Nursing Care Plan for Post Operative Knee Pain

nurse Care Plan for Post effective Knee PainEMORY UNIVERSITYNELL HODGSON WOODRUFF SCHOOL OF breast feedingNRSG 360 Clinical nurse IClinical do work Sheet for Weekly ClinicalsOVERVIEW (Preparation for clinical week 2)Clients Initials__L.W________ Age 74YRS___Admit Date_11/17/2014____ and/or action Date _11/17/2014________Todays Date_11/20/2014________Medical diagnosing/Reason for Admission __Post-operative _pain____ Admitting diagnosing RIGHT KNEE REVISIONDescribe (Brief Pathophysiology in your own words, including HPI)__Patient is a 74 years womanly with right stifle re flock payable to acute post-operative pain came in for surgical consultation payable to continued pain and a valgus deformity after having cast removed. She is on hinged knee brace for stability.Allergies Ancef, tolmetin sodium 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 atomic number 18 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 sound judgment 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 wakeful on S1 and S2. No extra heart sounds, murmurs, or ribs.Respiratory Breathing is unlabored, chest campaign is symmetric. Integumentary (include wounds) Skin is normal, warm and moist, no skin discoloration. contuse dressing on the right knee and right femur edema.GI Normal bowel sounds hyperactive in all quadrants.GU Clear yellow urineMusculoskeletal Active barf of motion on upper extremities, impaired range of motion on lower extremities with brace on righ t leg. Right foot is dissented.Safety Concerns turn over risk, Pressure sore risk.___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________DIAGNOSIS *Radiology results lab micro ordersPertinent Diagnostic Tests This includes abnormal and crucial normal. TestDateFindings/ResultsImplications/Nursing careX-RAY knee 1or 2 view right11/17/2014Degeneration joint diseaseRevision of the tibia and femoralX-ray chest 1or 2 view11/12/2014Cardiomegaly, Tortuous descending aorta, left basilar atelectasis. cognitive processLab Tests with rule for Abnormals and Implication of FindingsName of labReference RangeLevel at AdmitLevel on Last LabNursing ImplicationsReason for levelSSDateLevelDateLevel loss blood cell count3 .93- 5.22mmol/L11/17/20142.8210E6/mcl11/20/20142.6410E6/mclDue to functioningHemoglobin11.4-14.4 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 care for DIAGNOSTIC LABEL (Choose 1 antecedency problem for enduring)RELATED FACTORS Secondary to a Disease or ConditionDEFINING CHARACTERISTICS*(As evidenced by signs or symptoms)* Remember Risk For Diagnoses do not heretofore expect defining characteristicsAcute painRelated to knee replacement surgerySubjective As evidence by pain rate of 10/10 impersonal Lower extent weakness.Nursing Diagnosis Statement Acute Pain______________________________________________ patient of EXPECTED OUTCOMES/GOALS(Specific, Measurable, Achievable, Realistic, Timely)PLANNED nursing INTERVENTIONS RATIONALEEVALUATION(Not Met, partly Met or Met)Patient GoalPatient will indicate pain level decrease to little than 5/10You r handling assign pain medicationEvaluation of GoalGoal partly met, Patient pain level was managed to a level of 6/10.Your discourseFacilitate RestYour InterventionProvide uncompressation and guided imagery.Nursing Plan of CareNursing Diagnosis Statement_____Ineffective coping ______________________________________________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)Ineffective copingRelated to pain due to ineffective functionSubjective patient report of anxietyObjective patient appears withdrawnPATIENT EXPECTED OUTCOMES/GOALS(Specific, Measurable, Achievable, Realistic, Timely)PLANNED NURSING INTERVENTIONS RATIONALEEVALUATION(Not Met, part Met or Met)In patient footing only, summarize response to interventionPatient Goal (may have several)Patient will learn both coping skillsYour InterventionEncourage family supportEvaluation of GoalGoal me t, patient was able to relax by 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 Intervention prevail anticoagulant medicationEvaluation of GoalGoal met,Your InterventionEncourage ambulationYo ur InterventionGive compression stockingsNursing 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 Intervention answer 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 slip by of the bed upYour InterventionInvolve physical therapyReferences for your entire clinical worksheetRuth 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 LouisPearson Education http//wps.prenhall.com/Nursing interchange (200-2014) Using web sources in writing, Retrieved from http//www.unboundmedicine.com/Schedule *Pt Care Summary Med list Pt inscription 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 draw off 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 AssessmentMental/Neuro StatusLOCAlertness/ OrientationPERRLAMoodBehaviorCheck Patient ID Band cardiorespiratoryHeart SoundsApical Rate/rhythmLung soundsBreathing patternPeripheral pulsesEdemaCapillary replenishHemodialysis Access Graft/Fistula bruit/thrillOxygen EquipmentVital SignsBPPRTempPainSaO2GastrointestinalBowel soundsAbdominal palpationDegree of ABD distensionBowel excreta problems (diarrhea/constipation/flatulence)Nausea/vomitingGenitourinaryI O (quantity)Quality (color, clarity, burning)Continence/incontinence(Assistive devices) reproductive problems/sexual concernsMotor Sensory FunctionROMParalysisWeakness_______________________________________________________________________________________________________________________________/Numbness/TinglingAssistive DevicesAmbulationWoundCleanlinessSwelling/redness.infectionDrainageBandage dressingIntegumentaryColorTempTurgorMoistureIntegrityBraden plate Score (Mon, Thurs rescore at EUH)Invasive Tubes (IVs, NGT, Wound drains, Catheters, etc..)Device and locationIV Line (s) Fluids, Meds, Date of insertion/dressing/tubingPatency and positionRedness, swelling, tenderness at siteDrainage/Infusion rate modify 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 indite*Medication Name/Dose/RouteTimeClassificationPurposeSide Effects/Nursing ConsiderationsOxyCODONE(10mg=1tab)1 tablet PO900 amOpioid analgesicsReduce painRespiratory Depressionwhitethorn cause drowsinessExenatide (10mcg injection)1 each BIDPRNAntidiabeticsLower blood sugarPancreatitis, weaknessInsulin aspart (BG 150)(BG -100) /40= unitAntidiabeticsLower blood sugarAnaphylaxis, hypoglycemiaAtorvastin (liptor) 20mg=1 tab, 1 tablet PO900 amAntilipidemiaReduce Cholesterol levelChest pain, RhabdomyolysisBuPRion 300mg=1tab1tablet PO900 am antidepressantTreatment for depressionSeizure, anxiety, dry mouth, depressionClonazePAM (0.5mg=1tab)1mg=2tablets PO9 00 amAnticonvulsantPrevention of transportFatigue, constipation, suicidal thoughtDocusate sodium (100mg=1cap) 1capsule PO900 amlaxativePrevent constipation loony 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 attackChest pain, anorexia, itching, epistaxisHydrocodone (10mg-1tab)1tablet PO900 amopioidDecrease painRespiratory depression, apnea, anaphylaxis