65209370 Nursing Care Plan PDF

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1 NURSING CARE PLAN FOR THE PERIOPERATIVE PATIENT 2003 Elmhurst College Deicke Center for Nursing Education Name

Amanda Malmstrom

Faculty

Barb Zak

GENERAL DIRECTIONS Select a preoperative patient that you took care of for 2 days. Apply the nursing process and theoretical concepts to create an individualized nursing care plan. An optional draft may be submitted prior to the due date. A paper submitted on the due date cannot be revised and resubmitted. In addition to utilizing your texts, you will need to incorporate a professional journal article published within the last 5 years that relates to your patient's care. The article must be from a professional nursing journal. Lay oriented journals or magazines are not acceptable. This article must be cited within the paper. This paper must be word-processed. The text boxes are not meant to imply how much information you need to include in each section. They are designed to expand as you type in your data. You cannot work on the nursing care plan at Blackboard Web Site. Any data that you put on the form at the site will be lost. You must first save the document to your hard drive or USB storage device. If you must save the document to a floppy disk, work on it on the hard drive and transfer the finished product to an empty disk when you are done for the day. Otherwise, you may run out of disk space because of the large amount of formatting in this document. If you will be using your computer at home, see if it is compatible with your word processing program. If you have any problems with compatibility, ask for assistance in CSTC 107. If you work on the document in the CSTC, saving directly to a USB storage device is recommended to avoid losing all of your data if the computer freezes or needs to be rebooted. 16 MB devices are available for approximately $20-25. The computers in Room 110 have USB ports that are located on the front of each computer. GENERAL POINTS Demonstrate a professional level of writing. (2 pts.) Reference citations are incorporated within the nursing system design in APA format (Author, year) in designated sections. (1 pts.) Turn in the word-processed medication profiles for ALL routine and prn medications prescribed for this patient. (2 pts.) There will be a 10% deduction per day if the paper is not turned in on the date due.

2 THEORETICAL CONCEPTS List the health condition for which surgery was performed and the name of the surgery. (1/4 pt.) Prosthesis loosening of Right knee Health condition for which surgery was performed Surgical procedure performed Total Right knee replacement List the significant preexisting health conditions. (1/4 pt.) BILATERAL kNEE REPLACEMENTS – 3 TOTAL MI HISTORY OF ULCERS

Home Medications (dose and schedule) (1/4 pt.) Lopressor 50 mg ½ BID Smitriptlin 25 mg 2 QHS Saw Palmetto 1000mg QD Pravachol 40 mg QHS ASA QD Tylenol PM PRN

Nitro-Dur Patch 0.2 mg 12HR QD

All Hospital Medications (dose and schedule, including prn medications) (1/4 pt.) Ancef 1 gm IVPB Q8 HR Colace 100 mg PO BID Lovenox 30 mg SC Q12 HR Lopressor 25 mg PO BID Lactated Ringer’s 1000ml IV Q10HR Nitro-Dur 1 each TOP QD Tylenol 650 mg PO Describe the pathophysiology of the current health condition including signs, symptoms, usual diagnostic tests and treatments. Include citations in APA format. (3 pts.) The patient was admitted into the hospital for pain in the right knee. He was admitted on 11/03. He had a total knee replacement on his right knee in 97 and now six years later there is loosening of the prosthesis and damage to the polyethylene. The patient claims that the knee replacements that were used in 97 are being recalled and his might be that type. The patient’s surgery was a total knee replacement. A KNEE PROTHESIS KNEE REPLACED THE OLD PROTHESIS KNEE, WHICH IS AN IMPLANT OF METAL, HIGH-DENSITY POLYTHELENE, CERAMIC, AND OTHER SYTHETIC MATERIALS. For this surgery, the placement of the prosthesis knee was cemented in place. The patient was feeling pain in his right knee due to the surgery. it was rated a 9 on Tuesday and AN 8 on Wednesday out of 10. There was some tingling and burning on the right knee on Tuesday, which subsided on Wednesday. Briefly explain the pathophysiology of preexisting health conditions. Include citations in APA format. (3 pts.)

3 The patient’s preexisting health conditions included the following, bilateral knee replacements, myocardial infarction, and history of ulcers. The bilateral knee replacements are surgical insertion of a hinged prosthesis. Diseased surfaces are removed and a two piece metallic hinge is inserted into the medullary cavities of the femur and tibia. This was the patient’s third total knee replacement, the second in his right knee. a myocardial infarction is necrosis of cardiac muscle caused by an obstruction in a coronary artery THROUGH atherosclerosis, a thrombus, or SPASM, WHICH then triggers a heart attack. the patients history of ulcers is described as a circumscribed, craterlike lesion of the skin or mucous membrane resulting from necrosis that accompanied some inflammatory infectious or malignant process. Explain how the preexisting health conditions may impact upon the patient’s preoperative, intraoperative or postoperative course and each other. Include citations in APA format. (3 pts.)

The patients preexisting health conditions could have impacted the patient’s recovery in minimal to extensive complications. The best preexisting health condition this patient had was past total knee replacements. The patient then knew what he had to do to minimize his stay and decrease infection and more complications. This patient was though a little on the difficult side in means of not fully cooperating. Example would be that he was asked to do his incentive spirometer and he would put of a fight to not have to do it, but in the end he knew it was in the best interest of his health and would decrease his stay. With some assertiveness and aggressiveness the patient did do what he was told and cooperated. Due to a past myocardial infarction, medication WAS given to him to aide in increased cardiac output and decrease BP, WHICH would help maintain prevention of an anginal attack. These medications were the Nitro-dur patch and lopressor. Also, the history of ulcers could increase the patient’s risk of having one due to the stress and inflammation from the trauma of having this surgery. EXPLAIN THE SURGICAL PROCEDURE PERFORMED TO TREAT THE PATIENT'S HEALTH CONDITION. INCLUDE CITATIONS IN APA FORMAT. (1 PT.) The surgical procedure performed was a revision of the right knee prosthesis. The patient was under general anesthesia, while the right knee and leg were prepped and draped properly. A tourniquet was placed on the upper right thigh to help keep blood loss minimal. The tourniquet was inflated to 350mm Hg. The incision was a midline through the medial parapatellar, which then opened exposed the knee. The tibial component was addressed and the polyethylene was removed. The acetabular and femoral components were also removed due to them being loose. Then a trial and error approach was needed to find the parts that would fit the knee well to maintain patency. In order for the parts to fit right, addressing certain components to fit right were tried, then the trial components were removed and the final components were inserted and cemented into place. The knee was able to perform ROM and had good alignment and stability. The patellar was intact and left alone, irrigation was performed and then closure to the incision was done over a hemovac-solcotrans drain. Staples were used to keep the skin intact and a pressure bandage was applied with also cold pad therapy.

DATA COLLECTION, ANALYSIS & NURSING DIAGNOSIS

4 Include data for both days of care. When data does not change from day 1 to day 2, there is no need to rewrite the data. If the assessment is abnormal, (Abn) place an X in the first column. ASSESSMENT OF SOCIOCULTURAL, PSYCHOLOGICAL, DEVELOPMENTAL, AND SPIRITUAL VARIABLES Focus on the client’s discharge as well as the inpatient stay DEVELOPMENTAL ASSESSMENT (2 PTS.) Abn Assessment Category Data Specific to this Patient Age 59 Gender Male Developmental Stage Patient's stage according to Erikson is Erikson's Stage Generativity versus Stagnation Discuss the patient's ability to In this stage it includes adults from ages 25-65 years old. meet the tasks of this stage. There are positive tasks such as creativity, productivity, and Describe how the health concern for others. The negative tasks would be selfcondition has or has not altered indulgence, self-concern, and lack of interests and the patient's ability to meet commitments. The patient has no problem meeting these these tasks? tasks since there was not any health alterations that could affect him in any different way that he has not experienced before. Cognitive Developmental This patient is able to process reactions, problem solve, and Stage according to Piaget has the ability to learn. His memory and perception are also Educational data very well. His cognitive and intellectual level does not seem Literacy affected by his age or from surgery. According to Piaget’s Primary language phases of cognitive development, he has successfully carried out all stages. Formal operations phase which the use of rational thinking and reasoning is deductive and futuristic. This patient’s rational thinking and reasoning is presented and expressed in a positive way. He understands that the future does not hold a complete recovery with out sign or symptoms related to his knee, but is positive in looking ahead. He wants to get better not only for himself, but to enjoy his life and partake in ADL’s. How has the patient's health condition/surgery affected his ability to meet developmental tasks?

This patient’s ability to meet developmental tasks in not affected from his surgery. The only impact this patient could be feeling is that he has been off of work for 20 years due to a fall at work and has not returned since. He has had many operations performed in relation to his knee, so I believe that the only real affect this could have on him is that it is an ongoing problem and has impacted his career.

SOCIOCULTURAL & SPIRITUAL ASSESSMENT (2 pts.) Abn

Assessment Category Family dynamics:

Data Specific to this Patient The patient has a wife that was there both days and helped

Family Members Client’s role in family Family communication pattern Client’s support system

Occupational data Employment Health benefits Ability to meet economic needs after discharge

Living environment prior to hospitalization Housing Neighborhood Support/Resources Culture/Ethnicity Affiliation Practices/beliefs Impact on illness Spiritual practices Religious affiliation Practices Impact on illness

5 him and myself in assessment. She bathed him on Tuesday and helped feed him. She also helped encourage and tell him to listen to me. The communication between them was very well, and they seemed to have a very good relationship. His wife is his big supporter and encourager, while also two men came to visit and also were very polite and encouraging to the patient to get better and do what he was supposed to. My patient had respect for all three of these visitors and listened to what they had to say about getting better and doing the little things that would help increase his return to home and recovery. My patient was retired for 20 years due to a fall at work in 1983. He is on workman’s comp and has Medicare. He was an electrician prior to his fall. In being retired he does not have any real economic needs to get back to since he has not been working for so long. But in reality, we all have our own economic needs and feel as if certain things we do help out and are needed. I am sure him and his wife have needs economically and the sooner he is discharged and recovery fine, those needs will be met sooner. My patient was living in a rural neighborhood in a comfortable house with his wife and his bird.

Not available

My patient was catholic and was affiliated with a church in his hometown. He had communion when I was there and was very excited about it and shared it with everyone who walked into his room. He thought it was a neat thing. I know that he has strong feelings about praying due to having so many complication’s with his knees that he prays that one day this mess will get better and not have to worry about them getting bad and going through more pain

How are the sociocultural and/or spiritual variables affected by the client's health condition/surgery?

The client’s sociocultural assessment has positive affects on his health with the increasing help and assistance from his wife and friends. His moods were much better and he was more willing to listen when visitors were there. He showed more emotion such as excitement with them in the room, but at the same time he really liked the attention from his wife and made sure she was babying him. He made comments to me that he wishes he could still be working instead of going through all of the knee surgeries and complications and wish he could go back, but knows it can not happen. I believe that if he were still working that would give him a little more motivation to get better and have something extra to look forward too.

6

PSYCHOSOCIAL ASSESSMENT (2 pts.) Abn Assessment Category Data Specific to this Patient Behavior

Appearance

Emotional status & Affect Body image Decision making ability

Individual coping

Family coping

He was alert, orientated, speech was clear and understandable. He was a little crabby and uncooperative to with some things, but eager to get well and liked to talk. Healthy appearance, a little overweight though. Skin color was normal. Once bathed his hair was combed and he felt better. No distinct body odor. No irregular body movements. In pain, but otherwise everything else was fine. High spirited with wife there and had good coping skills. Patient was a little overweight, but overall no signs of abnormalities. Was able to make decisions on own, he knew what he wanted to do and when PT came in he wanted to walk to the bathroom and knew he was capable to do so. If he needed something he would always ask. His coping was fine, which I believe had a lot do with his previous knee surgeries. He was even educating me on his surgery and was not hesitant on showing me his other knee and talking about it. His wife was very supportive and her coping ability pushed him also to do better and cooperate.

How are the psychosocial variables affected by the client's health condition/surgery?

The client’s psychosocial variables are not too much affected by the surgery. This was his third total knee replacement surgery, which helped prepare him for the preoperative, intraoperative, and postoperative care. He also has nothing to lose out on since he not working any more and his wife was there with him and his friends were in and out also. He has a lot of support and being in otherwise fairly good health helps him cope easier.

HEALTH ASSESSMENT MENTAL STATUS (2 pts.)

7 Abn

Assessment Category Level of consciousness Orientation Thought processes Attention span

Ability to comprehend & communicate Appropriateness

Judgment

Attention Span Vision & hearing including assistive devices

VITAL SIGNS (1 pt.) Assessment Category Vital signs during days of care

Abn

Data Specific to this Patient Patient is alert, orientated, responds appropriately and asks and answers question’s. Patient is orientated to time, place, date, everything. No complications with this. Able to cognitively process thoughts, feelings, and concerns. Could put together sentences and communicate efficiently. Full attention was on me when I was in there. He was curious of what I was doing. He was able to concentrate on other things and me. Ability to comprehend and communicate well. No problems gathering thoughts or if he had questions he would ask. He was appropriate in most cases, with some things though he was inappropriate in ways to ask me to leave when I was assessing him. For example, I was emptying his foley bag and he asked me rudely to leave his room as I was in the middle of doing emptying it because he wanted to tell his visitors a story and could not wait to do so. His judgment was fine; he made good choices on what he should be doing and not doing. He knew exactly what needed to be done to help benefit his health. Some judgments with not cooperating were not adequately right, but that is just his personality. Full attention on me or whoever was in there. Had full attention on his knee and would favor his other leg and be protective of his bad one. He had perfect hearing and had glasses. I did not see him wear his glasses while I was with him.

Data Specific to this Patient Tues 130/60, 90, 20, 101.1

Wed 132/64, 90, 18, 99.4

PAIN ASSESSMENT (2 pts.) Abn

X

Assessment Category Location & Characteristics (Describe)

X

Pain rating Scale (e.g. 0-10) Presence of PCA Epidural /Intravenous Site Assessment

Data Specific to this Patient The patient expressed there was a tingling and burning sensation right above his knee. There was pressure on it when he would sit up and it felt very uncomfortable for him. Wed Tues 9 or 10/10 8/10 Basal rate= Dose None Morphine 1.5 mg/ 6 min. Frequency=

# of mg used on your shift

Pharmaceutical Interventions last 24 hours Nonpharmaceutical Interventions

4 hour lockout 1 hour maximum Morphine PCA 1.5 mg/ 6 min

8 # of attempts on your shift

Polar ice pack, pillows, CPM, also having visitors distracted him from his pain. PT came in BID to do exercises and ambulate him.

INTEGUMENT (2 pts.) Abn

Assessment Category

Data Specific to this Patient

X

Skin color, Temperature, Moisture

Skin color was normal, pinkish tan. Temperature was elevated and skin was warmer than normal. Moisture was normal Texture feels smooth and firm with even surface. According to the surgical report, there was a midline incision across the knee. I was unable to assess the incision due to the dressing and ace wrap applied. 17/23 with some risk due to age. The location of the incision was on the right knee, midline parapatellar. There was an ace wrap over it with the polar ice wrap on top of that. There was no drainage on the dressing from what I assessed. There was a drain that was intact. The location of the drain was on the right knee. It was a Hemovac-Soloctrans. There were serasanginous fluids irrigating from the intact drain, which collected about 40 cc. This was reported on a 24-hour shift.

Skin integrity

X

Braden score & Level of Risk Wound Location Description Wound Dressing Drainage type & amount Drain Location Type Drainage type Drainage amount per shift /24h

RESPIRATORY (2 pts.) Abn Assessment Category Respiratory rate (12-20), rhythm, breath sounds Pulse oximetry (94-100%) results: Include type and amount of oxygen in use when pulse oximetry was done

Signs of respiratory distress

Sputum: Amount, Color, Consistency

Data Specific to this Patient 20 bilateral and clear, deep and regular. Pulse oximeter was 89% on Tuesday with out oxygen. A nasal cannula was used at 2 L. The pulse oximeter then went up to 95%. He was not keeping it for the full time either. He was putting it on and taking it off all the time, but it helped maintain his percent with in normal limits. On Wednesday it was not done due to not being able to fine one for the time I was there. There were not any signs of respiratory distress that were of any serious complications. He did do deep breathing and coughing, which he showed minimal dis...