Nursing Care Plan


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Medical Diagnoses: Acute Pain related to incision on right knee, Impaired mobility and Risk for falls


1 .Acute Pain related to incision on right knee

·         Pt. rates pain 5 out of 10 on the pain scale before PO pain medication.

·         Physician prescribes PCA of Morphine and PO of Vicodin

·         Pain increases during ambulation and repositioning

2 Impaired mobility related to acute pain and incision

·         Unable to position self comfortably

·         Cannot bend over

·         On fall preventions per hospital policy

·         Pain and medication can have side effects that affect LOC

·         Cant bare weight on right leg

·         Needs assistance with walker and PT

6. Risk for falls related to acute pain and impaired mobility

·         On fall preventions per hospital policy

·         Pain and medication can have side effects that affect LOC

·         Cant bare weight on right leg

·         Needs assistance with walker and PT

3.Impaired skin integrity related to incision

·         12in incision vertical on right knee

·         Limited mobility that could cause incontinence

Chief Complaint:  A 73 year white male with pain from incision site in right knee from a right total knee replacement related to osteoarthritis.

 

Priority Assessment: Monitor vitals and pain. .  Practice standard precautious to help prevent infection.  Monitor LOC and mobility.  Monitor the volume of fluid and appearance of incision site.  Monitor I’s and O’s.

4. Activity intolerance related to acute pain and incision.

·         Unable to position self comfortably

·         Cannot bend over

·         On fall preventions per hospital policy

·         Pain and medication can have side effects that affect LOC

·         Cant bare weight on right leg

·         Needs assistance with walker and PT

8. Risk of nausea related to effects of medications and surgery

·         Physician prescribed Phenergan for nausea

5. Fatigue related to acute pain

·         Pt. rates pain 5 out of 10 on the pain scale before PO pain medication.

·         Physician prescribes PCA of Morphine and PO of Vicodin

·         Pain increases during ambulation and repositioning

7. Risk of infection related to incision

·         12in vertical incision on right knee

·         Limited  mobility that could cause incontinence

NANDA Diagnostic Statement: Acute pain related to incision on right knee AEB pain being 5 out of 10 on the pain scale

 

 

Behavioral Outcome / Goal: Pt. will report a decrease in pain from 5 down to 1 on the pain scale by 12/8/11. Pt. will only rely on PO pain medication for pain relief by 12/8/11. Pt. will increase physical mobility safely without injury. Pt. will have unimpaired incision healing.


Nursing Interventions:

 

1.      Monitor pt. for pain at least every 2 hours using the numeric pain scale and behavior assessment.

 

2.      Administer pt.’s PO pain medication of Vicodin as prescribed.  Reassess pain level and relief and document the effects.

 

3.      Teach Pt. to report pain as soon as it onsets and the description of pain and its contributing factors.

 

4.      Reposition pt. at least every 2 hours. Maintain alignment with pillows and monitor positioning around lumbar area.  Prevent skin breakdown

5.      Provide pt. a peaceful and quiet environment for resting and healing.______________________

Rationale:

 

1.      Pain is subjective in nature and only the client can fully describe it (Cox’s Clinical pg: 487)

2.      Response to pain and pain medication is unique to each client (Cox’s Clinical pg: 488)

 

3.      Pain is more readily controlled when it is treated early. (Cox’s Clinical pg: 487)

 

4.      Help stimulate circulation.  Alignment helps prevent pain malpractice and enhances comfort.  (Cox’s Clinical pg:488)

5.      Promotes action and effect of medication by providing decreased stimuli (Cox’s Clinical pg: 488)_______________________

Client Response:

 

1.      Pt.’s pain level at 5 while on PCA of Morphine. After PO pain medication of Vicodin, pain level decreased to 1.

2.      Pt. reported pain and asked for PO pain medication when PCA did not reduce pain.

 

3.      Pt. reported pain and asked for Vicodin when pain was not stabilized by the PCA medication of Morphine.

4.      Every 2 hours help pt. shift weight to different positions that do not affect incision site and do not hurt the healing process

 

5.      Pt. has private room. Pt. is calm, alert and watching t.v.  He is comfortable and under no distress.________________________ 

Summarize impressions of client progress toward outcomes / problem resolution:  Pt. is stable.  Pt. is experiencing pain of 5 on pain scale.  Physician prescribed Morphine through PCA and Vicodin orally.  Pt. has 12in incision vertically on right knee with a mepalex bandage and a right knee immobilizer to help keep leg positioned correctly for proper align and healing.  Pt. is void on own with no complications and pt. has had bm since post op.  Active bowel sounds and good appetite.  Pt. released from fall preventions by physical therapy and he is ambulating with assistance of walker and staff.  Wife is there for company and assisting with ambulation and hygiene.  Physician ordered physical therapy after discharge.  PT will be doing therapy at pt’s house for 3 days a week for 6 weeks. =============================


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