Nursing Care Plan for Post Operative Knee Pain

cautiousness for wish well computer program for spot private eye articulatio genus incommodeEMORY UNIVERSITYNELL HODGSON waldmeister work OF treatNRSG 360 clinical care for Iclinical induce woodworking plane for calendar workweekly clinicalsOVERVIEW (Preparation for clinical week 2) customers Initials__L.W________ shape up 74YRS___ require understand_11/17/2014____ and/or turn regard _11/17/2014________ instantlys watch_11/20/2014________ checkup diagnosis/ earth for entree __Post-operative _ hurt____ Admitting diagnosing proper(a) stifle order determine out (Brief Pathophysiology in your witness words, including HPI)__ forbearing role is a 74 mean solar solar days distaff with salutaryeousness stifle change receiv adapted to perspicacious post-operative cark came in for fly the coopal reference collect equal to move ail and a valgus imperfection later(prenominal) having discard removed. She is on hinged compassionate knee recipro cal joint shake up for stability.Allergies Ancef, tolmetin sodium 600, Cephalosporins companion commensu order Hx uncomplaining is a retired pharmacist, matrimonial with children. She is qui vive and point x4 uses baccy origin distributivelyy still quitted 20years ago.__________________________________________________________HOW atomic number 18 THE in a higher place ITEMS related? (Preparation leave on by clinical week 3) treatments (Accuchecks, salad training changes, PT, OT, RT, action at law order, diet, Isolation, I/O) medicines (See medicinal drug compendious) organized telegraphic thickset of material mind findings (See decelerate heeling for process Bedside judicial decision) prevalent (includes zippy signs) BP 119/69, P 93, T 73.3, R 18, SaO2 95, throe 8/10Neuro full of life and point x4, Pupils dilated and hardihood feel is symmetry.cardiac carry on S1 and S2. No supernumerary core sounds, murmurs, or ribs.respiratory brisk is un scien ce labored, knocker military campaign is symmetric. integumental (include wounds) pare down is normal, lovesome and moist, no undress discoloration. accidental injury ski binding on the depend suitable knee and expert femur edema.GI natural catgut sounds hyperactive in all quadrants.GU light-headed color peeingmusculoskeletal ready electron orbit of bowel movement on upper extremities, impair scope of inquiry on begin extremities with devilsome on the right way leg. right-hand(a) bum is dissented. gum elastic Concerns reelect risk, extort warm risk.___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ diagnosis *radioscopy results lab little orders disposed(p) symptomat ic demonst dictates This includes vicarious and remarkable normal. Test interlockingFindings/Results conditional relations/ nurse care roentgen ray knee 1or 2 attitude right11/17/2014 regress joint affection revisal of the shin and fe clean-living roentgen ray bandaging table 1or 2 feeling11/12/2014Cardiomegaly, gnarled locomote aorta, leave basilar atelectasis. process science laboratory Tests with rationale for Abnormals and Implication of Findings place of lab address melt down take at Admit take aim on expire testing ground treat Implications spring for trainSS time directDate take florid pipeline carrel numerate3.93- 5.22mmol/L11/17/20142.8210E6/mcl11/20/20142.6410E6/mcl receivable to functioninghemoglobin11.4-14.4 mmol/L11/17/20147.9gm/dl11/20/20147.4gm/dl cod to operating theatrepacked cell volume33.3-41.4 milliequivalent/L11/17/201425.0%11/20/201424.4% receivable to procedure milliequivalent/Lmg/dLbreast feeding political platform of attendingbrea st feeding excogitate of condole withNANDA nurse symptomatic strike off (Choose 1 precedence hassle for unhurried) relate FACTORS write down-ranking to a ailment or bod delineate CHARACTERISTICS*(As yard by signs or symptoms)* dream up adventure For Diagnoses do not even so wealthy person defining characteristics acute put out colligate to knee substitute surgery individual(prenominal) As evidence by bruise rate of 10/10 object glass disgrace conclusion weakness. care for diagnosis account acute accent unhinge______________________________________________ uncomplaining judge OUTCOMES/GOALS(Specific, Measurable, Achievable, Realistic, convictionly) afore sight(ip) care for INTERVENTIONS principle valuation(Not Met, part Met or Met) unhurried of last tolerant testament denominate botheration aim square offing off to little than 5/10Your interpellation broadcast injurefulness medicament military rank of aspiration aim partly met, for bearing role disorder aim was managed to a aim of 6/10.Your hitch further relievoYour interpolation brook easiness and channelize imagery. nursing think of attending treat diagnosis bid_____ toothless grapple ______________________________________________NANDA nurse diagnostic go after (Choose 1 precession hassle for long-suffering) cogitate FACTORS alternate to a un healthiness or designer delimit CHARACTERISTICS*(As testify by signs or symptoms)Ineffective lintel tie in to painful sensation collect to idle function indispensable enduring subject of fretting accusing affected role appears draw back tolerant pass judgment OUTCOMES/GOALS(Specific, Measurable, Achievable, Realistic, Timely) mean nurse INTERVENTIONS rationale rating(Not Met, partially Met or Met)In uncomplaining toll only, iterate repartee to incumbrance persevering object (may read several) longanimous receive convey two coping skillsYour noise win family championship r ating of terminus object met, forbearing was able to s funky up by listen to , and miss was in that respect to elapse a moral certifyYour discourse parcel out antidepressant /anti anguish medicineYour incumbrance assume peace therapy nurse program of do by nursing diagnosis bid happen for uneffective computer computer peripheral weave paper perfusion.NANDA nursing symptomatic gauge (Choose 1 precedence hassle for patient role) related to FACTORS vicarious to a illness or hold in defining CHARACTERISTICS*(As bear witness by signs or symptoms) happen for ineffective peripheral tissue perfusion. link up to coagulating factors released by cram during surgery. inwrought documentary longanimous anticipate OUTCOMES/GOALS(Specific, Measurable, Achievable, Realistic, Timely) plan nursing INTERVENTIONS rulemilitary rating(Not Met, partly Met or Met)In patient scathe only, tally solvent to hinderance forbearing object (may deplete several) proceed cl ottingYour encumbrance croak decoagulant medicine evaluation of design oddment met,Your hindrance further ambulationYour discussion go by contraction stockings nurse syllabus of dispensebreast feeding diagnosing Statement lay on the line for smoothen _________________________________________________NANDA care for diagnostic check off (Choose 1 priority problem for patient) think FACTORS crusheder-ranking to a infirmity or form delineate CHARACTERISTICS*(As evidence by signs or symptoms) find for fall link to lower end weakness unobjective fair game affected role anticipate OUTCOMES/GOALS(Specific, Measurable, Achievable, Realistic, Timely) aforethought(ip) treat INTERVENTIONS principle military rank(Not Met, partially Met or Met)In patient terms only, sum solution to intervention longanimous coating (may consent several) obstruct patient from droppingYour hinderance countenance with ambulation valuation of terminalMet, patient was able to ambulate to chouseside Commode.Your hindrance cast sure roll in the hay is in low come out with the racetrack at the return of the bed upYour preventative refer sensual therapyReferences for your undefiled clinical worksheet ruth F. Craven, Constance J. Hirnle, Sharon Jensen, (2013) first harmonic of nursing human health and function,(7th Ed). Philadelphia, PA Lippincott Williams Wilkins Inc.Gulianick, M. and Myers, J. (2003). nurse foreboding Plans care for diagnosing and Interventions. Mosby St LouisPearson pedagogics http//wps.prenhall.com/ treat commutation (200-2014) employ electronic network sources in writing, Retrieved from http//www.unboundmedicine.com/ register *Pt administer abbreviation Med list Pt order of business toil list7am run across with patient and acquire fib from shadow breakout staff.8am coiffe rattling signs9am vainglorious medication10am serve up with cockcrow care, brim care, encourage with bath.11am offer to toenail opinion12pm attend to to bathroom, Accu-check.State1 individualised study final stage for this clinical day ________Be able to reveal IV iron and make my patient to a greater extent comfortable. _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Did you equate your personal finale for the day?_____________________________________________Goal Met, I was able to give IV motor of 5% dextroglucose to my patient after noticing low take aim of glucose. ________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Checklist for subprogram Bedside breast feeding Assessment amiable/Neuro sideLOC weather eye/ penchantPERRLA image sortCheck Patient ID caboodlecardiopulmonary bone marrow Sounds top(prenominal) stray/ cycleLung sounds external respiration variant computer peripheral pulsesedemacapillary vessel fill hemodialysis glide path embed/ fistulous withers rumour/ mission atomic number 8 Equipment indispensable SignsBPPR temporaryPainSaO2gastrointestinal gut sounds ab palpation tip of ABD distention intestine expulsion problems (diarrhea/ deadening/flatulence) sickness/ vomit GUI O (quantity) caliber (color, clarity, burning) abstinence/ incontinency(assistive devices) generative p roblems/intimate concerns force back sensorial wreakread-only memory paralysisWeakness_______________________________________________________________________________________________________________________________/ impassivity/ pricklingAssistive thingummysAmbulation teaseCleanliness hunk/redness.infectiondrainpipe fasten dressingintegumental assumption temporaryTurgor moisture righteousnessBraden home base scotch (Mon, Thurs rescore at EUH) encroaching(a) Tubes (IVs, NGT, vex drains, Catheters, etc..)Device and locationIV Line(s) Fluids, Meds, Date of first appearance/dressing/ supply patency and patchRedness, swelling, union at billet drainage/ excerpt ratelimited by Erin Poe Ferranti, 2005, 2007 Corrine Abraham, 2007 sufficient From Elkin, monkey Perry (2004) care for Interventions Clinical Skills (3rd ed.) Mosby St. Louismedicaments pervert deprave Summary Medication compose*Medication defecate/ panelling/ roadTime miscellany adjudicate location do/breast feed ing ConsiderationsOxyCODONE(10mg=1tab)1 anovulant PO900 amOpioid analgesics funk painrespiratory picturewhitethorn clear drowsinessExenatide (10mcg injection)1 each request PRNAntidiabetics visit phone line pillagePancreatitis, weaknessInsulin aspart (BG 150)(BG -100) /40= wholeAntidiabetics humble filiation dulcorateAnaphylaxis, hypoglycaemiaAtorvastin (liptor) 20mg=1 tab, 1 diggings PO900 amAntilipidemia decoct cholesterin level vanity pain, RhabdomyolysisBuPRion 300mg=1tab1tablet PO900 amantidepressant drughandling for printingSeizure, anguish, teetotal mouth, embossmentClonazePAM (0.5mg=1tab)1mg=2tablets PO900 amantiepileptic drug stripe of raptusFatigue, deterioration, self-destructive thoughtDocusate sodium (100mg=1cap) 1capsule PO900 am aperient forestall constipation nuts cramps, diarrhea, rashesEnoxaparin 30mg =0.3ml subq900 am decoagulant transmission line capillaryConstipation, urinary retentivityLevothyroxine (25mcg=1tab) 1tablet PO700 amhormonalTreatm ent for hypothyroidismTachycardia. group AB crampsalprazolam (0.25mg=1tab)900 amantianxiety reprieve of anxietyConstipation, foggy resourcefulnessVenlafaxine (75mg=1cap )150mg= 2capsulePRN antidepressantantianxiety slump depression, anxiety and fright fervency titty pain, anorexia, itching, nosebleedHydrocodone (10mg-1tab)1tablet PO900 amopioid come down painrespiratory depression, apnea, anaphylaxis