TKR question

  1. why can't a pillow be placed under the knee while asleep for a patient that had a total knee replacement?
    •  
  2. 18 Comments

  3. by   Marie_LPN, RN
    It can allow the knee to get 'lazy,' and possibly remain with a slight bend.
  4. by   catjolpn
    There is risk of contracture when pillow is placed under knee after TKR. This causes a shortening or distortion of muscular or connective tissue which can result in deformity of the joint. Also make sure when they are sitting in recliners to place something under recliner bottom so that it doesn't fall downwards. Place rolled towels under heels. Hope this helps.

    Ortho, Neuro, general Surgery LPN for 3 years

    Catjo
  5. by   rntoon
    thanks for the advice...well appreciated!
  6. by   Grace Oz
    Added to the above advice ....... a pillow under the knee can cause pressure and increase the risk of DVT
  7. by   TracyB,RN
    ditto to the above posts, but why would you want to wake up a patient that is sleeping? If VS are scheduled Q4h, then do re-positioning, but not with a pillow under the knee.
    Waking up a peacefully sleeping post TKR is just as bad as waking up someone to give them a pain pill. They're asleep for a reason.... finally comfy enough to sleep, which is what the pt needs.
  8. by   NJNursing
    Additionally, bending the knee can actually be stressful to the incision site, especially the first couple of days post-op. The skin isn't fully approximated yet.
  9. by   JaredCNA
    While they are sleeping, don't you have them in a CPM (continuous passive motion) machine? We always do.
  10. by   november17
    Putting a pillow directly under the knee can make the new knee "go bad"

    Mainly, what Catjo posted. It's fine to put a pillow or preferably a rolled up towel under the operative leg's ankle though.

    NJ: It's important to get that knee bending as soon as possible. It's a proven fact that the patient will recover faster to their pre-op level of functioning. I don't think approximation is a big deal if the skin is stapled together. (So far) I've never seen or heard of an incision splitting open due to ROM exercises in the immediate postoperative period. We usually start at 65 degrees flexion on the day of surgery and often get the patient up to 90 degrees flexion by day 2 or 3. If it is a young patient they can usually get to 90 even faster.

    Jared: I'm usually cool with letting the patient take their CPM off if it is really bugging them (I work the night shift). It's really a matter of pain tolerance. Some patients say they really like the CPM. Some of them can't tolerate it at all, even if I practically snow them with narcotics. Like I said, if I have a patient complaining of pain I'll give them a break from it for a while (sometimes almost my entire shift). It is usually females in the 50+ age range that have problems with the CPM for some reason. I just document the situation and move on. Not really that big of a deal. Most of the surgeons are pretty understanding if a patient has a low pain tolerance (it's usually pretty apparent when they round). But the surgeons will get pissed if we don't at least make an effort to get a patient to use it.
  11. by   JaredCNA
    Quote from november551
    Putting a pillow directly under the knee can make the new knee "go bad"

    Mainly, what Catjo posted. It's fine to put a pillow or preferably a rolled up towel under the operative leg's ankle though.

    NJ: It's important to get that knee bending as soon as possible. It's a proven fact that the patient will recover faster to their pre-op level of functioning. I don't think approximation is a big deal if the skin is stapled together. (So far) I've never seen or heard of an incision splitting open due to ROM exercises in the immediate postoperative period. We usually start at 65 degrees flexion on the day of surgery and often get the patient up to 90 degrees flexion by day 2 or 3. If it is a young patient they can usually get to 90 even faster.

    Jared: I'm usually cool with letting the patient take their CPM off if it is really bugging them (I work the night shift). It's really a matter of pain tolerance. Some patients say they really like the CPM. Some of them can't tolerate it at all, even if I practically snow them with narcotics. Like I said, if I have a patient complaining of pain I'll give them a break from it for a while (sometimes almost my entire shift). It is usually females in the 50+ age range that have problems with the CPM for some reason. I just document the situation and move on. Not really that big of a deal. Most of the surgeons are pretty understanding if a patient has a low pain tolerance (it's usually pretty apparent when they round). But the surgeons will get pissed if we don't at least make an effort to get a patient to use it.
    I understand what you mean. I work nights too and I am the CNA that takes care of all the joints on our floor and I have been for a while. I think I was going on a very, very small amount of sleep at this time.

    On a side note, why aren't the joint replacement patients ever prescribed anti-inflammatory meds like Toradol? POD #2 all of our joints have their PCA removed and get Vicodin 5/500 PO q4h. I don't know if Vicodin would even take the edge off my pain if I was in that situation.
  12. by   P_RN
    http://www.medicalnewstoday.com/articles/40103.php

    This is an older article without some of the more recent info on the COX-2s. But some good info here.

    Nonsteroidal anti-inflammatory drugs (NSAIDs), including over-the-counter aspirin and ibuprofen, are the most prescribed medications to relieve pain and reduce inflammation post-surgery. A lesser prescribed -- and more potent -- set of pain relievers are COX-2 inhibitors, a special category of NSAIDs. Unlike COX-2 inhibitors, NSAIDs prevent blood from clotting, so patients are required to stop taking these medications one to two weeks prior to surgery to prevent excessive bleeding.
    So they may inhibit bone healing; nsaids increase bleeding/inhibit clotting.
  13. by   JaredCNA
    Quote from P_RN
    So they may inhibit bone healing; nsaids increase bleeding/inhibit clotting.
    Good info. I'm just full of questions right now because I've been flipping through my Pharmacology book for next semester.

    Now I'm wondering why our lumbar lams and ACDs get Toradol. And the doc who does the ACDs will schedule the Toradol q4h for his pts...not prn.
  14. by   november17
    Quote from JaredCNA
    Good info. I'm just full of questions right now because I've been flipping through my Pharmacology book for next semester.

    Now I'm wondering why our lumbar lams and ACDs get Toradol. And the doc who does the ACDs will schedule the Toradol q4h for his pts...not prn.
    I think it's really a matter of surgeon/facility preference. Most of the orthopedic surgeons where I work will prescribe PRN toradol, but we DC it before the patient starts any anti-coagulation therapy (like warfarin/lovenox). So usually we can give toradol for the first 24 hours. Sometimes patients don't get anti-coag therapy and in those cases I think we can give PRN toradol for up to 5 days. At that point it gets DCed so the pt's kidneys don't get screwed up. We just have to be on our toes and aware of the other meds the patient is on or conditions they have (like a hx of stomach ulcers) before we make the decision to go ahead and push toradol.

    Personally, I like toradol - since it is not an opiate type pain med. Not that I have a problem with opiates, but opiates have a LOT of side effects that toradol doesn't (like respiratory depression or making elderly people go off their rocker). For some people it really really works well. There are others that it doesn't work well on at all. I will usually try it in conjunction with an oral medication like oxycontin or vicodin. If toradol isn't cutting it I switch to SQ dilaudid. Believe me, if the toradol isn't working it usually pretty obvious within an hour or so!

    Like I said, it's just a matter of surgeon preference, so don't wrack your brain too hard trying to figure out the whys. At my facility there are 3 neurosurgeons who do lamis and discectomies. Surgeon A always prescribes IM demerol for pain control (and sometimes vicodin if the pt is lucky). Surgeon B will prescribe every pain med under the sun, except he will always choose morphine instead of dilaudid for the IV push pain med. Surgeon C only prescribes IV valium, SQ dilaudid, and tylox. It's not really consistent, but that's just the way they practice. I personally find that no one pain med is ever better than another 100% of the time, it's really just a matter of finding what works for the individual patient. If you are really curious about it, you could just ask the surgeon why they prescribe med A over med B, they'd probably be happy that you asked and would explain their point of view (they love talking about that kind of stuff).
    Last edit by november17 on Nov 21, '07

close