Discharge Pressure After Outpatient Knee Arthroscopy
A 44-year-old woman is being assessed for discharge two hours after outpatient knee arthroscopy under general anesthesia with an adductor canal block. Aldrete is 9: she loses one point on activity because she will not walk as far as she did preoperatively, which she attributes to the block. She is drowsy but oriented, pain 3/10, her last nausea was 40 minutes ago and has resolved after ondansetron 4 mg. She has not voided since 5 am. She arrived by rideshare alone; her plan is for a neighbor to check on her by phone that evening. Prescriptions sent: oxycodone 5 mg every 6 hours as needed and ibuprofen 600 mg. She asks whether she can drive herself home because she 'only had a little anesthesia.'
1. Is she ready for discharge? Address each criterion and what you will do about the unmet ones.
Read the worked answer
Criterion by criterion:
- Aldrete 9 with the deficit on activity is acceptable at many sites provided it reflects the residual motor block and not a new deficit; document the block assessment and that the score reflects anticipated, time-limited effect. Confirm the surgical site is not the reason.
- PONV: resolved, but 40 minutes is short. Observe symptom-free for a defined interval per policy and confirm she can tolerate oral intake and oral analgesia before discharge.
- Voiding: not a mandatory discharge criterion after general anesthesia for a non-urologic, non-spinal procedure. Bladder scanning if she has suprapubic discomfort or a history of retention. Do not delay discharge solely for absence of voiding, but instruct her to report inability to void.
- Escort: the real barrier. A rideshare alone plus a phone check from a neighbor does not meet the requirement for a responsible adult to accompany and stay with her through the first 24 hours. That is not a formality - she has an opioid, an insensate leg from a block, and is still drowsy.
- Driving: no. Sedation and anesthesia impair reaction time for at least 24 hours, and opioids extend that restriction further.
Plan: do not discharge until an acceptable escort is arranged or the case is otherwise resolved with the surgeon and charge nurse; document the discussion and the alternative offered.
2. List your discharge teaching priorities and how you would verify understanding.
Read the worked answer
Prioritized teaching - highest harm first:
- Opioid safety: take as prescribed, only for breakthrough pain, with food, no alcohol, no driving, expect constipation, never combine casually with other sedatives, secure and dispose of leftover medication. Emphasize that scheduled ibuprofen 600 mg with food is the backbone and the opioid is the backup.
- Block care: the leg may be numb and weak for hours; no walking without assistance, keep the knee protected, expect sensation to return gradually, and call if it does not return within the expected window or if there is new severe pain uncontrolled by medication.
- Escalation triggers: fever above 38 C, spreading redness or drainage, calf pain or swelling, shortness of breath, chest pain, uncontrolled pain, persistent vomiting, inability to void, or new numbness.
- Logistics: follow-up appointment date and time, 24/7 phone number to reach a clinician, activity and weight-bearing restrictions, wound care and shower instructions, when the dressing comes off.
Verification: use teach-back on the top three items - the patient restates which medication is for what, the red flags, and who she calls - not 'do you understand?' Document who was taught (including the escort), what method, and the patient's demonstrated understanding.
3. The next day she calls the recovery line reporting pain 7/10 despite oxycodone and new calf swelling. What is your response and what is the underlying reasoning?
Read the worked answer
Treat this as a possible thromboembolic event plus uncontrolled pain, not a refill request. Unilateral calf swelling after lower-extremity surgery with reduced mobility warrants same-day evaluation.
- Front-loaded questions: onset and progression, warmth or redness, shortness of breath, chest pain, calf measurement comparison, any bleeding, whether she is taking ibuprofen regularly and how often the oxycodone is being taken, whether the block has fully resolved.
- Action: direct her to same-day evaluation - surgeon or urgent/emergency care - rather than giving telephone advice to wait. Screen specifically for dyspnea or pleuritic chest pain, which converts this to an emergency (call emergency services).
- Do not simply increase opioid dosing to cover 7/10 pain when a new mechanical-exam finding blocks is present; the pain may be a symptom of the underlying problem.
Reasoning: the postdischarge call exists to catch exactly this. A nurse who adjudicates 'pain out of proportion' as a dosing failure misses the diagnosis. Document the call content, the advice given, the escalation route, and the patient's response plan.