Nursing care
Total Knee Replacement: the nurse's role, start to finish
Written and reviewed by Dana Whitfield, RN, MSN · 5 min read · Updated September 2026
Short answer
Total knee replacement nursing management focuses on regaining knee movement early, using continuous passive motion and prompt mobilisation. Pain is managed proactively so it does not block physiotherapy, rather than treated only after sessions are missed. Nurses also monitor for infection, thromboembolism, and neurovascular compromise while teaching the patient how to protect the new joint.
When it is done and why
Total knee replacement, or total knee arthroplasty, resurfaces the damaged ends of the femur, tibia, and often the patella with prosthetic components. The leading indication is advanced osteoarthritis with pain and stiffness that limits walking, stairs, and daily function despite conservative management. Rheumatoid arthritis and post-traumatic arthritis after a previous knee fracture or ligament injury account for most of the remaining cases.
Unlike a hip fracture, knee replacement is almost always an elective decision, made once a patient's pain and disability outweigh the risks of surgery. That changes the nursing rhythm: there is time for pre-assessment, weight and glycaemic optimisation, and pre-habilitation physiotherapy to build quadriceps strength before the operation, all of which improve post-operative recovery and make the early mobilisation programme achievable.
Preparing the patient
Pre-operative assessment establishes baseline knee range of motion, quadriceps strength, gait, and any pre-existing sensory or circulatory issues in the leg, since these are the reference points every post-operative check will be measured against. Screen for and treat infection sources, review anticoagulant and antiplatelet medications against the surgical plan, and confirm VTE risk assessment and prophylaxis are documented.
Set expectations honestly during teaching: recovery is active and can be uncomfortable, and the patient's own effort in physiotherapy drives the outcome more than almost any other factor. Introduce the idea of continuous passive motion and same-day or next-day mobilisation now, not after surgery, so it is not a surprise. Confirm crutches or a frame, home layout for stairs, and support at home are arranged, and address any fear of pain that might make the patient reluctant to move early.
The steps that matter for safety
The defining safety principle for this surgery is that pain control exists to enable movement, not to follow it. Analgesia is scheduled around physiotherapy sessions and continuous passive motion, given proactively so the joint can be moved through range while it is comfortable, rather than reactively once the patient is already guarding. A stiff, unmoved knee scars down quickly, and lost range of motion in the first weeks is difficult to recover later, so timing analgesia to protect mobility is itself a safety intervention, not just comfort care.
Multimodal analgesia, combining regional nerve blocks, scheduled paracetamol and NSAIDs where appropriate, and opioids for breakthrough pain, is standard, because it controls pain with less sedation than opioids alone. Continuous passive motion machines move the knee through a controlled, gradually increasing range and need correct positioning and skin checks under the straps to avoid pressure injury. Weight-bearing status is surgeon-specific and must be confirmed before every mobilisation attempt, since assuming full weight-bearing when the order says partial risks a fall or prosthesis stress.
During the procedure — the nurse's role
In theatre, the scrub and circulating nurse maintain the sterile field, manage the tourniquet time if one is used, and track instrument and implant counts. A tourniquet reduces blood loss but its inflation time must be recorded and kept within safe limits, and the circulating nurse communicates this to the surgical team throughout the case.
In recovery, standard post-anaesthetic monitoring applies alongside limb-specific checks: distal pulses, colour, warmth, sensation, and movement of the toes to detect compartment syndrome or nerve injury early, particularly if a regional block masks normal pain signalling. Dressings and any drains are checked for bleeding, and the leg is positioned as directed, often with the knee supported in slight extension rather than propped into flexion, to avoid a fixed flexion contracture forming before rehabilitation even begins.
After: monitoring and complications
Ongoing monitoring covers vital signs, wound and drain output, and pain scores, but the knee-specific focus is range of motion and swelling. Increasing calf pain or swelling raises concern for deep vein thrombosis, and VTE prophylaxis, whether pharmacological, mechanical compression, or both, continues per protocol. Watch the wound for excessive bleeding, spreading redness, or discharge, and monitor temperature for signs of surgical site infection, which in a prosthetic joint carries higher stakes than in soft tissue alone.
Continuous passive motion and physiotherapy typically begin the same day or the day after surgery, with the target range of motion increasing daily. Document degrees of flexion achieved at each session, since a plateau or regression is a clinical flag that needs physiotherapy and medical review, not just encouragement to try harder. Watch also for signs of peroneal nerve injury, foot drop or numbness over the lateral lower leg, which can follow prolonged flexion positioning or a tight dressing.
Documentation and teaching
Record range of motion achieved, weight-bearing status followed, wound condition, neurovascular checks, and pain scores relative to analgesia timing at every assessment, since this record is what shows whether the pain-before-physiotherapy plan is actually working. Note any missed or shortened physiotherapy session and why, because these gaps predict slower recovery and are worth escalating early rather than at discharge.
Discharge teaching covers the home exercise programme, the ongoing importance of regular movement to protect range of motion, icing and elevation for swelling, and safe use of crutches or a frame on stairs. Give clear red flags for return to hospital: fever, increasing redness or discharge from the wound, calf swelling or pain, or sudden loss of movement or sensation in the leg. Confirm outpatient physiotherapy and follow-up are booked before discharge, since continuity of the exercise programme is what protects the gains made on the ward.
The next step on this is the same as on everything else here: answer questions and read the rationales. Our med-surg practice questions are the closest set to what this page covers.
One question from the med-surg set
A client with chronic obstructive pulmonary disease has an oxygen saturation of 88% on 2 L/min via nasal cannula and is alert with no distress. What should the nurse do first?
Rationale
In COPD a saturation of 88–92% is the therapeutic target, not an emergency, and this client is alert with no distress. The first action is the independent nursing intervention that is least invasive and most likely to help: sit them up and reassess. Turning the oxygen up to 6 L/min risks blunting the hypoxic drive, and calling rapid response or drawing an ABG escalates ahead of an assessment you have not finished.
Answer: B
Common questions
Why is continuous passive motion used after knee replacement?
It moves the new joint through a controlled, gradually increasing range of motion to prevent stiffness and scar tissue forming while the patient is still recovering from anaesthesia and pain. It supplements, rather than replaces, active physiotherapy and walking.
How soon does mobilisation start after total knee replacement?
Most patients begin physiotherapy and walking the same day or the day after surgery, guided by the surgeon's weight-bearing order. Early mobilisation reduces stiffness, thromboembolism risk, and length of stay compared with delayed mobilisation.
How should pain be managed around physiotherapy after knee replacement?
Analgesia should be given proactively before physiotherapy or continuous passive motion sessions, not after pain has already built up, so the knee can be moved comfortably through range. Multimodal analgesia, often including a regional nerve block, is used to control pain with less sedation than opioids alone.
What are the warning signs of complications after total knee replacement?
Increasing calf pain or swelling suggests deep vein thrombosis; fever with wound redness or discharge suggests infection; and numbness or foot drop suggests peroneal nerve injury. Any of these needs prompt medical review rather than being managed as routine post-operative discomfort.
What happens if range of motion stalls after knee replacement?
A plateau or loss of range of motion is a clinical flag that needs physiotherapy and medical reassessment, since scar tissue forms quickly in an unmoved joint and lost range is hard to regain later. It should be documented and escalated rather than left to resolve on its own.
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