Nursing Care Plan for Post Operative Knee Pain

Nursing Care Plan for Post Operative Knee Pain EMORY UNIVERSITY NELL HODGSON WOODRUFF SCHOOL OF NURSING NRSG 360 Clinical Nursing I Clinical Work Sheet for Weekly Clinicals OVERVIEW: (Preparation for clinical week 2) Client’s Initials__L.W________ Age 74YRS___Admit Date_11/17/2014____ and/or Procedure Date _11/17/2014________ Today’s Date_11/20/2014________ 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 SS 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 â€Å"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