Postoperative Day 5 TKA With Rising Weight and Breathlessness

Hold mobilization. Findings that break the benign post-op pattern:

• Weight gain of 2.7 kg over 3 days. Post-op swelling is regional; a systemic gain in that range in a patient with HFpEF plus CKD points to volume overload (roughly 1 kg is about 1 L of retained fluid).
• Bilateral ankle edema. Arthroplasty swelling is unilateral and centered on the operative knee.
• New dry cough and orthopnea. This is the classic early pulmonary congestion picture.
• SpO2 91% on room air with HR 96 and RR 22. She is compensating at rest; upright exercise raises oxygen demand further.
• The 10-65 degree arc and effusion are expected after TKA and do not explain the respiratory findings.

Sequence: keep her upright with the head of bed elevated, apply oxygen per unit protocol, recheck a full set of vitals, and notify the surgeon/hospitalist (rapid response if she worsens or the SpO2 falls). Ask for evaluation of volume status (BNP, chest radiograph, diuretic adjustment). Hold therapy, then document objective findings, the decision to withhold treatment, and who was notified and when. Shift-change convenience does not override a decompensating cardiopulmonary picture.

Both change the dose of stress you apply, not the direction of the plan.

Apixaban (anticoagulation):

• Any fall is a bleed risk, including intracranial. Use a gait belt, clear the path, and train in a controlled area rather than a crowded hallway.
• Avoid aggressive end-range knee stretching, high-force joint mobilization, and deep soft tissue work over a fresh, effused, bruised knee; you can cause a hemarthrosis or intramuscular hematoma.
• Inspect for disproportionate swelling, bruising, or a new pop; report it.
• Tell the team to avoid IM injections; ask when the last dose was given relative to your session.

Stage 3b CKD:

• Apixaban is partly renally cleared, so bleeding risk is higher than in a normal-renal patient; dosing is often reduced.
• Hb 9.8 plus furosemide means low oxygen-carrying capacity and a real risk of orthostatic symptoms after diuresis. Check BP and symptoms with position changes; avoid long bouts without rest.
• Never suggest NSAIDs for her knee pain; flag that to the team if you see them ordered.

Practical session: low-velocity AAROM, patellar mobilization, quadriceps setting, seated terminal knee extension, then short gait bouts with seated rests and vitals before and after.

Script: 'I am not going to walk her right now. She is 91% on room air with a new cough, orthopnea, and 2.7 kg of weight gain in three days, which looks like fluid overload rather than post-op swelling. If she walks and desaturates in the hallway, we have created an emergency. I have elevated the head of the bed and given oxygen per protocol. Please page the hospitalist now; I will co-sign the message. If she needs the toilet, use a bedside commode with two staff and monitor her saturation during the transfer, or wait for the medical evaluation.'

Documentation should include: the objective data (weight trend, bilateral edema, SpO2, HR, RR, cough/orthopnea), the clinical concern, the intervention withheld and why, what was done instead, the specific clinician notified with time and method, and the plan to reassess after medical clearance.

Frame it as risk management rather than refusing care. Offer a safe alternative (bedside commode with monitoring) so the nursing goal is still met, and put the reassessment criteria in writing so the next therapist knows what would allow ambulation.