Grand Rounds: Impaired Physical

MobilityNursing 441: Clinical

Management of RehabilitationMaureen Clifford

The purpose of this assignment is to utilize critical thinking, independent judgment and integration of knowledge from the sciences to care for a patient with a disability.

Introduction of the Client:

~ Patient’s Initials: P. Y.~ Age: 75 years~ Ethnicity: Caucasian~ Sex: Female~ Admission Date: March 25, 2012~ Allergies: Penicillin and Sulfa~ Medical Diagnosis: Right total knee

replacement

WHAT IS THE INITIAL NURSING DIAGNOSIS?

Focus: Impaired Physical Mobility

P. Y. is a 75 year old Caucasian female,

who had a right total knee replacement at Mary Immaculate.

Grand Rounds Focus : Impaired Physical

MobilityWho should be included in GRAND

ROUNDS?

Health HistoryLET ME KNOW IF ANY OF THESE FACTORS RELATE TO

IMPAIRED MOBILITYRight total knee replacement due to DJD with “bone-on-bone pain

SLOW POST-SURGICAL PROGRESS AT MARY IMMACULATE Left total knee replacement, 10 years prior – Reported waiting “because of the severe pain.”Secondary Diagnoses: Osteoarthritis, Osteoporosis, Fibromyalgia, Hypertension, Hyperlipidemia, Cervical and Lumbar Stenosis, DJD Family Health History: The client and her sister are the first in their family to present with osteoarthritis, osteoporosis, and DJD.

Psychosocial History

82 year old husband is very helpful and has always done the cooking. “He doesn’t mind cleaning up either.” He is functionally independent and in reasonably good health.

Both are retired and live in a two-story home with a guest bedroom and bath on the main floor.

Strong support system with step children, extended family, and friends. Reports feeling comfortable about going home after rehabilitation.

Education level is post-graduate. Speech is clear and intelligible. The client is a retired elementary school principal.

Drinks occasionally and denies smoking or recreational drug use.

Physical Assessment

General appearance: Pleasant lady resting in bed with moderate pain and general weakness at 75 years of age. She is displeased with breakfast, of which she ate only 30%.

A & O x 4. Neuro checks normal. Denies numbness, tingling. Upper extremities have good ROM bilaterally. Left lower

extremity has good ROM and can be raised with resistance. Five-inch well approximated right knee incision with mild

erythema and reported pain at 6 to 7 of 10. Right lower extremity weakness that is pain inhibited & with trace edema.

+2 pedal pulses bilaterally. Remainder of ROS (-).

Abnormal Labs

Red Blood Cells 2.98 (L) Range: 4.2 – 5.4 x 10 12/L Hemoglobin 9.4 (L) Range: 12 – 16 g Hematocrit 27.5 (L) Range: 37% - 47% RBC Distribution Width 15.6 Range: 11% - 14.5%

[Indicates folic acid deficiency] Eosinophils 0.1 (L) Range: 1% - 4%

[Indicates phagocytosis activity of antigen-antibody complexes. As the allergic response diminishes, the eosinophil count decreases.]

Client’s Reasons for Rehabilitation

“My husband and I could not have managed this at home. He’s 82 years old, and we needed more help than just home health care. I needed extra help with my hygiene.”

“I didn’t want to deal with the pain alone.” Long term goal for rehab: “I want to be able to travel

and walk around touring and not be in pain – quality of life.”

HAVE YOU SEEN ANY OTHER NURSING DIAGNOSES?

Capabilities and Dependence

Level of function prior to surgery: Independent without devices. Full ROM in upper extremities. Left lower extremity has no limitation. Right lower extremity has 50% to 60% ROM. WBAT, ambulatory

250 feet. Bed bath and dressing upper body with no assist. One assist and

device assistance for lower extremities. Progress with using devices.

No assistance needed for eating. Ambulates with one assist and walker from bed to bathroom.

No assistance in wheelchair.

WBAT

Nursing Diagnoses

Impaired Physical Mobility Pain Imbalanced Nutrition: Less than body

requirements Self-Care Deficit Anxiety Knowledge Deficit Constipation Risk for Infection

Diagnoses RationalesImpaired Physical Mobility: The client’s primary medical diagnosis was right total knee replacement, and she was three days post-op upon admission to RRI. She showed slow post-surgery progress at Mary Immaculate. She has arthritis, fibromyalgia, spinal stenosis, and general weakness.

Pain: The client had an incision to the right knee, and she reported pain at 6 to 7 of 10 in the right lower extremity. She was not full weight bearing on the right lower extremity. She had arthritis, fibromyalgia, and spinal stenosis. She showed facial grimacing.

Imbalanced Nutrition: The client reported that she was “unhappy with the meals.” She generally ate only 30% of her meals. She also had GERD, which contributed to her low food intake. Most importantly, her abnormal lab values pointed to severe anemia.

Self-Care Deficit: One assist for bed bath and dressing. Ambulates with one assist and walker initially from bed to BSC, then from bed to bathroom.

Diagnoses Rationales

Knowledge Deficit: The client was observed and reported needing education on transfer safety, use of assistive devices, control of pain, tips for cutting or crushing large pills, polypharmacy, drinking fluids, and no deep tissue message on lower extremities after completing her Lovenox shots, unless cleared by her doctor.

Anxiety: The client had reported anxiety regarding the acute pain in her right knee, her chronic pain, being immobile, and the slow recovery from her surgery. The client stated, “I don’t want to deal with this pain alone.”

Constipation: The client had not had a bowel movement for three days, and her normal was daily. She reported abdominal discomfort.

Risk for Infection: The client had risk for infection related to the incision to her right knee, erythema at the incision site, and immobility.

InterventionsImpaired Physical Mobility~ Assess capabilities and dependencies. Rationale: Continually

assessing allows for increased measures to promote maximum mobility or decrease measures to avoid injury

~ Encourage self-care. Rationale: Increases functional independence

~ Reinforce education on assistive devices. Rationale: Increases functional independence

~ Administer pain meds as ordered. Rationale: Allows for increased mobility

~ Monitor reports from PT and OT. Rationale: Interdisciplinary teamwork

InterventionsPain~ Assess pain characteristics. Rationale: Allows for

planning pain management strategies

~ Administer pain meds as ordered. Rationale: Allows for patient comfort

~ Assess patient’s response to pain meds. Rationale: Allows for better pain control

~ Assess cultural factors contributing to pain. Rationale: Better pain control

~ Alternative: Encourage guided imagery, music therapy & message therapy. Rationale: Promotes relaxation and positive attitude

InterventionsImbalanced Nutrition~ Document weight and height and monitor lab values.

Rationale: Pt may be unaware of weight and height. Indicates degree of deficiency

~ Obtain nutritional history. Rationale: The pt’s perception of actual intake may differ

~ Monitor and explore attitudes toward eating and food. Rationale: Many psychological and psychosocial factors determine amount of food consumed

~ Aid in pain control. Rationale: Provides comfort for enjoying food

~ Consult dietician. Rationale: Provide greater understanding nutrition

InterventionsSelf-care Deficit~ Assess abilities to carry out ADLs. Rationale: Pt may require

assistance with only some activities

~ Set short range goals with pt and health care team. Rationale: Assisting the pt to set realistic goals will reduce frustration

~ Implement measures to facilitate independence, but intervene when pt cannot perform. Rationale: Appropriate level of assistive care can prevent injury

~ Allow adequate time for patient to complete self-care tasks. Rationale: Prevents frustration and injury

~ Provide positive reinforcement. Rationale: Promotes ongoing efforts

InterventionsAnxiety ~ Assess pt’s level of anxiety. Rationale: Mild anxiety enhances the

pt’s ability to identify and solve problems. Severe anxiety decreases the pt’s ability to integrate information or follow directions

~ Determine how the pt copes with anxiety. Rationale: Helps to assess the effectiveness of the pt’s coping strategies

~ Reassure the pt that she is safe. Rationale: The presence of a trusted one may help during an anxiety attack

~ Encourage the pt to talk about anxious feelings and examine anxiety provoking situations, recognizing factors leading up to anxiety. Rationale: Helps the pt perceive the situation in a less threatening way.

~ Alternative: Suggest aroma, music or message therapy for relaxation. Suggest deep breathing exercises for calming effect

InterventionsKnowledge Deficit ~ Assess motivation of the pt and caregiver to learn.

Rationale: Many adults need purpose for learning

~ Identify priority of learning needs. Rationale: Adults learn material that is important to them

~ Determine cultural influences on health teaching. Rationale: Provides a climate of acceptance

~ Determine pt’s learning style. Rationale: Some persons prefer written over visual instruction.

~ Provide physical comfort for the learner, ie: pain meds as ordered

InterventionsConstipation ~ Assess usual pattern of elimination. Rationale: Normal

frequency of passing stool varies from person to person~ Evaluate laxative use, type, and frequency. Rationale: Chronic

use causes the muscles and nerves of the colon to function inadequately

~ Evaluate usual dietary habits. Rationale: Change in mealtime and types of foods can cause disruption of usual schedule

~ Evaluate fear of pain. Rationale: Hemorrhoids and other anorectal disorders can cause the pt to ignore the urge to defecate

~ Encourage daily fluid intake. Rationale: Makes defecation easier~ Alternative: Encourage abdominal message for manual

assistance

Interventions Risk for Infection ~ Assess for presence, existence of, and history of risk

factors, such as surgical incision. Rationale: Represents a break in the body’s first line of defense

~ Monitor white blood cell count. Rationale: An increasing WBC count indicates the body’s efforts to combat pathogens

~ Monitor the following for signs of infection: redness, swelling, increased pain, purulent drainage from incisions, injury, exit sites of tubes, drains, and catheters

~ Monitor vital signs. Rationale: An increase in temperature, HR and RR suggests infection

~ Administer antibiotics as ordered. Wash hands. Rationale: Eliminates infection

Success of Interventions

Impaired Physical Mobility: Each day, the patient increased ambulation by 100% up to 250 feet. The patient ambulated safely and was able to perform a majority of ADLs independently. The patient will continue rehab on an outpatient basis.

Pain: The pt maintained an acceptable level of pain and learned how to control pain before it exacerbated mobility and activities.

Success of Interventions

Imbalanced Nutrition: A consultation was provided with the nutritionist. A low-fat, low-cholesterol diet was ordered, and the pt began eating 80% to 90% of meals.

Self-care Deficit: The pt learned use of assistive devices to become functionally independent. Her last day at RRI, she was “unsupervised” in her room, which equals independence.

Anxiety: The pt verbalized an excitement for going home, and a comfort about functioning alone if needed

Success of Interventions

Knowledge Deficit: The pt learned the use of assistive devices and returned demonstration. She learned control of pain and reported adequate relief.

Constipation: The pt had bowel movements every other day, which was closer to her normal schedule. She reported relief.

Risk for Infection: The pt remained infection free throughout her length of stay. Her incision was clean, dry and intact.

Time Comparison

Day 1: Required assistance with bed bath and

dressing below the waist Required one assist to BSC Uncontrolled pain level at 7 of 10, which

affected appetite, thus strength Ambulated with PT 40 feet Expressed anxiety

Time Comparison

Last Day: Pt was unsupervised in room, able to

ambulate at will Able to perform ADLs without assistance Pain level was at an acceptable level, and

the patient understood education about pain med schedule

Ambulated 250 feet and negotiated stairs Expressed comfort and excitement about

returning home. Confident in performing ADLs alone

Nursing Research

Klyak, E., Akdemir, N., Fescl H. (2009). The evaluation of the impact of the use of wool in patients with fibromyalgia on life quality. Australian Journal of Advanced Nursing, 26(3), 47-52.

When patients were given wool to apply to areas of fibromyalgia pain, pain was improved significantly. Wool is used on the CPM machines, this same wool could be used to decrease pain levels.

References

Gulanik, M., & Myers, J. L. (2007). Nursing care plans: Nursing-diagnosis and interventions. St. Louis, MO: Mosby.

Pagana, K. D., & Pagana, T. J. (2010). Mosby’s manual of diagnostic and laboratory tests (4th ed.). St. Louis, MO: Mosby Elsevier.