Problem #1: Acute Pain r/t R TKR Revision
Goal/Outcome: Patient will have pain no > 3/10 on my shift.
Assess pt’s sx & sx of pain and administer pain meds as prescribed. Monitor and record the Rx effectiveness and adverse effects. Assessment allows for care plan modification, as needed. (Potter & Perry, 965) Patient denies pain and discomfort, but stats pain is around a 4/10 at 11 am. (Last pain med given at 6 am) Plan Activities with pt to provide distraction, such as reading, crafts, tv, and visits to help pt focus on non pain related subjects. Keeping the patient occupied with activities helps relieve and subside the pain, even if only a few moments. (Potter & Perry, 967) Patient is intrigued to partake in conversation. Watches television when alone. Appears happy and content. Perform comfort measures to promote relaxation, such as massage, bathing, repositioning, and relaxation techniques. These measures reduce muscle tension or spasm, redistribute pressure on body parts, and help pt focus on non pain related subjects. (Lehne, 256) Patient is very happy after a bath. We repositioned her to relieve pressure on specific extremities. Help pt into a comfortable position and use pillows to split or support painful areas, as appropriate. Reduces muscle tension or spasm and to redistribute pressure on body parts. (Lehne, 256) Patient remains comfortable.
Collaborate with pt in administering prescribed analgesics when alternative methods of pain control are inadequate. Teach patient to ask for pain relief before pain > 4/10. Gaining pt’s trust and involvement helps ensure compliance and may reduce medication intake. (Ignativicius, 9) Patient does not ask for medication for pain. She is able to distract herself by talking to people and watching tv. Evaluation: Patient states that her pain is about a 3/10 on my shift.
Problem #2: Risk for Infection 2° R TKR Revision
Goal/Outcome: Patient will remain infection free on my shift.
Monitor Vital signs 2x a shift.
Temperature elevation can be indicative of the start of an infection. (Ignativicius, 46) Patient remains free from symptoms of infection.
VS @ 9:28 am:
BP: 123/77, *Pulse: 138, Respirations: 16, Temp: 98.1, SpO2%: 96
Teach good handwashing technique
Effective means of reducing spread of infection. (Potter & Perry, 399) Patient is fully educated on how to properly wash hands. She has demonstrated how to wash her hands. Encourage adequate rest with moderate activity. Teach importance of adequate nutritional intake. This will facilitate the healing process and enhance natural resistance. (Potter & Perry, 942) Patient verbalizes understanding of need to eat a varied & adequate diet to promote healing.
Use meticulous hand hygiene when caring for patient.
Help prevent transmission of microorganisms from the hospital and other patients. (Lehne, 82) Patient remains infection free.
Monitor dressing site for leakage, odor, or heat & pain. Foul Odor, Abnormal leakage, High temperature, and pain at or around dressing site can indicate infection to incision site. (Ignativicius, 50) Patient remains infection free, with no signs of infection. Pt states that the pain is minimal- 3/10 where incision site is located. Normal temperature and ace wrap appears clean and intact. Monitor IV lock for redness, inflammation, and maintain dry sterile dressing at site. IV site must be checked as often as possible for redness, swelling, inflammation, and infiltration. All signs of infection. (Potter & Perry, 948) Patient’s IV lock is clean & intact. No signs of inflammation or redness. Evaluation: Pt. remains free of infection on my shift.
Problem #3: Anxiety
Goal/Outcome: Patient states she feels less anxious, discuss ways to control her anxiety without medication, and vital signs will be stable (ex:HR)* on my shift. Nursing Intervention
Bibliography: Ignatavicius, D.D. (2013). Medical-Surgical nursing: patient-centered collaborative care (7th ed.). St. Louis: Elsevier Saunders.
Lehne, R.A. (2013) Pharmacology for Nursing Care (Vol. 8th edition). St. Louis, Missouri: Elsevier.
Potter,P., Perry, A. G., Stockhert, P.A., & Hall, A.M.(2013). Fundamentals of Nursing Eighth Edition. St.Louis: Elsevier Mosby.
Please join StudyMode to read the full document