.NURSING PROCESS WORKSHEET – CONTINUED NURSING NOTES
The content which follows, requires a research component to ensure an adequate assessment, to include peer reviewed articles, research data bases, etc. All information must relate to your patient during this admission and must be cited accordingly using the APA resources required by NURS 3313.
1. Based on the collected data, identify the client’s primary pathophysiology [related to primary diagnosis] for this admission.
Osteoarthritis is associated with the wearing down of the auricular cartilage and the subsequent attempts by the body to reform the missing cartilage leading to the development of osteocytes. The basis of this reformatting has to do with the cracking of the collagen layer in the joint due to overuse allowing to the inrush of synovial fluid resulting in edema of the joint. This edema leads to fissures forming with attached chondrocytes that cause a sloughing off of the cartilage. This free cartilage causes exposure of the bone leading to growth which forms into osteocytes ( bone spurs). The cascade of events is begun by the loss of proteoglycans which leads to imbalanced homeostatic repair of the auricular cartilage. This loss of proteoglycans many times comes as a result of IL-1 induction of protease related proteoglycan death (Porth, 2008).
The patient with osteoarthritis has pain related to movement and use of the affected joint. This pain is many times relieved by periods of rest. The relief related to rest begins to be minimized as the disease process progresses and there is more disruption of the auricular cartilage layer. This pain may become debilitating with the patient eventually electing for surgery to deal with it.
2. How does the client’s past medical and social history contribute to the primary admitting medical diagnosis?
In her youth, the client was a gymnast and a cheerleader and often performed stunts on the hard floor of her high school gymnasium. She attributes this to being the beginning of her knee problem, which progressed into osteoarthritis as she aged. The osteoarthritis caused a gradual wear and tear on the cartilage of her knees, eventually leading to an almost total loss of cartilage and a need for surgery.
3. How do the client’s co-morbidities and medical history impact the treatment and recovery?
The client’s diagnosis of Parkinson’s Disease may impact her ability to learn and process new information regarding post-operative teaching. Also, the disease is known to cause postural instability, which might increase her risk for falls. One of the side effects of Phenergan, which was precribed to her for nausea, could not be taken because of a risk of increased extrapyramidal side effects related to PD. This will impact her recovery, as she is currently nauseous and vomiting.
The client has also been diagnosed with an overactive bladder, which may cause her to rise frequently to use the restroom, also increasing her fall risk, although she is taking medication for this.
4. If identified, how does the interventional procedures/surgical interventions impact the client’s recovery?
The total knee replacement should result in an increased quality of life for the client. She will enjoy the benefits of her surgery when she recovers enough to return to the gym and continue her workout routine. Her willingness to recover rapidly will provide motivation for remaining free of injury and promoting health.
5. Briefly explain the abnormal lab values [if applicable] as they relate to your client’s pathophysiology and/or history. How were the abnormal values addressed?
The client had no abnormal lab values that related to her pathophysiology or history since this was an elective surgery and she is otherwise in good health.
6. Has the client had any cultures or drug levels obtained during this admission? Yes No If yes, what treatment and interventions were implemented as a result of positive cultures or abnormal drug levels.
7. Identify at least one teaching need for the client and/or family. If you were able to implement this teaching plan, please explain the impact on the overall plan of care.
The client was able to participate in the class offered by St. Joseph’s Hospital for patients undergoing orthopedic surgery. In the class, she and her husband were exposed to various exercises that were recommended for recovery. She has been practicing these exercises regularly and has a good understanding of their value. She stated that she learned a lot from the class about what to expect during and after surgery. The client is very willing to participate in these activities and will be compliant with the teaching. She has a good amount of resources available to her if she has any questions.
8. Identify the Joint Commission Safety Goal/s that is/are most applicable to your client during this admission.
[Please use the Joint Commission Accreditation Program: Hospital National Patient Safety Goals as seen on Blackboard/Georgia ViewVista]
a. What interventions and precautions were implemented to effectively address the client’s safety?
Goal 1: improve the accuracy of patient identification.
This was implemented by checking two patient identifiers each time medications were administered.
Goal 2: improve the effectiveness of communication among caregivers.
The results of critical tests and diagnostic procedures were communicated in a timely manner.
b. What interventions would you implement that were not, Why?
Goal 3: improve the safety of using medications.
The client’s IV site and tubing had no labels to indicate when they were placed and needed to be changed. This could lead to neglect to change IV tubing if necessary.
Please know that I randomly took out information on the Care plan so that it is not complete and you won’t be able to copy. It should be used as a guideline…..I left references that you might want to use. This was the careplan that was in the works as the group was doing their project. It is not complete
Nursing Diagnosis #1 / Risk for injury r/t altered mobility secondary to total knee replacement.Priority with Rationale / This is the first priority diagnosis because injuries after a total knee replacement are common and preventable. It is very important for the client to take preventive measures to ensure good recovery.
Goals / · To remain injury free for the duration of the shift.
· Patient will verbalize understanding of importance of CPM, TED hoses, and incentive spirometry exercises.
Interventions / 1. Modify environment to ensure patient safety (Doenges, 2010 p. 474):
· Place bed in the lowest position
· Put 2 bed rails up
· Ensure that the patient has access to call light, remote control, telephone and water
· Place assistive devices within reach (walker)
· Instruct the client to call for assistance when she wants to get out of bed or needs anything
· Ensure that pathway to bathroom is unobstructed and properly lighted
2. Perform neurovascular assessment q2hr. Monitor the affected extremity (right leg) and compare it with the unaffected (left leg). It is important for nurses to perform frequent neurovascular assessments of patients with musculoskeletal damage because the risk for tissue and nerve damage. The extensive nature of orthopedic surgery combined with the patient’s older age and co-morbidities require nursing staff carry out observations regularly until the patient is considered stable (Walker, 2010). Edema is a natural response to trauma, the patient may complain that the dressing is too tight. Vascular insufficiency and nerve compression due to unrelieved swelling can result in compartment syndrome (Smeltzer, 2010 p. 2027)
Assess:
· Pulses: posterior tibilais, and doralis pedis
· Edema
· Warmth
· Movement:
o To test the movement of tissue innervated by the Peroneal nerve: ask the patient to dorsiflex the foot and extend toes (Smeltzer, 2010 p.2019). Assess movement with and without resistance.
o To test movement of tissue innervated by the Tibial nerve: Ask the patient to plantar flex toes and foot. Assess movement with and without resistance.
· Sensation
o To assess the Peroneal nerve: ………… (Smeltzer, 2010 p. 2019)
o To assess the tibial nerve: ……….. (Smeltzer, 2010 p. 2019)
· Temperature
Evaluation / Neurovascular assessment revealed normal warmth, temperature, and sensation of affected extremity. The patient was edematous in right leg (2+) and decreased rom of the right leg (with and without resistance). Neurovascular assessment was performed at 1600, 1800 and 2000.
The client continued to use a CPM device until it was discontinued by the physical therapist. The client stated that it helped to keep her leg straight.
The client wore TED hose for the duration of the shift. Further teaching is necessary to ensure the client is capable and willing to continue wearing the TED hose after discharge.
Ambulation was progressive during the shift. First the client walked to the bathroom, next, she walked down the hallway and back. The client will meet with physical therapy in the morning to work on stair climbing techniques. (ASK ZACH HOW LONG THE HALLWAY IS)
The client was compliant in her use of the incentive spirometer. Ask beth for incentive spirometer instructions
Nursing Diagnosis #2 / Impaired physical mobility r/t total knee replacement surgery.
Priority with Rationale / This is the second priority diagnosis because increasing physical mobility is very important to the client. Impaired physical mobility was the reason the client decided to seek treatment and every effort should be taken to ensure that her mobility improves.
Goals / · The client will increase physical activity as tolerated throughout the shift.
·
Interventions / 1. Assess skin q4hr.
· Pressure ulcers are localized areas of necrotic tissue that develop when pressure applied to skin over time is greater than normal capillary refill, normal capillary refill is approximately 32 mm Hg……….
· …………..
· …………..
· …………..
· Evaluate level of mobility
· Evaluate circulatory status
o Peripheral pulses, edema
· Assess neurovascular status
· …………………………………
· Evaluate nutritional and hydration status
· Review the results of patient’s lab values
o Hematocrit, hemoglobin, electrolytes, albumin, transferrin, and creatinine
2. The client will walk down the hall and back during the shift. Put the length of hallway
Potential problems of immobility are far less likely to occur when clients become ambulatory as soon as possible (Berman & Snyder, 2012).
3. The client will demonstrate proper technique of the post-operative exercises that she learned from the class offered by St. Joseph’s. This includes the following:
· Bending the knee while keeping the heel on the bed.
· ………….
· ……………….
These exercises are recommended by the staff at St. Joseph’s hospital to help speed recovery time and decrease the risk of potential complications from surgery.
Evaluation / The client was successful in ambulating down the hallway without difficulty. She tolerated the ambulation well.
The client was able to demonstrate all of the exercises that were recommended to her in the teaching class. Client states that she has been practicing these exercises regularly at home for several weeks in anticipation of the surgery.
The client is not expected to use a walker after being discharged from the hospital, so this intervention is not appropriate at this time.
Nursing Diagnosis #3 / Deficient knowledge
Priority with Rationale / This is the third priority diagnosis because it
Goal
REFERENCE PAGE
Cuver, K., (2012).Chapter 34: Activity and Exercise. Kozer and Erb's: Fundamentals of nursing. (9 ed., pp. 1170-1171). Upper Saddle River, NJ: Pearson Education inc.
Bedner, B.M.L. (2012).Chapter 48: Urinary Elimination. Kozer and Erb's: Fundamentals of nursing. (9 ed., pp. 1170-1171). Upper Saddle River, NJ: Pearson Education inc.
Apfel, C. C., Korttila, K., & Abdalla, M. (2004). A factorial trial of six interventions for the prevention of postoperative nausea and vomiting. New England Journal of Medicine, 350(24).
Berman, A. & Snyder, S. (2012). Kozier & Erb’s Fundamentals of nursing: Concepts, process, and practice. Upper Saddle River, NJ: Pearson.
Brugioni, D. J., & Falkel, J. (2004). Total knee replacement and rehabilitation: The knee owner’s manual. Alameda, CA: Hunter House Inc.
Garrett, K., Tsuruta, K., & Walker, S. (2003). Managing nausea and vomiting: Current strategies. Critical Care Nurse, 23(1).
Smeltzer, S. C., Bare, B. G., Hinkle, J. L., Cheever, K. H. (2012). Brunner & Suddarth’s Textbook of medical-surgical nursing. Philadelphia, PA: Lippincott Williams & Wilkins.
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