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

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Contents
INTRODUCTION.....................................................................................................................................1
PART A...................................................................................................................................................2
NURSING CARE PLAN.............................................................................................................................2
PART B...................................................................................................................................................4
POTENTIAL RISK DUE TO COMORBIDITIES.............................................................................................4
DISCHARGE PLANNING..........................................................................................................................6
CONCLUSION.........................................................................................................................................7
REFERENCES..........................................................................................................................................8
1

INTRODUCTION
The assignment is the description of a case of post-surgical care of a male patient 76
years old with total knee replacement surgery. The essay will focus on preparation of
a post-surgical care planning of the patient using Clinical reasoning cycle by Levett-
Jones (2009). The clinical reasoning cycle is the model for nurses to be used to
enhance the critical thinking and decision making abilities. It is a useful tool that is
used by the nurses in their practice to be able to evaluate the patient appropriately
and frame the patient centred care plan for the high quality care and adequate
support. The assignment illustrates the clinical issues that are identified by using this
cycle and how these issues will be addressed using proper nursing assessment and
interventions. The rationale for using each intervention will also be provided that
helps in providing evidence for the claims. The essay will also include the potential
understanding of the clinical issues and surgical procedure with the comorbidities
present. The assignment will also highlight the importance of discharge planning in
the provided case.
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PART A
NURSING CARE PLAN
Using the Clinical reasoning cycle here the nursing care plan for the patient post-
surgically is prepared. Clinical reasoning cycle has seven important components.
The stages are followed in order to evaluate the case of Mr Frank and prepare the
post-surgical nursing care plan with the aim to address the identified issues. These
seven stages includes considering the patient’s situation, gathering the cues,
process information, identify the issues, establish goals, plan action and evaluate the
outcomes.
The given case scenario is of a 76 years old male patient Frank who is suffering from
osteoarthritis with minimal joint function and is advised total knee replacement. Frank
has a wife who is suffering from dementia and he is the primary carer for her, he is a
retired architect with two grandchildren. Frank is treated for total knee replacement
and is now requiring a nursing assessment, monitoring and observation with an
appropriate care plan for further recovery and care.
The foremost important aspect of nursing practice is the assessment of physical and
psychological state of an individual. The vitals were recorded to evaluate the current
situation of the patient (Beard et al., 2015). The vitals after surgery were recorded
as- heart beat was high with 106 beats per minutes, blood pressure was reduced to
100/54 mmHg, the respiratory rate was reduced to 12 breath per minute and oxygen
saturation was 95%. The urine output was evaluated to analyse renal function and
the vaccudrain provided for secretion of wound site fluid accumulation was also
assessed for proper function. The current vital assessment reveals that due to the
effect of general anaesthesia and comorbidities the respiratory rate and blood
pressure may be decreased. As the patient is chronic hypertensive the monitoring of
the blood pressure is to be done on regular basis and the interventions should be
planned adequately.
The patient also has hypercholesterolemia that is regulated by administration of
statins. The administration of statins pre-operatively is advised to avoid post-surgical
complications of inflammation and delayed healing (Beard et al., 2015). Following
the clinical reasoning cycle it is identified that the current situation and condition
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indicated three most priority nursing issues that are required to be taken care of by
planning appropriate nursing care and management plan. These three identified
issues are 1. Acute post-surgical pain, 2. Risk of infalmmation, and 3. Fear of limited
function.
Nursing assessment is the foremost important criteria to enable the nurse to identify
the intensity of the issue and plan accordingly the treatment or management regime
for the issue. According to Thomazeau et al (2016), most of the cases after knee
replacement surgery experience acute pain and is a sensation of common
discomfort and soreness around the operated area. Acute pain can have
psychological impact on the mental status of the individual even. The assessment of
pain that needs to be undertaken here is through pain scale that helps in verbal
description and rating of pain on the scale by the patient. Pain scale is a proficient
tool to estimate the severity and intensity of the pain and nature of the pain that
helps in evaluating the management for the issue. Here the pain after knee
replacement should be managed by pharmacological as well as non-
pharmacological interventions. Schug et al (2016), stated that acute pain is a
common post-surgical complaint and is reported by 54% of the cases. The
pharmacological interventions for pain relief include administration of narcotics and
analgesics. Use of opioids and NSAIDS are the choice of treatment to manage the
post-operative pain. Lunn (2018), suggested NSAIDS and analgesics act long term
and adequately by inhibiting the pain mediators in the body and preventing post-
surgical pain after total knee replacement surgery. Authors suggest that use of these
drugs helps in managing the post-surgical pain that otherwise can deteriorate the
overall quality of life of the individual.
Non-pharmacological interventions include use of massage, ice packs, diversion
techniques, meditation, repositioning and complementary therapies. Iannitti et al
(2016), reported that use of these techniques are helpful in reducing the levels of
depression and anxiety in patient associated with pain that helps on affecting the
pain mediators in the body. The evidences also suggest that use of proper alignment
in knee surgery helps in proper drainage of wound fluid and releases the pressure.
The second priority identified is the risk of inflammation. Inflammation is a common
attribute after any surgical procedure. Langkilde et al (2017), indicated that
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inflammation is a part of osteoarthritis pathophysiology and the patient undergoing
total knee arthroplasty experienced reduced functions. Surgery induced marked
inflammatory responses in conjunction with the pre-existing inflammation of the joint
due to degenerative disease. The assessment of inflammation can be done by
viewing the wound and feeling of heaviness in leg. The nursing interventions for
addressing these issues include providing ice packs for reducing the inflammation at
the site of operation. Song et al (2016), suggested that the use of ice packs helps in
reducing post-operative pain as well as inflammation after total knee replacement
surgery. The mechanism of action includes reducing the blood flow around the
surgical wound that pose the major cause of inflammation due to tissue damage and
intentional surgical injury. Ravindhran et al (2019), also stated that ice packs are
most common source of cold compression that helps in reducing the inflammatory
cells to aggregate and enhance swelling at the surgical site. Use of NSAIDS and
non-inflammatory drugs are also indicated for relieving the inflammation after
surgery.
The third nursing issue identified is the fear of impaired function and depression due
to limited mobility. Usually after knee replacement surgery the muscle tone and
function of the individual with degenerative disease of joint reduces that can lead to
loss of function. This fear of not able to walk again can lead to severe fear and
anxiety in the patient’s mind that can lead to deterioration of quality of life. Impaired
function is a common symptom but it can be assessed and managed by use of
appropriate and timely rehabilitation exercises and physiotherapy. Use of continuous
mild exercises and walking aids will help empower the patient and simultaneously
the use of psychiatric help and counselling will help reducing the effects of anxiety
and fear.
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PART B
POTENTIAL RISK DUE TO COMORBIDITIES
Comorbid diseases are referred to chronic associated disorders that influence the
overall functioning of the body. The patient in given scenario is suffering from
hypertension, hypercholesterolemia, osteoarthritis, and obstructive sleep apnoea.
Collaboratively the patient also has habit of smoking 10 cigarettes per day that can
further complicate the surgical procedure.
Shorrock & Bakerly (2019), explained how the smoking can complicate the process
of general anaesthesia. Smoking results in deterioration of cardiac and respiratory
function of human body. About 40% of total surgical complications in smokers occur
due to smoking. The general anaesthesia agents react adversely during the
influence of smoking on the human organs and can cause high risk of pulmonary
mortality during or post-surgically. The agents used in general anaesthesia are
mainly associated with lowering the blood pressure and acting as a vasodilator as
well as also leads to reduced breathing. These effects can be enhanced due to
smoking and can cause reduced cardiac function and monitoring during surgery and
difficulty in monitoring the system that may result in major complications (Turan et
al., 2018).
Hypertension is another comorbid disease that is associated with various
complications during surgery. As discussed general anaesthesia agents are
responsible for the reduction of blood pressure but in hypertensive patient it can act
by resulting in adverse increase in blood pressure and heart rate during surgery that
can lead to cardiac arrest and death. Hypercholesterolemia is the disorder that
requires regulation of lipids in the body. Triglycerides and lipid regulation can be
regulated by use of statins that is indicated before and after surgery to reduce the
inflammatory effects and delayed healing.
Obstructive sleep apnoea is another comorbid disease associated with given case. It
is the disorder in which the throat muscles relax during sleep and result in
intermittent breaking of breathing that can lead to complications. During the impact of
general anaesthesia the agents work on reducing the breathing of the individual and
this can act as a trigger to enhance the OSA (Fouladpour et al., 2016). The
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complications may arise in form that the individual will have difficulty gaining
consciousness from the anaesthesia and also the inoperative complications can lead
to death. The interventions to avoid such complications include use of appropriate
assessment for oxygen saturation during inoperative and post-operative monitoring.
Indication of any changes in saturation or breathing should be followed by putting the
patient on ventilator that will help in preventing any further progress of OSA
(Fouladpour et al., 2016).
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PART C
DISCHARGE PLANNING
In nursing practice discharge planning holds a very important role where the
discharge of the patient after surgery and recovery is well planned and evaluated for
better care. The discharge planning is the process where different professionals
come together in association of the patient and his family to plan appropriate
discharge guidance that will help the patient and their family to follow adequate care
guidelines at home. In given case the doctor, nurse, clinical associate, care
assistant, patient, family, and other professionals were included during the discharge
planning (Mabire et al., 2015). The foremost important step in discharge planning is
evaluation of the patient for better recovery and stable health then only the expert
can sanction the discharge request. Opinion and evaluation of the social worker
during discharge is also important and results in better post-discharge planning.
Frank was evaluated and the results indicated appropriate stable recovery after the
surgery thus the discharge was planned. Discharge interview and counselling was
done for Frank and his family by the nurse that provided instructions for them for how
to take care of the surgical wound and the leg at home. The instructions regarding
do’s and don’ts were provided and the guidelines for medication to be administered
was provided. Referral to the rehabilitation centre was also made for further
enhancement of function after surgery.
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CONCLUSION
The given case of Mr Frank was evaluated using clinical reasoning cycle and the
post-surgical plan included the assessment and interventions for acute pain, risk of
inflammation and fear of reduced function. The nursing interventions were focused
on physical as well as psychological aspects that helped in delivery of adequate
quality care and better recovery. The risk of comorbidities associated with general
anaesthesia was also discussed and well monitored for better recovery in this case.
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REFERENCES
1. 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.
2. Langkilde, A., Jakobsen, T. L., Bandholm, T. Q., Eugen-Olsen, J., Blauenfeldt,
T., Petersen, J., & Andersen, O. (2017). Inflammation and post-operative
recovery in patients undergoing total knee arthroplasty-secondary analysis of
a randomized controlled trial. Osteoarthritis and cartilage, 25(8), 1265-1273.
3. 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
4. Lunn, T. H. (2018). Postoperative pain management in total hip and knee
replacement. Medical doctoral thesis (submitted Copenhagen University
October 2016).
5. 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.
6. Ravindhran, B., Rajan, S., Balachandran, G., & Mohan, L. N. (2019). Do Ice
Packs Reduce Postoperative Midline Incision Pain, NSAID or Narcotic Use?.
World journal of surgery, 1-7.
7. Shorrock, P., & Bakerly, N. (2019). Effects of smoking on health and
anaesthesia. Anaesthesia & Intensive Care Medicine.
8. Song, M., Sun, X., Tian, X., Zhang, X., Shi, T., Sun, R., & Dai, W. (2016).
Compressive cryotherapy versus cryotherapy alone in patients undergoing
knee surgery: a meta-analysis. Springerplus, 5(1), 1074.
9. Thomazeau, J., Rouquette, A., Martinez, V., Rabuel, C., Prince, N.,
Laplanche, J. L., ... & Lloret‐Linares, C. (2016). Acute pain Factors predictive
of post‐operative pain and opioid requirement in multimodal analgesia
following knee replacement. European Journal of Pain, 20(5), 822-832.
10. 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
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postoperative outcomes. European journal of anaesthesiology, 35(4), 256-
265.
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