Nursing Care Plan for Left Knee Replacement

nursing C be Plan for Left Knee Replacement savant Name Elizabeth (Beth) AndrewsBrief patient of fib including medical diagnosis and summary of assessment findingsThe persevering is a 59 grade old female, widowed, who entered the Braintree reclamation Center for transitional care by and byward go forth knee arthroplasty due to osteoarthritis. She has a history of COPD obstructive sleep apnea spinal stenosis degenerative joint disease depression fleshiness fibromyalgia dyslipidemia hypothyroidism lymphedema tachycardia and idiopathic tremors. She experient a pulmonary embolism in 2009.The total knee replacement (TKR) was conducted at Metrowest/Leonard Morse infirmary on 5/21/12. The patient was transferred to Braintree Rehabilitation Center on 5/24/12. She had difficulty emerging from anesthesia and experienced urinary retention. She subsequently emerged from anesthesia and the urinary retention resolved. A neurologic consult was reproducible to assess the patients dif ficulty emerging from anesthesia no inauguration of this difficulty was identified during examination. The consultation suggested that her lethargy might be attri only whenable to oxycod bingle (patient is allergic to milnapricine and several other drugs) which the patient takes for ongoing ache and fibromyalgia.The patient has otherwise experienced good recovery with somatogenic therapy 1-2 hours per day/5 days per week. She continues to experience edema of the left working extremity no thromboembolus was identified and her physician ordered an additional diuretic. Her incision was healing well with no local swelling, spryth, or exudates and the wound erythema was receding from the scoring drawn around the incision. Staples remained intake.The patient is a former smoker with COPD she quit smoking just prior(prenominal) to the electric current surgery and chafferms to be managing this well. She is obese and indicates that she struggles with this and is aware of the race of her obesity to her osteoarthritis and current bit as well as to other current and potential diagnoses. Her past medical history is far-famed for fibromyalgia from which the patient experiences considerable disability. She associates the onset of fibromyalgia subsequent to being involved in a physically and aflamely abusive intimate adult relationship and to self-described slur traumatic stress disorder relative to puerility sexual abuse. In addition, her past medical history is noneworthy for obstructive sleep apnea patient uses a CPAP.The patient is widowed and lives alone in Natick. She has four children who live locally and whom she indicates are very supportive. matchless son comes to her home everyday to cook her dinner. The patient does not cook for herself and is maintained during the day with teatime until her son comes to make her dinner. The patient is very focused on understanding and accessing information near her conditions/diagnoses and treatments. When I first met her, she was suss outing information provided to her by the transitional care unit pertaining to difficulties in emerging from anesthesia and roughly her medications. The patients life appears to revolve around her infirmityes and conditions she describes herself as a multiply disabled someone. She does not leave her home very much except to attend medical appointments and is highly dependent upon her family for her ineluctably and care. The patient reports that depression is a signifi canistert factor in her life connect to prior physical, e transactional and sexual abuse and to her general state of disability. The patient is noteworthy for high level of health desire behavior and a high degree of medicalization. According to the patient, her home is outfitted with multiple assistive devices which embarrass a CPAP, a walker, a cane, an electronic chair to take her upstairs and a bidette to help her with private hygiene.In spite of her many disabilities, the patient i s progressing well and will be discharged in about a week.excess care for diagnosing without Care preparedness Specification employment Intolerance knowing PainAnxietyChronic Low Self EsteemChronic PainDeficient Diversional ActivityDepressionDisturbed Body ImageDisturbed Sleep PatternDisuse SyndromeFatiguewellness Seeking BehaviorsHopelessnessImbalanced Mobility Greater than Body Requirements impaired Bed Mobility impair Comfort stricken CommunicationImpaired Gas ExchangeImpaired Individual ResilienceImpaired Physical MobilityImpaired Social IsolationImpaired Transfer AbilityImpaired WalkingIneffective Activity PlanningIneffective Breathing PatternIneffective CopingPost Trauma SyndromePowerlessnessReadiness for Additional Health Seeking Behavior endangerment for Cardiac/Vascular Complications run a risk for Caregiver Role wrinkleRisk for Complications of Deep Vein ThrombosisRisk for Complications of Musculoskeletal DysfunctionRisk for ConstipationRisk for moveRisk for Hypothermi aRisk for Impaired Cellular RegulationRisk for Impaired Skin IntegrityRisk for Ineffective Respiratory FunctionRisk for InfectionRisk for InjuryRisk for LonelinessRisk for peripheral Neurovascular DysfunctionSedentary LifestyleSelf Care DeficitNANDA Approved Nursing Diagnosis I Impaired Physical Mobility Clients Medical Diagnosis Osteoarthritis, degenerative joint disease, spinal stenosis, status post total left knee replacement, fibromyalgia, obstructive sleep apnea, obesity, dyslipidemia, hypothyroidism, lymphedema, tachycardia, idiopathic tremorsDefinition A limitation in independent, purposeful physical move of the body or one or more extremities (Ackley Ladwig, 2011, p. 548).Defining Characteristics decreased reaction time difficulty turning engages in substitutions for movement (e.g., increase attention to others activity, controlling behavior, focus on pre-illness disability/activity exertional dypsnea gait changes, jerky movements exceptional ability to get along gross motor skills limited ability to perform fine motor skills limited range of query movement-induced tremor postural instability slowed movement uncoordinated movements (Ackley Ladwig, 2011, p. 549).Related FactorsActivity intolerance altered cellular metabolism anxiety body mass index above 75th age-appropriate percentile cognitive trauma contractures cultural beliefs regarding age-appropriate activity deconditioning decreased endurance depressive mood decreased brawn control decreased muscle mass decreased muscle strength deficient knowledge regarding value of physical activity developmental delay discomfort disuse joint stiffness lack of environmental supports (e.g., physical or social) limited cardiovascular endurance loss of integrity of bone structures malnutrition medications musculoskeletal impairment neuromuscular impairment hurt prescribed movement restrictions reluctance to initiate movement sedentary lifestyle sensoriperceptual impairments (Ackley Ladwig, 2011, p. 54 9).Suggested functional level classifications intromit the following0-Completely independent1-Requires use of equipment or device2-Requires help from another person for assistance, supervision or teaching3-Requires help from another person and equipment device4-Dependent (does not participate in activity)(Ackley Ladwig, 2011, p. 549)Instructions forStudentIn the space beneath, enter the subjective and objective information gathered during your client assessment.ASSESSMENTSubjective info EntryPatient reported pain of 4related to current acute pain 4 and 6 for chronic pain at home prior to admission based on outgo of from 0 to 10Patient reported that she uses assistive devices at home walker, cane, electronic chair for lift stairs while seated, bidette to assist with personal care CPAP for sleepPatient reported that she engages in microscopical social activity when at home, going out only for medical appointmentsPatient reported that she ofttimes sleeps during the day and has difficulty sleeping at nightPatient reported that she is frequently fatigued and that movement around the home is difficult even with assistive devicesPatient reported that chronic pain is related to osteoarthritis and fibromyalgiaPatient reported that she is dependent upon family member for mealsPatient reported that she is able to manage most dressing and bathing, but is dependent upon bidette for some of her perianal carePatient self-reports depression, PTSD, and fibromyalgia related to past physical, steamy and sexual abuse and to current status of general disabilityObjective Data Entrydecisive signs Temp Oral 97.3, HR, 105, Respirations, 20, BP r 121/75 L 123/79Pulses Radial 105, L and R cycle pulses presentHeight 4 ft 11 inches Weight 259 lbsCognition Alert and Oriented to person place and time X3Affect Pleasant, conversant, but subject to inattention due to dozing during conversationIntegumentary vibrissa clean, gray color, neat haircut, no lesions on scalpNasal moist, pi nkOral mucosa moist, pink, applauder moist, pink, no oral lesions. Skin Color PinkSkin Color pink Temp warm to touch Texture smooth Moisture/Hydration moist, turgor ordained at sternum Breakdown the only current manifestation of breakdown is skin rashes in groin area and under breasts. Operative incision is erythmetous, but erythema is receding as evidenced by line drawn around erythema. No swelling, warmth or exudate at the operative incisionRespiratory Respirations 20, depth even and rhythm even, O2 saturation 94% at rest on room air. Observed patient fatigue upon walking a light distance from bed to bathroom,CardiovascularApical Pulse 105 Rhythm regular Radial pulses left and right present Pedal Pulses left and right presentCapillary refill observed L X 5 fingers and R X 5 fingers L X 5 toes and R X 5 toes Musculoskeletal poor mobility. Left hand slightly weaker than right tremors appeared in left when squeeze play fingersGeneral Patient experiences generalized pain chronic ally and current acute pain at operative site. Patient used ice pack and lidocaine strips to moderate localized pain (in addition to pain medications). Patient experiences chronic sleep disturbances, in particular, chronic obstructive sleep disorder. Sleep is only moderately meliorate by use of CPAP Objective evidence entangles patient frequent dozing during interview. Patient is obese clog 259 lbs/ flower 4 feet, 11 inches BMI 52.3EvaluateStudent Instructions To be sure your client diagnostic report written below is accurate you need to review the defining characteristics and related factors associated with the nursing diagnosis and see how your client data match. Do you have an accurate match or are additional data required, or does another nursing diagnosis need to be investigated?DIAGNOSISDiagnostic StatementNursing Diagnosis (specify) Impaired Physical Mobility (Carpenito-Moyet , 2010, p. 285) related to pain, fatigue, obesity and sleep disturbances as evidenced by patient fatigue upon walking a short distance, patient report of limited mobility, patient dozing during interview, patient pain reports of 4 and 6 on scale of from 0 to 10 , patient BMI 52.3PLANNINGDesired Outcome The Client willand Client CriteriaReduce weight by 20% after one year compared to baseline of 259 lbsReduce feelings of depression by 20% as measured by the PHQ-9 questionnaire after one yearImprove mobility by 20% after one year compared to baseline determined by physical therapist assessmentReduce pain by 50% after one year compared to baseline of 6 on scale of from 0to10Improve feelings of self love and self-efficacy by patient report after one yearEvaluateThe want end must meet criteria to be accurate. The outcome must be specific, pictorial, measurable, and include a time frame for completion. Does the action verb describe the clients behavior to be evaluated? Can the outcome be used in the evaluation step of the nursing process to measure the clients response to the nur sing interventions listed below?InterventionsReferral to mental health counseling to identify and treat depression, issues of self-esteem and self efficacyReferral and active enfolding in physical therapy to improve mobilityUndertake regular exercise that includes ambulation for longer distances, higher frequency and increased repetition of performing ankle pumps, gluteal sets and quadriceps sets.Use heat and cold, stretching and range of motion exercises to manage symptoms of fibromyalgiaReferral to pulmonologist for sleep disturbance assessment.Referral to pain management specialist for assessment, planning and treatment related to various(a) sources of patient painReferral to nutritionist for assessment and planning related to nutrition and weight reduction. Set realistic goals for weight reduction, encourage patient to keep fare diaries, provide patient with information about the relationship of weight management to pain reduction and mobility improvement, identify stress iss ues related to obesity and support systems that can help patient in weight reduction.Rationale for Selected Intervention and References look for indicates that attention to psychosocial issues and mental health counseling can have a positive impact on reduction in obesity (Yilmaz et al, 2011). Depression has been related to weight control in patients with osteoarthritis (Possley et al, 2009). Mood disorders are related to fibromyalgia (Dell, 2007).Research has shown that active participation in physical therapy is important to improved mobility post TKR (Hall, Hardwick, Reden, Pulido, Colwell, 2004).Research indicates that behaviors such as ambulation for longer distances, higher frequency and increased repetition of performing ankle pumps, gluteal sets and quadriceps sets are related to greater self-efficacy in patients who have had total joint replacement (Moon Backer, 2000). Regular exercise improves pain, physical function and contributes to weight reduction in patients with os teoarthritis (Seed, Dunican Lynch, 2009). Active physical exercise has achieved modest positive results in reduction of signs and symptoms of fibromyalgia (Turk, 2009).Research has shown that heat and cold, stretching and range of motion exercises improves symptoms of fibromyalgia ((Turk, 2009).Research has shown that sleep disturbances should be evaluated and treated as a component of treatment of fibromyalgia (Dell, 2007).Patient has pain related to many sources and may influence the patients approach to obesity and mobility. Pain has been related to obesity (Janke, Collins, Kozak, 2007).Realistic goals, food diaries/monitoring/ understanding of the relationship between pain and mobility, stress issues and support systems have been shown to support undefeated obesity self care and illness prevention (Hindle Dell, 2012).EVALUATIONEvaluateDo your interventions assist in achieving the desired outcome? Do your interventions address further monitoring of the clients response to you r interventions and to the achievement of the desired outcome? argon qualifiers when, how, amount, time, and frequency used? Is the focus of the actions verb on the nurses actions and not on the client? Do your rationales provide fit reason and directions?What was your clients response to the interventions? (theoretic)Weight is reduced by 20% after one year (evaluation outcome 200 lbs)Feelings of depression are reduced by 20% as measured by the PHQ-9 questionnaire after one yearMobility is improved by 20% after one year compared to baseline realized by physical therapist assessmentPain is reduced by 50% after one year (evaluation outcome 3 on a scale of from 0 to 10Feelings of self esteem and self-efficacy are improved by patient report after one yearReferencesAckley, B.J. Ladwig, G.B. (2011). Nursing diagnosis handbook-an evidence-based guide to planning care. Ninth Edition. Mosby Elsevier, St. Louis, Missouri, 2011Carpenito-Moyet, L.J. (2010) Handbook of nursing diagnosis, 13th Edition, Used by arrangement with Wiley-Blackwell Publishing, a company of John Wiley Sons, Inc, Publisher Wolters Kluwer Health/Lippincott Williams Wilkins, Philadelphia, Baltimore, New York, London, Buenos Aires, Hong Kong, Sydney, TokyoDell, D.D. (2007) Getting the point about fibromyalgia. Nursing 2007, February 2007, 61-64. Retrieved from http//web.b.ebscohost.com.mbcproxy.minlib.net/ehost/pdfviewer/pdfviewer?vid=4sid=2a85447c-cc47-4b86-8e31-250d1b9e754d%40sessionmgr111hid=114Janke, E.A., Collins, A. Kozak, A. T. (2007) Overview of the relationship between pain and obesity what do we know? Where do we go next? daybook of Rehabilitation Research Development, Vol 44, No 2, 245-261. Retrieved from http//web.b.ebscohost.com.mbcproxy.minlib.net/ehost/pdfviewer/pdfviewer?vid=5sid=2a85447c-cc47-4b86-8e31-250d1b9e754d%40sessionmgr111hid=114Hall, V.L., Hardwick, M., Reden, L., Pulido, P. Colwell, C. (2004) Unicompartmental knee arthroplasty an overview with nursing implications. Orthopaedic Nursing, Vol 23, No 3, May/June 2004, 163-173. Retrieved from http//web.b.ebscohost.com.mbcproxy.minlib.net/ehost/pdfviewer/pdfviewer?vid=6sid=2a85447c-cc47-4b86-8e31-250d1b9e754d%40sessionmgr111hid=114Hindle, L. Mills, S. (2012) Obesity self-care and illness prevention. Practice Nursing, Vol 23, No 3, 130-134. Retrieved from http//web.b.ebscohost.com.mbcproxy.minlib.net/ehost/pdfviewer/pdfviewer?vid=10sid=2a85447c-cc47-4b86-8e31-250d1b9e754d%40sessionmgr111hid=114Moon, L.B. Backer, J. (2000) Relationships among self-efficacy, outcome expectancy, and postoperative behaviors in total jointreplacement patients. Orthopaedic Nursing, 19 (2) 77-85. Retrieved from http//web.b.ebscohost.com.mbcproxy.minlib.net/ehost/detail?vid=7sid=2a85447c-cc47-4b86-8e31-250d1b9e754d%40sessionmgr111hid=114bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3ddb=rzhAN=2000051848Possley. D. et al. (2009) Relationship between depression and functional measures in impenetrable and obese persons with osteoarthritis of the knee. Journal of Rehabilitation Research Development, Vol 46, No 9, 1091-1097. doi10.1682/JRRD.2009.03.0024Seed, S.M., Dunican, K.C., Lynch, A.M. (2009) Osteoarthritis a review of treatment options. Geriatrics, Vol 64, No 10, 20-28.Retrieved from http//web.b.ebscohost.com.mbcproxy.minlib.net/ehost/pdfviewer/pdfviewer?vid=9sid=2a85447c-cc47-4b86-8e31-250d1b9e754d%40sessionmgr111hid=114Turk, D.C. (2009). Fibromyalgia syndrome a guide for the perplexed. Psychiatric Times, 26(2), 50-54. Retrieved from http//web.b.ebscohost.com.mbcproxy.minlib.net/ehost/detail?vid=8sid=2a85447c-cc47-4b86-8e31-250d1b9e754d%40sessionmgr111hid=114bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3ddb=cin20AN=2010211647Yilmaz, J. et al. (2011) Adopting a psychological approach to obesity. Nursing Standard, Vol 25, No 21, 42-46. http//dx.doi.org/10.7748/ns2011.01.25.21.42.c8289