TKA INFECTION IN ELDERLY MALE CLIENT 1

TKA Infection in Elderly Male Client

Chloe J. Hamrick

School of Nursing, West Virginia Wesleyan College

NURS-235-01

Dr. Shannon Bosley

April 30, 2023

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Imagine being admitted to the hospital due to being scheduled for a TKA, or a total knee

arthroplasty. This procedure involves having your entire patellar region removed and replaced

with a metal prosthetic. That sounds rather brutal and invasive, doesn’t it? That’s because it is. A

TKA comes with a plethora of complications resulting from such a surgical intervention! Try to

picture how exposed and vulnerable one’s leg becomes to the environment outside and imagine

just how many things can go wrong! You may be asking yourself, why am I bringing this up?

Well, that’s because I will be discussing the care that I provided for a patient that went through

this very procedure! Overall, his care was delivered in a timely, skilled, and compassionate

manner. However, there were several risks to this patient’s health noted by me that deserve to be

brought up, which I will discuss throughout this paper! In that case, I will now begin!

Infection in any part of the body is a result of invasion by microbes. These microbes can

vary from viral, fungal, bacterial, and protozoal. Infections also occur when the body’s lines of

defense are compromised. Defenses of the body include the skin, respiratory tract, urinary tract,

digestive tract, eyes, blood, liver, spleen, and even bone marrow! Generally, infection becomes

apparent when all three lines of defense the body has are impaired. The defenses include

chemical and physical barriers, nonspecific innate responses, and specific adaptive responses

(Nath, 2023). It is also important to note that those at most risk for acquiring any infection are

young children, the elderly, and immunocompromised individuals. According to the Connecticut

State Department of Public Health (CSDPH, 2023), having risk factors such as these also

increases the likelihood of developing healthcare-associated or nosocomial infections. Following

the invasion of defense lines, an inflammatory response typically kicks in, which is mediated by

the cellular response. There are several types of cells that are activated during an infection,

which are leukocytes (white blood cells), neutrophils, macrophages, erythrocytes (red blood
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cells), lymphocytes, and platelets. Leukocytes are the primary cells that respond to infectious

growth of microbes. They are responsible for phagocytosis, which involves ingesting bacteria

and removing surrounding dead tissue cells. Neutrophils, a type of leukocyte, are the first

responders to an acute infection such as with TKA procedures. They are also phagocytic and

release inflammatory mediators to digest infected tissue. Macrophages are more abundant in

chronic infections, but they still play a vital role in the inflammatory response. They are mature

monocytes (WBCs) that are immensely powerful and potent. Along with ingesting pathogenic

organisms, macrophages secrete inflammatory and antimicrobial mediators, which may also

destroy healthy cells and tissue. Erythrocytes are a crucial carrier of oxygen to places all over the

body. In cases like infection, their delivery of oxygen to tissues, vessels, and cells provides

important nutrients needed to maintain vascularity and circulation to an infected area, which in

turn, prevents further cell death and tissue damage.

Lymphocytes, another type of leukocyte, often come in three subtypes. These include T

lymphocytes, B lymphocytes, and natural killer cells. T lymphocytes are generated in the thymus

and bind to antigens on carrier pathogenic cells. They also enhance and inhibit immune

responses. B lymphocytes are produced in bone marrow and bind to antigens. After contact, B

lymphocytes differentiate into plasma cells, which secrete antibodies that attack antigens.

Natural killer cells are large, cytotoxic lymphocytes that directly attack and kill threatening cells

by secreting enzymes to do so. Lastly, there are platelets. Platelets are blood cells that specialize

in clotting. This involves the coagulation of blood, which occurs when platelets form clusters to

seal off open areas in the skin and blood vessels. The plug formed from these cells also serves as

a barrier against other harmful microbes and particles (Nath, 2023).

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Secondly, let’s move on and discuss the patient. During this clinical day, I took care of a

Caucasian male in his late adulthood years. He was admitted to the healthcare facility for total

knee arthroplasty, as stated previously. He was a full code, had no known allergies, and reported

mild to moderate pain following the surgery. Upon assessment, he rated his pain as a four or five

on a one to 10 scale. The diagnostics used prior to surgery included x-rays of his right knee,

where the incision was located. X-rays of this knee showed wear and tear of his patellar bone and

cartilage. This wear and tear indicated prevalence of osteoarthritis. Certain lab values were also

abnormal as well. These included his WBCs, lymphocytes, creatinine, and BUN levels. This

indicated that he had already obtained an infection and altered kidney function. As far as health

history, he had several diagnoses documented prior to surgery. This included a paternal history

of type II diabetes, hyperlipidemia, hypertension, atrial fibrillation, chronic kidney disease, and

Alzheimer’s. Several of these conditions would potentially increase his risk of osteoarthritis and

a need for TKA, such as diabetes and hyperlipidemia. Hypertension and other cardiac issues are

often comorbidities of osteoarthritis due to high body stress.

The medical plan of care set in place for this patient involved ambulation at regular

intervals, wound care, dressing changes, wound culture, assessment of the surgical site, and

medications delivered PRN or on a schedule. The provider also made notes of keeping the

patient’s ankles elevated by inserting a pillow or blanket underneath them. This intervention is

extremely important for preventing pressure injuries, inhibiting swelling, and to prevent

additional flexion of the knee joint. Unnecessary flexion of the knee is a very serious

complication, as it could impair healing, gait, and placement of the new joint! While staying at

this healthcare facility, my patient was also prescribed up to 17 medications by his provider to

treat multiple diagnoses, which include the following:

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- Acetaminophen 500 mg one tab q6

- Amiodarone 200 mg one tab PO daily

- Apixaban 2.5 mg one tab PO BID

- Aspirin 81 mg one tab PO HS

- Atorvastatin 40 mg two tabs PO daily

- Bactroban 2% TOP BID

- Docusate 100 mg one cap PO BID

- Ferrous gluconate 324 mg one tab PO daily

- Furosemide 40 mg one tab PO daily

- Hydrocodone 325 mg one tab q4

- Maalox 30 mL PO q6

- Magnesium hydroxide 30 mL PO BID

- Metoprolol 100 mg two tabs PO daily

- Multivitamin w/ minerals one tab PO daily

- Nifedipine 60 mg two tabs PO daily

- Ondansetron 4 mg one tab PO BID

- Pantoprazole 40 mg one tab daily

Moving on from medications, there are also several nursing care plans that I have designed

for my patient. Based on his surgery alone, he is at risk for varying complications, but infection

was my primary concern whilst providing care for him. Overall, there were quite a few nursing

diagnoses that I considered when assessing and caring for this patient. The following diagnoses

are:
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Nursing Diagnosis #1

Risk for infection r/t right TKA AEB redness and discharge at incision site.

Goals & Outcomes

Patient will display adequate wound healing over a one-week period. Patient will

demonstrate effective methods to prevent infection.

Interventions

Use aseptic technique when changing the patient’s dressings.

Perform a physical assessment of the wound during dressing changes and note s/s of infection

such as swelling, discharge, warmth, redness, and pain. Administer antibiotics as ordered by a

provider. Educate patient on proper dressing change methods prior to discharge.

Evaluation

Patient reports reduced signs and symptoms of infection after one week of treatment.

Nursing Diagnosis #2

Impaired mobility r/t right TKA AEB slow movement and altered gait upon ambulation.

Goals & Outcomes

Patient will attend physical therapy as ordered prior to discharge. Patient will display

gradual independence in positioning and ambulating.

Interventions

Aid patient in ambulating and use assistive devices as needed. Ensure proper positioning of

the patient’s affected joint. Suggest performing light ROM exercises to reduce stiffness. Refer

the patient to a facility physical therapist.

Evaluation
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Patient demonstrated improved mobility, reduced joint stiffness, and independence when

ambulating and positioning

Nursing Diagnosis #3

Acute pain r/t right TKA AEB facial expression of pain and reports of pain.

Goals & Outcomes

Patient will report reduced pain prior to discharge. Patient will display effective methods to

relieve pain.

Interventions

Assess the patient’s pain level to formulate treatment accordingly. Educate patient on pain

relief methods such as rest, distraction, and compress therapy. Administer pain medication as

needed. Educate patient on proper positioning of affected joint. Monitor for sudden onset of

worsening pain.

Evaluation

Patient reported reduced incidence of pain and discomfort following treatment.

Nursing Diagnosis #4. Risk for DVT r/t right TKA AEB immobility, reports of

discomfort, and poor circulation at surgical site.

Goals & Outcomes. Patient will report reduced prevalence of discomfort in their affected

leg. Patient will display increased levels of mobility and ambulation prior to discharge.

Interventions. Provide comfort and elevation of the affected leg. Suggest the use of

compression devices. Ensure adequate fluid intake and hydration. Assist the patient in

ambulating as tolerated as often as tolerated. Administer anticoagulants and other thrombi

inhibiting medications as prescribed or unless contraindicated.

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Evaluation. Patient reports improved ability to ambulate without discomfort. Patient

demonstrates proper positioning of the affected leg to prevent further clotting. Patient’s affected

leg displays improved circulation upon assessment.

Nursing Diagnosis #5. Poor health literacy r/t right TKA AEB misinterpretation of

information, repeated questions, and altered follow-through of instructions.

Goals & Outcomes. Patient will verbalize understanding of instructions given by

caregivers prior to discharge. Patient will correctly demonstrate and explain self-care techniques

following education given by a nurse.

Interventions. Educate on expectations, potential complications, and disease process

following surgery. Suggest adequate rest to prevent fatigue during education. Review activity

limitations and correct performance of at-home wound care. Ensure that the patient will return to

a safe home environment after discharge. Review medications and their therapeutic functions.

Evaluation. Using the teach-back method, the patient demonstrated correct wound care,

safe positioning, and explained the reasoning and function for prescribed medications.

Following the nursing care plans, it is critical that evidence-based practice is discussed

next. Research is pivotal to providing the best care to patients, and the same can be said for a

total knee arthroplasty procedure. As mentioned previously, there are several factors that may

improve or decline a patient’s condition after such invasive surgery. Noted were the concepts of

patient education, regular ambulation, scheduled medication administration, pain and comfort

assessment, and infection treatment. A particular article (Wainwright et al., 2019) discussed

these topics in detail and provided information on TKA treatment not mentioned here.

Wainwright’s article stressed the importance of preoperative and postoperative education, as this

is one of the major determinants of how well a patient will recover. The article also states that
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pre and postoperative education has been found to reduce patient anxiety. Providing answers to a

patient’s questions also increases the likelihood of them being willing to participate in their own

care.

Next, according to Li et al. (2019), “In 1996, the American pain Society declared that pain

was “the fifth vital sign’”. Since then, researchers have introduced a regimen of medications to

be administered to patients in all stages of the operative procedure. These medications included

preemptive analgesia, opioids, cyclooxygenase-2 inhibitors, epidural anesthesia, peripheral nerve

blockade, local infiltration analgesia, patient-controlled analgesia, and multimodal analgesia.

These medications were consistent with what I saw in the provider’s notes during clinical. While

I did not see many anesthetics mentioned, I did notice COX-2 inhibitors which included

NSAIDS such as Acetaminophen, Aspirin, and Hydrocodone, which were all prescribed to my

patient by his provider. This information remains consistent with information stated in Li’s

(2019) journal.

Lastly, a journal article (Bian et al., 2021) from BMC Musculoskeletal Disorders brought

up a topic that not many healthcare professionals talk about, which is the psychological effects of

total knee arthroplasty. While the studies conducted found that psychological distress in patients

did not particularly affect recovery after surgery. However, Bian et al. (2021) found that up to

42% of patients in their study experienced some degree of psychological distress. This study also

reported that 15% of patients in their study experienced dissatisfaction with their surgery results.

While this number may not be significant, it is still worth bringing up. I noticed a slightly altered

mental state in my patient while providing care for him. At times, he was often withdrawn, quiet,

and even depressed. This could be due to a multitude of factors such as pain, poor body image,

or lack of activity. All in all, studies have shown that assessing a patient’s psychological state
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should be more of a priority, especially during perioperative care. As listed above, a patient

experiencing stress or anxiety due to a procedure has the potential to experience dissatisfaction

and a declined mental state.

In summary, there are a host of issues that can manifest with a total knee arthroplasty,

especially when at risk for infection as my patient was. The pathophysiology of infection is

easily explained, as it simply requires microbes to invade the body’s lines of defense. White

blood cells are also the primary responders to infection, as I have discussed prior. As for my

patient, he possessed several cardiac, renal, and endocrine disorders that amplified his risk for

osteoarthritis, which resulted in his TKA procedure. Several care plans and medications were

ordered for my patient as well, all with the purpose of treating postoperative complications, as

well as preventing prior diagnoses from worsening his condition. The nursing care plans for him

involved a focus on education, preventing infection, preventing DVT, managing pain, and

improving mobility. The provider’s plan of care was quite similar to the nursing diagnoses, only

focusing more on preventing flexion and specimen collection. Studies implementing evidence-

based practice were also consistent with the care plans ordered for my patient. Earlier, the studies

that I have cited discussed the importance of patient education, reducing anxiety and stress, pain

management, and psychological assessment. Each of these topics have been proven to be an

influential factor in the quality of a patient’s recovery, and as stated in previous passages,

caregivers have successfully implemented these concepts into my patient’s care!

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References

Bian, T., Shao, H., Zhou, Y., Huang, Y., & Song, Y. (2021). Does psychological distress

influence postoperative satisfaction and outcomes in patients undergoing total knee

arthroplasty? A prospective cohort study. BMC Musculoskeletal Disorders, 22(1).

https://doi.org/10.1186/s12891-021-04528-7

Cleveland Clinic. (2022, June 6). Infectious disease: Types, causes & treatments. Cleveland

Clinic. Retrieved April 29, 2023, from

https://my.clevelandclinic.org/health/diseases/17724-infectious-diseases

Li, J., Ma, Y., & Xiao, L. (2019). Postoperative pain management in total knee arthroplasty.

Orthopaedic Surgery, 11(5), 755–761. https://doi.org/10.1111/os.12535

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Nath, J. L. (2023). In J. Jonathan (Ed.), Applied pathophysiology: A conceptual approach (4th

ed., pp. 36-43, 105-115 ). Wolters Kluwer.

Wainwright, T. W., Gill, M., McDonald, D. A., Middleton, R. G., Reed, M., Sahota, O., Yates,

P., & Ljungqvist, O. (2019). Consensus statement for Perioperative Care in total hip

replacement and total knee replacement surgery: Enhanced recovery after surgery (eras®)

society recommendations. Acta Orthopaedica, 91(1), 3–19.

https://doi.org/10.1080/17453674.2019.1683790