Mar 14, 2020 in Medicine
Patient Care Study on Anterior Cruciate Ligament Reconstruction

Anterior cruciate ligament (ACL) is one of the cruciate ligaments located in the knee. One of the most common knee injuries involves an ACL sprain or tear. ACL injuries are common to people playing agility sports such as football, basketball, soccer, as well as those who go skiing. The majority of ACL injuries occurs in males than females, although women face a greater risk of being injured. Factors increasing the risk of ACL injury in women include knee valgus, wider pelvis, foot pronation, hamstring flexibility, hormonal differences, and joint laxity. Depending on factors such as activity level and severity, these injuries usually require surgery or reconstruction to regain full function of the knee joint. Approximately a half of all ACL injuries involve other neighboring structures such as the articular cartilage, the meniscus, and the medial collateral ligament. This essay looks at a case study involving a 24-year-old patient who had two incidences of a knee injury while stepping forward and playing trampoline and underwent an operation of the reconstruction of the ACL. It aims to discuss the ACL injury reconstruction in terms of the anatomy, diagnosis and applied physiology. It further describes the preoperative and postoperative nursing diagnoses, including the goals, nursing interventions, and evaluation.

Anatomy

The femur, patella, and tibia make up the skeletal structure of the knee joint. The ACL forms one of the main ligaments in the knee that connect the tibia to the femur. The knee is a type of a hinge joint supported by the anterior, posterior, medial, and lateral cruciate ligaments. The ACL originates from the posteromedial aspect of the lateral femoral epicondyle in the intercondylar notch. It then runs diagonally in the middle of the knee and inserts on an area anterior to the intercondylar eminence of the tibia. The proximal fibers of the ACL spread out along the medial side of the lateral condyle of the femur. It contains the anteromedial and the posterolateral bundles that are named based on their insertions on the tibia (School of Health Professions, n.d.). The ACL receives its blood and nerve supply from the middle genicular artery and the tibial nerve.

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Diagnosis

The diagnosis of the ACL injury is made based on a complete history, physical examination, and diagnostic imaging. In the history, the patient often states that the injury occurred during a non-contact activity that involved deceleration, rotation, hyperextension, sudden stop, or jumping. The patient may describe hearing or feeling a pop at the time of the injury, a feeling of the knee “giving way,” and occasionally having a sense of locking of the knee. Afterward, the patient is unable to continue with any activity, has difficulty in weight bearing and, after a few hours, the knee joint swells and becomes painful.

On examination, the knee area is swollen; there is a loss of full range of motion, instability, discomfort while walking, and tenderness along the joint line. Some tests can help to confirm the diagnosis of the ACL tear and rule out neurovascular involvement and concomitant injuries. The Lachman test is performed when the knee is flexed at 30 degrees while stabilizing the distal femur using one hand. The other arm then applies a manual force to the proximal tibia. Afterward, the anterior laxity is measured in the degree of anterior translation of the tibia in relation to the femur. This test is 98% accurate in predicting the ACL injury. The anterior drawer test is similar to the Lachman test, but knee flexion is 90 degrees. Another method that can be used is the pivot shift test, in which the knee is flexed and rotated internally after which there is flexion of the knee with the application of a valgus force to the proximal tibia. A positive test is confirmed when a clunk is felt during knee flexion. Finally, the KT-1000 arthrometer testing is a quantitative and objective method used to assess ACL injury. A maximum side-to-side difference that exceeds 3mm is indicative of the tear in the ACL.

ACL may also be diagnosed using imaging modalities. The MRI is useful in the diagnosis of ACL tears as it enables the visualization of both bundles of the ACL. It has a high specificity of 95% of diagnosing ACL injury and provides valuable information for surgical ACL reconstruction. Plain AP and PA X-rays help to rule out fractures, osteophyte formation, degenerative diseases, and other associated injuries. They may also contribute to the diagnosis of an avulsion fracture of the lateral capsule, which is highly indicative of an ACL injury.

Our Process

Applied Physiology

The ACL acts by providing about 85% of the total restraining force of the anterior tibial translation. It also prevents varus and valgus stresses, particularly in the extended knee. Additionally, it prevents excessive lateral and medial rotation of the tibia and, to a lesser degree, checks extension and hyperextension. Along with the posterior cruciate ligament, it directs the instant center of rotation of the knee joint, thereby regulating the joint kinematics. An injury or a tear in the ACL leads to abnormalities in the knee kinematics. Subluxations tend to occur and recur easily, producing abnormal shear forces on the articular cartilage and the meniscus, hence increasing the risk of meniscal injuries.

The Preoperative Nursing Diagnosis

The preoperative nursing diagnosis is deficient knowledge, which means that the patient lacks cognitive information related to the ACL reconstruction surgery. The lack of knowledge is often related to the unfamiliarity with sources of information, misinterpretation, or lack of exposure. This diagnosis is characterized or evidenced by an inaccurate follow-through of instructions given to the patient. Furthermore, the patient also exhibits exaggerated and inappropriate behaviors, such as hostility, agility, and agitation. Additionally, the patient verbalizes incorrect information and is always questioning the health care professionals. The patient also shows wrong task performance and expresses confusion or frustration during the performance of tasks.

Goals

  • The patient should be able to verbalize understanding of the disease and the surgical reconstruction process.
  • She should also be able to initiate lifestyle modifications after the reconstruction and fully take part in the treatment plan.
  • The patient should be able to perform all the required tasks and procedures and provide reasons for the actions.

Nursing Interventions

As part of nursing intervention, the nurse should:

  • Provide thorough, clear, and understandable information as it enables the patient to ask questions when she has the lack of the necessary information concerning the procedure.
  • Acknowledge and accept differences in races or ethnicity at the onset of care because recognizing these racial issues helps to build rapport, enhance communication, and ensure positive treatment outcomes.
  • Identify previous knowledge that the patient has concerning the diagnosis and the procedure as it is easier to assimilate new information into previously known facts.
  • Educate the patient by building on the patient’s literacy levels. In those with low literacy levels, the materials need to be short and with culturally sensitive demonstrations.
  • Focus the teaching sessions on a single concept to improve the patient’s concentration.
  • Pace the education and keep the sessions short to allow the patient to absorb learned materials quickly. Shorter sessions reduce fatigue and enhance learning.
  • Assess the level of understanding of the patient regarding the surgical procedures as this assists in identifying the needs of the patient and facilitates planning of preoperative teaching.
  • Go through the pathology of the ACL injury with the patient and explain the surgical reconstruction procedure. Furthermore, the nurse should make sure that the patient has signed the consent form. This step provides the patient with a knowledge base with the help of which she can approve the surgery and make informed decisions. It also gives an opportunity for clarification of misconceptions.
  • Use visual aids such as diagrams, videotapes, pictures, charts, and audiotapes to teach the patient concerning the reconstruction procedure as these materials help to promote patient education.
  • Assist the patient in identifying and using community resources for continued learning and acquisition of knowledge of the procedure and the condition because, by imitating those who are currently involved in lifestyle changes, the patient can adjust appropriately.
  • Evaluate the patient’s learning by using the teach-back method where the patient verbalizes and demonstrates the learned material as this helps to consolidate the information that the patient has concerning the procedure.
  • Discuss the patient’s plan to manage postoperative pain, identify misconceptions the patient has, and give accurate information. This step will increase the likelihood of the proper management of postoperative pain because, if the patient fears or expects no pain after the procedure, she may become addicted to narcotics.

Evaluation

  • After teaching the patient for three hours regarding the reconstruction procedure, she was able to explain her condition clearly, as well as recognize and understand the treatment process.
  • The patient also exhibited how she would deal with the condition after the operation and remained confident and in control of her life.
  • The patient showed motivation to learn and was able to identify all her learning requirements.
  • She could list all resources that were necessary for her continued learning and support.

Postoperative Nursing Diagnosis

The postoperative nursing diagnosis is acute pain related to the ACL reconstruction surgery. The pain is evidenced by reduced focus, alterations in muscle tone, reports of painful episodes, and guarding of the painful area.

Goals

  • The patient should appear relaxed and comfortable.
  • She should be able to sleep or rest.
  • The pain should be relieved or at least controlled.
  • The patient should demonstrate the use of diversional activities, stress management, and relaxation techniques.

Nursing Interventions

As part of nursing intervention, the nurse should:

  • Assess the pain and note the severity on a scale of 0-10, the duration, and location because this provides the information that helps to monitor the effectiveness of the interventions provided and compare changes in pain levels.
  • Check the surgical site to rule out any signs of infection after the surgery.
  • Ensure the patient maintains the proper position of the limb that was operated to assist in the reduction of tension and muscle spasms in the healing area where the surgery was performed.
  • Provide scheduled medications to the patient before any physical activities so that patient’s comfort is improved and muscle tension is reduced, thus enabling the patient can participate in activities.
  • Ensure the patient is comfortable through offering back massage, repositioning, and diversional activities. The nurse should also provide therapeutic touch and rubs and encourage stress relief activities like meditation, guided imagery, visualization, breathing techniques, and progressive relaxation. This set of activities refocuses the patient’s attention, promotes a sense of control, reduces the tension in the muscles and may adequately enhance the coping ability of the patient in the management of pain or discomfort.
  • Place ice packs on the recovering knee area to cause vasoconstriction and ultimately reduce bleeding and tissue edema in the surgical area, hence reducing pain and discomfort.
  • Ensure proper mobilization of the affected knee, physical exercise, ambulation, and physiotherapy because these procedures assist in improving circulation to the muscular compartments, relieving muscle spasms and pain, and reducing the stiffness in the joints.
  • Investigate reports of abrupt and intense pain in the knee joint, any form of muscle spasms, and joint stiffness so that the failure of the reconstruction is detected early and quick action is taken to prevent the occurrence of serious complications.
  • Administer narcotics, muscle relaxants, and analgesics when required to relieve pain, spasms, and tension.
  • Encourage verbal responses during and after the movements and nursing interventions to help to decide whether the interventions were effective in pain management.
  • Regularly monitor the vital signs of the patient as these show systemic evidence of discomfort.

Our Benefits

Evaluation

  • After 4 hours of adequate nursing interventions, the patient reports proper pain management and rates it as zero.
  • The patient takes part in pain management and shows proficiency in it.
  • The patient can verbalize various side effects of the analgesics and report to the health care provider during discharge.
  • The patient can describe the regimen provided for pain control post-surgery at the time of discharge.
  • The patient can provide realistic expectations of pain and discomfort after the surgery.

Conclusion

An ACL tear commonly follows a knee injury. ACL injuries are common to footballers, basketballers, and skiers because they engage in active sports. It is more common in males than females, though females are at a greater risk. The ACL forms one of the four ligaments in the knee joint. It arises from the lateral epicondyle and inserts on the intercondylar eminence of the tibia. It has an anteromedial and a posterolateral bundle. It receives blood supply from the middle genicular artery and nerve supply from the tibial nerve. The diagnosis of an ACL injury is made based on a proper medical history, physical examination, and diagnostic imaging. In the history, the patient may describe non-contact injury from deceleration, pop sound, difficulty in weight bearing, swelling, and inflammation. During the physical examination, there may be a reduction in the range of motion, instability, and tenderness. Special tests like Lachman’s and pivot shift tests can confirm the ACL tear. Imaging modalities like plain X-rays and MRI can also be used in diagnosis. The ACL functions to provide restraining force to limit anterior tibial translation. It also prevents hyperextension and medial and lateral knee rotation.

The preoperative diagnosis is deficient knowledge of the patient, which may be evidenced by inappropriate behaviors like hostility, verbalization of inaccurate information, and incorrect task performance. Goals in treatment include the patient’s ability to verbalize accurate information and perform all required tasks correctly. Nursing interventions can include pacing the teaching and keeping the sessions short, focusing each teaching session on a single concept, and using visual aids in patient teaching. The evaluation would be the patient being able to explain her condition clearly, as well as recognize and understand the treatment procedure after the learning. The postoperative diagnosis is acute pain following an ACL reconstruction surgery as evidenced by guarding the area. The goals would be a total pain relief and an ability to sleep and rest. The nursing interventions include stress management and providing analgesia. In the evaluation, there was complete pain relief following the interventions.

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