Care Plan Total Knee Replacement

Topics: Nursing care plan, Nursing diagnosis, Nursing Pages: 9 (1217 words) Published: May 19, 2015
GRADED ASSIGNMENTS

Data Assessment and Care Plan

Nursing Care Plan
Instructions: Prepare a plan of care for your patient. The plan of care must include a complete DATA ASSESSMENT with all pertinent data and interpretation of data completed. Based on the data, formulate an individualized care plan using (1) priority NANDA diagnosis and (2) secondary NANDA diagnoses. Each diagnosis requires at least (5) interventions, (5) rationales and (5) outcomes. CAREPLAN DATA ASSESSMENT

DEMOGRAPHIC DATA
Patient Initials: _______GJ_______ Age: ____77_____Sex: __M_____Race: _______CAUCASIAN_____________ Admission Date: ___03/30/2015__________

Admitted From: ____ORFC_________________________ Code Status: ____FULL CODE____________ Food/Drug Allergies__NKDA______________________________

Social Support System__WIFE________________________________________ Spiritual Support System ____CATHOLIC_______________________________________
MEDICAL/ SURGICAL DATA
Client’s Current Complaint/ Reason for admission: __LEFT TOTAL KNEE REPLACEMENT_________________________________________________________ _______________________________________________________________________________________________________________________________ Summarize Client Course since Admission: ____Hyperlipidemia, hx of DVT, bilateral knee arthritis, and left leg stripping______________________________ _______________________________________________________________________________________________________________________________ Current Abnormal Physical Assessment Data: _Acute pain________________________________________________________________________________

List Medical Diagnoses:
MEDICAL DIAGNOSIS (Primary)This admission
DEFINE AND INCLUDE PATHOPHYSIOLOGY AND CLINICAL MANIFESTATIONS (ATTACH SHEET IF NECESSARY) Left total knee replacement
Joint replacement is indicated for irreversibly damage joints with loss of function and unremitting pain, selected fractures, joint instability, congenital hip disorders.

CONCURRENT MEDICAL DX (History): List and define:

Knee Arthritis
Inflammation of one or more joint

DVT
Occurs when blood clot forms in one or more of the deep veins in your body, usually in your legs

Current Surgery: __Left total knee replacement___________________ Past Surgical History: __Left leg stripping_______________________________________________

DISCHARGE PLANNING
Will be discharged to: Home  Nursing Home  Rehab Center  ALF  Home services required: Hospice  O2  PT  ST  OT  _____ MEDICATION HISTORY: LIST OF TRADE NAMES OF ALL MEDICATIONS THE PATIENT IS RECEIVING: Lipitor

Tamsulosin
Acetaminophen - Oxycodone
Coumadin
Tums

MEDICAL TREATMENTS/ INTERVENTIONS/ SPECIAL EQUIPMENT: (Physical Therapy, Respiratory Therapy, SCD etc) List

Physical Therapy
Occupational Therapy
CPM
Walker

NUTRITION DATA AND ASSESSMENT

CORRELATE TO CONDITION
DIET TYPE: Regular

SUPPLEMENTS: No

CALORIE COUNT: No

ASPIRATION PRECAUTIONS: No

ENTERAL FEEDING: No TYPE: CONTINUOUS: RATE N/A INTERMITTENT N/A

ABNORMAL DIAGNOSTIC TESTS RESULTS (RECENT AND RELEVANT)
Test/date completed
Results (abnormals only)
Correlate to Medical DX
Test/date completed
Results (abnormals only)
Correlate to Medical DX
K-03/25/15
3.8
Surgery

Na-03/25/15
132
Surgery

Pt-03/25/15
218
DVT

CURRENT MEDICATIONS (include scheduled medications only)
Generic/Trade Name, Dose, Route, Frequency
Classification/
Action
Side Effects & Contraindications
Reason Medication Prescribed

Nursing Measures/Parameters
Coumadin
3 mg PO
1 tablet daily
Anticoagulant
Fever, dizziness, hepatitis, hemorrhage
Prevention of clotting
Monitor...
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