7. Total knee replacement: both sides of the joint are replaced by metal or plastic implants.
   1. Analysis: Total hip replacement
   2. Nursing plan/implementation:
      1. Goal: achieve active flexion beyond 70 degrees.
         1. Immediately postop: may have continuous passive motion (CPM) device for flexion/extension of affected kne Maximum flexion 110 degrees.
         2. Monitor drainage in Hemovac (q15 minutes for first 4 hours, q1h until 24 hours; q4h and prn while Hemovac in place).
         3. Analgesics as ordered for pain.
         4. While dressings are still on: quadricepssetting exercises for approximately 5 days (consult with physical therapist for specific instructions).
         5. After dressings removed: active flexion exercises.
         6. Avoid pressure on heel.
   3. Evaluation/outcome criteria:
      1. No complications of infection, hemorrhage note
      2. ROM of knee increases with exercises.


8. Amputation: surgical removal of a limb as a result of trauma or circulatory impairment (gangrene). The amount of tissue amputated is determined by the severity of disease or trauma and the ability of the remaining tissue to heal.
   1. Risk factors:
      1. Atherosclerosis obliterans.
      2. Uncontrolled diabetes mellitus.
      3. Malignancy.
      4. Extensive and intractable infection.
      5. Result of severe trauma.
   2. Assessment (preoperative):
      1. Subjective data: pain in affected part.
      2. Objective data:
         1. Soft-tissue damag
         2. Partial or complete severance of a body part.
         3. Lack of peripheral pulses.
         4. Skin color changes, pallor —> cyanosis —> gangren
         5. Infection, hemorrhage, or shock.
   3. Analysis/nursing diagnosis:
      1. Impaired physical mobility related to lowerlimb amputation.
      2. Body image disturbance related to loss of body part.
      3. Pain related to interruption of nerve pathways.
      4. Anxiety related to potential change in lifestyl
      5. Knowledge deficit related to rehabilitation goals.
   4. Nursing care plan/implementation:
      1. Goal: prepare for surgery, physically and emotionally.
         1. Validate that patient and family are aware that amputation of body part is planne
         2. Validate that informed consent is signed, Allow time for grievin
         3. Allow time for grievin
         4. If time allows, prepare patient for postoperative phase, , teach arm-strengthening exercises if lower limb is to be amputated; teach alternative methods of ambulation.
         5. Provide time to discuss feelings.
         6. Prepare surgical site to decrease possibility of infection (, shave, scrub as ordered).
         7. Discuss postoperative expectations.
      2. Goal: promote healing postoperatively.
         1. Monitor respiratory status ql-4h and prn: rate, depth of respiration; auscultate for signs of congestion; and question patient about chest pain (pulmonary emboli common complication).
         2. Monitor for hemorrhage; keep tourniquet at bedsid
         3. Medicate for pain as ordered-patient may have phantom limb pain.
         4. Support stump on pillow for first 24 hours; remove pillow after 24 hours to prevent contractur
         5. Position: turn patient on to stomach to prevent hip contractur
         6. ROM exercises for joint above amputation to prevent joint immobilization; strengthening exercises for arms, nonaffected limbs, abdominal muscles.
         7. Stump care:
            1. Early postoperative dressings changed prn.
            2. As incision heals, bandage is applied in cone shape to prepare stump for prosthesis.
            3. Inspect for blisters, redness, abrasions.
            4. Remove stump sock daily and prn.
         8. Assist in rehabilitation program.
   5. Evaluation/outcome criteria:
      1. Begins rehabilitation program.
      2. No hemorrhage, infection.
      3. Adjusts to altered body imag


9. Gout: disorder of purine metabolism; genetic disease believed to be transmitted by a dominant gene, characterized by recurrent attacks of acute pain and swelling of one joint (usually the great toe).
   1. Pathophysiology: urate crystals and infiltrating leukocytes appear to damage the intracellular phagolysosomes, resulting in leakage of lysomal enzymes into the synovial fluid, causing tissue damage and joint inflammation.
   2. Risk factors:
      1. Men.
      2. Age (>50).
      3. Genetic/familial tendency.
      4. Prolonged hyperuricemia (elevated serum uric acid).
      5. Obesity.
      6. Moderate to heavy alcohol intak
      7. Hypertension.
      8. Abnormal kidney function.
   3. Assessment:
      1. Subjective data:
         1. Pain: excruciating.
         2. Fatigue.
         3. Anorexia.
      2. Objective data:
         1. Joint: erythema (redness), hot, swollen, difficult to move; skin stretched and shiny over joint.
         2. Subcutaneous nodules, tophi (deposits of urate) on hands and feet.
         3. Weight loss.
         4. Fever.
         5. Sensory changes, with cold intoleranc
         6. Lab data:
            1. Serum uric acid: increased significantly (6.5/100 mL in women, 7.5/100 mL in men) in chronic gout; only slightly increased in acute gout.
            2. WBC: 12,000-15,000/μL.
            3. Erythrocyte sedimentation rate: >20 mm.
            4. 24 hours urinary uric acid: slightly elevate
            5. Proteinuria (chronic gout).
            6. Azotemia (presence of nitrogencontaining compounds in blood) in chronic gout.
         7. Diagnostic tests: arthrocentesis, x-rays.
   4. Analysis/nursing diagnosis:
      1. Pain related to inflammation and swelling of affected joint.
      2. Impaired physical mobility related to pain.
      3. Knowledge deficit related to diet restrictions and increased fluid needs.
      4. Altered urinary elimination related to kidney damage.
   5. Nursing care plan/implementation:
      1. Goal: decrease discomfort.
         1. Administer antigout medications as ordered:
            1. Treatment of acute attacks: colchicine, phenylbutazone (Butazolidin), indomethacin (Indocin), allopurinol (Zyloprim), naproxen (Naprosyn), corticosteroids (prednisone).
            2. Preventive therapy: probenecid (Benemid), sulfinpyrazone (Anturane). These drugs are not used during acute attacks.
         2. Absolute rest of affected joint-gradual increase in activities, to prevent complications of immobilization; at the same time, rest for comfort.
      2. Goal: prevent kidney damag
         1. Increase fluid intake to 2000-3000 mL/day.
         2. Monitor urinary output.
      3. Goal: health teachin
         1. Need for low-purine diet during acute attack.
         2. Importance of increased fluid in diet.
         3. Signs and symptoms of increased progression of diseas
         4. Dosage and side effects of prescribed medications.
   6. Evaluation/outcome criteria:
      1. Swelling decrease
      2. Discomfort alleviate
      3. Mobility returned to status before attack.
      4. Lab values return to normal.