Patient: Mr. R.B Age: 53y/o Ward/Bed No.

: Surgical Ward bed 4 Nursing Diagnosis: Impaired Physical mobility r/t pain

Supporting Cues

Background Knowledge Limitation in independent, purposeful physical movement of the body or of one or more extremities S/P total knee replacement

Nursing Outcome Criteria (NOC) After 8 hours of nursing intervention the client will improved physical mobility as evidenced by: 1. Maintain position of function

Nursing Intervention Criteria (NIC)

Rationale

Evaluation

Subjective Cues: S/P total knee replacement An burning pain of 7/10 (10 as the highest) on the left knee, occurs on movement and slowly relieved by analgesics. Objective Cues: Conscious and conversant Reluctance to attempt movement Limited ROM on left knee Uses walker Stands w/ light weight on the affected knee

Assess the following: -V/S and record A vital sign usually increases when client is in too much pain. Restricted movement affects the ability to perform most ADLs. Safety with ambulation is an important concern. To ensure that limb-threatening complications will not develop. Prevents skin irritation and breakdown Analgesia is a priority to

After 8 hours of nursing intervention the client has improved physical mobility as evidenced by: Can change position from sitting to standing and vice versa without the use of assistive device.

Surgical Wound

(+) pain

-Ability to perform ADLs effectively and safely on a daily basis.

Limited ROM Other s/sx -Neurovascular integrity.

Impaired physical mobility 2. Increased function of affected knee

Adjust bandage if it is too tight. Administer P-dol every 6 hours as

Able to move affected leg slowly.

indicated.

3. Absence of muscle fatigue

Increase time out of bed, as tolerated

Encourage and facilitate early ambulation and other ADLs when possible. Collaborate with the physical therapist about the rehabilitative program and instruct client with the following: Infrared therapy Not to look at the lamp at close range. Avoid applying any kind of essential oil, lotion or cream to your skin before using the heat lamp.

decrease pain, reduce muscle tension and spasm, and facilitate participation in therapy. Promotes ambulation as well as circulation. The longer the patient remains immobile the greater the level of debilitation that will occur.

No signs and symptoms of muscle fatigue

Ultraviolet light is also known to be a factor in formation of cataracts. Oils can heat up and cause a burn.

Physical therapy tolerated