CENTRAL LAKES COLLEGE Associate Degree Nursing Program Nursing Care Plan

GRADE = S /NI/ U

Student Name: Andrea Dumond Date of Clinical Experience: 11-16-11 Patient Initials: ML Reason For Visit (Medical Diagnosis and/or Surgical Priority Nursing Assessments: Diagnosis/Procedure): Safety, education, pain management, TKA( left) ambulation, exercise, VS, labs,

Age: 76 Allergies: PNC, Lipitor

Health Perception/Health Management Allergies: PNC, Lipitor Falls risk: 9 (he is not a falls precautions). He is a past smoker but quit several years ago, about 15yrs ago I quit smoking. He drinks daily 1 glass a wine/ ol fashion daily is what he reports.

Self Perception Self Concept Pattern He is a healthy man that has been suffering from pain in his left knee for about 5 years. I am very active; I am not just going to sit around in a rocking chair all day long. He is a retired business man with 17 years of education. He attended a private college for business management. He has a strong support system in the community and with his direct family.

Cognitive Perceptual Pattern He was alert, orientated, speech was clear and understandable. He wears glasses for reading only. Hearing: WNL, he does not use a hearing aid and shows no signs of hearing loss. He is able to convey his needs and pain level.

Role Relationship Pattern He enjoys reading, classical He is a father of 5 music, church, and being a children. Three of the member on many children live in the area community boards. He also and one in the cities, and enjoys spending time with the other in New Zealand. his family and fiance. He lost his wife 12 years ago to bone cancer, it went quick, but I am glad she did not suffer.

Coping/Stress Tolerance

Nutrition

HT: 6 ft WT: 225 lbs. BMI: 30 (obese-over weight) He is follows a regular

Nutritional Metabolic Pattern F/E Skin Integrity/Wound Healing Body Temperature LOC: he is alert and Braden scale: 22. oriented X4, his skin Skin was warm and pink in turgor is elastic and color. Skin was soft and mucous membranes are elastic. The location of the pink, moist, and intact. He incision was on left knee, did not have edema in his midline patellar. There was

Sleep/Rest Pattern

Value Belief Pattern Spirituality He is a Lutheran man who is very involved in his church. He met his fianc at church after severing as greeters before Sunday service 8 years ago. He is

He sleeps about 7-8 hours night with no napping during the day. Since hospitalization he has been sleeping 5 hours a night, It is not like sleeping in my

diet. He does not have dentures he has his own teeth and denies any dental pain/ problems. He is not suffering from nausea. Diet at home patient reports to not like to eat foods that are high in fiber. I dont like wheat bread or cerals. I like eggs and bacon for breakfast. Marge and I eat a lot of steak, but sometimes we will eat venison but not usually.

extremities. He is not on I&O log and does not have fluid restrictions.

a 4X4 loosely covering incision. Thigh high compression hose kept 4X4 in place. Incision was dry and proximal in all areas except of distal to knee there was a small scab in between staple 30-32 with staple one proximal to the knee. There was no drainage on the 4X4 dressing. Skin was not bruised around the knee. He did have a bruise on the left anterior side of his hand from IV placement. He showered and dressed independently.

own bed, but I am still able to sleep well.

Full code and he does have a health care directive on file.

Activity Exercise Pattern Cardiovascular Respiratory B/P: 122/ 68 He was able to deep R: 18 breathe and cough Temp:98.7 effectively. He was able O2: 95% to do this efficiently, but I Pedal pulses: present and needed to be reminded to strong bilaterally. cough. Sputum was not CMS <3 sec, present WNL present. He was able to in all extremities. use the incentive P: 72, rhythm is regular, and spirometer effectively S1-S2 are strong and easily with hourly prompts. auscultated. His respirations are even JVD: not present and unlabored. Edema: not present Lung sound clear in all lobes. Past smoker of 1ppd for 20 years.

Elimination Pattern: Urinary/Bowel Mobility He is walking with a He is independent with transfer belt in place, a toileting. He reports that he walker, and assist of one has no pain, pressure, staff. burning, or urgency Gait is even and steady. associated with urination. He is walking around the He is on a bowel log and unit 4 times a day and his last recorded BM was doing leg exercises when 11/13, but he did have a reminded. He did/will BM prior to discharge use a cane at home for today (11-16-11). Without extra help and to take the use of a stool softener. pressure off of his knee, Bowel sounds active in all but he hopes after 4 quadrants. recovery he will not have He reports flatus/ he is able to use the cane. to pass gas. Reports having suffered

Sexuality/Reproductive He is a Caucasian widow that does have a fiance. His wife died 12 years ago to bone cancer. He had a vasectomy 30 years ago. He is not currently taking any medications that affect sexuality.

from constipation in the past. Discussed increasing fiber and fluid intake to reduce constipation.

Assessment of available resources, support system, etc. Resources: Marge (fiance) children, church

Lab/x-ray results and significance for your patient.

Brief review of main pathophysiologic processes (Must use a Reference with Citation)

members, community members.

Developmental Stage: Late adulthood: Integrity

vs. Despair: This patient is currently on the integrity spectrum of this developmental stage. This patient feels that he is happy with his life. He enjoys spending time with his family and friends. He feels that he has made something of his life and continues to contribute to society.
Safety Needs: Call light, phone, and tray table

within reach. Floor free from clutter, assist 1/ standby staff with ambulation, prompts to cough and use incentive spirometer.
Focus Charting: (Minimum 2)

HgB: pre op- 14, post op 12.6 (This could be a due to lost blood during surgery or dehydration prior to surgery.) Hemocrit: pre op-250, post op 158 (This could be a due to lost blood during surgery.) WBC 5.8 RBC 4.39N ( a little on the low end- possibly due to blood loss during surgery) All other lab values W/N/L ABO blood type was not obtained for the surgery (but I did check for his blood type) Lipids : lab value was not obtained by lab draw ( this is an important value to know due to the arterioscleriosis risk, and a fat embolism could cause a blockage)

Arthritis: Arthritis is inflammation of one or more of your joints. The main symptoms of arthritis are joint pain and stiffness, which typically worsens with age. Osteoarthritis is wear and tear damage to cartilage, which causes the bone on bone grinding. This grinding of bone causes pain and restricts movement TKA is a method of treating severe arthritis of the knee. The primary indication for total knee arthroplasty is to relieve pain caused by severe arthritis. If dysfunction of the knee is causing significant reduction in the patient's quality of life, this should be taken into account.

Medications: (Name, classification, why is your patient on this medication?)

Health History (Significance to current hospitalization and overall health)

Pain- 11-16-11 1030 D: pain level a 4/10 in left knee a dull but continuous, front of knee, some facial grimacing, patient stated 2/10 to be a tolerable level of pain/ discomfort for him. A: Oxycotin 5mg given per doctors orders. Offered ice pack and repositioning which did not help the pain. R: follow up to pain medication patient stated pain was now 2/ 10 which he reported to be a tolerable level. Ambulation- 11-16-11 1100

Aspirin enteric coated/ ecotrin Hyperlipidemia, diverticulistis, mild osteo/ Calcium D/ Oscal- calcium salt- strengthen lumbar spine bone density. Vasectomey, colon polyps. Celebrex/ celecoxib- nonsteroidal anti inflammatory. Reduces the symptoms of osteoarthritis. Oxicotin- narcotic analgesic- moderate to severe pain relief.

D: ambulated around unit 2 times with the use of a walker. Gait was steady and even. No discomfort with ambulating. A: Standby assist with ambulation for safety. Assessed patients level of discomfort and tolerance of activity. Noted gait and respiratory effort. R: Patient stated I am amazed how much easier gets to ambulate with every passing day. Patient reported no pain or discomfort with ambulation.

Nursing Diagnoses/ Collaborative Problem (Indicate order of priority with numbers) 1. Acute pain R/T tissue trauma secondary to surgery AEB complaints of pain, 4/10 on pain scale, facial grimacing. 69

Patient Outcomes (Measurable= clientcentered, timeframe, feasible, realistic) Patient will report pain level above a 2 / 10 on pain scale.

Nursing Interventions (Holistic, individualized, must have frequencies)

1. Assess pain level using 0-10 scale including location and quality every 4 hours while awake. 2. Assess aggravating and relieving factors influencing pain and record findings one time this shift. 3. Use empathy to convey understanding of pain. 4. Assess other factors contributing to pain; fear, fatigue, anger etc. and record findings one time this

Evaluation of Patient Outcomes (Goal met, not met, partially met) Explain. Goal partially met: Patients pain on follow up was 2/10. Patient repositioned, and used cold pack in addition to medication.

Modifications to Nursing Care Plan (diagnoses, goals, or nursing interventions) Patient was discharged from hospital. Follow up with doctor in 2 weeks, discharge information about medications were given to patient.

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shift. Encourage patient to turn on call light to report increasing pain. Offer ice packs, repositioning, and listening to classical music for break through pain. Administer pain medications as order by MD. Schedule analgesic administration prior to meals and activities. Assess pain level 30 minutes after giving pain medication to evaluate effectiveness. Evaluate patients response to nonpharmaceutical pain relief measures throughout shift to determine most effective techniques for patient. Collaborate with patient, family, physician, and other health care team members when changes in pain management are necessary.

2. Risk for infection R/T a site for organism invasion secondary to surgery. 236

Patient will report signs and symptoms of infection at incision site: redness, warmth, swelling, increased pain, and drainage

1. Assess incision site every shift. 2. Document assessment findings including drainage amount, color and consistency, as well as any presence of warmth redness or inflammation. 3. Educate patient on symptoms of infection. 4. Encourage good hand washing to prevent touching the site with germs present. 5. Monitor patient s temperature each shift. 6. Monitor lab values such as: white blood cell count, neutrophils, serum protein, serum albumin, and cultures. 7. Evaluate patients understanding of symptoms of

Patient was free from infection, and he was also able to verbalize the signs and symptoms of infection on this shift 11-16-11.

Referral for a home health care nurse to follow up with assessing the incision until incision is approximated.

infection.

3. Readiness for enhanced nutrition

Patient will identify 2 new ways to incorporate more fiber into diet by discharge today 11-16-11.

1. Assess patients usual meal choices, and preferences. 2. Assess patients likes and dislikes in whole grain foods and fruits. 3. Report patients dietary
preferences to dietary department to coordinate with meal choices

Goal partially met: Patient stated I will try to eat more apples, bananas, brown rice, almonds, peas, and corn.

Follow up with phone call from dietarian to determine further education needs, meal planning ideas, or recipes which are high in fiber. Continue to reinforce education and evaluate patients understanding of material.

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4. Offer education/ pamphlets on benefits of fiber in diet such as reducing constipation, reducing cholesterol, and satisfying hunger for longer periods of time promoting weight management. 5. Encourage patient to track diet intake in a journal. 6. Educate patient on risk factors for obesity and benefits of weight loss. 7. Evaluate patients understanding of education and materials provided. 8. Referral to dietary for consult regarding low fiber diet. 9. Discuss simple strategies to facilitate weight loss with diet such as portion control, smaller plate, refusing

second helpings etc. 10. Demonstrate the use of food

labels to make healthful choices. Alert the patient to focus on serving size, total fat, and simple carbohydrate, and fiber content.

4. Readiness for enhanced therapeutic regimen management. 524

Patient will verbalize 3 strategies to continue healing progression by the end of this shift of discharge from hospital on 11-16-11

1. Assess patient s strengths in the management of the therapeutic regimen. 2. Encourage all efforts to understand and manage therapeutic regimens. 3. Assess contributing factors that may need to be improved now or in the future. 4. Identify contributing
factors that may need to be improved now or in the future.

Goal met: Patient verbalized the need to perform leg exercises to promote circulation and prevent blood clots, use his incentive spirometer during commercials, and to walk on tred mill for 5 minutes 3x a day increasing time gradually as activity is tolerated.

Continue to reinforce education and assist in integrating regimen into daily living routines

5. Educate patient importance of leg exercises what this activity prevents. 6. Help the client
maintain existing support and seek

additional supports as needed.

7. Educate patient on the importance of deep breathing, coughing, and using incentive spirometer, in prevention of fluid building up in the lungs. 8. Remind patient to perform breathing exercises above every two hours while awake. 9. Encourage patient to track leg exercises and breathing exercises in journal. 10. Discuss strategies to integrate regimen into daily living routines. 11. Evaluate patients understanding of the education provided.

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DAILY JOURNAL ENTRIES

Goals: You will take charge of your own learning by using writing to reflect on clinical experiences and assess your own needs and growth. Throughout your clinical courses, you will be asked to keep a daily journal of your responses to experiences in the clinical area. Journals record your individual travel through the academic world. This assignment has four purposes. a) b) c) d) to encourage getting in touch with your feelings about nursing i.e., how you respond to both good and bad days, how you react to peers, how you feel about your role in the lives of patients and their families; to help you identify your individual needs and clinical objectives; to encourage you to daily evaluate your own clinical performance, building on your strengths and improving any weak areas; to provide a format through which you can identify and think through ethical concerns in clinical practice.

Your journal should be done as soon after clinical as possible while your thoughts are fresh. We respect honesty and confidentiality. We would like your journal to reflect on the above (a-d) while answering the following: What was your greatest learning experience today?

What did you do today that made you feel like an RN and what specifically can you do to progress in the RN role?

Give at least of one example of critical thinking you did and/or you observed an RN make. Be specific with how you interpreted this as critical thinking.

Describe how you have applied what you have previously learned in theory or lab to the care of your client today?