Knee replacement surgery (knee arthroplasty) is a procedure that replaces parts of a damaged knee joint to relieve discomfort and resolve issues with mobility and ambulation. Artificial plastic or metal implants are used to replace worn-out bone and cartilage.
In this article:
- Overview
- Nursing Process
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- Impaired Physical Mobility
- Risk for Falls
- Risk for Infection
- Risk for Injury
Overview
The knee joint is the largest joint in the body. The knees are involved in most physical movements and support most of the body’s weight, making them prone to injuries and overuse. The most common reason patients seek knee arthroplasty is due to symptoms of arthritis.
The knee joint is divided into three compartments. The medial compartment on the inside of the joint and the lateral compartment on the outside connect the end of the femur to the top of the tibia. The patellofemoral compartment contains the kneecap on the front of the femur. The bones are held together by ligaments, tendons, and cartilage. The synovial membrane lines the joint to allow for lubrication and ease of movement.
There are two types of knee replacement surgeries:
- Total knee arthroplasty – The entire joint is replaced; the most common procedure
- Partial knee arthroplasty – Only the damaged knee compartment is replaced
Knee replacement surgery is a major procedure and is only recommended if other conservative treatments like steroid injections and physiotherapy have not relieved discomfort or improved mobility.
Nursing Process
Knee arthroplasty can be completed as an inpatient or outpatient procedure. Nurses prep the patient for surgery and monitor the patient post-op for pain and complications. The nurse prepares the patient for discharge by educating on continued recovery at home, scheduling follow-up appointments, coordinating outpatient services or durable medical equipment (DME), and encouraging adherence to physical rehabilitation.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to knee replacement surgeries.
Review of Health History
1. Determine the need for knee replacement surgery.
The most common causes for this procedure include the following:
- Osteoarthritis
- Rheumatoid arthritis
- Knee deformity
- Severe injury or trauma
- Conservative treatment failure
- Severe pain that limits movement
2. Ask the patient about their issues with mobility.
Assess the patient’s mobility and the changes in their activities of daily living. Note the patient’s reports of range of motion limitations and how this affects their quality of life.
3. Review attempted treatments.
Document and review pharmacological and nonpharmacological treatments the patient has tried to relieve their pain and poor mobility, such as:
- Oral medications
- Steroid injections
- Supplements (glucosamine, chondroitin)
- Physical therapy
- Braces or assistive devices
- Reducing movement
4. Document a risk for bleeding.
Inquire about the current use of anticoagulant medications, including aspirin, as well as NSAIDs, vitamins, and supplements that also increase bleeding risk. Note any conditions that increase the risk of bleeding. Provide education on holding these medications prior to surgery as directed by the surgeon.
Physical Assessment
1. Perform a physical assessment.
Assess the patient’s range of motion of both knees for comparison and observe their mobility, gait, and balance. Obtain vital signs. Immediately inform the surgeon of any significant changes in the patient’s health status.
2. Use a pain scale.
Have the patient rate their pain before and after surgery to evaluate for effectiveness.
Diagnostic Procedures
1. Ensure completion of preoperative screening tests.
Anticipate orders for blood tests before the knee replacement surgery, such as a coagulation panel, to ensure the patient is safe to undergo surgery. Tests will depend on the patient’s medical history and may also include an ECG, chest X-ray, or stress test and clearance if under the guidance of another specialist.
2. Perform imaging tests of the affected knee.
An X-ray or MRI helps visualize the extent of damage to the knee to decide on the best surgical approach.
3. Advise on dental procedures.
If needing dental work, advise the patient to complete it well before the knee replacement surgery. Dental procedures can introduce bacteria into the bloodstream and cause infection.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient having a knee replacement surgery.
1. Perform preoperative care.
Ensure a completed and signed consent form. Document any allergies and preoperative care and note the site to be operated on, confirming it with the patient. Instruct the patient about fasting, hygiene, and medications to hold prior to surgery. Answer questions about the procedure and postoperative care within the scope of the nurse.
2. Prep the patient for surgery.
The nurse is tasked with ensuring a patent IV line, inserting a urinary catheter, and cleaning and/or shaving the surgical site. Administer preoperative medications as prescribed, which may include antibiotics for infection prophylaxis and sedatives.
3. Closely monitor vital signs.
The PACU nurse will frequently monitor the patient’s vital signs, which will continue once the patient is transferred to the floor.
4. Perform wound care.
Maintain a clean and dry incision site. The incision may be closed with sutures or staples. After surgery, expect drainage and note the color and amount. If a drain was inserted, document the output. Perform wound care per the surgeon’s orders. Monitor closely for signs of infection, such as warmth, swelling, or erythema.
5. Manage pain.
The patient may be prescribed a combination of oral and IV analgesics in the inpatient setting and will be discharged home with a prescription for oral narcotics and NSAIDs to control pain and swelling.
6. Monitor for complications.
As with any procedure, there are risks involved. Complications may arise quickly after surgery or may not be identifiable for several months. The most common complications include:
- Bleeding at the surgical site
- Infection
- Blood clots
- Nerve damage
- Chronic pain
7. Elevate and ice the affected knee.
Elevate and support the affected knee above the level of the heart. Cold therapy may be recommended to alleviate pain and swelling.
8. Encourage movement.
Ambulation is crucial to reduce the risk of post-operative complications like pneumonia or deep vein thrombosis. Follow the surgeon’s activity guidelines to gradually increase movement. Utilize assistive devices as needed.
9. Implement VTE prophylaxis.
Following surgery, implement pneumatic compression devices or anticoagulants as ordered to prevent venous thromboembolism.
10. Collaborate with physical therapy.
Physical therapists will instruct patients on exercises that should be completed daily to mobilize and strengthen their new knee. A continuous passive motion (CPM) machine may be used to gently move the new knee joint through its range of motion while resting in bed.
11. Prepare the home environment for recovery.
Prior to discharge, the nurse should advise the patient on strategies to modify their home or living environment to prevent falls and make their recovery easier. Ensure the patient has a caregiver to help at home or coordinate home health services. Other recommendations include:
- Installing modifications such as grab bars or safety rails
- Obtaining shower benches or raised toilet seats
- Limiting the use of stairs
- Removing loose rugs and hiding electrical cords
- Utilizing a cane or walker to ambulate
Nursing Care Plans
Once the nurse identifies nursing diagnoses for a knee replacement surgery, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for a knee replacement surgery.
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.
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.
Risk for Falls
Following knee replacement surgery, patients experience reduced joint range of motion, pain, muscle weakness, and gait dysfunction, which increases the risk of falls.
Nursing Diagnosis: Risk for Falls
Related to:
- Postoperative recovery
- Impaired mobility
- Reduced range of motion
- Knee pain
- Gait dysfunction
- Muscle weakness
- Cluttered environment
- Older age
- History of falls
- Living alone
- Use of assistive device
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred yet, and nursing interventions are directed at prevention.
Expected outcomes:
- Patient will remain free of falls.
- Patient will demonstrate the correct use of assistive devices.
Assessment:
1. Complete a fall risk assessment.
After knee replacement surgery, various factors may further increase the patient’s fall risk, including sedating medications, weakness, pain, dizziness, and altered mobility.
2. Assess the patient’s baseline level of physical conditioning.
Nurses will care for patients of various ages and activity levels receiving knee arthroplasty. Assess the patients overall physical functioning, strength, and balance to gather a complete clinical picture and determine their appropriate level of fall risk.
3. Note contributing factors that increase the risk for falls.
Older adults are at a higher risk for falls, especially if they have a history of falls. Inquire if the patient lives alone, as this may affect their safety. Poor vision or hearing and chronic medical conditions may also increase their fall risk.
Interventions:
1. Affix a fall-risk armband to the patient.
The patient recovering from knee replacement surgery will be at an increased risk for falls. Ensure they are wearing a fall-risk armband and encourage other interventions, such as wearing nonslip socks when ambulating.
2. Instruct on the correct use of mobility aids.
Mobility aids like canes and walkers support ambulation after knee replacement surgery and reduce the risk of falls. To ensure safety, have the patient demonstrate the use of devices prior to discharge.
3. Encourage adherence to physical therapy.
Physical therapy is essential in the recovery from knee replacement surgery. Specific exercises are beneficial in rehabilitating the affected knee, reducing complications and the risk of falls, and prompting the early return of knee function.
4. Instruct the patient to reposition slowly.
After knee arthroplasty, patients will likely receive opioid analgesics that may cause drowsiness or dizziness as common side effects. Instruct the patient to transition from lying to sitting to standing slowly to prevent fainting and falls.
5. Ensure the environment is free from any clutter.
Interventions that ensure environmental safety include keeping pathways well-lit and clear from clutter that can cause falls for patients ambulating after knee replacement surgery.
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.
Risk for Injury
Surgical procedures carry inherent risks that predispose the patient to unintentional injuries. Additionally, postoperative complications that can lead to injuries may also arise, like nerve damage, infection, bleeding, and deep vein thrombosis.
Nursing Diagnosis: Risk for Injury
Related to:
- Iatrogenic harm
- Reduced mobility
- Knee pain
- Gait dysfunction
- Muscle weakness
- Reduced range of motion
- Knowledge deficit
- Surgical complications
- Unsafe home environment
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred yet, and nursing interventions are directed at prevention.
Expected outcomes:
- Patient will remain free from any injuries.
- Patient will demonstrate strategies to reduce their risk of injuries.
- Patient will not experience iatrogenic harm before, during, or after knee arthroplasty.
Assessment:
1. Verify the correct patient, site, and procedure.
When preparing the patient for surgery, the nurse should confirm their name and date of birth, the procedure they are receiving, and which knee is being operated on. This prevents surgical errors and follows the ethical principle of nonmaleficence, or “do no harm,” to avoid unnecessary injury.
2. Review preoperative directions.
If the patient arrives at the surgical center for outpatient knee replacement surgery, ensure they have followed preoperative instructions such as not eating or drinking within a certain timeframe before surgery and holding specific medications to prevent potentially serious complications.
3. Assess for assistance at home.
The patient will likely require some assistance at home, at least for the first few weeks, as they recover. Assess for the presence of a family member or caregiver to help the patient ambulate and perform ADLs as needed to prevent injuries.
Interventions:
1. Implement infection control measures.
The nurse is involved with prepping the patient for surgery which may include shaving and disinfecting the surgical site. The nurse should perform hand hygiene per facility protocols and maintain sterile technique if inserting a urinary catheter.
2. Review medications at discharge.
The patient may be discharged home with new medications, including opioid analgesics, NSAIDs, and anticoagulants. Ensure they understand the rationale for these medications and how to take them to prevent dangerous side effects.
3. Encourage adherence to follow-up appointments.
The patient will need to complete follow-up appointments with the surgeon to ensure proper healing of the incision and progress of surgical success. Ongoing follow-up ensures the patient is not experiencing long-term complications like nerve damage or issues with the implant that could predispose the patient to injuries.
4. Instruct the patient not to drive while taking pain medication.
The patient will require transportation from the hospital home after surgery and should be advised not to drive while taking narcotics or until they are aware of the effects of their medications.
5. Instruct the patient to use a knee brace or immobilizer after surgery as indicated.
After knee replacement surgery, a knee immobilizer may be indicated to help maintain stability and alignment for healing. A knee brace allows for more movement and may be worn during physical therapy or ambulation for support. Both devices aid in preventing injury to the knee.
6. Coordinate DME at discharge.
The patient may require medical equipment at home like a shower bench or raised toilet seat to promote independence with ADLs and prevent falls.
References
- ACCN Essentials of Critical Care Nursing. 3rd Edition. Suzanne M. Burns, MSN, RRT, ACNP, CCRN, FAAN, FCCM, FAANP. 2014. McGraw Hill Education.
- How long does it take to recover from knee replacement surgery? (2023, July 18). Cleveland Clinic. Retrieved February 2024, from https://my.clevelandclinic.org/health/treatments/8512-knee-replacement#risks-benefits
- 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
- Knee replacement – Mayo Clinic. (2022, December 21). Top-ranked Hospital in the Nation – Mayo Clinic. Retrieved February 2024, from https://www.mayoclinic.org/tests-procedures/knee-replacement/about/pac-20385276
- Knee replacement surgery procedure. (2021, December 22). Johns Hopkins Medicine, based in Baltimore, Maryland. Retrieved February 2024, 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/
