Total knee replacement (TKR), also known as total knee arthroplasty, is a common and effective surgical procedure designed to alleviate pain and restore mobility in patients with severely damaged knee joints. As a major orthopedic intervention, TKR necessitates comprehensive post-operative nursing care to ensure optimal patient recovery and prevent complications. This guide delves into the essential nursing diagnoses associated with total knee replacement, providing a framework for nurses to deliver patient-centered care.
Knee joints are intricate structures bearing significant body weight, making them susceptible to injury and degenerative conditions. When conservative treatments fail to provide relief from debilitating knee pain and mobility issues, TKR becomes a viable option. This procedure involves replacing the damaged cartilage and bone in the knee joint with artificial implants made of metal and plastic.
There are primarily two types of knee replacement surgeries:
- Total Knee Replacement (TKR): Replacement of the entire knee joint, the most frequently performed procedure.
- Partial Knee Replacement (PKR): Replacement of only a damaged compartment of the knee joint.
TKR is typically considered when conditions such as osteoarthritis, rheumatoid arthritis, bone growth disorders, knee injuries, or deformities severely impair knee function and quality of life. Before recommending surgery, healthcare providers thoroughly assess patients, utilizing X-rays to evaluate the extent of joint damage and assessing their range of motion and mobility.
While TKR is generally safe and effective, it is associated with potential risks, including bleeding, infection, blood clots, nerve damage, and persistent pain. Therefore, diligent nursing care is paramount in the pre-operative, intra-operative, and post-operative phases to mitigate these risks and optimize patient outcomes.
The Nursing Process in Total Knee Replacement Care
Nurses play a crucial role throughout the patient’s TKR journey. Pre-operatively, nurses are involved in obtaining informed consent and educating patients about the surgical procedure and the expected recovery process. Post-operatively, nurses are responsible for continuous monitoring, pain management, early mobilization, and patient education to facilitate a smooth recovery and prevent complications. Discharge planning, including coordinating home care or outpatient rehabilitation services, is also a vital nursing responsibility.
Nursing care plans are essential tools that guide and prioritize nursing interventions for patients undergoing TKR. By identifying relevant nursing diagnoses, nurses can create individualized care plans that address both immediate post-operative needs and long-term rehabilitation goals. The following sections outline common nursing diagnoses in the context of total knee replacement and provide examples of nursing care plans.
Acute Pain Management Following Total Knee Replacement
Post-operative pain is an anticipated and significant concern following TKR. Effective pain management is crucial not only for patient comfort but also for facilitating early mobilization and preventing complications. However, persistent or escalating pain can indicate underlying issues that require prompt attention.
Nursing Diagnosis: Acute Pain
Related Factors:
- Surgical incision and tissue trauma
- Inflammatory response to surgery
- Muscle spasms
- Nerve irritation or damage during surgery
- Presence of the knee prosthesis
- Joint tenderness and swelling
Evidenced By:
- Patient reports of pain (verbal or non-verbal cues)
- Pain rating scales (e.g., numerical rating scale)
- Facial expressions of pain (grimacing, wincing)
- Guarding behavior or protective posturing
- Distraction behaviors (restlessness, moaning)
- Changes in vital signs (increased heart rate, blood pressure, respiratory rate)
- Diaphoresis (sweating)
Desired Outcomes:
- Patient will report a satisfactory level of pain control using a pain scale (e.g., pain rating of 3 or less on a 0-10 scale).
- Patient will demonstrate effective use of pain management techniques, both pharmacological and non-pharmacological.
- Patient will be able to participate in rehabilitation activities without being hindered by pain.
Nursing Assessments and Interventions:
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Conduct a comprehensive pain assessment: Regularly assess pain characteristics, including location, intensity, quality, duration, and aggravating/relieving factors. Utilize pain assessment tools consistently. Rationale: A thorough pain assessment provides a baseline, helps to evaluate the effectiveness of pain management strategies, and can indicate potential complications.
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Monitor vital signs, noting any changes associated with pain: Assess blood pressure, heart rate, and respiratory rate. Rationale: Pain can trigger physiological stress responses, leading to changes in vital signs. Unrelieved pain can contribute to anxiety and hinder recovery.
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Ensure proper positioning and support of the affected knee: Use pillows and wedges to maintain the knee in a slightly elevated and extended position as prescribed. Avoid placing pillows directly under the knee, which can promote flexion contractures. Rationale: Proper positioning can reduce muscle spasms, minimize tension on the surgical site, and promote venous return, reducing swelling.
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Monitor for signs of disproportionate or escalating pain: Pay attention to reports of sudden, severe pain, pain that is not relieved by prescribed analgesia, or pain that is out of proportion to the expected post-operative course. Rationale: Unusual or escalating pain may indicate complications such as infection, deep vein thrombosis (DVT), or prosthesis dislocation.
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Administer pain medications as prescribed: Provide analgesics in a timely manner, considering the patient’s pain level and medication orders. Utilize a multimodal approach, combining opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and adjuvant analgesics as appropriate. Educate the patient about the purpose and potential side effects of pain medications. Rationale: A multimodal approach to pain management can provide more effective pain relief while minimizing opioid use and side effects. Preemptive analgesia before physical therapy can improve patient participation.
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Implement non-pharmacological pain relief measures: Encourage and assist with non-pharmacological techniques such as:
- Ice or cold therapy: Apply ice packs to the surgical site for 15-20 minutes at a time, several times a day, as prescribed. Rationale: Cold therapy helps reduce inflammation, swelling, and pain by numbing nerve endings and constricting blood vessels.
- Heat therapy: Apply heat packs or warm compresses as prescribed, typically after the initial inflammatory phase. Rationale: Heat therapy can help relax muscles, reduce stiffness, and promote blood flow to the area, aiding in healing.
- Distraction techniques: Engage the patient in activities that divert their attention from pain, such as listening to music, watching movies, or engaging in conversation. Rationale: Distraction can help reduce pain perception and improve coping.
- Relaxation techniques: Teach and encourage relaxation techniques such as deep breathing exercises, guided imagery, or progressive muscle relaxation. Rationale: Relaxation techniques can reduce muscle tension, promote a sense of calm, and enhance pain coping.
- Transcutaneous Electrical Nerve Stimulation (TENS): Apply TENS unit as prescribed. Rationale: TENS can provide pain relief by stimulating nerves and interfering with pain signals.
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Coordinate pain management with physical therapy: Administer pain medication prior to physical therapy sessions to optimize patient comfort and participation in rehabilitation exercises. Rationale: Adequate pain control allows patients to engage more effectively in physical therapy, which is crucial for regaining mobility and function.
Addressing Impaired Physical Mobility Following Total Knee Replacement
Restoring mobility is a primary goal of TKR surgery. However, post-operative pain, swelling, and surgical trauma can significantly impair physical mobility. A structured rehabilitation program, guided by nursing and physical therapy interventions, is essential to facilitate the patient’s return to functional movement.
Nursing Diagnosis: Impaired Physical Mobility
Related Factors:
- Post-operative pain and discomfort
- Joint stiffness and swelling
- Surgical intervention and tissue trauma
- Presence of the knee prosthesis
- Muscle weakness and decreased strength
- Fear of falling or re-injury
Evidenced By:
- Limited range of motion in the affected knee
- Difficulty with ambulation and weight-bearing
- Altered gait and balance
- Slowed movement and uncoordinated movements
- Pain with movement
- Reluctance to move
- Use of assistive devices (walker, crutches, cane)
- Decreased muscle strength and endurance
Desired Outcomes:
- Patient will demonstrate progressive improvement in mobility and functional abilities.
- Patient will achieve independence in ambulation and transfers to the extent possible.
- Patient will actively participate in physical therapy and rehabilitation programs.
- Patient will verbalize understanding of safe mobility practices and precautions.
Nursing Assessments and Interventions:
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Assess baseline mobility and functional status: Evaluate the patient’s pre-operative mobility level, including gait, balance, range of motion, and ability to perform activities of daily living (ADLs). Rationale: Baseline assessment provides a point of comparison for evaluating post-operative progress and identifying specific mobility deficits.
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Assess range of motion, muscle strength, and pain with movement in the affected knee: Regularly assess the patient’s active and passive range of motion, muscle strength, and pain levels during movement. Rationale: Monitoring range of motion and strength helps track progress and identify limitations that require targeted interventions. Pain assessment guides pain management strategies during mobilization.
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Ensure proper positioning and alignment of the operated leg: Maintain the knee in a prescribed position, often with slight elevation and extension, using pillows and wedges. Rationale: Proper positioning supports joint stability, reduces stress on the surgical site, and prevents contractures that can further limit mobility.
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Utilize Continuous Passive Motion (CPM) machine as prescribed: Apply and monitor CPM machine use according to physician orders and hospital protocols. Rationale: CPM machines passively move the knee joint through a controlled range of motion, preventing stiffness, promoting circulation, and aiding in cartilage healing.
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Provide progressive mobilization and ambulation: Initiate early mobilization as soon as medically stable, following physician orders and physical therapy guidelines. Gradually progress from bed exercises to chair transfers, standing, and ambulation with assistive devices (walker, crutches, cane). Rationale: Early mobilization prevents complications associated with immobility, promotes circulation, strengthens muscles, and improves functional recovery.
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Instruct and assist with therapeutic exercises: Teach and supervise the patient in performing prescribed exercises, including ankle pumps, quadriceps sets, gluteal sets, and range-of-motion exercises. Gradually progress the intensity and complexity of exercises as tolerated. Rationale: Therapeutic exercises strengthen muscles around the knee, improve joint flexibility, and enhance overall mobility and function.
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Provide assistive devices and gait training: Ensure appropriate use of assistive devices (walker, crutches, cane) and provide gait training to promote safe and efficient ambulation. Rationale: Assistive devices provide support and stability during ambulation, reducing the risk of falls and promoting confidence in movement. Gait training helps patients learn proper walking techniques with their new knee joint.
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Collaborate with physical therapy: Work closely with physical therapists to coordinate rehabilitation plans, reinforce exercises, and ensure consistent and progressive mobility training. Rationale: A collaborative approach between nursing and physical therapy optimizes patient care and ensures a comprehensive rehabilitation program.
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Educate the patient on safety precautions and fall prevention: Instruct the patient on strategies to prevent falls, such as using assistive devices, ensuring a clear environment at home, wearing supportive shoes, and avoiding slippery surfaces. Rationale: Patients are at increased risk of falls post-operatively. Education on safety precautions is crucial to prevent injury and promote safe mobility at home.
Minimizing the Risk of Infection After Total Knee Replacement
Infection is a serious complication following TKR, potentially leading to implant failure, prolonged hospitalization, and significant morbidity. Meticulous infection prevention strategies are paramount in nursing care to minimize this risk.
Nursing Diagnosis: Risk for Infection
Related Factors:
- Surgical incision and disruption of skin integrity
- Invasive procedure (implantation of prosthesis)
- Foreign body (prosthesis) implantation
- Decreased mobility and potential for impaired circulation
- Pre-existing conditions (e.g., diabetes, rheumatoid arthritis)
- Compromised immune system
Evidenced By:
- Risk diagnosis, not evidenced by signs and symptoms. Nursing interventions are directed at preventing infection.
Desired Outcomes:
- Patient will remain free from signs and symptoms of infection throughout the post-operative period.
- Patient will demonstrate proper wound care and infection prevention practices.
- Patient will achieve timely wound healing without complications.
Nursing Assessments and Interventions:
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Assess for risk factors for infection: Identify patients with pre-existing conditions that increase infection risk, such as diabetes, obesity, rheumatoid arthritis, or compromised immune systems. Rationale: Identifying risk factors allows for targeted preventive measures and heightened vigilance for infection.
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Monitor vital signs, particularly temperature: Regularly assess temperature and other vital signs. Elevated temperature may be an early sign of infection. Rationale: Fever is a common systemic sign of infection. Early detection allows for prompt intervention.
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Assess the surgical incision site regularly: Inspect the incision site for signs of infection, including redness, warmth, swelling, increased pain, purulent drainage, and delayed healing. Rationale: Local signs of infection at the surgical site are crucial indicators of wound infection.
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Monitor laboratory values: Review white blood cell count (WBC) and other relevant laboratory values. Elevated WBC count may suggest infection. Rationale: Laboratory values can provide supporting evidence of infection and monitor the body’s response to infection.
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Maintain aseptic technique during wound care and dressing changes: Adhere to strict aseptic technique when performing dressing changes and wound care procedures. Rationale: Aseptic technique prevents the introduction of microorganisms into the surgical site, minimizing infection risk.
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Administer prophylactic antibiotics as prescribed: Administer prophylactic antibiotics as ordered, typically pre-operatively and post-operatively. Rationale: Prophylactic antibiotics help to reduce the risk of surgical site infection by preventing bacterial colonization.
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Promote wound healing: Encourage adequate nutrition, hydration, and rest to support wound healing. Rationale: Optimal nutrition, hydration, and rest are essential for the body’s natural healing processes and immune function.
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Educate the patient and family on infection prevention: Instruct the patient and family about:
- Proper hand hygiene techniques. Rationale: Hand hygiene is the most effective way to prevent the spread of infection.
- Signs and symptoms of infection to report to healthcare providers (fever, chills, increased pain, redness, swelling, drainage). Rationale: Early recognition of infection signs allows for prompt medical attention and treatment.
- Proper wound care and dressing change procedures if applicable for home care. Rationale: Proper wound care at home is crucial to prevent infection after discharge.
- Importance of completing the prescribed course of antibiotics, if applicable. Rationale: Completing antibiotics ensures effective treatment and prevents antibiotic resistance.
- Avoiding activities that increase infection risk, such as soaking the incision in a tub or swimming pool until cleared by the physician. Rationale: Immersion in water can increase the risk of infection at the surgical site.
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Emphasize the importance of follow-up appointments: Reinforce the importance of attending all scheduled follow-up appointments for monitoring and early detection of potential complications, including infection. Rationale: Regular follow-up allows healthcare providers to monitor wound healing, assess for signs of infection, and address any concerns promptly.
By diligently addressing these nursing diagnoses and implementing evidence-based interventions, nurses play a vital role in ensuring positive outcomes and a successful recovery for patients undergoing total knee replacement. Comprehensive nursing care, focused on pain management, mobility restoration, and infection prevention, is fundamental to optimizing patient well-being and facilitating their return to an active and fulfilling life.
References
- AACN Essentials of Critical Care Nursing. 3rd Edition. Suzanne M. Burns, MSN, RRT, ACNP, CCRN, FAAN, FCCM, FAANP. 2014. McGraw Hill Education.
- Knee Replacement. NHS. Reviewed: August 2, 2019. From: https://www.nhs.uk/conditions/knee-replacement/
- Knee Replacement Surgery Procedure. Johns Hopkins Medicine. 2022. From: https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/knee-replacement-surgery-procedure
- Lewis’s Medical-Surgical Nursing. 11th Edition, Mariann M. Harding, RN, Ph.D., FAADN, CNE. 2020. Elsevier, Inc.
- Total Knee Replacement. OrthoInfo. Jared R. H. Foran, MD, FAAOS. Reviewed: June 2020. From: https://orthoinfo.aaos.org/en/treatment/total-knee-replacement/
