knee replace care plan
TRANSCRIPT
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D: ambulated around unit 2 times with the use
of a walker. Gait was steady and even. Nodiscomfort with ambulating.
A: Standby assist with ambulation for safety.Assessed patients level of discomfort and
tolerance of activity. Noted gait and respiratoryeffort.
R: Patient stated I am amazed how mucheasier gets to ambulate with every passing
day. Patient reported no pain or discomfortwith ambulation.
Nursing Diagnoses/
Collaborative Problem
(Indicate order of priority
with numbers)
Patient Outcomes
(Measurable= client-
centered, timeframe,
feasible, realistic)
Nursing Interventions
(Holistic, individualized,
must have frequencies)
Evaluation of Patient
Outcomes
(Goal met, not met,
partially met) Explain.
Modifications to Nursing
Care Plan
(diagnoses, goals, or
nursing interventions)
1. Acute pain R/T tissue
trauma secondary tosurgery AEB complaints of
pain, 4/10 on pain scale,facial grimacing.
69
Patient will report pain
level above a 2 / 10 on painscale.
1. Assess pain level
using 0-10 scale
including location and
quality every 4 hours
while awake.
2. Assess aggravating
and relieving factors
influencing pain and
record findings onetime this shift.
3. Use empathy to
convey understanding
of pain.
4. Assess other factors
contributing to pain;
fear, fatigue, anger
etc. and record
findings one time this
Goal partially met:
Patients pain on follow upwas 2/10. Patient
repositioned, and used coldpack in addition to
medication.
Patient was discharged
from hospital. Follow upwith doctor in 2 weeks,
discharge information aboutmedications were given to
patient.
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shift.
5. Encourage patient to
turn on call light to
report increasing pain.
6. Offer ice packs,
repositioning, andlistening to classical
music for break
through pain.
7. Administer pain
medications as order
by MD.
8. Schedule analgesicadministration prior to
meals and activities.
9. Assess pain level 30
minutes after giving
pain medication to
evaluate effectiveness.
10.Evaluate patients
response to non-
pharmaceutical pain
relief measures
throughout shift to
determine most
effective techniques
for patient.
11. Collaborate withpatient, family,
physician, and other
health care team
members when
changes in pain
management are
necessary.
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2. Risk for infection R/T a
site for organism invasionsecondary to surgery.
236
Patient will report signs and
symptoms of infection atincision site: redness,
warmth, swelling, increasedpain, and drainage
1. Assess incision site
every shift.
2. Document
assessment findings
including drainageamount, color and
consistency, as well
as any presence of
warmth redness or
inflammation.
3. Educate patient on
symptoms of
infection.
4. Encourage good
hand washing to
prevent touching
the site with germs
present.5. Monitor patients
temperature each
shift.
6. Monitor lab valuessuch as: white blood
cell count,
neutrophils, serum
protein, serum
albumin, and
cultures.
7. Evaluate patientsunderstanding of
symptoms of
Patient was free from
infection, and he was alsoable to verbalize the signs
and symptoms of infectionon this shift 11-16-11.
Referral for a home health
care nurse to follow up withassessing the incision until
incision is approximated.
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infection.
3.Readiness for enhanced
nutrition
519
Patient will identify 2 newways to incorporate more
fiber into diet by dischargetoday 11-16-11.
1. Assess patients usualmeal choices, and
preferences.2. Assess patients likes and
dislikes in whole grainfoods and fruits.
3. Report patients dietarypreferences to dietary departmentto coordinate with meal choices4. Offer education/
pamphlets on benefits offiber in diet such as
reducing constipation,reducing cholesterol, and
satisfying hunger for longer
periods of time promotingweight management.5. Encourage patient to
track diet intake in ajournal.
6. Educate patient on riskfactors for obesity and
benefits of weight loss.7. Evaluate patients
understanding of educationand materials provided.
8. Referral to dietary forconsult regarding low fiber
diet.9. Discuss simple strategies
to facilitate weight loss withdiet such as portion control,
smaller plate, refusing
Goal partially met:Patient stated I will try to
eat more apples, bananas,brown rice, almonds, peas,
and corn.
Follow up with phone callfrom dietarian to determine
further education needs,meal planning ideas, or
recipes which are high infiber.
Continue to reinforceeducation and evaluatepatients understanding of
material.
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second helpings etc.
10. Demonstrate the use of foodlabels to make healthful choices.
Alert the patient to focus on
serving size, total fat, and simple
carbohydrate, and fiber content.
4.
Readiness for enhancedtherapeutic regimen
management. 524
Patient will verbalize 3
strategies to continuehealing progressionby the
end of this shift ofdischarge from hospital on
11-16-11
1. Assess patients
strengths in the
management of the
therapeutic
regimen.
2. Encourage all
efforts to
understand and
manage therapeutic
regimens.
3. Assess contributingfactors that may
need to be
improved now or in
the future.
4. Identify contributing
factors that may need
to be improved now
or in the future.
5. Educate patient
importance ofleg
exercises what this
activity prevents.
6. Help the clientmaintain existing
support and seek
Goal met:
Patient verbalized the needto perform leg exercises to
promote circulation andprevent blood clots, use his
incentive spirometer duringcommercials, and to walk
on tred mill for 5 minutes3x a day increasing time
gradually as activity istolerated.
Continue to reinforce
education and assist in
integrating regimen into
daily living routines
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additional supports as
needed.
7. Educate patient on
the importance of
deep breathing,
coughing, and using
incentive
spirometer, in
prevention of fluid
building up in the
lungs.
8. Remind patient to
perform breathing
exercises above
every two hours
while awake.
9. Encourage patient
to track legexercises and
breathing exercises
in journal.
10.Discuss strategies to
integrate regimen
into daily living
routines.
11.Evaluate patients
understanding of
the education
provided.
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References:
DAILY JOURNAL ENTRIES
Goals: You will take charge of your own learning by using writing to reflect on clinical experiences and assess your own needs and growth. Throughout your clinical
courses, you will be asked to keep a daily journal of your responses to experiences in the clinical area. Journals record your individual travel through the
academic world.
This assignment has four purposes.
a) to encourage getting in touch with your feelings about nursing i.e., how you respond to both good and bad days, how you react to peers, how
you feel about your role in the lives of patients and their families;b) to help you identify your individual needs and clinical objectives;c) to encourage you to daily evaluate your own clinical performance, building on your strengths and improving any weak areas;d) to provide a format through which you can identify and think through ethical concerns in clinical practice.
Your journal should be done as soon after clinical as possible while your thoughts are fresh. We respect honesty and confidentiality. We would like your journal to reflect on the
above (a-d) while answering the following:
What was your greatest learning experience today?
What did you do today that made you feel like an RN and what specifically can you do to progress in the RN role?
Give at least of one example of critical thinking you did and/or you observed an RN make. Be specific with how you interpreted this as critical thinking.
Describe how you have applied what you have previously learned in theory or lab to the care of your client today?
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