The knees are one of the most complex joints in the body. They support most of the body’s weight, making it prone to injuries and overuse.
Knee replacement surgery is a procedure that replaces parts of an injured knee joint to relieve knee discomfort and resolve issues with mobility and ambulation. Artificial plastic or metal parts are used to replace worn-out bone and cartilage.
There are two types of knee replacement surgeries:
- Total knee replacement – The entire joint is replaced; the most common procedure
- Partial knee replacement – Only one compartment of the knee joint is repaired
Knee replacement surgery is major surgery and is only recommended if other conservative treatments like steroid injections and physiotherapy have not relieved discomfort or improved mobility. The most common conditions requiring this procedure include the following:
- Osteoarthritis
- Rheumatoid arthritis
- Disorders causing unusual bone growth
- Knee injury
- Knee deformity
Providers assess patients for eligibility by performing x-rays to view the extent of damage and observe the patient’s mobility and range of motion.
As with any procedure, there are risks involved. The most common complications include:
- Bleeding at the surgical site
- Infection
- Blood clots
- Nerve damage
- Continued pain
Nursing Process
Nurses are involved with obtaining consent before surgery and educating the patient on what to expect following the procedure. Nurses will monitor the patient post-op for pain and complications. The nurse will administer ordered medications, promote mobility, and educate the patient and family prior to discharge, including coordinating outpatient or home-care services.
Nursing Care Plans Related to Knee Replacement
Impaired Physical Mobility
Knee joint injury can cause pain and affect a patient’s mobility. The goal of knee replacement surgery is to relieve discomfort and improve mobility. The recovery process and physical rehabilitation can be long-term and is essential to improved movement.
Nursing Diagnosis: Impaired Physical Mobility
Related to:
- Musculoskeletal impairment
- Joint pain or discomfort
- Surgical intervention
- Presence of prosthesis
- Joint stiffness
As evidenced by:
- Altered gait
- Decreased range of motion
- Difficulty ambulating
- Postural instability
- Uncoordinated movement
- Slowed movement
- Painful ambulation
- Decreased muscle strength
- Use of assistive devices
- Inability to participate in activities
Expected outcomes:
- Patient will demonstrate independence in ambulating and positioning.
- Patient will participate in physical therapy as ordered.
Assessment:
1. Assess the extent of the patient’s mobility problems.
The patient’s mobility and range of motion should be assessed before surgery as a baseline. After recovering from surgery, reassessment will demonstrate the success or limitations of the surgery.
2. Assess the cause of impaired mobility.
Several factors, including arthritis or a traumatic injury, may cause the inability to ambulate and move efficiently. Patients who have had knee replacement surgery may be anxious to ambulate, in pain, or fear falling.
Interventions:
1. Ensure that the affected joint is positioned as prescribed.
Proper positioning of the knee joint after knee replacement surgery can ensure the stabilization of the prosthesis, promote recovery, and reduce the risk of injuries.
2. Utilize continuous passive motion.
Continuous passive motion (CPM) is a machine that moves the knee joint passively to prevent stiffness and pain and improve mobility.
3. Assist the patient in ambulating with the use of assistive devices.
Assistive devices like walkers, crutches, canes, and wheelchairs can help the patient ambulate independently as their mobility improves.
4. Refer the patient to a physical therapist.
Physical therapy is required after knee replacement surgery as this can help strengthen affected muscle groups and promote recovery. PT may be inpatient, outpatient, or at the patient’s home.
5. Encourage the patient to adhere to rehabilitation interventions.
Early initiation of postoperative exercises and ambulation promotes early recovery and healing and prevents complications.
Acute Pain
Acute pain after a surgical procedure like knee replacement is expected and is managed with pain medications. If the pain doesn’t decrease over the next few days to weeks after surgery, this may indicate a developing complication.
Nursing Diagnosis: Acute Pain
Related to:
- Effects of surgery
- Inflammatory process
- Surgical intervention
- Muscle spasms
- Nerve damage
- Presence of prosthesis
- Joint tenderness
As evidenced by:
- Altered physiological parameters
- Diaphoresis
- Facial expressions of pain
- Reports of pain
- Guarding behavior
- Distraction behavior
- Protective behavior
- Positioning to ease pain
Expected outcomes:
- Patient will report decreasing pain relief following surgery.
- Patient will effectively demonstrate interventions to relieve pain and discomfort.
Assessment:
1. Assess the patient’s pain characteristics.
A comprehensive pain assessment, including the location, intensity, duration, and characteristics, can guide the effectiveness of treatment. Pain that is unrelieved or severe may signal a complication.
2. Assess the patient’s vital signs.
Unrelieved pain can have physiological and psychological consequences like anxiety and altered vital signs, resulting in negative health outcomes.
Interventions:
1. Ensure proper positioning of the affected joint.
Proper positioning of the affected joint after knee replacement can help reduce muscle spasms and prevent tension on the new knee prosthesis. The nurse can use pillows and wedges to keep the knee straight. Elevating the knee for short periods can reduce swelling.
2. Monitor for any sudden and severe joint pain following knee replacement surgery.
Sudden and severe joint pain after knee replacement can indicate a developing complication like blood clots, infection, or prosthesis dislocation.
3. Administer pain medication as indicated.
Opioid analgesics are prescribed to help relieve surgical site pain, while NSAIDs help with inflammation and are often prescribed together.
4. Encourage non-pharmacologic pain relief interventions.
Nonpharmacologic pain relief interventions can help reduce muscle tension, enhance coping abilities, and refocus attention, relieving overall discomfort. Encourage rest, distraction, and alternating ice and heat.
5. Premedicate prior to physical therapy.
Ambulation and physical therapy start immediately. Movement will be painful at the beginning, and the nurse can help the patient adhere to treatment by premedicating prior.
Risk for Infection
There is an increased risk of infection after a knee replacement surgery. The infection can occur in the surgical wound or around the artificial implants and may develop weeks or months after discharge from the hospital.
Nursing Diagnosis: Risk for Infection
Related to:
- Inadequate primary defenses
- Impaired skin integrity
- Invasive procedure
- Implantation of a foreign body or prosthesis
- Decreased mobility
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred yet, and nursing interventions will be directed at the prevention of signs and symptoms.
Expected outcomes:
- Patient will remain free from any symptoms of infection and demonstrate timely wound healing.
- Patient will demonstrate interventions that can help prevent infection.
Assessment:
1. Assess for any signs of infection.
Signs of surgical site infection include delayed healing, bleeding, redness, tenderness, warmth, swelling, and pain.
2. Assess and review laboratory values.
Alterations in laboratory values like increased white blood cell count can indicate a developing infection.
3. Assess risk factors that can predispose patients to infection following knee replacement surgery.
Patients with seropositive rheumatoid arthritis or those who previously had a knee fracture have a higher risk of developing an infection after knee replacement surgery.
Interventions:
1. Use a strict aseptic technique when dressing the surgical site.
Aseptic technique prevents contamination and infection of the surgical site.
2. Instruct on symptoms of infection to be alert for.
Educate the patient and their family to monitor for fever, increased swelling, redness, or drainage at the incision site. Contact the healthcare provider if this is observed.
3. Assess for any signs of increased surgical site pain.
Increased surgical site pain described as deep, dull, constant, and aching can indicate a developing joint infection.
4. Administer antibiotics as ordered.
Antibiotic therapy is often given prophylactically after knee replacement surgery.
5. Emphasize the importance of follow-up consultations.
Follow-up consultations are important in monitoring patients after knee replacement surgery to ensure they are not developing complications like infection.
References
- ACCN Essentials of Critical Care Nursing. 3rd Edition. Suzanne M. Burns, MSN, RRT, ACNP, CCRN, FAAN, FCCM, FAANP. 2014. McGraw Hill Education.
- Knee Replacement. NHS. Reviewed: August 2, 2019. From: https://www.nhs.uk/conditions/knee-replacement/
- Knee Replacement Surgery Procedure. Johns Hopkins Medicine. 2022. From: https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/knee-replacement-surgery-procedure
- Lewis’s Medical-Surgical Nursing. 11th Edition, Mariann M. Harding, RN, Ph.D., FAADN, CNE. 2020. Elsevier, Inc.
- Total Knee Replacement. OrthoInfo. Jared R. H. Foran, MD, FAAOS. Reviewed: June 2020. From: https://orthoinfo.aaos.org/en/treatment/total-knee-replacement/
