Knee joints, some of the most intricate structures in the human body, bear a significant load, rendering them susceptible to injuries and the cumulative effects of overuse. When knee discomfort becomes persistent and mobility is compromised, total knee replacement (TKR) surgery emerges as a transformative solution. This procedure involves the replacement of damaged knee joint components with artificial implants, typically crafted from plastic or metal, effectively alleviating pain and restoring mobility.
Total knee replacement is categorized as major surgery, typically considered when conservative treatments such as corticosteroid injections and physical therapy fail to provide adequate relief or functional improvement. Conditions that commonly necessitate total knee replacement include:
- Osteoarthritis
- Rheumatoid arthritis
- Bone growth disorders
- Knee injuries
- Knee deformities
To determine patient eligibility for TKR, healthcare providers conduct thorough evaluations, including X-rays to assess the extent of joint damage and evaluations of the patient’s range of motion and mobility.
Like all surgical procedures, total knee replacement carries potential risks. Common complications may include:
- Bleeding at the surgical site
- Infection
- Blood clots (deep vein thrombosis or pulmonary embolism)
- Nerve damage
- Persistent pain
The Role of Nursing Care in Total Knee Replacement Recovery
Nurses play a pivotal role throughout the total knee replacement journey, from pre-operative education and consent acquisition to post-operative monitoring and discharge planning. Post-surgery, nursing care focuses on vigilant monitoring for pain and complications, administering prescribed medications, facilitating early mobilization, and providing comprehensive education to patients and their families. This includes coordinating necessary outpatient or home healthcare services to ensure a smooth transition and continued recovery at home.
Nursing Care Plans for Total Knee Replacement: Diagnosis-Focused Approach
Nursing care plans are indispensable tools for structuring and delivering patient-centered care. Following a total knee replacement, these plans guide nurses in prioritizing assessments and interventions, setting both short-term and long-term goals. The following sections detail nursing care plan examples relevant to total knee replacement, focusing on common nursing diagnoses.
Acute Pain Management Following Total Knee Replacement
Post-operative pain is an anticipated consequence of total knee replacement surgery. Effective pain management is crucial for patient comfort and facilitating early rehabilitation. However, persistent or escalating pain may indicate underlying complications requiring prompt attention.
Nursing Diagnosis: Acute Pain
Related to:
- Surgical trauma and tissue disruption
- Inflammatory response
- Surgical incision and tissue repair
- Muscle spasms secondary to surgery
- Potential nerve irritation or damage
- Presence of prosthetic joint components
- Tenderness around the surgical site
As evidenced by:
- Changes in vital signs (increased heart rate, blood pressure, respiratory rate)
- Diaphoresis (sweating)
- Facial grimacing or other pain expressions
- Verbal or nonverbal reports of pain (pain scale ratings)
- Guarding behavior of the affected knee
- Distraction behaviors (restlessness, inability to focus)
- Protective postures to minimize pain
- Positioning to alleviate discomfort
Expected Outcomes:
- Patient will report a progressive decrease in pain intensity within the first few post-operative days and weeks.
- Patient will effectively utilize pain management strategies, both pharmacological and non-pharmacological, to achieve satisfactory pain relief.
Assessments:
1. Conduct a comprehensive pain assessment, noting characteristics such as location, intensity, quality, onset, duration, and aggravating/relieving factors.
A thorough pain assessment serves as the foundation for effective pain management, allowing for tailored interventions. Unrelieved or severe pain may be a sign of surgical complications such as infection, bleeding, or nerve compression.
2. Monitor vital signs regularly, noting any changes that may indicate poorly controlled pain.
Physiological responses to pain, such as elevated heart rate and blood pressure, can signal inadequate pain management and may contribute to anxiety and hinder recovery.
Interventions:
1. Ensure proper positioning of the operated knee joint, utilizing pillows or wedges to maintain alignment and support.
Optimal positioning minimizes strain on the new prosthesis, reduces muscle spasms, and promotes comfort. Keeping the knee straight and slightly elevated for brief periods helps reduce swelling.
2. Closely monitor for any sudden onset of severe joint pain, which could indicate complications.
Abrupt and intense pain post-TKR may be indicative of serious complications such as deep vein thrombosis (DVT), infection within the joint, or prosthesis dislocation, requiring immediate medical evaluation.
3. Administer prescribed pain medications promptly and as needed, including opioid analgesics and non-steroidal anti-inflammatory drugs (NSAIDs).
Opioids are often prescribed for immediate post-operative pain relief, while NSAIDs help manage inflammation and can be used in conjunction with opioids for a multimodal pain management approach.
4. Implement and encourage non-pharmacological pain relief techniques, such as rest, ice or heat application, distraction, relaxation techniques, and repositioning.
Non-pharmacological methods complement medication, reduce reliance on analgesics, promote relaxation, and enhance the patient’s sense of control over their pain experience. Alternating ice and heat can address both pain and muscle stiffness.
5. Pre-medicate with analgesics prior to physical therapy or ambulation sessions to optimize participation and comfort.
Pain management before physical therapy is essential to facilitate patient engagement in rehabilitation exercises and promote adherence to the recovery plan. Adequate pain control allows for more effective movement and reduces fear of pain associated with activity.
Impaired Physical Mobility Following Total Knee Replacement
The primary goal of total knee replacement is to restore mobility and alleviate pain associated with damaged knee joints. However, post-operative recovery and physical rehabilitation are essential for achieving optimal functional outcomes.
Nursing Diagnosis: Impaired Physical Mobility
Related to:
- Musculoskeletal surgery and joint replacement
- Post-operative pain and discomfort
- Surgical intervention and tissue trauma
- Presence of knee prosthesis and altered joint mechanics
- Joint stiffness and limited range of motion
As evidenced by:
- Altered gait or difficulty walking
- Decreased range of motion in the affected knee
- Difficulty with ambulation or weight-bearing
- Postural instability or balance issues
- Uncoordinated movements
- Slowed or hesitant movements
- Pain reported with movement or ambulation
- Decreased muscle strength in the affected leg
- Use of assistive devices for mobility (walkers, crutches)
- Limitation in ability to participate in desired activities
Expected Outcomes:
- Patient will demonstrate improved mobility and independence in ambulation and positioning within the prescribed post-operative timeframe.
- Patient will actively participate in physical therapy and rehabilitation programs as directed by the healthcare team.
Assessments:
1. Assess and document the patient’s pre-operative mobility status as a baseline for comparison post-surgery. Reassess mobility regularly throughout the recovery process.
Baseline assessment is crucial for tracking progress and identifying any limitations in mobility. Post-operative assessments help determine the effectiveness of the surgery and guide rehabilitation efforts.
2. Identify and address factors contributing to impaired mobility, such as pain, fear of falling, muscle weakness, or joint stiffness.
Understanding the specific barriers to mobility allows for tailored interventions. Addressing pain, anxiety, and muscle weakness are critical components of a successful rehabilitation plan. Patients may be hesitant to move due to pain or fear of damaging the new joint.
Interventions:
1. Ensure the operated knee is positioned according to post-operative orders to maintain prosthesis stability and promote proper healing.
Correct positioning supports the new joint, prevents stress on surgical sites, and minimizes the risk of complications like dislocation. Proper alignment is essential for long-term joint function.
2. Utilize continuous passive motion (CPM) machines as prescribed to gently move the knee joint through a range of motion.
CPM machines help prevent stiffness, reduce pain, and improve circulation in the operated leg, facilitating early recovery of range of motion. CPM is often initiated immediately post-operatively.
3. Assist the patient with ambulation using appropriate assistive devices such as walkers, crutches, or canes, progressing as tolerated.
Assistive devices provide support and stability during ambulation, enabling patients to regain mobility gradually and safely. The type of device used will depend on the patient’s strength, balance, and stage of recovery.
4. Refer the patient to physical therapy (PT) for a comprehensive rehabilitation program tailored to their individual needs.
Physical therapy is a cornerstone of TKR recovery. PT professionals design exercise programs to strengthen muscles, improve range of motion, and restore functional mobility. PT may be inpatient, outpatient, or home-based.
5. Encourage and motivate the patient to actively engage in prescribed rehabilitation exercises and ambulation activities.
Patient adherence to the rehabilitation plan is crucial for optimal outcomes. Early and consistent participation in exercises promotes healing, strengthens muscles, and prevents complications associated with immobility.
Risk for Infection Following Total Knee Replacement
Total knee replacement surgery inherently carries a risk of infection, which can occur at the surgical site or around the artificial implants. Infections can manifest weeks or even months after hospital discharge.
Nursing Diagnosis: Risk for Infection
Related to:
- Compromised primary defenses due to surgical incision
- Disruption of skin integrity at the surgical site
- Invasive surgical procedure
- Implantation of a foreign body (prosthesis)
- Potential for decreased mobility and circulation
As evidenced by:
A “Risk for” nursing diagnosis is not evidenced by current signs and symptoms, as the problem is potential, not actual. Nursing interventions are focused on preventing the occurrence of infection.
Expected Outcomes:
- Patient will remain free from signs and symptoms of infection throughout the post-operative period and demonstrate timely wound healing.
- Patient will demonstrate understanding and implement infection prevention measures at home.
Assessments:
1. Monitor for any clinical signs and symptoms of surgical site infection, such as increased redness, warmth, swelling, tenderness, purulent drainage, or delayed wound healing.
Early detection of infection is critical for prompt intervention and preventing serious complications. Signs of infection may be subtle initially and require careful monitoring.
2. Review laboratory values, particularly white blood cell (WBC) count and inflammatory markers, as indicators of potential infection.
Elevated WBC count or C-reactive protein (CRP) levels can suggest an inflammatory or infectious process. Lab values provide objective data to support clinical assessment.
3. Identify patient-specific risk factors that increase susceptibility to post-operative infection, such as diabetes, obesity, smoking, or compromised immune status.
Identifying risk factors allows for targeted preventive measures. Patients with certain pre-existing conditions may require enhanced infection control strategies.
Interventions:
1. Utilize strict aseptic technique during surgical dressing changes and wound care procedures.
Aseptic technique minimizes the introduction of microorganisms into the surgical wound, reducing the risk of infection. Maintaining a sterile environment during wound care is paramount.
2. Educate the patient and family about the signs and symptoms of infection to watch for at home and when to contact the healthcare provider.
Patient and family education empowers them to participate in monitoring for infection and seeking timely medical attention if concerns arise. Early reporting of symptoms is crucial for prompt treatment.
3. Assess for any reports of deep, dull, constant, aching pain at the surgical site, which may be indicative of a developing joint infection.
While post-operative pain is expected, a change in the character or intensity of pain, especially if described as deep and aching, can be an early sign of joint infection. This type of pain is distinct from typical post-surgical pain.
4. Administer prophylactic antibiotics as prescribed to reduce the risk of post-operative infection.
Prophylactic antibiotics are commonly administered before and after TKR surgery to minimize the risk of surgical site infections. Adherence to the antibiotic regimen is essential.
5. Emphasize the importance of scheduled follow-up appointments for post-operative monitoring and early detection of potential complications, including infection.
Regular follow-up visits allow healthcare providers to assess wound healing, monitor for signs of infection, and address any concerns promptly. Follow-up care is essential for long-term success after TKR.
References
- ACCN 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/
