Concept Care Map: Part 1 (Diagram)

Student Name:

Client Initials:

K.W. Clinical Dates:

Key Problem # 1
Impaired physical mobility r/t surgical incision aeb limited
range of motion.
-1 day post right total knee arthroplasty
- Reports no pain, but grimaces during ambulation and
hesitates when flexing right knee.
- Limited range of motion in LRE
- Walker use when ambulating.

1/22/2015
Key Problem # 2
Activity intolerance level II r/t sedentary lifestyle, chronic
pain in LRE aeb patient statememtns
- Patient reports fatigue after activity
- Patient grimaces during ambulation
- Refused transfer to a chair, or a sitting position.
- VSs increased after moderate ambulation, pulse increased
from 78 at rest to 98, respirations increased from 17 to 22

Patient: 58 y/o African American female, 220lbs

Reason for Needing Health Care: Post op care
Procedure: Total knee arthroplasty right extremity
Background: History of hypertension, obesity, degenerative joint
disease, limited mobility in LRE

Key Problem # 3
Acute and chronic pain r/t right knee arthroplasty aeb
facial expression when ambulating
-1 day post op
-Grimacing when moving right leg
-Surgical incision on right knee
- Ice applied to affected limb
- Medication for pain with PRN orders

I dont know how this fits:

Hyperstension well controlled

Key Problem # 4
Readiness for enhanced family processes r/t role performance
aeb changing family dynamics
-Husband was present during surgery and recovery
-Both showed an understanding of each others restrictions
-They both showed a willingness to work together
-Husband recently retired due to disability
-They showed a mutual respect for each other

Aiken Technical College

PNR____
Concept Care Map: Part 2
Student Name:

Nick Haislip

Client Initials:

K.W.

Clinical Dates:

1/22/2015

Problem #1 (Nursing Diagnosis) Impaired physical mobility r/t surgical incision aeb limited range of motion.
General Goal: Patient will ambulate with minimum assistance
Expected Outcome
Behavioral, measurable, observable, realistic & time-limited
Patient will move from bed to walker and ambulate 250 feet on two separate occasions by the end of my shift on 1/22/2015

Nursing Interventions/Rationale

Patient Responses to Interventions

Note the emotional or behavioral responses to immobility.

The patient stated that she could never lift her leg up before, due to
the pain, and that she always had to use her hands to move her leg.
She was hesitant to try now due the her history.
Activities were scheduled around one hour after medications were
administered; patient reported a low level of pain prior to and during
activities.
Patient would do foot pump exercises every hour, this was noted on
several occasions.

Frustration or past problems may impede attainment of goals.

Administer medications prior to activity as needed for pain relief
Promotes effort and involvement from the patient
Encourage ROM exercises.
Promotes activity and exercise.
Educate the patient on fall risks and prevention, such as loose rugs
and other items on the floor, medications prescribed, use of a device
to assist in ambulation (walker), and exercises along with practicing
ambulating.

The patient showed an understanding by repeating some of the fall

risks, and calling for assistance when transferring from the bed to
the walker. Patient ambulated with minimal help, and is continuing
foot pumps and practice ambulating.

The patient is using an assistive device, and

Evaluation: Goal met, patient moved from the bed to the walker, and ambulated 250 feet on two separate occasions. The patient was also
able to navigate a set of 3 practice stairs with railing, up once and down once, on both of these occasions.

Aiken Technical College

PNR____
Concept Care Map: Part 2
Student Name:___________________________ Client Initials:___________

Clinical Dates:____________

Problem #2 (Nursing Diagnosis): Activity intolerance level II r/t sedentary lifestyle, chronic pain in LRE aeb patient statements
General Goal: Patient will increase activity tolerance
Expected Outcome
Behavioral, measurable, observable, realistic & time-limited
Patient will identify ways to increase activity tolerance by her discharge date of 1/23/2015.

Nursing Interventions/Rationale

Patient Responses to Interventions

Instruct the patient and her husband in monitoring response to

activity and in recognizing signs of overexertion

The patient and her husband showed understanding of respiration

rates and pulse rates increases, and explained how to watch for
perspiration or the patient being out of breath.

Will alert the patient when she needs to rest or limit exertion.
Teach patient methods to conserve energy
Reduces fatigue
Encourage participation in recreation, social activities, and hobbies
Provides activity and socialization.
Evaluate patients actual and perceived limitations and severity of
deficit in light of usual status

Patient states that she will take breaks regularly during activity.
Patient expressed interest in weekly activities at her church that she
will look in to joining.

Patient was afraid to move her right leg due to a habit of having to
use her hands to move it, and prior pain. After ambulating and
stretches she realized that she had more mobility than prior to her
Limitations may have changed after surgery
surgery.
Evaluation: Goals met, patient identified ways to increase her activity tolerance, and how to monitor her exertion to conserve energy.

Aiken Technical College

PNR____
Concept Care Map: Part 2
Student Name:___________________________ Client Initials:___________

Clinical Dates:____________

Problem #3 (Nursing Diagnosis) Acute and chronic pain r/t right knee arthroplasty aeb facial expression when ambulating
General Goal: Patient will remain within tolerable levels of pain.
Expected Outcome
Behavioral, measurable, observable, realistic & time-limited
Patient will report tolerable levels of pain, less than 4/10, during my shift on 1/22/2015

Nursing Interventions/Rationale

Patient Responses to Interventions

Assess patients pain level throughout shift

Patient reported low levels of pain, 1/10 throughout the day, some
grimacing and grunting was noted during ambulation

Allows a comparison with base levels, and shows if pain is

increasing
Monitor skin color and vital signs
Onset of pain may alter vital signs
Provide comfort measures
Non-pharmacological pain management will work together with
pharmacological pain management to decrease pain
Work with client on ways to prevent pain

Patients vital signs remained WDL.

Ice was applied to the post op knee, ace bandage was applied for
pressure, patient talked to staff and spouse, and watched TV, pain
levels were reported as low, 1/10.

Patient displayed an understanding of the importance of reporting

pain, taking medications as prescribed, and the use of
Timely intervention of pharmacological and non-pharmacological
complementary medicines, such as imagery, distraction, and the
pain management is more likely to successfully reduce pain.
application of ice packs.
Evaluation: Goal met, patient reported that pain was non existent, some grimacing and grunting was noted on ambulation, but patient
denied severity and has a calm happy demeanor.

Aiken Technical College

PNR____
Concept Care Map: Part 2
Student Name:___________________________ Client Initials:___________

Clinical Dates:____________

Problem #4 (Nursing Diagnosis) Readiness for enhanced family processes r/t role performance aeb changing family dynamics
General Goal: Patient will verbalize a desire for enhanced family dynamics
Expected Outcome
Behavioral, measurable, observable, realistic & time-limited
The patient and her husband will demonstrate the desire for open communication, and expressing their needs and abilities by their discharge date.

Nursing Interventions/Rationale

Patient Responses to Interventions

Determine family composition

Patient and husband have grown children with grandchildren. Their

children no longer live at home. The patient and her husband live
together in a single home.
The patient and her husband were very involved in each others
learning process. Her husband paid attention during teaching, took
part during physical therapy, and watched and learned whenever he
could.
The patients husband understood her limitations, and what she
needs to do to recover from her surgery. He showed a willingness to
assist when possible. The patient understood that her husband was
disabled, and knew his limitations.

Helps to determine what their needs are as a family

Involve family members in setting goals and planning
When individuals are involved in the process they are more likely to
be committed to assisting with plans.
Assist family members in identifying situations that may cause
problems or stress
Thinking ahead can help people anticipate actions to potential
problems
Stress the importance of continuous, open dialogue

The patient and her husband understood that they both have
limitations, and that they needed to tell each other when there were
Facilitates ongoing expression or open, honest, feeling, and
problems with their ability. They know each others limitations, and
effective problem solving
will stay involved.
Evaluation: Goals met, the patient and her husband are comfortable with communicating with each other and expressing their needs and
abilities.