Discussing Total Knee Replacement Tourniquet Use: Nursing Priorities And Harms

Using the DETECT Framework to Identify Nursing Priorities

Question:

Discuss About The Total Knee Replacement Use Of A Tourniquet?

The ability to detect the nursing priorities and harms is a major challenge for the nurses. DETECT table acts as a theoretical framework for nurses to detect the immediate nursing actions and interpret the risk signals of patients in context to patient safety and better health outcomes. In the given case scenario, the DETECT table is used for Mrs. Kate to recognize the immediate nursing actions and interventions to stabilize her condition.

RTKR is a mainstream surgery and from the case study, it is evident that Kate is suffering from post-operative pain (4 hours after surgery) (Carr et al., 2012). The pain score is 5/10 that is alarming enough indicating serious complications. In this situation, pain assessment, wound location and chances of infection is important. The nurse should assess the pain and avoid complications of post-operative pain in RTKR like injuries to veins, arteries from anesthesia administration. Moreover, there was no monitoring of PCA in the past one hour. This is important to avoid any kind of postoperative pain or complications (Lamplot, Wagner & Manning, 2014). The vital signs of the patient was also concerning. The HR was 118 indicating tachycardia, BP-105/56 (hypotension) and BGL 3.5 (hypoglycemic) condition. Hypoglycemic condition need to be stopped from falling as it can make the patient unwell like creating disorientation, confusion and loss of consciousness (Han & Kang, 2013). As Kate is a NIDDM patient, it is evident that sepsis or anesthesia complications can lead to hypoglycemic condition (Jørgensen et al., 2015). Another nursing priority is increase in peripheral capillary refill, >3 seconds (normal <2 seconds) and this prolonged capillary refill time can be a sign of shock, decreased peripheral perfusion and dehydration (Ait-Oufella et al., 2014).

Apart from pain assessment, neurovascular complications are also associated with RKRT (Parvizi & Diaz-Ledezma, 2013). Although, the incidence is low, it is underestimated and can be devastating. The monitoring of the neurovascular deterioration is also a nursing priority as delay in recognition can cause severe complications like permanent deficits that occurs after surgery (Solimeno et al., 2012). These abnormalities in vital signs and complications are witnessed in Mrs. Kate indicating deterioration.

Considering Mrs. Kate deteriorating condition, tachycardia and increase in capillary refill period are the major concerns. Hypoglycemia also need immediate intervention as it may cause complications in RKRT post operation. These are early signs of nonvascular deterioration in the patient. The increase in capillary refill time with pale cool digits is the major complications after knee replacement therapy. The nurse need to evaluate the alternate peripheral perfusion in Mrs. Kate as it is strongly associated with poor health outcomes in patients who undergo surgery. The assessment of peripheral perfusion during the days after surgery need to be monitored to avoid postoperative complications (Ait-Oufella et al., 2012).

Post-operative arrhythmia is a risk involved in older patients who undergoes non-cardiac surgery like knee replacement therapy. There is also well-documented risk of myocardial infarction (MI) within 90 days of surgery. Preventative interventions are required for minimizing severe cardiopulmonary complications like pulmonary embolism in knee replacement therapy.  She is a heavy smoker and it has serious implications on post surgery like arterial venous complications following surgery (Jans et al., 2014). Therefore, the nurse should manage the arrhythmia condition to reduce the chances of cardiac events like stroke.

RTKR and Postoperative Pain: Critical Nursing Actions

Diabetes and morbid obesity are independently associated with infection after knee replacement surgery (Wukich, 2015). It results in complications resulting in adverse outcomes after knee replacement therapy (Friedman et al., 2013). The management of glycemic control is necessary for improved outcomes for Kate.

The treatment plan for Mrs. Kate is pain management and reduction of risk for peripheral neurovascular complications (increased capillary refill period). As her PCA was not administrated in the past one hour, the nurse should assess the pain through scale and major vital signs like BP, HR and oxygen saturation levels. For the pain management, non-steroidal anti-inflammatory drugs (NSAIDs) can be administered like ibuprofen, naproxen and strong pain relievers like oxycodone or tramadol, in case the pain persists. Apart from regular pain reporting, it is important to maintain proper position as it helps to reduce undue tension and muscle spasms on prosthesis and surrounding area (Chang & Cho, 2012).

The orthopedic surgeon needs to be informed about the deteriorating condition of Mrs. Kate as it can lead to severe complications like blood loss or coma. The increased capillary refill also increases the risk for neurovascular perfusion and therefore, these are the major concerns that need to be escalated to the healthcare professionals for managing patient’s condition and avoiding further complications.

ISBAR is an effective communication tool that helps healthcare professionals to be aware of a patient’s current condition that need immediate intervention (Liaw et al., 2014). Patient identification, the current situation, past medications and medical history, background, assessments and current recommendations are listed in ISBAR to help each member of healthcare team to understand the patient’s current condition and developing interventions (Cornell et al., 2013).

Collaboration between the members of the multi-disciplinary team is necessary as it helps to manage Kate’s condition in a coordinated and timely manner (Tomek et al., 2012). The nurse-in-charge can help to supervise the interventions, promote clear communication between the members so that there are no medical errors, and stabilize Kate’s condition (Pape et al., 2013).  The orthopedic surgeon along with the physiotherapist can be helpful in restoring her mobility and avoid further complications.

From the above discussion, it can be concluded that tachycardia, hypoglycemia and increase in capillary refill are the main nursing priorities that are guided by DETECT framework. The recognition of clinical deterioration in Kate is recognized through this framework. It comprises of detection of deterioration, evaluation of patient, treatment, escalation to the concerned authorities, communication and collaborative teamwork to stabilize her condition.

References

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The Importance of Monitoring Vital Signs after Surgery

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