Care Plan for the Patient Undergoing Knee Arthroplasty

Care plan for the patient undergoing knee arthroplasty With the increase in life expectancy, knee arthroplasty is one of the interventions most performed today in Traumatology units, requiring nursing care to meet the needs of the patient and avoid possible complications. The implantation of joint prostheses has represented the most important advance in Orthopedic Surgery in the 20th century. The prostheses were designed primarily in the UK, then Switzerland, and elsewhere, later developed in the US to modern day technology. The first total knee prosthesis was carried out by Dr. De la Cerda in 1970, based on the extensive experience obtained in England and the USA in the last years of the 1960s1. A knee replacement is a surgery that replaces either the inner (middle) or outer (lateral) parts of the knee. During knee replacement surgery, damaged cartilage and bone are removed from the knee joint. Then Artificial pieces, called prostheses, are placed in the knee. These pieces can be placed on up to three surfaces of the joint: the femur, the tibia, or the posterior side of the patella (patella) 2. At present, 14.2 / 10,000 people between the ages of 80 and 84 will require an arthroplasty; 9.7 / 10,000 between 85 and 89 years old and 4.9 / 10,000 people over 90 years old will require a total replacement arthroplasty3. These figures will surely increase in the future due to the doubling of the aging of the world population, which will lead to an increase in degenerative diseases such as osteoarthritis and with it, joint replacement and revision surgery procedures (known such as total arthroplasties) 4. For the Traumatologist Leyes Vence, in a statement made for the newspaper ABC, some 55,000 knee prostheses are implanted per year5. This fact justifies the existence of nursing care plans for the care of this type of patients. Graph 1. Main diagnoses in the Mobile Rehabilitation and Physiotherapy Units Sources: Own elaboration. The health personnel of the Mobile Rehabilitation and Physiotherapy Units of Almería comment in their article that the sequelae due to immobilization and hip fractures are one of the most common diagnoses in patients treated in this unit. Knee prostheses account for 11.9% of cases6. According to Subiela et al7, the predominant population in these interventions is predominantly female, with a good functional level and with a very low prevalence of chronic diseases and geriatric syndromes, without cognitive impairment and with a low risk of depression, as is referenced in other studies8 . The patient experiences changes in his state of health and changes in needs, which leads him to require nursing care for optimal recovery, in addition, this will also be responsible for the prevention of possible complications and the promotion of the patient's autonomy seeking a early and good recovery. This nursing care is mainly aimed at helping joint mobilization, preventing complications, reducing pain, caring for the surgical wound, helping with ambulation, preventing falls and providing health education to the patient. related to your process 9. Due to the large number of patients undergoing TKA and the mean hospital stay it generates, it has motivated the trauma units to develop a standardized nursing care plan that serves as a guide and, based on this, provide individualized care to each patient9. In recent years, both total hip replacements (THR) and knee replacements (TKR) have become safe and reliable interventions, a fact that has led to their volume increasing every year around the world10. Patients who require this intervention have common symptoms, including severe and / or chronic pain, swelling and limitation / difficulty in the extension and flexion of the knee that limits the ability to walk normally. The pain tends to be progressive onset, more frequently after a period of inactivity, for example, when getting up in the morning; increases after activities such as walking for a long time, going up and down stairs, etc. Environmental changes (cold and humidity) can increase pain. Furthermore, pain does not subside with conservative treatment and is usually accompanied by functional failure of the joint11. The main cause for this type of treatment is degenerative knee osteoarthritis; They can also be the cause of knee arthroplasty, inflammatory arthritis, sequelae of fractures, After total knee arthroplasty, the pain and mobility limitation that led to the patient's functional disability was resolved. Furthermore, independence is achieved for activities of daily living and an improvement in the quality of life of patients with severe degenerative knee disorders9. Therefore, there is no doubt the need for special nursing care that helps to satisfy the needs that the patient presents and must follow a standard care plan. In this way, we systematize care so that the patient is not affected by problems derived from the variability in their care. And for this, special attention has been paid to the involvement of the patient himself in his recovery. Administratively, a Care Plan facilitates and improves the registration of all nursing activities and makes the responsibilities of the members of the health team clearer12. The work methodology used by nursing is the Nursing Process, a dynamic and systematized method that helps and makes problem solving easier, directing interventions towards the achievement of specific results13, 14. The implementation of nursing diagnoses means better planning of care and progress in improving communication between the different members of the staff, and between them and the patient11. We are currently witnessing important demographic and social changes, which are giving rise to new demands on health services and with it the need to provide integrated and continuous responses to people who require it. Thus, the improvement in communication of which I spoke earlier helps the continuity of care provided by the nurse to the patient, which today is a powerful instrument for improving care for citizens who move from one area of care to another , paying special attention to fragile patients and their carers15. Well, as Marjory Gordon says, "good communication increases the possibility that nursing care will continue without interruption" 16. The continuity of care is a continuum made up of three essential elements: people (patients and caregivers), information (caregiving interventions / health management resources), and environments (hospitals, services, units, areas, centers, homes, residences). To ensure continuity of care at every level care, the figure of the Case Management Nurse (EGC) is implemented: EGC in Primary Care - EGC in Hospital. This is in charge of managing the continuity of care report that is prepared by the nurse who cared for the patient during their hospitalization. This is written upon discharge and includes the fundamental aspects of the nursing care process during the patient's stay on the ward, and is aimed at the professionals who will attend to them later in Primary Care, thus ensuring continuity of care13. All of the above is the main reason that has led me to choose this topic on the care of patients undergoing knee arthroplasty. 1. OBJECTIVES. - Overall objective: The general objective of the work is focused on analyzing a practical case of a patient who is going to undergo TKA for which an individualized care plan will be drawn up. - Specific goal: The specific objective is to contrast this care plan with the different standard care plans belonging to the different Traumatology units, guides and articles found on the subject. 2. METHODOLOGY: To carry out the work, the bibliographic search in databases and free search in Internet search engines have been used as a method to find different care plans for this type of patients. The databases used were Medline, Cochrane Plus, Cuiden Plus, Cinahl, Lilacs, Proquest, Guia Salud, Joanna Brigs ... The web pages of scientific associations related to Traumatology and / or nursing methodology have also been directly consulted. For the assessment in the clinical case, the Marjory Gordon's model has been followed, based on the 11 functional patterns that represents a framework constructed of humanistic approaches, but also has an operational development adapted to the current demands of nursing practice. which includes a comprehensive view of the vital processes that can affect the health of the patient. In preparing the care plan, the diagnostic taxonomy proposed by the North American Nursing Diagnosis Association (NANDA) of 201217 has been used to enunciate the nursing diagnosis labels. A target or two of the NOC is added to each diagnosis. And finally, the nursing interventions are described for each problem using the NIC, in each of them a list is displayed with the most appropriate activities to achieve the objectives set, making the nursing work more specific. The keywords have been "knee osteoarthritis", "nursing care plans", "knee replacement", "standard care plan" and "knee replacement". 3. WORK DEVELOPMENT: In this work, an assessment has been made of a patient who is going to undergo knee replacement surgery in which both her physiological and psychological needs are considered, in addition to taking into account the teaching that the patient and the main caregiver should receive, to avoid possible home complications. Then a care plan is made to meet the needs that have been detected in which it is intended to provide comprehensive care to the patient. Next, our care plan has been compared with the different care plans, guides and articles found. 3.1. CASE STUDY. Sex: Female. Age: 76 years. Allergies: doubtful to penicillin, streptomycin, and opiate intolerance. Clinical judgment: Scheduled implantation of a left total knee replacement Description of usual health: Hypertension, untreated hyperglycemia, uncomplicated AMI in August 2012 (last review February 2013) Previous hospitalizations: Causes: IQ cholescystectomy, uterine polyps. Treatments / self-care: AAS 100, clopidroguel 75, enalapril 5, carvedilol 6.25, atorvastatin 40, orfidol, rabeprazole and omeprazole. Service: Traumatology Unit. Torrecárdenas Hospital. 3.2. MARJORY GORDON'S VALUATION BY FUNCTIONAL HEALTH PATTERNS: Pattern 1. Perception - Health Management. The patient reported feeling independent for activities of daily living but felt a certain limitation due to knee pain. Know your state of health and why you have entered. He does not smoke and drink alcoholic substances. Pattern 2. Nutritional - Metabolic. The patient reports that she has never had swallowing problems. It does not wear false teeth. Does not require assistance with eating / drinking. Keep your appetite. She follows a diabetic diet without salt to try to control her hyperglycemia and hypertension, she refers to digesting this type of diet better than the one she previously followed. She has also lost a couple of kilos making her feel lighter. Drink approximately 1.5l of water and two glasses of milk a day. He measures 1.68 and weighs 65 kg, so his body mass index is within the limits that indicate an ideal weight. He does not report significant changes in temperature that have reached fever. The condition of the skin and mucous membranes is intact and well perfused. Good body hygiene. It is independent for hygiene. She says she feels safer since her children installed a shower tray because that way she does not need help to get into the shower for fear of falling. Pattern 3. Elimination. The patient refers to having a bowel movement approximately a day, without alterations. She says that since adding more fiber to her diet, she has stopped having gastrointestinal problems ranging from diarrhea to constipation. As for urination, he tells us that he does about 6 or 7 a day, without any type of problem, he does not report having had any type of incontinence. Pattern 4. Activity - Exercise. On admission he breathes eupneically and breathes regularly through the nose. She is not an active or passive smoker. Her heart rate is 70x 'and a blood pressure of 130/80 In recent years, physical activity has decreased due to knee discomfort, which sometimes limits the time or distance of walking. However, it is independent for ambulation although it refers to using a crutch due to the pain it feels when walking. In addition, this helps you to stabilize in the march since it says that it does not put much weight on the "bad knee" and in the end it ends up losing balance a bit, to this is added a decrease in the range of joint movements. The wardrobe you choose along with the footwear is appropriate for the time of year. The daughter says that to avoid possible falls a year ago they did work on the house and put a bedroom on the ground floor of the house. However, there has been no drop in the last four months. Pattern 5. Sleep - Rest. He sleeps about 7 hours at night and an hour at nap. Take alprazolam to help you rest. He tells us that in order to fall asleep he takes a hot shower and takes a linden tea before going to sleep. She acknowledges getting up rested, although with knee pain. It has an articulated bed that has sometimes been useful when your legs have swollen in summer. Pattern 6. Cognitive - Perceptual. The patient arrives conscious and oriented both in time and space. He says he feels the same pain that he always feels in his knee. He knows how to read and write what would help him to be well informed when signing the informed consent or receiving information about the procedure in writing. When he wants to know something about his health, he turns to his family or his doctor. She wishes she could one day learn to use a computer so she could look up recipes and read the news. He tells us to feel a slight sensitivity to the cold that makes him go out for walks less in winter for fear of catching a cold, as well as that with the cold his knee hurts more. His memory is well preserved for his age. Pattern 7. Self-perception - Self-concept. Regarding the intervention, she says she feels anxious and fearful that the procedure may not go well or that the pain does not subside later. Communicate that you want to be asleep during the procedure to avoid getting too nervous. On the other hand, he hopes that he will need the crutch less, as it makes him feel less useful by having to use it to walk. The daughter tells me that since she knows the need for intervention she is more emotionally susceptible. Pattern 8. Role - Relationships. She is retired and lives with her husband in a duplex near one of her daughters and takes care of most of the daily activities, in cleaning she is helped by two daughters. He has two sons and two daughters. Her main occupation is cooking and sewing, although she says that in recent years she has lost her vision. She tells us that she has a satisfactory communication with her husband, children and grandchildren that helps her reduce anxiety related to the intervention. He goes out for walks with his family and sometimes attends the senior club to which he belongs to attend dance and craft workshops. Pattern 9. Sexuality - Reproduction. She has been menopausal since the age of 50 but says she has been dealing with the symptoms of menopause very well since it began. She has had 5 pregnancies and 4 deliveries. Pattern 10. Adaptation - Tolerance to stress. In recent years his knee pain has become his main concern. You feel a little stressed because you can't do the same activities you did a few years ago. Pattern 11. Values - Beliefs. She is a practicing Catholic and goes to mass on Sundays that one of her children is available to take her to church, she says it also helps her to interact with the neighbors of the town. 3.3. CARE PLANS Anxiety r / c change in health status m / p concern, difficulty reconciling sleep and fear of nonspecific consequences. NOC results 1211: Anxiety level 121105 - Restlessness. Value: 4 - Slight. Current value: 3 121117 - Verbalized anxiety. Value: 4- Slight. Target Score: 1 1302: Coping with problems Current value: 2 Final score: 5 130201 - Identify effective improvement patterns. Scale 4 - Frequently demonstrated. 130204 - Refers to decrease in stress. Scale 4 Frequently verbalized. 140208 - Adapts to development changes. Scale 4 - Often demonstrated. NIC interventions and activities 5820: Decreased anxiety. 582005 - Encourage the manifestation of feelings, perceptions and fears. 582010- Create an environment that facilitates trust. 582012 - Listen carefully. 582015 - Explain all the procedures, including the possible sensations to be experienced during the procedure. 582021- Provide objective information regarding the diagnosis, treatment and prognosis. 4920: Active listening. 492011: Encourage the expression of feelings. 492014: Show interest in the patient. 5270: Emotional support. 5230: Increase coping. 527002: Help the patient to express feelings of anxiety, anger or sadness. 527008: Encourage conversation or crying as a means of reducing emotional response. 527011: Stay with the patient and provide feelings of security during periods of heightened anxiety. 523005: Encourage the manifestation of feelings, perceptions and fears. 523006: Encourage an attitude of realistic hope as a way to deal with feelings of helplessness. 523026: Decrease environmental stimuli that could be misinterpreted as threatening. Degradation of physic movility r / c musculoskeletal impairment and pain m/p limited of amplitude of movements. NOC results and indicators 0208 - Mobility 020804 - Joint movement, Scale Value: 5 - Not Current score: 2 compromised Target Score: 5 020814 - Moves easily, Scale Value: 5 - No committed 0217 - Joint 021704 - Extension of 0º (i), Scale Value: 4 - slight Movement: Knee 021705 - Flexion of 130º (i), Value Scale: 4 - slight Current Score: 2 021706 - Hyperextension of 15 ° (i), Value Scale: 4 Target Score: 5 slight NIC interventions and activities 0200 - Exercise 020002 - Help the patient to develop an exercise promotion program appropriate to their needs 020003 - Help the patient to set goals to 0221 - Exercise therapy: ambulation 0224 - Exercise therapy: joint mobility 5612 - Teaching: prescribed activity / exercise. short and long term exercise program. 020004 - Help the patient to integrate the exercise program into their weekly routine. 022105 - Help the patient to stand up and to walk determined distances and with a specific number of personnel. 022107 - Assist the patient in the transfer when necessary. 022108 - Assist the patient in starting ambulation, if necessary. 022109 - It will help the patient to establish increases of realistic distance with ambulation. 022402 - Help the patient to position himself in an optimal position for passive / active joint movement. 022403 - Help the patient develop an active arc of motion exercise program. 022404 - Assist in regular and rhythmic joint movement within the limits of pain, resistance and joint mobility. 022413 - Encourage walking, if appropriate. 561205 - Teach the patient to keep an exercise diary, if possible. 561207 - Teach the patient to warm up and cool down before and after activity / exercise and the importance of such action, if applicable. 561216 - Inform the patient of the purpose and benefits of the prescribed activity / exercise. Pain r / c chronic physical disability m / p verbal reports of pain. NOC results and indicators 1605 - Pain Management Current Score: 2 Target Score: 5 2102 - Pain Level Current Score: 4 Target Score: 1 0226 - Exercise therapy: muscle control 160504 - Uses non-analgesic relief measures, Scale Value: 4 - Frequently demonstrated 160508 - Uses available resources, Scale Value: 3 - Sometimes proven 210201 - Referred pain, Scale Value: 4 - Mild NIC interventions and activities 022602 - Encourage the patient to exercise independently, if indicated. 022609 - Help the patient to develop the exercise protocol to achieve resistance, strength and flexibility. 0840 - Change of position 1400 - Pain Management 2210- Administration of analgesics 022612 - Help or encourage the patient to practice warm-up and relaxation activities before and after the exercise protocol. 084001 - Encourage the patient to participate in position changes, if applicable. 084006 - Place in a position that avoids tension on the wound, if applicable. 084019 - Avoid placing the patient in a position that increases pain. 140001 - Encourage the patient to discuss the painful experience, if applicable. 140002 - Encourage the patient to monitor their own pain and intervene accordingly. 140004 - Ensure that the patient receives the corresponding analgesic care. 221001 - Administer analgesics and / or complementary drugs when necessary to enhance analgesia. 221002 - Administer analgesics at the appropriate time to avoid peaks and valleys of analgesia, especially with severe pain. 221023 - Maintain a comfortable environment and other activities that aid in relaxation to facilitate the response to analgesia. 6650 - Surveillance Fear r / c unfamiliarity with the experience m / p report feeling worried NOC results and indicators 1210 - Fear Level Current 121015 - Concern for the source of fear, Score: 4 Score Value Scale: 3 -Moderate target: 1 1404 - Fear Self-Control 140403 - Seeks information to reduce fear, Value Current Score: 1 Target Scale: 4 - Often demonstrated 140417 - Controls Score: 4 fear response, Scale Value: 5 - Always proven 4920 - Active listening NIC interventions and activities 492004 - Determine the meaning of the messages reflecting on attitudes, past experiences and the current situation. 492011 - Encourage the expression of feelings. 492013 - Show awareness and sensitivity to emotions. 492014 - Show interest in the patient 5380 - Enhancement of 538004 - Help the patient to use the problem- security. solving skills responses that have been successful in the past. 538007 - Discuss upcoming changes (a room transfer), before the event. 538010 - Listen to the fears of the patient / family. 538012 - Explain to the patient / family all tests and procedures. 5610 - Teaching: preoperative 5618 - Teaching: 561801 - Correct unrealistic expectations of procedure / treatment surgery, if applicable. 561802 - Allow time for the patient to ask questions and discuss their concerns. 561804 - Describe the activities of the procedure / treatment. Poor knowledge r / c lack of exposure m / p verbalization of the problem NOC results and indicators 1814 - Knowledge: Therapeutic Procedures Current Score: 1 Target Score: 5 1828 - Knowledge: Fall Prevention Current Score: 3 Target Score: 5 5580 - Information sensory preparatory 5612 - Teaching: prescribed activity / exercise 181401 - Description of the therapeutic procedure, Scale Value: 3 -Moderate 182801 - Description of the correct use of assistive devices, Scale Value: 4 - Substantial 182803 - Description of suitable footwear, Scale Value: 4 -Substantial NIC interventions and activities 561203 - Help the patient to correctly alternate periods of rest and activity. 561204 - Help the patient to incorporate activity / exercise into the routine / lifestyle. 561205 - Teach the patient to keep an exercise diary, if possible. 5618 Teaching: procedure / treatment 561802 - Allow time for the patient to ask questions and discuss their concerns. 561806 - Determine the expectations of the surgery by the patient. After the intervention, an assessment is made of the patient in which we find new diagnoses and interventions adding them to those already exposed. Risk of infection r / c invasive procedures NOC results and indicators 1102 First intention 110213- Approximation of the wound edges. Scale 6- wound healing Extensive. 110214 - Scar formation. Scale 4- Substance. 1921 Preparation before 192104 - Knowledge of potential risks and process complications Maintenance of venous access devices. NIC interventions and activities 3660- Wound care - Monitor the characteristics of the wound, including drainage, color, size, and odor. - Clean with normal saline or a non-toxic cleaner, if applicable. - Maintain sterile bandage technique when performing wound care. Risk of falls r / c prosthesis in the lower extremities NOC results and indicators 0202 - Balance 020203 - Balance when walking, Scale Value: Current score: 2 4 - Slightly compromised Target Score: 5 0212 - Movement 021205 - Movement control, Scale value: 4 - coordinated Slightly compromised Current score: 2 Target Score: 5 NIC interventions and activities 0222 - Exercise therapy: balance 022205 - Help the patient to walk at regular intervals. 022211 - Help you to stand (or sit) and balance your body from side to side to stimulate the balance mechanisms 0224 - Exercise therapy: joint mobility 022411 - Teach the patient / family to systematically perform passive or active arc of motion exercises. 022412 - Explain to the patient / family the object and the plan of joint exercises. 0226 - Exercise therapy: muscle control 022602 - Encourage the patient to exercise independently, if indicated. 022612 - Help or encourage the patient to practice warm-up and relaxation activities before and after the exercise protocol. 665405 - Implement and maintain the precautionary state for the patient at high risk of exposure to the specific hazards of the care environment. 665406 - Provide the appropriate level of supervision / surveillance to monitor the patient and allow therapeutic actions, if necessary. 6654 Surveillance: security 4. DISCUSSION: The diagnoses that I have found when evaluating the patient have been: anxiety, impaired physical mobility, pain, fear, poor knowledge, risk of infection and risk of falls. These diagnoses are similar to those found in the different protocols analyzed. The care plan that has been carried out for the patient differs from the protocol established in Torrecárdenas18 for this patient in that the latter divides the interventions into different stages: care at admission, pre-surgical teaching, surgical preparation, postoperative care and planning at discharge. Unlike our plan of care that establishes the diagnoses for the hospital stay in general. Regarding pain, in our care plan it is considered as a care guideline like Sánchez Criado et al9. However, at Torrecárdenas Hospital18 and Reina Sofía Hospital19 pain does not appear as a diagnosis. Unlike the other protocols, Sánchez Criado et al.9 mention the possible deterioration of the sleep pattern related to the lack of familiarity with the bed and the room and the lack of intimacy. Authors such as Bustos López et al20 and Villar Alén et al21 focus their attention above all on postoperative care. Both plans are similar but differ in that Villar et al21 pay special attention to the deficit of self-care and elimination and Bustos López et al20 do not, despite their extensive list of postoperative diagnoses. Due to the lack of information about the patient that we detected when making the initial assessment, we included the diagnosis of anxiety. As it appears in the standard protocol of the Reina Sofía Hospital19 and in the care plan of Bustos López et al20. However, a study conducted by Marín Romero et al22 concludes that there are no significant differences in terms of anxiety levels, being between the groups that have received preoperative information and those that have not. It is noteworthy that the members of the UGC of Orthopedic, Trauma and Rheumatological Surgery of the Virgen del Rocío University Hospital23 use the clinical pathway tool as a multidisciplinary organizational method to decrease variability, improve teamwork, adjust resources, increase clinical safety and the satisfaction of patients who receive a total knee replacement. In it, numerous resources are made available to healthcare personnel that will be useful for patient care. The most innovative part of the plan is the elaboration of an informative video in which all the knowledge about the process that the patient and / or family needs is collected so that it culminates with the greatest possible success. On the other hand, the author Fdez-Lasquetty24, however, does not base her interventions on NANDA diagnoses. The mode of organization used is based on the presentation of the tasks that the nurse must carry out on each of the days that the patient remains in the hospital, the days are divided as follows: previous day surgery, operating room day and postoperative days numbered from 0 to 5. 5. CONCLUSION. According to the established objectives, we reached the following conclusions. After creating a care plan for our patient and the following analysis of the different care plans of the different hospitals and articles, it can be seen that they all have in common patient care in terms of mobility. Second, not only have we found care plans based on NANDA, NOC results and NIC interventions, but it has also been proven that other entities work with another type of organization such as the use of the clinical pathway or the distribution of tasks for days. Finally, after analyzing the different bibliographies, I have found quite a few differences in the care plans that could lead to patients not being treated in the same way in all hospitals. So that this does not happen, the nurse must take into account at the time of the evaluation of the patient, the idiosyncrasy of each person and that he must identify the possible problems that the patient presents and that is not reflected in the standard plan in order to do so. offer individualized care and that no need is left unmet