Nursing care plan

Surname of client: Lam____________________ Age: 67_____________ Sex: Female__________

Medical diagnosis OA bilateral knee __________________ Date of assessment 25th November, 2021___________
Diagnostic statement (PES): Acute pain related to tissue and bone trauma secondary to surgery of total knee replacement done as evidenced by patient ‘s swelling on knee
and complained left knee pain score 7/10.

Assessment Nursing Diagnosis Goal(s) & Nursing Interventions Rationales Methods of

Expected Outcomes Evaluation

Subjective Data: Problem: Goals: 1. On-going assessment 1. Assessment 1. Intervie

 Perform pain assessment for every 4 hours by  Pain threshold is the point which a client report that a w the patient
 Ms Lam complained of severe Acute pain at right The patient will report
stimulus is painful (Pasero & McCaffery, 2011). every 4 hours to
pain over her surgical wound knee continuous improvement interviewing pain characteristics with PQRST
Patient is alert and orientated, able to response report the pain
site. of pain with verbalize pattern includes provocative by any situation of
numeric rating scale and score as a measure of pain level on a
relief of pain level before less pain, quality of pain by assessing the sharp
 She reported pain score 7/10 discharge to home. pain feeling, radiation of pain by asking if any
be reliable and documentable. numeric rating
scale 0 to 10.
on left knee.. Etiology: shift of pain location, severity by assessing  Records of pain experiences and characteristics
 She described pain as Related to tissue and numeric pain rating scale, score 0-10/10, and provide directions for pain management plan 2. Review
timing. (Gulanick & Myers, 2011) the characteristic
constant, sharp, pricking and bone trauma Expected outcomes of pain to
continue whole day. secondary to surgical  Record the assessment results and keep observe  Observe the objective signs of patients help to evaluate if any
 She reported severe pain when wound on lt knee  Patient report her the progress. monitor the discomfort and sign of infection to downtrend of pain
physiotherapist having constant sharp pain  Keep observations for objective signs of pain
2.
provoke pain and complications.
Pharmacological pain relief methods
level and
walking exercise with her like general walking posture, sleeping pattern, effectiveness of
decrease to less than 5
 She reported only used on a 0 to 10 numeric vital sign and other sign of infection like fever  Paracetamol plus tramadol is a rational combination both
provoked by bone fracture. that utilises the complementary pharmacodynamics pharmacological
paracetamol and Tramadol for rating scale after 8 pain relief
pain relief and the drug effect Signs & Symptoms: hours of interventions. 2. Administer pharmacological pain and pharmacokinetics of two agents which offer the
potential to improve efficacy and/or tolerability and methods.
was fair. relief medication
(major defining  Patient report safety compared with single-agent analgesia (Schug, 3. Ask
Objective Data: characteristics) effectiveness on pain  According to doctor’s prescription, administer 2006). Multiple analgesia can be more effective than patient to
control by using pain control medications in combination of non- one class only. The combined lower doses of each demonstrate the
 Ms Lam diagnoses OA Knee,  Lam’s chief pharmacological pain opioid oral analgesic paracetamol 1000mg QID class are more effective than higher doses of one use of new
cannot tolerated the normal complaint was left PO and opioid oral analgesic Pregabalin 50mg classes with less side effects (Pasero & McCaffery, strategies to
relief method like 2011) relieve pain and
ROM,LL numbness knee nocte. Oxycodone 5mg administered before
paracetamol and physiotherapy. 3. Non-pharmacological pain relief methods reports their
 She cannot extend her leg for  She shouted for tramadol as prescribed.
3. Teach and encourage the use of  Use of non-invasive pain relief measure can enhances effectiveness in
short time, suffered from
severe pain.
sitting long even  Patient learn and non-pharmacological pain relief methods the therapeutic effects of pain relief medications.
two days after
sat out for lunch as teaching non-
perform non- (Fellowes et al., 2004)
 She only tolerate to walk 4-5 daily basis.  Provide comfort positioning with pillows pharmacological
steps with frame and 2 people
pharmacological pain
elevated left knee and keep knee extend and  Non-pharmacological interventions provide a pain relief
relief methods and methods.
assistance. report effectiveness Nursing care plan
pressure stocking insitu. major treatment approach for pain with an increased
sense of control, promote active involvement, reduce 4.
 She keepofbed
Surname client: Fok____________________
rest and avoid Age:
before67____________
the end of shift  Teach patient additional
Sex: Female__________ strategies to relief pain stress and anxiety and raise the pain threshold
Observe
and discomfort like distraction, relaxation, the patient
mobility
Medical to control pain.
diagnosis: duty.
OA bilateral knee __________________ Date of assessment: 25th November 2020____________ (McGuire, Sheidler, & Polomano, 2000). mobility to
cutaneous stimulation.
 She showedstatement
Diagnostic weak concept(PES):
in Impaired physical mobility related to decreased muscle strength and endurance
4. Range of motion exercise and ambulation
secondary to surgery of total knee evaluatedone
replacement if she as
non-pharmacological
4.
pain was chair-bound and bed-bound after operation, limited range of motion on left knee and weakness
Encourage and assist with range of Reduce muscle and joint stiffness from pain and could resume
evidenced by the patient motion exercise and ambulation in extremities power. activities and
relief methods. maintain mobility which is significant of
 She is alert and orientated.  Assess patient’s mobility and tolerance on sit physiological functioning because it greatly influence tolerate longer sit
out duration.
up duration. maintenance of independence (Miller, 2009)
Vital sign 138/72mmHg, P Observe the
86pbm, RR18, SpO2 98% in  Refer to physiotherapist for evaluation and  Physical therapists are professional experts on walking steps
RA. All in normal range. development of mobility rehabilitation plan. mobility (Carpenito, 2013) quantity to
evaluate if resume
Dysfunctional Health mobility.
Pattern:
Cognition and perception
Assessment Nursing Goal(s) & Nursing Interventions Rationales Methods of
Diagnosis Expected Outcomes Evaluation
Subjective Data:
Problem: Goals: 1. On-going assessment 1. Assessment
 Ms Lam was suffered from 1. Observe and
Bilateral OA knee and reported Impaired physical Patient will report  Perform muscle strength assessment by muscle  The muscle strength testing is to evaluate the record the
limited walk when admission. mobility increase strength and strength testing on a 0-5 scale (M.R.C., 1943) complaint of weakness, involved testing key tolerance
progress on
 She reported concerns on her Etiology: endurance of limbs. every 4 hours on both upper and lower limbs. muscle from upper and lower extremities against
sitting out
mobility level and self-care  Assess for impediments to mobility. the examiner’s resistance and grading the patient’s
strength on a 0-5 scale (Naqvi, Sherman Al., 2019) duration every
Decreased muscle Expected outcomes
regarding her illness and
hospitalization. strength and  Assess patient’s ability to perform ROM to all  Identifying barriers to mobility, guides design of an
shift within
hospitalisation.
 Patient is able to tolerate joints.
 She felt stress on her self-care endurance
longer sitting out time to 2. Pharmacological intervention
optimal treatment plan (Gulanick & Myers, 2011).
2. Ask the patient
ability due to impaired physical secondary to
1.5 hours in the next day  Assessment provides data on extend of ant physical to demonstrate
mobility. fracture on right
and keep improvement  Administer medications as prescribed for pain problems and guides therapy (Gulanick & Myers, the correct
distal radius and
 She had history of prophylactic right superior rami.
afterward. relief management. 2011). application of
intramedullary nailing to both  Patient understand the 3. Increase limbs mobility and determine type of 2. Pharmacological interventions using sling to
protected her
femur in 2013, she complained application on conservative ROM exercises appropriate for the patient  Analgesics may reduce plain that impedes right arm by the
mild weakness of both leg after
that surgery and needed to walk Signs &
treatment on fracture wrist  Teach and encourage patient to perform active movement (Gulanick & Myers, 2011). end of the shift
by using mechanical device and before
with stick to balance herself. Symptoms: sling correctly.
ROM exercises on unaffected limbs at least 4 3. Increase limbs mobility by ROM exercise discharge.
times a day.
Objective Data: (major defining  Patient can demonstrate the  Teach and encourage patient to perform  Active ROM increases muscle mass, tone, and 3. Ask the patient
strength and improves cardiac and respiratory
 Ms Lam required assistance characteristics) use of adaptive techniques
to increase mobility by the
passive or active assistive ROM exercises on functioning (Carpenito, 2013).
to demonstrate
when turning and change of affected limbs every 4 hours, or increase if she can use
diaper. Most of her time was on  Limited range of end of shift duty. frequency if tolerate, on supine or sitting  Passive ROM improve joint mobility and walking frame
bed after admission. motion with right  Patient performs position. circulation and decrease likelihood of contractures. correctly by the
end of the shift
4. Maintain Good body alignment when When doing the exercise slowly can allow muscle
 She cannot sit out for long time lower limb 0-20
degree flexion
improvement in physical
activity within limits of time to relax and support the extremities above and and observe
due to severe pain of her surgical mechanical device sling is used when she is
only. disease one week after. below the joint to prevent strain on joint and tissue
wound side, poor tolerance,  Demonstrate and assess the correct application (Carpenito, 2013). walking with
always shouted for help after  Inability to move frame.
sitting out for 1 hour.
of using sling to protect arms, sling should be 4. Correct application on mechanical device Sling
purposefully with loose around the neck and should support the 4. Assess mobility
 She can only tolerate to walk 4-5 physical elbow and wrist at the level of heart.  Compression of nerves by casts, braces, slings and by testing
environment, she
steps with frame and 2 people
required assistance  Assess the circulation, sensation, pressure point other mechanical devices or improper positioning
can cause ischemia and nerve degeneration
patient’s
assistance. muscle strength
when turning, and skin conditions every 4 hours when using (Carpenito, 2013). and record
 Physically, Muscle power change of diaper, sling.
strength exam done and result walk with 2 people 5. Teach the patient how to ambulate with  Frequent assess of circulation, sensation, pressure progress every
shift. Assess
2/5 on both right upper and assistance. point and skin conditions can detect problems early
adaptive equipment like frame walker patient’s ROM
to prevent complications (Carpenito, 2013).
lower limbs which indicated  Reluctance to  Instruct the patient in weight-bearing status. and ability to
muscle activation with gravity
attempt movement 5. Ambulate with adaptive equipments assist on self-
eliminated and full range of Observe and teach the use of frame walker by
motion. Morse fall scale score
due to severe pain. using arm strength to support weakness in  Ambulatory aids must be used correctly and safely care activities
within limited
85/125 indicated high risk of lower limbs, gait varies with patient’s problems to ensure effectiveness and prevent injury
disease every 8
fall. and adjust to ensure a slight bend at the elbow (Carpenito, 2013).
hours until
Dysfunctional Health when the patient is standing with hands on the 6. Consult physiotherapist discharge.
walker.
Pattern:
6. Consult physical therapist for evaluation and  Physiotherapist can help patient with exercises to
Activity and exercise promote muscle strength and joint mobility and
development of a mobility plan
therapies to promote relaxation of tense muscles.
 Refer to physiotherapist for evaluation and These interventions can contribute to effective pain
develop mobility plan and encourage patient to management (Gulanick, & Myer 2011).
follow treatments regime from physiotherapist.