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 8 out of 10 on the pain scale before PO and IV pain medication.

·         Physician prescribes PO 7.5 Norcos  Q4H PRN and IV 2mg Morphine Q2H PRN

·         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 left 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 left leg

·         Needs assistance with walker and PT

3.Impaired skin integrity related to incision

·         12in incision vertical on left knee

·         Limited mobility that could cause incontinence

Chief Complaint:  A 74 year white female with pain from incision site in left knee from a left 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. Monitor RBC, Hgb, Hct, Plt and Glucose levels.

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 left leg

·         Needs assistance with walker and PT

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

·         Physician prescribed Phenergan IV Q4H PRN for nausea

5. Fatigue related to acute pain

·         Pt. rates pain 8 out of 10 on the pain scale before PO and IV pain medication.

·         Physician prescribes prescribes PO 7.5 Norcos  Q4H PRN and IV 2mg Morphine Q2H PRN

·         Pain increases during ambulation and repositioning

7. Risk of infection related to incision

·         12in vertical incision on left knee

·         Limited  mobility that could cause incontinence


NANDA Diagnostic Statement: Acute pain related to incision on right knee AEB pain being 8 out of 10 on the pain scale

 

 

Behavioral Outcome / Goal: Pt. will report a decrease in pain from 8 down to 2 on the pain scale by 2/12. Pt. will only rely on PO pain medication for pain relief by 2/12. 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 pain medication of PO Norcos and IV Morphine 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.

6.      Check bowel elimination at least once per shift.____________________

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)

6.      Immobility caused by pain may decrease the parasympathetic stimulation to the bowel (Cox Clinical pg:564)__________________________

Client Response:

 

1.      Pt.’s pain level at 8 before IV        Morphine. 30 mins after admin. Pt.’s pain level went down to a 5 on pain scale.

2.      Pt. reported pain and asked for the scheduled pain medication that was available at that time. Pt was relieved once pain meds kicked in.

3.      Pt. reported pain and asked for IV Morphine when pain was not controlled with Norcos.

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

5.      Pt. has semi private room but the no roommate. Pt. is calm, alert and watching t.v. She is comfortable and not in distress.

6.      Pt. knows that the physician has ordered some aiding medication for bowel elimination if pt. cannot go on own and she has to a healthy BM before discharge.________________

Summarize impressions of client progress toward outcomes / problem resolution:  Pt. is stable.  Pt. is experiencing pain of 8 on pain scale.  Physician prescribed IV Morphine and Norco orally.  Pt. has 12in incision vertically on left knee with an ace bandage and a left knee immobilizer and a polar pack to help keep leg positioned correctly for proper align and healing.  Pt.’s foley was removed on 2/20 and is void on own with no complications and pt. has not had bm since post op, physician ordered aid meds in needed.  Hypoactive bowel sounds but good appetite.  Pt. released from fall preventions by physical therapy and she is ambulating with assistance of walker and staff.    Physician ordered physical therapy after discharge.  PT will be going to a rehab facility until physical therapy is complete.

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