Nursing Management of Mr. Wright After Total Knee Replacement Surgery

This paper focuses on the post-surgical recovery of Mr. Frank Wright, a 76-year-old man who underwent a total knee replacement (TKR). It is divided into three parts. The first part outlines the three priorities of nursing care during the first 24 hours after surgery, highlighting the clinical priority using the clinical reasoning cycle. The second part discusses the pathophysiology of smoking, hypertension, hypercholesterolemia, and obstructive sleep apnea (OSA) in delaying post-surgical recovery, along with nursing interventions. The third part elaborates on the discharge planning for the patient, including patient education and referrals to multidisciplinary teams like occupational therapists and dieticians. The paper emphasizes the importance of managing fluid volume, pain, and DVT, along with the assessment of vital parameters and addressing co-morbidities to improve overall health and well-being.

Running head: NURSING
Nursing
Name of the Student
Name of the University
Author Note

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Introduction
The following paper is will focus on the post surgical recovery of Mr Frank Wright, a
76-year old man who has undergone total knee replacement surgery (TKS) of this right knee.
The assignment is divided into three parts. The first part of the paper will focus on the three
priorities of nursing care during the first 24 hours after surgery. The highlighting the clinical
priority will be done with the help of the clinical reasoning cycle. The second part of the
assignment will highlight the pathophysiology underlying smoking, hypertension,
hypercholesterolemia and obstructive sleep apnoea (OSA) in delaying the post surgical
recovery like coping up with the condition of general anaesthesia and nursing interventions in
order to overcome those complications. Third part of the assignment will elaborate the
discharge planning for the patient.
Part A
Effective management of the fluid volume of the body
According to the case study, the estimated blood loss for Mr Wright is 200 ml and the
Vacudrain in-situ is 50 ml in the bag and thus indicating further blood loss post surgery.
Significant blood loss post surgery leads to the generation of the hypo-volemia. Hypo-
volemia increases the vulnerability of developing cardiogenic shock. Hyppovolemia is a
pathological condition where haemoglobin concentration in the blood drops below the normal
range due to extreme blood loss. Decrease in haemoglobin concentration within the body
decreases the oxygen saturation leading to breathing trouble of shortness of breath (Faverani
et al, 2014). Mr Wright was fitted with external supply of oxygen (2L through nasal prongs).
Under this condition, collaborative intervention will be crucial. The collaborative
interventions for the management of hypovolemia resulting from blood loss will be

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restoration of the blood volume by blood transfusion. It is the duty of the nursing professional
to match the blood group of the patient before initiation of the blood transmission.
Contaminated or mis-matched blood samples can give rise of anaphylactic medication (type 1
hypersensitivity reaction) leading of agglutination of the blood cells. The blood must be
stored under proper storage consideration and the blood transfusion guidelines must occur as
per the specification stated by the doctor. Documentation of the patients’ status like the
oxygen saturation level, fluid volume in the body and the blood pressure must be done in
order to estimate the prospective outcome of the intervention (El Ayadi et al., 2016).
Reduction in Pain
TKR surgery is associated with severe pain. Thus, in order to manage pain during
post-surgical condition, Mr Wright was administered different types of pain management
medication like Aspirin and morphine with PCA 1 mg bolus and 5 minutes lockout.
However, prolong use of the pain management medication can prove to be detrimental for the
patients who have hypertension or high blood pressure. Mr. Wright’s blood pressure during
post operative condition is 140/95 mm Hg (normal range: 120/80 mm Hg). Thus it would be
the duty of the nurse to strictly monitor the cardiac parameter like the heart rate, cardiac
output and blood pressure during the administration of the pain killers. The administration of
medication must be done by the nursing professionals by following six rights of medication
administration that is right client, right route, right drug, right dose and right time (Devereaux
et al., 2014). Apart from the pharmacological interventions, non-pharmacological
interventions must be used for the effective management of pain. The main non-
pharmacological intervention that will be suitable for Mr. Wright is cryo-therapy. The cryo-
therapy will be nurse initiated intervention that will include use of the cold pack in order to
reduce the temperature of the surface that is experiencing pain creating numbness and thus
reducing the sensation of pain. The cooling of the surface area of pain also increases the

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blood circulation of the affected area and thereby helping to reduce the pain further. In order
to evaluate the effectiveness of the pain management therapy the severity of the pain will be
measured with the help of the PQRST (provocative, quality, radiation, severity and temporal)
framework (Secrist et al., 2016).
Management of the DVT
Post operative instructions for the management of the deep-vein thrombosis (DVT)
for Mr Wright will include the use of TED stockings (Thrombo-Embolic Deterrent). Thus,
the prioritized nursing interventions for the management of the DVT are the proper selection
of the size and the length of the TED sticking. Additionally, under collaborative
interventions, correct dosage of anticoagulant must be administered (heparin) under the active
supervision of the doctors in order prevent unnecessary blood clot. This will be followed by
the mobilization and leg exercise under the collaborative partnership with the other member
of the multidisciplinary team like the physiotherapists in order to improve the blood
circulation at the calf muscle of the legs. Doppler test will be done in order to estimate the
severity of DVT (Büyükyılmaz, Şendir, Autar & Yazgan, 2015).
Part B
Peri-operative hypertension is common in majority of the cases of knee replacement
about the subjects who have previous history of hypertension (140/95 mm Hg). However, the
post surgical data of Mr Wright showed that he has low blood pressure (100/54 mm Hg) thus
increase in blood pressure is not a concern for Mr Wright. Mr Wright smokes 10 cigarettes
per day and has high blood cholesterol (hypercholesterolemia). The medication history of Mr
Wright has Simvastatin in order to lower the high cholesterol level. However, in order to
reduce the cholesterol level further, proper management of the diet must be done under the
active supervision of the multidisciplinary expert, trained dietician. Pharmacological and non-

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pharmacological management of cholesterol level in blood will help to decrease the
narrowing of the arteries and thus helping to control DVT (Montori, Brito & Ting, 2014).
Smoking might hamper the flow of the blood in the different parts of the part. Decrease flow
of the blood delays the process of wound healing and might increase the severity of DVT. It
also hampers the process of recovery from general anesthesia. Thus, nursing intervention will
include helping Mr Wright to combat the withdrawal symptoms of smoking with the help of
the music therapy or mindfulness based therapy (Scolaro, Schenker, Yannascoli, Baldwin,
Mehta & Ahn, 2014). OSA severity increases with body weight. Mr. Wright is 92 kilograms
in weight and 170 cms in height. OSA increases the cardiovascular threats among the patients
having hypertension and delays the process of post surgical recovery. I also hampers the
sleep at night creating insomnia. Lack of proper sleep at night creates mental distress leading
to delay in the recovery. Mr Wright must be given mild to moderate sleeping pills under the
active supervision of the doctors for ensuring sound sleep at night while monitoring the level
of oxygen saturation within the body with the help of the pulse oxymetry (. Additional
nursing assessment that must be undertaken in order to crosscheck the prognosis of the
patient will include ABCDE assessment (Airways, Breathing, Circulation, Disability and
Exposure) (Jordan, McSharry & Malhotra, 2014).
Part C
Discharge planning for Mr Wright will include patient education for the promotion of
healthy lifestyle interventions. Mr Wright is suffering from osteoporosis (hips and knees), he
is also over-weight and smokes 10 cigarettes per day. Thus awareness about the healthy
lifestyle intervention will focus on the education of the harmful effects of smoking, strategies
to fight against the withdrawal symptoms of smoking and proper maintenance of healthy diet
and regular practice of physical activity. Physical activity will not be feasible for Wright at

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present as he has underwent TKR surgery. Health education comes under the principle of the
participation and rights of the social justice theory (SJT). Health education helps in disease
awareness and thereby helping to increase patients’ participation in the care plan (Tuntland,
Aaslund, Espehaug, B., Førland & Kjeken, 2015).
The discharge planning of Mr Wright will include referrals to different members of
the multidisciplinary team like the occupational therapists. Occupational therapist helps to
reduce the chances of accidental falls among the older adults. Consultation with the
occupational therapists will be help full for Wright as he is prone to fall post surgery and his
wife who has dementia (Fraker, Kales, Blazek, Kavanagh & Gitlin, 2014). Additional allied
healthcare professionals include dietician for the effective management of the diet plan for
reducing body weight and high level of blood cholesterol. Referrals must also be done to the
social workers of the aged care from the non-government organisations in order to assist
Wright and his wife to accomplish the activities of healthy living (Tuntland, Aaslund,
Espehaug, Førland & Kjeken, 2015).
Conclusion
Thus from the above discussion, it can be conclude that the three main nursing
priorities for Wright during the post surgical condition include management of the wound,
blood loss and DVT. Additionally the nursing professional must document the vital
parameters of the patient by ABCDE assessment in order to effectively manage the
complications arising out of hypertension, high cholesterol, cigarette smoking and OSA. The
referral must be done to dietician, occupational therapists and social care professionals in
order to improve his overall health and well-being.

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