Last updated on December 31st, 2022 at 11:53 am
Knee Replacement Nursing Care Plans Diagnosis and Interventions
Total Knee Replacement NCLEX Review and Nursing Care Plans
Knee replacement, also known as knee arthroplasty, is an alternative for patients who have failed non-invasive treatments for arthritis-damaged knees.
The knee’s diseased articular surfaces are removed during this process and are resurfaced with metal and polyethylene prosthetic components. Moreover, partial knee replacement can be done with patients who exhibit symptoms of osteoarthritis that are localized to one compartment of the knee.
Patients who have undergone this kind of surgical procedure will have significant pain relief and improved motor function. Despite these presented benefits, knee replacement should always be performed on an elective basis and should not be considered as the first line of treatment.
Indications of Knee Replacement
The following are the most common indications for knee replacement:
- When severe knee pain or stiffness secondary to osteoarthritis starts to hinder daily activities and decreases ambulatory capacity.
- When knee pain is severe or moderate even when resting and interferes during sleep
- When a knock knee (knee deformity) occurs. The uneven stress it applies to the knees over time can result in discomfort, joint degeneration, and early-onset of arthritis.
- When there is consistent knee inflammation and swelling even with therapy or medications
- When non-surgical therapies such as non-steroidal anti-inflammatory medication, intra-articular steroid injection, viscosupplementation, bracing, weight loss, and physical therapy fail to improve knee status.
Risks of Knee Replacement
Just like any other surgeries, knee replacement also comes with risks and possible complications. Risks of knee replacement could include the following:
- Infection. Infection may develop deep around the prosthesis or in the wound days, weeks, or even years after the surgery. Any infection that the patient may incur can spread to their artificial joint.
- Deep venous thrombosis. A typical side effect of knee replacement surgery is deep venous thrombosis wherein blood clots in the leg veins. If these clots escape and move to the lungs, it could be fatal.
- Implant deterioration and loosening. Implant surfaces may deteriorate and its components may become loose despite the employment of sturdy implant design and materials, and advanced surgical methods. High impact activities, excessive body weight and wearing out of the polyethylene component may all contribute to the loosening or dislodgement of prostheses. As a result, scarring of the knee can occasionally happen and motion may be more restricted, especially in patients who had limited motion before surgery.
- Continuing knee pain. Although uncommon, a small percentage of individuals still experience discomfort after getting a knee replacement.
- Injury of adjacent nerves and blood vessels. Although rare, surgery-related injury of the nerves and blood vessels around the knee might happen.
Pre-Procedure Nursing Care: Preparing the Patient for Knee Replacement
Before undergoing surgery, the patient should be prepared by the attending physician or healthcare professional.
- A signed informed consent form, which specifies the steps of the procedure, its indication and importance, as well as the risks, contraindications, and possible consequences, must be obtained from the patient. This implies that the patient has understood the procedure and voluntarily permits the physician to perform the procedure on him/her.
- A comprehensive medical history of the patient should be given to the attending physician before surgery. The doctor should be notified immediately of any allergic reactions to medications and anesthetic agents. Additionally a complete physical examination must be performed to ensure that the patient is fit and a good candidate for surgery. Blood tests, urinalysis, and an ECG may be obtained before the conduct of the surgery.
- Prior to the surgery, the patient should fast for at least 8 hours.
- Sedatives may also be administered to help the patient relax before any surgical procedures.
- Before undergoing surgery, ensure that the patient has a companion at home which will assist him/her around the house for a week or two. If a companion is unavailable, make arrangements with a home care nurse to assist the patient.
What Happens During Knee Replacement
Having a knee replacement necessitates a hospital stay. Most of the time, knee replacement surgery is done while the patient is unconscious and under general anesthetic. Procedures depend on the patient’s conditions and the surgeon’s practice.
- The patient will be asked to remove any jewelry and clothing that can obstruct the procedure. A hospital gown will be offered to wear instead.
- Knee replacement surgery requires anesthesia. A general anesthesia or spinal anesthesia may be administered during the procedure.
- An intravenous line may be inserted on the patient’s arm or hand. Intravenous antibiotics can also be administered to prevent any post-surgical infections.
- To access the patient’s patella, the surgeon creates a cut along the front of the patient’s knee. In order for the surgeon to reach the knee joint posterior to it, this is then shifted to the side.
- The patient’s shin bone and thigh bone have their damaged ends removed. To fit the prosthetic replacement, the ends are precisely measured and molded. To ensure that the joint is functioning properly, a mock joint is placed. The final prosthesis is fitted after corrections are made and the ends of the bone are cleansed.
- A curving metal piece replaces the end of the patient’s thigh bone, and a flat metal plate replaces the end of the patient’s shin bone. These are either treated to help their bone to merge with the new portions, or they are fixed using a specific bone “cement.” The metal components are separated by a plastic spacer. As the patient’s joint moves, this works like a cartilage and reduces friction.
- Depending on the need for repair, the back of the patella may also be replaced.
- The doctor places a dressing on the wound after the incision has been stitched or clipped shut. Although a splint may occasionally be needed to keep the patient’s leg immobile, the patient will typically be urged to move their knee as soon as possible.
Post-Procedure Nursing Care for Knee Replacement
In the post-anesthesia care unit (PACU), knee replacement patients often stay for 2 hours. During this time, their vital signs are monitored and recorded every 5 to 10 minutes for the first hour or until they reach a stable condition, and then every fifteen minutes until PACU discharge.
- Post-operative Assessment of Vital Signs. Vital signs should be checked every shift and as needed once the patient has returned to the unit. The nurse should compare the patient’s present level of consciousness, comfort and pain levels, range of motion, and mobility to the preoperative baseline results. Monitor the patient’s body temperature and note any readings that are higher than 100.5° F (38° C).
- Post-operative Pulmonary Management. To prevent pulmonary congestion, the nurse should encourage deep breathing and coughing exercises. Examine the patient for signs and symptoms of pulmonary embolism such as chest pain or shortness of breath.
- Post-operative Management of Hemodynamics. The nurse should monitor the patient’s foot circulation. Record the temperature, color, pedal pulses, capillary refill time, and movement of the lower extremities. Examine and record any complaints of swelling or soreness in the calves as these may indicate the presence of DVT. The nurse should elevate the affected limb to lessen swelling. Utilize pneumatic compression as directed to improve blood flow through leg vessels and to aid in the prevention of deep venous thrombosis (DVT). The nurse should administer anticoagulants (typically warfarin) as directed.
- Postoperative Management of Hemorrhage. The nurse must pay close attention to the incisional area during inspection. Keep an eye out for bruises and report any swelling, warmth, or redness at the surgical site. Monitor the quantity of drainage, and report any excess drainage promptly as this may signify bleeding into the joint. The nurse should be aware that many patients report moderate edema, numbness, or stiffness at the incision site.
- Post-operative Neurologic Management. The nurse should assess the patient for neurologic deficits by evaluating plantarflexion, dorsiflexion, and toe wiggling.
- Post-operative Management of Mobility and Ambulation. On the first postoperative day, active movement normally starts with a brief walker stroll around the room with the assistance of a therapist. The nurse should assist the patient in performing ankle pump exercises as directed to strengthen the leg and improve venous return. For the first 15 to 20 seconds, instruct them to slowly lift their toes upward toward the ceiling and then downward.
- Post-operative Pain Management. In order for the patient to self-administer analgesics, a patient-controlled analgesia unit is frequently employed. To provide long-lasting pain relief, small dosages given at short intervals assist in stabilizing serum drug concentrations. The nurse must provide NSAIDs as directed. Administer antiemetics as needed because a lot of painkillers might cause gastrointestinal distress. After surgery, knee pain should subside within a few days; if it does not, contact the surgeon.
- Post-operative Management of Possible Infection. Intravenous antibiotics should be continued for the first 24 hours after the surgery.
- Post-operative Rehabilitation. It is strongly recommended to refer the patient to a physical therapist for post-surgery rehabilitation.
Home Care After Knee Replacement
After being discharged, the patient needs to continue receiving treatment and rehabilitation in order to regain and preserve mobility and function. The nurse must give the following instructions during discharge teaching:
- As directed, take prescription drugs.
- Perform blood tests as directed (often every two weeks) until there is an instruction by the physician to stop.
- Schedule follow-up visits with the surgeon.
- Report immediately any signs or symptoms of deep venous thrombosis, such as:
- progressing calf pain,
- soreness or swelling above or below the knee
- progressing calf, ankle, or foot edema
- Promptly report any signs and symptoms of pulmonary embolism such as:
- abrupt increase in shortness of breath
- sudden chest discomfort
- localized chest pain accompanied by coughing
- Report any indications of a knee implant infection as soon as possible, particularly the following:
- prolonged fever (over 101° F or 38.3° C)
- trembling chills
- profuse drainage at the incision site
- unusual swelling or warmth near the incision
- escalating knee pain
Nursing Diagnosis for Knee Replacement
Nursing Care Plan for Total Knee Replacement 1
Nursing Diagnosis: Impaired Physical Mobility related to pain, discomfort, and musculoskeletal impairment secondary to knee replacement as evidenced by Inability to move with purpose or hesitation when trying to move in a physical environment, complaints of discomfort/pain while moving, restricted range of motion; and weakened muscle.
Desired Outcomes:
- The patient will maintain his or her functioning condition, and there will be no contracture.
- The patient will exhibit improved limb and joint function as well as strength.
- The patient will take part in an ADLs/rehabilitation program.
| Nursing Interventions for Total Knee Replacement | Rationale |
| Keep the patient’s body aligned and the affected joint in the prescribed posture while in bed. | Lowers the risk of harm when recovering from the effects of anesthesia and provides for prosthesis stabilization. |
| Examine the patient’s skin for any reddened spots. Maintain the linens dry and wrinkle-free. Regularly massage the skin and bony prominences. Elevate the entire length of the leg with a pillow and place the heel on a water glove to protect it if a burning sensation is observed. | Prevents skin breakdown and relieves discomfort. |
| Move the unoperated side while keeping the operated extremity in the appropriate alignment. Position can be supported using pillows or wedges. | Reduces the risk of tissue ischemia and/or disintegration by preventing displacement of the hip prosthesis and continuous skin or tissue pressure. |
| Administer prescribed medication prior to operations and activities. | Pain is lessened, muscle tension and/or spasm are reduced, and therapeutic participation is made easier with the use of muscle relaxants, opioids, and analgesics. |
| Provide assistance with using mobility devices like a trapeze or walker as well as transfer procedures. | Allows for self-care and patient independence. Shearing injuries to the skin and falls are avoided with proper transfer techniques. |
| Promote engagement in ADLs. | Improves self-esteem; increases control and independence. |
Nursing Care Plan for Total Knee Replacement 2
Nursing Diagnosis: Acute Pain related to surgical procedure secondary to knee replacement as evidenced by pain score of 7 out of 10 , diverting actions, narrowed attention or self-focusing, changes in muscular tone, and autonomic responses.
Desired Outcomes:
- The patient will report that his or her discomfort has been eased, with an improved pain score of 4 out of 10.
- The patient will be at ease and capable of getting enough rest or sleep.
- The patient will demonstrate the application of relaxation techniques and diversionary activities as indicated by the individual situation.
| Nursing Interventions for Total Knee Replacement | Rationale |
| Evaluate complaints of pain, including location, duration, and intensity (on a scale of 0-10). | Gives information on which to measure and evaluate the success of treatments. |
| Maintain the correct posture of the operated extremity. | Reduces muscle spasms and excessive strain on the artificial prosthesis and associated tissues. |
| Offer relaxation techniques (regular repositioning, back massages) and interesting activities. Promote stress management strategies (progressive relaxation, guided imagery, visualization, meditation). Use Therapeutic Touch as needed. | Helps manage discomfort or pain that can last for a long time by easing muscle tension, refocusing the mind, fostering a perception of control, and possibly improving coping skills. |
| Administer medications medication regularly and before activities. | Reduces muscle tension, promotes comfort, and increases participation easier. |
| Monitor reports of sudden, acute knee pain with muscle spasms and changes in joint mobility; and sharp, severe chest pain with breathlessness and agitation. | Early detection of emerging issues gives the chance for timely management and the avoidance of more serious consequences, such as pulmonary emboli (blood/fat) or displacement of the prosthesis. |
| Provide ice packs as directed. | Encourages vasoconstriction to minimize bleeding or tissue swelling in the operative region and reduces pain perception. |
| Start and sustain the mobilization of the extremities by ambulation, physical therapy, exercise, and/or the use of a CPM device. | Improves circulation to the injured muscles. Reduces joint stiffness and muscular spasms caused by inactivity. |
Nursing Care Plan for Total Knee Replacement 3
Nursing Diagnosis: Risk for Infection related to implantation of foreign body secondary to knee replacement.
Desired Outcomes:
- The patient will experience prompt wound healing, be erythema- and purulent drainage-free, and be healthy.
- The patient will continue to be infection-free as shown by normal vital signs and an absence of infection-related symptoms and indications.
| Nursing Interventions for Total Knee Replacement | Rationale |
| Encourage patient, family/caregiver, and staff to do proper hand washing. | Hand washing is one of the efficient methods of infection prevention. |
| Use strict aseptic or clean techniques as directed when cleaning wounds or changing dressings and dealing with drains, Instruct the patient not to touch or scrape the incision. | Reduces the possibility of contamination and wound infection, which could necessitate removing the prosthesis. |
| Maintain the patency of any drainage devices (Hemovac, Jackson Pratt) that are attached. Take note of the wound drainage characteristics. | Prevents the buildup of blood and fluids in the joint area, which lowers the risk of infection (medium for bacterial growth). Continuous drainage from an incision may indicate a forming skin tract, which can amplify the infectious process, and pus, non serous, foul-smelling drainage is suggestive of infection. |
| Examine skin/incision color, temperature, and stability; notice the occurrence of redness or inflammation, and lack of wound closure. | Provides updates on the recovery process and notifies professionals to early indicators of infection. |
| Monitor temperature on regular basis. Take note of the chills. | Although fevers are frequently experienced in the initial stages of recovery, fevers that persist for five days or longer and/or the presence of chills typically necessitate medical attention to avoid more serious problems such infection, septic arthritis, ulcerations, and prosthesis failure. |
| Recommend increasing water intake and eating a high-protein diet with fiber. | Prevents dehydration and maintains a healthy balance of nutrients to improve tissue perfusion and supply the nutrients required for cellular renewal and tissue healing. |
| If necessary, keep reverse or protective isolation. | Reduce contact with potential infection sources at first, especially if the patient is elderly, immunosuppressed, or diabetic. |
Nursing Care Plan for Total Knee Replacement 4
Risk for Peripheral Neurovascular Dysfunction
Nursing Diagnosis: Risk for Peripheral Neurovascular Dysfunction related to orthopedic surgery secondary to knee replacement.
Desired Outcomes:
- The patient will sustain function as shown by sensation and mobility within safe limits for the particular situation.
- The patient will exhibit appropriate tissue perfusion as shown by palpable pulses, efficient capillary refill, warm/dry skin, and normal color.
| Nursing Interventions for Total Knee Replacement | Rationale |
| Palpate both sides for pulses. Assess skin warmth, color, and capillary refill. Compared to the unoperated leg. | Reduced or missing pulses, decreased capillary refill time, pale complexion, blanching, bluish discoloration, and skin coldness all indicate a lack of circulation or perfusion. To determine if the neurovascular issue is localized or generalized, a comparison with the unoperated limb is helpful. |
| Evaluate how the operated extremity feels and moves. | Growing discomfort, numbness or tingling, and the inability to make the anticipated movements (flex foot) point to a nerve damage, poor circulation, or prosthetic displacement, all of which call for prompt medical attention. |
| Assess the capacity to dorsiflex the toes following joint replacement and test the peroneal nerve’s sensibility by pinching or pricking the dorsal site between the first and second toe. | The peroneal nerve’s position and length raise the danger of direct trauma or constriction by tissue edema or hemorrhage. |
| Keep track of and document vital signs. | Rapid heart rate and lower blood pressure may indicate a reaction to hypovolemia or blood loss, or they may imply anaphylaxis due to methyl methacrylate absorption into the blood circulation. Due to the development of prosthetics with a porous covering that encourages bone ingrowth rather than just relying on adhesion to internally fix the device, this happens less frequently. |
| Make sure that stabilizing equipment, such as an abduction pillow or splint, is properly positioned and isn’t putting too much pressure on the skin or underlying tissue. Do not place a pillow or knee gatch under the knees. | Reduces the possibility of underlying nerve pressure or impaired circulation to the extremities. |
| Examine for calf discomfort, Homans’ sign positivity, and inflammation. | The development of emboli can be avoided by detecting thrombus early and taking appropriate action. |
| Administer drugs as prescribed | To lower the risk of thrombophlebitis and pulmonary emboli, anticoagulants and/or antiplatelet medicines may be administered. |
Nursing Care Plan for Total Knee Replacement 5
Nursing Diagnosis: Deficient Knowledge related to information misinterpretation secondary to knee replacement as evidenced by instructions not being followed precisely and the development of avoidable difficulties.
Desired Outcomes:
- The patient will express verbally his or her comprehension of the surgical process and prognosis.
- The patient will correctly carry out necessary actions and provide an explanation of the activities’ justification.
| Nursing Interventions for Total Knee Replacement | Rationale |
| Examine the medical condition, the surgery, and the anticipated outcomes. | Offers a knowledge base from which the patient can make educated decisions. |
| Promote alternating between exercise and rest periods. | Conserves energy for recovery and avoids excessive weariness, both of which raise the possibility of injury or falling. |
| Maintain the specified exercise and/or rehabilitation program within the patient’s tolerance: crutches, cane walking, weight-bearing activities, stationary bicycling, or swimming. | Use crutches, a cane, weight-bearing exercises, stationary cycling, or swimming as part of the prescribed exercise and/or rehabilitation activities as tolerated by the patient. |
| Review the activity restrictions for jogging, leaping, extreme bending, lifting, twisting, or crossing your legs if you have hip or knee replacements. Such restrictions vary based on the joint that was replaced. | Protects the implant from excessive stress. Restrictions for the long term can be based on a patient’s circumstances or a doctor’s protocol. |
| Describe the precautions for bleeding. Teach how to use an electric razor, a soft toothbrush, and to avoid trauma or sneezing forcefully. | Minimizes the danger of bleeding and/or hemorrhaging caused by therapy. |
Nursing References
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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