CASE PRESENTATION TOTAL KNEE REPLACEMENT

Presented by: Group 1 Group Leader: Comprendio, Cristian Mae Members: Cacho, Lucille Campos, Jessa Casaquite, Nevalyn Castroverde, Aldrece Ne Chan, Pauline Cercado, Argyl Dadivas, Mary Mae Rhiwa Depakakibo, Chelsea Marie Dilag, Graceous Faith Nepomuceno, Ina

August 28, 2013

Case Scenario: Mr. Giester is an 82-year-old man who underwent surgery for a total knee replacement. He is alert and oriented and has been able to give good feedback when asked to explain activity restrictions at home. He will be taking pain medication for his knee along with his regular antihypertensive medication and vitamins. Mr. Giester will continue to go to rehabilitation even after discharge. His doctor has recommended using a walker and gait training and muscle strengthening. What health care services might you refer Mr. Giester to, and what is your rationale? ______________________________________________________________________ MINI-LECTURE ANATOMY OF THE KNEE FOUR BONES MAKE UP THE KNEE: Tibia (shin bone) Patella (knee cap) Femur (thigh bone) Fibula (long, thin bone)

CARTILAGE A. MENISCI Act as "cushions" or "shock absorbers". Sit between the femur and the tibia. Help provide stability to the knee.

B. ARTICULAR CARTILAGE A white, smooth, fibrous connective tissue that covers the ends of bones. Allows the knee bones to move easily as the knee bends and straightens.

TENDONS Elastic tissues that connect muscles to bones. Serve to stabilize the knee. Two major tendons: quadriceps patellar LIGAMENTS Attach bones to bones and give strength and stability to the knee. Strong, tough bands that is not particularly flexible.

JOINT CAPSULE BURSA Bursa is a small fluid filled sac that decreases the friction between two tissues. Protects bony structures. MUSCLES Quadriceps muscles are the main muscles that straighten the knee. Hamstring muscles are the main muscles that bend the knee. The capsule is a thick, fibrous structure that wraps around the knee joint. Synovial membrane which is lined by the synovium.

TOTAL KNEE REPLACEMENT Also known as KNEE ARTHROPLASTY. Helps relieve pain and restore function in severely diseased knee joints. Surgeon cuts away damaged bone and cartilage and replaces it with an artificial joint made of metal alloys, high-grade plastics and polymers.

CAUSE Osteoarthritis Rheumatoid arthritis Post-traumatic arthritis Bleeding into the joint (e.g. hemarthosis)

RISKS Infection Blood clots in the leg vein or lungs Heart attack Stroke Nerve damage

Signs of infection: Fever greater than 100 F (37.8 C) Shaking chills Drainage from the surgical site Increasing redness, tenderness, swelling and pain in the knee

PREOPERATIVE Joints adjacent to the diseased knee (hip and ankle) are carefully evaluated. Blood-thinning medications such as warfarin (Coumadin) and anti-inflammatory medications such as aspirin may have to be adjusted or discontinued prior to surgery. Smoking should be stopped. Routine blood tests of liver and kidney function and urine tests are evaluated. Chest X-ray and EKG are performed. Preoperative laboratory evaluation should also be included. Antibiotics and anti-thrombotic prophylaxis are given approximately 30 minutes before the incision is made.

INTRAOPERATIVE Knee is in a bent position so that all surfaces of the joint are fully exposed. After making an incision about 6 to 10 inches (15 to 25 centimeters) in length, the surgeon moves aside the kneecap and cuts away the damaged joint surfaces. The surgeon inserts and attaches the pieces of the artificial joint.

POSTOPERATIVE The knee is dressed with a compression bandage. Ice may be applied. Encourage active flexion of the foot every hour when the Mr. Giester is awake .

Wound suction drain removes fluid accumulating in the joint. Continuous Passive Motion (CPM) machine is first attached to the operated leg, which increases circulation and range of motion of the knee joint.

Assist Mr. Giester to get out of the bed on the evening or the day after surgery. Mr. Giester must wear a support hose or compression boots to further protect against swelling and clotting.

Knee is usually protected with a knee immobilizer (splint, cast or brace) and is elevated when Mr. Giester sits in a chair.

Progressive ambulation, using assistive devices and within the prescribed weight bearing limits begin on the day after surgery.

Begin physical therapy 48 hours after surgery. Teach Mr. Giester instructions about deep breathing and using incentive spirometer.

COMPETENCY STANDARDS FOR NURSING PRACTICE A. Safe and Quality Nursing Care Identification of the Problem Patient is an elderly man who underwent surgery for a total knee replacement. Patient is unaware of the health care services that he needs. Prioritized Problem

Health Care Related Services and Health Education for post operative Total Knee Replacement Therapy.

While Mr. Giester is still in the hospital, assist him do the basics of personal maintenance such as walk with an aid (walker or crutches) to the bathroom, stand for short periods at the sink, and go up and down a few stairs.

Encourage Mr. Giester to move his foot and ankle immediately following surgery to increase blood flow in his leg muscles to help prevent leg swelling and blood clots.

Provide an environment where Mr. Giester can perform various exercises safely. Always put the side rails up when Mr. Giester is on bed to prevent fall and injuries.

Maintain the privacy and confidentiality while performing procedures such as in drug administration.

Provide wound care in order to prevent infection.

Watch out for signs of infection such as:

Persistent fever (higher than 100F orally) Shaking chills Increasing redness, tenderness, or swelling of the knee wound Drainage from the knee wound Increasing knee pain with both activity and rest

Prevent further complications such as pneumonia by encouraging Mr. Giester to move out of bed more often and take frequent deep breaths.

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

B. Management of Resources and Environment Check the availability of supplies and equipment (such as BP apparatus, walker or crutches) at home. Check if equipments are properly functional. Check the availability of medication for pain and high blood pressure and vitamins for his health. Check the contact numbers or tell Mr. Giester to have a number of a relative or any emergency department to help him in case of emergency happened to him. Keep an environment that is clean and safe for Mr. Giester to perform various exercises. Place unnecessary things on an empty box or cabinet so that it will not scattered all around and to prevent injury to occur. Observe proper waste disposal within the environment to promote cleanliness.

Observe proper hand washing or use of universal precaution to avoid development of any infectious diseases or communicable diseases.

C. Health Education Teach Mr. Giester not to do the following: Put a pillow behind his knee when lying. Kneel on his new knee joint. Deep squats (squatting down to the floor).

After surgery, encourage him to: Sit on a raised chair or use a cushion. Use long-handled aids, like a shoehorn and reacher, to help you get dressed or pick up items. How to do wound care at home. Eat a balanced diet, often with an iron supplement. Exercise particularly during the first few weeks after surgery.

Resuming other normal household activities, such as sitting, standing, and climbing stairs is a good activity once at home.

Teach Mr. Giester and the family ensure safe home set- up: Ensure hallways and rooms are free of clutter and tripping. Add non-slip surfaces to outside stairs and walkways. Install stair railings or make sure the existing ones are secure. Ensure good lighting in hallways and other well used areas.

Move frequently used household items to counter height. Consider moving items in the lower parts of the fridge/freezer to a higher shelf.

Keep an ice pack in the freezer for possible joint swelling after surgery. Alternatively, use a bag of frozen peas.

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

Install a raised toilet seat with armrests/toilet safety frame to assist when sitting or standing.

Remove sliding doors from the bathtub and replace with a shower curtain. Use a non-slip bathmat both inside and outside the bathtub or shower. Install a hand-held shower hose in the bathtub. Grab bars in the bathtub/shower stall and by the toilet are very useful. Removable grab bars are available. Do not use towel racks or toilet paper holders to assist you to stand or sit.

D. Legal Responsibility Apply the Ten Golden Rules in medication administration. Document accurately all activities concerning the patient. Adhere with RA 9173 or Philippine Nursing Law of 2002 for rendering quality care. Adhere with RA 9994 or the Expanded Senior Citizen Act of 2010.

Section 4 of Republic Act No. 7432, as amended by Republic Act No. 9257, otherwise known as the "Expanded Senior Citizens Act of 2003", is hereby further amended to read as follows:

"SEC. 4. Privileges for the Senior Citizens. - The senior citizens shall be entitled to the following:

"(1) on the purchase of medicines, including the purchase of influenza and pnuemococcal vaccines, and such other essential medical supplies, accessories and equipment to be determined by the Department of Health (DOH).

"(2) on the professional fees of attending physician/s in all private hospitals, medical facilities, outpatient clinics and home health care services;

"(3) on the professional fees of licensed professional health providing home health care services as endorsed by private hospitals or employed through home health care employment agencies;

"(4) on medical and dental services, diagnostic and laboratory fees in all private hospitals, medical facilities, outpatient clinics, and home health care services, in accordance with the rules and regulations to be issued by the DOH, in coordination with the Philippine Health Insurance Corporation (PhilHealth).

E. Ethico-moral Responsibility Respect the rights of the patient: Right to privacy and confidentiality Right to Information - regarding the details of the procedure to be performed, its possible complications and risks factors after the surgery and access to his medical records. Right to Self-determination-decide on what type of health care services, personnel and treatment he prefer Right to be Informed of his rights and obligations as a patient-particularly on his current prognosis and status while undergoing rehabilitative services. Principle of justice - rendering care of what is due or merited One should give Mr. Geister what he owed, what he deserve, or what he can legitimately claim according to a proper allocation of benefits and burdens where he will be treated equally. Principle of respect for persons- all individual human beings are presumed to be free and responsible persons and should be treated as such in proportion to their ability in the circumstances. As a subject, and not merely an object, Mr. Geister must be treated with respect in such a way that recognizes his human dignity while performing the surgery and undergoing treatment.

Principle of integrity and totality - these principles dictate that the well-being of the whole person must be taken into account in deciding about any therapeutic intervention or use of technology Treat Mr. Giester as a subject and not an object of care. Provide holistic nursing care, not merely attending to his physical needs but also to other aspects of care (social, spiritual, emotional, etc.)

F. Personal and Professional Development Nurse must know about effective management to achieve his/her goals and read journals, search for the latest updates about caring and dealing with patient. Improve self-knowledge and skills through attending conventions and seminars especially in cases related to the subject matter. Must present ones self appropriately and also demonstrate professionalism towards the patient. Capacity and ability to work cooperatively and positively with other health team members as well as the patient and significant others. Take time to ask from the patient or folks if they are satisfied with the care and services rendered to them.

G. Records Management Ensure confidentiality and privacy of Mr. Giester. Document problems identified with Mr. Giester for intervention to takes place.

Record Mr. Glisters status such as vital signs to update his condition and provide baseline data.

Document all the procedures, equipments used and attached to the Mr. Giester. Refrain from releasing records and data about him without proper authority to ensure confidentiality and privacy of Mr. Giester.

Ask permission to proper authority if releasing of records is needed. Ensure the completeness of the Mr. Giesters data on the chart following the hospital protocol (hospital number, name, age, informed consent etc.) and refrain from making errors.

H. Quality Improvement Nurses should have a sufficient knowledge regarding on patients condition. Ask feedback from the patient regarding treatment process to improve or change any procedure that the patient is not comfortable with or is having any significant reactions. Share any experience that you have in dealing with the patient with the health team and any other significant need of the client to be prioritized. Report any variance to the health care team in order to come with solutions to prevent any further complications with the patients condition. Suggest appropriate teaching on corrective and preventive measures for the patient. Report objectively what you observed during the visit on the patient.

I. Research Total knee replacement plus physical and medical therapy or treatment with physical and medical therapy alone: a randomised controlled trial in patients with knee osteoarthritis (Skou, S.T.,et al.,2012) This study is about the lack of high quality evidence concerning the efficacy of total knee arthroplasty (TKA). Treatment of knee osteoarthritis (KOA) should include patient education, exercise and weight loss. Insoles and pharmacological treatment can be included as supplementary treatments. If the combination of these non-surgical treatment modalities is ineffective, TKA may be indicated. Result: There is a lack of high quality evidence concerning the efficacy of TKA and around 20% of KOA patients experience little or no improvement in pain, disability and quality of life following the TKA.

J. Communication Establish rapport with Mr. Giester, significant others and members of the health team to gain trust and to have confidence in rendering care to the patient. Explain the purpose of being there. Establish rapport to gain trust and perform the tasks with confidence. Ask how the patient is feeling. Express interest in his aches and pains if he elaborates on them, but don't press him if he simply answers yes or no. Respond to the needs. Provide confidence through therapeutic, touch, warmth and comforting words of encouragement.

Speak in terms that the patient can understand. Provide complete attention. Effective, "active" listening in which the provider gives small verbal or non-verbal feedback that indicates to the clients that they are being heard and understood.

K. Collaboration and Teamwork Coordinate with other health team members in providing care for Mr. Giester: Orthopedic surgeon - responsible for the diagnosis and preoperative, operative, and postoperative treatment of diseases and injuries. Attending physician - oversees the care and treatment decisions of the patient. Staff nurse - provides bedside care. Ortho Care Technicians (OCT) - if the doctor ordered special ortho equipment as part of the treatment, the OCT is the one who will set it up and then make rounds to check the patient and the equipment. Pharmacologist - evaluate medications for possible interactions and their impact on your disease or condition. Physical Therapist - teaches the patient proper and safe techniques for exercises, bed mobility, transfers in and out of chairs and automobiles, walking with crutches or walker and reinforces precautions. Occupational Therapists - teaches the patient proper and safe techniques for bathing, toileting and dressing. Maintain a good interpersonal relationship with the patient and other support system.

Discuss information concerning the patient to the health care team involve. Nurses and other health care personnel should participate actively in patient care and management for the improvement of patients condition.

Always do what is best for the patient through collaboration and teamwork. If there would be any abnormalities noted, urgent reporting to the physicians should be done and if possible recommend appropriate intervention to improve patient care.

Contributes to decision making regarding patients needs and recommend appropriate intervention to improve patient care.

NURSING CARE PLAN Assessment Objective Cues:

Imposed restrictions of movement, including mechanical, medical protocol, and impaired coordination

limited range of motion gait changes (e.g., decreased walking speed, difficulty initiating gait, shuffles feet, lateral postural sway)

Nursing Diagnosis Impaired physical mobility related to pain and discomfort in surgical site as well as contralateral joint, musculoskeletal impairment, total knee replacement surgery and restrictive therapies. Outcome Criteria After 1 month of effective nursing interventions, Mr. Giester will verbalize feeling of increased strength in affected joint and limb and ability to move independently with use of assistive device.

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

Performs physical activity independently or with use of assistive devices (wheelchairs, walkers) as needed.

Participate in Activities of Daily Living (ADLs) and rehabilitation program. Display increased strength, ROM, and function of affected joint and limb.

Nursing Interventions and Rationale Independent 1. Screen for mobility skills in the following order: (1) bed mobility; (2) supported and unsupported sitting;

(3) transition movements such as sit to stand, sitting down, and transfers; and (4) standing and walking activities. Screening mobility skills helps provide baselines of performance that can guide mobility-enhancement programming and allows nursing staff to integrate movement and practice opportunities into daily routines and regular and customary care. 2. Encourage and facilitate early ambulation and other ADLs when possible. Assist with each initial change: dangling, sitting in chair, ambulation. The longer the patient remains immobile the greater the level of debilitation that will occur. 3. Obtain any assistive devices needed for activity, such as walking belts, walkers, canes, crutches, or wheelchairs, before the activity begins. Assistive devices can help increase mobility. 4. Perform passive range of motion (ROM) exercises on the affected side at least twice a day unless contraindicated; repeat each maneuver three times. Passive ROM exercises help maintain joint mobility, prevent contractures and deformities, increase circulation, and promote a feeling of comfort and wellbeing. 5. Ensure that chairs fit the patient. Chair seat should be 3 inches above the height of the knee. Provide a raised toilet seat if needed. Raising the height of a chair can improve the ability of many older clients to stand up.

6. Turn on unoperated side using adequate number of personnel and maintaining operated extremity in prescribed alignment. Prevents dislocation of knee prosthesis and prolonged skin and tissue pressure, reducing risk of tissue ischemia and breakdown and reduces risk of injury during recovery from effects of anesthesia. 7. Allow patient to perform tasks at his or her own rate. Do not rush patient. Encourage independent activity as able and safe. Hospital workers and family caregivers are often in a hurry and do more for patients than needed, thereby slowing patient's recovery and reducing his or her self-esteem.

Collaborative 1. Consult with physical therapist for further evaluation, strength training, gait training, and development of a mobility plan. Techniques such as gait training, strength training, and exercise to improve balance and coordination can be very helpful for rehabilitating clients. Evaluation Met. After 1 month of effective nursing intervention Mr. Giester was able to verbalize feeling of increased strength in affected joint and limb and ability to move independently with use of assistive device.

Discharge Planning Medication- instruct Mr. Giester and family to comply with the medications prescribed. Environment- provide a safe environment. Instruct to maintain the bed in low position, sit on a firm, raised chair with armrest, and use the handrails on the toilet. Ensure good lighting and hallways and rooms are free of clutter and tripping hazards. Treatment- assist with range of motion active / passive exercises. Instruct to
perform his exercise routine 3 times a day as instructed by the PT and place an ice bag on his knee for 5-10 minutes after exercising and walk daily, each time lengthening his walking distance as his strength improves.

Health Teaching- teach him that until his balance, flexibility, and strength improve,
he should use a cane, crutches, a walker, handrails, or have someone to assist him. When allowed to shower, encourage him to carefully wash the incision with soap and water, rinse well, then gently pat it dry.

OPD Follow up- reinforce the importance of keeping scheduled follow-up appointments with health care provider.

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

Support System- encourage family members and caregivers to work with Mr. Giester during self-care activities such as eating, bathing, grooming, dressing, and transferring rather than letting him be a passive recipient of care.

LEVELS OF CARE PROMOTIVE

Wound Care Teach Mr. Giester to avoid soaking the wound in water until it has thoroughly sealed and dried. He may continue to bandage the wound to prevent irritation from clothing or support stockings.

Diet Encourage to eat a balanced diet, often with an iron supplement, which is important to help the wound heal and to restore muscle strength.

Give instructions about deep breathing and using incentive spirometer to help keep lungs clear.

PREVENTIVE

Blood Clot Prevention Provide Mr. Giester with special support hose or tight-fitting, anti-embolism stockings as prescribed by the orthopedic surgeon. Encourage to move his foot and ankle immediately following surgery. The warning signs of possible blood clots in your leg include:

o o o

Increasing pain in your calf Tenderness or redness above or below your knee Increasing swelling in your calf, ankle, and foot

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

o o o

Sudden shortness of breath Sudden onset of chest pain Localized chest pain with coughing

Preventing Pneumonia Teach and encourage the patient to do deep breathing exercises.

Preventing Infection After knee replacement, administer preventive antibiotics after surgical procedures. Notify your doctor immediately if you develop any of the following signs of a possible knee replacement infection:

o o o o o

Persistent fever (higher than 100F orally) Shaking chills Increasing redness, tenderness, or swelling of the knee wound Drainage from the knee wound Increasing knee pain with both activity and rest

Avoiding Falls

The surgeon and physical therapist will help decide what assistive aides will be required following surgery and when those aides can safely be discontinued.

CURATIVE

Medications Administer medications as prescribed. Prescriptions for pain (Lyrica, Celebrex and Norco) Evaluate renal function and encourage Mr. Giester to increase fluid intake for adequate hydration. Administer Zofran (odansetron) to control nausea. DVT Prevention: Aspirin 325 mg BID for six weeks to reduce the risk of clot formation. Administer stool softener as prescribed for constipation as a result of use of pain medication. Teach Mr. Giester to exercise his knee the day after surgery to restore knee movement to allow walking and other normal activities. Assist him in daily physical therapy, which includes active and passive range of motion exercises, walking, getting out of bed, and getting up from a chair. Apply ice to help control pain and swelling. Keep the wound dry. Advise him to elevate his operative leg or lie down for 30 minutes or an hour during the day to reduce swelling.

REHABILITATIVE Teach Mr. Giester to avoid strenuous activities that may irritate his knee for about six weeks following surgery.

Teach and encourage the use walker as recommended by his doctor. Encourage exercise to promote normal activities of daily living weeks after surgery.

Activity program should include:

A walking program to slowly increase mobility. Resuming other normal household activities, such as sitting, standing, and climbing stairs.

Specific exercises several times a day to restore movement and strengthen the knee.

Tell Mr. Giester that he may have a physical therapist to help him at home or in a therapy center the first few weeks after surgery.

Refer Mr. Giester to the Philippine Orthopedic Center. POC caters mainly to a patient with Orthopedic and Neuromuscular conditions. Its Rehabilitation Medicine Department has the Medical Rehabilitation Service, Physical Therapy section, the Occupational Therapy Section.

BIBLIOGRAPHY Electronic Resources eNurse Care Plan. (n.d.). Retrieved August 21, 2013, from www.enurse-careplan.com: http://www.enurse-careplan.com/2011/06/impaired-physical-mobility-nursingcare_29.html

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Home Safety Renovations (lowincomeseniors). Retrieved August 21, 2013 from http://www.viha.ca/NR/rdonlyres/08D419A4-23B2-4515-B4FAB428909E9061/0/hip_knee_booklet.pdf

Boardman, Rebecca. (2007). Recovery From total Replacement. Retrieved August 21, 2013 from http://www.ehow.com/way_6170544_recovery-total-kneereplacement.html

Total Knee Replacement Exercise Guide. (March 2011). Retrieved August 21, 2013 from http://orthoinfo.aaos.org/topic.cfm?topic=A00301

Rasul, Abraham Jr.(April 16, 2012).Total Joint Replacement Rehabilitation.Retrieved from http://emedicine.medscape.com/article/320061-overview

Soren T. Skou, E. M.-N. (2012). Total knee replacement plus physical and medical therapy alone: a randomised controlled trial in patients with knee osteoarthritis. Denmark: BioMed Central.