Mr. Wright is under the
sedation of anesthesia it I necessary that the nurse uses a tongue binder to keep the tongue over the
lower palette of the jaw (Strasinger et al., 2014). This will prevent falling off the tongue over the trachea
and thus will reduce the chance of obstructive sleep apnea (Madarevic et al., 2011).
If not taken care in the first 24 hours after the surgery Mr. Wright would deteriorate further and may
land up with fatal complications of the surgery. Hypertension needs to be monitored now and then in
the first 24 hours because the medications given post-operation might hinder with the rhythm of the
heart (Madarevic et al., 2011). The nurse must monitor the blood pressure in every two-hour (Strasinger
et al., 2014). The nurse must be well-oriented with all the devices and apparatuses which are in the
vicinity of the patient and must be vigilant enough towards the sirens and beeps of the monitors. If
anything goes wrong the machine gives signals which need to look upon immediately. Any emergency
needs to be dealt with immediately or should call the senior staff officers to take charge.
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PART C
The discharge planning of any patient includes the following points-
The evaluation is done by highly qualified personnel and in-charge (Gonçalves‐Bradley et al., 2016). The
discussion did within the patient and family members. Planning of where the patient will stay, the
environment and surroundings of the patient must be according to his condition. To determine whether
the family member is sufficient to take care of some health professional is needed to take care of the
latter. Referring the patient to some other institute or hospital if needed for further care and
management (Gonçalves Bradley et al., 2016). Last comes the arrangements where the locality of the‐
house setup of the patient is modified according to his/her condition. For instance, in the case of Mr.
Wright, the kitchen should be modified according to his height. The height of the toilet seat must be
modified to avoid discomfort. Installation of ramps and railings if he stays on higher floors.
Mr. Wright who has undergone surgery of right total knee replacement was kept under the surveillance
for 24 hours after the surgery and then was shifted to the general ward (Longstaff et al., 2009). Further
complaints and problems of Mr. Wright after the surgery are solved out here. Now when he is all fine he
is scheduled to meet his GP and ask further protocol, preventions, and precautions.
The GP prescribes all the required medication including the ones of hypertension and
hypercholesterolemia. Mr. Wright is instructed to follow a normal and regular diet with lots of protein,
calcium, and fiber in it (Hussain et al., 2014). This will aid in the speedy recovery and will keep the bowel
movement proper so that he feels light (Ambrogio et al.,2009). He is prescribed all the medications of
pain. This will help in his management of pain. If pain is not managed properly then it will disturb his
walking pattern and may confine him in his bed.
The surgery of the knee is made to make him walk without pain and to look after him and his wife who is
suffering from dementia (Shepperd et al., 2013). If pain is not managed appropriately, he won’t be able
to walk as desired and then will again lead a life which may be dependent on others (Shepperd et al.,
2013).
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Mr. Wright’s nurse has made his appointment before discharge with his GP where the GP will talk to him
and will counsel him on the social and psychological grounds. This will motivate him and will provide him
an urge to walk and recover soon (Ambrogio et al.,2009). Also, the OPD appointment with Dr.
McMeniman is made who will look after the surgery, stitches and further follow-ups of Mr. Wright.
Further, follow up will provide Mr. Wright information about how well he is doing and what all things
need to add on. Mr. Wright is advised to take sessions of physiotherapy which will help him regain his
lost strength and will provide him acquire correct movement pattern. He is also advised to exercise
regularly so that he does not get obese. Obesity may then again lead to damaging of the knee joint and
increasing pain (Shepperd et al., 2013).
CONCLUSION
The assignment includes all the nooks and corners of the total knee replacement. Mr. Wright a 76-year-
old man admitted to the hospital for knee replacement undergoes a thorough assessment by his nurse
pre-operatively. Then he was certified health and was posted for surgery. As soon as the surgery is over
he gets shifted to the ward where gain a post-operative assessment is made by his nurse and he is kept
under monitoring for 24 hours to rule out the complications of surgery. There were certain co-
morbidities with Mr. Wright due to which special care was required (Shepperd et al., 2013).
The nurse was vigilant enough towards the patient care and checked every minute detail of the patient’s
records to make sure that everything is going well. The discharge planning was done very well by
keeping in mind all the aspects of discharge such as- evaluation, discussion, planning, determining,
referrals and arrangements (Gonçalves‐Bradley et al., 2016). Thus the above-mentioned essay is helpful
in understanding and critically evaluating the recent researches in the context of total knee
replacement.
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REFERENCES
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mechanical axis alignment on the fifteen-year survival of modern, cemented total knee
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 Beswick, A. D., Wylde, V., Gooberman-Hill, R., Blom, A., & Dieppe, P. (2012). What proportion of
patients report long-term pain after total hip or knee replacement for osteoarthritis? A
systematic review of prospective studies in unselected patients. BMJ open, 2(1), e000435.
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(2014, February). Incidence of total knee and hip replacement for osteoarthritis in relation to
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Surgeons guideline for the perioperative management of antirheumatic medication in patients
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 Madarevic, T., Tudor, A., Sestan, B., Santic, V., Gulan, G., Prpic, T., & Ruzic, L. (2011).
Postoperative blood loss management in total knee arthroplasty: a comparison of four different
methods. Knee surgery, sports traumatology, arthroscopy, 19(6), 955-959.
 Adie, S., Kwan, A., Naylor, J. M., Harris, I. A., & Mittal, R. (2012). Cryotherapy following total knee
replacement. Cochrane Database of Systematic Reviews, (9).
 Ambrogio, C., Lowman, X., Kuo, M., Malo, J., Prasad, A. R., & Parthasarathy, S. (2009). Sleep and
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