Introduction

Osteoarthritis is a common form of Arthritis that causes disability (Mora, Przkora & Cruz-Almeida, 2018). A large percentage of the patients are elderly, and around one out of eleven Australians suffer from osteoarthritis. In the years 2015-2016, knee replacement rate due to osteoarthritis increased by a high 38% (Australian Institute of Health and Welfare, 2020). In the current scenario, John Grant is elderly man (63) who has been suffering from bilateral knee osteoarthritis and is currently admitted to undergo total knee replacement. This essay aims to highlight the pathophysiology and risk factors of his condition, post-operative assessments, the possible complications that may arise from his surgery and the evaluation of his care.

Risk Factor and Pathophysiology

There have been some risk factors for OA, including being overweight or obese, old age or previous knee injuries. It is more prevalent in females than in males. These risk factors can be identified, along with increasing knee pain (Silverwood et al., 2015). According to John’s medical history, he has Type 2 Diabetes which has been shown to increase the chances of suffering from Osteoarthritis (Williams et al., 2016).

Knee experiences a high amount of stress, including trauma, inflammation and mechanical damage, are also responsible. The pain is caused by the changes in the non-cartilaginous areas, which may include joints, bones, ligaments, muscles and bone remodelling. In the case osteoarthritis, the synovial fluid has been seen to contain plasma proteins, leukotrienes, prostaglandins and other components. These are responsible for stimulating matric metalloproteases, causing the increase of hydrolytic enzymes, leading to the disintegration of cartilage and destruction of collagen. White blood cells may also cause irregular inflammation via the mast cells. Prolonged inflammation may lead to the breakdown of tissues (Mora, Przkora & Cruz-Almeida, 2018).

Post-Operative Assessment and Rationale

The Post-operative assessments immediately undertaken by the nurse must be tailored to the patient and address the problems that he is facing. The patient should be assessed for Postoperative Deep Vein Thrombosis. It is a potentially fatal complication that may arise due to major surgery. This is an important nursing assessment in this context due to various factors. It has been observed that total knee replacement has a greater chance of resulting in deep vein thrombosis than other major similar surgeries. The incidence of Deep Vein Thrombosis is higher in elderly patients than their younger counterparts. It has been observed that the patients aged- 50 to 69 have a five times higher chance of developing the condition than those aged below 49 (Lee et al., 2015). Individuals suffering from Type 2 Diabetes Mellitus also has a higher chance of developing complication (Yang et al. 2015). Another factor in the post-operative deep vein thrombosis development is high blood pressure. John has a history of hypertension, and is currently showing 145/70 which may be concerning Huang, Li & Jiang, 2016). Finally, he is showing an elevated heart rate (105 bpm), which may be an indication of Deep Vein Thrombosis. Hence, this assessment is important in this context.

Postoperative pain assessment may also be important in the case of John. He has been complaining of pain (7/10). An important way may be a non-invasive assessment of immediate postoperative pain utilizing analgesia/nociception index (ANI) (Boselli et al., 2013). John has suffered from depression previously, and it has been seen that when patients with depressive disorders are put under pain medications, complications may arise. They may experience more pain than a normal patient after the operation. On a similar context, an assessment for depression may also be a good idea in the case of John (Ghoneim & O’Hara, 2016).

Post-Operative Complication (Pulmonary Embolism)

After a major surgery, there are many complications that may arise in the patient due to various factors. Two of the most important complications include post-surgical wound infections and pulmonary embolism. Pulmonary embolism can be described as simply a blocked blood vessel in the patient’s lung. This is often characterized by pain in the back of the patient or having trouble to breathe (nhs.uk., 2020). These complications can be potentially life-threatening for a patient. In the year of 2015, there were around 340 deaths in Australia that was caused by pulmonary embolism (Racgp.org.au., 2020).

Pulmonary embolism may happen when a blood clot moves up to the lungs and cause obstruction in the pulmonary vessels. The larger clot or thrombus may get stuck in the pulmonary artery while smaller clots may lodge in the peripheral vessels. This leads to blockage of the pulmonary arteries, creating dead space ventilation. This refers to ventilation in the alveoli becoming greater than capillary blood flow leading in the pulmonary vessels, leading to ventilation-perfusion mismatch. The pulmonary systolic pressure may increase, leading to failure of the right ventricle. This progresses to myocardial ischemia, increasing the risk of mortality (Tarbox & Swaroop, 2013).

In terms of risk factors, the chances of pulmonary embolism have been observed to be high after a major surgery like knee replacement. Prolonged bed rest has been seen to cause pulmonary embolism as well. The chances of pulmonary embolism have been seen to be higher in patients who are older or overweight (Marcano et al., 2017). Patients with Type 2 Diabetes has been seen to have a higher chance of mortality from a pulmonary embolism as well (de Miguel-Díez et al., 2019).

A Lung Ventilation-Perfusion Scan can be conducted to check if the patient has a Pulmonary Embolism. Ventilation refers to the airflow in the lungs, and Perfusion refers to blood flow in the lungs. A small amount of radioisotope is injected into the patients, and their chest is scanned (Nhlbi.nih.gov., 2020). It looks for any evidence of a blood clot in the system. If the air is more, there is a chance that the blood flow is obstructed and there may be a pulmonary embolism. Throughout the ages, pulmonary embolism has evolved more and more, and they are pretty accurate. However, sometimes they may result in over-diagnosis (Metter, Tulchinsky & Freeman, 2017). Pulmonary embolism is characterised by elevated heart rate and elevated blood pressure, as present in John (healthlinkbc.ca., 2020).

Plan of Care

Pulmonary embolism is a life-threatening complication that often has a high mortality rate and danger. Pulmonary embolism can be categorised into few types – massive pulmonary embolism, followed by submassive pulmonary embolism as well as low-risk pulmonary embolism. The patients who suffer from massive pulmonary embolism show symptoms of obstructive shock. The care plan largely depends on the danger presented by the embolism. One of the major ways of taking care of the patient is through dissolving the thrombus or the blood clot. This sort of intervention is known as thrombolytic therapy. Systemic thrombolytic therapy may be an option for the patient. This involves administration of certain chemicals or elements that helps in the dissolving of the clot. It has been observed to decrease fatality in the individuals with pulmonary embolism. Catheter-directed thrombolysis is also a very safe option for the patient where a catheter is inserted into the patient’s chest, and the clot is dissolved via the catheter. It is a minimally invasive procedure and reduces the risk of bleeding in the patient. Inferior Vena Ceva Filter is an intervention that may reduce the risk of formation of additional clots (Handal-Orefice & Moroz, 2019). Blood thinner may be needed to prevent the formation of further clots or even to break down smaller blood clots.

The next priority of care is to manage the pain in the patient. The patient is already on pain medications, and that should be enough to manage the overall. This is because chest pain is a very common symptom of pulmonary embolism.

The patient may require oxygen therapy in the majority of the times in case of pulmonary embolism. This may be done by providing oxygen to the patient via a High Flow Nasal Cannula. It increases the concentration of oxygen in the patient’s blood and helps in the possible right ventricle failure as it balances the ventilation-perfusion rate in the patient. It has been proven to help patients with severe pulmonary embolism (Messika et al., 2017).

It must be remembered that John has been suffering from depression, so it is possible that such as a postoperative complication will cause him major anxiety. It is important that the nurse focuses on relieving his anxiety. This includes telling him to take slow deep breaths and supporting him throughout his care process. This will ensure that his anxiety stays in check.

Evaluation of Care

According to Gibb’s Reflective Cycle (ed.ac.uk., 2020), the description of the event lies in coming up with the care plan for John. To come up with the care plan, I utilized the clinical reasoning cycle (Utas.edu.au., 2020), where I assessed the patient and formulated the care plan. While caring for this patient, I was appalled by how severe postoperative complications could be. This was a big learning experience for me as I only had a handful of patients with pulmonary embolism before, and none of them had has many comorbidities as John. I could have provided John with better care if I had taken into consideration his depression more while caring for him. In future, I will aim to give more personalized care to the patient than I was able to for John.

Conclusion

From this essay, it can be concluded that total knee replacement is a major surgery that has the chance of developing post-operative complications such as post-surgical wound infection and pulmonary embolism. Certain assessments should be conducted after the surgery to identify if the patient has developed any such complications or not. Pulmonary embolism is a serious complication with high morbidity, which can be controlled with the use of thrombolytic agents and proper care. Personalized nursing care after major surgery ensures better patient outcomes.

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