Nurse/Patient Teams Tackle Pain Management After Total Knee Arthroplasty
Wednesday September 15, 2004
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TKA is an extensive surgery that is done to eliminate constant pain or improve function of the knee by replacing the entire knee joint. During the surgery, a tourniquet is placed around the thigh to decrease bleeding during the surgery. The knee capsule is opened; the ends of both the femur and the tibia are cut and prepared for placement of the artificial joint. After the artificial joint is cemented in place, the capsule and the incision are closed. The patient is placed in a splint to keep the leg straight. The splint is usually removed in two to three days when the muscles are strong enough to keep the joint in place. The patient will be up at the bedside and walking as soon as tolerated, usually either the evening of surgery or the following day. Pain after the surgery is considerable, but it's manageable and decreases in intensity each day.
When performing a TKA admissions assessment, the nurse should include questions about what type of pain control the patient currently uses, what type of pain control has been used successfully in previous surgeries, and any special concerns the patient may have about pain. The nurse should tell patients all of their options for pain management and discuss differences in pain perception, including cultural responses to pain and high or low pain tolerance. Through this assessment, the nurse/patient team can determine the best management plan. Use of balanced analgesia, including several different types of medications and methods of pain control, are advantageous in keeping the opioid consumption and its many side effects at a minimum.1
The Perioperative Period
Medications, medication delivery systems, physical intervention and alternative methods can be combined to provide balanced analgesia with the fewest side effects for the patient. Often, some medication for pain are given before surgery. A cox-2 medication or opioid medication may be given for preemptive pain management. Preemptive medication acts to block pain impulses from the surgery to the central nervous system before the injury occurs.2
An epidural catheter or a pain pump with a catheter into the knee joint may be placed intraoperatively to control postoperative pain. These catheters usually remain in place for 24 to 48 hours. Nurses must assess these catheters after surgery to make sure they work properly and cause no bleeding. With the epidural catheter, neurology assessments are of paramount importance because most patients are receiving an anticoagulant to prevent deep vein thrombosis. Bleeding at the site of the epidural catheter placement increases pressure on the nerves exiting the spinal cord and can lead to paralysis.3
Other methods of pain control are intramuscular or patient-controlled analgesia using an opioid like morphine. Monitoring of pain control and side effects of opioids is important when using either of these methods. The most serious side effect is decrease in respirations, which may require a reversal drug to counteract the opioid. As the patient progresses, he or she advances to oral pain medication, which is also often an opioid. The opioid may be supplemented with a cox-2 medication to assist in reducing surgical pain and swelling in the joint.
The nurse/patient team can use ice packs or a cooling pad to help control pain. The cold helps relieve pain by decreasing swelling and stimulating nerve endings in the knee. Some patients report that activity decreases pain by stimulating nerve endings. When continuous passive motion is used after knee replacement, patients initially report increased pain, but as the activity continues, the pain level appears to decrease.
Use of healing touch, which nurses have practiced since the 1970s, has been reported to assist in surgical pain control. If a nurse is skilled in healing touch and the patient agrees to participate, it can be used in conjunction with other pain control measures. Patients may also use guided imagery, self-hypnosis, or music therapy as adjuncts to traditional pain control methods.
A TKA patient is usually up and walking either the evening after surgery or the following morning. The nurse can help the patient manage the pain that occurs from this activity by encouraging the use of pain medication before walking.
Learning to Assess Pain
Nurses must be trained in assessment of pain. The most commonly used assessment tool is the scale of 0 to 10, with 10 being the worst pain possible. Reviewing the pain scale with the patient before surgery strengthens the team approach by allowing the patient to respond appropriately to the nurse's questions. Physical signs of pain may be splinting (holding oneself rigid), facial expressions, and increased pulse and blood pressure. These signs can be used for assessment in conjunction with the patient's response to the amount of pain he has, but they should not be used independent of a patient's response. Pain is individual to each patient and is subjective to what the patient is feeling. Studies have shown that when nurses and patients are queried separately about the patient's pain level, the nurse's response is usually significantly lower than the patient's reported level of pain.
Educating the patient about home management of pain is also important. The patient may have a home health nurse and/or physical therapist after discharge who can help with pain management. But often, patients have to figure out how to control their pain on their own. Knowing how quickly the medication acts, the side effects, and the interactions of pain medications with other medications allows patients to use pain medication intelligently.
By providing the patient with education about pain management before surgery, he or she can work with the nurse in controlling pain in the perioperative setting. This is one way the nurse and patient work as a team to promote recovery from surgery.
Mary E. Hardwick, RN, MSN, works at Scripps Clinic Center for Orthopaedic Research & Education, La Jolla, Calif.
References
1. Pasero CL, McCaffery M. Managing postoperative pain in the elderly. Am J Nurs. 96(10):38-45.
2. Golinski MA, Fill DM. Preemptive analgesia. CRNA: Clin Forum Nurs Anaesth. 1995;6(1):16-20.
3. Horlocker TT. Low molecular weight heparin and neuraxial anesthesia. Thromb Res. 2001;101(1):V141-54.
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