CASE PRESENTATION

TOTAL KNEE REPLACEMENT

Presented by:

Group 1

Group Leader:

Comprendio, Cristian Mae

Members:

Cacho, Lucille

Campos, Jessa

Casaquite, Nevalyn

Castroverde, Aldrece Ne

Chan, Pauline

Cercado, Argyl

Dadivas, Mary Mae Rhiwa

Depakakibo, Chelsea Marie

Dilag, Graceous Faith

Nepomuceno, Ina

August 28, 2013

Case Scenario:

Mr. Giester is an 82-year-old man who underwent surgery for a total knee replacement.

He is alert and oriented and has been able to give good feedback when asked to

explain activity restrictions at home. He will be taking pain medication for his knee along

with his regular antihypertensive medication and vitamins. Mr. Giester will continue to

go to rehabilitation even after discharge. His doctor has recommended using a walker

and gait training and muscle strengthening. What health care services might you refer

Mr. Giester to, and what is your rationale?

______________________________________________________________________

MINI-LECTURE

ANATOMY OF THE KNEE

FOUR BONES MAKE UP THE KNEE:

• Tibia (shin bone)

• Patella (knee cap)

• Femur (thigh bone)

• Fibula (long, thin bone)

CARTILAGE

A. MENISCI

• Act as "cushions" or "shock absorbers".

• Sit between the femur and the tibia.

• Help provide stability to the knee.

B. ARTICULAR CARTILAGE

• A white, smooth, fibrous connective tissue that covers the ends of bones.

• Allows the knee bones to move easily as the knee bends and straightens.

TENDONS

• Elastic tissues that connect muscles to bones.

• Serve to stabilize the knee.

• Two major tendons:

quadriceps

patellar

LIGAMENTS

• Attach bones to bones and give strength and stability to the knee.

• Strong, tough bands that is not particularly flexible.

JOINT CAPSULE

• The capsule is a thick, fibrous structure that wraps around the knee joint.

• Synovial membrane which is lined by the synovium.

BURSA

• Bursa is a small fluid filled sac that decreases the friction between two

tissues.

• Protects bony structures.

MUSCLES

• Quadriceps muscles are the main muscles that straighten the knee.

• Hamstring muscles are the main muscles that bend the knee.

TOTAL KNEE REPLACEMENT

Also known as “KNEE ARTHROPLASTY”.

Helps relieve pain and restore function in severely diseased knee joints.

Surgeon cuts away damaged bone and cartilage and replaces it with an artificial

joint made of metal alloys, high-grade plastics and polymers.

CAUSE

Osteoarthritis

Rheumatoid arthritis

Post-traumatic arthritis

Bleeding into the joint (e.g. hemarthosis)

RISKS

Infection

Blood clots in the leg vein or lungs

Heart attack

Stroke

Nerve damage

Signs of infection:

Fever greater than 100 F (37.8 C)

Shaking chills

Drainage from the surgical site

Increasing redness, tenderness, swelling and pain in the knee

PREOPERATIVE

• Joints adjacent to the diseased knee (hip and ankle) are carefully evaluated.

• Blood-thinning medications such as warfarin (Coumadin) and anti-inflammatory

medications such as aspirin may have to be adjusted or discontinued prior to

surgery.

• Smoking should be stopped.

• Routine blood tests of liver and kidney function and urine tests are evaluated.

• Chest X-ray and EKG are performed.

• Preoperative laboratory evaluation should also be included.

• Antibiotics and anti-thrombotic prophylaxis are given approximately 30 minutes

before the incision is made.

INTRAOPERATIVE

Knee is in a bent position so that all surfaces of the joint are fully exposed.

After making an incision about 6 to 10 inches (15 to 25 centimeters) in length,

the surgeon moves aside the kneecap and cuts away the damaged joint

surfaces.

The surgeon inserts and attaches the pieces of the artificial joint.

POSTOPERATIVE

The knee is dressed with a compression bandage.

Ice may be applied.

Encourage active flexion of the foot every hour when the Mr. Giester is awake.

Wound suction drain removes fluid accumulating in the joint.

Continuous Passive Motion (CPM) machine is first attached to the operated leg,

which increases circulation and range of motion of the knee joint.

Assist Mr. Giester to get out of the bed on the evening or the day after surgery.

Mr. Giester must wear a support hose or compression boots to further protect

against swelling and clotting.

Knee is usually protected with a knee immobilizer (splint, cast or brace) and is

elevated when Mr. Giester sits in a chair.

Progressive ambulation, using assistive devices and within the prescribed weight

bearing limits begin on the day after surgery.

Begin physical therapy 48 hours after surgery.

Teach Mr. Giester instructions about deep breathing and using incentive

spirometer.

COMPETENCY STANDARDS FOR NURSING PRACTICE

A. Safe and Quality Nursing Care

Identification of the Problem

Patient is an elderly man who underwent surgery for a total knee replacement.

Patient is unaware of the health care services that he needs.

Prioritized Problem

Health Care Related Services and Health Education for post operative Total

Knee Replacement Therapy.

While Mr. Giester is still in the hospital, assist him do the basics of personal

maintenance such as walk with an aid (walker or crutches) to the bathroom,

stand for short periods at the sink, and go up and down a few stairs.

Encourage Mr. Giester to move his foot and ankle immediately following surgery

to increase blood flow in his leg muscles to help prevent leg swelling and blood

clots.

Provide an environment where Mr. Giester can perform various exercises safely.

Always put the side rails up when Mr. Giester is on bed to prevent fall and

injuries.

Maintain the privacy and confidentiality while performing procedures such as in

drug administration.

Provide wound care in order to prevent infection.

Watch out for signs of infection such as:

Persistent fever (higher than 100°F orally)

Shaking chills

Increasing redness, tenderness, or swelling of the knee wound

Drainage from the knee wound

Increasing knee pain with both activity and rest

Prevent further complications such as pneumonia by encouraging Mr. Giester to

move out of bed more often and take frequent deep breaths.

Make Mr. Giester feel comfortable by giving pain medications as ordered.

B. Management of Resources and Environment

Check the availability of supplies and equipment (such as BP apparatus, walker

or crutches) at home.

Check if equipments are properly functional.

Check the availability of medication for pain and high blood pressure and

vitamins for his health.

Check the contact numbers or tell Mr. Giester to have a number of a relative or

any emergency department to help him in case of emergency happened to him.

Keep an environment that is clean and safe for Mr. Giester to perform various

exercises.

Place unnecessary things on an empty box or cabinet so that it will not scattered

all around and to prevent injury to occur.

Observe proper waste disposal within the environment to promote cleanliness.

Observe proper hand washing or use of universal precaution to avoid

development of any infectious diseases or communicable diseases.

C. Health Education

Teach Mr. Giester not to do the following:

Put a pillow behind his knee when lying.

Kneel on his new knee joint.

Deep squats (squatting down to the floor).

After surgery, encourage him to:

Sit on a raised chair or use a cushion.

Use long-handled aids, like a shoehorn and reacher, to help you get

dressed or pick up items.

How to do wound care at home.

Eat a balanced diet, often with an iron supplement.

Exercise particularly during the first few weeks after surgery.

Resuming other normal household activities, such as sitting, standing, and

climbing stairs is a good activity once at home.

Teach Mr. Giester and the family ensure safe home set- up:

Ensure hallways and rooms are free of clutter and tripping.

Add non-slip surfaces to outside stairs and walkways.

Install stair railings or make sure the existing ones are secure.

Ensure good lighting in hallways and other well used areas.

Move frequently used household items to counter height. Consider moving

items in the lower parts of the fridge/freezer to a higher shelf.

Keep an ice pack in the freezer for possible joint swelling after surgery.

Alternatively, use a bag of frozen peas.

Have a thermometer at home to check the temperature if needed after

surgery.

Install a raised toilet seat with armrests/toilet safety frame to assist when

sitting or standing.

Remove sliding doors from the bathtub and replace with a shower curtain.

Use a non-slip bathmat both inside and outside the bathtub or shower.

Install a hand-held shower hose in the bathtub.

Grab bars in the bathtub/shower stall and by the toilet are very useful.

Removable grab bars are available. Do not use towel racks or toilet paper

holders to assist you to stand or sit.

D. Legal Responsibility

Apply the Ten Golden Rules in medication administration.

Document accurately all activities concerning the patient.

Adhere with RA 9173 or Philippine Nursing Law of 2002 for rendering quality

care.

Adhere with RA 9994 or the Expanded Senior Citizen Act of 2010.

Section 4 of Republic Act No. 7432, as amended by Republic Act No. 9257,

otherwise known as the "Expanded Senior Citizens Act of 2003", is hereby

further amended to read as follows:

"SEC. 4. Privileges for the Senior Citizens. - The senior citizens shall

be entitled to the following:

"(1) on the purchase of medicines, including the purchase of influenza

and pnuemococcal vaccines, and such other essential medical supplies,

accessories and equipment to be determined by the Department of Health

(DOH).

"(2) on the professional fees of attending physician/s in all private

hospitals, medical facilities, outpatient clinics and home health care services;

"(3) on the professional fees of licensed professional health providing

home health care services as endorsed by private hospitals or employed

through home health care employment agencies;

"(4) on medical and dental services, diagnostic and laboratory fees in

all private hospitals, medical facilities, outpatient clinics, and home health

care services, in accordance with the rules and regulations to be issued by

the DOH, in coordination with the Philippine Health Insurance Corporation

(PhilHealth).

E. Ethico-moral Responsibility

Respect the rights of the patient:

Right to privacy and confidentiality

Right to Information - regarding the details of the procedure to be performed,

it’s possible complications and risks factors after the surgery and access to

his medical records.

Right to Self-determination-decide on what type of health care services,

personnel and treatment he prefer

Right to be Informed of his rights and obligations as a patient-particularly on

his current prognosis and status while undergoing rehabilitative services.

Principle of justice - rendering care of what is due or merited

One should give Mr. Geister what he owed, what he deserve, or what he can

legitimately claim according to a proper allocation of benefits and burdens

where he will be treated equally.

Principle of respect for persons- all individual human beings are presumed to

be free and responsible persons and should be treated as such in proportion to

their ability in the circumstances.

As a subject, and not merely an object, Mr. Geister must be treated with

respect in such a way that recognizes his human dignity while performing the

surgery and undergoing treatment.

Principle of integrity and totality - these principles dictate that the well-being of

the whole person must be taken into account in deciding about any therapeutic

intervention or use of technology

Treat Mr. Giester as a subject and not an object of care. Provide holistic

nursing care, not merely attending to his physical needs but also to other

aspects of care (social, spiritual, emotional, etc.)

F. Personal and Professional Development

Nurse must know about effective management to achieve his/her goals and read

journals, search for the latest updates about caring and dealing with patient.

Improve self-knowledge and skills through attending conventions and seminars

especially in cases related to the subject matter.

Must present one’s self appropriately and also demonstrate professionalism

towards the patient.

Capacity and ability to work cooperatively and positively with other health team

members as well as the patient and significant others.

Take time to ask from the patient or folks if they are satisfied with the care and

services rendered to them.

G. Records Management

Ensure confidentiality and privacy of Mr. Giester.

Document problems identified with Mr. Giester for intervention to takes place.

Record Mr. Glister’s status such as vital signs to update his condition and

provide baseline data.

Document all the procedures, equipments used and attached to the Mr. Giester.

Refrain from releasing records and data about him without proper authority to

ensure confidentiality and privacy of Mr. Giester.

Ask permission to proper authority if releasing of records is needed.

Ensure the completeness of the Mr. Giester’s data on the chart following the

hospital protocol (hospital number, name, age, informed consent etc.) and refrain

from making errors.

H. Quality Improvement

Nurses should have a sufficient knowledge regarding on patient’s condition.

Ask feedback from the patient regarding treatment process to improve or change

any procedure that the patient is not comfortable with or is having any significant

reactions.

Share any experience that you have in dealing with the patient with the health

team and any other significant need of the client to be prioritized.

Report any variance to the health care team in order to come with solutions to

prevent any further complications with the patient’s condition.

Suggest appropriate teaching on corrective and preventive measures for the

patient.

Report objectively what you observed during the visit on the patient.

I. Research

Total knee replacement plus physical and medical therapy or treatment with

physical and medical therapy alone: a randomised controlled trial in patients with

knee osteoarthritis (Skou, S.T.,et al.,2012)

This study is about the lack of high quality evidence concerning the

efficacy of total knee arthroplasty (TKA). Treatment of knee osteoarthritis

(KOA) should include patient education, exercise and weight loss. Insoles

and pharmacological treatment can be included as supplementary

treatments. If the combination of these non-surgical treatment modalities

is ineffective, TKA may be indicated.

Result: There is a lack of high quality evidence concerning the efficacy of

TKA and around 20% of KOA patients experience little or no improvement

in pain, disability and quality of life following the TKA.

J. Communication

Establish rapport with Mr. Giester, significant others and members of the health

team to gain trust and to have confidence in rendering care to the patient.

Explain the purpose of being there.

Establish rapport to gain trust and perform the tasks with confidence.

Ask how the patient is feeling. Express interest in his aches and pains if he

elaborates on them, but don't press him if he simply answers yes or no.

Respond to the needs. Provide confidence through therapeutic, touch, warmth

and comforting words of encouragement.

Speak in terms that the patient can understand. Provide complete attention.

Effective, "active" listening in which the provider gives small verbal or non-verbal

feedback that indicates to the clients that they are being heard and understood.

K. Collaboration and Teamwork

Coordinate with other health team members in providing care for Mr. Giester:

Orthopedic surgeon - responsible for the diagnosis and preoperative,

operative, and postoperative treatment of diseases and injuries.

Attending physician - oversees the care and treatment decisions of the

patient.

Staff nurse - provides bedside care.

Ortho Care Technicians (OCT) - if the doctor ordered special ortho

equipment as part of the treatment, the OCT is the one who will set it

up and then make rounds to check the patient and the equipment.

Pharmacologist - evaluate medications for possible interactions and

their impact on your disease or condition.

Physical Therapist - teaches the patient proper and safe techniques for

exercises, bed mobility, transfers in and out of chairs and automobiles,

walking with crutches or walker and reinforces precautions. 

Occupational Therapists - teaches the patient proper and safe

techniques for bathing, toileting and dressing. 

Maintain a good interpersonal relationship with the patient and other support

system.

Discuss information concerning the patient to the health care team involve.

Nurses and other health care personnel should participate actively in patient care

and management for the improvement of patient’s condition.

Always do what is best for the patient through collaboration and teamwork.

If there would be any abnormalities noted, urgent reporting to the physicians

should be done and if possible recommend appropriate intervention to improve

patient care.

Contributes to decision making regarding patient’s needs and recommend

appropriate intervention to improve patient care.

NURSING CARE PLAN

Assessment

Objective Cues:

Imposed restrictions of movement, including mechanical, medical protocol,

and impaired coordination

limited range of motion

gait changes (e.g., decreased walking speed, difficulty initiating gait,

shuffles feet, lateral postural sway)

Nursing Diagnosis

Impaired physical mobility related to pain and discomfort in surgical site as well

as contralateral joint, musculoskeletal impairment, total knee replacement

surgery and restrictive therapies.

Outcome Criteria

After 1 month of effective nursing interventions, Mr. Giester will verbalize feeling

of increased strength in affected joint and limb and ability to move independently

with use of assistive device.

Planning

After 1 month of effective nursing interventions, Mr. Giester will be able to:

Performs physical activity independently or with use of assistive devices

(wheelchairs, walkers) as needed.

Participate in Activities of Daily Living (ADLs) and rehabilitation program.

Display increased strength, ROM, and function of affected joint and limb.

Nursing Interventions and Rationale

Independent

1. Screen for mobility skills in the following order:

(1) bed mobility;

(2) supported and unsupported sitting;

(3) transition movements such as sit to stand, sitting down, and transfers; and

(4) standing and walking activities.

Screening mobility skills helps provide baselines of performance that can

guide mobility-enhancement programming and allows nursing staff to

integrate movement and practice opportunities into daily routines and regular

and customary care.

2.  Encourage and facilitate early ambulation and other ADLs when possible.

Assist with each initial change: dangling, sitting in chair, ambulation.

The longer the patient remains immobile the greater the level of debilitation

that will occur.

3. Obtain any assistive devices needed for activity, such as walking belts,

walkers, canes, crutches, or wheelchairs, before the activity begins.

Assistive devices can help increase mobility.

4. Perform passive range of motion (ROM) exercises on the affected side at

least twice a day unless contraindicated; repeat each maneuver three times.

Passive ROM exercises help maintain joint mobility, prevent contractures and

deformities, increase circulation, and promote a feeling of comfort and well-

being. 

5. Ensure that chairs fit the patient. Chair seat should be 3 inches above the

height of the knee. Provide a raised toilet seat if needed.

Raising the height of a chair can improve the ability of many older clients to

stand up.

6. Turn on unoperated side using adequate number of personnel and

maintaining operated extremity in prescribed alignment.

Prevents dislocation of knee prosthesis and prolonged skin and tissue

pressure, reducing risk of tissue ischemia and breakdown and reduces risk of

injury during recovery from effects of anesthesia.

7. Allow patient to perform tasks at his or her own rate. Do not rush patient.

Encourage independent activity as able and safe.

Hospital workers and family caregivers are often in a hurry and do more for

patients than needed, thereby slowing patient's recovery and reducing his or

her self-esteem.

Collaborative

1. Consult with physical therapist for further evaluation, strength training, gait

training, and development of a mobility plan.

Techniques such as gait training, strength training, and exercise to improve

balance and coordination can be very helpful for rehabilitating clients.

Evaluation

Met. After 1 month of effective nursing intervention Mr. Giester was able to

verbalize feeling of increased strength in affected joint and limb and ability to

move independently with use of assistive device.

Discharge Planning

Medication- instruct Mr. Giester and family to comply with the medications

prescribed.

Environment- provide a safe environment. Instruct to maintain the bed in low

position, sit on a firm, raised chair with armrest, and use the handrails on the

toilet. Ensure good lighting and hallways and rooms are free of clutter and

tripping hazards.

Treatment- assist with range of motion active / passive exercises. Instruct to

‘perform his exercise routine 3 times a day as instructed by the PT and place an ice

bag on his knee for 5-10 minutes after exercising and walk daily, each time

lengthening his walking distance as his strength improves.

Health Teaching- teach him that until his balance, flexibility, and strength improve,

he should use a cane, crutches, a walker, handrails, or have someone to assist him.

When allowed to shower, encourage him to carefully wash the incision with soap and

water, rinse well, then gently pat it dry.

OPD Follow up- reinforce the importance of keeping scheduled follow-up

appointments with health care provider.

Diet- encourage to eat foods high in fiber and protein and increase oral fluid

intake.

Support System- encourage family members and caregivers to work with

Mr. Giester during self-care activities such as eating, bathing, grooming,

dressing, and transferring rather than letting him be a passive recipient of

care.

LEVELS OF CARE

PROMOTIVE

Wound Care

Teach Mr. Giester to avoid soaking the wound in water until it has thoroughly

sealed and dried. He may continue to bandage the wound to prevent irritation

from clothing or support stockings.

Diet

Encourage to eat a balanced diet, often with an iron supplement, which is

important to help the wound heal and to restore muscle strength.

Give instructions about deep breathing and using incentive spirometer to help

keep lungs clear.

PREVENTIVE

Blood Clot Prevention

Provide Mr. Giester with special support hose or tight-fitting, anti-embolism

stockings as prescribed by the orthopedic surgeon.

Encourage to move his foot and ankle immediately following surgery.

The warning signs of possible blood clots in your leg include:

o Increasing pain in your calf

o Tenderness or redness above or below your knee

o Increasing swelling in your calf, ankle, and foot

The warning signs that a blood clot has travelled to your lung include:

o Sudden shortness of breath

o Sudden onset of chest pain

o Localized chest pain with coughing

Preventing Pneumonia

Teach and encourage the patient to do deep breathing exercises.

Preventing Infection

After knee replacement, administer preventive antibiotics after surgical

procedures.

Notify your doctor immediately if you develop any of the following signs of a

possible knee replacement infection:

o Persistent fever (higher than 100°F orally)

o Shaking chills

o Increasing redness, tenderness, or swelling of the knee wound

o Drainage from the knee wound

o Increasing knee pain with both activity and rest

Avoiding Falls

The surgeon and physical therapist will help decide what assistive aides will

be required following surgery and when those aides can safely be discontinued.

CURATIVE

Medications

Administer medications as prescribed.

Prescriptions for pain (Lyrica, Celebrex and Norco)

Evaluate renal function and encourage Mr. Giester to increase fluid

intake for adequate hydration.

Administer Zofran (odansetron) to control nausea.

DVT Prevention: Aspirin 325 mg BID for six weeks to reduce the risk

of clot formation.

Administer stool softener as prescribed for constipation as a result of

use of pain medication.

Teach Mr. Giester to exercise his knee the day after surgery to restore knee

movement to allow walking and other normal activities.

Assist him in daily physical therapy, which includes active and passive range

of motion exercises, walking, getting out of bed, and getting up from a chair. 

Apply ice to help control pain and swelling.

Keep the wound dry.

Advise him to elevate his operative leg or lie down for 30 minutes or an hour

during the day to reduce swelling.

REHABILITATIVE

Teach Mr. Giester to avoid strenuous activities that may irritate his knee for about

six weeks following surgery.

Teach and encourage the use walker as recommended by his doctor.

Encourage exercise to promote normal activities of daily living weeks after

surgery.

Activity program should include:

A walking program to slowly increase mobility.

Resuming other normal household activities, such as sitting, standing, and

climbing stairs.

Specific exercises several times a day to restore movement and strengthen

the knee.

Tell Mr. Giester that he may have a physical therapist to help him at home

or in a therapy center the first few weeks after surgery.

Refer Mr. Giester to the Philippine Orthopedic Center. POC caters mainly to a

patient with Orthopedic and Neuromuscular conditions. Its Rehabilitation

Medicine Department has the Medical Rehabilitation Service, Physical Therapy

section, the Occupational Therapy Section.

BIBLIOGRAPHY

Electronic Resources

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http://www.enurse-careplan.com/2011/06/impaired-physical-mobility-nursing-

care_29.html

Health care ethics. (2013). Retrieved August 21, 2013, from

http://www.ascensionhealth.org/: http://www.ascensionhealth.org/index.php?

option=com_content&view=article&id=32&Itemid=170

Home Safety Renovations (lowincomeseniors). Retrieved August 21, 2013 from HYPERLINK

"http://www.viha.ca/NR/rdonlyres/08D419A4-23B2-4515-B4FA-B428909E9061/0/

hip_knee_booklet.pdf"http://www.viha.ca/NR/rdonlyres/08D419A4-23B2-4515-B4FA-

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Boardman, Rebecca. (2007). Recovery From total Replacement. Retrieved August 21,

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Total Knee Replacement Exercise Guide. (March 2011). Retrieved August 21, 2013

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BIBLIOGRAPHY Soren T. Skou, E. M.-N. (2012). Total knee replacement plus physical and medical

therapy alone: a randomised controlled trial in patients with knee osteoarthritis. Denmark:

BioMed Central.