Cypress College Department of Nursing

Nursing Care Plan Subjective Data:

09/15/11 at 0850: Pain level at 7 after walking to bathroom 09/15/11 at 1255: My pain is at a 3 after being medicated

Objective Data:
Dx: Osteoarthritis Surgery: Left Total Knee (Total Joint Anthroplasty) PT: Patient has limited bending Knee bends at 65 CPM machine set at 80 09/15/11 at 0850: Independently ambulate to bathroom and back. 09/15/11 at 1135: Independently ambulate 150ft. with front-wheeled walker Facial grimacing when left leg is moved Cannot lift left leg up while on bed

Nursing Diagnosis: (NANDA)

Impaired mobility r/t loss of integrity of bone structures secondary to surgical procedure as evidenced by inability to ambulate independently

Goal / Expected Outcome(s)

The patient will: 1. Improve mobility As evidenced by: a. Get out of bed independently without assist.

Target Date/Time 09/15/11

b. Ability to ambulate independently with walker 100 feet by 1500

Goal / Expected Outcome(s)

The patient will: 2. Be able to have 90 degrees of flexion in the operative knee upon discharge. As evidenced by: a. b.

Target Date/Time Discharge

Plan of Care:
Nursing Interventions The nurse will: Monitor VS and pain Q4H, before and after activity Rationale for Nursing Interventions Vital signs and level of pain needs to be assessed before, during and after activity. This evaluates patients activity tolerance and need for medication. (Taylor et al., 2011, p.1050) Effectiveness of Interventions Patients vital signs were taken every 4 hours and before patients appointment with physical therapist and occupational therapist. Pain displayed through facial grimacing and labored breathing when walking without pain medication. Pain is controlled when walking with pain medication. The dorsal-pedal pulse on the left leg was slightly stronger than the right leg. Patient did not verbalize any abnormal sensation in her leg. Mobility on the left leg was limited. Patient has a hard time flexing and

Check circulation, sensation, and mobility (CSM) Q2H

When there is musculoskeletal trauma, especially in the lower leg, there is an increased pressure that compromises the circulation to the area of trauma. The internal pressure results from blood or fluid accumulation. Pressure on the nerve may cause a tingling or numb sensation on the lower leg. Checking the CSM helps identify post-surgical complicationswhich may affect

Nursing Interventions The nurse will: M Medicate patient Q4H/PRN before activity

Effectiveness of Interventions patients mobility. (Ignatavicus & Workman, 2006, p. 1191) extending her leg. Managing of pain level help achieve comfort level goal as well as encouraging patients agreement to take on recommended activity. (Ignatavicus & Workman, 2006, p. 349) Patient c/o pain of 7 when ambulating at 0850 to bathroom without medication. She refused to continue walking. When medications were given an hour before her physical and occupational therapy session, patient showed more compliance as evidenced by walking 150ft. Before the patient stands up, she sits on the edge of the bed to acclimate herself.

Rationale for Nursing Interventions

Once the patient is standing, evaluate patient for orthostatic hypotension.

Place ted hose on patient. Take them off after 8 hours and wait for one hour before putting it back on.

Turn on sequential compression device(SCD) per MD order.

Orthostatic hypotension usually occurs when a person experience dizziness and lightheadedness when she moves from a supine, flat position to a sitting or standing position. When a patient exhibit orthostatic hypotension, they are very susceptible to falling. Falling is very dangerous as it is the leading cause of injury fatality. (Ignatavicus & Workman, 2006, p. 691) (Taylor, Lillis, LeMone, and Lynn, 2011, p.619) Immobility makes patients susceptible to thrombi formation due to venous stasis. This occurs because calcium leaves the bones and enters the blood stream. This increase blood coagulation and leads to an increase risk of thrombus formation. To prevent thrombus formation, ted hose are placed. TED hoses are compression socks that help maintain pressure on the patients lower extremity.( Ignatavicus & Workman, 2006, p. 812) (Taylor, Lillis, LeMone, and Lynn, 2011, p.843) SCD enhances blood flow and venous return on the legs by applying pressure on the legs in increments. Pressure is is caused by the air pump that is connected to the extremity sleeves. It is used to decrease the risk of thromboplebitis after surgery because patients are not as active. (Taylor, Lillis, LeMone, and Lynn, 2011, p.844)

Ted hose were place on the patient and were taken off every eight hours.

Patient was placed on SCD when she is laying in bed. Only take it off when she is ambulating.

Nursing Interventions The nurse will: Encourage patient to ambulate Q4H as tolerate

Rationale for Nursing Interventions

Physical activity reduces risk of cardiovascular and respiratory complications after an operation. It is imperative that patient engage in physical activity to achieve optimal recovery. (Taylor, Lillis, LeMone, and Lynn, 2011, p.883) Reposition patient Q2H/PRN. Although dislocation is not a big concern for total knee Make sure patient is in proper replacement and special repositioning is not important, body alignment. Use pillows repositioning prevents pressure sores and maintains PRN to alleviate pressure alignment. The knee should be in neutral position and not sores. rotated internally or externally. Correct alignment promotes proper healing.(Ignatavicus & Workman, 2006, p. 390) Encourage patient to discuss Discussion helps relieves anxiety towards mobility. This any concerns related to also helps establish a helping relationship between nurse ambulation and patient. (Taylor, Lillis, LeMone, and Lynn, 2011, p. 1051) Place ice pack on site of Swelling and bruising is common at the surgical site. incision per MD order. Placing ice packs over the surgical site will decrease swelling. (Ignatavicus & Workman, 2006, p. 390) Teach patient how to use The incentive spirometer is used to induce deep breathing incentive spirometer 10 times because the lungs completely expand. This will prevent over an hour while awake. pulmonary problems such pneumonia. To use the incentive spirometer, the patient must seal lips around the mouthpiece and inhale. She must hold her breath 3 to 5 seconds. Repeat cycle at least three times. (Ignatavicus & Workman, 2006, p. 309) Assess dressing for bleeding Dressing should remain dry and intact. Drainage amount or other drainage Q4H. Ensure and color should be monitored. Large amount of dressing does not constrict sanguineous drainage indicates a possible internal circulation or sensation. bleeding. (Ignatavicus & Workman, 2006, p. 346)

Effectiveness of Interventions Patient got up out of bed at least twice every 4 hour. Patient engages in physical activity with OT and PT. She ambulates to the bathroom with oversight. The patient kept her legs in neutral position unless when her left leg is on the CPM machine. Patient c/o pain when leg is not in correctly placed on the CPM machine. Patient verbalized her worries about ambulation when she is out of the hospital. The ice machine on the floor was broken. Ice pack was placed on surgical site at 1420. Patient already knew how to use the incentive spirometer already. However, the importance of using it was reinforced. Patient used the spirometer throughout the shift when laying in bed. Dressing and surrounding area was dry and intact. There was blood on patients shorts but no sign of bleeding at the actual surgical site. Drainage was not visible. Patient followed surgeons protocol. Left knee was on CPM

Place continuous passive motion (CPM) machine per

The CPM machine keeps the prosthetic knee in motion and prevents the formation of scar tissue. Scar tissue can

Nursing Interventions The nurse will: MD order.

Rationale for Nursing Interventions obstruct mobility and aggravate postoperative pain. The degree of knee flexion gradually increases. (Ignatavicus & Workman, 2006, p. 390)

E D

Instruct family member, significant other or caregiver to help patient for 4-6 weeks after discharge.

Patient is not fully recovered once they are discharged. It is imperative that someone is home to with the patient at all times because it is the time where they need the most help. Patient is susceptible to falling and hurting herself if there is no one assisting her. (Ignatavicus & Workman, 2006, p. 393)

Effectiveness of Interventions machine for 2 hours and was off for 2 hours before repeating the cycle. At 1420 on 09/15/11, OT set machine at 80 of flexion and full extension (0). Patient stated that her husband(retired) will be at home at all times to help her with activities.

Evaluation of Expected Outcome(s):

As of Date:09/15/11 Time: 1645

Discuss if the goal/expected outcome(s) was met, not met or partially met. Describe actual patient changes assessed that indicate progress towards expected outcomes. Discuss your recommendations for further nursing care planning.

1. a. The expected outcome was met. Patient was able to get out of bed without assistance. She utilizes her right leg to assist her left leg when she swivels her body to the edge of the bed. She used her upper body strengths and right leg to help her get up on the walker. b. The expected outcome was met. Patient was able to independently ambulate down the hallway and back with a front-wheeled walker. Patient exhibit a steady gait. The OT stated that patient has the opportunity to either go home the following day (09/16/11) or stay at the hospital longer. Her physical status lies between the two options. Patient stated that she can only ambulate with pain medication. Patient shows progress in ambulation when she has pain medication an hour prior to activity.

Reinforce the need of activity to the patient. Encourage patient to walk 200ft. with the assistance of a front wheeled walker after dinner time. 2. The goal was partially met. Patient was able to flex her operative knee to 65. She displays progress in flexing her operative knee. Patient will continue to engage in physical exercises. Instruct her to use the CPM machine to increase her ability to flex her operative knee. Patient will be able to have 90 of flexion on operative knee upon discharge.

References: (APA)
Ignativicus, D.D. & Workman, M.L (2006) Medical-surgical nursing: Critical thinking for collaborative care (4th ed.) Philadelphia:W.B Saunders Company Taylor, C, Lillis, C, LeMone, P, & Lynn, P(2011). Fundamentals of nursing:the art and science of nursing care. (7 ed.). Philadelphia: Lippincott Wiliams & Wilkins.