Nursing care after a total knee replacement is very essential in promoting a speedy and safe recovery for a patient. In an attempt to replicate the knee’s natural ability to roll and glide as it bends by cutting away damaged bone and cartilage and replacing it with an artificial joint, acute pain following the procedure can be unbearable. In assisting the patient in controlling the pain would only guarantee the best recovery possible.
With pain control, the patient will be able to perform follow up care and exercises to the best of their ability and over 90% of patients who undergo a total knee replacement have good results with recovery and ability to resume performing normal daily activities and minimizing the risks of complications to the surgical site. Keywords: Pain management, encouragement, total knee replacement, arthritis, prosthetic Care of a Patient in Acute Pain from a Total Knee Replacement A common medical condition seen in many aspects of the medical field is arthritis.
Arthritis is the inflammation of a joint and the most common type of arthritis is osteoarthritis, also known as wear and tear. Pain from any medical condition or procedure can be very stressful to a patient and inhibit any recovery. Arthritis can be diagnosed by performing an x-ray to determine the extent of joint damage. Someone with arthritis of the knee usually has difficulty walking, climbing stairs and getting in and out of chairs. An orthopedic physician can recommend interventions.
The most common joint replacement surgical intervention to help control and alleviate chronic pain for a patient is a Total Knee Replacement, also known as arthroplasty. A total knee replacement is performed to relieve moderate or severe pain and restore function in severely diseased knee joints. This procedure is not performed until pain is no longer controlled with non-operative treatment such as weight loss, activity modification, anti-inflammatory medications, joint supplements and cortisone injections. It is also not performed frequently on younger patients due to the implant wearing out quickly.
An orthopedic physician would determine the type of prosthetic needed in order to achieve the most success. There are also modified implants to provide the best possible functioning with long lasting results such as partial knee, rotating knee, gender specific knee and custom knee. To perform the procedure, an orthopedic surgeon would administer general anesthesia, which means one is unconscious during operation, or spinal or epidural anesthesia in which a person is awake but cannot feel any pain from the waist down.
During the procedure, the knee is in a bent position to fully expose the joint surfaces. An incision of 6 to 10 inches (15-25cm) is made on the front of the knee. The kneecap is moved aside and damaged surfaces are cut away. The femur is cut to match the corresponding surface of the metal femoral component that is placed on the end of the femur and the tibia is prepared with a flat cut on top to fit the metal and plastic tibial component that is inserted into the bone so the femoral component will slide as the knee is bent.
If needed, the patella is cut flat and fitted with a plastic patella component and plastic spacers are inserted between the metal components for smooth gliding. Prior to completion, the knee is tested during surgery to ensure correct sizing and then closed with stitches or staples. The procedure would take 1 to 2 hours and recovery would be another 1 to 2 hours and then require a hospital stay of a couple of days. During the hospital stay, encouragement to move the foot and ankle to increase blood flow and prevent swelling or clots and blood thinners, support hoses or compression boots are very important.
A nurse should also encourage the patient to cough regularly and take deep breaths to promote the movement of mucus that settles in the lungs during the procedure while being under anesthesia. Caring for a patient in acute pain after a procedure and managing pain levels is a very important part of recovery. Without pain control a patient will not be able to achieve recovery levels as quickly as possible without causing other injuries. Acute pain is related to tissue injury secondary to the surgical intervention.
Upon discharge, teaching on follow up care is very important. A patient needs to know what to do and what to watch for as part of their recovery. Vital discharge instructions that a patient must be taught are: * When allowed to shower, usually 3 to 4 days after surgery, carefully wash incision with soap and water, rinse well and gently pat dry. Do no rub or apply creams. * Sit when showering to avoid falls. Avoid soaking to prevent infections. Try using non-slip mats, grab bars and elevated toilet seat or shower chair to prevent falls. Take pain medications as directed, do not double up doses if any doses are missed and do not drive when taking narcotics, usually about 6 weeks before it is ok to drive. * If taking a blood thinner, always verify with physician if it is ok to take Ibuprofen or any anti-inflammatory medications
* Always sit in chairs with arms to make it easier to stand or sit but only 30 to 45 minutes at a time. * Sleep with pillow under ankle and keep knee straight but change leg position at night and nap if tired but don’t stay in bed all day. Wear support stockings for about 4 to 6 weeks and do not pivot, twist or kneel. * Walk up and down stairs with support, one step at a time using good knee to step up and bad knee to step down. As a fall prevention, always remove loose wires, throw rugs and have good lighting and keep items within reach. * Before and after any activity, ice the area for 30 minutes. Most importantly, teaching about potential risks such as nerve damage, stroke, and heart attack, blood clots in leg vein or lungs or infection should really be emphasized when discussing discharge instructions.
Signs of infection would include increased redness, tenderness, swelling and pain of surgical site, stiffness, and fever with temperatures above 100 degrees Fahrenheit, shaking chills and drainage from site. If any of these symptoms occur, a call to the physician should be made immediately. Recovery will take several weeks during which time crutches or a walker will be needed and arrangements for transportation and everyday tasks will have to be made.
Physical activity should be resumed slowly with normal household activities, a graduated walking program and knee strengthening exercises until staples or stitches are removed 2 to 3 weeks after surgery. Low impact exercising such as swimming or riding a stationary bicycle is tolerable but high impact activities such as running are not recommended due to an increased risk of joint failure because the knee joint components can loosen. During recovery from the surgical intervention, a nurses care to help control acute pain for the patient is one of the most important factors in helping a patient fully recover without further complications.
Walking and knee movement begins soon after surgery so less pain would benefit the patient to move sooner and get strength back quickly. Pain control can be done with the use of analgesic and non-analgesic relief measures and reporting uncontrolled symptoms immediately. A nurse can assist with pain management interventions such as: * Performing comprehensive assessment of pain to include location, characteristics, onset, duration, frequency, quality, intensity or severity and precipitating factors. Always consider cultural differences and in non-verbal patient use the analog pain scale to evaluate pain control measures required * Reducing or eliminating increasing pain factors like fear or lack of knowledge * Teaching non pharmacological techniques like relaxation, massage, guided imagery and distraction
* Checking vitals every 4 hours and neurovascular checks every hour during the first 12 to 24 hours then every 2 to 4 hours and always report any abnormal findings * Providing prescribed analgesics before activity to increase participation and assessing levels of comfort frequently * Initiating physical therapy, exercises and range of motion while teaching and reinforcing the use of techniques to prevent weight bearing on affected extremity and recommending home health or a rehabilitation facility * Monitoring incision bleeding, emptying and recording drainage every 4 hours and changing dressing every 24 to 48 hours * Encouraging increased fluid intake and high fiber diet, stool softener and a well-balanced diet with increased protein * Encouraging use of compression stockings to decrease swelling. Nursing care of a patient is very crucial in order to help the patient avoid potential complications with the prosthetic. An infected knee would require surgery to remove artificial parts and antibiotics to kill the bacteria then after clearing the infection another surgery would be required to install a new prosthetic.
A nurse’s role in recovery is very important in many aspects of the patient’s care and the nurse can encourage and support the patient in building the confidence that they are able to perform the necessary steps to gain the ability to restore normal functions. Most importantly, helping the patient keep pain levels under control by whatever measures are comfortable to the patient should be first in mind. Pain can be the main factor that would prevent a patient from doing any follow care or treatment they are required to do in order to keep the prosthetic functioning adequately. The patient should be able to rely on the nurse to keep them in a comfortable state with the assistance of keeping in communication with the physician and without this patient-nurse relationship the patient would not be able to recover properly and achieve goals set as part of their recovery treatment plan.
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