SONJA HUMAN

BASIC PAIN
MANAGEMENT
KNEE REPLACEMENT SURGERY
The knee is a hinge joint involving the femur and tibia. The surgery involves
exposure of the front of the knee, with detachment of part of the quadriceps
muscle from the patella. The patella is displaced to one side of the joint
allowing exposure of the distal end of the femur and the proximal end of the
tibia. The ends of these bones are then accurately cut to shape using guides
oriented to the long axis of the bones. The cartilages and the anterior
cruciate ligament are removed; the posterior cruciate ligament may also be
removed but the collateral ligaments are preserved. Metal component are
then impacted onto the bone or fixed using cement. A round ended implant
is used for the femur, mimicking the natural shape of the bone. On the tibia
the component is flat, although it often has a stem which goes down inside
the bone for further stability. A flattened or slightly dished high density
polyethylene surface is the inserted onto the tibia component so that the
weight is transferred metal to plastic not metal to metal. Any deformities
must be corrected, and the ligaments balanced so that the knee has a good
range of movement and is stable.

Knee replacements can be used to replace a knee joint affected by a range of

conditions including:

• Severe osteoarthritis
• Ligament damage of infection
• Rheumatoid arthritis
• Hemophilia
• Crystal deposition diseases such as gout
• Avascular necrosis – death of bone following of blood supply
• Bone dysphasia’s – disorder of the growth of the bone

HEALTH HISTORY
A 75 year old woman cannot walk with left knee due to worked out joints.
Knee injured after she fell on knee. The lady now complains of difficulty in
moving around, swelling pain most of the time during the day walking, at
night time to get comfortable position to lay in. This was an on going
situation for a year. She was treated with analgesics. She consults Dr M.D.
Heyns, was sending for x-rays, ECG and booked for a knee replacement.
MEDICAL HISTORY

• Cholesterol
• Hormone treatment

SURGICAL HISTORY

• Hysterectomy year 2000

• Cataract operation year 2006
• Cholecystectomy

FAMILY HISTORY

• FATHER: Hypertension
Cholesterol

• MOTHER: Diabetes
Cholesterol
Leak Heart

ADMISSION
Patient was admitted in ward. She was coming in the ward walking with her
husband. Observations were done: BP 138/86, PULSE 76, TEMP 36.1c,
RESPERATION RATE 20, SATURATION 95%, WEIGHT 90kg, HEIGHT
1,68m. The urine test was done and 1+ protein was found, 3+ leucocytes.
The patient was made comfortable in bed with the bell and bed locker in
reach. Omnopon was the known allergy.

PRE – OPERATION ASSESSMENT

1. Pain relief methods must be discussed with the patient, using the numeric
pain scale. Patient must be taught how to evaluate his pain scale, on the
scale of 0 – 10.
2. Confirm the patient’s right to pain medication
3. encouraged patient to report pain before it becomes severe
4. Report the location and character of the pain
5. Discuss how the pain will affect her recovery
WHAT TO EXPECT
• After the spinal anesthetic she may be pain free, and may not be able to
move her legs
• The knee will be covered with dressings and a drainage tube to remove
excess fluids form the wound
• Vital signs will be regularly check by the staff
• She will have a infusion in one of the arms for giving antibiotics and to
monitor fluid intake and out put
• She will also have a catheter in, because of the fluid intake and out put
and she will not be able to step on that knee for a few days
• Medication will be given to thin the blood and reduce the risk of clots
after the operation
• She will be encourage to move her feet and bend the other leg as soon as
possible – reduce the risk for deep vein thrombosis
• Physiotherapist show you how to perform knee exercises
• Will be nursed one day in High care before transfer to ward

USED FOR PAIN RELIEF

Side effect: addicted, GI disturbs, dry mouth, facial flush, bradycardia,
palpitations, respiratory depression, hypotension, allergic reaction, moisis.

RAYZON

Management of post – op pain

Side effects: insomnia, hyper/hypotension, GI disturbs, bradycardis, post –

op anemia, serious wound drain and back pain.

PERFALGON

Pain relief

Side effects: skin rash, dry mouth, bladder disorder.

CLEXANE

Prevent post – op venous thrombosis and embolism in high risk patients,

prophylaxis in bed ridden patients, and treatment of deep vein thrombosis.

Side effects: hemorrhage, skin necrosis, systemic allergic reactions, local

reactions

KYTRIL

Nausea and vomiting, prevent treatment post – op.

Side effects: headaches, constipation, skin rash

SYNAP FORTE

Pain relief

Side effects: GI disturbs, flush, dry mouth, skin reaction, sweat, urine
difficulty, tight chest, blur vision, allergic reaction, and thicken respiratory
tract secretion, respiratory depression

FLOXAPEN

Antibiotic – infection

Side effects: GI disturbs, allergic/sensitive reactions, anaphylaxis, sore

mouth/tongue, electrolyte disturbs

SPECIFIC PATIENT PLAN

Pain outcome: to be kept pain free-
• Place patient in comfortable position
• Give analgesic as prescribed
• Evaluate effect of medication after 1 hour
Wound outcome: to prevent infection and promote healing-
• Keep wound clean and dry
• Do wound care as prescribed
• Observe wound for any abnormality and report

Circulation outcome: promote blood circulation

• Check pedal pulses and capillary refill
• Encourage active and passive exercises
• Ensure that flowtron pumps are in situ both legs
• Report any abnormalities
• Provide help when mobilizing and assist physiotherapist

Intake and out put: control electrolyte balance and prevent dehydration-
• Administer infusion as prescribe and at prescribed rate: GP Alaris
125ml/hour
• Observe puncture are for any redness, swelling
• Record intake and out put
• Empty catheter, do catheter care and prevent infection
• Empty portavac and report twice daily: morning and evening

CONTINUOUS PROGRESS REPORT

DAY 1:

12:00 Patient in High care admitted from theatre, Ringers lactate infusion
on right arm, Foleys catheter in for free drainage, portavac in situ
and draining minimal. Pain scale 1/10 reported, patient awake and
responding.

13:00 Rayzon 40mg IVI given

13:30 Perfalgon 1g IVI given-

14:00 Kefzol 1g IVI given

14:25 Morphine 10mg given IMI

14:45 Patient says pain sustained

15:00 Patient brushed her teeth

17:00 Kefzol 1g IVI given, patient in stable condition, infusion still

running well, no swelling on puncture area, moral support given,
urine concentrated, Voluven 500ml given as bolus, blood pressure
low

17:30 Patient transfer to ward- complains of mild pain, portavac still in

situ, drained 200ml, pedal pulses palpable on feet, flowtron pumps
in situ both legs.
Observations: BP 134/68, TEMP 35.1C, RESP 21, SPO2 100%, O2
1L flow

18:00 Perfalgon 1g IVI given, mouth care done by patient

20:00 Infusion still in situ, no redness or swelling at puncture area,

catheter draining will, portovac drain well on negative pressure
according to doctors orders, wound clean and dry, pedal pulses
palpable, feet warm, bell, locker within reach of patient,
complaining of slightly pain 5/10 score.
Observation: BP 121/76, TEMP 36 C, RESP 22, SPO2 92%. On
doctors orders the observations must be done 2 hourly

21:45 Rayzon 40mg IVI given

22:00 Observation: BP 132/81, PULSE 65, TEMP 36 C, RESP 22/min,

SPO2 92%, PAIN SCALE 6/10

DAY 2

00:00 Perfalgon 1g IVI given

00:00 Kefzol 1g IVI given

Observation: BP 112/66, PULSE 75/min, RESP 22, SPO2 90%,
TEMP 36 C

02:00 Patient awake no complaints, raised pain better.

Observation: PAIN SCALE 2/10, BP 134/78, PULSE 72/min,
TEMP 36 C, RESO 20/min, SPO2 90%
04:00 Observation: BP 139/83, RESP 20/min, PAIN SCALE 0/10, SPO2
91%

05:00 Catheter drain 500ml, patient complain of pain, Rayzon 40mg IVI
& Perfalgon 1g IVI given, wound dressings clean and dry, feet
warm and pink, Infusion in still in situ, flowtron pumps in situ,
Foleys catheter draining well

06:00 Portovac drain 150ml, and put on negative pressure.

Observation: BP 120/83, SPO2 92%, RESP 22/min, Clexane 20mg
S/C given, 6 hours after operation then 40mg S/C daily

07:20 Patient says pain feels better, wound dressings still intact, clean and
dry, infusion in situ in left arm, no redness or swelling present,
patient on full diet catheter drain straw urine, bell and locker within
reach of patient, still nursed in bed, communicate well

07:50 Doctors rounds- seen by Dr Heyns, must mobilize with

physiotherapist

08:00 Observation: BP 148/80, TEMP 36,8 C, RESP 20, SPO2 93%,

PAIN SCALE 3/10

12:55 Patient experience pain in left knee. Perfalgon 1g IVI given,

wound Dressings in position, clean and dry, protovac in situ and
still draining Ringer lactacte infusion still in left arm

13:10 Kefzol 1g IVI given

16:15 Observation: CATHETER DRAIN 3600ml, PORTOVAC DRAIN

50ml, BP 145/84, PULSE 78/min, RESP 20/min, SPO2 93%,
PAIN SCALE 0/10

17:15 Patient experience some pain, but its not unbearable, Kefzol 1g is
given IVI, dressing still clean and dry, flowtron pumps in position
on both legs, pedal pulses felt, feet and toes pink and warm

18:00 No complains of pain or any discomfort

20:20 Rayzon 40mg IVI & Perfalgon 1g IVI given as prescribed,
infusion still in situ with no abnormality, catheter still in situ and
draining straw urine, wound dressings clean and dry, flowtron
pumps still on both legs in working order blood circulation to feet
good, O2 in situ via nasal cannula at 2L flow, patient still nursed in
bed

DAY 3

00:00 Patient asleep and comfortable

02:00 Patient asleep and comfortable

06:00 Perfalgon 1g IVI & Rayzor 40ml IVI given, wound dressing
clean and dry, portovac drain 5ml, flowtron pumps still on both
legs, catheter drain 500ml. Kefzol 1g IVI given, Cloxane 40mg
daily given

06:10 Patient has no pain at the moment, patient comfortable

08:40 Observation: BP 150/99, PULSE 74/min, RESP 20, SOP2 91%,

TEMP 36 C

09:05 Doctors rounds- seen by Dr Heyns, removed portovac, removed

catheter, stop infusion, Ted stockings on, flowtron pumps on both
legs

11:00 BP 149/88, PULSE 80/min, RESP 18/min, SPO2 92%,

TEMP 36.2 C, PAIN SCALE 1/10

11:30 Patient is complaining of pain, Synap forte ii tablets given,

Floxapen 500mg per os given

13:10 Portovac is removed, infusion stop, no redness or swelling at

puncture area, wound open- clips still in tact, no redness or
swelling, put gauge on wound and close with opsite. TED
stockings on both legs as well as flowtron pumps

16:15 No complaints of pain, wound dressings still position, clean and

dry, feet still warm, pink and moveable, pedal pulses felt.
 Floxapen 500mg per os given
16:25 Observation: BP 142/75, RESP 20/min, SPO2 90%, TEMP 36 C,
PAIN SCALE 1/10, PULSE 80/min

18:00 No complains of any pain

19:00 Assist patient with bed wash, mouth care, flowtron pumps still
working according to doctors orders, TED stockings on, feet warm
and moveable

20:00 Patient comfortable in bed, monkey chain, locker bell within reach
of patient

20:55 Observation: BP 152/87, PULSE 76/min, SPO2 90%, RESP

20/min, PAIN SCALE 1/10, TEMP 36 C,

22:30 Patient complains of pain. Synap Forte ii tablets given as

prescribed, Floxapen 500mg per os given as prescribed

DAY 4

00:00 Patient asleep and comfortable

02:00 Patient awake but not complaining of any pain

05:15 Observation: BP 142/80, PULSE 86/min, RESP 20/min, SPO2

90%, TEMP 36 C

05:30 No pain or any discomfort, TED stockings and flowtron pumps in

situ – both legs, wound clean and dry, Clexane 40mg S/C given.
Floxapen 500mg per os given

06:00 Patient has no pain at the moment, comfortable in bed, bell, locker
in reach of patient

09:20 Observation: BP 148/80, PULSE 90/min, RESP 18/min, PAIN

SCALE 1/10, TEMP 35,8 C

13:00 Dr Aucamp seen patient for discharge tomorrow

13:30 Synap Forte ii tablets given, Floxapen 500mg given as prescribed
14:30 No complains of any pain, mobilize well with walking frame, TED
stockings in position

16:30 Observation: BP 146/85, PULSE 90/min, RESP 18/min, SPO2

93%, TEMP 36.2 C, PAIN SCALE 1/10

18:00 No complains of any pain

20:45 Synaps Forte ii tablets, Floxapen 500mg, given as prescribed for

pain

21:00 Observations: BP 154/95, PULSE 86/min, SPO2 95%, RESP

20/min, TEMP 36 C, PAIN SCALE

DAY 5

00:00 Patient asleep with rounds

01:00 Patient asleep with rounds

03:00 Patient asleep with rounds

04:00 Observations: BP 148/73, PULSE 90/min, SPO2 90%, RESP

20/min, TEMP 36 C, PAIN SCALE 1/10

05:35 Patient slept well, Clexane 40mg S/C given, Floxapen 500mg per
os given, wound dressing still in situ, clean and dry, TED stockings
still in situ

06:20 Patients condition stable, is independent of basic needs, says she

slept well, no complains of pain, went spontaneously to the toilet,
bell and locker within patients reach

07:30 Doctors rounds- seen by Dr M.D. Heyns discharge

DISCHARGE
Synap Forte tablets – used as prescript by doctor for pain.
Floxapen 500mg caps – used as prescript by the doctor – must drink all the
caps because it’s an antibiotic.
All the medication must be taken after eaten a meal and not on an empty
stomach.
Follow –up at doctor’s room on Tuesday

TAKE CARE OF YOURSELF

• Lift leg to prevent swelling

• Keep your wound site clean and dry
• Avoid smoking- smoke can increase risk of lung infection
• Avoid sport activities for at least two months
• Following suggestions on how walk, climb stairs get in and out of a chair
safety
• Avoid jumping, jolting the knee joint or kneeling down
• Use walking frame/crutches/walking stick
• Check knee carefully for any signs of infection- redness, swelling,
warmth
• See doctor if you experience any unusual sounds coming from the knee
joint, or sudden loss of joint control or movement

TOTAL KNEE REPLACEMENT EXERCISE

GUIDE
Regular exercise to restore your knee mobility and strength and a gradual
return to everyday activities are important for your full recovery. Your
orthopedic surgeon and physical therapist may recommend that you exercise
approximately 20 to 30 minutes two or three times a day and walk 30
minutes, two or three times a day during your early recovery.

Your orthopedic surgeon may suggest some of the following exercises. The
following guide can help you better understand your exercises/activity
program, supervised by your therapist and orthopedic surgeon.
EARLY POSTOPERATIVE EXERCISES

Start the following exercises as soon as you are able. You can begin these in
the recovery room shortly after surgery. Yu may feel uncomfortable at first,
but these exercises will speed your recovery and actually diminish your
postoperative pain.