Patient Empowerment After Total Knee Replacement - Essay Example

Care of Patient Undergoing Total Knee Replacement Surgery Introduction Total Knee Replacement is relatively common procedure, according to Kane and others (2003); it is one of the most common orthopaedic procedures in both the UK and United States. It is a procedure that involves replacing an arthritic or otherwise damaged knee joint with an artificial joint - prosthesis, made of metal and plastic, and it has been demonstrated to be a highly effective treatment for arthritis. Total Knee Replacement involves implanting the artificial joint or prosthesis into the healthy portions of the femur and tibia bones, which is the secured with or without a bone cement. While the term 'total replacement' might indicate that everything about the joint is being replaced, this is not usually the case. The procedure merely involves what can be considered as 'resurfacing' of the bones of the joint. The prosthesis implanted is placed on the surface of the bones that meet at the knee - the femur and tibia and cemented to the bones, while most of the ligaments and usually all of the tendons of the joint are spared (Soohoo et al, 2006). Reporting on the frequency of Total Knee replacement surgeries, Kane and others (2003) indicated that in 2001 alone approximately 171,335 primary knee replacements and 16,895 revisions were performed. Kane et al (2003) argue that due to the fact that Knee replacement surgery is an elective procedure and especially because the prevalence of arthritis is expected to grow as the population ages, the care for patients undergoing total knee replacement surgery becomes an increasing concern for the healthcare profession. As with every other surgical procedure, in Total Knee Replacement surgery, scrub nurses prepares the surgical set-up, maintains surgical asepsis while draping and handling instruments, and assists the surgeon by passing instruments, sutures, and supplies. Therefore, the scrub nurse must have extensive knowledge of all surgical instruments and how they are used. On, the other hand, the circulating nurse serves as a liaison between scrubbed personnel and those outside of the operating room. The circulating nurse is free to respond to request from the surgeon, anaesthesiologist or anaesthetist, obtain supplies, deliver supplies to the sterile field, and carry out the nursing care plan. Other functions of the circulating nurse includes: initial assessment of the patient on admission to the operating room, helping monitoring the patient; assisting the surgeon and scrub nurse to don sterile gowns and gloves; anticipating the need for equipment, instruments, medications, and blood components, opening packages so that the scrub nurse can remove the sterile supplies, preparing labels, and arranging for transfer of specimens to the laboratory for analysis; saving all used and discarded gauze sponges, and at the end of the operation, counting the number of sponges, instruments, and needles used during the operation to prevent the accidental loss of an item in the wound (Mcewen, 1996). In the following pages, the organisation and layout of Total knee replacement surgery will be discussed using my experience with the surgical procedure of Mr. A as a yardstick. Intraoperative care for Mr. A included all the activities performed by the health care team during surgery that ensured the patient's safety and comfort, implementation of the surgical procedure, monitor and maintain vital functions, and document care given. The intraoperative time period can vary greatly from less than one hour to 12 hours or more, depending on the complexity of the surgery being performed. Since the purpose of intraoperative care is to maintain patient safety and comfort during surgical procedures, decisions about patient positioning and other features of the operating room is influenced by a number of factors, especially conditions of the patient and potential risks or complications of the surgical procedure. The goals of intraoperative care include maintaining homeostasis during the procedure, maintaining strict sterile techniques to decrease the chance of cross-infection, ensuring that the patient is secure on the operating table, and taking measures to prevent haematomas from safety strips or from positioning. Therefore, On the part of the patient, factors that influence organisation of the surgical process includes age, body weight, nutritional status, medications, chronic disease states (e.g., diabetes mellitus, vascular insufficiency, acquired immune diseases), and pre-existing pressure ulcers (Armstrong and Bortz, 2001; Kleinveck and McKennett, 2000). Total Knee Replacement surgery is a procedure that is most frequently carried out in the elderly. Considering the fact that elderly surgical patients face higher risks of developing intraoperative pressure injuries because of thinned skin and decreased muscle mass and subcutaneous fat over their bony prominences, age becomes a major factor that influences the organisation of Total Replacement Surgery. Patient body weight is another factor that influences patient positioning for surgery. For example, obese patients may be at right of pressure and nerve injuries because increased tissue mass compresses blood vessels and nerves in dependent areas and decreases tissue perfusion. Furthermore, medications such as immunosuppressant (e.g., corticosteroids) may affect patients' appetites and nutritional statuses and may impair wound healing and tissue synthesis by altering patients' immune responses, while chronic disease state such as diabetes mellitus, AIDS etc are also considered in making the appropriate decisions about the organisation and layout of the surgical operation (Armstrong and Bortz, 2001). As a result of all these, during the preoperative interview and assessment, it is the function of the preoperative nurse to routinely note the patient's age, weight, pre-existing medical problems, prescribed medications, skin condition, laboratory test results, range of motion of all extremities, baseline vital signs, presence or absence of peripheral pulses, and mobility impairments. The patient's level of consciousness and his or her ability to follow instructions at the time of this assessment should also be noted. This information then forms the grounds on which the surgical procedure is based. From the angle of the surgical team, surgical procedures are often characterised by use of several surgical instruments, drapes and sponges, also several care providers may be working in the operative field performing different tasks. These factors combined with the complexity of the surgical procedure and length of the surgical procedure may provide extensive opportunity for trauma to the patient from equipment malfunction or the failure of the surgical team to avoid using full weight on the sedated patient, or the theatre practitioners. To decrease these chances of risk to all parties involved it is recommended that: the ventilation system in an operative area provide a minimum of fifteen exchanges of filtered air per hour; the temperature in the intraoperative area should be maintained at 68-73F (20-23C), and the relative humidity should be maintained at 30%-60%; theatre practitioners; must not be permitted to work if they have open lesions on the hands or arms, eye infections, diarrhoea, or respiratory infections; scrub attire must be worn by all personnel entering the operating room and fresh scrub attire must be donned daily and, if heavily soiled during one case, should be changed before the next case; shoe covers are required and should be changed often; head and facial hair must be completely contained in a lint-free cap or hood; properly fitting disposable surgical masks must be worn at all times and discarded immediately after use; sterile gloves and sterile gowns must be worn by those working in, and in proximity to, the sterile field; careful skin preparation with appropriate antiseptic solutions should be preformed on the patient's arrival to the operating area. Additionally, it is the responsibility of the nurse working in the operating room to maintain an accurate count of all sponges, instruments, and sharps that may become foreign bodies upon incision closure; failure to make accurate counts can be a reason for litigation (Kleinveck and McKennett, 2000; Lopez-Bushnell et al., 2004; Gunta et al., 2000). The complex nature of Total Knee Replacement surgery is better appreciated when the arrangement of bones in the knee joint is sufficiently understood. The knee joint is a complicated joint made up of several intertwining muscles, tendons, ligaments and bones. There are three primary bones that constitute the knee joint and these are the femur or thigh bone, the tibia or shin bone and the patella or knee cap. The surface of the ends of these bones is covered in cartilage, while a cartilage pad known as the meniscus occupy the space between the femur and the tibia. Together with the binding tendons, these structures permit movements of the knee joint in a number of directions, while the slippery synovial fluid that bathe the entire joint helps prevents friction during movement and also provide nutrient to the bone cartilage (Bradbury et al., 1998; Palmer, 2001). Besides the shape and orientation of the meeting surfaces of the bones, there are four major ligaments in the knee joint that modulates the movement of the knee joint and these are the anterior and posterior cruciate ligaments and the medial and lateral collateral ligaments (Palmer, 2001). In all, the movements of the knee joints can be classified as having six degrees of freedom: three translations: anterior/posterior, medial/lateral, and inferior/superior and three rotations: flexion/extension, internal/external, and abduction/adduction. It should be noted that the mechanical axis of the lower limb can be seen as an imaginary line through which the weight of the body passes. This line runs from the centre of the hip to the centre of the ankle through the middle of the knee. In the presence of trauma or disease or any deformity to the knee joint this arrangement is altered. Because of this considerable weight of the body that the knee carries, degeneration of the articular cartilage, especially due to inflammatory arthritis is dominated with pain. Initially, this pain occurs on weight bearing, but eventually the pain may become constant. Other symptoms include stiffness, swelling, locking etc. Therefore, the aim of the knee replacement surgery is to reconstitute the normal arrangement that was in place in the lower limb before the onset of disease. However, with the complexity of the knee joint, it is not completely possible to reproduce a completely 'normal' knee with present modern techniques. The prosthesis implanted is made of metal and plastics and the relief of pain, in most instances, is the indicator of successful outcome of the procedure (Rand and Ilstrup, 1991; Palmer, 2001). Furthermore, preoperatively, it is important that the patient fully comprehends the benefits, risks and possible complications of the procedure to be carried out. Prouty et al (2006) explains the importance of patient education to any surgical procedure. They explain that the fear of the unknown is an expected characteristic of patient admitted for surgery; however, with structured and comprehensive patient education this fear is removed or greatly minimised. They posit that once patients have been made to be aware of the possible risks associated with the procedure, what to expect from the procedure and how to use equipments properly in the postoperative period, patients feel less vulnerable and more in control of the situation. Moreover, the requirement of patient education is further strengthened by the NMC regulation that every patient has a right to receive sufficient information about their conditions and to accept or reject treatment (NMC, 2004). Therefore, not only sufficiently educating the patient, but also obtaining the patient's consent for the procedure is absolutely necessary. While patient education is sometimes seen as the responsibility of the nurse, these authors contend that clear and consistent message from the multidisciplinary theatre team better improves patient confidence (Prouty et al, 2006). While the selection of regional or general anaesthesia is often decided after a discussion between the anaesthetist and the patient, the surgical team and the medical condition of the patients also often play a role in the choice of anaesthesia for the procedure. Considering the fact that thromebolism and infections are the two commonest complications following a knee replacement surgery, steps are usually taken preoperatively to avert such developments. In this regard, antibiotics and anti thrombotic prophylaxis should be given about thirty minutes before the onset of the procedure. Personnel should be kept to the smallest number and traffic in and out of the operating room should be kept at a minimum. Furthermore, use of vertical laminar flow in the operating theatre, use of prophylactic antibiotics, ultraviolet light, body exhaust systems to prevent bacterial shedding are all important in ruling out or reducing the chances of post operative infection (Geerts et al., 2004). Also, anti-thromboembolic devices such as stockings and foot pumps should be used intra-operatively (Lopez-Bushnell et al., 2004). In the final preparations for surgery, the leg to be operated is disinfected and sufficiently cleaned, the patient should be set up on the operating table in a supine position, and the operation should be carried out in a laminar flow operating theatre with the use of a high tourniquet to adequately expose the surgical site, except in patients with a history of previous deep vein thrombosis or significant vascular disease. Intraoperatively, the knee joint should be approached anteriorly through a medial parapatellar approach, however, it should be noted that a lateral or subvastus approach can be used in some cases. Once assess is gained into the joint, osteophytes and intra-articular soft-tissues are cleared. Cuts in the distal femur bone should be made perpendicular to the mechanical axis usually using an intramedullary alignment system which can then be checked against the centre of the hip. Also, the bone cuts in the proximal parts of the tibia should be perpendicular to the mechanical axis of the tibia using either intra or extramedullary alignment rods. This is because, as mentioned earlier, the lower limbs weight carrying features follows a particular axis from the hip to the ankle through the knee joint, proper surgical restoration of this mechanical alignment is very important for optimum load sharing in the lower limbs, thus preventing the prosthesis from overloading. Documentation is an important aspect of nursing intraoperative care for patients. It is recommended that the patient's record reflect the perioperative patient's plan of care, including assessment, diagnosis, outcome identification, planning, implementation and evaluation. The patient's record should reflect an assessment (ie, physical, psychosocial, cultural, spiritual) performed by the nurse prior to surgery or other invasive procedures. Such documentation forms the baseline for the development of nursing diagnoses and planning patient care. Moreover, this assessment should continue through every phase of the surgical procedure (Recommended Practices..., 1996; Prouty et al., 2006). Furthermore, nursing documented patient's record should reflect the care planned by the intraoperative nurse. This planning process begins when the nurse identifies nursing interventions that will address the patient's actual or potential risk for health problems (i.e., nursing diagnoses). The goals of nursing interventions should be to prevent potential patient problems or to intervene in actual patient problems. Patient outcomes should be individualised, prioritised, measurable, realistic, and obtainable (Recommended Practices..., 1996).Also more importantly, the patient record should specify what nursing interventions were performed and when, where, and by whom during each phase of perioperative care. Such documentation of nursing interventions promotes continuity of patient care and improves communication among health care team members. This implementation process is a result of assessment and planning, utilising nursing judgment and critical thinking skills. Nursing interventions are implemented to treat patient problems and to prevent potential patient injury or complications. Documentation of all nursing activities performed is legally and professionally important for clear communication and collaboration among health care team members and continuity of patient care. Finally, the patient's record should reflect a continuous evaluation of nursing care and the patient's response to applied nursing interventions. This is because the nursing process requires that the intraoperative nurse evaluates the effectiveness of nursing interventions toward the attainment of patient outcomes. The evaluation process provides information for continuity of care, quality improvement activities, research, and risk management (Recommended Practices, 1996; Prouty et al., 2006). As with very other form of nursing care, the ethical principles concerning the care for patients undergoing total knee replacement surgery are adequately spelt out in the NMC code of professional conduct. According to the NMC (2004), the nurse must always act to protect and support the health of the individual patients and clients; protect the health of the wider community, uphold the good reputation of the profession and act in a manner that justifies the confidence reposed in the profession by the society. More importantly, the nurse is accountable and answerable for every intervention, decisions, actions or inactions during the intraoperative settings, irrespective of whether there was an influence from another member of the healthcare team. The nurse is expected to respect the dignity of the client, and to promote and protect the interests of the client and dignity of patients and clients, irrespective of gender, age, race, ability, sexuality, economic status, lifestyle, culture and religious or political beliefs. Considering the potential risks associated with every surgical procedure, the nurse is expected to provide adequate information to the client to help make the right choice. The patient's decision to receive or reject any intervention must also be upheld, irrespective of the consequences. Since surgical procedures often involve multidisciplinary teams, the nurse is expected to work co-operatively within such teams and to respect the skills, expertise and contributions of members of the surgical team without cultural, religious or professional discrimination. Importantly, nurses are required to practice competently. The nurse is required to possess the adequate knowledge, skills and abilities that are required to provide lawful, safe and effective care, and to limit interventions to within the scope of professional competence. However, on the side of patients, there is clear evidence of racial/ethnic disparities in the choice of knee replacement surgery; although it has been demonstrated that racial and ethnic differences in healthcare interventions are not limited to knee replacement surgery. While the role of economic and access to healthcare is among the primary cultural factors that influence the provision of care for intraoperative patients, other common factors include: racial differences in acceptance of the physician's recommendation, for example, the study carried out by Rankin et al (2004) for the National Institutes of Health (NIH) Consensus Development Panel on Total Knee Replacement reveals that out of the population that potentially needs knee replacement surgery only about 12.7 percent of women and 8.8 percent of men were "definitely willing" to have the procedure; minority patient's mistrust of the healthcare system, personal beliefs about the best treatment of joint problems, and the unfamiliarity with the procedure among some ethnic groups are all ethnic factors that could influence the provision of care for patients undergoing knee replacement surgery. Also, the changing nature of the healthcare system, especially the commercialisation of healthcare is greatly changing the face of nursing care. Knee replacement surgery is both an elective and expensive procedure. Kane et al (2003) reports that approximately $3.2 billion was paid in 2000 alone for knee and hip replacement surgery. While the cost might be prohibitive, the tendency for increase in the prevalence of arthritis as the population ages means that more people in the society will require the procedure. The result is that the procedure is likely to come under continuously scrutiny with the resultant development of better techniques and care provision, which is likely to ensure better outcomes for patient undergoing knee replacement surgery. Conclusion Total knee Replacement surgery is a procedure that involves replacing the damaged parts of the knee joint with a prosthesis made of metal and plastic. The destruction of the knee joint often results from trauma, such as sport injuries or car accident; or most likely due to disease, especially inflammatory arthritis of the knee joint. The primary aim of the procedure is to ease the pain and discomfort that comes with the disability and to improve movement. Considering the complex nature of this procedure, this paper has attempted to critically appraise the care provided to a patient undergoing knee replacement surgery. The organisation and procedures involved with the surgery, the pre-operative and intraoperative care of the patient, the ethical issues regarding the procedure and the influence of ethnicity and culture of the procedure were all examined in this essay. References Armstrong, D, and P. Bortz (2001). An Integrative Review of Pressure Relief in Surgical Patients. AORN Journal, Vol 73 (3):645-8, 650-3, 656-7. Bradbury N, Borton D, Spoo G, Cross M J (1998). Participation in sports after total knee replacement. Am J Sports Med, Vol 26(4):530-5. Callaghan, J John (2001). Mobile-Bearing Knee Replacement: Clinical Results: A Review of the Literature. Clinical Orthopaedics, Vol 392:221-225. Geerts, W H, Pineo, G F, Heit, J A, Bergqvist, D, Lassen, M R, Colwell, C W (2004). Prevention of venous thromboembolism: The seventh AACP conference on antithrombotic and thrombolytic therapy. Chest, Vol 126 (Suppl. 3):338S-400S. Gunta, K, Lewis, C, and Nuccio, S (2000). Prevention and management of postoperative nausea and vomiting. Orthopaedic Nursing, Vol 19 (2):39-48. Kane R L, Saleh K J, Wilt T J, Bershadsky B, Cross W W, MacDonald R M, Rutks I (2003). Total Knee Replacement. Evidence Report/Technology Assessment No. 86 AHRQ Publication No. 04-E006-2. Rockville, MD: Agency for Healthcare Research and Quality. Kleinveck, S.V., and M. McKennett (2000). Challenges of Measuring Intraoperative Patient Outcomes. AORN Journal, Vol 72 (5):845-50. Loft, M, McWilliam, C, and Ward-Griffin, C (2003). Patient empowerment after total hip and knee replacement. Orthopaedic Nursing, Vol 22 (1):42-47. Lopez-Bushnell, K, Gary, G, Mitchell, P, and Reil, E (2004). Joint replacement and case management in indigent hospitalized patients. Orthopaedic Nursing, Vol 23 (2):113-117. Mcewen, R. Donna (1996). Intraoperative Positioning of Surgical Patients. AORN Journal, Vol 63 (6):pp: 1058-1063,1066-1075,1077-1079. Nursing and Midwifery Council [NMC](2004). The NMC code of professional conduct: standards for conduct, performance and ethics. Retrieved Feb 21, 2007 from Palmer, Simon (2001). Total Knee Replacement. Nuffield Orthopaedic Centre, Oxford. Palmeri, Joan (1996). Developing a comprehensive perioperative nursing documentation form. Association of Operating Room Nurses. Prouty, Anne, Maureen Cooper, Patricia Thomas, Judy Christensen, Cheryl Strong, Lori Bowie, Marilyn H. Oermann (2006). Multidisciplinary Patient Education for Total Joint Replacement Surgery Patients. National Association of Orthopaedic Nurses, Vol 25(4): 257-261. Rand J A, Ilstrup D M (1991). Survivorship analysis of total knee arthroplasty. Journal Of Bone & Joint Surgery, Vol 73-A:397. Rankin, Anthony, Graciela S. Alarcn, Jane Knight Lowe et al (2004). National Institutes of Health (NIH) Consensus Development Panel on Total Knee Replacement - Independent Expert Panel, Department of Health and Human Services. Recommended Practices for Documentation of Perioperative Nursing Care. AORN JOURNAL, VOL 63(6):1145-1148. Soohoo, Nelson F, Jay R Lieberman, Clifford Y Ko, And David S. Zingmond (2006). Factors Predicting Complication Rates Following Total Knee Replacement. Journal Of Bone & Joint Surgery, Vol 88-A (3): 480-487. Steelman, V M, Bulechek, G M, McCloskey, J C (1994). Toward a standardized language to describe perioperative nursing. Association of Operating Room Nurses, Vol 60:786-795. White R H and Henderson M C (2002). Risk factors for venous thromboembolism after total hip and knee replacement surgery. Curr Opin Pulm Med. Vol 8:365-71. Read More