TKR(Total knee replacement)

Name: Ng Ah GeokAge/Sex: 67/FOccupation: house wifeDoctor: Dr. J.K. Lee (surgeon) Dr. J.Lam (Anesthetist)Reason for admission @ 7/7/08H/O having Rt knee pain X 2 yrs, seen

Dr. Lee on 3/7/08, advice for above op. Diagnosis: 9/7/08 - Rt TKR GA &

epidural

Past medical history: Hypt diagnosed 3 yrs ago DMPast surgical history: NilAllergy: ? Anti-inflammatory medicationMedication: T.Atenolol 100mg dly – antihypt (beta

blockers) Viartril-s 2 tabs tds

A degenerative condition attacking the articular cartilage & aggravated by an impaired blood supply, mainly affecting weight-baring joints & causing pain. Osteophytes formed at the edge of the joint.

Primary OA (ageing) Metabolic factors (hypertiroidism) Genetic factors (< synthesize collagen) Chemical factors ( medication such as

steroid will affect the producing of the enzyme to digest the collagen at the sinovial membrane)

Mechanical factors (pressure to the joints)

Secondary OA Trauma- abnormality at the surface

artikular Congenital deformity Obesity, occupation & exercise –

pressure to the abnormal joints Past inflammation –sepsis,

rheumatoid artritis

Pain, usually made worse by activities that involve weight bearing such as standing.

Less movable & eventually may not be able to fully straighten or bend

The irregular cartilage surface cause joints to grind, grate, crackle when they are moved

The ligament, which surround & support the joints become unstable.

A total knee replacement involves cutting away the damaged bone of the knee joint and replacing it with a prosthesis. This “new joint” prevents the bones from rubbing together and provides a smooth knee joint.

Knee replacement surgery is performed to treat advanced or end-stage arthritis. When arthritis in the knee joint or joints had progressed to the point where medical management is not effective, or deformity has become severe and debilitating, knee replacement surgery might be indicated.

Infection in the artificial joint Neurovascular (ie, nerve and/or blood

vessels) damage Wear and tear of prosthesis (ie, the knee

implant device) due to heavy use Stiffness of the knee if scar tissue develops Complications involving the lungs, heart,

gastrointestinal, or neurological system Failure to relieve knee pain Loss of the leg due to blood clots Death

7/7/08Lumbasacral spine AP & lateral Alignment & vertebral body ht appear N Minimal anterior displacement of L3 over

L4 is seen The intervewing disc space ht appear N Anterior & lat osteophytes are seenImpression Grade 1 spondylolisthosis of L3 over L4 Osteophytes suggest degenerative

changes.

CXR N heart size & shape c cardio-

thoracic ratio of 13cm/26.5cm No evidence of congestive cardiac

failure Lung are clear

Echo EF: 74%

X-ray both knees wt bearing Prominent join margin osteophytes at the

medial & lateral Knee joint are noted billaterally as well as at

the patello-femoral joints, worse on the Rt side

Rather prominent tibial spine seen in the Rt knee

Supicion of chondrocalcinosis may be present billaterally as well as involing the synovial lining at the posterior part of the knee joints

Summary Bilat OA, worse at the Rt knee

7/7/08FBC – NRBS – 7.8mmol/lSr creatinine –

63umol/l

11/7/08 Hb – 8.7g/dl

BUSE urea 5.5mmol/l sodium 134mmol/l potassium

4.3mmol/l chloride 97mmol/l

8/7/08HbA1C – 6.0%, idea

controlU/FEME – NLipid profile Total chol

7.2mmol/l HDL 1.58mmol/l LDL 5.0mmol/l Triglycerides

1.4mmol/l Sr appearance clear

PT PT 13.3 PR 1.0 INR 1.0APT N control 35.0 Pt 35.7 Ratio 1.0

7/7/08- admitted to Fatimah - Op on 9/7/08 @ 3 pm- Ordered to do FBC, BUSE, RBS, Sr creatinine, GXM 2

pint whole blood, CXR, X-ray both knee (AP, lateral), ECG & collect urine FEME

8/8/08- Ordered to give Zantac, Maxolon @ 8 am- Dormicun when call- NBM after full breakfast - IV Hartman @ D/saline 6hly

9/9/08Dr J.K.Lee Hourly BP, PR NBM till fully conscious IV 3 pint / 24 hrs- 2 pint N/ saline alt

1 pint D 5% Elevated RT leg with pillow IM Voltaren 75 mg PRN

Dr J.Lam O2 in ward KIV 2 L nasal prong VAN inhaler bd x3/7 Continue IV drip If blood more than 500 mls, 1 pint

voluren over 4 hrs Check level of block

RTW. G/C drowsy but arousable. IV Hartman in progress with no redness & swelling seen. Epidural infusion 8 mls /hr in progress. Level of block: T10. drsg at Rt knee dry & intact. Quicky drain x1 insitu with vaccum. Rt leg kept elevated with pillow. Circulation, sensation & movement are good, slight oedema noted.

9/9/08 RR total drain amount: 300 mls, if >

than 500 mls to run IV hartman RR drain amount: 300 mls + ward drain

amount: 240 mls =540 mls Ordered to run 1 pint Voluven 8 hly 1 pint Voluven alt 1 pint N/Saline alt 1

pint D5% then continue back 2 pint N/saline alt 1 pint D5%

10/7/08 (1st POD) Noted pain because epidural tubing kinked &

vomited after breakfast & med Ordered ~epidural infusion 10 mls/hr~Celebrex, IV Maxolon, T. Losec~to check level of block > 2 hrs~Rt side ≥ T10-T11, Lt ≥ L2-L3~to keep drain, dressing & CBD Encourage exercise in bed ↓ epidural infusion 8 mls/hr Breathing exercise done Epidural infusion completed

11/7/08(2nd POD) Drain amount: 110 mls Noted oedema at Rt foot ↓ drip IV D/saline alt N/saline 12hly Continue epidural infusion Cold pack x1 continuously Keep drain Dressing stat Start Tab Panadeine & IM Pethedine 50 mg 8

hly & prn once IV epidural infusion complete breathing exercise done Epidural infusion completed

12/7/08 (3rd POD) Drain amount:8 mls Complain pain at the wound site, IM

Pethedine 50 mg given Ordered to:~off drip~teach patient self exercise in bed~keep drain & CBD~ cold pack continuously

13/7/08 (4th POD) Drain amount: 1 mls Shaking knee exercise taught by Dr J.K.Lee Sit up & shaking knee exercise Sit out, stand & walk tomorrow Off CBD, keep drain Physiotherapy form sign by him14/7/08 (5th POD) Drain amount: 3 mls Voiding well post CBD Ambulate with frame, physiotherapy done When walking drainage flowing more

Continue ambulate 5% providine dressing stat Keep drain15/7/08 (6th POD) Drain amount: 88 mls Keep drain Continue mobilization16/7/08 (7th POD) Drain amount: 44 mls Assisted patient to toilet with walking frame Sit out of bed Keep drain, continue ambulate

17/7/08 (8th POD) Off drain Continue ambulate KIV discharge cm18/7/08 For home Sign off with consultation &

prescription, appointment x 1/52 @ 25/7/08

Dr.Thye7/7/08 Micardis 40mg dly Atenolol 120mg dly8/8/08 Cardiprin 100mg dly Lipitor 20mg ON Micardis 80mg dly Micardis 40mg stat

Dr.J.K.Lee9/7/08 IV Zinacef 750mg tds IM Voltaren 75mg

PRN Leftose 250mg tds Mobic 7.5mg bd Panadeine 1 tab bd

(restart once IV epidural off)

Dr.J.Lam8/8/08 Tab Imorne 7.5mg

ON Tab Zantac 150mg

8am Tab Maxolon 10mg

8am Tab Dormicum

3.75mg when call9/7/08 Celebrex 400mg stat IV Voluven 1Θover

8H Van Inh bd X 3/7

10/7/08 IV Zofran 4mg bd Cap Celebrex 1 bd X

3/7 Tab Losec 40mg dly IV Maxolon 10MG 8h

PRN11/7/08 IM Pethedine 50mg

8H prn (to start once IV epidural infusion completed)

Tab Singobion 1 dly

Start the following exercises as soon as patient is able. Patient can begin these in the recovery room shortly after surgery. Patient may feel uncomfortable at first, but these exercises will speed their recovery and actually diminish patient postoperative pain.

Quadriceps Sets Tighten the thigh muscle. Try to straighten the

knee. Hold for 5 to 10 seconds. Repeat this exercise approximately 10 times

during a two minute period, rest one minute and repeat. Continue until the thigh feels fatigued.

Tighten the thigh muscle with the knee fully straightened on the bed, as with the Quad set. Lift the leg several inches. Hold for five to 10 seconds. Slowly lower. Repeat until the thigh feels fatigued. Patient also can do leg raises while sitting. Fully tighten the thigh muscle and hold the knee fully straightened with the leg unsupported. Repeat as above. Continue these exercises periodically until full strength returns to the thigh.

Move the foot up and down rhythmically by contracting the calf and shin muscles. Perform this exercise periodically for two to three minutes, two or three times an hour in the recovery room. Continue this exercise until patient are fully recovered and all ankle and lower-leg swelling has subsided.

Place a small rolled towel just above the heel so that it is not touching the bed. Tighten the thigh. Try to fully straighten the knee and to touch the back of the knee to the bed. Hold fully straightened for five to 10 seconds. Repeat until the thigh feels fatigued.

Bend the knee as much as possible while sliding the foot on the bed. Hold the knee in a maximally bent position for 5 to 10 seconds and then straighten. Repeat several times until the leg feels fatigued or until patient can completely bend the knee.

While sitting at bedside or in a chair with the thigh supported, place the foot behind the heel of the operated knee for support. Slowly bend the knee as far as you can. Hold the knee in this position for 5 to 10 seconds. Repeat several times until the leg feels fatigued or until patient can completely bend the knee.

While sitting at bedside or in a chair with the thigh supported, bend the knee as far as patient can until the foot rests on the floor. With the foot lightly resting on the floor, slide the upper body forward in the chair to increase the knee bend. Hold for 5 to 10 seconds. Straighten the knee fully. Repeat several times until the leg feels fatigued or until patient can completely bend the knee.

PAIN RELATED TO THE OPERATION WOUND

Asses the pain level by interview the patient & the pain chart to plan next nursing intervention.

Teach patient the breathing exercise to reduce the pain.

Elevate the Rt leg with pillow to help in venous return & reduce the swelling & pain.

Teach patient the diversional therapy such as watching television, listening radio, reading so that patient do not focus to the pain.

Apply ais pack to the pain & swelling area according doctor’s order to reduce the pain & swelling.

Give analgesic such as Panadeine 1 tab bd according doctor’s order to reduce the pain

Asses the effectiveness of the analgesic after 30 minutes to make sure that the dosage is enough for the pain

Tell doctor if the pain still persist after the analgesic to prevent any complication.

Asses the range of motion of the patient to plan next nursing intervention.

Make sure patient rest in bed till fully conscious to help in healing proses

Advise patient to do isometric exercise every 4 hourly at the Rt leg to prevent muscles atrophy

Help patient in ROM exercise to the effected area to prevent muscles atrophy & maintain joint’s function & strength.

Encourage patient change position every 2 hours when resting on the bed to help in blood circulation & prevent bedsores

Help patient to sit out of bed according Dr’s order to expand the lung & help in blood circulation

Give analgesic before starting the exercise to prevent severe pain at the wound site

Monitor vital signs 4 hourly to detect any abnormalities such as tachycardia, hypotension, tachypnea to plan next nursing intervention

Monitor dressing for any signs of bleeding to detect any excessive bleeding so that early treatment can be given

Monitor drain amount to detect any abnormality such > 100mls/ hour

Monitor blood profile such as hematocrit, Hb level, & coagulation profile to detect any abnormalities so that early signs of blooding can be detect

Give patient IV therapy according Dr’s order to maintain blood volume

Monitor vital signs every 4 hours to detect any abnormalities such as HR, RR, & T shows signs of infection

Make sure the dressing is clean & dry to prevent wound infection

Make sure the room is clean & tidy to prevent wound infection

Advice patient to take balance diet & in vitamin(fruits & vegetables) to increase the immune system

Practice aseptic technique during doing dressing to prevent wound contaminate with microorganism

Report to Dr immediately if fever / wound have any signs of infection such as redness, swelling, discharges so that treatment can be given earlier

Give antibiotic such as IV Zinacef 750 mg tds according Dr’s order as prophylaxis antibiotic to prevent wound infection