Nursing Care Plan for Post Operative Knee Pain

Nursing Care Plan for Post Operative articulatio genus joint PainEMORY UNIVERSITYNELL HODGSON WOODRUFF SCHOOL OF NURSINGNRSG 360 clinical Nursing IClinical Work Sheet for Weekly ClinicalsOVERVIEW (Preparation for clinical week 2)Clients Initials__L.W________ Age 74YRS___Admit Date_11/17/2014____ and/or Procedure Date _11/17/2014________To solar days Date_11/20/2014________Medical Diagnosis/Reason for Admission __Post-operative _ paroxysm____ Admitting Diagnosis regenerate KNEE REVISIONDescribe (Brief Pathophysiology in your own words, including HPI)__Patient is a 74 years female with advanced 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 tender 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 think? (Preparation Add on by Clinical week 3) discourses (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 8/10Neuro 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 urineMusculoskeletal Active range of doing on upper extremities, impaired range of motion on lower extremities with brace on right leg. Right foot is dissented.Safety Concerns Fall risk, wring sore risk.___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________DIAGNOSIS *Radiology results lab micro ordersPertinent Diagnostic Tests This includes abnormal and significant normal. TestDateFindings/ResultsImplications/Nursing careX-RAY knee 1or 2 survey right11/17/2014Degeneration joint diseaseRevision of the tibia and femoralX-ray chest 1or 2 view11/12/2014Cardiomegaly, Tortuous descending aorta, left basilar atelectasis.SurgeryLab Tests with Rationale for Abnormals and Implication of FindingsName of labReference Range train at AdmitLevel on Last LabNursing ImplicationsReason for levelSSDateLevelDateLevelRed descent cell count3.93- 5.22mmol/L11/17/2014 2.8210E6/mcl11/20/20142.6410E6/mclDue to SurgeryHemoglobin11.4-14.4 mmol/L11/17/20147.9gm/dl11/20/20147.4gm/dlDue to SurgeryHematocrit33.3-41.4 mEq/L11/17/201425.0%11/20/201424.4%Due to SurgerymEq/Lmg/dLNursing Plan of CareNursing Plan of CareNANDA NURSING DIAGNOSTIC LABEL (Choose 1 priority problem for patient) relate FACTORS Secondary to a Disease or ConditionDEFINING CHARACTERISTICS*(As evidenced by signs or symptoms)* Remember Risk For Diagnoses do not yet know defining characteristicsAcute painRelated to knee replacement surgerySubjective As evidence by pain rate of 10/10Objective Lower extremity helplessness.Nursing Diagnosis avowal Acute Pain______________________________________________ uncomplaining EXPECTED OUTCOMES/GOALS(Specific, Measurable, Achievable, Realistic, Timely)PLANNED NURSING INTERVENTIONS RATIONALEEVALUATION(Not Met, partially Met or Met)Patient endingPatient will indicate pain level decrease to less than 5/10Your intercessionAdminister pain medicineEv aluation of GoalGoal partially met, Patient pain level was managed to a level of 6/10.Your InterventionFacilitate RestYour Intervention go away relaxation and guided imagery.Nursing Plan of CareNursing Diagnosis Statement_____Ineffective heading ______________________________________________NANDA NURSING DIAGNOSTIC LABEL (Choose 1 priority problem for patient) colligate FACTORS Secondary to a Disease or ConditionDEFINING CHARACTERISTICS*(As evidenced by signs or symptoms)Ineffective copingRelated to pain due to inefficacious functionSubjective patient reveal of anxietyObjective patient appears withdrawnPATIENT EXPECTED OUTCOMES/GOALS(Specific, Measurable, Achievable, Realistic, Timely)PLANNED NURSING INTERVENTIONS RATIONALEEVALUATION(Not Met, Partially Met or Met)In patient terms only, summarize result to interventionPatient Goal (may have several)Patient will learn two coping skillsYour InterventionEncourage family supportEvaluation of GoalGoal met, patient was able to relax b y listening to , and daughter was there to give a moral supportYour InterventionAdminister antidepressant /antianxiety medicationYour InterventionInvolve relaxation therapy Nursing Plan of CareNursing 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 ConditionDEFINING CHARACTERISTICS*(As evidenced by signs or symptoms)Risk for ineffective peripheral tissue perfusion.Related to coagulating factors released by bone during surgery.SubjectiveObjectivePATIENT EXPECTED OUTCOMES/GOALS(Specific, Measurable, Achievable, Realistic, Timely)PLANNED NURSING INTERVENTIONS RATIONALEEVALUATION(Not Met, Partially Met or Met)In patient terms only, summarize response to interventionPatient Goal (may have several)Prevent clottingYour InterventionGive anticoagulant medicationEvaluation of GoalGoal met,Your InterventionEncourage ambulationYour InterventionGive crunch stocki ngsNursing Plan of CareNursing Diagnosis Statement Risk for fall _________________________________________________NANDA NURSING DIAGNOSTIC LABEL (Choose 1 priority problem for patient)RELATED FACTORS Secondary to a Disease or ConditionDEFINING CHARACTERISTICS*(As evidenced by signs or symptoms)Risk for fallRelated to lower extremity weaknessSubjectiveObjectivePATIENT EXPECTED OUTCOMES/GOALS(Specific, Measurable, Achievable, Realistic, Timely)PLANNED NURSING INTERVENTIONS RATIONALEEVALUATION(Not Met, Partially Met or Met)In patient terms only, summarize response to interventionPatient Goal (may have several)Prevent patient from fallingYour InterventionAssist with ambulationEvaluation of GoalMet, patient was able to ambulate to bedside Commode.Your InterventionMake sure bed is in low position with the rails at the top of the bed upYour InterventionInvolve physical therapyReferences for your correct clinical worksheetRuth F. Craven, Constance J. Hirnle, Sharon Jensen, (2013) Fundamen tal 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 LouisPearson Education http//wps.prenhall.com/Nursing Central (200-2014) exploitation web sources in writing, Retrieved from http//www.unboundmedicine.com/Schedule *Pt Care Summary Med list Pt schedule task list7amVisit with patient and getting report from night shift staff.8amPerform vital signs9amGiving medication10amAssist with morning care, mouth care, assist with bath.11amHead to toe Assessment12pmAssist 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 intellectual/Neuro StatusLOCAlertness/OrientationPERRLAMoodBehaviorCheck Patien t ID BandCardiopulmonaryHeart SoundsApical Rate/rhythmLung soundsBreathing coursePeripheral pulsesEdemaCapillary refillHemodialysis Access Graft/Fistula bruit/thrillOxygen EquipmentVital SignsBPPRtemporary workerPainSaO2GastrointestinalBowel soundsAbdominal palpationDegree of ABD distensionBowel elimination problems (diarrhea/constipation/flatulence)Nausea/vomitingGenitourinaryI O (quantity)Quality (color, clarity, burning)Continence/incontinence(Assistive devices)Reproductive problems/sexual concernsMotor Sensory FunctionROMParalysisWeakness_______________________________________________________________________________________________________________________________/Numbness/TinglingAssistive DevicesAmbulationWoundCleanliness protuberance/redness.infectionDrainageBandage dressingIntegumentaryColorTempTurgorMoistureIntegrityBraden Scale Score (Mon, Thurs rescore at EUH)Invasive Tubes (IVs, NGT, Wound drains, Catheters, etc..)Device and kettle of fishIV Line(s) Fluids, Meds, Date of insertion/dressing/tubingPatency and positionRedness, swelling, tenderness at siteDrainage/Infusion rateModified by Erin Poe Ferranti, 2005, 2007 Corrine Abraham, 2007Adapted From Elkin, Potter Perry (2004) Nursing Interventions Clinical Skills (3rd ed.) Mosby St. LouisMedications MAR MAR Summary Medication Profile*Medication Name/Dose/RouteTime salmagundiPurposeSide Effects/Nursing ConsiderationsOxyCODONE(10mg=1tab)1 tablet PO900 amOpioid analgesicsReduce painRespiratory DepressionMay front drowsinessExenatide (10mcg injection)1 each BIDPRNAntidiabeticsLower blood sugarPancreatitis, weaknessInsulin aspart (BG 150)(BG -100) /40= unitAntidiabeticsLower blood sugarAnaphylaxis, hypoglycaemiaAtorvastin (liptor) 20mg=1 tab, 1 tablet PO900 amAntilipidemiaReduce Cholesterol levelChest pain, RhabdomyolysisBuPRion 300mg=1tab1tablet PO900 amAntidepressantTreatment for depressionSeizure, anxiety, dry mouth, depressionClonazePAM (0.5mg=1tab)1mg=2tablets PO900 amAnticonvulsantPrevention of seizureFatigue, constipation, suicidal thoughtDocusate sodium (100mg=1cap) 1capsule PO900 amlaxativePrevent constipationMild cramps, diarrhea, rashesEnoxaparin 30mg =0.3ml subq900 amanticoagulantBlood thinnerConstipation, urinary retentionLevothyroxine (25mcg=1tab) 1tablet PO700 amhormonalTreatment for hypothyroidismTachycardia. Abdominal crampsAlprazolam (0.25mg=1tab)900 amantianxietyRelief of anxietyConstipation, blurred visionVenlafaxine (75mg=1cap )150mg= 2capsulePRNAntidepressantantianxietyDecrease depression, anxiety and panic outpouringChest pain, anorexia, itching, epistaxisHydrocodone (10mg-1tab)1tablet PO900 amopioidDecrease painRespiratory depression, apnea, anaphylaxis