Research Articles Base: Total Knee Replacement Surgery

TOTAL KNEE REPLACEMENT SURGERY

Introduction               People undergo total knee replacement when arthritis or injury erodes the joint’s natural cushioning to the point where it’s hard to walk even short distances without severe pain.             Knee replacements now cost the NHS more each year than total hip replacements. An ageing population and an increase in obesity-related conditions are placing an increasing strain on NHS resources, with the number of knee replacements performed rising by 15 per cent last year from 59,391 to 68,300. Doctors predict that by 2010, suchoperations could cost the NHS almost pounds 1 billion per year.             The average age for a total knee replacement is 70. Osteoarthritis, one of the four most common problems linked to obesity, is the major cause of surgery. Overweight and obese people are 24 per cent more likely to require knee surgery. About 68,300 knee replacements were performed in the UK in 2002, costing the NHS in the region of pounds 375 million (Blakemore, 2003).             There are more replacement operations performed on the knee than any other joint in the body: more than 600 000 total knee replacements are performed each year globally. The annual total global knee market is estimated to be worth billion (Advanced Ceramics Report).             Total knee replacement, which is defined as the surgical insertion of a hinged artificial joint, relieves pain and restores motion to a knee which is affected by arthritis or injury. In a standard total knee replacement, the damaged areas of the thighbone, shinbone and kneecap are removed and replaced with prostheses.  The diseased bone surfaces are removed and a two-piece metallic hinge is cemented into the cavities of the upper and lower leg bones (femur and tibia). After surgery, the knee is held in position, usually with a plaster cast. The ends of the remaining bones are smoothed and reshaped to accommodate the prostheses. Pieces of the artificial knee are typically held in place with bone cement or plaster cast. Physical therapy includes exercise and whirlpool baths. The mobility and range of motion of the joint increase slowly. It is healing of the muscle and tendon that causes much of the pain during recovery, as clients must stretch those injured parts in order to regain knee motion. Despite excruciating pain and decreased mobility, many people with knees damaged by arthritis put off joint-replacement surgery out of fear and uncertainty.   Body   The largest joint in the body, the knee joint is formed where the lower part of the thighbone (femur) joins the upper part of the shinbone (tibia) and the kneecap (patella). Shock-absorbing cartilage covers the surfaces where these three bones touch (Snell, 2000). In a normal knee, the bone surfaces that come together at the joint-thighbone, shinbone and kneecap–are smooth and hard. A cushioning layer of tissue (cartilage) prevents direct contact between these bones. When the cartilage is damaged, these bones rub together, causing friction, pain and, eventually, deterioration of the bone surfaces (Bren, 2004). As it is the largest joint in the body, it is also prone to pain and loss of function and stability, which therefore requires surgery to be done.             Remedies included not using the affected joint but more recently researchers have found some substances such as glucosamine and chondroitin, as well as apple pectin which have in some cases been able to stimulate regeneration of the cartilage. But often the recommendation consists of losing weight, use of pain killers from aspirin to ibuprophen, and the cox 2 inhibitors, one of which (Vioxx) got into trouble recently because they found it enhanced heart problems. Injecting a gel substitute into the knees has helped but often the relief lasts for only about six months. The ultimate remedy by the doctors is total knee replacement. What this means is that they open up the knee, cut off or shave the ends of the leg bone and the thigh bone and cap them with a metal and hard plastic that allows articulation of the knees. The main benefit is the removal of pain. There are actually three reasons the doctor (an orthopedic surgeon) will recommend an artificial knee. These are: 1) to relieve pain 2) to restore function and 3) to achieve stability. As the arthritic knee becomes more painful, the patient will use it less. Function, therefore, is lost. As the arthritic knee continues to deform, the patient will feel that the joint is wobbly or unstable.             The most common indication for total knee replacement is osteoarthritis, or degenerative joint disease. The end stage of osteoarthritis is wearing out of cartilage (smooth, gliding bone ends) resulting in bone-to-bone contact in diseased joints. It is progressive and becomes increasingly painful as the cartilage erodes. Younger people who get knee replacements have damaged their joints by trauma (accidents that destroy joint surfaces), infection, cancer or tumor, and inflammatory conditions such as rheumatoid arthritis.             Painful knees are the most common manifestation of osteoarthritis, while osteoarthritis in turn is the most common of the different kinds of arthritis. About 60 percent or more of arthritis sufferers have this form. But this is not the most difficult. Rheumatoid arthritis is often deforming and most painful of the hundred or so forms of arthritis. Osteoarthritis can found in all weight-bearing joints such as the spinal column, the hips, the ankles, and the knees. Osteoarthritis in the knees is basically the loss of cartilage between the bones of the knees (Marieb, 2004). What causes it is still not clear. As the cartilage is eroded in the knees, standing or walking becomes more and more painful as the knee bones grind against each other without a cushion. An accident or high-impact sports like basketball or jogging can trigger the condition but often it is accompanied by overweight in the individual. According to growth consultants, the rapid graying of Europe’s population with related increases in the incidence of musculoskeletal problems (particularly osteoarthritis) is expected to be a key driver for orthopaedic prosthetic implant devices over the long term. At the same time, enhanced clinical outcomes and clinical efficacy are boosting the number of procedures carried out on patients in younger age groups (PR Newswire).      Experts believe the total knee replacement could dramatically cut the recovery time of patients, freeing up hospital beds more quickly and saving money (Blakemore, 2003). The operation uses a minimally invasive technique to insert knee implants through an incision half the size of the usual ten to 13 inch wound. This results in much less cutting of the thigh muscles, leading to less pain and faster recovery. A well-executed total knee replacement can last up to 15 years (95% predicted survival of the implant). Still, the operation and recovery can be grueling. Traditionally, surgeons make a 12-inch incision in the front of the knee, peel back the kneecap, and cut through the quadriceps muscle and a tendon that attaches it. That allows open access to the thigh and shin bones, which are cut to fit the metal-and-plastic joint implant (Neergaard, 2004).  Like any surgery, knee joint replacement carries certain life-threatening risks, such as infection, blood clots and complications from anesthesia. Other complications include nerve damage, dislocation of breakage after surgery, and wearing out or loosening of the joint over time (Bren, 2004). After the operation, there can be wound infection and worse, infection of the knee replacement. These may require prolonged antibiotics and possible removal of the implants. Perioperative complications as defined by the investigator occurred in 5.4 percent of patients and 7.6 percent of knees. Most of these complications were “knee related” or deep venous thrombosis. There were only eight cardiovascular or pulmonary complications reported among nearly 6,000 patients, suggesting that these adverse effects were not fully addressed in the literature (Torrey, 2004).   Post-Operative Care               After the knee replacement surgery, it is expected that the care of the client can become complex as a result of physiological changes that may occur. Another thing is that, the client now has an artificial knee in him and this is something that the client has to get used to.             To assess the client’s condition after the knee replacement surgery, the nurse should apply critical thinking while relying on information from the preoperative nursing assessment, knowledge regarding the surgical procedure performed, and the events that occurred after surgery (Kozier & Erb, 2004).             The information that the nurse gathered from the client will help the nurse to detect any change and make decisions about client’s care. A variation from the client’s normal signs may indicate the onset of surgically related complications (Potter & Perry, 2004).             The nurse should thoroughly document the assessment, including vital signs, level of consciousness, comfort level, pain, range of motion or mobility among other things. The initial findings are a baseline for comparing changes before and after the surgery.             The nurse also has the responsibility of explaining to the client and his/her family the purpose of post-operative procedures or equipment and the status of the client.   Assessment and Nursing Diagnosis               Two acute needs of the client after total knee replacement surgery are pain and mobility. The physiology of these two are altered after surgery and the nurse needs to be extra attentive to these needs. The pain after undergoing knee replacement surgery is intense but is still somewhat manageable (Ault, 2003). In the pain treatment of the patient, the nurse has to first and foremost assess resources for pain management. After this, the healthcare team looking after the patient should develop a collaborative plan. In assessing the client’s pain, his or her self-report of the pain is the single most reliable indicator of the existence and intensity of the pain experienced and any related discomfort (Kozier & Erb, 2004). It is also important to take note that if the client senses that the nurse doubts that the client felt pain, there is a possibility that the client will share little information about their pain. Therefore the nurse should see to it that the client will feel comfortable in discussing whatever he or she feels. It is imperative that the nurse set the stage for the relationship that allows for open communication about pain. Simple measures such as sitting when talking to clients about pain lets clients know that the nurse has the time and the interest to assess the pain felt by the client (Potter & Perry, 2004). The kind of pain that the client experiences after surgery is acute pain which everyone experiences some level of during one’s lifetime. It is actually protective and has an identifiable cause, in this case, the surgery itself was the cause of the pain. This kind of pain has limited tissue damage and emotional response. Acute knee pain usually follows injury or surgery. Chronic knee pain on the other hand can be related to disease such as osteoarthritis or associated with overuse or untreated injuries to muscles, ligaments, or tendons. Since acute pain is expected to be healed and the cause can be identified, healthcare teams are usually willing to treat the acute pain experienced by the client. Nurses should be aware that unrelieved acute pain can progress to chronic pain (Potter & Perry, 2004).                                                              Assessment of the client’s mobility enables the nurse to determine the client’s coordination and balance while walking, bending, and doing usual movements with the knee. The assessment of mobility has three components: range of motion, gait, and exercise (Potter & Perry, 2004). Assessing the range of motion is used to determine the degree of damage or injury to the joint or it could be from recovery. The nurse should ask questions about joint stiffness, swelling, pain, limited movement, and unequal movement. Assessing the client’s gait or the manner and style in walking allows the healthcare professional like the nurse to draw conclusions about balance and posture (Potter & Perry, 2004). Other than that, malignant hypothermia could occur and is a potentially lethal condition that can occur in clients who underwent knee replacement surgery and received general anesthesia. This should be suspected when there is unexpected tachycardia and tachypnea, jaw muscle rigidity, body rigidity of limbs, abdomen and chest, or hyperkalemia (Potter & Perry, 2004)              Clients who have temperature elevations should be assessed and nursing interventions should be planned for a possible infectious process. Postoperative interventions of deep breathing and coughing, early ambulation, and aseptic care of the surgical wound of the knees will decrease the client’s risk of postoperative infections.             Temperature regulation is important after surgery. Clients are often cool after the procedure and should be provided with warmed blankets. It is also important to note that when the client is shivering, it may not be a sign of hypothermia           but rather a side effect of certain anesthetic agents. Meperidine (Demerol) may be given in small increments to decrease shivering as prescribed by the physician (Potter & Perry, 2004).   Implementation               The client may be recommended to rest, the use of knee supports, the use of walking aids such as canes and walkers. Physical therapy and appropriate exercises may also be suggested. Occasionally, steroid injections into the knee may decrease pain and inflammation. A variety of drugs for arthritis exists. These range from painkillers aspirin and acetaminophen to NSAIDs (nonsteroidal anti-inflammatory drugs) such as diclofenac, meloxicam, piroxicam, mefenamic acid, ibuprofen, to the latest COX-2 inhibitors (rofecoxib and celecoxib).             Patients whose pain level is reported as tolerable should to be more active and willing to engage in physical therapy. With emphasis being placed on providing quality care while striving for cost-effectiveness, such adverse outcomes need to be targeted for prevention from all possible angles (Nussenzveig, 1999).   Summarization and Conclusion             Knee replacement surgery is a safe and cost-effective treatment for persistent knee pain and disability, and increasing numbers of patients are seeking it at an earlier age in order to minimize or eliminate pain and difficulty in moving the knee joint              Total knee replacement is “highly successful in relieving pain and restoring joint function. In a standard total knee replacement, the damaged areas of the thighbone, shinbone and kneecap are removed and replaced with prostheses. The ends of the remaining bones are smoothed and reshaped to accommodate the prostheses.             Although knee replacement surgeries are effective in treating osteoarthritis and other knee injuries, there are also post-operative complications which have to be taken cared of by the healthcare team. There are also needs that need to be taken cared of. These are the acute needs for the management of pain and mobility after surgery.             After surgery, the nurse still has many important factors to assess in order to make sure that the client is doing well after the surgery. The nurse should continue assessing the client until the critical factors are on a less intensive basis and the client can then be discharged.   Credit:ivythesis.typepad.com

TOTAL KNEE REPLACEMENT SURGERY

Introduction People undergo total knee replacement when arthritis or injury erodes the joint’s natural cushion...

TOTAL KNEE REPLACEMENT SURGERY

Introduction               People undergo total knee replacement when arthritis or injury erodes the joint’s natural cushioning to the point where it’s hard to walk even short distances without severe pain.               Knee replacements now cost the NHS more each year than total hip replacements. An ageing population and an increase in obesity-related conditions are placing an increasing strain on NHS resources, with the number of knee replacements performed rising by 15 per cent last year from 59,391 to 68,300. Doctors predict that by 2010, suchoperations could cost the NHS almost pounds 1 billion per year.               The average age for a total knee replacement is 70. Osteoarthritis, one of the four most common problems linked to obesity, is the major cause of surgery. Overweight and obese people are 24 per cent more likely to require knee surgery. About 68,300 knee replacements were performed in the UK in 2002, costing the NHS in the region of pounds 375 million (Blakemore, 2003).               There are more replacement operations performed on the knee than any other joint in the body: more than 600 000 total knee replacements are performed each year globally. The annual total global knee market is estimated to be worth billion (Advanced Ceramics Report).               Total knee replacement, which is defined as the surgical insertion of a hinged artificial joint, relieves pain and restores motion to a knee which is affected by arthritis or injury. In a standard total knee replacement, the damaged areas of the thighbone, shinbone and kneecap are removed and replaced with prostheses.   The diseased bone surfaces are removed and a two-piece metallic hinge is cemented into the cavities of the upper and lower leg bones (femur and tibia). After surgery, the knee is held in position, usually with a plaster cast. The ends of the remaining bones are smoothed and reshaped to accommodate the prostheses. Pieces of the artificial knee are typically held in place with bone cement or plaster cast. Physical therapy includes exercise and whirlpool baths. The mobility and range of motion of the joint increase slowly.             It is healing of the muscle and tendon that causes much of the pain during recovery, as clients must stretch those injured parts in order to regain knee motion. Despite excruciating pain and decreased mobility, many people with knees damaged by arthritis put off joint-replacement surgery out of fear and uncertainty.   Body   The largest joint in the body, the knee joint is formed where the lower part of the thighbone (femur) joins the upper part of the shinbone (tibia) and the kneecap (patella). Shock-absorbing cartilage covers the surfaces where these three bones touch (Snell, 2000). In a normal knee, the bone surfaces that come together at the joint-thighbone, shinbone and kneecap–are smooth and hard. A cushioning layer of tissue (cartilage) prevents direct contact between these bones. When the cartilage is damaged, these bones rub together, causing friction, pain and, eventually, deterioration of the bone surfaces (Bren, 2004). As it is the largest joint in the body, it is also prone to pain and loss of function and stability, which therefore requires surgery to be done.                         Remedies included not using the affected joint but more recently researchers have found some substances such as glucosamine and chondroitin, as well as apple pectin which have in some cases been able to stimulate regeneration of the cartilage. But often the recommendation consists of losing weight, use of pain killers from aspirin to ibuprophen, and the cox 2 inhibitors, one of which (Vioxx) got into trouble recently because they found it enhanced heart problems. Injecting a gel substitute into the knees has helped but often the relief lasts for only about six months.   The ultimate remedy by the doctors is total knee replacement. What this means is that they open up the knee, cut off or shave the ends of the leg bone and the thigh bone and cap them with a metal and hard plastic that allows articulation of the knees. The main benefit is the removal of pain.   There are actually three reasons the doctor (an orthopedic surgeon) will recommend an artificial knee. These are: 1) to relieve pain 2) to restore function and 3) to achieve stability. As the arthritic knee becomes more painful, the patient will use it less. Function, therefore, is lost. As the arthritic knee continues to deform, the patient will feel that the joint is wobbly or unstable.               The most common indication for total knee replacement is osteoarthritis, or degenerative joint disease. The end stage of osteoarthritis is wearing out of cartilage (smooth, gliding bone ends) resulting in bone-to-bone contact in diseased joints. It is progressive and becomes increasingly painful as the cartilage erodes. Younger people who get knee replacements have damaged their joints by trauma (accidents that destroy joint surfaces), infection, cancer or tumor, and inflammatory conditions such as rheumatoid arthritis.               Painful knees are the most common manifestation of osteoarthritis, while osteoarthritis in turn is the most common of the different kinds of arthritis. About 60 percent or more of arthritis sufferers have this form. But this is not the most difficult. Rheumatoid arthritis is often deforming and most painful of the hundred or so forms of arthritis.   Osteoarthritis can found in all weight-bearing joints such as the spinal column, the hips, the ankles, and the knees. Osteoarthritis in the knees is basically the loss of cartilage between the bones of the knees (Marieb, 2004). What causes it is still not clear. As the cartilage is eroded in the knees, standing or walking becomes more and more painful as the knee bones grind against each other without a cushion. An accident or high-impact sports like basketball or jogging can trigger the condition but often it is accompanied by overweight in the individual.   According to growth consultants, the rapid graying of Europe’s population with related increases in the incidence of musculoskeletal problems (particularly osteoarthritis) is expected to be a key driver for orthopaedic prosthetic implant devices over the long term. At the same time, enhanced clinical outcomes and clinical efficacy are boosting the number of procedures carried out on patients in younger age groups (PR Newswire).             Experts believe the total knee replacement could dramatically cut the recovery time of patients, freeing up hospital beds more quickly and saving money (Blakemore, 2003). The operation uses a minimally invasive technique to insert knee implants through an incision half the size of the usual ten to 13 inch wound. This results in much less cutting of the thigh muscles, leading to less pain and faster recovery.             A well-executed total knee replacement can last up to 15 years (95% predicted survival of the implant). Still, the operation and recovery can be grueling. Traditionally, surgeons make a 12-inch incision in the front of the knee, peel back the kneecap, and cut through the quadriceps muscle and a tendon that attaches it. That allows open access to the thigh and shin bones, which are cut to fit the metal-and-plastic joint implant (Neergaard, 2004).    Like any surgery, knee joint replacement carries certain life-threatening risks, such as infection, blood clots and complications from anesthesia. Other complications include nerve damage, dislocation of breakage after surgery, and wearing out or loosening of the joint over time (Bren, 2004). After the operation, there can be wound infection and worse, infection of the knee replacement. These may require prolonged antibiotics and possible removal of the implants.             Perioperative complications as defined by the investigator occurred in 5.4 percent of patients and 7.6 percent of knees. Most of these complications were “knee related” or deep venous thrombosis. There were only eight cardiovascular or pulmonary complications reported among nearly 6,000 patients, suggesting that these adverse effects were not fully addressed in the literature (Torrey, 2004).   Post-Operative Care               After the knee replacement surgery, it is expected that the care of the client can become complex as a result of physiological changes that may occur. Another thing is that, the client now has an artificial knee in him and this is something that the client has to get used to.               To assess the client’s condition after the knee replacement surgery, the nurse should apply critical thinking while relying on information from the preoperative nursing assessment, knowledge regarding the surgical procedure performed, and the events that occurred after surgery (Kozier & Erb, 2004).               The information that the nurse gathered from the client will help the nurse to detect any change and make decisions about client’s care. A variation from the client’s normal signs may indicate the onset of surgically related complications (Potter & Perry, 2004).               The nurse should thoroughly document the assessment, including vital signs, level of consciousness, comfort level, pain, range of motion or mobility among other things. The initial findings are a baseline for comparing changes before and after the surgery.               The nurse also has the responsibility of explaining to the client and his/her family the purpose of post-operative procedures or equipment and the status of the client.   Assessment and Nursing Diagnosis               Two acute needs of the client after total knee replacement surgery are pain and mobility. The physiology of these two are altered after surgery and the nurse needs to be extra attentive to these needs.             The pain after undergoing knee replacement surgery is intense but is still somewhat manageable (Ault, 2003). In the pain treatment of the patient, the nurse has to first and foremost assess resources for pain management. After this, the healthcare team looking after the patient should develop a collaborative plan.             In assessing the client’s pain, his or her self-report of the pain is the single most reliable indicator of the existence and intensity of the pain experienced and any related discomfort (Kozier & Erb, 2004). It is also important to take note that if the client senses that the nurse doubts that the client felt pain, there is a possibility that the client will share little information about their pain. Therefore the nurse should see to it that the client will feel comfortable in discussing whatever he or she feels.             It is imperative that the nurse set the stage for the relationship that allows for open communication about pain. Simple measures such as sitting when talking to clients about pain lets clients know that the nurse has the time and the interest to assess the pain felt by the client (Potter & Perry, 2004).             The kind of pain that the client experiences after surgery is acute pain which everyone experiences some level of during one’s lifetime. It is actually protective and has an identifiable cause, in this case, the surgery itself was the cause of the pain. This kind of pain has limited tissue damage and emotional response.                         Acute knee pain usually follows injury or surgery. Chronic knee pain on the other hand can be related to disease such as osteoarthritis or associated with overuse or untreated injuries to muscles, ligaments, or tendons.   Since acute pain is expected to be healed and the cause can be identified, healthcare teams are usually willing to treat the acute pain experienced by the client. Nurses should be aware that unrelieved acute pain can progress to chronic pain (Potter & Perry, 2004).                                                                        Assessment of the client’s mobility enables the nurse to determine the client’s coordination and balance while walking, bending, and doing usual movements with the knee. The assessment of mobility has three components: range of motion, gait, and exercise (Potter & Perry, 2004).             Assessing the range of motion is used to determine the degree of damage or injury to the joint or it could be from recovery. The nurse should ask questions about joint stiffness, swelling, pain, limited movement, and unequal movement. Assessing the client’s gait or the manner and style in walking allows the healthcare professional like the nurse to draw conclusions about balance and posture (Potter & Perry, 2004).             Other than that, malignant hypothermia could occur and is a potentially lethal condition that can occur in clients who underwent knee replacement surgery and received general anesthesia. This should be suspected when there is unexpected tachycardia and tachypnea, jaw muscle rigidity, body rigidity of limbs, abdomen and chest, or hyperkalemia (Potter & Perry, 2004).               Clients who have temperature elevations should be assessed and nursing interventions should be planned for a possible infectious process. Postoperative interventions of deep breathing and coughing, early ambulation, and aseptic care of the surgical wound of the knees will decrease the client’s risk of postoperative infections.               Temperature regulation is important after surgery. Clients are often cool after the procedure and should be provided with warmed blankets. It is also important to note that when the client is shivering, it may not be a sign of hypothermia            but rather a side effect of certain anesthetic agents. Meperidine (Demerol) may be given in small increments to decrease shivering as prescribed by the physician (Potter & Perry, 2004).   Implementation               The client may be recommended to rest, the use of knee supports, the use of walking aids such as canes and walkers. Physical therapy and appropriate exercises may also be suggested. Occasionally, steroid injections into the knee may decrease pain and inflammation. A variety of drugs for arthritis exists. These range from painkillers aspirin and acetaminophen to NSAIDs (nonsteroidal anti-inflammatory drugs) such as diclofenac, meloxicam, piroxicam, mefenamic acid, ibuprofen, to the latest COX-2 inhibitors (rofecoxib and celecoxib).               Patients whose pain level is reported as tolerable should to be more active and willing to engage in physical therapy. With emphasis being placed on providing quality care while striving for cost-effectiveness, such adverse outcomes need to be targeted for prevention from all possible angles (Nussenzveig, 1999).   Summarization and Conclusion             Knee replacement surgery is a safe and cost-effective treatment for persistent knee pain and disability, and increasing numbers of patients are seeking it at an earlier age in order to minimize or eliminate pain and difficulty in moving the knee joint.               Total knee replacement is “highly successful in relieving pain and restoring joint function. In a standard total knee replacement, the damaged areas of the thighbone, shinbone and kneecap are removed and replaced with prostheses. The ends of the remaining bones are smoothed and reshaped to accommodate the prostheses.                         Although knee replacement surgeries are effective in treating osteoarthritis and other knee injuries, there are also post-operative complications which have to be taken cared of by the healthcare team. There are also needs that need to be taken cared of. These are the acute needs for the management of pain and mobility after surgery.               After surgery, the nurse still has many important factors to assess in order to make sure that the client is doing well after the surgery. The nurse should continue assessing the client until the critical factors are on a less intensive basis and the client can then be discharged.   REFERENCES Ault, A. 2003, For Greater Mobility Panel Recommends Joint Replacement, International Herald Tribune. Blakemore, S. 2003, Pioneering Knee Surgery Could Save NHS Millions, Birmingham Post. Bren, L. 2004, Joint Replacement: An Inside Look, FDA Consumer. Guyton, A. and Hall, J. 2000, Textbook of Medical Physiology 10th Edition. Harcourt Asia Pte Ltd. Kozier, B. and Erb, G. 2004, Fundamentals of Nursing: Concepts, Process, and Practice 7th Edition. Pearson Education Inc. Marieb, E. 2004, Essentials of Human Anatomy and Physiology 7th Edition, Pearson Education Inc. Neergard, L. 2004, New Knee Replacement Surgery Gets Patients on Their Feet Faster, AP Worldstream. No Author. 2005, European Market for Hip and Knee Replacements, PR Newswire Europe. No Author. 2001, Knee Replacement for Pain Relief, Advanced Ceramics Report. Nussenzveig, T.C.L. 1999, Pain Management After Total Joint Replacement and its Impact on Patient Outcomes, AORN Journal. Potter, P. and Perry, A. 2004, Fundamentals of Nursing. Mosby. Snell, R. (2000). Clinical Anatomy for Medical Students 6th Edition. Lippincott Williams and Wilkins. Torrey, B. 2004, AHRQ Report on Total Knee Replacement, American Family Physician. Credit:ivythesis.typepad.com

TOTAL KNEE REPLACEMENT SURGERY

Introduction People undergo total knee replacement when arthritis or injury erodes the joint’s natural cushion...

CASE STUDY

CASE STUDY   Background of the Case Study               M.M., a 76-year old retired schoolteacher, had a fall in her retirement home and underwent Open Reduction Internal Fixation of her left femur. Open reduction internal fixation is a method of surgically repairing a fractured bone. Her preoperative control prothrombin time (PT) was 11 seconds.             She was then on bed rest for the first 2 days after the operation. At six in the morning on the second post operative day, her vital signs were 132/84mm Hg blood pressure, regular pulse of 84 beats, 16 respirations which are unlaboured, and temperature of 37.2° C. She is awake, alert and oriented. There are no adventitious heart sounds and breath sounds are clear but diminished in the bases bilaterally. Bowel sounds are present, and she is taking sips of clear liquids. Her medication orders include O2 to maintain an oxygen saturation (SaO2) of greater than 90%.             Based on the patient’s vital signs, her vital signs are normal, as well as her heart and breath sounds, and bowel sounds. The oxygen saturation value is normally 95-100% of capacity. She is on an oxygen medication in order to maintain normal saturation since she was just operated and the tendency is for oxygen to lower. Right to left shunts in the heart are strongly suspected if the arterial oxygen saturation is less than normal in the absence of lung disease, pulmonary congestion, or alveolar hypoventilation. Tests have therefore to be done to rule out the possibility of a heart disease or infarction in the patient. M.M.’s laboratory results show her hematocrit at 34%, Hemoglobin at 113 g/L, potassium at 4.1 mmol/L, and activated partial prothrombin time at 44 sec. Normal values for hematocrit in women are 37-47% (0.37-0.47) ( 2001). Laboratory results show that M.M.’s hematocrit is slightly lowered from the normal values. Normal values for hemoglobin in women are 12-16 g/dL (1.86-2.48 mmol/L). Normal potassium values range from 3.5-5 meq/L or 3.5-5 mmol/L (2000) which would reflect that the patient’s normal values are normal. Normal values for the activated partial thromboplastin time is between 25-37 seconds (2000), showing that the patient has a slightly elevated partial thromboplastin time. Pain is controlled with morphine sulfate 4 mg IV and promethazine (Phenergan) 25 mg IV q3h. She is also taking clexane 20mg units sub cutaneous injection daily, docusate sodium, and wearing a glyceryl trinitrate patch. At 2330 on the second postoperative day, the nurse answers M.M. call light and finds her lying in bed breathing rapidly and rubbing her right chest. She is complaining of right-sided chest pain and appears to be restless. She is slightly hypotensive, tachypnoeic, restless, and slightly confused. The pulse oximeter reads 86%, so the nurse started her on 3 to 6 L O2/NC. The nurse identified faint crackles in the posterior bases bilaterally; they were clear that morning. The monitor shows non-specific T wave changes and tachycardia.             The ventricular T wave represents the stage of repolarization of the ventricles, at which time the ventricular fibers begin to relax. It is normally positive in all the standard bipolar limb leads of an electrocardiogram. The T wave becomes abnormal or shows changes when the normal sequence of repolarization does not occur. Several factors can change this sequence of repolarization and cause non-specific T wave changes ( 2000).   Question 1: What will the nurse do?   The nurse notified the physician and gave a comprehensive handover describing the condition of the patient and what he/she had instigated. The physician ordered the patient to be transferred to intensive care unit (ICU), undergo blood coagulation studies, tests on arterial blood gases (ABGs) on room air, continued pulse oximetry, STAT chest x-ray (CXR), and STAT 12-lead electrocardiogram (ECG). These are tests that could check if the patient has pulmonary embolism. Once pulmonary embolism is diagnosed, the nurse should provide Airway management and oxygen administration. It is safe and efficacious to start anticoagulation therapy as soon as an embolism is strongly suspected and while diagnostic testing is in progress. Anticoagulants prevent the development of clots but do not aid in the lysis of an already existing clot (2004).   Question 2: What information will the physician gain from each of the above orders?   The patient’s vital sign at this time are 150/92 mm Hg blood pressure, 110 beats per minute pulse rate, 28 respirations per minute, and a temperature of 37.2°C. Note that from the vital signs alone, the patient is already hypertensive and is breathing rapidly. When pulmonary embolism is first suspected, patients should receive heparin at therapeutic doses until pulmonary embolism is excluded, provided that no contraindications to anticoagulation are present (2002). Such procedure is a blood coagulation study. Blood coagulation studies are used to rule out any diseases that have blood coagulation as a manifestation. Virchow’s triad on embolism are as follows: hypercoagulability; stasis; and injury to the vessel wall ( 2002). The case study did not mention what the results of the blood coagulation study were. An arterial blood gas determination on room air is typically ordered during the evaluation of a patient with suspected pulmonary embolism ( 1996). Determination of oxygen content of blood at different levels within the heart and the great vessels aids in determining the presence, direction, and volume of central shunt which could also rule out the presence of a serious heart condition. ABG analysis is the best way to evaluate acid-base balance. Measurement of ABGs involves analysis of six components. Deviation from a normal value will indicate that the patient is experiencing an acid-base imbalance (2004). These six components are pH, PaCO2, PaO2, oxygen saturation, base excess and bicarbonate (HCO3). The ABGs return for M.M. are as follows: pH 7.55, arterial carbon dioxide pressure (PaCO2) 24 mm Hg, bicarbonate 24 mmol/L, and arterial oxygen pressure (PaO2) 56 mm Hg. Oxygen saturation is 86% on room air.   Question 3: What is your interpretation of the ABGs, and what do you think the physician will order next?               The pH or arterial plasma which measures hydrogen ion concentration in the body fluids (2004) is normally 7.35 to 7.45 in value. PaCO2 which is the arterial and alveolar carbon dioxide tension is normally 35 to 45 mm Hg ( 2000). M.M.’s pH values are above the normal values. Normal values for bicarbonate is 24-28 meq/L or 24-28 mmol/L (2000). Compared to the normal values, the ABG results of M.M. show normal bicarbonate values.             Her PaCO2 is less than the normal values. This is an indication that hyperventilation has occurred (2004). Her PaO2 is 56 mm Hg which is bad since values lesser than 60 mm Hg can lead to anaerobic metabolism, resulting in lactic acid production and metabolic acidosis ( 2004). The oxygen saturation is 86% on room air. Since M.M.’s arterial PaO2, falls below 60 mm Hg, there is also a large drop in the oxygen saturation (2004). This is reflected also in the pulse oximeter that is why M.M. was started on 3 to 6 L O2/NC. There is no mention of base excess in the laboratory results. Findings reveal that there is no acid base imbalance in the patient since these values are not manifestations of certain signs and symptoms that are characteristic of any of the acid base imbalances (2004). Yet, deviances from the normal values show that there is indeed something wrong which the ABG analysis alone cannot point out. Therefore there is a need to do more tests. An electrocardiogram is used to rule out any heart problems which could be possibly given the presence of restlessness and severe pain on the chest of the patient. Since ECG changes are characteristically transient, serial tracings may be helpful in the diagnosis and exclusion of a myocardial infarction (Merck Manual, 2006). The standard 12-lead ECG is very useful in the detection of infarctions of the inferior, anterior, and lateral walls of the left ventricle. 12-lead ECG has been useful in the early detection and rapid reperfusion of patients with acute MI ( 2002). ECG tracings can be used to support and extend impressions gathered from the history, physical signs, blood gases, and x-rays. There is no mention of ECG tracings indicative of a heart failure, therefore that condition is ruled out as what the patient is experiencing. In pulmonary embolism, the electrocardiogram is usually abnormal, but nonspecific ST-segment or T-wave changes are the most common finding (1996), the last one being the case for M.M. prompting tests to identify the presence of pulmonary embolism. The use of chest x-rays can rule out the presence of infarctions also ( 2006). Chest x-ray findings show a small right infiltrate on M.M. The chest x-ray findings of M.M. indicates some sort of characteristic of infarction, yet the case study did not mention also anything that would indicate an embolism. An infiltrative lesion is usually characteristic of a myocardial infarction (2000). From the results of all the tests and medical screenings that were done, a pulmonary embolus is suspected. The physician could order a lung scan to further verify that it is indeed a pulmonary embolus. The physician should then order appropriate treatment for the patient.   Question 4: A pulmonary embolus is suspected. What are the most likely sources of the embolus?   This condition is known as pulmonary embolism or otherwise called thromboembolism. It is the lodgment of a blood clot in a pulmonary artery with subsequent obstruction of blood supply to the lung parenchyma. The most common type of pulmonary embolus is a thromboembolus which usually has formed in the deep leg veins or the pelvic veins. Most of the causing serious hemodynamic disturbances form in the ileofemoral veins.             When the emboli or the lodge blood clot block larger branches of the pulmonary artery, they provoke a rise in the pulmonary arterial pressure, which is reflected in the ABG tests, and a rapid, shallow respiration, a medical condition called as tachypnea (2001), which was already observed by the nurse. Tachypnea almost always occur following an embolic episode, therefore there is a need to do tests that will check if what the patient is experiencing is embolism or something else. This tachypnea experienced by M.M. is a reflex response to activation of vagally innervated receptors close to the vessel walls that appear to be activated by serotonin released from platelets at the site of embolization (2000). The site of thrombus formation is usually clinically inapparent in more than 50% of cases since associated inflammatory changes are insufficient. It can be detected in cases without physical signs only by using angiographic or isotopic diagnostic technics.             The pathophysiologic changes that occur following pulmonary embolism are complex, involving alterations in pulmonary hemodynamics, gas exchange, and mechanics. All the results of the tests show pathophysiologic changes that are characteristic of pulmonary embolism. Cardiopulmonary function is affected in the event of embolism (2000), that is why M.M. is experiencing breathing problems.             Although at first the patient was hypotensive, later on her vital signs taken by the nurse show that her blood pressure increased indicative of hypertension which is a characteristic of pulmonary embolism. Hypertension is the most important physiologic alteration following embolization which results from the increased pulmonary vascular resistance.             Risk factors for pulmonary embolism include immobilization, trauma and surgery, particularly for hip fracture (1996). The last one could be the reason why M.M. developed pulmonary embolism. Surgery further increases the risk of having pulmonary embolism. The frequency of pulmonary embolism in patients after undergoing an operation varies with site of operation. A rate 40 % of pulmonary embolism after operation on back and extremities was reported ( 1995). Major orthopedic surgery such as hip or knee replacement or fractures is related to a higher prevalence of pulmonary embolism (1995), thus could be the major reason of M.M. developing the condition.   Summary, Conclusion and Recommendations               Based on the findings of the medical tests and procedures that were ordered by the physician to be performed on M.M., it was found out that the patient has pulmonary embolism. Her pulmonary embolism probably resulted from the open reduction internal fixation surgery of her left femur. Yet although she has already been diagnosed as having pulmonary embolism in the case study, certain descriptions merit further investigation on her condition. Some of the symptoms exhibited by M.M., such as infiltrations in the chest x-ray findings, are actually characteristic of a heart failure or myocardial infarction. The presence also of faint crackles in the lungs could be indicative of a myocardial infarction since examination of the lungs in a condition of pulmonary embolism alone is usually normal ( 2006). Pulmonary infarction is defined as one with the presence of an infiltrate (2002). It should also be taken into consideration that the manifestations of a pulmonary embolus usually develops abruptly over a period of minutes which is not the case for M.M. The manifestations of infarction, on the other hand, develops over a period of hours ( 2006). The physician should order more medical tests and procedures to be done since it is not unlikely that with pulmonary embolism the patient has also developed myocardial infarction which the first set of tests and procedures have not shown.                           Credit:ivythesis.typepad.com

CASE STUDY

CASE STUDY Background of the Case Study M.M., a 76-year old retired schoolteacher, had a fall in her retirement home ...

TOTAL KNEE REPLACEMENT SURGERY

TOTAL KNEE REPLACEMENT SURGERY   Introduction               People undergo total knee replacement when arthritis or injury erodes the joint’s natural cushioning to the point where it’s hard to walk even short distances without severe pain.               Knee replacements now cost the NHS more each year than total hip replacements. An ageing population and an increase in obesity-related conditions are placing an increasing strain on NHS resources, with the number of knee replacements performed rising by 15 per cent last year from 59,391 to 68,300. Doctors predict that by 2010, such operations could cost the NHS almost pounds 1 billion per year.               The average age for a total knee replacement is 70. Osteoarthritis, one of the four most common problems linked to obesity, is the major cause of surgery. Overweight and obese people are 24 per cent more likely to require knee surgery. About 68,300 knee replacements were performed in the UK in 2002, costing the NHS in the region of pounds 375 million (2003).               There are more replacement operations performed on the knee than any other joint in the body: more than 600 000 total knee replacements are performed each year globally. The annual total global knee market is estimated to be worth billion ().               Total knee replacement, which is defined as the surgical insertion of a hinged artificial joint, relieves pain and restores motion to a knee which is affected by arthritis or injury. In a standard total knee replacement, the damaged areas of the thighbone, shinbone and kneecap are removed and replaced with prostheses.   The diseased bone surfaces are removed and a two-piece metallic hinge is cemented into the cavities of the upper and lower leg bones (femur and tibia). After surgery, the knee is held in position, usually with a plaster cast. The ends of the remaining bones are smoothed and reshaped to accommodate the prostheses. Pieces of the artificial knee are typically held in place with bone cement or plaster cast. Physical therapy includes exercise and whirlpool baths. The mobility and range of motion of the joint increase slowly.             It is healing of the muscle and tendon that causes much of the pain during recovery, as clients must stretch those injured parts in order to regain knee motion. Despite excruciating pain and decreased mobility, many people with knees damaged by arthritis put off joint-replacement surgery out of fear and uncertainty.   Body   The largest joint in the body, the knee joint is formed where the lower part of the thighbone (femur) joins the upper part of the shinbone (tibia) and the kneecap (patella). Shock-absorbing cartilage covers the surfaces where these three bones touch ( 2000). In a normal knee, the bone surfaces that come together at the joint-thighbone, shinbone and kneecap–are smooth and hard. A cushioning layer of tissue (cartilage) prevents direct contact between these bones. When the cartilage is damaged, these bones rub together, causing friction, pain and, eventually, deterioration of the bone surfaces (2004). As it is the largest joint in the body, it is also prone to pain and loss of function and stability, which therefore requires surgery to be done.                         Remedies included not using the affected joint but more recently researchers have found some substances such as glucosamine and chondroitin, as well as apple pectin which have in some cases been able to stimulate regeneration of the cartilage. But often the recommendation consists of losing weight, use of pain killers from aspirin to ibuprophen, and the cox 2 inhibitors, one of which (Vioxx) got into trouble recently because they found it enhanced heart problems. Injecting a gel substitute into the knees has helped but often the relief lasts for only about six months.   The ultimate remedy by the doctors is total knee replacement. What this means is that they open up the knee, cut off or shave the ends of the leg bone and the thigh bone and cap them with a metal and hard plastic that allows articulation of the knees. The main benefit is the removal of pain.   There are actually three reasons the doctor (an orthopedic surgeon) will recommend an artificial knee. These are: 1) to relieve pain 2) to restore function and 3) to achieve stability. As the arthritic knee becomes more painful, the patient will use it less. Function, therefore, is lost. As the arthritic knee continues to deform, the patient will feel that the joint is wobbly or unstable.               The most common indication for total knee replacement is osteoarthritis, or degenerative joint disease. The end stage of osteoarthritis is wearing out of cartilage (smooth, gliding bone ends) resulting in bone-to-bone contact in diseased joints. It is progressive and becomes increasingly painful as the cartilage erodes. Younger people who get knee replacements have damaged their joints by trauma (accidents that destroy joint surfaces), infection, cancer or tumor, and inflammatory conditions such as rheumatoid arthritis.               Painful knees are the most common manifestation of osteoarthritis, while osteoarthritis in turn is the most common of the different kinds of arthritis. About 60 percent or more of arthritis sufferers have this form. But this is not the most difficult. Rheumatoid arthritis is often deforming and most painful of the hundred or so forms of arthritis.   Osteoarthritis can found in all weight-bearing joints such as the spinal column, the hips, the ankles, and the knees. Osteoarthritis in the knees is basically the loss of cartilage between the bones of the knees (2004). What causes it is still not clear. As the cartilage is eroded in the knees, standing or walking becomes more and more painful as the knee bones grind against each other without a cushion. An accident or high-impact sports like basketball or jogging can trigger the condition but often it is accompanied by overweight in the individual.   According to growth consultants, the rapid graying of Europe’s population with related increases in the incidence of musculoskeletal problems (particularly osteoarthritis) is expected to be a key driver for orthopaedic prosthetic implant devices over the long term. At the same time, enhanced clinical outcomes and clinical efficacy are boosting the number of procedures carried out on patients in younger age groups ().             Experts believe the total knee replacement could dramatically cut the recovery time of patients, freeing up hospital beds more quickly and saving money (2003). The operation uses a minimally invasive technique to insert knee implants through an incision half the size of the usual ten to 13 inch wound. This results in much less cutting of the thigh muscles, leading to less pain and faster recovery.             A well-executed total knee replacement can last up to 15 years (95% predicted survival of the implant). Still, the operation and recovery can be grueling. Traditionally, surgeons make a 12-inch incision in the front of the knee, peel back the kneecap, and cut through the quadriceps muscle and a tendon that attaches it. That allows open access to the thigh and shin bones, which are cut to fit the metal-and-plastic joint implant (2004).    Like any surgery, knee joint replacement carries certain life-threatening risks, such as infection, blood clots and complications from anesthesia. Other complications include nerve damage, dislocation of breakage after surgery, and wearing out or loosening of the joint over time ( 2004). After the operation, there can be wound infection and worse, infection of the knee replacement. These may require prolonged antibiotics and possible removal of the implants.             Perioperative complications as defined by the investigator occurred in 5.4 percent of patients and 7.6 percent of knees. Most of these complications were “knee related” or deep venous thrombosis. There were only eight cardiovascular or pulmonary complications reported among nearly 6,000 patients, suggesting that these adverse effects were not fully addressed in the literature (2004).   Post-Operative Care               After the knee replacement surgery, it is expected that the care of the client can become complex as a result of physiological changes that may occur. Another thing is that, the client now has an artificial knee in him and this is something that the client has to get used to.               To assess the client’s condition after the knee replacement surgery, the nurse should apply critical thinking while relying on information from the preoperative nursing assessment, knowledge regarding the surgical procedure performed, and the events that occurred after surgery ( 2004).               The information that the nurse gathered from the client will help the nurse to detect any change and make decisions about client’s care. A variation from the client’s normal signs may indicate the onset of surgically related complications (Potter & Perry, 2004).               The nurse should thoroughly document the assessment, including vital signs, level of consciousness, comfort level, pain, range of motion or mobility among other things. The initial findings are a baseline for comparing changes before and after the surgery.               The nurse also has the responsibility of explaining to the client and his/her family the purpose of post-operative procedures or equipment and the status of the client.   Assessment and Nursing Diagnosis               Two acute needs of the client after total knee replacement surgery are pain and mobility. The physiology of these two are altered after surgery and the nurse needs to be extra attentive to these needs.             The pain after undergoing knee replacement surgery is intense but is still somewhat manageable (2003). In the pain treatment of the patient, the nurse has to first and foremost assess resources for pain management. After this, the healthcare team looking after the patient should develop a collaborative plan.             In assessing the client’s pain, his or her self-report of the pain is the single most reliable indicator of the existence and intensity of the pain experienced and any related discomfort (2004). It is also important to take note that if the client senses that the nurse doubts that the client felt pain, there is a possibility that the client will share little information about their pain. Therefore the nurse should see to it that the client will feel comfortable in discussing whatever he or she feels.             It is imperative that the nurse set the stage for the relationship that allows for open communication about pain. Simple measures such as sitting when talking to clients about pain lets clients know that the nurse has the time and the interest to assess the pain felt by the client ( 2004).             The kind of pain that the client experiences after surgery is acute pain which everyone experiences some level of during one’s lifetime. It is actually protective and has an identifiable cause, in this case, the surgery itself was the cause of the pain. This kind of pain has limited tissue damage and emotional response.                         Acute knee pain usually follows injury or surgery. Chronic knee pain on the other hand can be related to disease such as osteoarthritis or associated with overuse or untreated injuries to muscles, ligaments, or tendons.   Since acute pain is expected to be healed and the cause can be identified, healthcare teams are usually willing to treat the acute pain experienced by the client. Nurses should be aware that unrelieved acute pain can progress to chronic pain (2004).                                                                        Assessment of the client’s mobility enables the nurse to determine the client’s coordination and balance while walking, bending, and doing usual movements with the knee. The assessment of mobility has three components: range of motion, gait, and exercise ( 2004).             Assessing the range of motion is used to determine the degree of damage or injury to the joint or it could be from recovery. The nurse should ask questions about joint stiffness, swelling, pain, limited movement, and unequal movement. Assessing the client’s gait or the manner and style in walking allows the healthcare professional like the nurse to draw conclusions about balance and posture ( 2004).             Other than that, malignant hypothermia could occur and is a potentially lethal condition that can occur in clients who underwent knee replacement surgery and received general anesthesia. This should be suspected when there is unexpected tachycardia and tachypnea, jaw muscle rigidity, body rigidity of limbs, abdomen and chest, or hyperkalemia (2004).               Clients who have temperature elevations should be assessed and nursing interventions should be planned for a possible infectious process. Postoperative interventions of deep breathing and coughing, early ambulation, and aseptic care of the surgical wound of the knees will decrease the client’s risk of postoperative infections.               Temperature regulation is important after surgery. Clients are often cool after the procedure and should be provided with warmed blankets. It is also important to note that when the client is shivering, it may not be a sign of hypothermia            but rather a side effect of certain anesthetic agents. Meperidine (Demerol) may be given in small increments to decrease shivering as prescribed by the physician ( 2004).   Implementation               The client may be recommended to rest, the use of knee supports, the use of walking aids such as canes and walkers. Physical therapy and appropriate exercises may also be suggested. Occasionally, steroid injections into the knee may decrease pain and inflammation. A variety of drugs for arthritis exists. These range from painkillers aspirin and acetaminophen to NSAIDs (nonsteroidal anti-inflammatory drugs) such as diclofenac, meloxicam, piroxicam, mefenamic acid, ibuprofen, to the latest COX-2 inhibitors (rofecoxib and celecoxib).               Patients whose pain level is reported as tolerable should to be more active and willing to engage in physical therapy. With emphasis being placed on providing quality care while striving for cost-effectiveness, such adverse outcomes need to be targeted for prevention from all possible angles ( 1999).   Summarization and Conclusion             Knee replacement surgery is a safe and cost-effective treatment for persistent knee pain and disability, and increasing numbers of patients are seeking it at an earlier age in order to minimize or eliminate pain and difficulty in moving the knee joint.               Total knee replacement is “highly successful in relieving pain and restoring joint function. In a standard total knee replacement, the damaged areas of the thighbone, shinbone and kneecap are removed and replaced with prostheses. The ends of the remaining bones are smoothed and reshaped to accommodate the prostheses.                         Although knee replacement surgeries are effective in treating osteoarthritis and other knee injuries, there are also post-operative complications which have to be taken cared of by the healthcare team. There are also needs that need to be taken cared of. These are the acute needs for the management of pain and mobility after surgery.               After surgery, the nurse still has many important factors to assess in order to make sure that the client is doing well after the surgery. The nurse should continue assessing the client until the critical factors are on a less intensive basis and the client can then be discharged.   Credit:ivythesis.typepad.com

TOTAL KNEE REPLACEMENT SURGERY

TOTAL KNEE REPLACEMENT SURGERY Introduction People undergo total knee replacement when arthritis or injury erod...