M7A2: Nursing Care Plan: A patient with a total knee replacement

Mrs. S. is a 61-year-old female who is 2 days post-operative total knee replacement (TKR) of the right leg. The right knee is wrapped in an ace compression bandage; the closed drainage system was removed by the orthopedic surgeon early this morning. Mrs. S. would only pivot to the chair with the assist of the physical therapist. While in bed she is using the continuous passive motion (CPM) device as ordered. She reports pain as 5 on a 0-10 verbal pain scale. Additional assessment includes: Pulse 96 bpm; Resp 18 bpm; BP 144/90; T 100.1 F (temporal); skin is warm and dry to touch; nail beds are pink; capillary refill is less than 3 seconds; pedal pulses are present bilaterally; breath sounds are clear but diminished in the bases. The following orders are in effect: Regular diet as tolerated OOB to chair 2 times daily with one assist Ambulate in hall with Physical therapy Vital signs every 4 hours while awake CPM flexion increased daily by Physical Therapy Intermittent Infusion Device (IID) Patien controlled analgesia (PCA) with Morphine Sulfate Medications: enoxaparin sodium (Lovonex), hydrochlorthizide (Hydrodiuril), metformin (Glucophage) Using the Nursing Process Overview and information from your textbooks, develop a Nursing Care Plan for the above patient. Your Nursing Care Plan (NCP) must include: One (1) priority nursing diagnostic statement (must be an actual nursing diagnosis) based on the information presented. One (1) measurable patient outcome. Four (4) nursing interventions including one (1) nurse-initiated intervention, one (1) physician-initiated intervention, one (1) interdependent intervention, and one (1) additional intervention. (The types of nursing interventions are described in the implementation chapter of the Fundamentals of Nursing textbook.) Identify criteria that will be used to establish the patient outcome has been met. Complete your nursing care plan using the Nursing Care Plan form (you must save the file to your computer before completing the form). When you're ready to submit your work, click Browse My Computer and find your file. Once you've located your file click Open and, if successful, the file name will appear under the Attached files heading. Scroll to the bottom of the page, click Submit and you're done. Be sure to check your work and correct any spelling or grammatical errors before you post it. This activity will be assessed according to the AD Nursing: Nursing Process Rubric.

The RN collects and validates the patient data. Communication of this data to the relevant care providers is also the RN's responsibility.
The patient's medical history must be recorded accurately. Physically assessing the patient, reviewing the patient's medical records, and going through the nursing literature are all activities that the RN carries out during this portion of the process. The RN may also consult with the patient's family and friends (with the patient's permission) or with other health care professionals. All the data that has been collected is validated and continuously updated.

The RN analyzes the patient data in order to identify any health problems. After interpreting all the available data the RN creates a prioritized list of nursing diagnoses. The nursing diagnoses are classified as actual (the patient has defining characteristics which support the nursing diagnosis) or risk* (the patient does not have defining characteristics but is vulnerable to develop the nursing diagnosis).
The nursing diagnosis statement includes the following:
•    Nursing diagnosis (problem)
•    Etiology
•    Defining characteristics*
*For risk nursing diagnoses, there are no defining characteristics.

Once the nursing diagnosis statement has been formulated, the RN must develop:
•    A measurable patient outcome that prevents, reduces, or resolves the identified patient health problem (nursing diagnosis).
•    Nursing interventions which the RN performs to aid the patient in achieving the outcome specific to the nursing diagnosis statement.

The nursing care plan is implemented. The RN continuously collects and documents relevant data about the patient's health and modifies the plan of care as required.

The RN assesses the patient's response to the care received. Factors that influence the achievement of the outcomes listed in the implementation stage are identified and the plan of care is revised as required.