Care Plan Total Knee Replacement
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
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