Knee pain pathophysiology?

[kelly2006]

I'm doing a care plan on a patient who is in the hospital for L knee pain r/t a total knee replacement, and N/V. How do you come up with pathophysiology for those? I've always had pts with actual diseases until now, and the pathos were easy to come up with.

I would appreciate any help at all!! Am I making it harder than it is??

Thanks!!! :)

[Daytonite, BSN, RN]

Hi, Kelly2006!

You're looking at your basic post-op care plan + problems that may occur with the prosthesis. For the post-op part of your care plan take into consideration these potential complications:

• hemorrhage
  
• hypovolemia or shock
  
• dehiscence of the sutures
  
• infection (High risk for infection. . .)
  
• urinary retention (always a big consideration in first hours following OR)
  
• thrombophlebitis
  
• failure to learn proper follow up care
  
• operative pain (related to surgical interruption of body structures)

One of your post op goals is going to be to manage and minimize post-op complications. Is this patient's N/V related to the anesthesia he got or perhaps to his pain medication?

For the knee replacement part of your care plan take into consideration these potential complications:

• dislocation or subluxation of the new prosthesis
  
• neurovascular compromise (compromised circulation)
  
• hematoma formation
  
• sepsis

Your post op goal is going to be to manage and minimize vascular and joint complications.

Some nursing diagnoses to get you started:

• Impaired physical mobility related to pain, stiffness and fatigue
  
• High risk for impaired skin mobility (think of bed rest and pressure sores)
  
• High risk for ineffective management of therapeutic regimen (think of patient teaching about using mobility aides, signs of complications, follow up care, discharge teaching)

You need to find patient information on living with a knee prosthesis post-operatively to help you out with writing your teaching part of the care plan. The Internet is loaded with stuff on this.

http://www.nlm.nih.gov/medlineplus/tutorials/kneereplacement/htm/index.htm - an interactive video on Knee Replacement at Medline Plus

http://www.nlm.nih.gov/medlineplus/kneereplacement.html - here are links into lots of information for the general public on knee replacement

http://www.medicinenet.com/script/main/srchcont.asp?src=knee+replacement&op=mm - information on knee replacement from MedicineNet.com

Think you have enough to get you started, kiddo? Knock yourself out!

[shock-me-sane]

i would think that the patho would have something to do with the reason they needed the total knee. degenerative joint disease? you could work with that.

[Daytonite, BSN, RN]

With regard to the knee you want to start looking first at the reason for the prosthesis in the first place. It's usually due to one of the forms of arthritis, but could also be due to trauma, some sort of deformity or even a tumor of some kind. When a post-op surgical patient continues to have pain in the surgical site you have to think of possible infection (osteomyelitis being the worst of the worst that could happen), a possible dislocation of the new joint, or compromised circulation and compressed nerves due to swelling and edema in the operative area. The most obvious cause of infection would be contamination during surgery. However, there can be other causes. These joint implants can become infected from another site in the patient's body particularly if the patient has a history of chronic UTIs, GI infection (as is ulcers), poor dental condition and dental infection (some dental abscesses take months before they are known). If the patient does not follow the correct positioning techniques they have been shown then the potential for a mechanical problem occurring with the new prosthesis increases. Once active patients who get a new knee often find that they are good to go and sometimes overdo themselves because they are so thrilled to be able to move about again. All those internal tissues around the surgical area need time to heal. A lot of irritation will only cause swelling which pushes on nerves which sets off pain. There is also the reverse, patients who just will not move out of pain or fear of damaging the new prosthesis.

With regard to the nausea and vomiting, the pathophysiology for that needs to list all the possible reasons that nausea and vomiting can occur. It could be the pain medication the patient is on. If the patient has one of those chronic GI infections I mentioned above, that would put him right in line to have nausea and vomiting. Perhaps he doesn't know he has a GI problem and this is something that needs to be investigated. The stress of undergoing surgery can certainly exacerbate a gastric infection that was once insignificant to a full blown crisis. Also, you need to look at the effects on the GI track of general anesthesia. I don't know how long this patient is out of surgery, but some people do not fair well in the recovery from anesthesia and it takes some time for their peristaltic function to return to normal. Anytime peristalsis slows or stops, the result is nausea and vomiting if there is food in the front part of the GI track. Constipation will also cause N/V. Older people on narcotic pain medication who are not moving around a lot can get constipated up pretty quickly. Sometimes this very basic nursing assessment gets overlooked. If the patient is a poor historian and his self-reporting of having regular BMs is false it would be very easy for something like this to happen.

[kelly2006]

Thanks so much to both of you for helping!! Your posts made it so much easier to figure out. Thanks again!! :)