knee replace care plan

8/3/2019 Knee Replace Care Plan

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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

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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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knee replace care plan

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