CASE STUDY

Right Knee ACL (Anterior Cruciate Ligament)

Tear and Lateral Meniscus Tear

BY NURSING STUDENT
STATE HEALTH POLYTECHNIC OF MALANG
CLINICAL ATTACHMENT IN NORMAH MEDICAL SPECIALIST CENTRE
FEBRUARY 19TH – MARCH 2ND 2018
 INTRODUCTION
PATIENT IDENTITY
NAME Mr. A
MRN 350878
AGE / SEX 24 years / Male
Height/WEIGHT 172cm / 76kg
ADDRESS Lorong B Jln. Tunku KPG Tunku RPR Fasa Dua
Petra Jaya 93050 Kuching, Serawak, Malaysia
MAIN COMPLAIN Right knee pain and unstability for 2 years
ago
DIAGNOSIS Right knee ACL tear and lateral Meniscuss
Tear
SURGERY DONE Arthoscopic ACL Recontruction (Right knee)
Partial Manisectomy and repair of posterior
horn lateral meniccus
DATE ADMISSION 23/02/2018 Time: 12.50 PM
FAMILY HISTORY Nil family medical history
ALLERGIC Nil
DATE DISCHARGE 27/02/2018
FOLLOW UP 06/03/2018 with dr. A and meet the
physiotherapis
 Case Overview

 Mr. A 24 years old, male had right knee pain for about 2 years. He feel
pain after injury when playing football.
 He feel pain on his right knee, swelling, and hear “pop” sound
 After injury he feel instability walk and he didn’t check up for a long
time
 Patient had MRI at BMC hospital on 21th February 2018
 Patient was diagnose by MRI with ACL Tear and Meniscus Tear
 DEFINITION
Meniscuss Tear ACL Tear
A meniscus tear is a common knee ACL injury is the tearing of the anterior
joint injury. Meniscal tears can occur cruciate ligament one of the major
when the knee is forcefully twisted, ligaments in the knee.
sustains a direct blow, deep squatting
or during activities that require
changing directions.
 ETIOLOGY
Meniscus Tear ACL Tear
1. Activities that cause joint 1. Suddenly slowing down and
stress changing direction (cutting)
2. Age 2. Pivoting with your foot firmly
3. Knee joint arthritis planted
4. Previous ligament injury 3. Landing from a jump
incorrectly
4. Receiving a direct blow to the
knee or collision, such as a
football tackle
SIGN SYMPTOM
Meniscuss Tear ACL Tear
• Pain • A loud “pop” or a “popping”
• Swelling sensation in the knee
• Severe pain and inability to
• Stiffness on and off
continue activity
based on your activity • Swelling that begins within a
level few hours
• Loss of range of motion
• A feeling of instability or
“giving way” with weight
bearing
 Etiology
Increase
Directed
Risk Factor ( blood flow
posteriorly Rupture
Sport, age 15 force to the Trauma to the
– 25 yrs) ligament
front of tibia injury
from a location
tackle

Lowering Stimulate
function Painfull top of Swollen
of joint nerve
 TREATMENT PLAN
A. SURGERY
Arthroscopic ACL Reconstruction
A surgical tissue graft
replacement of the anterior
cruciate ligament, located in the
knee, to restore its function after
an injury. The torn ligament is
removed from the knee before
the graft is inserted in an
arthroscopic procedure.
Lateral Meniscectomy Repair of posterior horn lateral
Meniscuss
A procedure to remove some or The posterior horn of the lateral
all of a meniscus from the tibio- meniscus includes the main
femoral joint of the knee using body of the lateral meniscus,
arthroscopic (keyhole) surgery. posterior to the popliteus
tendon, and its root attachment
on the posterior aspect of the
tibia.
VITAL SIGN
POST
Temperature
DATE BP (mmHg) HR (bpm) RR (minutes) WOUND
(Celcius)
DRESSING
Pre Operation
23/02/2018 121/62 65 20 36 Dry & intact
Post Operation
23/02/2018 110/60 50 20 36 Dry & intact
115/65 Dry & intact
24/02/2018 52 – 61 20 – 21 36.8-37.2
102/50
125/65 Dry & intact
25/02/2018 50 – 65 20 - 21 36.5-37.1
105/50
125/70
26/02/2018 50-65 20-21 36.5-37.5 Dry & intact
110/70
INPUT AND OUTPUT
BOWEL
DATE INPUT OUTPUT BALANCE
ELIMINATION
23/02/2018 1472 700 +177 BNO
24/02/2018 2894 2200 +644 BNO
25/02/2018 1200 1750 - 550 BNO
26/02/2018 1150 PU X 9
 TREATMENT PLAN

B. Non Invasive Treatment / Non

Surgery
1. Diagnostic Test
MRI : Right Knee 21/2/2018
 Tear of the ACL
 Tear posterior horn medial
 Radial tear body of the
lateral meniscus
 LABORATORY REPORT
CATEGORY RESULT UNIT NORMAL
RANGE
FULL BLOOD COUNT
• Haemoglobin 15,8 gr/dL 13.0 – 18.0
• Total Red Cell 5,4 x10^12/L 4.5 – 6.5
• PCV 0,47 L/L 0.40 – 0.54
• MCV 88 fl 76 – 96
• MCH 30 pg 27 – 33
• MCHC 34 gr/dL 30 – 37
• Total White Cell 7,4 x10^9/L 4.0 – 11.0

DIFFERENTIAL COUNT
• Neutrophils 59 % 40 – 75
• Lymphocytes 31 % 20 – 45
• Monocytes 6 % 2 – 10
• Eosinophyls 3 % 1–6
• Basophils 1 % 0–2 DATE: 23/02/2018
• Platelet Count 331 x10^9/L 150 - 400
 2. PHARMACOLOGY
MEDICINE DOSAGE INDICATION SIDE EFFECT
IV Tramadol 50 mg Indicated for the Dizziness, nausea,
Date start : 25-02-18 (TDS/PRN) management of constipation, headache,
moderate to severe pain somnolence, and
in adults vomiting

IV Maxolom 10 mg Induced nausea and Drowsiness, dizziness,

Date Start : 25-02-18 (TDS/PRN) vomitting, and treatment tiredness, trouble
of nausea and vomitting sleeping, agitation,
headache, and diarrhea
may occur.
 MEDICINE DOSAGE INDICATION
• Tablet Panadine 1 gr Provides effective
Date Start : 25-02-18 (TDS) temporary relief from strong
pain and discomfort
associated with headache,
muscle pain, period pain,
etc.
SIDE EFFECT
Constipation, nausea,
vomiting, stomach pain,
dizziness, drowsiness, skin
rashes, sweating.

• Tablet Acoxia 120 mg Indicated for chronic Nausea, vomiting,

Date Start : 25-02-18 (OD) muskuloskeletal pain, relief heartbun, indigestion,
of acute pain, to treat pain in stomach, and
acute gouty arthritis. high blood pressure.

• Tablet Reparil 20 mg Reduction of localised Allergic reactions in very

Date Start : 26-02-18 (TDS) swelling following injuries rare cases
 MEDICINE DOSAGE INDICATION SIDE EFFECT
Epidural infusion
• Chirocaine 10 ml Surgical Anaesthesia May have numbness of the
Major: Epidural (including for tongue, dizziness, blurred vision,
caesarean section), muscle twitching, severe
intrathecal, peripheral nerve breathing difficulties (including
block. stopping breathing) and even
Minor: Local infiltration, oral, fits (convulsions).
peribulbar block in ophthalmic
surgery.

• Fentanyl 100 mcg A pain medication and Nausea, vomitting,

together with other constipation, lightheadedness,
medications for anesthesia. It dizziness, drowsiness, or
has a rapid onset and effects headache may occur.
generally last less than an hour
or two.

• Nsaline 0.9 % 38 ml
Date start : 23-02-18
Date Stop : 25-02-18
Can be used as the vehicle for Hypernatremia (high levels of
many parenteral drugs and as sodium), fluid retention, high
an electrolyte replenisher for blood pressure, heart failure,
maintenance or replacement intraventricular hemorrhage in
of deficits in extracellular fluid, neonates, injection site
it can be also be used as reactions, kidney damage,
sterile irrigation medium. electrolyte abnormalities,
 MEDICINE DOSAGE INDICATION SIDE EFFECT
IV Zinacef 1,5 gr (stat For the short-term Nausea, stomachache,
IV Zinacef given in OT) treatment of constipation, vomiting,
Date Start : 23-02-18 750 mg (TDS postoperative pain in dizziness, ear ache, back
Date Stop : 25-02-18 given regular adults. pain, swollen and sore
in ward) gums.

IV Dynastat 40 mg (BD) Acute pain and post-op Thrombophlebitis,

Date Start : 23-02-18
Date Stop : 25-02-18
pain. Pre-op to prevent or pseudoumembranous
reduce post-op pain. colitis, pruritus, urticaria,
erythema multiforme,
interstitial nephritis, toxic
epidermal necrolysis,
thrombocytopenia,
elevations in serum
creatinine
 MEDICINE DOSAGE INDICATION SIDE EFFECT

IV fluid 1.5 liter/24 Can be used as the Hypernatremia (high

Normal Saline 0,9 hours vehicle for many levels of sodium),
% parenteral drugs and fluid retention, high
Date start : 23-02- as an electrolyte blood pressure, heart
18 replenisher for failure,
Date Stop : 25-02- maintenance or intraventricular
18 replacement of hemorrhage in
deficits in neonates, injection
extracellular fluid, it site reactions, kidney
can be also be used damage, electrolyte
as sterile irrigation abnormalities.
medium.
3. Physiotherapy

Physiotherapy:
 Teach patient how to use cruthes
 Advise patient for non weight
bearing for three months at right leg
 Maintain knee brace
 Advise patient for check up to the
physiotherapy at 2 next weeks
 HEALTH EDUCATION DURING
HOSPITALIZATION

PAIN MANAGEMENT ADVICE TO USE CRUTCHES WOUND CARE TO PREVENT

WIHEN AMBULATE AND INFECTION (KEEP WOUND
CALL FOR THE NURSES IF DRY)
NEED ASSISTANCE

DIET
MAINTAIN KNEE BRACE ALL
THE TIME
DISCHARGE PLANNING

Wound Care
Follow up with Dr. A and
Physiotherapy at 6/03/2018

Use knee brace until

meet doctor

Non weight bearing for

three months at right leg
 Nursing care
Nursing Desired
Intervention Evaluation
Diagnose Outcome/Goals
Acute pain  Patient will report a 1. Review factors that 1. Patient verbalize
related to post decrease of pain aggravate or alleviate pain less pain after
Surgery  Patient will be free 2. Encourage pain reduction surgery (pain
from pain and technique with cold score 0/10
demonstrate compress 2. Patient able to
relational skills 3. Provide adequate risk and control the pain
put on comfortable position
4. Administer analgesic to
maintain acceptable level of
pain if not contraindicated
5. Instruct client to perform
deep breathing exercises
6. Monitor effectiveness of pain
medications
7. Inform doctor if pain
increasing even after
analgesics
 Nursing Desired
Intervention Evaluation
Diagnose Outcome/Goals
Risk of Falls The patient will 1. Assess patients every shift with 1. Patient safe
related to post be free from any Morse & Hendrich Fall Risk from fall risk
operation falls during his Assessment Score during
anterior hospitalization 2. Apply green tag to the patient hospitalization
cruciate so other nursing staff will know 2. Patient and
ligament and the patient has high risk for fall family
meniscectomy 3. Keep the patients’s bed in the understanding
lowest position at all times high risk of fall
4. Keep side rails up at all times area
5. Put call bell within reach
6. Monitor patient more frequent
and assist if they needd to use
the bathroom (using commode
chair/crutches)
 Nursing Desired
Intervention Evaluation
Diagnose Outcome/Goals
Risk of Patient will free from 1. Assess for signs of 1. Patient free from
infection infection until symptoms of infection at infection during
related to discharge wound site hospitalization
surgical 2. Observe vital sign 2. No sign and
wound at 3. Maintain aseptic symptom of
knee technique during infection
dressing
4. Advise patient to keep
self hygiene
5. Keep wound dressing
moist and intact
6. Education patient and
wound care
 Nursing Desired
Intervention Evaluation
Diagnose Outcome/Goals
Impaired Patient 1. Warm compress on bladder 1. Patient can pass
urinary demonstrates 2. Catheterize as indicated urine freely after
elimination behaviors and 3. Help patient when need to off catheterize
related to techniques to Toilet 2. Patient free from
sensory motor prevent 4. Inform doctor if patient urinary tract
impairment retention/urinary unable to pass urine. infection during
infection hospitalization
THANK YOU....