Nursing Care Plan for Post Operative Knee Pain

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Medical Diagnosis/Reason for Admission __Post-operative _pain____ Admitting Diagnosis: RIGHT KNEE REVISION

Describe (Brief Pathophysiology in your own words, including HPI)__Patient is a 74 years female with right knee revision due to acute post-operative pain came in for surgical consultation due to continued pain and a valgus deformity after having cast removed. She is on hinged knee brace for stability.

Allergies: Ancef, Tolectin 600, Cephalosporins

Social Hx Patient is a retired pharmacist, married with children. She is alert and oriented x4; uses tobacco before but quitted 20years ago.__________________________________________________________

HOW ARE THE ABOVE ITEMS RELATED? (Preparation – Add on by Clinical week 3)

Treatments (Accuchecks, dressing changes, PT, OT, RT, activity order, diet, Isolation, I/O)

Medications (See Medication Summary)

Systematic & Concise Summary of Physical Assessment findings (See Checklist for Routine Bedside Assessment)

General: (includes vital signs) BP: 119/69, P: 93, T: 73.3, R: 18, SaO2: 95, Pain: 8/10

Neuro: Alert and oriented x4, Pupils dilated and face expression is symmetry.

Cardiac: Clear on S1 and S2. No extra heart sounds, murmurs, or ribs.

Respiratory: Breathing is unlabored, chest movement is symmetric.

Integumentary: (include wounds) Skin is normal, warm and moist, no skin discoloration. Wound dressing on the right knee and right femur edema.

GI: Normal bowel sounds hyperactive in all quadrants.

GU: Clear yellow urine

Musculoskeletal: Active range of motion on upper extremities, impaired range of motion on lower extremities with brace on right leg. Right foot is dissented.

Safety Concerns Fall risk, Pressure sore risk.

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

DIAGNOSIS: *Radiology results; lab; micro; orders

Pertinent Diagnostic Tests This includes abnormal and significant normal.

Test

Date

Findings/Results

Implications/Nursing care

X-RAY knee 1or 2 view right

11/17/2014

Degeneration joint disease

Revision of the tibia and femoral

X-ray chest 1or 2 view

11/12/2014

Cardiomegaly, Tortuous descending aorta, left basilar atelectasis.

Surgery

 

 

 

 

Lab Tests with Rationale for Abnormals and Implication of Findings:

Name of lab

Reference Range

Level at Admit

Level on Last Lab

Nursing Implications

Reason for level

S&S

Date

Level

Date

Level

Red blood cell count

3.93- 5.22mmol/L

11/17/2014

2.8210E6/mcl

11/20/2014

2.6410E6/mcl

Due to Surgery

Hemoglobin

11.4-14.4 mmol/L

11/17/2014

7.9gm/dl

11/20/2014

7.4gm/dl

Due to Surgery

Hematocrit

33.3-41.4 mEq/L

11/17/2014

25.0%

11/20/2014

24.4%

Due to Surgery

 

mEq/L

 

 

 

 

 

 

mg/dL

 

 

 

 

 

Nursing Plan of Care

Nursing Plan of Care

NANDA NURSING DIAGNOSTIC LABEL (Choose #1 priority problem for patient)

RELATED FACTORS Secondary to a Disease or Condition

DEFINING CHARACTERISTICS*

(As evidenced by signs or symptoms)

* Remember “Risk For” Diagnoses do not yet have defining characteristics!

Acute pain

Related to knee replacement surgery

Subjective: As evidence by pain rate of 10/10

Objective: Lower extremity weakness.

Nursing Diagnosis Statement: Acute Pain______________________________________________

PATIENT EXPECTED OUTCOMES/GOALS

(Specific, Measurable, Achievable, Realistic, Timely)

PLANNED NURSING INTERVENTIONS & RATIONALE

EVALUATION

(Not Met, Partially Met or Met)

Patient Goal

Patient will indicate pain level decrease to less than 5/10

Your Intervention:

Administer pain medication

Evaluation of Goal

Goal partially met, Patient pain level was managed to a level of 6/10.

Your Intervention:

Facilitate Rest

Your Intervention:

Provide relaxation and guided imagery.

Nursing Plan of Care

Nursing Diagnosis Statement_____Ineffective coping ______________________________________________

NANDA NURSING DIAGNOSTIC LABEL (Choose #1 priority problem for patient)

RELATED FACTORS Secondary to a Disease or Condition

DEFINING CHARACTERISTICS*

(As evidenced by signs or symptoms)

Ineffective coping

Related to pain due to ineffective function

Subjective: patient report of anxiety

Objective: patient appears withdrawn

PATIENT EXPECTED OUTCOMES/GOALS

(Specific, Measurable, Achievable, Realistic, Timely)

PLANNED NURSING INTERVENTIONS & RATIONALE

EVALUATION

(Not Met, Partially Met or Met)

In patient terms only, summarize response to intervention

Patient Goal (may have several)

Patient will learn two coping skills

Your Intervention:

Encourage family support

Evaluation of Goal

Goal met, patient was able to relax by listening to , and daughter was there to give a moral support

Your Intervention:

Administer antidepressant /antianxiety medication

Your Intervention:

Involve relaxation therapy

Nursing Plan of Care

Nursing Diagnosis Statement: Risk for ineffective peripheral tissue perfusion.

NANDA NURSING DIAGNOSTIC LABEL (Choose #1 priority problem for patient)

RELATED FACTORS Secondary to a Disease or Condition

DEFINING CHARACTERISTICS*

(As evidenced by signs or symptoms)

Risk for ineffective peripheral tissue perfusion.

Related to coagulating factors released by bone during surgery.

Subjective:

Objective:

PATIENT EXPECTED OUTCOMES/GOALS

(Specific, Measurable, Achievable, Realistic, Timely)

PLANNED NURSING INTERVENTIONS & RATIONALE

EVALUATION

(Not Met, Partially Met or Met)

In patient terms only, summarize response to intervention

Patient Goal (may have several)

Prevent clotting

Your Intervention:

Give anticoagulant medication

Evaluation of Goal

Goal met,

Your Intervention:

Encourage ambulation

Your Intervention:

Give compression stockings

Nursing Plan of Care

Nursing Diagnosis Statement: Risk for fall _________________________________________________

NANDA NURSING DIAGNOSTIC LABEL (Choose #1 priority problem for patient)

RELATED FACTORS Secondary to a Disease or Condition

DEFINING CHARACTERISTICS*

(As evidenced by signs or symptoms)

Risk for fall

Related to lower extremity weakness

Subjective:

Objective:

PATIENT EXPECTED OUTCOMES/GOALS

(Specific, Measurable, Achievable, Realistic, Timely)

PLANNED NURSING INTERVENTIONS & RATIONALE

EVALUATION

(Not Met, Partially Met or Met)

In patient terms only, summarize response to intervention

Patient Goal (may have several)

Prevent patient from falling

Your Intervention:

Assist with ambulation

Evaluation of Goal

Met, patient was able to ambulate to bedside Commode.

Your Intervention:

Make sure bed is in low position with the rails at the top of the bed up

Your Intervention:

Involve physical therapy

References for your entire clinical worksheet:

Ruth F. Craven, Constance J. Hirnle, Sharon Jensen, (2013) Fundamental of nursing: human health and function,

(7th Ed). Philadelphia, PA: Lippincott Williams & Wilkins Inc.

Gulianick, M. and Myers, J. (2003). Nursing Care Plans: Nursing Diagnosis and Interventions. Mosby: St Louis

Pearson Education http://wps.prenhall.com/

Nursing Central (200-2014) Using web sources in writing, Retrieved from http://www.unboundmedicine.com/

Schedule: *Pt Care Summary; Med list; Pt schedule; task list

7am

Visit with patient and getting report from night shift staff.

8am

Perform vital signs

9am

Giving medication

10am

Assist with morning care, mouth care, assist with bath.

11am

Head to toe Assessment

12pm

Assist to bathroom, Accu-check.

State1 personal learning goal for this clinical day: ________Be able to give IV push and make my patient more comfortable. _________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

Did you meet your personal goal for the day?

_____________________________________________Goal Met, I was able to give IV push of 5% dextrose to my patient after noticing low level of glucose. _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Checklist for Routine Bedside Nursing Assessment

Mental/Neuro Status

LOC

Alertness/Orientation

PERRLA

Mood

Behavior

Check Patient ID Band

Cardiopulmonary

Heart Sounds

Apical Rate/rhythm

Lung sounds

Breathing pattern

Peripheral pulses

Edema

Capillary refill

Hemodialysis Access – Graft/Fistula – bruit/thrill

Oxygen Equipment

Vital Signs

BP

P

R

Temp

Pain

SaO2

Gastrointestinal

Bowel sounds

Abdominal palpation

Degree of ABD distension

Bowel elimination problems (diarrhea/constipation/flatulence)

Nausea/vomiting

Genitourinary

I & O (quantity)

Quality (color, clarity, burning)

Continence/incontinence

(Assistive devices)

Reproductive problems/sexual concerns

Motor Sensory Function

ROM

Paralysis

Weakness_______________________________________________________________________________________________________________________________/Numbness/Tingling

Assistive Devices

Ambulation

Wound

Cleanliness

Swelling/redness.infection

Drainage

Bandage dressing

Integumentary

Color

Temp

Turgor

Moisture

Integrity

Braden Scale Score (Mon, Thurs: rescore at EUH)

Invasive Tubes (IV’s, NGT, Wound drains, Catheters, etc..)

Device and location

IV Line(s): Fluids, Meds, Date of insertion/dressing/tubing

Patency and position

Redness, swelling, tenderness at site

Drainage/Infusion rate

Modified by Erin Poe Ferranti, 2005, 2007; Corrine Abraham, 2007

Adapted From: Elkin, Potter & Perry (2004) Nursing Interventions & Clinical Skills (3rd ed.) Mosby: St. Louis

Medications MAR; MAR Summary: Medication Profile*

Medication: Name/Dose/Route

Time

Classification

Purpose

Side Effects/Nursing Considerations

OxyCODONE(10mg=1tab)

1 tablet PO

9:00 am

Opioid analgesics

Reduce pain

Respiratory Depression

May cause drowsiness

Exenatide (10mcg injection)

1 each BID

PRN

Antidiabetics

Lower blood sugar

Pancreatitis, weakness

Insulin aspart (BG > 150)

(BG -100) /40= unit

 

Antidiabetics

Lower blood sugar

Anaphylaxis, hypoglycemia

Atorvastin (liptor) 20mg=1 tab, 1 tablet PO

9:00 am

Antilipidemia

Reduce Cholesterol level

Chest pain, Rhabdomyolysis

BuPRion 300mg=1tab

1tablet PO

9:00 am

Antidepressant

Treatment for depression

Seizure, anxiety, dry mouth, depression

ClonazePAM (0.5mg=1tab)

1mg=2tablets PO

9:00 am

Anticonvulsant

Prevention of seizure

Fatigue, constipation, suicidal thought

Docusate sodium (100mg=1cap) 1capsule PO

9:00 am

laxative

Prevent constipation

Mild cramps, diarrhea, rashes

Enoxaparin 30mg =0.3ml subq

9:00 am

anticoagulant

Blood thinner

Constipation, urinary retention

Levothyroxine (25mcg=1tab) 1tablet PO

7:00 am

hormonal

Treatment for hypothyroidism

Tachycardia. Abdominal cramps

Alprazolam (0.25mg=1tab)

9:00 am

antianxiety

Relief of anxiety

Constipation, blurred vision

Venlafaxine (75mg=1cap )150mg= 2capsule

PRN

Antidepressant

antianxiety

Decrease depression, anxiety and panic attack

Chest pain, anorexia, itching, epistaxis

Hydrocodone (10mg-1tab)

1tablet PO

9:00 am

opioid

Decrease pain

Respiratory depression, apnea, anaphylaxis

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