Nursing Assessment for a Patient with Pain post RTKA
Clinical reasoning and use of good judgment is a necessary element of nursing practice to provide safe and high quality care to patient. There are several tools available for nurses to understand patient problem and prioritize best nursing intervention for the safety of patient. This paper provides an insight into the process of clinical decision making done by the analysis of the case study of Mrs. Kate Ham, a 79 year old patient with complains of pain post right total knee arthroplasty (RTKA). The nursing assessment, action and nursing interventions and the rational for nursing action is provided with the use of DETECT framework.
Nursing assessment, nursing action and nursing interventions:
D (Detect deterioration): The nursing assessment that is necessary for Mrs. Kate Ham, 79 year old patients with right total knee arthroplasty (RTKA) are:
- Assessment of severity and location of acute pain
- Monitor the use of PCA in patient
- Monitor neurovascular status of patient by assessing sensation and motor function and pulse of patient
- Assessment for signs of hypoglycemia and infection in patient (Hadlandsmyth et al., 2017; Shohat et al., 2018).
E (Evaluate your findings):
- The heart rate of patient and peripheral capillary refill value of patients shows his deteriorating condition
- The BGL value of 3.5 is also a concern for patient post-operatively because his normal BGL should be between 4-7mmol/L.
- The vital observation shows sign of tachycardia and since patient is a heavy smoker, this symptom should be taken seriously (Glassman, Meschbach, & Everhart, 2018; Dunning, 2016).
T (Treatment)
- Based on severity of pain, the main nursing intervention needed is changing the status of PCA and consulting with clinician regarding change in medication.
- For management of post operative pain, position of patient should also be changed and proper education needs to be provided
- Implement relevant intervention to prevent neurovascular damage and infection in patient
- Controlling blood sugar level in patient (Skou et al., 2016).
E (Escalate concerns)
- It will necessary to escalate to the surgeon or other clinicians involved on care of Kate, when excessive blood loss, neurovascular damage and infection is seen in patient.
C (Communicating in):
- Consult the surgeon or other involved clinician regarding issues of hypoglycemia and high peripheral capillary refill in patient
- Consult regarding adjustment in PCA administration
- Share assessment findings and clinical priority with all involved team members (See et al., 2018).
T (Teams)
- Appropriate handover information related to PCA check, medications needed for Kate and diet management of client needs to be provided.
Clinical reasoning related to nursing decisions applied to the patient:
Detect deterioration (Pain): As Mrs. Kate’s most immediate concern was pain, treatment of pain in patient was one major clinical priority. The main treatment rational for this is that severe post-operative pain can affect the recovery of patient and lead to other serious complications like ischemic cardiac events and myocardiac insufficiency (Society, 2012). Hence, deciding on necessary treatment option to prevent complications and determine adequate treatment option for Mrs. Kate was the most vital step. Evidence by Dumolard, Gök & Le, (2017) also suggests that nurses should first assess severity of pain to determine the treatment needed for patient. Pain assessment was a necessary nursing decision as it supported finding relevant pain intervention for patient. Monitoring the PCA was also important to determine whether the analgesic is effective for patients or it needs to be changes. Since Kate’s peripheral capillary refill was 1 second greater than normal rate, it is necessary to check patients for signs of decreased peripheral perfusion to risk of peripheral disease. Inappropriate level of post-operative pain is a common experience for majority of patient after RTKA.
Apart from management of pain, there were two reasons for controlling signs of neurovascular damage and infection in patient. Firstly, monitoring neurovascular status was important because review peripheral capillary refill value of Mrs. Kate revealed inadequate arterial supply. This indicated signs of neurovascular complication in patient. Monitoring neurovascular status is an effective step for early recognition of neurovascular deterioration in patient. Such patient experience pain disproportionate to injury due to neurovascular problem and non-verbal signs of pain in patients include grimacing, tachycardia and hypotension (Rch.org.au. 2018). All these symptoms were present in Mrs. Kate too. Hence, treatment for these signs and symptoms was necessary. Secondly, controlling blood sugar level was also a nursing priority because patient was NIDDM patient and evidence has shown that imbalance in the time of insulin administration, sepsis and other drug related causes increase risk of hypoglycemia in surgical patient (Kalra et al. 2013).
Detect Deterioration
Evaluate your findings (E): As per nursing assessment of patient, I have identified symptoms of tachycardia (indicated by HR-118) and peripheral deterioration (indicated by capillary values greater than two seconds) as a major concern for patient. This is because these symptoms are signs of neurovascular complication in patient. This conclusion has been made because evidence has shown that postoperative tachycardia within the first four day of surgery should be reviewed very carefully (Sigmund et al., 2017). This is because tachycardia is a symptom that can be caused by venous thrombo-embolic disease (VTED) and it is a major reason for readmission post TKA surgery (Mont et al., 2012). Hence, high capillary values indicates the risk of VTED in patients and this sign of deterioration needs to be discussed with the nurse-in charge. This will help to identify appropriate preventive strategies to minimize development of serious complications like infection and hematoma in patient.
Another clinical judgment for deciding tachycardia as a symptom of clinical deterioration in Mrs. Kate is that tachycardia increases the likelihood of stroke and sudden cardiac arrest in patient. This nursing consideration is also important because Kate was found to be a heavy smoker and smoking increases the chance of heart attack post surgery. Review of evidence also shows link between smoking and risk of vascular and respiratory events in patients undergoing surgery. Current as well as past smoking has impact on post-operative mortality and arterial and venous events in patient. The risk of arterial event is even higher in current smokers compared to past smokers (Musallam et al., 2012).
Treatment (T): After the analysis of assessments done on patient, major nursing priorities for care of Mrs. Kate includes relieving pain, reducing neurovascular complication and address symptom tachycardia patient. The first intervention decided for patient was consultation regarding change in medication. This was important because the symptom of pain along with tachycardia and low blood pressure was giving indication of neurovascular deterioration in patient. Mrs. Kate was taking medications only for asthma (Seretide) and blood glucose control (Metformin). Pain management can be done by pharmacological methods like prescribing non-steroidal inflammatory drugs (NSAIDS) like obuprofen and naproxen to Kate. However, paracemtamol will be a good pharmacological option for Kate as she is a patient with history of asthma. While using PCA for pain management, nurse should assess pain level, BP and pulse changes regularly (Sandika et al., 2015).
Communicating In
The main rational for position change in patient is to properly manage the risk of neurovascular complication in patient. Although vascular injuries are rare, however if it occurs, it can increase the risk of morbidity and mortality post RTKA surgery. Early signs of arterial injury include persistent pain and shock to acute limb ischaemia. These symptoms were found in Mrs. Kate too. Hence, leg alignment and positioning strategies like lifting legs are necessary nursing intervention to ensure the success in RTKA. It helps to maintain hemodynamic stability and elevation legs improve venous return to the heart (Rozet & Vavilala, 2007). In cases of cast application, assessment of sensation and motor ability of patient is also necessary to manage neurovascular complications. The risk for infection can be checked by providing antibiotics and providing high protein diet to patient to facilitate tissue healing.
Escalate concerns (E):
It is necessary to quickly escalate to surgeon or other health care professional when infection or blood loss is seen in Kate because this may complicate patient’s condition and lead to increased hospital stay or repeated surgery for patient. Higher BMI also increases the risk of venous thromboembolism. Hence, escalating these concerns to the clinician will help in timely management of complications and promoting recovery in patient (Zhang et al. 2015).
Communicating in (C):
Structure communication tool ISBAR will be used to make other members of the health care team aware about current symptoms and signs of deterioration in patient. All possible interventions applied and current clinical priority will also be listed so that each member understand the health status of Mrs. Kate and their role in management of Kate’s health. Proper collaboration with inter-professional team is regarded as a necessary step to provide timely treatment and prevent errors during delivery of care (Boaro et al., 2010).
Teams (T):
To promote collaboration between health care team to manage the condition of Kate, coordinating activities and communicating clearly with team leader and other member of the team is necessary. Consultation with nurse in-charge related to key nursing priorities for Kate may help to determine the role of each member in reducing adverse symptoms in Kate. A physiotherapist may also need to be involved to prevent risk of complication and improve mobility in patient in the future.
ISBAR to develop handover script for Mrs. Kate:
Identify: In the surgical ward 1, Mrs. Kate Ham, a 79 years old patient has undergone RTKA surgery and is currently under PCA for pain management.
Evaluate Your Findings
Situation: This handover information is provided because patient is an asthma patient with signs of grimacing pain, peripheral venous complications and tachycardia. All her symptoms are giving indication of neurovascular complication in patient.
Background: Patient has history of asthma and she is a heavy smokers too. Mrs. Kate is taking Seretide medication for asthma and she is also a NIDDM patient currently on Metformin medication.
Assessment: Pain assessment, sensation of feet, motor ability of patient and neurovascular status of patient has been examined. Positioning changes has been made and NSAIDS medication has been prescribed for pain relief.
Recommendation: It is advised to assess pulse rate and heart rate of patient after taking medications to understand improvements in symptoms in patient. Excessive bleeding or adverse reaction related to drug must also be examined.
Conclusion:
From the analysis of the process used to prioritize treatment for Mrs. Kate, it can be concluded that patient after RTKA are prone to high rate of complication particularly when they are diabetic patients. Hence, regular assessment of patient post surgery is necessary to control changes in vital signs and minimize risk of other complications. The skills related to clinical reasoning and evaluation of patient outcomes based on nursing knowledge also supports nurses to take the best decision for patient.
References:
Boaro, N., Fancott, C., Baker, R., Velji, K., & Andreoli, A. (2010). Using SBAR to improve communication in interprofessional rehabilitation teams. Journal of interprofessional care, 24(1), 111-114, Available at: https://doi.org/10.3109/13561820902881601
Dumolard, P., Gök, M., & Le, N. (2017). Nurses’ responsibilities in postoperative pain management following total hip arthroplasty, Available at: https://www.theseus.fi/bitstream/handle/10024/131818/Dumolard_Pierre.PDF?sequence=1
Dunning, T., 2016. How to monitor blood glucose. Nursing Standard (2014+), 30(22), p.36.
Glassman, A. H., Meschbach, N. T., & Everhart, J. S. (2018). Assessing the High-Risk Patient for Revision Total Knee Replacement. In Revision Total Knee Arthroplasty (pp. 389-399). Springer, Cham.
Hadlandsmyth, K., Sabic, E., Zimmerman, M. B., Sluka, K. A., Herr, K. A., Clark, C. R., … & Rakel, B. A. (2017). Relationships among pain intensity, pain-related distress, and psychological distress in pre-surgical total knee arthroplasty patients: a secondary analysis. Psychology, health & medicine, 22(5), 552-563.
Kalra, S., Bajwa, S. J. S., Baruah, M., & Sehgal, V. (2013). Hypoglycaemia in anesthesiology practice: Diagnostic, preventive, and management strategies. Saudi journal of anaesthesia, 7(4), 447, Doi: 10.4103/1658-354X.121082
Mont, M., Jacobs, J., Lieberman, J., Parvizi, J., Lachiewicz, P., Johanson, N., & Watters, W. (2012). Preventing venous thromboembolic disease in patients undergoing elective total hip and knee arthroplasty. The Journal of Bone and Joint Surgery. American volume., 94(8), 673, Doi: 10.2106/JBJS.9408edit
Musallam, K. M., Rosendaal, F. R., Zaatari, G., Soweid, A., Hoballah, J. J., Sfeir, P. M., … & Lotta, L. A. (2013). Smoking and the risk of mortality and vascular and respiratory events in patients undergoing major surgery. JAMA surgery, 148(8), 755-762, Doi:10.1001/jamasurg.2013.2360
Rch.org.au. (2018). Clinical Guidelines (Nursing) : Neurovascular observations. Retrieved 27 February 2018, from https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Neurovascular_observations/
Rozet, I., & Vavilala, M. S. (2007). Risks and benefits of patient positioning during neurosurgical care. Anesthesiology clinics, 25(3), 631-653, Doi: 10.1016/j.anclin.2007.05.009
Sandika, G., Sandika Gunnapana Gedara, G., Kauppinen, R. M., & Le Louarn, S. (2015). Post-operative pain management methods and nursing role in the relief of pain of total knee replacement patients, Available at: https://www.theseus.fi/bitstream/handle/10024/104715/THESIS%2027.11.docx%20modified.pdf?sequence=1&isAllowed=y
See, M. T. A., Kowitlawakul, Y., Tan, A. J. Q., & Liaw, S. Y. (2018). Expectations and experiences of patients with osteoarthritis undergoing total joint arthroplasty: An integrative review. International journal of nursing practice, DOI: 10.1111/ijn.12621
Shohat, N., Muhsen, K., Gilat, R., Rondon, A. J., Chen, A. F., & Parvizi, J. (2018). Inadequate Glycemic Control Is Associated with Increased Surgical Site Infection in Total Joint Arthroplasty: A Systematic Review and Meta-analysis. The Journal of Arthroplasty.
Sigmund, A. E., Fang, Y., Chin, M., Reynolds, H. R., Horwitz, L. I., Dweck, E., & Iturrate, E. (2017, January). Postoperative Tachycardia: Clinically Meaningful or Benign Consequence of Orthopedic Surgery?. In Mayo Clinic Proceedings (Vol. 92, No. 1, pp. 98-105). Elsevier, DOI: https://doi.org/10.1016/j.mayocp.2016.08.005
Skou, S. T., Roos, E. M., Simonsen, O., Laursen, M. B., Rathleff, M. S., Arendt?Nielsen, L., & Rasmussen, S. (2016). The effects of total knee replacement and non?surgical treatment on pain sensitization and clinical pain. European Journal of Pain, 20(10), 1612-1621.
Society, K. K. (2012). Guidelines for the management of postoperative pain after total knee arthroplasty. Knee surgery & related research, 24(4), 201, Doi: 10.5792/ksrr.2012.24.4.201
Zhang, Z. H., Shen, B., Yang, J., Zhou, Z. K., & Pei, F. X. (2015). Risk factors for venous thromboembolism of total hip arthroplasty and total knee arthroplasty: a systematic review of evidences in ten years. BMC musculoskeletal disorders, 16(1), 24, Available at: https://doi.org/10.1186/s12891-015-0470-0
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