INTRODUCTION

As a part of my clinical postings in medical surgical nursing, I was posted to the

surgical ward of Shree Ram Hospital, Jodhpur there was about 22 patients. Among them I
selected Mr. Kumar as my client who was suffering from osteoarthritis for my studies.

BIOGRAPHICAL INFORMATION

Name : Mr. Kumar

Age : 40yrs

Sex : male

Address : s/o Mr. Ashok kumar, kirti nagar jodhpur.

Religion : Hindu

Education : 12th STD

Marital status : married

Income : 20000 /m

Occupation : agriculture

Ward : male ortho ward

Date of admission : 07-6-2017

I.P No. : 234247

Medical diagnosis : Osteoarthritis

Name of the surgery : Arthoplasty.

Date of surgery : 11-02-2017

Date of care started : 12-02-2017

Date of care ended : 15-02-2017

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CHIEF COMPLAINTS
Mr. Kumar was admitted in Shree Ram Hospital with the complaints of,
- Hip joint pain since one week.
- Difficulty in movement.
- Fever since 2 days
PRESENT MEDICAL HISTORY

PRESENT ILLNESS
1) Symptom : joint pain.
Onset : gradual
Duration : 7 days
Quality : severe.

Associated phenomena : more in the morning time

Aggravating factors : Increases when he tries to change the position.
Alleviating factor : medication

PAST HISTORY

Past illness : Nothing significant

Childhood illness : Nothing significant
Surgeries : Nothing significant
Allergies : Not allergic to food or drugs
Injuries : Nothing significant
Hospitalization : no such experience of hospitalization
Other major illness : Nothing significant
Immunization : completed.
Medication : Nothing significant

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 SURGICAL HISTORY
PRESENT SURGICAL HISTORY
Mr. Kumar was admitted to in the Shree Ram hospital with the complaint of pain in
the right knee. He had undergone arthoplasty of right knee under spinal anesthesia on
16-01-2017.

PAST SURGICAL HISTORY

Nothing significant.

FAMILY HISTORY
There are 4 members in his family, including his wife, son and daughter. There is no
hereditary or communicable disease in his family. All other family members, except him
are healthy.

PERSONAL HISTORY
Habit: Mr. Kumar is not having any bad habits.
Diet: Mr. Kumar takes mixed diet, 3 meals a day
Social interaction: he is social with neighbors and family members.
Sleeping pattern: His sleeping pattern altered due to hospitalization.

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SOCIO ECONOMIC HISTORY
Mr. Kumar is a member of middle class family. He is the earning member of the family.
He is farmer and monthly income is Rs. 20000/-. Their living standard is average. He is
having good relationship with family members and friends.

ENVIRONMENTAL HISTORTY
Mr. Kumar is residing in his own house. It is a semi- pucca house having electricity
connection, it is well ventilated. They are using tap water for drinking and cooking
purposes. They are practicing open waste disposal method. They are using latrine for
defecation.

NUTRITIONAL HISTORY
He takes mixed diet, 3 meals a day. Dietary pattern:
Type of diet Timings Calories Calories
present provided
Break fast
8 am 156 kcal + 216 kcal
2 Idly + chutney 60 kcal

Lunch
1 pm 706 Kcal
Ganji + Sambar 556Kcal +
140Kcal
Supper

Ganji + Dhal 7.30pm 712 Kcal

556Kcal +
156 Kcal Total : 16341
Kcal

ELIMINATION PATTERN
His bowel & bladder pattern are normal. No Burning micturition.

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 PHYSICAL EXAMINATION
GENERAL OBSERVATION
Constitution : Mesomorphic
Stature : Moderately built
Posture : No deformity,
Personal appearance : hygienic,
Emotional state : Anxious and dull
Co-operative ness : co-operative

VITAL SIGNS
Temperature : 98.0 0 F
Pulse : 78 beats/min
Respiratory rate : 20breaths/min
Blood pressure : 130/90 mm of Hg

HEIGHT AND WEIGHT

Height : 138cm
Weight : 44 kg

SKIN AND MUCOUS MEMBRANE

Color of the skin : No cyanosis or lesions
Edema : Absent
Moisture : Warm and normal

HEAD
Shape & size : Normal size and shape, normal range of
Motion
Scalp : No lesions or dandruff, normal hair
Distribution

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EYES
Expressions : Normal
Eyelids : Symmetric, no edema
Eyeballs : Globes clear and firm
Conjunctiva : Pale
Sclera : Creamy White and clear
Iris : Brown color
Visual acuity : Normal
Pupils ‘PERRLA’ : Round, symmetrical, equally reacting to light
Eye movements : Normal

EARS
Appearance : Auricles are symmetric, wax present
Hearing : Normal

NOSE
Appearance : Normal, no nasal septal deviation
Sense of smell : Normal

MOUTH AND THROAT

No inflammation or infection
Lips : Dry, no cracks
Tongue : No glossitis or coating
Gum : No inflammation
Buccal mucosa : No stomatitis
Palate : Intact, no deformity
Taste : Normal.

NECK
Appearance : No deformity or stiffness
Trachea : No deviation

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Lymph node : Not palpable
Thyroid gland : Symmetric, no enlargement

CHEST AND RESRPIRATORY SYSTEM

INSPECTION
Symmetry : Bilaterally symmetrical
Expansion : Equal
Equality of movement : Normal
Type of respiration : Abdomino-thorasic
Rate : 20 breaths/min
PALPATION
Expansion : normal
Local swelling : Absent
Vocal tactile fremitus : Present, normal
PERCUSSION
Basal : Normal
Apical : Normal
Axillaries of midzone : Normal
AUSCULTATION
Bronchial breath sounds : normal
Broncho vesicular : normal
Vesicular : normal
Friction rub : normal

CARDIO VASCULAR SYSTEM

INSPECTION
Chest contour : Normal, no sternal depression
Pericardium : No Bulging
Neck : No normal venous pulsation, jugular venous
Distension

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PALPATION
Pericardium : No thrill
Supra sternal notch : no thrill
Neck : Arterial pulsation, Weak peripheral pulsation is
seen.

PERCUSSION

Cardiac outline : Difficult to find cardiac border.

AUSCULTATION
Apical late : S1 & S2 heart sounds was present
Blood pressure : 130/90 mm of Hg
Neck : No murmurs

ABDOMEN:
INSPECTION
Shape : Scaphoid shape.
Movement : normal.
Skin texture : No discoloration, cyanosis, distention
Contour : Normal flat, no mass, normal bowel.

AUSCULTATION : Bowel sound is diminished.

PERCUSION
Organ borders : Normal, bladder dullness not found, no gaseous
Distention

PALPATION
Mass : Tenderness is present in lower abdomen.

BACK
Spinal curvature : No deformity

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 Concavity in the cervical-lumbar regions,
Concavity in the thorax
Symmetry : Normal
Movement of mobility : Normal ROM
Tenderness : Slight tenderness over costo vertebral region

GENITALIA : Nothing significant

UPPER AND LOWER EXTRIMITIES

Range of motion : is normal.
Cyanosis : Absent
Injury : nothing
Strength : normal.

NERVOUS SYSTEM
Higher function : Nothing significant
Speech : Fluent or clear words
Cranial nerves : Normal
Motor function : Normal muscle tone, less in left leg.
Sensory function : Respond to pain, position of light touch
Reflexes : Normal superficial, deep of visceral reflexes.

INVESTIGATIONS

Name of the investigation Patient Value Normal Value

Blood
- Hb 8.2 gm% 12-14gm%
Urine Dark in color, more
concentrated. Pale in color.

x- ray - No deformity

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DRUG FILE

Name of the Route Dosage Frequency Action Side effects

drug
T. diclofenac Oral 125mg BD analgesic Jaundice, anemia, renal
toxicity.
Inj.cefotaxime IV 500mg OD antibiotic Rash, tightness in the chest,
diarrhea, abdominal cramps.
Inj. Amikacin IV 100mg OD antibiotic Nausea, vomiting, dizziness,
tinnitus, hearing loss.

NURSING MANAGEMENT
PRE OPERATIVE NURSING DIAGNOSIS
1. Chronic pain related to osteoarthritis as manifested by the facial expression.
2. Impaired physical mobility related to joint pain as manifested by decreased daily
activities.
3. Imbalanced nutritional status less then body requirement as manifested by
anorexia, weight loss.
4. Knowledge deficit regarding disease process, prognosis, treatment and follow up
care related to lack of exposure to treatment modalities.
SHORT TERM GOAL
- To relieve pain
- To maintain normal activity.
- To maintain nutritional status.
- To reduce anxiety.
LONG TERM CARE
- Health education.
- Follow up care.

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POST OPERATIVE NURSING DIAGNOSIS.
1. Pain related to surgical procedure as manifested by the facial expression.
2. Activity intolerance related to restriction movement as manifested by decreased
daily activities.
3. Imbalanced nutritional status less then body requirement as manifested by
anorexia, weight loss.
4. Impaired sleeping pattern related to pain as manifested by awakens during night.
5. Ineffective therapeutic regimen management related to lack of knowledge
regarding long term management.

6. Anorexia related to hospitalilization as manifested by facial expression.

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 Nursing
Assessment Objective Planning Rationale Implementation Evaluation
Diagnosis

Subjective Chronic pain Client will To assess the To plan for Assessed the The client
data related to experience location on set, appropriate location, onset, experienced
I am fed up osteoarthritis reduced pain duration and intensity interventions duration and Relief from
with pain in As manifested and will feel of pain using severity/intensity of pain.
my left thigh more comfort numerical pain scale. pain. The severity of
by the facial
Objective table. pain ranges from 5-6
data expression. in the numerical
Evidenced by To immobilize or To reduce pain pain scale.
fatigue, support the affected and to prevent Immobilized and
restlessness, leg pathologic fracture supported the
guarding etc affected leg using
To reduce pillows.
swelling and to
To elevate the provide comfort.
affected extremity. Elevated the
To relieve affected extremity to
infection and pain reduce swelling
Administer
medications like Administered
analgesics and Inj : CP and
antibiotics To reduce the Ciprofloxacin.
need for
analgesics
Teach the use of
diversional activities
like relaxation
distraction etc.

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Assessment Nursing Objective Planning Implementation Evaluation
Diagnosis

Subjective Activity To relieve the patient - Assess the onset, degree - Patient feels pain The client got some
Data: The intolerance due to from pain and duration of pain so during walking and relief from the pain.
patient acute pain related appropriate intervention are standing. The pain
complains that to inflammation, planned subsides when the
he has severe edema edema of patient takes rest with
pain in his the right leg as his leg elevated.
right leg and manifested as - Provide comfortable
knee. communication of position to the patient and - Taught the patient
pain descriptions teach the patient about the
Objective data: and behavioural about elevating the leg
On observation indicative of pain. activities to assist in regularly while sitting
the patients reducing the strain on the and sleeping while on
expression leg. bed with use of extra
reveals that he pillows.
- Use pain control measures,
is in extreme with the use of medications - The patient was
pain. as directed by the physician. administered
medications as directed
by the physician to
control pain.

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Subjective Imbalance in The client To assess the It give a clear Assessed the nutritional The client’s
data nutrition less will maintain nutritional status of idea about the status of the client. nutritional
I feel so tired than body adequate the client health status of status has
and I don’t requirement due nutritional the client been
want to eat to loss of status improved.
any thing. appetite related To know Assessed the current
to fever. To assess the current whether he is timing & contents of the
timing and contents of getting adequate meals.
the food nutrition

Objective
Data To advise the client to Helps in better Advised the client to
Evidenced by take small & frequent digestion & take small and frequent
weakness and meals absorption. meals.
fatigue.

To monitor the weight Weight shows

of the client the adequacy / Monitored the weight of
inadequacy of the client.
nutrition.

To administer To reduce
medications as acidity and to Administered
prescribed. improve the Inj:Ranitidine, IV.
appetite.

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 Nursing Expected
Assessment Planning Rationale Implementation Evaluation
Diagnosis outcome
Acute pain Client will To assess the location To plan for Assessed the location, The client
Subjective related to experience on set, duration and appropriate onset, duration and experienced
data surgical reduced intensity of pain using interventions severity/intensity of relief from
I am fed up procedure as pain and numerical pain scale. pain. The severity of pain.
with pain in manifested will feel pain ranges from 5-6 in
my left thigh by facial more the numerical pain
Objective data expression. comfort To immobilize or To reduce pain and scale.
Evidenced by table. support the affected leg to prevent Immobilized and
fatigue, pathologic fracture supported the affected
restlessness, leg using pillows.
guarding etc To reduce swelling
To elevate the affected and to provide
extremity. comfort. Elevated the affected
extremity to reduce
To relieve infection swelling
Administer medications and pain
like analgesics and Administered
antibiotics Inj : CP and
Ciprofloxacin.
To reduce the need
Teach the use of for analgesics
diversional activities
like relaxation
distraction etc.

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POST OPERATIVE NURSING DIAGNOSIS
Subjective data Impaired The client To assess the Helps to know Assessed the The client got
I don’t have sleeping gets adequate sleeping pattern of about the quality sleeping pattern of adquate sleep.
good sleep due pattern sleep. the client. of sleep he gets. the client.
to the pain in related to
the leg severe To know if effect
pain in the To assess the on sleeping Assessed the
leg and severity of pain in pattern. severity of pain in
cough. the leg. the leg using
numerical pain
Objective Data To reduce scale. It ranges
Evidenced by infection and pain from 5-6
weakness To administers
sunken eyes etc. medications as per Administered
orders. To promote sleep. medications like
Inj:CP
To provide
comfortable bed To avoid the
and position. disturbances in Provided
the sleep. comfortable bed
To limit the and position.
distractions in the
environment. Limited the
distractions in the
environment.

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Subjective Ineffective Client will To assess the level of To know the Assessed the level of The client
data therapeutic demonstrate know ledge & skills areas where he knowledge and skills demonstrated
I don’t know regimen care of the of the client about the has good of the client about the the care of
how to take management leg and will therapeutic regimen. knowledge & therapeutic regimen. the leg.
care of my leg related to lack of describe the where he lacks
at home. knowledge treatment
regarding long regimen o demonstrate the To improve the Demonstrated the care
term care of the leg to the knowledge of of the leg
management. client the client

Objective To improve the Instructed the client

Data To instruct the client patient’s about the action, route,
Evidenced by about the action, knowledge. dosage side effects of
verbalization dosage, route and each drug.
of concern side effects of each
uncertainty medication. To evaluate the
about client’s Evaluated the clients
procedures & To evaluate the performance ability to self
skills needed patient’s ability to administer the
for home care self administer the For better and medications.
medications. quick recovery.
Educated the client
To educate the about the importance
patient about the of taking the
importance of taking medications at the
medications at the correct time.

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correct time.

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HEALTH EDUCATION .
1. NUTRITION
Advised my patients regarding taking a balanced dirt and also have explained
about importance of nutrition.
2. PERSONAL HYGIENE.
Taught the client about the need of personal hygiene. Assted in bathing brushing
and grooming.
3. REST AND SLEEP.
Advised the client to have adequate sleep and rest . Advised the client to have not
sleep during the day and sleep well in night.
4. EXERCISE.
Advised about the importance of exercise in normal health. Advised the client to
do active and passive exercise .
5. MEDICATION.
Advised the client about the importance of taking medication at the correct time.
6. FOLLOW UP
Advised the client about the importance of follow up care like medication
schedules.
CONCULSION
I was posted in the surgical ward of Shree Ram Hospital, Jodhpur. I taken a
patient name of Mr. Kumar admitted with complaints of difficulty in walking
since one week. After investigation doctor diagnosed this case as osteoarthritis.
And he had undergone the Arthoplasty surgery. He had taken some treatment
also.
BIBLOGRAPHY
1. Suzanne C Smelter and Brenda ‘Text book of medical surgical nursing ’’.
10th ed. Philadphia p1025-1027
2. Lewis, coller and Heitkemper ‘Medical surgical nursing assessment of
clinical problems ’’ 4th Ed St Louis pp 1200-1203.
3. Basavanthappa B.T ‘Medical surgical nursing’’ 1st ed. Bangalore Jaypee
publications. P269-272.

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