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NURSING CARE PLAN FOR THE PERIOPERATIVE PATIENT 2003

Elmhurst College
Deicke Center for Nursing Education
Name

Amanda Malmstrom

Faculty

Barb Zak

GENERAL DIRECTIONS
Select a preoperative patient that you took care of for 2 days. Apply the nursing process
and theoretical concepts to create an individualized nursing care plan.
An optional draft may be submitted prior to the due date. A paper submitted on the due date
cannot be revised and resubmitted.
In addition to utilizing your texts, you will need to incorporate a professional journal article
published within the last 5 years that relates to your patient's care. The article must be from
a professional nursing journal. Lay oriented journals or magazines are not acceptable.
This article must be cited within the paper.
This paper must be word-processed. The text boxes are not meant to imply how much
information you need to include in each section. They are designed to expand as you type
in your data.
You cannot work on the nursing care plan at Blackboard Web Site. Any data that you put on
the form at the site will be lost. You must first save the document to your hard drive or USB
storage device. If you must save the document to a floppy disk, work on it on the hard drive
and transfer the finished product to an empty disk when you are done for the day.
Otherwise, you may run out of disk space because of the large amount of formatting in this
document. If you will be using your computer at home, see if it is compatible with your word
processing program. If you have any problems with compatibility, ask for assistance in
CSTC 107. If you work on the document in the CSTC, saving directly to a USB storage
device is recommended to avoid losing all of your data if the computer freezes or needs to
be rebooted. 16 MB devices are available for approximately $20-25. The computers in Room
110 have USB ports that are located on the front of each computer.
GENERAL POINTS
Demonstrate a professional level of writing. (2 pts.)
Reference citations are incorporated within the nursing system design in APA format
(Author, year) in designated sections. (1 pts.)
Turn in the word-processed medication profiles for ALL routine and prn medications
prescribed for this patient. (2 pts.)
There will be a 10% deduction per day if the paper is not turned in on the date due.

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THEORETICAL CONCEPTS
List the health condition for which surgery was performed and the name of the surgery. (1/4
pt.)
Health condition for which surgery was
Prosthesis loosening of Right knee
performed
Surgical procedure performed
Total Right knee replacement
List the significant preexisting health conditions. (1/4 pt.)
BILATERAL kNEE REPLACEMENTS 3 TOTAL
MI
HISTORY OF ULCERS
Home Medications (dose and schedule) (1/4 pt.)
Lopressor 50 mg BID
Smitriptlin 25 mg 2 QHS
Saw Palmetto 1000mg QD
Pravachol 40 mg QHS
ASA QD
Tylenol PM PRN

Nitro-Dur Patch 0.2 mg 12HR QD

All Hospital Medications (dose and schedule, including prn medications) (1/4 pt.)
Ancef 1 gm IVPB Q8 HR
Colace 100 mg PO BID
Lovenox 30 mg SC Q12 HR
Lopressor 25 mg PO BID
Lactated Ringers 1000ml IV Q10HR
Nitro-Dur 1 each TOP QD
Tylenol 650 mg PO
Describe the pathophysiology of the current health condition including signs, symptoms,
usual diagnostic tests and treatments. Include citations in APA format. (3 pts.)
The patient was admitted into the hospital for pain in the right knee. He was admitted on 11/03. He
had a total knee replacement on his right knee in 97 and now six years later there is loosening of the
prosthesis and damage to the polyethylene. The patient claims that the knee replacements that were
used in 97 are being recalled and his might be that type. The patients surgery was a total knee
replacement. A KNEE PROTHESIS KNEE REPLACED THE OLD PROTHESIS KNEE, WHICH IS
AN IMPLANT OF METAL, HIGH-DENSITY POLYTHELENE, CERAMIC, AND OTHER SYTHETIC
MATERIALS. For this surgery, the placement of the prosthesis knee was cemented in place. The
patient was feeling pain in his right knee due to the surgery. it was rated a 9 on Tuesday and AN 8 on
Wednesday out of 10. There was some tingling and burning on the right knee on Tuesday, which
subsided on Wednesday.
Briefly explain the pathophysiology of preexisting health conditions. Include citations in
APA format. (3 pts.)

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The patients preexisting health conditions included the following, bilateral knee replacements,
myocardial infarction, and history of ulcers. The bilateral knee replacements are surgical insertion of
a hinged prosthesis. Diseased surfaces are removed and a two piece metallic hinge is inserted into
the medullary cavities of the femur and tibia. This was the patients third total knee replacement, the
second in his right knee. a myocardial infarction is necrosis of cardiac muscle caused by an
obstruction in a coronary artery THROUGH atherosclerosis, a thrombus, or SPASM, WHICH then
triggers a heart attack. the patients history of ulcers is described as a circumscribed, craterlike lesion
of the skin or mucous membrane resulting from necrosis that accompanied some inflammatory
infectious or malignant process.
Explain how the preexisting health conditions may impact upon the patients preoperative,
intraoperative or postoperative course and each other. Include citations in APA format. (3
pts.)
The patients preexisting health conditions could have impacted the patients recovery in minimal to
extensive complications. The best preexisting health condition this patient had was past total knee
replacements. The patient then knew what he had to do to minimize his stay and decrease infection
and more complications. This patient was though a little on the difficult side in means of not fully
cooperating. Example would be that he was asked to do his incentive spirometer and he would put of
a fight to not have to do it, but in the end he knew it was in the best interest of his health and would
decrease his stay. With some assertiveness and aggressiveness the patient did do what he was told
and cooperated. Due to a past myocardial infarction, medication WAS given to him to aide in
increased cardiac output and decrease BP, WHICH would help maintain prevention of an anginal
attack. These medications were the Nitro-dur patch and lopressor. Also, the history of ulcers could
increase the patients risk of having one due to the stress and inflammation from the trauma of having
this surgery.
Explain the surgical procedure performed to treat the patient's health condition. Include
citations in APA format. (1 pt.)
The surgical procedure performed was a revision of the right knee prosthesis. The patient was under
general anesthesia, while the right knee and leg were prepped and draped properly. A tourniquet was
placed on the upper right thigh to help keep blood loss minimal. The tourniquet was inflated to
350mm Hg. The incision was a midline through the medial parapatellar, which then opened exposed
the knee. The tibial component was addressed and the polyethylene was removed. The acetabular
and femoral components were also removed due to them being loose. Then a trial and error
approach was needed to find the parts that would fit the knee well to maintain patency. In order for
the parts to fit right, addressing certain components to fit right were tried, then the trial components
were removed and the final components were inserted and cemented into place. The knee was able
to perform ROM and had good alignment and stability. The patellar was intact and left alone,
irrigation was performed and then closure to the incision was done over a hemovac-solcotrans drain.
Staples were used to keep the skin intact and a pressure bandage was applied with also cold pad
therapy.

DATA COLLECTION, ANALYSIS & NURSING DIAGNOSIS

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Include data for both days of care. When data does not change from day 1 to day 2, there is
no need to rewrite the data. If the assessment is abnormal, (Abn) place an X in the first
column.
ASSESSMENT OF SOCIOCULTURAL, PSYCHOLOGICAL, DEVELOPMENTAL, AND
SPIRITUAL VARIABLES
Focus on the clients discharge as well as the inpatient stay
DEVELOPMENTAL ASSESSMENT (2 pts.)
Assessment Category
Data Specific to this Patient
Age
59
Gender
Male
Developmental Stage
Patient's stage according to Erikson is
Erikson's Stage
Generativity versus Stagnation
Discuss the patient's ability to
In this stage it includes adults from ages 25-65 years old.
meet the tasks of this stage.
There are positive tasks such as creativity, productivity, and
Describe how the health
concern for others. The negative tasks would be selfcondition has or has not altered indulgence, self-concern, and lack of interests and
the patient's ability to meet
commitments. The patient has no problem meeting these
these tasks?
tasks since there was not any health alterations that could
affect him in any different way that he has not experienced
before.
Cognitive Developmental
This patient is able to process reactions, problem solve, and
Stage according to Piaget
has the ability to learn. His memory and perception are also
Educational data
very well. His cognitive and intellectual level does not seem
Literacy
affected by his age or from surgery. According to Piagets
Primary language
phases of cognitive development, he has successfully
carried out all stages. Formal operations phase which the
use of rational thinking and reasoning is deductive and
futuristic. This patients rational thinking and reasoning is
presented and expressed in a positive way. He understands
that the future does not hold a complete recovery with out
sign or symptoms related to his knee, but is positive in
looking ahead. He wants to get better not only for himself,
but to enjoy his life and partake in ADLs.

Abn

How has the patient's health condition/surgery affected his ability to meet developmental
tasks?
This patients ability to meet developmental tasks in not affected from his surgery. The only impact
this patient could be feeling is that he has been off of work for 20 years due to a fall at work and has
not returned since. He has had many operations performed in relation to his knee, so I believe that
the only real affect this could have on him is that it is an ongoing problem and has impacted his
career.

SOCIOCULTURAL & SPIRITUAL ASSESSMENT (2 pts.)

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Abn

Assessment Category
Family dynamics:
Family Members
Clients role in family
Family communication
pattern
Clients support system

Occupational data
Employment
Health benefits
Ability to meet economic
needs after discharge

Living environment prior to

hospitalization
Housing
Neighborhood
Support/Resources
Culture/Ethnicity
Affiliation
Practices/beliefs
Impact on illness
Spiritual practices
Religious affiliation
Practices
Impact on illness

Data Specific to this Patient

The patient has a wife that was there both days and helped
him and myself in assessment. She bathed him on Tuesday
and helped feed him. She also helped encourage and tell
him to listen to me. The communication between them was
very well, and they seemed to have a very good relationship.
His wife is his big supporter and encourager, while also two
men came to visit and also were very polite and encouraging
to the patient to get better and do what he was supposed to.
My patient had respect for all three of these visitors and
listened to what they had to say about getting better and
doing the little things that would help increase his return to
home and recovery.
My patient was retired for 20 years due to a fall at work in
1983. He is on workmans comp and has Medicare. He was
an electrician prior to his fall. In being retired he does not
have any real economic needs to get back to since he has
not been working for so long. But in reality, we all have our
own economic needs and feel as if certain things we do help
out and are needed. I am sure him and his wife have needs
economically and the sooner he is discharged and recovery
fine, those needs will be met sooner.
My patient was living in a rural neighborhood in a
comfortable house with his wife and his bird.

Not available

My patient was catholic and was affiliated with a church in

his hometown. He had communion when I was there and
was very excited about it and shared it with everyone who
walked into his room. He thought it was a neat thing. I
know that he has strong feelings about praying due to
having so many complications with his knees that he prays
that one day this mess will get better and not have to worry
about them getting bad and going through more pain

How are the sociocultural and/or spiritual variables affected by the client's health
condition/surgery?
The clients sociocultural assessment has positive affects on his health with the increasing help and
assistance from his wife and friends. His moods were much better and he was more willing to listen
when visitors were there. He showed more emotion such as excitement with them in the room, but at
the same time he really liked the attention from his wife and made sure she was babying him. He
made comments to me that he wishes he could still be working instead of going through all of the

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knee surgeries and complications and wish he could go back, but knows it can not happen. I believe
that if he were still working that would give him a little more motivation to get better and have
something extra to look forward too.

PSYCHOSOCIAL ASSESSMENT (2 pts.)

Assessment Category
Data Specific to this Patient

Abn

Behavior
Appearance

Emotional status &

Affect
Body image
Decision making ability

Individual coping

Family coping

He was alert, orientated, speech was clear and

understandable. He was a little crabby and uncooperative to
with some things, but eager to get well and liked to talk.
Healthy appearance, a little overweight though. Skin color
was normal. Once bathed his hair was combed and he felt
better. No distinct body odor. No irregular body
movements.
In pain, but otherwise everything else was fine. High spirited
with wife there and had good coping skills.
Patient was a little overweight, but overall no signs of
abnormalities.
Was able to make decisions on own, he knew what he
wanted to do and when PT came in he wanted to walk to the
bathroom and knew he was capable to do so. If he needed
something he would always ask.
His coping was fine, which I believe had a lot do with his
previous knee surgeries. He was even educating me on his
surgery and was not hesitant on showing me his other knee
and talking about it.
His wife was very supportive and her coping ability pushed
him also to do better and cooperate.

How are the psychosocial variables affected by the client's health condition/surgery?
The clients psychosocial variables are not too much affected by the surgery. This was his third total
knee replacement surgery, which helped prepare him for the preoperative, intraoperative, and
postoperative care. He also has nothing to lose out on since he not working any more and his wife
was there with him and his friends were in and out also. He has a lot of support and being in
otherwise fairly good health helps him cope easier.

HEALTH ASSESSMENT
MENTAL STATUS (2 pts.)
Assessment Category
Level of consciousness

Abn

Orientation
Thought processes
Attention span

Ability to comprehend &

communicate
Appropriateness

Judgment

Attention Span
Vision & hearing including
assistive devices
VITAL SIGNS (1 pt.)
Assessment Category
Vital signs during days of care

Abn

PAIN ASSESSMENT (2 pts.)

Assessment Category
X
Location & Characteristics
(Describe)
Abn

Pain rating Scale (e.g. 0-10)

Presence of PCA
Epidural /Intravenous

Data Specific to this Patient

Patient is alert, orientated, responds appropriately and asks
and answers questions.
Patient is orientated to time, place, date, everything. No
complications with this.
Able to cognitively process thoughts, feelings, and concerns.
Could put together sentences and communicate efficiently.
Full attention was on me when I was in there. He was
curious of what I was doing. He was able to concentrate on
other things and me.
Ability to comprehend and communicate well. No problems
gathering thoughts or if he had questions he would ask.
He was appropriate in most cases, with some things though
he was inappropriate in ways to ask me to leave when I was
assessing him. For example, I was emptying his foley bag
and he asked me rudely to leave his room as I was in the
middle of doing emptying it because he wanted to tell his
visitors a story and could not wait to do so.
His judgment was fine; he made good choices on what he
should be doing and not doing. He knew exactly what
needed to be done to help benefit his health. Some
judgments with not cooperating were not adequately right,
but that is just his personality.
Full attention on me or whoever was in there. Had full
attention on his knee and would favor his other leg and be
protective of his bad one.
He had perfect hearing and had glasses. I did not see him
wear his glasses while I was with him.

Data Specific to this Patient

Tues
130/60, 90, 20, 101.1

Wed
132/64, 90, 18, 99.4

Data Specific to this Patient

The patient expressed there was a tingling and burning
sensation right above his knee. There was pressure on it
when he would sit up and it felt very uncomfortable for him.
Tues
Wed
9 or 10/10
8/10
Dose
Basal rate=
Morphine 1.5 mg/ 6 min.
None

Site Assessment

Frequency=
4 hour lockout
1 hour maximum

Pharmaceutical Interventions
last 24 hours
Nonpharmaceutical
Interventions

INTEGUMENT (2 pts.)
Assessment Category

Abn

Skin color, Temperature,

Moisture
Skin integrity

Braden score & Level of Risk

Wound
Location
Description
Wound Dressing
Drainage type & amount
Drain
Location
Type
Drainage type
Drainage amount per shift /24h

RESPIRATORY (2 pts.)
Assessment Category
Respiratory rate (12-20),
rhythm, breath sounds
Pulse oximetry (94-100%)
results: Include type and amount
of oxygen in use when pulse
oximetry was done

Abn

Signs of respiratory distress

8
# of mg used on your shift
# of attempts on your shift

Morphine PCA 1.5 mg/ 6 min

Polar ice pack, pillows, CPM, also having visitors distracted
him from his pain. PT came in BID to do exercises and
ambulate him.

Data Specific to this Patient

Skin color was normal, pinkish tan. Temperature was
elevated and skin was warmer than normal. Moisture was
normal
Texture feels smooth and firm with even surface. According
to the surgical report, there was a midline incision across the
knee. I was unable to assess the incision due to the
dressing and ace wrap applied.
17/23 with some risk due to age.
The location of the incision was on the right knee, midline
parapatellar. There was an ace wrap over it with the polar
ice wrap on top of that. There was no drainage on the
dressing from what I assessed. There was a drain that was
intact.
The location of the drain was on the right knee. It was a
Hemovac-Soloctrans. There were serasanginous fluids
irrigating from the intact drain, which collected about 40 cc.
This was reported on a 24-hour shift.

Data Specific to this Patient

20 bilateral and clear, deep and regular.
Pulse oximeter was 89% on Tuesday with out oxygen. A
nasal cannula was used at 2 L. The pulse oximeter then
went up to 95%. He was not keeping it for the full time
either. He was putting it on and taking it off all the time, but it
helped maintain his percent with in normal limits. On
Wednesday it was not done due to not being able to fine one
for the time I was there.
There were not any signs of respiratory distress that were of
any serious complications. He did do deep breathing and
coughing, which he showed minimal distress in.

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Sputum: Amount, Color,
Consistency
Ability to deep breathe & cough
effectively
Ability to use incentive
spirometer

Volume achieved on incentive

spirometer.
Chest tube N/A

Not available
He was able to deep breathe and cough effectively. He was
able to do this efficiently, but I needed to be persistent with
him to do and when he did do it he said it felt better and
cleared his lungs out.
He was able to use the incentive spirometer effectively as
well. He also was not very cooperative with this, but when
he did do it, his lungs cleared and it was more comfortable
for him. On his first few breaths there was coughing, but
with the last few, it was clear.
Volume achieved=
Volume predicted=
250
250
Waterseal
Drainage type
Type/amt of suction
Air leak Yes

No

SQ emphysema
Yes No
Fluctuation Yes No

Smoking history (packs/day for

# of years)
CARDIOVASCULAR (2 pts.)
Assessment Category
Heart rate & rhythm (60-100)

Abn

Heart sounds
BP
Peripheral pulses in extremities
Radial
Pedal
Capillary refill (<3 sec)

Clamps & Vaseline gauze taped

above bed Yes No
My patient did smoke

Tues Drainage in
cc's/shift=
Wed Drainage in
cc's/shift=
Tues Drainage in
cc's/24 hours=
Wed Drainage in
cc's/24 hours=
Total drainage since
surgery=

Data Specific to this Patient

Rate is 90, rhythm is regular, and s1-s2 are normal, no
diminishing, no extra sounds or murmurs for both days when
doing 1200 VS on Tuesday and 1100 on Wednesday.
Strong and easily auscultated.
Tues. 130/60
Wed 132/64
L
R
Present and 2+ bilaterally
Present, 2+ bilaterally
L
R
Strong, present, 2+
Strong, present, 2+
bilaterally
bilaterally. Wednesday 1+
due to weaker pulse
LUE
LLE
Immediate return of color < 3 Immediate return of color < 3
seconds on Tuesday and
seconds on Tuesday and
Wednesday.
Wednesday.

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Edema including site, 0-4+scale

& pitting
JVD at 30-45 degree HOB
elevation
DVT assessment: Unilateral leg
edema, calf pain, or positive
Homan's sign
DVT prophylaxis in use: TED's,
SCD's, Plexipulse, Heparin or
Lovenox SQ

RUE
RLE
Immediate return of color < 3 Immediate return of color < 3
seconds on Tuesday and
seconds on Tuesday and
Wednesday.
Wednesday.
On Tuesday it was +2 and on Wednesday it was +1 on the
right foot.
There was no degree to the HOB. The patient could not
tolerate the pressure that it radiated to the knee.
No calf pains when asked to wiggle, flex, extend feet and
move toes around. Edema was either a +1 or +2 on the
right foot.
Lovenox SQ 30 mg/0.3 ml syringe q 12 hr. was administered
to prevent DVT after surgical procedures, such as knee
surgery.

GASTROINTESTINAL/NUTRITION (2 pts.)
Assessment Category
Data Specific to this Patient
Oral Cavity
Pink, moist, no lesions, soft and symmetric contour

Abn

Nausea or vomiting

None present

Ability to swallow

His ability to swallow was not altered. He was on a clear,

soft diet and was able to swallow pills with out a problem.
Rounded, symmetric bilaterally. Skin surface was smooth,
and even. Good color and pigmentation.
Bowel sounds were active, and high pitched due to not
having any solid food for a couple of days. The sounds were
gurgling and a whooshing sound.

Abdominal contour
Bowel sounds

NG/GT to gravity/suction
Description of drainage N/A

Type & amt of suction

Type of drainage

Tues Output in cc/shift =

Wed Output in cc/shift=

Tues Output in cc/24h=

Wed Output in cc/24h=

Nutrition
X

Ideal body weight

Height & weight
Usual diet at home
Hospital Diet
Appetite (% consumed)
Tolerance of diet

160 lbs. Is the ideal body wt. And with calculating the
percent of IBW it shows that this patient is obese.
5 ft 9 in. and 268 lb.
He is not on any diet to decrease intake or watch what he
eats. He eats normal meals and snacks through out the day.
Currently, the patient prefers to be on a soft, liquid diet
because he wants to be able to ambulate to the bathroom if
he has to have a BM. He was intaking 100% of his meals
and on Wednesday he was going to try a general diet.

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NG ,GT, JT N/A

Feeding formula & rate

Placement=

TPN
Intralipids
Stress ulcer Prophylaxis

Residual=

Rate

Bowel Elimination
Usual home bowel elimination
pattern
Passage of flatus

Every day or every other day

Date of last BM (<2days)

Color, amount, & consistency
Ostomy: Type and condition of
stoma and peristomal skin
Type, color, & amount of
drainage or flatus

11/03 the day of surgery.

URINARY (2 pts.)
Assessment Category
Usual urinary elimination pattern

Abn

Current urinary elimination

pattern
Catheterization: # of days:
Foley, Suprapubic, or Straight
Signs of retention: Inability to
void, Dribbling
Incontinence(Describe type and
management)
Signs of UTI: Burning,
Frequency, Urgency, Odor,
Cloudiness, Hematuria
FLUID BALANCE (2 pts.)
Assessment Category
I&O

Abn

Weight, if on daily weights

Yes, depends on diet for an increase or decrease.

N/A

Data Specific to this Patient

His elimination patterns are normal.
He has a foley catheter so it is continuous drainage
Has had a Foley catheter for 3 days
Not available due to foley catheter
Not available due to continuous foley catheter irrigating the
bladder
There is not any burning, odor, and frequency and urgency
are not recorded due to foley. There is neither cloudiness
nor hematuria in the urine. It is clear, yellow.
Data Specific to this Patient
Intake Mon in cc/24h=
Output Mon in cc/24h=
Not available
Not available
Intake Tues in cc/24h=
Output Tues in cc/24h=
Intake Tues in cc/shift=
500 cc
Intake Wed in cc/shift=
380 cc
Tues

Output Tues in cc/shift=

1500 cc
Output Wed in cc/shift=
775 cc
Wed

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X

Edema
Location
Grade (1+ 4+)
IV Fluids : Type & rate
Peripheral IV Access
Site
# of days
Central IV Access
Site
Type
# of days
IV Assessment
Site Appearance
(infiltrate/phlebitis)
Patency
Dressing

NEUROMUSCULAR (2 pts.)
Assessment Category
Usual pattern of ambulation

Abn

Usual ability to perform ADLs

X

Ability to ambulate & transfer

postop

Evaluate risk for falls using fall

risk assessment tool (Attach
results. See Elkin, Potter &
Perry, 2004, page 82.)

Ability to perform ROM

Musculoskeletal deformities,
paralysis (Describe)
Numbness, tingling, sensory
loss, Impaired motion (Describe)
Physical Therapy: Type,
tolerance

Edema is +2 on right foot.

The IV fluid is a Lactated Ringers Solution bag of 1000 mL,
100 ml/hr
The IV is inserted on his right hand and has been present for
3 days
Not available

There is no redness, tenderness, or swelling present at the

IV site. It is patent and there is tape on it to keep it in place

Data Specific to this Patient

Uses a cane to ambulate with when his knees are bothering
him, but can also walk with no problem with out it. Has
difficulty walking for long periods of time.
Can perform with out a problem, but does experience
stiffness in his knees and sometimes swelling.
He was able to ambulate 2nd day post op with PT. He
walked to the bathroom with a walker and sat up in a chair
for about 15 minutes and then complained of an increase in
throbbing, so we moved back to the bed.
Using the risk for falls assessment tool, this client is at risk.
He has 4 elements checked, two under general data which
are postoperative surgery and smoker. The other two are
under medications and he is taking an antihypersensitive
and a medication that increases gastrointestinal motility, a
laxative. These medications are Lopressor, and Colace.
Also, the fall in 1983 at work is what has caused his knees
so much damage is a risk with an asterisk by it which means
that with that checked alone, he is at risk for falls.
Was able to perform with assistance. When PT came they
helped him do ROM of his lower extremities. He felt pain,
but was able to tolerate it with out complaint.
N/A
On Tuesday there was tingling and a burning sensation
above his right knee. This did subside by Wednesday.
PT came in BID, he had some pain with ROM, but was very
cooperative and was appreciative of them helping him
ambulate to the bathroom.

Difficulty moving d/t pain,

stiffness, weakness, fatigue,
dyspnea (Describe)

Use of assistive devices:

walkers, canes, etc.

Orthopedic postop assessment:

CMS, cast, traction, braces,
CPM, weight bearing status

SLEEP AND REST (1 pt.)

Assessment Category
Usual sleep pattern & routines

Abn

Postop sleep pattern & quality

13
The right knee was in pain, which made it difficult for his
right leg to be moved. There was no fatigue or dyspnea,
some stiffness though since his leg had not been moved for
2 days.
He did use a walker when ambulating at the hospital, and
uses a cane at home for extra help and to take pressure off
of his knee.
He had a CPM machine and his knee was covered in an ace
wrap bandage.

Data Specific to this Patient

Sleeps fine through the night at home and when he has pain
in his knees, he does have difficulty sleeping.
On Monday night he did not sleep very well do to the pain,
but on Tuesday he slept much better and slept a lot during
the morning too.

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EVALUATION OF ABNORMAL ASSESSMENT RESULTS (3 pts.)
List each abnormal clinical manifestation found during your health assessment. Explain
the reasons for the abnormal clinical manifestation based on the patients health
condition(s) and pathophysiology.
Clinical Manifestation Rationale
Pulse Oximeter
Pulse oximeter was abnormal on Tuesday with a reading of 89%.
This has to do with lying supine in bed after surgery. Unable to sit up
allows for development of hypoxia, low oxygen in the blood. Lying
on your back also allows one to accumulate fluid and contract
infection due to poor lung aeration.
Temperature
Temperature was elevated and skin was warmer than normal due to
surgery. This could be in relation to the surgery, stress from the
surgery, environment, or even infection.
Employment
My patient was retired for 20 years due to a fall at work in 1983. He
is on workmans comp and has Medicare. He was an electrician
prior to his fall. Usually, retirement is not until the mid 50s-early 60s.
So this is kind of abnormal since he has been retired for so long.
Edema
Edema is +2 on right foot. With the surgery this is normal due to the
impact on the knee and swelling post-op. this being abnormal is a
sign for the nurse to monitor the feet to make sure the edema does
not increase due to risk for DVT.
Dressing
The location of the incision was on the right knee, midline
parapatellar. There was an ace wrap over it with the polar ice wrap
on top of that. There was no drainage on the dressing from what I
assessed and there was a drain intact from the incision site. This is
normal due to the surgery to help with irrigation, preventing clotting
and swelling of the area.
IV
The IV is inserted on his right hand and has been present for 3 days.
Lactated Ringers solution was used and this is an alkalinizing
solution that may be given to treat metabolic acidosis. It contains
sodium, chloride, potassium, calcium, and lactate. This solution
remains in the vascular compartment, expanding vascular volume.
The use of IVs is to supply the client effectively with electrolytes that
they are losing due to not consuming the electrolytes in food or drink.
CPM
He had a CPM machine that helped with flexion of theknee. This is
abnormal for anyone who has not had traumatic damage or surgery
to the knee. This increased the patients ROM and increased the
ability to ambulate faster.
Walker
He did use a walker when ambulating at the hospital, and uses a
cane at home for extra help and to take pressure off of his knee.
These devices increase ambulation and decrease risk of falls. These
are used as assistant devices to decrease the risks. This is a good
way of practicing safe mobility for the patient.
Pain
The right knee was in pain, which made it difficult for his right leg to
be moved. The patient expressed there was a tingling and burning
sensation right above his knee. There was pressure on it when he
would sit up and it felt very uncomfortable for him. Due to the
surgery these findings are normal, but will also diminish. The

15

Weight

Sleep patterns
Risk for falls

surgery is a painful, and unpleasant. The amount of sawing and

pounding at the bone and tearing of the joint, tissue, and skin is a
painful healing process.
268 lb. This weight is abnormal even preoperatively. According to
what his ideal weight should be, 160 lb, his IBW percentage is over
120%, which qualifies him as obese. This could also initiate the pain
and problems he has with his knees. The more weight there is, the
more pressure and trauma to the area.
On Monday night he did not sleep very well do to the pain, but on
Tuesday he slept much better and slept a lot during the morning too.
Using the risk for falls assessment tool, this client is at risk. For
having this kind of surgery, it is normal to be at risk for falls due to the
balance, immobility postop, and medications. It takes time and
practice, and with a lot of therapy to get the knee (joint) back to what
is was. Using assisstive devices will decrease the risk of this
assessment.

16
ASSESSMENT OF LABORATORY AND DIAGNOSTIC TESTS (1 pt.)
List all laboratory and diagnostic tests completed for this client. Include numerical results.
If the admission result is significantly different than the postop results, include both values.
DIAGNOSTIC TESTS
X-Ray of
MRI of
EKG
Ultrasound of
Endoscopy of
Nuclear Scan of
Other:
H&H

Gram Stain Smear of wound

INR

RBC were low pre-op and within normal level postop.

Hemoglobin and hematocrit were normal preop and post op
they were low. The values of the Hgb were 9.1 and Hct was
27.4. These tests were done on 10/28 preop and 11/05 postop. Glucose level was high at 250 on 10/28.
No organisms were seen and no WBC were present
INR was tested on 10/28 and was 1.0. it was low pre-op and
was not done again after that date.

17
ASSESSMENT OF LABORATORY AND DIAGNOSTIC TESTS (CONTINUED)

X 11/05
X 11/05

X 10/28

X 11/04
89%
Nasal 2L

HEMATOLOGY/CBC
WBC ( 3.8-10.1x103/mm3)
RBC (3.9-5.2-million/mm 3)
Hgb (12.0-15.6g/dl )
Hct (35-46)
Platelets (150-400 x 103/mm3)
MCV (80-100%)
MCH (27-33 pg)
MCHC (32-36 g/dl)
WBC DIFFERENTIAL
Polys, PMN, Neut, Seg (40-75%)
Bands (0-8%)
Lymph (18-47%)
Monos (0-10%)
Eosin (0-5%)
Baso (.5-1%)
Metamyelocytes (0)
Myelocytes ( 0)
Other
COAGULATION
PT (11-14.2 sec)
INR (Coumadin 2-3)
APTT (22-32 sec)

CHEMISTRY
Glucose ( 70-110 mg/dl)
Sodium (135-145 mEq/1)
Potassium (3.5-5.3 mEq/1)
Chloride (97-107 mEq/1)
BUN (10-20 mg/dl)
Creatinine (0.1-1.2 mg/dl)
BUN/Creat ratio (10-20/1)
CO2 Content (24-32 m/Eq/1)
Anion gap (8-16)
Magnesium (1.8-2.4 mg/dl)
Phosphorus (2.7-4.5 mg/dl)
Amylase
Calcium (8.2-10.2) mg/dl)
Phos ( 2.5-4.5 mg/dl)
Bilirubin (.2-1.3 mg/dl)
Total Protein ( 6.2-8.2 g/dl)
Albumin ( 3.5-5 g/dl)
Globulin (2.0-3.5 g/dl)
Uric Acid (2.1-8.5 mg/dl)
Alk Phos (50-130 U/l)
AST(SGOT) (5.35 U/l)
LDH (45-90 U/ml)
CPK (CK) (5-75 mU/ml)

ARTERIAL BLOOD GASES

ABG's on __________%O2

CARDIAC TESTS
Cholesterol (<200 mg/dl)

PH (7.35-7.45
PCO2 (35-45 mm Hg
PO2 (80-100 mm Hg)

Triglycerides (40-150 mg/dl)

CPK mb
Troponin

HCO2 (22-26 mmEq/1

Base (+2)
SAT ( 94-99%)
K+ (3.5-5.3 mEq/1

Myoglobin

Pulse Oximetry
Result
Type/amt of oxygen
Result
Type/amt of oxygen
Result
Type/amt of oxygen

X 10/28

DRUG LEVELS
Digoxin level ( 0.5-2.0 mg/dl)
Theophylline
Dilantin
ANTIBIOTIC LEVELS
Drug
Peak (
)
Trough (
)

CULTURES
Site
Organism
Sensititivity
Site
Organism
Sensititivity

URINALYSIS/URODIPSTICK
Color (Amber-Yellow)
Clarity (Clear)
Spec. Gravity (1.003-1.030)
pH (5-8)
Protein (N)
Glucose (N)
Ketones (N)
Bilirubin (N)
Blood (N)
Nitrite (N)
Urobilinogen (0.1-1.0 ng)
Leukocyte esterase (N)
WBC (0-5)
RBC ( 0-2)
Epith Cells (N)
Bacteria (N)
Casts (N)
Crystals (N)
Mucous (N)
OTHER TESTS
CEA
CA-125

BEDSIDE DIAGNOSTIC
TESTS
Hemoccult ( N)
Gastroccult (N)

Bedside Glucose Monitoring

Date/Time
Insulin
Date/Time
Insulin
Date/Time
Insulin
Date/Time
Insulin
Date/Time
Insulin
Date/Time
Insulin
Date/Time
Insulin
Date/Time
Insulin

18
ANALYSIS OF LABORATORY AND DIAGNOSTIC TEST RESULTS (3 pts)
List each abnormal laboratory or diagnostic test result.
Describe the purpose of each laboratory and diagnostic test.
Explain the reason for your patient's abnormal results based on the patient's health
condition(s), surgical procedure, and pathophysiology.
Abnormal Test
Value
Hgb

Purpose of the Diagnostic Test

Explanation of Patient's Result

Hgb is a component of RBCs. Hgb

binds with oxygen and is released
into the blood. The amount of Hgb in
the blood changes the blood volume.

Hct

Hematocrit is measured to find out

the volume of the cell. Measure the
percentage of blood that is
erythrocytes.
Glucose in the urine indicates high
blood glucose levels. Glucose
should not be present. This is also
test for Diabetes Mellitus.
This is used to assess the
oxygenation in the blood. The normal
value is from 95-100%

This could be a risk for hemorrhage, or

hemodilution due to fluid retention. In this
patient case it is not detrimental, but needs to
be monitored incase of hemorrhaging or
infection.
A low value means that there is not enough
hemoglobin in the blood forming.

Glucose

Pulse oximeter

INR

This test is to find out the ratio of the

patients PT to the normal PT. This is
used to monitor anticoagulant
therapy.

The Glucose level was 250 on 10/28, preop.

This value was high which means that the
urine had high levels of glucose.
This patient is tested with the pulse oximeter
to get the value of oxygen in his blood. Due
to surgery and immobility, this can decrease
the oxygen in the lungs that will decrease the
oxygen in the blood.
This patient had a low INR on 10/28 which
was 1.0. this means that with low INR, his
bloods ability to clot is high. This then can
increase the risk of DVT and PE.

19
RISK ASSESSMENT FOR IMPAIRED WOUND HEALING - (1 pt.)
On the assigned clinical patient assess for factors which could inhibit wound healing.
Abn

Assessment Category
Low hemoglobin/hematocrit
Low WBC count or total lymphocyte count(Must be
calculated even if numbers are normal)
TLC=WBC count x %of Lymphs
Degree of TLC deficiency: mild = 1500 - 1800, moderate
= 900 - 1500, severe = <900
Low albumin level

Data Specific to this Patient

Hgb = 9.1
Hct = 29.7
WBC count=
% of lymphs=
Total Lymphocyte count=
Degree of TLC deficiency=

Albumin (serum)=

Degree of deficiency: mild = 3.0-3.5, moderate = 2.5-3.0,

severe = <2.5
Less than ideal body weight or obese

Degree of deficiency=

Age (>65)
Physiologic stressor in addition to surgery
NPO, eats poorly or eats poorly balanced meals
(Describe)
Diabetes, peripheral vascular disease, COPD or other
chronic disease (list)
Disease of immune system (list)
Takes Immunosuppressant or corticosteroid drugs (list)
Decreased tissue oxygenation
Impaired tissue perfusion (Describe)
Presence of infection (Describe)
Positive wound culture/sensitivity results

Age=

Disruption of suture line (Describe)

Wound caused by accident/trauma or contaminated d/t
bowel perforation (Describe)
Wound requires packing (Describe)
Wound exposed to feces or urine (Describe)
Copious wound drainage (Describe)

% over or under ideal body

weight

Pulse oximetry= 89%

Site

Organism

20
NURSING DIAGNOSES: ACTUAL & RISK FOR (6 PTS.)
To obtain the nursing diagnoses:
Analyze all data. (Include past history, medications, admitting diagnosis, surgical
procedure, developmental, psychosocial and health assessment, laboratory and diagnostic
tests.)
List and cluster abnormal findings (Data may be used to support more than one nursing
diagnosis.)
Look up possible nursing diagnoses in your nursing diagnosis book to determine which
ones fit your data.
Don't forget to include psychosocial nursing diagnoses.
Assign the appropriate NANDA nursing diagnosis to each cluster of data.
Write nursing diagnoses in PES format (Problem, Etiology, Symptom).
Prioritize list of nursing diagnoses.
#
1

Clusters of abnormal data

Patients pain rate was 8-9/10
Some tingling above knee on
Tuesday. With ambulation and
sitting for a while increased
throbbing sensation. Patient had
morphine PCA due to pain.

Nursing Diagnosis in PES Format

Pain related to surgery.

2nd day post op was out of bed with

PT. Did not ambulate on own, nor
get out of bed with out assistance.
Needed a walker for balance and to
help with ambulating.
Laying supine in bed most of the
day, low hemoglobin, hematocrit,
elevated temperature, moderate
edema, pulse oximeter on Tuesday
was low with a 89%.

Impaired physical mobility and postop management

related to surgery

Risk for infection related to immobility, wound care,

and foley catheter due to surgery

Was not cooperating with incentive Knowledge deficit related to incentive spirometer,
spirometer. Had some fluid in lungs DB&C, wound care, CPM, ambulation, and
when coughing and deep breathing. assisstive devices.
Had elevated temperature and
pulse oximeter reading was 89% on
Tuesday. Used a walker with
ambulation. Needed emphasis on
explanation of not using it to keep
his balance. It used as a guide to
help with ambulation and to make it
easier and safer.

21

Based on theoretical concepts, develop a list of "Risk for" nursing diagnoses specific to
your client.
#
1

Risk For Nursing Diagnosis in PE

Format
Risk for wound infection related to surgical
procedure, and exposure to pathogens.

Risk for fluid volume deficit related to

increase blood loss from OR

Risk for decreased tissue perfusion related

to immobility due to surgical procedure.

Risk for fall related to knee surgery

Risk for constipation related to immobility

and decrease food intake.

Rationale for Nursing Diagnosis

Due to patient lying down after surgery for
approximately 24 hr. the patient has an increase
of contracting an infection. The patient is
showing a slight fever and has been doing deep
breathing and coughing (incentive spirometer),
but there is fluid when he coughs.
The patient has low hemoglobin and hematocrit
levels, and a risk for hemorrhaging is increased.
With lying down and having a surgery in the
lower extremity the patient is at risk for having a
DVT and could travel up which would result in a
Pulmonary embolus.
The patient just had knee surgery and with that
is a lot of swelling and inflammation because of
damaged or destroyed tissue. This could
increase the risk of blocking blood flow to the
lower extremity; his foot and cause unilateral
edema. Edema was +2 on Tuesday and +1 on
Wednesday, but Wednesday the pedal pulses
were weaker.
Due to surgery, my patients fall risk is increased
because his leg is immobilized and in pain. He
has to favor his other leg that could put him off
balance and he could reach for something
unsteady or just fall due to lack of balance.
Patient did not want to eat solid food due to not
being able to ambulate to bathroom, so
monitoring for constipation, diarrhea, and
impaction is important. With not ambulating he
is at risk for constipation. His bowels are not as
active when he is lying down. He is at risk for
this and has been a laxative to soften stools.
Colace was given.

22

NURSING CARE PLAN FOR THE 1ST PRIORITY NURSING DIAGNOSIS

Write the 1st priority nursing diagnosis in PES format.
Pain related to knee surgery
Write 1 discharge-related outcome (long term goal) for this nursing diagnosis. (1 pt.)
Client will be able to perform ADLs with minimal pain after recovery. There will be less swelling and
pain once the patient recovers fully from surgery.
Write 2-3 expected outcomes (short term goals) for this nursing diagnosis appropriate to
the days of care. The outcomes must be specific to the patient, measurable and realistic. (2
pts.)
Client will rate his pain lower each day in the hospital and will go home with a pain level that is
comfortable for him to mobilize.
Client will have PCA discontinued and will be on oral medications.
Client will be able to tolerate ROM easier and with out so much discomfort.
Complete a comprehensive list of specific individualized nursing interventions and
rationales for the nursing diagnosis. The nursing interventions should relate to the
problem, as stated. The interventions should include all interventions that would be
appropriate for this patient whether you had the opportunity to implement them or not.
Document your sources in APA format. (5 pts.)
Nursing Intervention
Assess pain q 2-4 hr.

Apply polar ice pack and change ice

continuously as needed.

Elevating the knee with pillows

Monitor PCA and encourage to use PCA
prior to activity and hr before PT.

Rationale
Client will rate pain on the scale out of 10 to
assess the level of pain and make sure it is being
controlled well enough with the medication or if
needs to be increased. What we really want is the
pain to be decreasing, to show inflammation is
subsiding and that infection rate is going down.
Client will report location, intensity, and quality of
pain. The patients report on pain is the most
important and reliable indicator of his pain.
Unrelieved pain can result in immune function,
which can lead to infection.
Cold therapy will help decrease the inflammation,
which goes hand in hand with decreasing the
throbbing pain. Nonpharmacological interventions
should be used to supplement, not replace,
pharmacological interventions.
This helps decrease the inflammation also. May
also provide a more comfortable position for the
knee.
Watch for how many times the patient is
attempting the medication and how much is

23
actually being administered. Monitoring this will
help show if the pain is increasing, leveled out, or
decreasing. The IV site is the preferred route for
rapid control of severe pain.
Write a nursing progress note for this nursing diagnosis. Your note may be in Focus (Data,
Action, Response) , SOAP (Subjective, Objective, Assessment, Plan), or PIE (Problem,
Intervention, Evaluation) format. (2 pts.)
D= Pain was rated an 8, polar ice pack was cold and applied to knee. Patient was comfortable with
pillows underneath and the PCA attempts were minimizing. Emptied foley bag.
A= I filled the polar ice pack with ice and made sure the patient was comfortable and the pain was not
intolerable.
R= patient was doing well and respectful to my assistance in making his stay as comfortable as
possible related to his pain.

24

NURSING CARE PLAN FOR THE 2ND PRIORITY NURSING DIAGNOSIS

Write the 2nd priority nursing diagnosis in PES format.
Impaired mobility related to surgery
Write 1 discharge related outcome (long term goal) for this nursing diagnosis. (1 pt.)
Client will be able to walk smoothly with out complaints of pain or soreness
Write 2-3 expected outcomes (short term goals) for this nursing diagnosis appropriate to
the days of care. The outcomes must be specific to the patient, measurable and realistic. (2
pts.)
Client will be able to move right leg with little assistance and decreased pain
Client will be able to walk to the bathroom and sit up in a chair.
Complete a comprehensive list of specific individualized nursing interventions and
rationales for the nursing diagnosis. The nursing interventions should relate to the
problem, as stated. The interventions should include all interventions that would be
appropriate for this patient whether you had the opportunity to implement them or not.
Document your sources in APA format. (5 pts.)
Nursing Intervention
Explain how to use assisstive device, such
as walker
Encouraged ROM of all extremities due to
immobility BID.

When getting out of bed, instruct client to

sit for a couple of minutes
Encourage getting up in chair qid for 15-30
min.

Rationale
Patient was told not to use the walker
inappropriately; such as leaning over too much
could increase risk of patient to fall.
Express ROM is extremely beneficial with the
surgery he had done due to keeping the joint
loose and strong. Tightening of the joints and
muscle around the knee can make it more painful.
ROM will maintain muscle movement and
strength. It also prevents contracture.
Reason for doing this is because he is lying down
for a lengthy amount of time and when he gets up
he could be feeling faint or dizzy. The medications
can also trigger this response.
This will help with maintaining movement of
muscles and keep strength. Also motivate the
person to get better. Will help to decrease this
patients temperature and increase pulse oximeter.

25

Write a nursing progress note for this nursing diagnosis. Your note may be in Focus (Data,
Action, Response) , SOAP (Subjective, Objective, Assessment, Plan), or PIE (Problem,
Intervention, Evaluation) format. (2 pts.)
D= PT assisted him to the bathroom, and in the chair. Did ROM exercises with him while he was in
bed and in the chair. BP was fine before PT came and after, so was respirations and pulse.
A= Check BP, for edema in right foot, ask about pain rate. Made sure client was feeling good, not
feeling sick or short of breath. Kept doing his incentive spirometer to decrease the fluid in his lungs
from lying down so much. Helped patient back into bed from the chair.
R= patient felt fine on the second day. Was happy that he got up to the bathroom and sat for a while.

26

NURSING CARE PLAN FOR THE 1ST PRIORITY PSYCHOSOCIAL OR DEFICIENT

KNOWLEDGE NURSING DIAGNOSIS
Write the 1st priority psychosocial or deficient knowledge nursing diagnosis in PES format.
Knowledge deficit: Risk of post-op infection.
Write 1 discharge related outcome (long term goal) for this nursing diagnosis. (1 pt.)
Client will not have an infection, pneumonia, or respiratory distress.
Write 2-3 expected outcomes (short term goals) for this nursing diagnosis appropriate to
the days of care. The outcomes must be specific to the patient, measurable and realistic. (2
pts.)
Clients fever will go down and be in the normal ranges.
Client will have an increased pulse oximeter reading within normal ranges.
Client will use the incentive spirometer less or not at all.
Complete a comprehensive list of specific individualized nursing interventions and
rationales for the nursing diagnosis. The nursing interventions should relate to the
problem, as stated. The interventions should include all interventions that would be
appropriate for this patient whether you had the opportunity to implement them or not.
Document your sources in APA format. (5 pts.)
Nursing Intervention
Teach use of Incentive Spirometer.

Assess willingness of family to incorporate

new information, and modifications in
support of client.

Evaluate clients understanding through

demonstrations, and verbalizations.

Rationale
Teaching the use of the spirometer will decrease
the likelihood of infection. Maintaining a check on
this will allow one to notice if his oxygen in the
blood is decreased which could increase his risk
for infection.
Address wife to see if she is willing to help
increase and encourage use of incentive
spirometer. Also, how important it is to get him up
in bed and in the chair. With his wife there
encouraging, might have a bigger success with
utilizing the spirometer.
Watch patient demonstrate the use of the
incentive spirometer to make sure he has the right
understanding and knows the correct way of using
it. If he does not use it correctly, encourage and
assist him with it. A demonstration back is more
successful than providing information alone.

27

Write a nursing progress note for this nursing diagnosis. Your note may be in Focus (Data,
Action, Response) , SOAP (Subjective, Objective, Assessment, Plan), or PIE (Problem,
Intervention, Evaluation) format. (2 pts.)
D= pulse oximeter was 89% on Tuesday. Clients deep breathing and coughing and use of incentive
spirometer helped clear his lungs out. On Tuesday his voice was raspy in the morning and by the
time I was leaving his voice was clear from doing his exercises.
A= enforced the incentive spirometer every time I was in the room. Made sure he got up to 250 on all
inhalations. Did pulse oximeter q 2-4 hr, and auscultated his lungs sounds to make sure they were
clear bilaterally. Also checked pedal pulses to make sure those were still strong.
R= he did not like to do the incentive spirometer, but every time he did do it, he said he felt much
better. He stated that he would use it more while I was out of the room because he understood that
he needed to do it more to decrease his fever and decrease his stay.

28

NURSING CARE PLAN FOR A PRIORITY RISK FOR NURSING DIAGNOSIS

Write a priority Risk For nursing diagnosis in PE format.
Risk for infection related to immobility of knee surgery
Write 1 discharge related outcome (long term goal) for this nursing diagnosis. (1 pt.)
Client will demonstrate no evidence of infection.
Write 2-3 expected outcomes (short term goals) for this nursing diagnosis appropriate to
the days of care. The outcomes must be specific to the patient, measurable and realistic. (2
pts.)
Client will have a lower fever than 99
Client will have a higher pulse oximeter reading that will be within normal range
Client will maintain clear lungs sounds
Complete a comprehensive list of specific individualized nursing interventions and
rationales for the nursing diagnosis. The nursing interventions should relate to the
problem, as stated. The interventions should include all interventions that would be
appropriate for this patient whether you had the opportunity to implement them or not.
Document your sources in APA format. (5 pts.)
Nursing Intervention
Monitor temperature q 4 hr or prn
Monitor pulse oximeter q 4 hrs

Monitor vital signs

Encourage DB&C q 1 hr- 3 repetitions

Rationale
Make sure it does go up, if it goes up it can be a
response to an infection
Make sure it is within normal ranges, if not he
needs to be on oxygen due to the chance of
hemorrhaging and infection. Auscultate lungs to
Make sure lungs stay clear bilaterally, if not then
there is fluid, which increases risk of infection.
If any are out of normal ranges, the risk for
infection increases
Keep these exercises up due to decreasing likely
hood of infection. If fluid sits in lungs could result
in pneumonia.

Instruct client on Incentive Spirometer q

1hr, 10 inhalations

Make sure client uses these properly to decrease

the risk and time of using it and doing them.

Assess Hemovac drain for abnormal

drainage.

Monitoring this is just to make sure that the

drainage is not showing any forms of infection and
that it is not excessive.

29
Write a nursing progress note for this nursing diagnosis. Your note may be in Focus (Data,
Action, Response), SOAP (Subjective, Objective, Assessment, Plan), or PIE (Problem,
Intervention, Evaluation) format. (2 pts.)
D= VS were 132/62, 90, 18, 99.4 and pulse oximeter was at 89%. Edema was present with +1 or +2.
Pedal pulses were strong on Tuesday but a little weaker on Wednesday. The incentive spirometer
reached 250 with every inhalation. DB&C were still assessed and there was less coughing on
Wednesday with that exercise. Lungs were clear bilaterally.
A= Checked vital signs q 2-4hr, including pulse oximeter. Had patient wear nasal cannula at 2 L to
increase oxygen in the blood. Monitored the Hemovac drain, which was serasanginous fluid.
R= client was uncooperative with incentive spirometer even though he knew that it was in his best
interest to maintain healthy and not increase his risk for infection. He felt better with inhalations and
DB&C and started to cooperate by Wednesday with them. But he was a little more tired Wednesday
so I believe he did not want to put up a fight.

30
PROFESSIONAL JOURNAL ARTICLE (2 pts.)
Attach a copy of a professional journal article published within the last 5 years that relates
to some aspect of your patient's care. The article must be from a professional nursing
journal. Foreign nursing journals or lay oriented magazines are not acceptable. This article
should be cited in one of the previous sections of this paper. In the space below, explain
how the information in the article could be used to improve the nursing care provided.
In reading the article on total hip replacement rehabilitation, it educated me in finding out that this
surgery and the postoperative care have not been fully studied. Experiments and studies still need
to go underway to actually find out more information regarded to the specific areas that are being
questioned along with what therapies are good, how long therapy should last, what activities can
induce more problems on the replacement. In this article many studies addressed did not have
enough or adequate information to make a factual statement, or outcome on the findings.
Total hip replacement is one of the most common and successful surgeries. In this procedure, the
hip is resected and replaced with a prosthetic bone. This procedure is meant for long-lasting
function and to decrease pain. The real question is not the preoperative care or intraoperative, but
the postoperative. Many studies investigated the use of PT after surgery and all came up with
different outcomes.
In doing this procedure, posteroperatively the main concerns are restoring normal function back to
the hip, with mobility, strength, and flexibility. An in other procedures, reducing and preventing
complications such as pain, DVT, ROM, and weight-bearing precautions.
With total hip replacement, the postoperative restrictions are based primarily on the patient. With
weight bearing activities the surgeon usually assesses the status as well as looking at what type of
implant was used, the bone integrity, and strength and structure of the tissues. With cemented
stems, partial body weight is allowed usually. With uncemented stems, only allows minimal pressure
for 6-12 weeks postop. Some ROM is prohibited depending on what kind of surgery was performed.
With posterior and lateral surgical approaches, hip flexion, adduction, and rotation are avoided past
the midline. With anterior approach, hip extension, external rotations are not allowed. In the first
week postoperatively, dislocation is at the greatest risk. There has been notable leg length
discrepancy after total hip replacement. Those that do have one can wear a shoe lift to help with gait
training, but those cannot be worn until 6 months postop. Exercise is important in recovery from this
surgery. Lower extremity range of motion exercises is encouraged, with strengthening of the hip
abductors. In doing proper exercise it should maximize strength and flexibility. In managing pain,
analgesics and cold packs are the best form of nonpharmacological and pharmacological treatments
so far. As with most surgeries, patient and family education is a key part in recovery. Discussing
postoperative care and therapy with the patient along with home exercise programs and outpatient
therapy are part of the discharge care. There are some long term physical impairments associated
with hip surgery such as, decreased muscle strength, limited hip ROM, and abnormalities in gait.
Long-term activities recommended are diving, cycling, golfing. While discouraged sports are soccer,
football, baseball, hockey due to impact and reinjury.
With experiments and studies performed on total hip replacement, it shows that there still needs to
be experiments done in areas addressing therapy, strength, ROM, reliability of the hip. Also, with the
most cost-efficient and safe therapies that can be performed with maximum recovery.

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List references in APA format. Include at least one professional journal article. (2 pts.)
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