# A nurse is caring for a patient on the first postoperative day following total knee replacement surgery. Which assessment finding requires the most immediate nursing intervention?

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## 문제

A nurse is caring for a patient on the first postoperative day following total knee replacement surgery. Which assessment finding requires the most immediate nursing intervention?

## 보기

1. Moderate incisional pain rated 6/10 on the pain scale
2. Serosanguineous drainage on the surgical dressing
3. Inability to perform straight leg raises
4. Sudden onset of severe chest pain and shortness of breath **✔ 정답**

**정답: 4**

## 해설

Sudden chest pain and shortness of breath indicate pulmonary embolism, a life-threatening emergency requiring immediate intervention. Other findings are expected postoperative issues manageable with standard care.

## 심화 해설

Clinical Reasoning and Priority Setting

The correct answer is the sudden onset of severe chest pain and shortness of breath. This clinical presentation is a classic manifestation of a pulmonary embolism (PE), a life-threatening postoperative complication that requires the most immediate nursing intervention.

Pathophysiology and Clinical Significance

Following total knee replacement (TKA), patients are at a significantly increased risk for developing venous thromboembolism (VTE), which includes both deep vein thrombosis (DVT) and pulmonary embolism (PE) [3]. The surgical trauma, venous stasis from immobility, and a hypercoagulable state induced by the procedure collectively fulfill Virchow's triad, creating a perfect storm for thrombus formation in the deep veins of the lower extremities. When a portion of a DVT dislodges, it travels through the venous system to the right side of the heart and lodges in the pulmonary arterial circulation, creating a ventilation-perfusion mismatch. This acutely impairs gas exchange and increases pulmonary vascular resistance, which can rapidly lead to right heart failure and cardiovascular collapse. The sudden onset of severe chest pain and shortness of breath signals an acute obstruction in the pulmonary vasculature, making it a true medical emergency that takes precedence over all other findings.

Analysis of Assessment Findings

The other options, while requiring nursing attention, do not represent an immediate threat to the patient's airway, breathing, or circulation.

-   Moderate incisional pain rated 6/10: Pain is an expected finding on the first postoperative day following a major orthopedic procedure. While effective pain management is a nursing priority for promoting mobility and recovery, it is not life-threatening and can be addressed after the emergency is managed.

-   Serosanguineous drainage on the surgical dressing: A small to moderate amount of serosanguineous drainage is a normal postoperative finding. The nurse should monitor the drainage, outline the area on the dressing, and reassess, but this does not indicate an acute, life-threatening event.

-   Inability to perform straight leg raises: This is an expected finding on the first postoperative day due to pain, quadriceps muscle inhibition, and surgical trauma. It is a focus for physical therapy and rehabilitation, not an immediate physiological emergency.

Evidence-Based Context for VTE Risk

The critical nature of this assessment finding is underscored by the high incidence of VTE in this patient population. A 10-year retrospective cohort study found that VTE remains a significant clinical concern following primary TKA, necessitating rigorous prophylactic strategies with agents like aspirin or direct oral anticoagulants (DOACs) . The clinical burden of this complication is substantial, and patients undergoing total joint arthroplasty are at an inherently increased risk for developing a postoperative VTE [3]. A multicenter study evaluating prophylactic anticoagulation after TKA further identified patient-related risk factors for thrombotic events, reinforcing that despite prophylaxis, breakthrough PEs can occur and must be recognized immediately . The nurse's role at the bedside is to identify the clinical signs of this breakthrough event, as prophylactic regimens are not 100% effective. The sudden onset of respiratory distress and chest pain in this context is a sentinel sign of a PE, a diagnosis that, while sometimes masquerading as other conditions, carries a high potential for rapid deterioration and mortality .References (research sources)

- [3]Determining the Appropriate Pharmaceutical Prophylaxis for Venous Thromboembolism Following Total Joint Arthroplasty: A Systematic Literature Review.Research articleLayne E. (2026) · DOI: 10.1097/nor.0000000000001208

## 임상 시나리오

Recognizing Postoperative Pulmonary EmbolismA Priority Emergency After Total Knee Replacement
A sudden onset of severe chest pain and shortness of breath in a postoperative TKA patient is a classic sign of a pulmonary embolism (PE), a life-threatening complication. This presentation indicates an acute obstruction in the pulmonary vasculature and requires immediate intervention over all other findings.

The risk stems from Virchow's triad: venous stasis from immobility, endothelial injury from surgery, and a postoperative hypercoagulable state. A dislodged deep vein thrombosis (DVT) creates a ventilation-perfusion mismatch, rapidly leading to impaired gas exchange and potential cardiovascular collapse.

CautionDo not dismiss this as anxiety or incisional pain. Immediate actions include administering high-flow oxygen, notifying the rapid response team, and preparing for diagnostic tests like a CT pulmonary angiogram. Expected findings like moderate incisional pain or serosanguineous drainage are lower priority.

## 핵심 개념

- **Virchow's Triad** — The three broad categories of factors that contribute to thrombosis: venous stasis, endothelial injury, and hypercoagulability.
- **Pulmonary Embolism (PE)** — A blockage in one of the pulmonary arteries in the lungs, most often caused by blood clots that travel from the deep veins in the legs.
- **Venous Thromboembolism (VTE)** — A condition that includes both deep vein thrombosis (DVT) and pulmonary embolism (PE); a significant risk after major orthopedic surgery.
- **Ventilation-Perfusion (V/Q) Mismatch** — An imbalance in the amount of air reaching the alveoli and the amount of blood flowing to the alveoli, as occurs with a PE obstructing blood flow.

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