Post-Surgical Care Plan for Total Knee Replacement: A Case Study

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Contents
INTRODUCTION.....................................................................................................................................1
PART A...................................................................................................................................................2
CLINICAL REASONING CYCLE.................................................................................................................2
NURSING CARE PLAN.............................................................................................................................2
PART B...................................................................................................................................................5
POTENTIAL CORRELATION WITH THE COMORBIDITIES.........................................................................5
PART C...................................................................................................................................................7
DISCHARGE PLANNING..........................................................................................................................7
CONCLUSION.........................................................................................................................................8
REFERENCES..........................................................................................................................................9
1

INTRODUCTION
A 76 years old male patient with osteoarthritis was presented to the hospital and
treated with total knee replacement surgery. The post-surgical care of the patient
was to be monitored and regulated as per the aim to address nursing issues. The
clinical reasoning cycle by Levett-Jones (2009), will be followed to enhance the
decision making ability and framework for the nurses and this model will allow the
framing of the post-surgical nursing care plan for the patient in the given scenario.
This assignment will be separated into three sections and each will provide a well
framed explanation of the case and the care planning and management of the
identified issues for the given patient. Clinical reasoning cycle is a well framed
guiding tool that helps in the delivery of the appropriate high quality care for the
patient. This cycle consists of a seven component or staged process which allows
easy evaluation and identification of the clinical issues as well as helps the nurse in
making appropriate decisions and plan for the post-surgical care of Mr Frank Wright.
The potential associations with comorbidities will be also discussed and the
discharge planning for the patient will also be explained.
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PART A
CLINICAL REASONING CYCLE
NURSING CARE PLAN
Clinical reasoning cycle has following seven components that are followed here to
device a post-surgical nursing care plan for the patient. These seven staged includes
1) Considering patient situation, 2) gathering the cues from the patient’s
presentation, 3) process the information, 4) identify the problem, 5) establish goals,
6) action plan, and 7) evaluate the outcomes (Levett-Jones., 2009). Considering
these stages the patient post and pre-operative data was evaluated and analysed as
well as the patient was examined for the current situation to develop the appropriate
care plan.
Frank is a 76 years old male patient who is treated for right leg total knee
arthroplasty and is shifted to the ward after the surgery for further recovery and care.
Frank has a wife who is suffering from dementia and is the primary carer for her; he
is married with two grandchildren and is a retired architect. The current situation of
the patient suggested that he is out from surgery and needs to be evaluated for the
vital signs and examination for any clinical issues requiring nursing interventions for
care.
The current vitals indicated following records- the patient is tachycardia with 106
beats per minute, blood pressure is reduced to 100/54 mmHg, the patient has very
low breath rate of 12 per minute and SaO2 saturation levels of 95%. These vitals
show that the patient requires continuous monitoring and regular interventions to
normalize the physiological functioning of the patient after surgery. The first 24 hours
after surgery are crucial as major complications can occur during these hours. The
urine output is evaluated to examine the normal renal function and respiration is
evaluated by monitoring the oxygen saturation and peripheral blood flow.
As the patient is hypertensive the medicines were indicated before surgery to avoid
any complication during the surgery as well as the cholesterol control was indicated
after and before the surgery to ensure better inflammation control and healing of the
wounds.
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The most priority based issues that are identified during the evaluation in this case
were identified to be 1) acute post-surgical pain, 2) risk for infection, and 3) impaired
physical functioning.
The interventions for these issues include physical as well as psychological
assessment, management and monitoring. Acute post-surgical pain according to
Schug et al (2016), is a common complaint and is experienced by around 41 to 57%
of patients undergoing total knee replacement surgery. The pain is acute in nature
but is severe and intense. The nursing interventions planned for the relief of this pain
for Mr Frank includes various strategies, the patient was provided pharmacological
interventions that include administration of narcotics and analgesics. According to
Golladay et al (2017), analgesics and oral administration of drugs after total knee
replacement surgery are proved to be highly beneficial in preventing and reducing
acute post-surgical pain. The authors suggested that these medications help in
inhibiting the pain mediators in the body. Pain is also related to the inflammation and
associated fear and anxiety. The intervention to prevent these aspects includes
complementary therapies such as massages, back rubs, reflexology, meditation and
repositioning of the patient. Iannitti et al (2016) suggested that the use of these non-
pharmacological interventions provide reduced anxiety and better pain relief.
Risk towards infection is another clinical issue that is identified in this case. As the
patient is hypertensive and has high cholesterol levels the healing process of the
body is low as well as the wound site infection is the common risk associated. The
assessment includes appropriate cleaning and inspection of wound regularly and
using of aseptic measures to prevent nosocomial infections. The nurse used a
vaccudrain to secrete the fluid accumulation at the wound site that is the most
feasible medium for growth of the bacteria.
Risk of impaired function is another common issue identified after knee artheroplasty
(Beard et al., 2015). The patient with osteoarthritis and joint degenerative disease
can easily undergo reduced muscle tone and impaired function due to joint
degeneration. After knee artheroplasty the normal function of the joint is to be
assessed by the nurse at a regular basis. Intervention for improving the joint function
includes prescribed exercises and physiotherapy. Henderson et al (2018), suggested
that active physiotherapy is highly beneficial in improving the functioning after total
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knee replacement and is usually implemented to enhance the working ability of the
person.
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PART B
POTENTIAL CORRELATION WITH THE COMORBIDITIES
Comorbid condition is the diseases and disorders that are interrelated and pose
effects on the functioning of different systems in the body. The patient in this case is
suffering from hypertension, hypercholesterolemia, osteoarthritis, obstructive sleep
apnoea and is also habitual to chronic smoking (Beard et al., 2015). These
conditions play a significant role in affecting the delivery of general anaesthesia
during surgery and its effects post-surgically too. The association of these
comorbidities with general anaesthesia are as follows- Pierre et al (2017), stated that
smoking is responsible for majority of post-surgical complications and about 40%
major surgical mortalities. Smoking reduces the functioning of cardiac and
respiratory system in the body that leads to impact of general anaesthesia on the
systems adversely. Hence, it is seen that in major cases the anaesthesia agents
react with body functioning in undesirable manner and cause pulmonary mortality
during or after surgery. It is indicated to cease smoking at-least 8 weeks before
surgery (Turan et al., 2018).
Hypertension being another concern while administrating general anaesthesia
agents. Meidert et al (2017), suggested that hypertension is a risk for administrating
general anaesthesia as the agents of GA can lower the blood pressure and result in
renal failure, myocardial infarction and stroke. The authors suggested how the
monitoring of BP during the surgery and after the surgery is very crucial for non-
complicated surgical outcomes. Similarly the blood pressure of Mr Frank was
reduced when estimated after surgery this can be the effect of general anaesthesia
agents and the interventions for improving these readings include proper positioning
of legs, diet enhancement and intravenous application of pharmacological
interventions.
Obstructive sleep apnoea is a condition where the muscles of throat are relaxed
during sleep and this causes intermittent disturbances in breathing and this can
leads to choking and death. General anaesthesia reduces the respiration rate to very
high level and this can present as a trigger for the Obstructive sleep apnoea.
Fouladpour et al (2016), illustrated that 46% of the perioperative cases of OSA when
not monitored appropriately intra-operatively and postoperatively resulted in major
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complications. To monitor the patient in this case regular monitoring of the oxygen
saturation is done and the breathing pattern is evaluated. In case the readings of the
assessment are not regular the patient should be put immediately on the ventilator to
avoid any complications. This condition also leads to complications while gaining
consciousness from the surgery.
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PART C
DISCHARGE PLANNING
Discharge planning is the process that is associated with the planning of the care
and services for the individual after proper evaluation and observation of treatment
(Rodakowski et al., 2017). When the patient is fit to be discharged from the hospital
the team of experts including nurse, doctors, therapists, professionals, social worker,
care assistant, family and patient involves in the evaluation and planning of the
discharge. Discharge planning is provided thorough attention in contemporary health
and social care (Mabire et al., 2015). This aspect holds a great deal in better
recovery and appropriate care of the patient post-surgically. After discharge the
person can be referred to other services or gets back to his resident where the
primary carer is the family members. In a knee replacement surgery it is essential to
evaluate all the possible aspects that the person is going through to be thorough with
the current health status of the patient. In given case Mr Frank was evaluated for his
physical, physiological, metabolic and psychological requirements. All the issues and
risk associated with comorbidities were well analysed before discharging him.
A team of professionals evaluated his current status and when perceived him fit to
be discharged filed his discharge documentation. There are several tasks that are
carried out during the discharge some of the crucial parameters includes discharge
interview and counselling for the patient and their family. During these sessions the
patient and their family members are instructed for the expected signs and care to be
included in their routine for better recovery. The discharge kit is also designed that
includes the list for medications, first aid, crepe bandages, ice slab, ointment, and list
for do’s and don’ts (Ulin et al., 2016). During discharge the patient is thoroughly
instructed to follow and adhere to medication regime and also include the referral for
rehabilitation where the physiotherapy would be stimulated for better functional
support and enhancement of the joint.
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CONCLUSION
Joint replacement surgeries are very common now-a-days. It is highly successful
with good prognosis and high success rate and is advised to the individuals with
osteoarthritis or joint degenerative diseases. In given case the patient was treated for
right knee replacement using knee arthroplasty that helps in revaluating better motor
functioning. The case was monitored appropriately and the post-surgical care plan
as per identified nursing and clinical issues were created for better delivery of
services and care. The assignment also highlighted the risk factors associated with
the chronic diseases and comorbidities present with the patient in this case and its
effect on the general anaesthesia. The association of smoking, hypertension and
obstructive sleep apnoea is well defined with the effects of general anaesthesia
during and after the surgery. The essay helps in understanding the in-depth
knowledge regarding the issues that may arise after knee replacement surgery and
how these issues can be addressed through nursing interventions with collaboration
of medicinal interventions. The last part of the assignment also portrayed the
importance of the discharge planning and its relevance in the nursing practice.
Hence, it can be concluded that proper nursing plan with well-prepared interventions
are essential for the better recovery post-surgically.
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REFERENCES
Levett-Jones, T., et al. (2009), The ‘five rights’ of clinical reasoning: An educational
model to enhance nursing students’ ability to identify and manage clinically ‘at risk’
patients. Nurse Education Today, 30 (6) 515-520. doi:10.1016/j.nedt.2009.10.020
Schug, S. A., Palmer, G. M., Scott, D. A., Halliwell, R., & Trinca, J. (2016). Acute
pain management: scientific evidence, 2015. Medical Journal of Australia, 204(8),
315-317.
Golladay, G. J., Balch, K. R., Dalury, D. F., Satpathy, J., & Jiranek, W. A. (2017).
Oral multimodal analgesia for total joint arthroplasty. The Journal of arthroplasty,
32(9), S69-S73.
Iannitti, T., Morales-Medina, J. C., Bellavite, P., Rottigni, V., & Palmieri, B. (2016).
Effectiveness and safety of Arnica montana in post-surgical setting, pain and
inflammation. American journal of therapeutics, 23(1), e184-e197.
Henderson, K. G., Wallis, J. A., & Snowdon, D. A. (2018). Active physiotherapy
interventions following total knee arthroplasty in the hospital and inpatient
rehabilitation settings: a systematic review and meta-analysis. Physiotherapy,
104(1), 25-35.
Pierre, S., Rivera, C., Le Maître, B., Ruppert, A. M., Bouaziz, H., Wirth, N., ... &
Martinet, Y. (2017). Guidelines on smoking management during the perioperative
period. Anaesthesia Critical Care & Pain Medicine, 36(3), 195-200.
Turan, A., Koyuncu, O., Egan, C., You, J., Ruetzler, K., Sessler, D. I., & Cywinski, J.
B. (2018). Effect of various durations of smoking cessation on postoperative
outcomes. European journal of anaesthesiology, 35(4), 256-265.
Meidert, A. S., Nold, J. S., Hornung, R., Paulus, A. C., Zwißler, B., & Czerner, S.
(2017). The impact of continuous non-invasive arterial blood pressure monitoring on
blood pressure stability during general anaesthesia in orthopaedic patients.
European journal of anaesthesiology, 34(11), 716-722.
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Fouladpour, N., Jesudoss, R., Bolden, N., Shaman, Z., & Auckley, D. (2016).
Perioperative complications in obstructive sleep apnea patients undergoing surgery:
a review of the legal literature. Anesthesia & Analgesia, 122(1), 145-151.
Beard, D. J., Harris, K., Dawson, J., Doll, H., Murray, D. W., Carr, A. J., & Price, A. J.
(2015). Meaningful changes for the Oxford hip and knee scores after joint
replacement surgery. Journal of clinical epidemiology, 68(1), 73-79.
Rodakowski, J., Rocco, P. B., Ortiz, M., Folb, B., Schulz, R., Morton, S. C., ... &
James III, A. E. (2017). Caregiver integration during discharge planning for older
adults to reduce resource use: A metaanalysis. Journal of the American Geriatrics
Society, 65(8), 1748-1755.
Mabire, C., Büla, C., Morin, D., & Goulet, C. (2015). Nursing discharge planning for
older medical inpatients in Switzerland: A cross-sectional study. Geriatric Nursing,
36(6), 451-457.
Ulin, K., Olsson, L. E., Wolf, A., & Ekman, I. (2016). Person-centred care–An
approach that improves the discharge process. European Journal of Cardiovascular
Nursing, 15(3), e19-e26.
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