A total knee replacement surgery as defined by Long & Scuderi, (2011) is an operation entailing removal of an extensively damaged knee joint and insertion of an artificial knee. In most cases, candidates for this surgery usually have an underlying pathology such as wearing off of the knee articular surfaces that leads to knee pain which is usually increasing and progressive, crepitus during movement, knee swelling and ultimately restriction to joint movement. All these, being pathognomonic of osteoarthritis. Patients usually recover well without significant complications and resume total knee function, eventually following proper nursing care and absence of co-morbidities.
More importantly, nurse to assess, monitor, and provide quality preventative measures to prevent occurrences of complications arising post-operative. This is achieved by using a comprehensive nursing care plan together with applying the clinical reasoning cycle to detect, evaluate, and intervene in any clinical issues which might be of importance in the recovery of the patient.
Part A: Care Plan
Vitals are necessary to keep track of and should include Blood pressure, temperature, heart rate, pulse rate, and respiratory rate. These help determine the stability of the patient and detect potential complication in the post-anesthetic period. In Frank’s case, there is a possible increased heart rate and blood pressure due to his smoking habit, which raises the peripheral vascular resistance and lowers gaseous exchange and alveolar level and the co-morbidity of hypertension. Hypothermia is also a possible issue as in many post-operative patients. The nurse should provide warm blankets or administer warm of I.V fluids if he/she detects hypothermia. Administering oxygen via a nasopharyngeal tube or nasal prongs will help minimize the risk caused by the cardiovascular compensation’s mechanism of low oxygen levels. (Kyriacos, Jelsma, & Jordan, 2011, p.36)
Airway, Breathing, and Circulation
Considering that Frank is known to have obstructive sleep apnea, there is a great need to give attention to his airway. Chances are he will develop airway obstruction in the first few hours in his unconscious state. If left uncorrected, this might lead to respiratory distress and hypoxia. The airway needs to be maintained patent by either a nasogastric tube or jaw thrust maneuver. Obstructive sleep apnea makes the muscles of the pharynx to relax hence blocking the airway which can be exacerbated by anesthesia. Slow I.V salbutamol, a beta-2 blocker and inhaled ipratropium bromide act against bronchoconstriction (Lauri Paavolainen 2016)
Besides, the nurse should assess for maximum chest expansion, any use of accessory muscles while breathing, feeling the flow of air right below the nose and listening by auscultation for breath sounds. If breathing is compromised, possibilities of developing hypoxemia and increased blood pressure and heart rate are likely. Ventilators should be employed in such a scenario while investigations are underway to determine the cause.
Furthermore, the circulatory status of the patient has to be assessed by checking the pulse, pallor, capillary refill, temperature gradient in the extremities and auscultation of heart sounds. The compromised circulatory system leads to hypoperfusion of the tissues and if not corrected organ failure sets in. (Duke, 2016, p. 721)
Franks urinalysis results are typical although, despite that, an input-output chart with the guidance of a catheter and urine bag for monitoring functioning of the kidneys should be used, and the patient checked for any signs or bladder distention if a catheter is absent and the nurse should take the urine collected for lab analysis to detect any infections. Acute kidney injury may occur if the patient has lost a substantial amount of blood during the surgery, which might lead to increased blood pressure and eventually end-organ damage. I.V fluids should be used to correct shock and electrolyte imbalance together with diuretics to keep the kidneys active and to prevent volume overload. (Sharma & Slawski, 2018)
Pain assessment and management
Pain is a common complication in patients who have undergone surgical procedures. Having undergone a total knee replacement surgery, Frank might experience pain brought about by positioning of the affected limb in a manner that inflicts pain, prolonged stay in the same decubitus and some cases increased drug tolerance for analgesics, especially in smokers. Patients in pain tend to have raised heart rate and blood pressure caused by its stimuli, therefore, measures to relieve pain such as the provision of analgesics, proper positioning of the affected part and cryotherapy should be put in place. Jonathan Cluett (2019) stated that some of the common issues causing pain after the procedure are bursitis, mal-alignment of the implant, and pinching of the nerve.
In another research by Han-Lian Chiang et al. (2016), it was found out that patients who are smokers required more substantial doses of pain relievers to achieve relief. The smokers also tended to have much pain following surgery unlike non-smokers
On top of that, Wittig-Wells, D., Johnson, I., Samms-McPherson, J., Thankachan, S., Titus, B., Jacob, A., & Higgins, M. (2015) concluded that cryotherapy helps reduce inflammation, pain and also facilitates the healing process of the surgical wound.
Assessment is done by palpation of the area near where the operation was done to determine the sensory status, signs of thromboembolism which include pulselessness, increased local temperature, tenderness, and swelling. The defective neurovascular system can lead to amputation of the limb. ("Neurovascular Assessment: Orthopaedic Nursing," 2011.)
Part B: impact of smoking and other comorbidities
Tobacco, commonly consumed through smoking of cigarettes contains tar, nicotine and hundreds of other chemical components. Smoking tends to lower pain tolerance; hence, the anesthesiologist will be required to use larger doses of anesthesia perioperatively to achieve his goals. This increases the risks of developing serious complications arising from high doses of the anesthesia used. In combination with obstructive sleep apnea, hypoxia is a common finding due to the impaired respiratory system caused by damaged alveolar tissue and blockage of the airway at the pharynx. If left unattended, the patient presents with signs or breathlessness, use of accessory breathing muscles and cyanosis. Low levels of oxygen saturation in the blood necessitate the heart to work extra hard to supply the body tissues the little available oxygen, and this causes increased heart rate and increased blood pressure. The patient will require to be intubated if the airway is compromised and administered oxygen, and monitoring of oxygen saturation levels. ("Smoking and anesthesia," 2016.)
Hypertension, on the other hand, is exacerbated by smoking as it causes increased blood pressure, increased heart rates, and vasoconstriction ultimately causing peripheral vascular resistance, which is a pathologic basis of development of chronic hypertension. As mentioned above reduced oxygen also results in high blood pressure. ("General Anesthesia in Hypertensive Patients: Impact of Pulse pressure but not Cardiac Diastolic Dysfunction on Intraoperative Hemodynamic Instability," 2011)
Recent studies have shown that cholesterol levels tend to increase after administration of anesthesia as compared to the pre-anesthetic state. High cholesterol levels in the blood lead to its deposition to the arterial walls leading to atherosclerosis, which ultimately causes hardening of the vessels. This, in turn, reduces the elasticity of the vessels and significant narrowing. Narrowed blood vessels mean less blood being supplied to the body tissues, especially to the myocardium. This poses a great risk to the development of myocardial infarction which precedes angina and embolization which results from detachment of a cholesterol lump from the tunica interna hence pulmonary embolism and deep venous thrombosis or even stroke, which is extremely fatal. The patient should continue with statins throughout treatment even during surgery to minimize the occurrence of complications. (Issa et al., 2015, p. 143-147)
Obstructive sleep apnea is an issue of concern to a surgical patient. In this condition, there is a collapse of the airway at the level of pharynx. General anesthesia poses a risk of cardiopulmonary complications postoperatively. This is due to relaxing of the muscles at the pharyngeal region hence worsening the condition. Hypoxemia and raised blood pressure together with heart rate are common in patients having a cardiopulmonary complication. Sedatives if in use should be cautiously administered. Airway support by intubation is to be advised and, in some cases, mechanical ventilation is to be employed until the patient regains consciousness. Continuous positive airway pressure (CPAP) machine will be used in extreme cases. (Flatman & Raj, 2017, p. 201)
In 2016 Pieracci, Comp and Barie found out that “Severe and prolonged episodes of hypoxemia were a consistent finding, despite aggressive preoperative diagnosis and treatment of OSA, including use of CPAP postoperatively. Although some postoperative hypoventilation is expected, the degree and frequency of desaturation were surprising.” (pg. 622)
Part C: Discharge plan
Should Frank’s vitals remain stable and develops no complications during the recovery period, he qualifies to be fit for discharge. His renal function tests should be normal, pressures controlled, and show no signs of post-anesthetic complications. Considering that he is the sole caregiver of her ailing wife, a relative or a close person should be called upon to take care of the couple and provide the necessary assistance. Follow up should be done after one week and should include physical examination, local examination, assessment of healing progress, and adjustment of drugs.
(Gonçalves-Bradley, Lannin, Clemson, Cameron, & Shepperd, 2016,)
On top of the discharge precautions and orders, the are specific signs and symptoms that should necessitate immediate readmission and surgical/medical intervention and these include:
(Lin, Cheng, Shih, Chu, & Tjung, 2012)
Total knee replacement surgery is one of the most common surgical procedures done. With proper consideration of comorbidities of the patient and use of a well-defined nursing care plan, many post-surgical complications are avoided. Frank had four comorbidities with him: obstructive sleep apnea, hypertension, hypercholesterolemia, and cigarette smoking, all these, if not taken care of professionally and meticulously could lead to catastrophic complication on the operating table or even after surgery. Each person is different and should be analyzed thoroughly for any existing known or unknown comorbidity and proper measures put in place to mitigate any possible complications. The care of the patient should be multidisciplinary and entailing consultations of superiors and colleagues and use of evidence-based techniques. Besides, the clinical reasoning cycle if of significant importance when it comes to making decisions concerning the patient's health and should be the guide for all the medical staff in charge of a patient.
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