Introduction
Osteoarthritis of the knee also known as the degenerative arthritis is a major and growing problem for the elder population all over the globe. Approximately, 27 million individuals have been reported to suffer from osteoarthritis by the Arthritis Foundation in United States (US). Women have been more commonly reported to suffer from osteoarthritis as compared to men. The prevalence of developing arthritis has been found to increase after the age of 45 . Although, mostly elderly population are most affected yet there are few evidences of young people suffering from it. Osteoarthritis is also commonly defined as wear- and- tear condition of arthritis. In this condition, the cushioning exists naturally in between the joint and cartilage wears off. The wearing off of the cushioning leads to a lot of friction between the joints with a little or no shock- absorbing advantages of the cartilage. This continuous rubbing process results in a lot of pain, which when becoming worse results in stiffness of joints, swelling, difficulty or reduced capability to move, severe pain and bone spur formation .
Risk Factors to develop Osteoarthritis
A number of factors can lead to the increased risk of developing osteoarthritis of the knee. The most common is the age factor i.e., over and above 45 years of age, when the muscles weaken the body and thereby delaying the self- healing process or when with time, the knee joints has totally worn out. The chances of acquiring this disease are higher in women as compared to men. The prevalence of acquiring osteoarthritis has been found with the increase in the body weight of an individual, which eventually worsens with time. In some cases, osteoarthritis has been also found to be hereditary i.e., the disease runs in the family where either the siblings or the parents had osteoarthritis. Osteoarthritis has been associated with knee injury as well such as a torn meniscus. Individuals who had a surgery on their knee i.e., for meniscectomy or repairing of the cruciate ligaments also tend to develop osteoarthritis. Research has also proved that in some cases, that due to hard, repetitive physical activity can also lead to mining or farming. Osteoarthritis can also result in patients who are already suffering from other type of diseases associated with joints that damage the joints such as gout or rheumatoid arthritis. Often individuals who suffer from some kind of metabolic disorders such as excessive secretion of growth hormones or iron overload also develop osteoarthritis.
Etiology of osteoarthritis
Osteoarthritis has been regarded as a multifactorial disease, which eventually the main cause of work disability among individuals who are over 45 years of age. The published epidemiological data shows that approximately 10% to 15% of the total world population suffers from osteoarthritis, of which 70% of them are women while 60% of them are men who are above 65 years of age . With the growing burden of this disease with no cure discovered yet, the incidence of this disease is expected to increase in the future to an extent where it might become an important public health issue. The etiology of this disease has been associated with lack of adaptation to meet the body’s functional demands such as the micro- traumas, macro traumas or surges. It is classified as an idiopathic (primary) as its exact etiology yet remains to be determined. It is stated as secondary when it occurs in patients as a result of any specific disease .
The secondary often occurs as a result of trauma, genetic predisposition, or neuropathic, inflammatory, endocrine or metabolic disorders as a result of a congenital abnormality of the joints or joint infection, metabolic arthritis, inflammatory disorder, repeated hemochromatosis, deformities or traumatic injuries, joint misalignment, joint instability or acquired articular incongruity. The most affected areas are the hips, knees, neck, hands, and lumbar spine. The most common hypotheses of this diseases process are collagen metabolism or articular cartilage defect. Genes such as insulin- like growth factors (IGF-I/ IGF- II), oligo proteins of the cartilage matrix, Vitamin D receptor (VDR), and certain parts of the Human Leukocyte Antigens (HLA). The loci linked to this disease have been previously linked to chromosomes 11q and 2q. The structural protein defects in collagen type II or IX has been also hypothesized to result in osteoarthritis in patients .
Pathophysiology of osteoarthritis
Osteoarthritis is a chronic, degenerative, and progressive joint disease that affects the synovial joints mobility. The disease occurs as a result of several interactions between the joint and cartilage and its adjacent tissues as a result of injury and chondrocyte extracellular matrix. It mostly affects the lower and the upper limbs. The lesions lead to matrix degradation due to proteolytic enzymes like Matrix Metalloproteinase (MMP) - 1, MMP- 8 and MMP- 13, which are specific collagenases. These enzymes are classified based on their capability to cause degradation of triple helical helix region of the collagen type 1, II and III. Other group of enzymes such as the gelatinase A (MMP- 2) and gelatinase B (MMP- 9) also play an important role in degrading collagenase IV, collagenase V, collagenase Vii and collagenase XI. The gelatinases act in synergy with the collagenase in the collagen cleavage. They also degrade the elastin, cartilage link proteins and agrecans . Other enzymes also degrade the extracellular matrix, such as the cleaving of telopeptides areas on collagen type I and II by the cathepsins B and L; degradation of agrecans by cathespin D resulting in depolymerisation of the agrecans, collagen fibrils, and some of the helical regions of collagen type IX and type XI. The serine proteases like the plasmin also directly cause the degradation of the extracellular matrix or activation of metalloproteinase precursors .
Consequently, the components of the cartilage are organized such that it can manage the progression degeneration. The proteoglycan and collagen bundle decomposition can trigger the increase in the water content, the gaps in between the fibrils following the chondrocyte necrosis and decreased cell density. This triggers the change in the joint surface by affecting the sub- chondral bone, joint capsule, ligaments, tendons, and muscles. The increased proteoglycan and cartilage hydration further result in change in the tissues’ mechanical properties, triggering the loss of articular surface integrity and the progression of the vertical cracks into deep erosions that ultimately exposes the sub- chondral bone. These multiple processes result in swelling, severe pain, loss of ability to move the joints.
Complications associated with Osteoarthritis
Osteoarthritis can lead to a number of complications due to the chemical or mechanical stimulation. It results in the calcium crystal accumulation in the cartilage and cyst formation. The chalky calcium crystal deposition in the cartilage is known as chondrocalcinosis or calcification. The formation of this crystals leads to the severity of the disease. These can result in a sudden attack of pain in the swelling known as the acute calcium pyrophosphate crystal arthritis (acute CPP crystal arthritis). Another complication is the Baker’s cysts that occur due to the production of extra joint fluid by the joint that gets trapped in a hernia that sticks out of the lining of the joint. These cysts are not painful but a soft to firm lump can be felt on the back side of the knee . However, these can result in tenderness or aching during exercise. These cysts seldom do not require treatment, but if in case it needs treatment then the extra fluid is drawn out using a syringe and by injecting steroids into it.
Pre-operative nursing assessment
Prior to the surgery, pre- operative nursing assessments were carried out, which included coagulation studies, CBC, urine analysis, and chemistry panel. The salt levels (K, Na, Cl, CO2, BUN, creatinine, glucose and Ca) were analyzed in serum and all of them were in the normal range except for the glucose and calcium levels. No other issues were found. X- ray of his left knee and ECG was also done and showed no apparent pathologies. Additionally, his joint pain was assessed by moving it. His pain worsened due to the stress and the stiffness increased mostly in the morning, which occurred bilaterally and this affected his QoL. Cardiovascular assessment comprised of assessing his hands Raynaud’s phenomenon. Furthermore, his mental and financial status were also assessed, which included assessing helplessness and hopelessness, financial problems, relationship with others, disability, suicidal tendencies, body image perception, and personal identity. The nurses also assessed his fluid and food intake along with his allergies. Additionally, his inability to chew, losing weight, and mouth dryness were also noted. They also assessed his capacity to maintain his personal hygiene. He had a family history of osteoarthritis and thus was provided with a brief counselling in order to make him understand and confident about the operation. This helped in managing his anxiety and nervousness prior to the surgery .
Nursing Diagnosis of Osteoarthritis
The nursing diagnosis confirmed the presence of chronic pain due to the tissue distension, which occurred due to the fluid accumulation or due to the inflammatory process taking place in his left knee. They also identified liquor joints, which was one of the major causes of severe pain . The assessment also helped in diagnosing that he had impaired physical mobility, which was associated with skeletal deformities, discomfort, reduced muscle strength and severe pain. All other diagnostic test reports showed no major complication which could hinder the surgery. The total knee replacement would help in reducing his sufferings and improve his QoL.
Patient- education is important prior to the surgery as it helps in preparing the patient for the surgery and helps him deal with his nervousness and anxiety. The anaesthesiologist performs tests to check which anesthesia suited the best. The routine blood tests are done to check the blood count of the patient. The EKG is done to check the heart condition and presence of ischemia, heartbeat patterns, and arrhythmia. The urine analysis is done to check the presence of urinary tract infection as infection present in the body can lead to knee prosthesis and can delay the operation. The CXR is done to check the lung functioning of the patient. Blood is collected prior to surgery as during total knee replacement the chances of blood loss are high. Dental check- up is also important to rule out the possibility of infections. Medication adjustment is done a week prior to surgery to eliminate the usage of Coumadin therapy, insulin, NSAIDs, and aspirin as they hinder the platelet functioning .
The medical history of Mr. J did not have any complications that could hinder his left total knee replacement. Mr. J had earlier undergone right total knee replacement and he experienced no pain thereafter. Thus, as compared to other patients, Mr. J required less counselling and patient- family education. The medication adjustment was done based on his medical history to prevent complications during the or after the surgery. He was given general anesthesia over regional anesthesia in which he was totally asleep .
Operative procedure
Post- operative intervention
In the PACU, the nurses checked for Mr. J’s vital signs such as his temperature, pulse, R, blood pressure, oxygen delivery and flow rate were checked every 15 minutes. Other changes such as the cardiovascular status were checked to identify any signs of bleeding, infection or fluid volume deficit. Neurovascular status was also checked on his left leg every hour for at least 28 – 48 hours. To tame his pain due to surgery, he was given oxycodone, morphine, Lovenox 30 bid and DVT prophylaxis. All his intravenous fluids were assessed and the nurses conducted thorough check- up of the surgical site. Nose prongs were provided to allow him to breathe steadily. The anesthelogist thoroughly checked all the reports and patients recovery from the anesthesia and transferred him to the intensive care unit .
On the post- operative day 1, the severity of his pain was assessed and it was found that his pain was under control and did not experience sobs or fever or chest pain. His blood pressure also was maintained after 18 hrs. The incisional bleeding was also monitored every 4 hours by emptying and noting the suction drainage and the dressing were also frequently assessed to check blood loss. The dressing was changed after 24- 48 hours post- surgery . His dressing status was also checked and it was dry, clean and intact. His extremities post- surgery appeared to be normal but had motor showed partial motion. Mr. J was kept under complete bed- rest and the position was prescribed using abduction, sling, brace, immobilizer, splint, or other devices. This is vital because improper positioning could result in dislocation. Mr. J was repositioned every 2 hours to prevent bed sores. In case of coughing, incentive spirometer was used to remove the cough every 2 hours. Following this Mr J’s comfort level was also frequently assessed and his epidural infusion, PCA and other analgesia were maintained to give him maximum comfort. A continuous passive range- of- motion (CPM) device was prescribed to help Mr. J exercise and regain his motion. Diet plan was planned to provide him with more of fibre in order to prevent constipation. A protein- rich diet was also suggested to provide adequate nutrition. Post- discharges exercises were taught to him in order to enable him to function independently and were followed-up after the discharge. Additional help such as physical therapy and home health agencies were recommended to help him get back to his life .
Post- operative complications
A number of complications can occur after total knee replacement. One of the major and common complications is a blood clot that occurs in the vein, which is known as thrombosis. It usually occurs deep inside the veins and is called as deep vein thrombosis (DVT) . These clots results in severe pain and swellings. Other complications include infection which is a serious complication, which can result in pain, fever, chills and swelling that worsens with time. Occasionally, stiffness has been also witnessed due to which the patients are unable to move, straighten or bending their legs. Other complication is the early failure of the implant, which occurs due to implant loosening, instability, infection, and fracture around the implants. In case of Mr. J, not many complications had aroused. He was thus discharged upon recovery with proper education and referrals .
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