TKR

(Total knee replacement)

Name: Ng Ah Geok
Age/Sex: 67/F
Occupation: house wife
Doctor: Dr. J.K. Lee (surgeon)
Dr. J.Lam (Anesthetist)
Reason for admission @ 7/7/08
H/O having Rt knee pain X 2 yrs, seen
Dr. Lee on 3/7/08, advice for above
op.
Diagnosis: 9/7/08 - Rt TKR GA &
Past medical history:
Hypt diagnosed 3 yrs ago
DM
Past surgical history:
Nil
Allergy:
? Anti-inflammatory medication
Medication:
T.Atenolol 100mg dly – antihypt (beta
blockers)
Viartril-s 2 tabs tds
A degenerative condition attacking the
articular cartilage & aggravated by an
impaired blood supply, mainly affecting
weight-baring joints & causing pain.
Osteophytes formed at the edge of the
joint.
Primary OA (ageing)
Metabolic factors (hypertiroidism)
Genetic factors (< synthesize collagen)
Chemical factors ( medication such as
steroid will affect the producing of the
enzyme to digest the collagen at the
sinovial membrane)
Mechanical factors (pressure to the
joints)
Secondary OA
Trauma- abnormality at the surface
artikular
Congenital deformity
Obesity, occupation & exercise –
pressure to the abnormal joints
Past inflammation –sepsis,
rheumatoid artritis
Pain, usually made worse by activities
that involve weight bearing such as
standing.
Less movable & eventually may not be
able to fully straighten or bend
The irregular cartilage surface cause
joints to grind, grate, crackle when they
are moved
The ligament, which surround &
support the joints become unstable.
A total knee replacement involves cutting
away the damaged bone of the knee joint
and replacing it with a prosthesis. This
“new joint” prevents the bones from
rubbing together and provides a smooth
knee joint.
Knee replacement surgery is performed to
treat advanced or end-stage arthritis.
When arthritis in the knee joint or joints
had progressed to the point where medical
management is not effective, or deformity
has become severe and debilitating, knee
replacement surgery might be indicated.
Infection in the artificial joint
Neurovascular (ie, nerve and/or blood
vessels) damage
Wear and tear of prosthesis (ie, the knee
implant device) due to heavy use
Stiffness of the knee if scar tissue develops
Complications involving the lungs, heart,
gastrointestinal, or neurological system
Failure to relieve knee pain
Loss of the leg due to blood clots
Death
7/7/08
Lumbasacral spine AP & lateral
Alignment & vertebral body ht appear N
Minimal anterior displacement of L3 over
L4 is seen
The intervewing disc space ht appear N
Anterior & lat osteophytes are seen
Impression
Grade 1 spondylolisthosis of L3 over L4
Osteophytes suggest degenerative
changes.
CXR
N heart size & shape c cardio-
thoracic ratio of 13cm/26.5cm
No evidence of congestive cardiac
failure
Lung are clear

Echo
EF: 74%
X-ray both knees wt bearing
Prominent join margin osteophytes at the
medial & lateral
Knee joint are noted billaterally as well as
at the patello-femoral joints, worse on the
Rt side
Rather prominent tibial spine seen in the
Rt knee
Supicion of chondrocalcinosis may be
present billaterally as well as involing the
synovial lining at the posterior part of the
knee joints
Summary
7/7/08
FBC – N BUSE
RBS – 7.8mmol/l urea 5.5mmol/l
Sr creatinine – sodium
63umol/l 134mmol/l
potassium
4.3mmol/l
chloride 97mmol/l
11/7/08
Hb – 8.7g/dl
8/7/08
HbA1C – 6.0%, idea PT
control PT 13.3
U/FEME – N PR 1.0
Lipid profile INR 1.0
Total chol APT
7.2mmol/l
N control 35.0
HDL 1.58mmol/l
Pt 35.7
LDL 5.0mmol/l
Ratio 1.0
Triglycerides
1.4mmol/l
Sr appearance
clear
 7/7/08
- admitted to Fatimah
- Op on 9/7/08 @ 3 pm
- Ordered to do FBC, BUSE, RBS, Sr creatinine, GXM 2
pint whole blood, CXR, X-ray both knee (AP, lateral),
ECG & collect urine FEME
8/8/08
- Ordered to give Zantac, Maxolon @ 8 am
- Dormicun when call
- NBM after full breakfast
- IV Hartman @ D/saline 6hly
9/9/08
Dr J.K.Lee
Hourly BP, PR
NBM till fully conscious
IV 3 pint / 24 hrs- 2 pint N/ saline alt
1 pint D 5%
Elevated RT leg with pillow
IM Voltaren 75 mg PRN
Dr J.Lam
O2 in ward KIV 2 L nasal prong
VAN inhaler bd x3/7
Continue IV drip
If blood more than 500 mls, 1 pint
voluren over 4 hrs
Check level of block
RTW. G/C drowsy but arousable. IV
Hartman in progress with no redness
& swelling seen. Epidural infusion 8
mls /hr in progress. Level of block:
T10. drsg at Rt knee dry & intact.
Quicky drain x1 insitu with vaccum.
Rt leg kept elevated with pillow.
Circulation, sensation & movement
are good, slight oedema noted.
9/9/08
RR total drain amount: 300 mls, if >
than 500 mls to run IV hartman
RR drain amount: 300 mls + ward drain
amount: 240 mls =540 mls
Ordered to run 1 pint Voluven 8 hly
1 pint Voluven alt 1 pint N/Saline alt 1
pint D5% then continue back 2 pint
N/saline alt 1 pint D5%
10/7/08 (1st POD)
Noted pain because epidural tubing kinked &
vomited after breakfast & med
Ordered
~epidural infusion 10 mls/hr
~Celebrex, IV Maxolon, T. Losec
~to check level of block > 2 hrs
~Rt side ≥ T10-T11, Lt ≥ L2-L3
~to keep drain, dressing & CBD
Encourage exercise in bed
↓ epidural infusion 8 mls/hr
Breathing exercise done
Epidural infusion completed
11/7/08(2nd POD)
Drain amount: 110 mls
Noted oedema at Rt foot
↓ drip IV D/saline alt N/saline 12hly
Continue epidural infusion
Cold pack x1 continuously
Keep drain
Dressing stat
Start Tab Panadeine & IM Pethedine 50 mg 8
hly & prn once IV epidural infusion complete
breathing exercise done
Epidural infusion completed
12/7/08 (3rd POD)
Drain amount:8 mls
Complain pain at the wound site, IM
Pethedine 50 mg given
Ordered to:
~off drip
~teach patient self exercise in bed
~keep drain & CBD
~ cold pack continuously
13/7/08 (4th POD)
Drain amount: 1 mls
Shaking knee exercise taught by Dr J.K.Lee
Sit up & shaking knee exercise
Sit out, stand & walk tomorrow
Off CBD, keep drain
Physiotherapy form sign by him
14/7/08 (5th POD)
Drain amount: 3 mls
Voiding well post CBD
Ambulate with frame, physiotherapy done
When walking drainage flowing more
 Continue ambulate
5% providine dressing stat
Keep drain
15/7/08 (6th POD)
Drain amount: 88 mls
Keep drain
Continue mobilization
16/7/08 (7th POD)
Drain amount: 44 mls
Assisted patient to toilet with walking frame
Sit out of bed
Keep drain, continue ambulate
17/7/08 (8th POD)
Off drain
Continue ambulate
KIV discharge cm
18/7/08
For home
Sign off with consultation &
prescription, appointment x 1/52 @
25/7/08
Dr.Thye Dr.J.K.Lee
7/7/08 9/7/08
Micardis 40mg dly IV Zinacef 750mg tds
Atenolol 120mg dly IM Voltaren 75mg
8/8/08 PRN
Cardiprin 100mg dly Leftose 250mg tds
Lipitor 20mg ON Mobic 7.5mg bd
Micardis 80mg dly Panadeine 1 tab bd
(restart once IV
Micardis 40mg stat
epidural off)
Dr.J.Lam 10/7/08
8/8/08 IV Zofran 4mg bd
Tab Imorne 7.5mg Cap Celebrex 1 bd X
ON 3/7
Tab Zantac 150mg Tab Losec 40mg dly
8am
Tab Maxolon 10mg IV Maxolon 10MG 8h
8am PRN
11/7/08
Tab Dormicum
3.75mg when call IM Pethedine 50mg
9/7/08 8H prn (to start once
IV epidural infusion
Celebrex 400mg stat completed)
IV Voluven 1Θover Tab Singobion 1 dly
8H
Van Inh bd X 3/7
 Start the following exercises as soon as
patient is able. Patient can begin these in the
recovery room shortly after surgery. Patient
may feel uncomfortable at first, but these
exercises will speed their recovery and
actually diminish patient postoperative pain.
Quadriceps Sets
Tighten the thigh muscle. Try to straighten
the knee. Hold for 5 to 10 seconds.
Repeat this exercise approximately 10 times
during a two minute period, rest one minute
and repeat. Continue until the thigh feels
Tighten the thigh muscle with
the knee fully straightened on
the bed, as with the Quad set.
Lift the leg several inches.
Hold for five to 10 seconds.
Slowly lower.
Repeat until the thigh feels
fatigued.
Patient also can do leg raises
while sitting. Fully tighten the
thigh muscle and hold the
knee fully straightened with
the leg unsupported. Repeat
as above. Continue these
exercises periodically until full
strength returns to the thigh.
Move the foot up and down
rhythmically by contracting
the calf and shin muscles.
Perform this exercise
periodically for two to three
minutes, two or three
times an hour in the
recovery room.
Continue this exercise until
patient are fully recovered
and all ankle and lower-leg
swelling has subsided.
Place a small rolled towel
just above the heel so
that it is not touching the
bed. Tighten the thigh.
Try to fully straighten the
knee and to touch the
back of the knee to the
bed. Hold fully
straightened for five to 10
seconds.
Repeat until the thigh
feels fatigued.
Bend the knee as much
as possible while sliding
the foot on the bed.
Hold the knee in a
maximally bent position
for 5 to 10 seconds and
then straighten.
Repeat several times
until the leg feels
fatigued or until patient
can completely bend
the knee.
While sitting at bedside or
in a chair with the thigh
supported, place the foot
behind the heel of the
operated knee for support.
Slowly bend the knee as far
as you can. Hold the knee
in this position for 5 to 10
seconds.
Repeat several times until
the leg feels fatigued or
until patient can completely
bend the knee.
While sitting at bedside or in
a chair with the thigh
supported, bend the knee as
far as patient can until the
foot rests on the floor. With
the foot lightly resting on the
floor, slide the upper body
forward in the chair to
increase the knee bend. Hold
for 5 to 10 seconds.
Straighten the knee fully.
Repeat several times until
the leg feels fatigued or until
patient can completely bend
PAIN RELATED TO THE OPERATION
WOUND
Asses the pain level by interview the
patient & the pain chart to plan next
nursing intervention.
Teach patient the breathing exercise
to reduce the pain.
Elevate the Rt leg with pillow to help
in venous return & reduce the swelling
& pain.
Teach patient the diversional therapy such
as watching television, listening radio,
reading so that patient do not focus to the
pain.
Apply ais pack to the pain & swelling area
according doctor’s order to reduce the
pain & swelling.
Give analgesic such as Panadeine 1 tab bd
according doctor’s order to reduce the
pain
Asses the effectiveness of the analgesic
after 30 minutes to make sure that the
dosage is enough for the pain
Tell doctor if the pain still persist after the
analgesic to prevent any complication.
Asses the range of motion of the
patient to plan next nursing
intervention.
Make sure patient rest in bed till fully
conscious to help in healing proses
Advise patient to do isometric exercise
every 4 hourly at the Rt leg to prevent
muscles atrophy
Help patient in ROM exercise to the
effected area to prevent muscles
atrophy & maintain joint’s function &
Encourage patient change position
every 2 hours when resting on the
bed to help in blood circulation &
prevent bedsores
Help patient to sit out of bed
according Dr’s order to expand the
lung & help in blood circulation
Give analgesic before starting the
exercise to prevent severe pain at
the wound site
Monitor vital signs 4 hourly to detect any
abnormalities such as tachycardia, hypotension,
tachypnea to plan next nursing intervention
Monitor dressing for any signs of bleeding to
detect any excessive bleeding so that early
treatment can be given
Monitor drain amount to detect any abnormality
such > 100mls/ hour
Monitor blood profile such as hematocrit, Hb
level, & coagulation profile to detect any
abnormalities so that early signs of blooding can
be detect
Give patient IV therapy according Dr’s order to
maintain blood volume
Monitor vital signs every 4 hours to detect
any abnormalities such as HR, RR, & T 
shows signs of infection
Make sure the dressing is clean & dry to
prevent wound infection
Make sure the room is clean & tidy to
prevent wound infection
Advice patient to take balance diet & in
vitamin(fruits & vegetables) to increase
the immune system
Practice aseptic technique during
doing dressing to prevent wound
contaminate with microorganism
Report to Dr immediately if fever /
wound have any signs of infection
such as redness, swelling, discharges
so that treatment can be given
earlier
Give antibiotic such as IV Zinacef 750
mg tds according Dr’s order as
prophylaxis antibiotic to prevent
wound infection