MANAGEMENT OF PATIENT UNDER

SPINAL ANAESTHESIA
(ACL TEAR WITH ARTHROSCOPY
PROCEDURE AND MENISCECTOMY )
Prepared By RN Amar Nur Arif Bin Zazuli
Services: Operation Theatre
Staff ID: 12356
 LEARNING OBJECTIVE
At the end of the study , I will be able to:-
1. Explain the Anatomy and Physiology of Knee.
2. State the definition of ACL Tear.
3. Describe the etiology of ACL Tear.
4. Discuss the statistic of ACL Tear.
5. Explain the pathophysiology of ACL Tear.
6. State the clinical manifestation of ACL Tear.
7. State the complication of ACL Tear.
8. Describe the Diagnostic investigation to confirm the ACL Tear.
 LEARNING OBJECTIVE (CONT.)

9. Explain the treatment for the patient with ACL Tear.

10. Implement the effective nursing care plan to the patient with
ACL Tear.
11. Appreciate the importance of health education in order to prevent
recurrent ACL Tear.
PATIENT’S PERSONAL DATA
 PATIENT’S PERSONAL DATA
DATA DETAILS
Name Mr N
MRN 8XX5XX
Sex / Age Male / 35 Year
Race Malay
Religion Islam
Marital Status Married
Occupation Businessman
Language Spoken Bahasa Malaysia
Consultant Dr N
 ADMISSION DATA
Date And Time 20th December 2021@ 0830hrs
Reason of Admission Complain of pain at the right knee for 3 days
after falling down while running while
working.
Medical History Nil
Surgical History Nil
Family Medical History Mother Have Hypertension
Current Medication Nil
Allergic Nil
Diagnosis Anterior Cruciate Ligament Tear And
Meniscus Tear.
PRE ADMISSION
 VITAL SIGN

135/76 mmHg 68bpm 12bpm

8/10 36.2⁰C 76.4kg / 164cm

PHYSICAL EXAMINATION
 PHYSICAL EXAMINATION

PAIN AT
RIGHT
KNEEE

Right Left Left Right

ACTIVITY DAILY LIVING
 EATING DRINKING URINATING DEFECATING

SLEEPING COMMUNICATION PERSONAL MOBILITY

HYGIENE
ANATOMY AND PHYSIOLOGY
ANATOMY AND PHYSIOLOGY OF KNEE
ANATOMY AND PHYSIOLOGY OF KNEE AND
JOINTS.
• The Knee is the most largest and complex joints in the body.
• The the thigh bone (Femur) with the shin bone (Tibia).
• The smaller bone that runs alongside the (Fibula) and
(Patella) are the other bones that make knee joints.
• Tendons connect the knee bones to the leg muscles that move the joint.
ANATOMY AND PHYSIOLOGY OF LIGAMENT

4
ANATOMY AND PHYSIOLOGY OF LIGAMENT
ANATOMY AND PHYSIOLOGY OF KNEE AND
JOINTS.
• Ligaments join the knee bones and provide stability to the knee:
A. The Anterior Cruciate Ligament prevents the femur from sliding
backward on the tibia (or the tibia sliding forward on the femur).
B. The Posterior Cruciate Ligament prevents the femur from sliding
forward on the tibia (or the tibia sliding backward on the femur).
C. The Medial and Lateral Collateral Ligament prevent the femur
from sliding side to side.
• Two C-shaped pieces of cartilage called the medial and lateral menisci act
as shock absorbers between the Femur and Tibia.
• Numerous, Bursea or fluid-filled sacs, help the knee move smoothly.
 FUNCTION OF LIGAMENT.
• The Main Funtion Of The Ligament is:-
• To provide stability to joints and bones throughout the body.

• Rather than that:-

• Connect bone to bone.
• Give supports to joints.
• Limit their movement.
WHAT
IS
ACL
TEAR?
 DEFINITION OF ACL TEAR
• An anterior cruciate ligament injury is the over stretching or tearing of
the anterior cruciate ligament(ACL) in the knee.
(Cheung EC et.al,2020)

• Ligament is a tough band of white fibrous connective tissue that links

two bones together at a joint. Ligaments are inelastic but flexible ,they
strengthen the joint and limit its movement to certain directions.
( Oxford Dictionary of Nursing 4th Edition,Penerbit Fajar Bakti Sdn.Bhd.page 275 )
 RISK FACTOR
• Age
While an ACL tear can affect anyone of any age, they are most
common among people between the ages of 15 and 45. People in this
age range are more likely to participate in the types of activities that
frequently cause ACL tears, such as competitive sports.

• Gender
ACL injuries are two to eight times more likely to occur in women.
While the exact reason for this is still up for debate, researchers suspect
that it is multifactorial including anatomic differences.
 RISK FACTOR
• Extreme Activities.
Participating in sports or activities that require you to pivot, twist, or
jump can increase your risk of an ACL injury. The most high
risk sports are as follows:
ØBasketball
ØSoftball/Baseball
ØSoccer ØWrestling
ØFootball ØSkiing
ØLacrosse ØRunning
ØVolleyball
 RISK FACTOR
• Age
• Female
• Obesity
• Previous knee injury
• Lower extremity mal alignment
• Repetitive knee bending
• High impact activities
• Muscle weakness
PATHOPHYSIOLOGY
 PATHOPHYSIOLOGY
Sudden fall during running while working

“Popping” sensation and sounds during the time of

injury

Twisting to the right knee

Suddenly deceleration at right knee

PATHOPHYSIOLOGY

Develop pain during walking

Swelling at right knee

Anterior cruciate ligament tear

 CLINICAL MANIFESTATIONS
• A loud pop or a "popping" sensation in the knee.
• Severe knee pain and inability to continue activity.
• Discomfort while walking.
• A feeling of instability or "giving way" with weight bearing.
• Rapid swelling.
• Loss of range of motion.
• Stiffness in joint after getting out of bed or getting for a long time
 COMPLICATION
1. Deep Venous Thrombosis
A blood clot that forms in the deep veins of the lower leg ; may be
symptomless or can cause redness , swelling , tenderness and fever.

2. Infection
• Because of the incision patient can get the potential infection.
• The staff must maintain aseptic technique to prevent the infection
during done dressing.

3. Stiffness
Patient will get limb stiffness if he didn’t done physiotherapy
and exercise doctor recommended.
 COMPLICATION
• Osteoarthritis
People who experience an ACL injury have a higher risk of developing
osteoarthritis in the knee. Arthritis may occur even if you have surgery
to reconstruct the ligament.
STATISTIC
 STATISTIC OF ACL TEAR PATIENTS IN KPJ JOHOR
SPECIALIST HOSPITAL (JANUARY-DECEMBER 2021)

8
7
Number of patients

6
5
4
3
2
1
0
0-10 1 1-20 21-30 31-40 41-50 51-60 >60
Male 0 4 4 7 1 0 1
Female 0 2 2 2 1 0 0
 SUMMARY OF STATISTIC
• This is the Statistic of ACL Tear in KPJ Johor Specialist Hospital from January
To December 2021. From the statistic the total number of patient is 24.
• From the statistic we can look that the number of men that having this injury is
more than the female. According to Dr. Richard Nordenvall, man are more prone
to have ACL than women coated from American News. This is due men are
more active than female, espacially people around 31 until 40 because they are
still young and more active than the others.
• Rather than that we also can looks that from the age of 0-10 there is no cases
recorded, and from 11 until 20 and 21 until 30 the number of cases is 6 for both
of them, and 41 until 50 is 2 cases recorded and more than 60 years old is only 1
cases recorded and according to Wendy J. Hurd et,al , the average individual
who sustains an ACL injury is young age and likely to experience knee
instability upon a return to demanding sports activities without surgical
reconstruction.
INVESTIGATIONS
 INVESTIGATION
INVESTIGATION DATE ISSUED TIME
Blood Test 20/12/2021 0830hrs
Electrocardiogram 20/12/2021 0830hrs
X-ray Right Knee 20/12/2021 0830hrs
MRI Right Knee 20/12/2021 0830hrs
Gene-Expert 20/12/2021 0830hrs
TYPES OF BLOOD TEST DATE ISSUED
GP1J(Full Blood Count) 20/12/2021
GP31(Blood Urea Serum 20/12/2021
Electrolyte)
GP31(Hepatitis B 20/12/2021
Screening)
 FULL EXTENDED SCREENING STUDIES (18KS3)

--Hematology--
Date/Time: 20/12/2021 @ 0830hrs
Test Result (Unit) References
Heamoglobin 16.0g/dL 13.0 - 18.0
Red Cell Count 5.8 10^12/L 4.5 - 5.9
Hematocrit(PCV) 49% 41 - 53
MCV 84 fL 76 -103
MCH 28 pg 26 - 34
MCHC 33 g/dL 31 - 36
Platelet Count 327 10^/uL 150 - 450
MPV 8.5 fL 5.8 - 12.0
White Blood Cell Count 10.1 10^3/uL 4.3 - 10.5
White Blood Cell Diffrential Count
Neutrophil 69.2 % 40 - 75
Lymphocyte 22.1 % 20 – 45
Eosinophil 3.3 % 0 – 6.0
Monocyte 4.8 % 1 - 11
Basophil 0.6 % 0-2

--Biochemistry--
Creatinine 102 umol/L 51 - 102
Urea Electrolyte / BUSE
Urea 3.6 mmol/L 2.0 – 6.8
Sodium 139 mmol/L 135 - 155
Potassium 3.8 mmol/L 3.5 - 5.5
Chloride 100 mmol/L 95 - 111

-Serology-
HIV I/II / Antibodies Non-Reactive Non-Reactive
Hepatitis B Screening (GP31)
Result (Unit) References
HBs Antigen Non Reactive Non-Reactive
HBs Antibody <2.0 mlU/ml

Types Of Test Result (Unit) References

Gene-Expert Non-Reactive Non-Reactive
 ELECTROCARDIOGRAM(ECG)
Date/Time: 20/12/2021 @ 0830hrs

Result:
Normal ECG Rhythm
 X-RAY RIGHT KNEE
Date/Time: 20/12/2021 @ 0830hrs
Findings:
• Normal No Fracture Seen.
 MRI RIGHT KNEE
Date/Time: 20/12/2021 @ 0830hrs
Findings:
• Partial Tear Of ACL And Lateral
And Medial Meniscus Tear.
TREATMENT AND
MANAGEMENTS
 TREATMENT AND MANAGEMENT

1. Surgical Management: Arthroscopy And Reconstruction

2. Medical Management: Medication

3. Rehabilitation: Physiotherapy
 SURGICAL MANAGEMENT
ARTHROSCOPY : ACL RECONSTRUCTION :
Arthroscopy is a surgical procedure in Anterior cruciate ligament
which a small fiberoptic telescope reconstruction (ACL reconstruction) is
(arthroscope) is inserted into a joint. a surgical tissue graft replacement of
the anterior cruciate ligament,
■ Fluid is then inserted into the joint to located in the knee, to restore its
distend the joint and to allow for the function after anterior cruciate
visualization of the structures within that ligament injury.
joint.
■ Arthroscopes are approximately 5
The torn ligament is removed from the
mm in diameter, so the incisions are knee before the gra ft is inse rte d
very small (approximately 1/8 inch ) through a hole created by a single hole
punch. The surgery is performed
vARTROSCOPY : arthroscopically.
• Arthroscopy is a surgical procedure in which a small fd into a joint.

• ■ Fluid is then inserted into the joint to distend the joint and to allow for the visualization of the structures within that joint.

• ■ Arthroscopes are approximately 5 mm in diameter, so the incisions are very small

• (approximately 1/8 inch )

 SURGICAL MANAGEMENT
ARTHROSCOPY : ACL RECONSTRUCTION :

• Arthroscopy is a surgical procedure in

which a small fd into a joint.
• ■ Fluid is then inserted into the joint to
distend the joint and to allow for the
visualization of the structures within that
joint.
• ■ Arthroscopes are approximately 5 mm
in diameter, so the incisions are very
small
• (approximately 1/8 inch )
OPERATION THEATRE FLOW
OPERATION THEATRE FLOW
Receive patient from ward or A&E

Check patient using check list together with staff sending patient

Proceed to holding bay to waiting for surgery

Transfer patient to operation room for surgery

Post operation monitoring in recovery area

Return patient to ward / ICU / CICU / HDU / day care

 NURSING RESPONSIBILITIES IN OPERATION
THEATRE

PRE-OPERATIVE:
1. Patient brought in to the operating theatre reception area.
2. Patient verification using perioperative checklist.
3. Ask patient to state :
• Full name
• Or at least one at the identifying data such as identity card number, date of
birth, address or spouse name.
• What plan of surgery.
• Side and site of surgery.
4. Checking against patient identification band or medical record.
 NURSING RESPONSIBILITIES IN OPERATION
THEATRE

PRE-OPERATIVE:
5. Check the relevant document.
Consent must include :
• Name, I/C number, date of birth.
• Description of surgery.
• Side and site of surgery.
• Specific implants or devices to be placed or removed.
• Patient/relative/guardian signature.
• Surgeon signature.
• Signature of witness.

6. Ensure availability of relevant documents such as :

• Patient medical record
• Radiograph image
• Laboratory result
• Diagnostic report
 NURSING RESPONSIBILITIES IN OPERATION
THEATRE

INTRA-OPERATIVE:

GA NURSE
1. Identify the correct patient, correct procedure and correct side of operation
before transferring patient in operation room.
2. Reconfirm with the patient which side of operation and same as consent form.
3. Observe and monitor pulse, blood pressure and spo2 during operation.
4. To maintain progression of iv drip during operation.
5. Record all documentation until finish the operating procedure.
6. Fill up the Anaesthetic Record form.
 SPINAL ANAESTHESIA

• Spinal anaesthesia also called spinal analgesia or sub-arachnoid block (SAB), is a

form of regional anaesthesia involving injection of a local anaesthetic into the
subarachnoid space, generally through a fine needle.
• The fine needle in spinal anaesthesia usually 9 cm long (3.5 inches).
• For extremely obese patients, some anaesthesiologists prefer spinal needles
which are 12.7 cm long (5 inches).
• The tip of the spinal needle has a point or small bevel.
SPINAL ANAESTHESIA
SPINAL ANAESTHESIA
 SPINAL ANAESTHESIA
Anaesthetic agent (drug) are used (heavy marcaine)
↓
Injection to lumbar region ( L3/ L4/ L5 ) into the sub-arachnoid cerebrospinal fluid
space (CFS)
↓
Block the transmission of afferent nerve signals from peripheral nociceptors
↓
Sensory signals from the site are blocked
↓
Thereby eliminating pain.
↓
The desired result is total numbness of the area
↓
Allows surgical procedures to be performed with no painful sensation to the person
undergoing the procedure
 INDICATION

1. An irritable airway (bronchial asthma or allergic bronchitis).

2. Anatomical abnormalities which make endotracheal intubation very
difficult (micrognathia).
3. Borderline hypertensives where administration of general anaesthesia
or endotracheal intubation can further elevate the blood pressure.
4. Procedures in geriatric patients.
 CONTRAINDICATIONS

1. Non-availability of patient's consent

2. local infection or sepsis at the site of lumbar puncture
3. Bleeding disorders
4. Space occupying lesions of the brain
5. Disorders of the spine
6. Maternal hypotension.
 COMPLICATIONS

1. Spinal shock.
2. Hypotension
3. Hypothermia.
4. Bleeding resulting in haematoma
5. Infection
 PREPARATION
• Epidural set
• Povidine - cleaning
• Hibitane alcohol - cleaning
• Spinal needle (25G / 27G)
• Needle ( 21G / 24G )
• Lignocaine 1 % - Local
Anaesthesia
• Spinal Heavy Marcain
• Epidural Set . • Spinal Needle .

• 25G

• 27G
 PREPARATION
• Syringe 3cc, 5cc
• Sharp Bin
• Clinical Waste
• General Waste
• Sterile Glove
 PROCEDURE SPINAL ANAESTHESIA
• Ask patient name,MRN, I.C number,
the operation that patient will go through and Surgeon.
(sign-in).
• Check patient consent and compare with the patient ID band.
• Re-inforce patient regarding spinal to reduce patient anxiety.
• Prepare spinal set.
• Position patient (C-shape / Sitting).
• Stay beside patient.
• Doctor perform the procedure.
 PROCEDURE SPINAL ANAESTHESIA
• First of all the doctor will palpate at the location of spinal anaesthesia
wil be given.
• Then doctor will clean the area of spinal witk the povidine and
chlorhexidine.
• Then doctor will palpate again to ensure the correct site whereby the
medication will be injected.
• Then doctor will inject the local anesthesia at the correct site.
 PROCEDURE SPINAL ANAESTHESIA
• Then doctor will insert the needle 24G at the spinal site.
• Then doctor will insert the spinal needle inside the needle 24G.
• Then doctor will inject the medication which is Heavy Marcain
Spinal.
• Then doctor will remove the needle and clean the patient.
 NURSING RESPONSIBILITIES IN OPERATION
THEATRE

POST-OPERATIVE:
1. Document the time ending of the surgery.
2. Inform the patient that the surgery has been finished.
3. Unattached the ECG lead, blood pressure cuff and oxygen saturation
cable .
4. Stand beside the patient to prevent any fall from operation bed.
 NURSING RESPONSIBILITIES IN OPERATION
THEATRE

POST-OPERATIVE:
6. Stand beside until the patient transfer to the bed or trolley.
7. Use the roller to transfer the patient from OT table to bed.
8. Bring the patient to the recovery bay to monitor the vital sign
including SPO2, blood pressure, temperature, pulse rate, respiration
rate and level of conscious.
9. Give the report to the recovery nurse including type of anesthesia,
name of operation, dressing side, have any drain or not and iv drip.
 NURSING RESPONSIBILITIES IN OPERATION
THEATRE

RECOVERY:
1. Check the patency of the airway.
- Clear the airway by sucking the secretion.
- Insert the artificial airway as necessary.
- Perform the head tilt chin lift as necessary.
2. Administer oxygen therapy.
3. Check the breathing pattern and rate.
4. Check the circulation by assess the skin color, nail beds, lips and oral mucosa.
5. Monitor patient’s level of consciousness.
6. Monitor the vital sign every 5 minutes.
7. Check dressing for oozing.
 NURSING RESPONSIBILITIES IN OPERATION
THEATRE
RECOVERY:
8. Provide physical and emotional comfort :
- Provide radian warmer as necessary.
- Administer pain relief as ordered.
9. Elevated both leg using pillow.
10. Record all observation, complication, treatments, patient response and
medications given in the observations chart.
11. Care of the patient until the physical and emotional status is stable for at
least 30 minutes.
12. Perform the Aldrette Score and get the anesthetist’s signature before
sending patient to ward.
13. Past over the patient data and condition to the ward staff.
 POST OPERATIVE CONDITION

Knee
Brace IV Branula
Primapore 20G @
Dressing 28/11/21

Crepe
Bandage
Right Left Left Right
 MEDICAL MANAGEMENT
• INTRA OPERATION MEDICATION:-
NO DRUG DOSAGE FREQUENCY GROUP ROUTE DATE ON DATE
OFF

1 Dormicum 5mg Stat Analgesic IV 20/12/2021 20/12/2021

(non-opioid)
and antipyretic)

2 Pethidine 10mg Stat Analgesic IV 20/12/2021 20/12/2021

 MEDICAL MANAGEMENT
• MEDICATION DURING HOSPITALIZATION:-
NO DRUG DOSAGE FREQUENCY GROUP ROUTE DATE ON DATE
OFF

1 Dynastat 40mg BD Non Steroidal Anti IV 20/12/2021 23/12/2021

Inflammatory Drug
(NSAID)

2 Pethidine 75mg PRN Analgesic IM 20/12/2021 23/12/2021

BRAND NAME DYNASTAT

GENERIC NAME Pericoxib

GROUP Nonsteroidal Anti- inflammatory
INDICATIONS Acute or chronic treatment of sign and symptom
of osteroarthritis,acute gouty arthritis, acute
pain and primary dysmenorrhoea.

CONTRA INDICATION Hypersensitivity to Pericoxib

ADVERSE REACTIONS Asthenia / fatigue , dizziness , hypertension.

BRAND NAME PETHIDINE

GENERIC NAME Pethidine HCL

GROUP Analgesic
INDICATIONS Short term relief of the moderate to severe
pain .As an anaesthetic adjunct and for obstetric
analgesic.

CONTRA INDICATION Respiratory depression or where respiratory

reserve is depleted.

ADVERSE REACTIONS Respiratory depression , Ligtheadedness ,

dizziness , sedation , sweating.
BRAND NAME DORMICUM

GENERIC NAME Midazolam

GROUP Hypnotic & Sedative
INDICATIONS Short term treatment of insomnia,
Sedation in pre med before surgical or diagnostic
procedure.

CONTRA INDICATION Severe respiratory & hepatic insufficiency,

sleep apnea syndrome.

ADVERSE REACTIONS Dizziness , Headache, reduce alertness.

 REHABILITATION

CRYOTHERAPY QUAD STRECHING

EXERCISE
 REHABILITATION

ICE PACK KNEE BRACE

REHABILITATION

PARTIAL WEIGHT BEARING

CRUTCHES
NURSING CARE PLAN
 NURSING CARE PLAN
PRE-OPERATIVE:
1.Alteration in emotional status , anxiety related to right anterior eruciate
ligament reconstruction and arthroscopy and spinal procedure.
INTRA-OPERATIVE:
2. Alteration in body temperature; hypothermia related to spinal anaesthesia.

POST-OPERATIVE:
3.Alteration in body movement; potential fall related to loss of sensation at
lower body part.
4. Alteration in comfort , risk of nausea and vomitting due to spinal anaesthesia.

5.Knowledge deficit related to home care management post ACL

reconstruction and arthroscopy.
 NURSING CARE PLAN 1
DATE/TIME:21/12/2021 @ 0800hrs
NURSING DIAGNOSIS:Alteration in emotional status , anxiety related
to right anterior eruciate ligament reconstruction and arthroscopy and
spinal procedure.

SUPPORTING DATA:
1.Mr. N asked a lot of questions regarding the surgical operation ( ACL
reconstruction and Athroscopy) and spinal procedure.
2.Patient verbalized that he worried about surgery and unfamiliar
procedure.
3.Patient verbalized that this is first time he going for operation
4.Patient’s facial expression looks anxious and fear.
 NURSING CARE PLAN 1
GOAL:Patient will be verbalized less of anxiety within ½ and hours
after nursing
interventions given and during hospitalization.
 NURSING CARE PLAN 1
NURSING INTERVENTIONS:

1. Assess patient’s general conditions such as facial expression and level

of knowledge regarding surgical operation that have done on him.
® :Act as baseline data to plan nursing interventions
I : During my assessment, Mr.N look so worried and anxious. He
also ask a lot of question regarding the surgical operation (ACL
reconstruction and Athroscopy) and spinal anaesthesia.
 NURSING CARE PLAN 1
2. Reinforce doctor explanation regarding the procedure, purpose and
benefit of ACL procedure and spinal anaesthesia.
® To reduce patient’s anxiety and make patient confident before going
to operation.
I :I reinforce doctor explanation to patient regarding the
procedure ,purpose, benefit for surgery. Example this operation take
about 2-3 hours, patient will give anesthetic under spinal, so patient
will paralyses on the lower limb 6-8 hours
 NURSING CARE PLAN 1

3. Encourage patient to ask questions regarding any doubt about the

operation.
®: To clarify any doubt and prevent misunderstanding
I: I encourage Mr.N to ask questions anytime in order to promote his
understanding and to gain of his confident.
 NURSING CARE PLAN 1

4. Communicate with patient and be good listener.

® Verbalization of fear or anxious will help to reduce patient’s burden
of fear and worry psychologically.
I: Before Mr.N go to operation theatre, I visit and talk to him, to
ensure that patient was ready to go for operation. I also encourage
him to be more relax by doing Deep Breathing Exercise and demonstrate the
Deep Breathing Exersice technique whereby inhale via nose and exhale via
mouth with pursed lips technique.
 NURSING CARE PLAN 1
5.Informed patient what procedure he will going through during pre
operation, intra operation, and post operation.
® In order to reduce Mr.N's anxiety ,by understanding what to
prepare before and to expect after operation will promote his
understanding what he go through will reduce his anxiety.
I: I explained about pre operation ,intra operation and also the post
operation management such as need to fasting before go operation,
during operation, he will give spinal anaesthesia, so that he would not
felt pain and he will be give pain killer after operation.
 NURSING CARE PLAN 1

6. Advice patient to rest and be more relax such as sleeping and take a
deep breath while waiting for operation.
®: Act as divertional therapy like DBE will divert patient’s mind from
worry for operation
I: I encourage patient to rest, sleeping or do DBE while waiting for
operation.
 NURSING CARE PLAN 1
DATE/TIME:21/12/2021 @ 0830hrs

EVALUATION:
Patient verbalized less of anxiety within 30 minutes and after nursing
interventions given and before send him to operation theater and during
hospitalization.

SUPPORTING DATA:
-Patient verbalize less anxiety.
- Patient look more calm.
 NURSING CARE PLAN 2
DATE/TIME: 21/12/2021 @ 0835hrs
NURSING DIAGNOSIS:
Alteration in body temperature; hypothermia related to spinal
anaesthesia.

SUPPORTING DATA:
-Patient complain of cold.
-Patient body looks shivering.

GOAL:
Patient will verbalize not feeling cold and feel more comfortable and
patient body seen no shivering after nursing intervention given.
 NURSING CARE PLAN 2
NURSING INTERVENTIONS:
1. Assess patient general condition (pallor, body movement, facial
expression).
® to detect any abnormality.
I: I assess patient general condition. Patient looks shivering and weak.

2. Provide warming mattress on the operation table.

® to keep patient warm during operation.
I: I put the warming mattress on the operation table.
 NURSING CARE PLAN 2
3. Cover patient with warm blanket at non-operation site.
® To prevent patient from shivering and for patient comfortable.
I :I cover patient body with warm blanket.

4. Explain to the patient regarding temperature in operation theater.

® For patient understanding that room temperature in operation
theater is in low temperature to prevent infection spread.
I : I explain to the patient regarding temperature in operation theater.
 NURSING CARE PLAN 2
5. Limit the amount of skin exposure between prepping and drapping.
® To limit the temperature at the other site decrease and prevent from
hypothermia.
I : I put extra blanket on the upper part of patient body.
 NURSING CARE PLAN 2
DATE/TIME:21/12/2021 @ 0855hrs

EVALUATION:
Patient verbalize no shivering and patient body seen no shivering after
nursing intervention given.

SUPPORTING DATA:
Patient verbalize not feel cold anymore.
Patient look more relaxation.
 NURSING CARE PLAN 3
DATE/TIME:21/12/2021 @ 1100hrs
NURSING DIAGNOSIS:
Alteration in body movement; potential fall related to loss of sensation
at lower body part.

SUPPORTING DATA:
-Patient ask regarding when his lower limb back to normal.
-Patient tryed to raise his lower limb.

GOAL:
Patient will be able to raise his lower limb after nursing intervention
given.
 NURSING CARE PLAN 3
NURSING INTERVENTIONS:

1.Assess patient general condition such ability to move especially the lower
limbs.
® To detect any abnormality on the patient.
I : I assess patient general condition. Patient still unable to move his lower
limb.

2. Explain to the patient regarding side effect of spinal anesthesia such as sense
of lower limb take 4 – 6 hours back to the normal.
® For patient knowledge and to prevent patient get up from bed.
I : I explain to the patient about side effect of spinal anesthesia.
 NURSING CARE PLAN 3
3.Raise up the side rail on patient bed or trolley.
® For patient safety and to prevent patient from fall down to the floor.
I : I raise up the side rail on patient trolley.

4.Provide urinal or bedpan to the patient for elimination(if need).

® To prevent patient from get up from the trolley and prevent from
fall.
I : I provide urinal to the patient.
 NURSING CARE PLAN 3
DATE/TIME: 21/12/2021 @ 1125hrs

EVALUATION:
Patient verbalize that he understand the reason of post spinal
anaesthesia after nursing intervention given.

SUPPORTING DATA:
Patient understand and feel more comfortable.
 NURSING CARE PLAN 4
DATE/TIME:21/12/2021 @ 1100hrs
NURSING DIAGNOSIS: Alteration in comfort , risk of nausea and
vomitting due to spinal anaesthesia.

SUPPORTING DATA:
-Patient will complain nauseated and will vomit during
monitoring in recovery.

GOAL:
Patient will be lessen feeling nauseated and stop vomit after half an
hour nursing intervention given and during hospitalization.
 NURSING CARE PLAN 4
NURSING INTERVENTIONS:

1.Assess patient general condition such any complain of feeling nauseated and
urge of having a vomit.
® To detect any abnormality on the patient.
I : I assess patient general condition. Patient does not complain of feeling
nauseated and patient also does not vomit.

2. Provide patient oxygen 6 litre via face mask .

® To reduce and relive the feeling of nauseated and prevent from vomit.
I : I provide patient oxygen 6 litre via face mask. Patient seem comfortable
and sleeping well.
 NURSING CARE PLAN 4
3.Position patient in low fowlers position in 20 degree.
® to reduce the urge of nauseated and vomitting and makes patient
more comfortable.
I : I Position patient in low fowlers position in 20 degree.Patient looks
comfortable and no complain of nauseated and does not vomit.

4. Provide condusive environment to the patient such as quiet

environment.
® To reduce and relieve the feeling of nauseated and prevent from
vomit and let patient have a proper rest.
I : I provide patient condusive environment to the patient such as quiet
environment Patient seem comfortable and sleeping well.
 NURSING CARE PLAN 4
DATE/TIME: 21/12/2021 @ 1130hrs

EVALUATION:
Patient verbalize that he feel comfortable and does not have any urge to
vomit and does not feel nauseated after nursing intervention given.

SUPPORTING DATA:
Patient feel more comfortable.
 NURSING CARE PLAN 5
DATE/TIME:22/12/2021 @ 0800hrs
NURSING DIAGNOSIS:
Knowledge deficit related to home care management post ACL
reconstruction and artroscopy.

SUPPORTING DATA:
1- Patients ask a lot of questions regarding the what he can and cannot
do at home.
2- Patient look curious to know the home care management.
 NURSING CARE PLAN 5
GOAL:
Patient’s understanding and will be gained a knowledge
regarding self care management after nursing intervention
given and during hospitalization.
 NURSING CARE PLAN 5
NURSING INTERVENTIONS:

1. Assess patient’s level of knowledge and understanding regarding

self care at home.( e.g: what can do and cannot do after operation )
® To act as baseline data for plan further nursing interventions
I : I assessed Mr.N’s level of knowledge and understanding by asking
him about he self care at home and he answered me that he only know
that he cannot cross his leg to prevent joint dislocation.
 NURSING CARE PLAN 5

2) Assess for hazard of the home environment (e.g.: physical

barriers especially stairs and bath room.
® As they may limit patient’s ability to ambulate and care for
self at home and may causing fall.
I : I asked Mr.N whether his house got any stairs and he answered me
that don’t have stair .
 NURSING CARE PLAN 5
3. Reinforce doctor’s explanation about home care by using simple
word and language and avoid to use medical term.
® To promote understanding and allay anxiety.
I : I reinforce Dr.N’s explained to Mr.N about his self care at home by
using simple words such as do not bend the knee more than doctor
permissions, do not lifting heavy things , walking with use of the
crutches and knee brace.
 NURSING CARE PLAN 5
4. Encourage patient to ambulate by using supportive device such as
crutches and knee brace at least for 6 weeks as ordered by Dr.N.
® To prevent falling down and use crutches easy for his to mobilize
I : I encouraged Mr.N to always walk with crutches and knee brace at
least 6 weeks as ordered by doctor to maintain stability during walking
and standing.
 NURSING CARE PLAN 5

5. Advise patient to continue the exercise at home such as Quad

Stretching Exercise( QSE), Partial Weight Bearing Crutches ( PWBC)
as what taught by physiotherapist.
® To promote knee control and strengthen thigh muscle and to
prevent from muscle atrophy.
I: I encouraged Mr.N to do the exercise as taught by physiotherapist at
home frequently and explained to him regarding the benefits of
exercise.
 NURSING CARE PLAN 5
6. Advise patient to avoid cross his leg while sitting, standing, and lying
down.
® To prevent dislocation the joint prosthesis
I: I advised Mr.N to avoid cross her right leg while sitting ,standing, and
lying down .

7) Encourage patient to use elevated seats toilet for elimination and avoid
squad.
® To prevent dislocation of joint and to promote healing process.
I : I encouraged Mr.N to used elevated seats toilet during elimination
and avoid squad.
 NURSING CARE PLAN 5
8) Advise Mr.N to avoid heavy activity ( e.g.: playing football,netball,
lifting heavy thing for 6 months as telling by doctor. )
® To avoid from tear and promote wound healing.
I : I Advise Mr.N to avoid heavy or vigorous activity ( e.g.: playing
football, netball , lifting heavy thing for 6 months as telling by doctor. )

9) Encourage Mr.N to take and complete all the medication on time as

prescribed by Dr.N and avoid missing it.
® To ensure the effectiveness of the treatment and prevent any
complications.
I : I emphasize to Mr.N to take and complete the medication on time as
prescribed by Dr.N and avoid missing it.
 NURSING CARE PLAN 5
10.Encourage patient to take well balance diet with high protein , (fish,
egg, soya bean) high vitamin c,(orange,mango) high fiber (vegetables,
fruits ) increase calcium diet and fluid intake.
® High vitamin c enhance body resistance ,high protein is to promote
wound healing, fiber is to prevent constipation, calcium to strong the
bone and fluid intake to maintain fluid in the body.
I : I advice and encourage patient to take well balance diet with high
protein , high vitamin C,high fiber, increase calcium diet and fluid
intake in patient’s meal to enhance wound healing and boost up the
immune system..
 NURSING CARE PLAN 5
11. Emphasize to patient to come for follow up and to obtain more
information pertaining the progress of patient’s right knee by asking
questions.
® Follow up helps patient to enhance the progress of his health as
doctor will prescribe necessary medical interventions.
I : I had informed patient that doctor will for sure give an appointment
date to come back to the clinic in order to see the progress of his
knee and emphasize to him that the important of follow up.
 NURSING CARE PLAN 5
DATE/TIME: 22/12/2021 @ 1030hrs

EVALUATION:
Patient’s understanding and gained knowledge regarding self care
management after nursing intervention given and during hospitalization.
HEALTH EDUCATION
 HEALTH EDUCATION

Medication Diet Wound Care

Safe use of Lifestyle-activity

Follow Up ambulatory aids limitations
DISCHARGE
 After being review by Dr N at 9.00am on 23 December 2021
and seen his condition that allows him to be discharged, Dr N decided to
allow him discharged with Tablet Celebrex 200mg Daily and Tablet
Paracetamol 500mg PRN for him as medication to bring home.

Mr N condition was very good with his blood pressure was

128/90mmHg , the pulse was 65bpm and respiration rate was 20bpm.
Rather than that before Mr N leave the hospital I also remind him about
his follow up on 6 January 2022 and also revise back to him regarding
health education on wound care , medication , diet , the safe use of
ambulatory aids and also the limitation that he will face post surgery in
the process of his recovery and also I reminded him to come to the
hospital for physiotheraphy that has been schedule by Dr N to help him
more in his recovery.
FOLLOW UP
 On 6 January 2022 at 9.00am, after two week from the
date of discharge, Mr.N came to Doctor’s N clinic for his
follow up. Mr.N looked healthy and verbalized that he able
to cope with his new activity daily living control by knee
brace and crouches.

Doctor N had examined Mr.N knee and no complication

such as infection seen. Doctor advised him to keep doing
exercise to prevent stiffness of the joint.

Mr.N was given for his next follow up on 20 January

2022 at 9.00am. No prescription of medication was given to
Mr.N. Mr.N should continue physiotherapy and no
medication ordered.
SUMMARY
 My patient , Mr.N , Male , 35 years old was admitted to
KPJ Johor Specialist Hospital on 20 December 2021 at
8.00am . He was admitted because complain of pain at the
right knee after fall during running while working .

Mr.N have done MRI right knee for investigation. On

admission , Mr.N is conscious and orientated but he having
pain at the right knee and got problem for immobility.Dr N
diagnosed Mr N as ACL Tear And Meniscus Tear .
 Mr.N have done Right ACL reconstruction and arthroscopy on 21
December 2021. After the surgery, my patient knee become better. On
23 January 2022 Dr.N review my patient in the morning and see the
patient progress , doctor ordered to discharge him.

Before discharge , I was gave health education regarding

the disease, diet, medication, lifestyle ,follow up , Wound care, safety
environment,hygiene and exercise to Mr.N.
REFERENCE
BOOK :

• Martin,E.(2005). Dictionary of Nursing Malaysian Edition; Oxford Fajar; pp.22-

242.

• Romano M.B, (2006). MIMS, 113th Edition, Hong Kong: CMP Median Pacific Ltd

• Smeltzer, S.(2008). The Skeletal System in Brunner & Suddarth’s Textbook of

Medical Surgical Nursing 11TH Edition ,Philadelphia: Linpincott Williams and
Wilkins ; pp72-158.

• Walsh,M.(2002). The Skeletal System in Watson’s Clinical Nursing and Related

Sciences 6th Edition, USA : Elsevier Limited; p2200.

• Waugh,A. and Grant,A. (2014).The Skeletal System in Ross and Wilson Anatomy
and Physiology in Health and Illness12th Edition,London: Elsevier Churchill
Livingstone; pp390-420.
INRTERNET :

ACL Tear:

1.http://www.mayoclinic.com/health/ACLTEAR/DS00031/DSECTION
=riskfactors
[Date assessed :29 December 2021]
THANK YOU