knee replacement surgery is a common inpatient surgical procedure

knee replacement surgery is a common inpatient surgical procedure

Introduction

This essay will look at a 76-year-old patient suffering from the post-operative complications of the total knee surgery (arthroplasty) in an orthopaedic ward under the care of a non-medical prescriber. It will look at an overview of the patient, her presenting symptoms, brief assessment and about the decision to prescribe. The Essay will also look at the rationale for choosing the particular medicines and other options that could have been used instead, i.e., the pharmacological process and also the medical management issues. The essay will go on to analyse the evidence provided for the use of the product, and its suitability. It will go on to discuss the professional role of the non-medical prescriber and, their responsibilities as a prescriber and accountability to their patients and the public as a whole in terms of patient care service and the safe practice norms.

The total knee replacement surgery is a common inpatient surgical procedure. As per literature records, osteoarthritis (OA) of the knee can be considered to be the most important reason of disability among adults specifically among those who are elder than 65 years of age (Neogi, 2013). Individuals who are suffering from osteoarthritis (OA) goes through huge pain considerably and also faces compromising ability in terms of normal functional daily activities which results in reduced efficiency, degrading quality of the life of the patients (Kurtz, et al, 2007; Fingar, et al, 2006; Sayeed, et al, 2016). There are many available conventional modes of treatment to manage mild to moderate level of osteoarthritis complications and pain, but the ultimate solution to the problem is the total knee replacement or arthroplasty which is considered to be one of the optimal solutions of this problem (Jüni, et al, 2006). To manage the conditions of arthroplasty, implementation of the clinical care pathways (CCPs) has resulted in the enhanced operation of the multidisciplinary team who can provide excellent quality of the patient care by including the primary care providers, specialists specifically the anesthesiologist and the critical care, pre and post-operative caregivers which includes the social workers, nurses, occupational therapist and physiotherapist. Several pieces of literature have reported that utilization of the CCPs has resulted in the developed patient outcome reports (PROs), supports mobility much earlier and therefore reduces the length of the stay (LOS) of the patient. It was also observed that there is 54 per cent or approx reduction in the cost due to the reduction in the operating room time or the OR time and also because of the better resource utilization with respect to the operating room (Barbieri, et al, 2009; Kee, et al, 2017; Gooch, et al, 2012; Schwarzkopf, et al, 2016).

Clinical Manifestations and Background history of the patient:

Rosemary Reynolds was 76 years old having a past medical record of rheumatoid arthritis. She had experienced increasingly severe pain, swelling and stiffness in her right knee for the past two years. Treatment with physiotherapy and exercises and regular steroid injections had not been effective and Rosemary had now decided to undergo a right total knee replacement. Rosemary’s symptoms affected her quality of life and prevented her from leading an active social life and disrupted her sleep pattern. She was considered to be fit and well and had no other significant past medical records and she had lived alone in a ground floor flat with regular visits from her daughter. Rosemary had undergone a right total knee (arthroplasty) replacement about 3 days before and was then shifted to the orthopaedic ward. Her surgery happened well and there were no complications associated with the procedure of surgeries. She was only intaking very little amounts of food and fluids due to persistent problem of frequent vomiting, nausea and mild dyspepsia. She had not passed her bowels since before the surgery (5-day postoperatively) and therefore was having problems of mild pruritus or itching in her trunk and back. She had a small dressing on her knee wound, which did not show any signs of infections and was also wearing anti-embolism stockings (AES). Rosemary had to take a morphine patient-controlled analgesia pump (PCA) in progress and tried managing to mobilise gently for a short distance to the toilet and back with the assistance of a walking frame and one nurse. She was finding her physiotherapy exercises difficult to manage due to excessive pain, persistent nausea and fatigueness. The nurse who was providing care to Rosemary had just completed the pain assessment with the use of the numerical rating scale tool (NRS) where 1-3 is calculated as mild pain and 7-10 as severe pain (Refer Figure 1). Rosemary had stated that she was experiencing moderate to severe pain which the nurse rated as 6-7 when mobilising and mild to moderate pain: 3-4 when resting in her chair. Her sedation score based on the existing situation according to the Alert, Confusion, Verbal, Pain and Unresponsive tool (ACVPU) (NEWS2 2017) was recorded as an alert. All the clinical observations were within normal range. She continued to experience persistent nausea and also vomited once after breakfast one morning, her back and chest showed itchiness with no visible rash present.

Medications prescribed:

The management of the pain is a very crucial phase after knee replacement surgery. Excessive pain can result in decreased mobility and beginning of the physiotherapy can be delayed because of these reasons. The surgeons can prescribe several oral medications to manage the pain such as morphine, hydromorphone or Dilaudid, hydrocodone, oxycodone, meperidine or Demerol, PCA pumps, nerve blockers and liposomal bupivacaine. The surgeons generally prefer a multimodal approach to manage the pain which generally includes an opioid along with NSAIDs, Cox -2 inhibitors other pain medication non-opioid in nature (Buvanendran, et al, 2003). The above patient was advised with the following list of medicines:

Drug: Intravenous (IV) morphine PCA Dosage: 50mg/50ml (concentration of 1mg/ml). There is no continuous or background infusion 1mg (1ml) bolus with a lockout period of 5 minutes. Total dose: 12mg/hr Drug: Paracetamol (acetaminophen), Dosage: 1 gram every 6 hours: maximum daily amount 4 grams (PO) Drug: Enoxaparin sodium, Dosage: 40mg once a day, subcutaneous (S/C) Drug: Ondansetron, Dosage: 8mg twice a day (PO) Drug: Diclofenac, Dosage: 50mg three times a day (PO), when required Drug: Lactulose 15ml, Dosage: Twice a day (PO) Rosemary has a morphine patient-controlled analgesia pump (PCA) in progress.

Pharmacology of the drugs: Patient-controlled analgesia (PCA) pumps

PCA pumps generally comprise of pain medications of opioid origin. The machine helps to control the dose of the medications, i.e., by switching on the machine more amount of medicines gets released. The pump is designed in such a way that does not deliver an excessive amount of pain medication and the dose gets regulated with time. It is manufactured in such a way that within an hour only a measured dose of morphine will be released. Generally, patients of knee replacement surgery experience severe pain (about 60% of the patients) and moderate to mild pain (30% of the patients) (Hecker, et al, 1988).

Drug: Enoxaparin sodium

The significance of the drug Enoxaparin sodium is that it reduces the risk of intraoperative bleeding. It is a prophylactic anticoagulant and is generally administered before and after the surgery as the half-life of the drug is only 4 hours after a single subcutaneous dose and 7 hours after repeated dosing. The drug binds and enhances the effect of circulating anticoagulant to form a complex which inactivates the clotting factor Xa irreversibly. But the drug has less potentiality against the clotting factor IIa also known as thrombin in comparison to heparin (an anticoagulant) because of its smaller size and lower molecular weight (Brophy, et al, 2001).

Drug: Ondansetron

The feeling of nausea and vomiting after the surgery also known as Postoperative nausea and vomiting (PONV) is a very common scenario. It causes distress to the patients and interferes with the early mobility of the patient and thereby increases the length of stay of the patient. Aprepitant which is an antiemetic is administered to patients who receive chemotherapy. The drug ondansetron is administered to relieve the symptoms of PONV. This particular medication belongs to the class of serotonin 5-HT3 receptor antagonists. The mechanism of action of the drug is simple that it blocks the action of serotonin which results in vomiting and nausea naturally (Roila, et al, 1995).

Drug: Diclofenac

Several non-steroidal anti-inflammatory drugs are prescribed to lessen the pain and inflammation by inhibiting the synthesis of prostaglandins. This particular medicine has been used for the past 15 years. It is a potent inhibitor of the prostaglandin synthetase in comparison to other non-steroidal anti-inflammatory drugs. It is prescribed to reduce the post-operative pain, in case of osteoarthritis and rheumatoid arthritis. Researchers have also shown that there is a significant reduction in the demands of morphine drugs with the administration of the diclofenac. It is also an active ingredient of Voltaren which is a non-steroidal anti-inflammatory drug designed based on the steric hindrance and physicochemical properties. The mechanism of action of the drug is by inhibiting the cyclo-oxygenase, reduced release of the arachidonic acid and in turn, increased uptake of the arachidonic acid. Diclofenac can’t be prescribed to any patient, who is allergic to certain medications such as aspirin, ibuprofen. It is also safe to administer diclofenac along with with another pain killer such as paracetamol (Demir, et al, 2013).

Adverse side effects of the drugs:

The drug Enoxaparin can induce a mild level of irritation, redness, swelling. Fever along with fatigue may appear and the medication can also result in bleeding. Drug Ondansetron can cause headache, fatigue ness, constipation, dizziness, rash and flushing. The adverse effects of the drug diclofenac are: headache, drowsiness, indigestion, stomach pain, nausea, constipation, itching, hyper sweating, high blood pressure and swelling in the arms, pain and legs (Brophy, et al, 2001; Roila, et al, 1995; Demir, et al, 2013).

The patient also reported about the symptoms of persistent nausea, vomiting and mild dyspepsia. Due to this, the patient reported having a mild intake of food and fluids. She also didn’t pass the bowels for the past 5 days after the surgery and therefore reported about mild pruritus or itching to her trunk and back. She was also facing difficulty to continue with her physiotherapy due to her constant fatigue ness, excessive pain and nauseating tendencies. All these symptoms may appear due to the adverse side effects of the drugs prescribed.

Medicine management by the nurses:

The activities related to medicine management are carried out by nurses and midwives based on the individual patient's needs, the policies and regulations of the health care organisation and also on the available scope of practice of the nurses. The activities related to medication management require the nurses to be accountable to the patient or the service users, the regulatory body, the public and any related supervisor in the authority position. The major factors that are considered to determine the scope of practice of the nurse for medicine management are:

• The competence of the nurse
• The accountability and autonomy
• Encouraging the professional development
• Handling of the emergency situations
• Support for the professional practice of nursing and midwife activities
• Allocation

There are five considerations to medication management activities that each nurse should follow which include: the right medication, patient, form, time and dosage. Based on the evidence of the best practice the preparation and the administration of the medication should be performed the same nurse. Nurses should also retain the accountability of the administration of the medication administered and do not demand the monitoring of their work by any other colleague. It is mandatory that the nurses should maintain the guidelines of aseptic techniques and the safety precautions while managing and administering the cytotoxic therapy. Double-checking of the medications is mandatory in case of application of medication of high alertness. It significantly reduces medication errors and ensures good at the same time safe medication management. The nurses should check the vital signs and the laboratory findings of the patient prior to administration of the drug, they should also check the route of administration of the drug to ensure the efficacy, should observe any possible side effects of medication such as allergy associated to medicines, toxicity and adverse reactions, the interactions and antagonism observed due to the application of the several medicines and also monitoring the effectiveness of the prescribed medication. All of the above information should be accurately documented as per the local health service guidelines. The education of the patient and their relatives about the uses of the medicines should be carried out in a comprehensive way. Information regarding the mechanism of action of the medicines, the possible side effects, symptomatic features of the adverse reactions, the possible interaction of the medicines with other medications and the food intake, the instructions and the precautions to follow regarding the route, time, and way of administration of the medicines, the importance behind adhering to the prescribe therapy and reporting after the regular follow up are the part of nurse’s role with respect to medication management. The nurses should discuss about withholding the medicine which has shown any adverse reactions or if the patient refuses to take the medicine with the concerned clinician. They should be able to provide complementary therapies which may include massage therapy, yoga etc to provide optimal healthcare. Transcribing practice involves the transferring of medication order from the original prescription to the current medication prescription sheet. The transcribing order should be signed with the date by the concerned nurse and counter signed by the doctor. This act of transcribing is subjected to an audit (ABA, 2007).

The nursing role for the patient:

The nursing role for the post-operative care of the patient who had undergone arthroplasty are the nurses should adhere to the limitations mentioned by the doctor, should make the patient attend and stick with the rehab, guide the patient to begin light, lesser impact activities to bring tolerance such as swimming and light walking and must avoid strenuous activities such as running a long distance, playing basketball, practising aerobics. Nurses should monitor the vital signs and symptoms of the patient, should regularly check the wound and monitor the wound drainage and dressings, should ensure the physiotherapy process, should assess the neurovascular problems, manage the pain relief process by administering the proper medications at the right time and should also encourage early ambulation in the evening or the day after the surgery. The movement of the knee should be carried on only under doctor’s advice. The post-operative rehabilitation includes starting of a wide range of motions, attachment of the continuous passive motion (CPM) to the knee that had undergone the surgery, providing passive extension by keeping a pillow under the foot (nurse should monitor that nothing should be placed under the operative knee so that maximum extension can be achieved), practising flexion (active flexion q 1hr when the patient is awake) and other muscle-strengthening exercise. Certain postoperative complications may occur which the nurses should continuously keep a check which includes: hypovolemic shock, pneumonia and other infections, the problems associated with the retention of urine, thromboembolism, and uneasiness due to prolonged constipation. The nursing interventions are required in case of compressed bandage and ice has to be applied, should help in elevating the knee when the patient tries to sit. The nurses should prepare the patient for the proper hospital discharge which is usually within 3 to 4 days after the surgery. Moreover, the patient has to continue the physiotherapy at the rehabilitation centre or at home under proper guidance (Lucas, et al, 2007; Pellino, et al, 2005; Mac Lellan, et al, 2004).

For the above patient, the nurse had checked regularly the vital signs of the patient. All the records were kept up to date and discussed with the concerned clinician for accurate medications. The patient was administered with the above-listed medications from time to time under the guidance of a nurse. The dressing of the wound and practising the physiotherapy were ensured by the nurse by continuous monitoring. The nurse also assessed the pain experience on the basis of the score obtained using the numerical setting tool. The sedative drug was also prescribed based on the current sedation score obtained on the Alert, Confusion, Verbal, Pain and Unresponsive tool (ACVPU) (NEWS2 2017). Safe practice and the nursing role:

The nurse monitoring at the bedside of the patient ensures patient safety. With increasing the number of the patient the ability of the nurse gets compromised to provide quality care. Therefore there is a link between the ratio of nursing staff and patient safety. The increase in the workload of the nurse results in increased stress which causes exhaustion of the nurse hampering the patient safety aspect. A medication error is considered to be the most common type of error affecting the patient safety aspect. It is defined as a preventable incident which leads to incorrect medication causing harm to the patient through the situation is under control of the health care organisation. The event may include the following aspect such as communication regarding the order, prescribing the medicines, labelling of the product, procedures related to packaging and nomenclature, dispensing, education, distribution, administration and monitoring. In case any medication errors occur the nursing and medical interventions should be exercised to ensure the patient safety aspect. In nursing education the significance of critical thinking is immense. The skills of critical thinking that the nurses should apply in their studies are critical analysis, rationalization about the valid introduction and conclusion, differentiating between several facts and opinions, ensuring the trustworthiness of the source of information, expounding the concepts and identification of the current conditions. To provide quality care to the patients the nurses should be able to manage the priorities, staffs and the other resources to deal with the risk and by putting the demands of the patient in the front. They should have the knowledge, skills and competence for ensuring safe practice and should also know about the act of raising questions in any circumstances where the code need to be broken (ABA, 2007; Clarke, et al, 2006; Feng, et al, 2008; NMC code, 2015).

Conclusion

In the essay, the detailed clinical manifestations of the patient along with the background history had been discussed. The prescribing medicines have been critically analysed based on the pharmacology and medication management issues. The nurse’s role in terms of the post portative management of the patient who had undergone arthroplasty had also been discussed in details. The role of nurses to ensure safe practice and ensuring the patient safety based on the guidelines provided in the NMC code, 2015 had been discussed in the assignment.

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