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Nursing 217
Surgical Rotation
January 8, 2015
Planning/Implementation/Evaluation
Nursing Diagnosis: Risk for peripheral neurovascular dysfunction r/t orthopedic (TKR) surgery and trauma to tissues
Long-Term Goal: Experiences no peripheral vascular dysfunction
Outcome Criteria
1.
Interventions
1. Perform neurovascular
assessment q 4 hours
Assessment
Rationale
1. Perform a neurovascular assessment every 4 hours by
assessing CSMT to assess nerve function and circulatory
status. Assess circulation by finding peripheral pulses
(dosalis pedis & posterior tibial) distal to the trauma/surgical
site to assure blood and oxygen are circulating through the
entire extremity. If the pulses are present, there arent signs
of disruption in circulation to the extremity. Assess sensation
by lightly touching the skin proximal & distal to the surgical
site. Ask the pt. if she has any unusual sensations like
hypersensitivity, tingling, prickling, decreased feeling, or
numbness. If the pt. has any of these unusual sensations,
this may be sign of peripheral neurovascular dysfunction
(compartment syndrome, caused by hemorrhage &/or
edema). Assess movement by asking the pt. to perform
appropriate ROM exercises on the unaffected extremity &
then the affected extremity. If pt. is unable to move
extremities, this can indicate impending muscle, nerve, &
vascular cellular death, &/or compartment syndrome. Lastly,
assess color & temperature below the surgical site. If
extremity is cold &/or bluish, pt. may have arterial
insufficiency or arterial damage. A reddened, very warm-hot
extremity may indicate infection. Any disruption to
circulation, sensation, movement, or temperature to an
extremity indicates peripheral neurovascular dysfunction.
This pt. needs this assessment because of her TKR and
having trauma to her R knee. This surgery could have
potentially disrupted neurovascular function.
Ackley, Ladwig Nursing Diagnosis Handbook
Evaluation
1. Pt. fully met
this outcome.
Plan is ongoing.
a) edema in 1 or both
extremities
b) pt. c/o
cramping/soreness
pain or tenderness in
extremity
c) red, warm
extremity
Plan is ongoing.
Assessment
Independent
Dependent
5. Elevate operative
extremity with 2-3 pillows
under calf/ankle to keep
above heart level per MD
order
Dependent
5. Partially met
this outcome.
Times during
shift, pt. c/o 7/10
pain in extremity.
Plan is ongoing.
Lewis p. 1598
6. Pt. will have H&H
WNL (Hgb 12-16,
Hct 37-47) by 1/9/15
6. Unsure if pt.
met this outcome.
No order for CBC
Monitor/Dependent
Dependent
Independent
Lewis 1598
9. Pt. will have no
s&s of DVT AEB:
a) edema in 1 or both
extremities
b) pt. c/o
cramping/soreness
pain or tenderness in
extremity
c) red, warm
extremity
Dependent
Dependent
s&s of DVT or PE
aeb:
a) pain, tenderness,
edema, warmth,,
erythema in
extremities
b) dyspnea,
tachypnea, pleuritic
chest pain,
hemoptysis, cough,
syncope,
tachycardia
30 mg SC q12h per MD
order
Dependent
this outcome.
Plan is ongoing.
13. Administer
oxycodone-APAP (5325mg) PO PRN q4h 30
minutes prior to
ambulating
Independent
Dependent
Teaching
Collaborate