Nursing Care Plan for Left Knee Replacement

Definition :

“A limitation in independent, purposeful physical movement of the body or one or more extremities” (Ackley & Ladwig, 2011, p. 548).

Defining Characteristics :

“ Decreased reaction time; difficulty turning; engages in substitutions for movement (e.g., increased attention to other’s activity, controlling behavior, focus on pre-illness disability/activity; exertional dypsnea; gait changes, jerky movements; limited ability to perform gross motor skills; limited ability to perform fine motor skills; limited range of motion; movement-induced tremor; postural instability; slowed movement; uncoordinated movements” (Ackley & Ladwig, 2011, p. 549).

Related Factors

“Activity intolerance; altered cellular metabolism; anxiety; body mass index above 75^th age-appropriate percentile; cognitive impairment; contractures; cultural beliefs regarding age-appropriate activity; deconditioning; decreased endurance; depressive mood; decreased muscle control; decreased muscle mass; decreased muscle strength; deficient knowledge regarding value of physical activity; developmental delay; discomfort; disuse; joint stiffness; lack of environmental supports (e.g., physical or social); limited cardiovascular endurance; loss of integrity of bone structures; malnutrition; medications; musculoskeletal impairment; neuromuscular impairment; pain; prescribed movement restrictions: reluctance to initiate movement; sedentary lifestyle; sensoriperceptual impairments” (Ackley & Ladwig, 2011, p. 549).

“Suggested functional level classifications include the following:

0-Completely independent

1-Requires use of equipment or device

2-Requires help from another person for assistance, supervision or teaching

3-Requires help from another person and equipment device

4-Dependent (does not participate in activity)”

(Ackley & Ladwig, 2011, p. 549)

Instructions for

Student

In the space below, enter the subjective and objective data gathered during your client assessment.

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Subjective Data Entry

Patient reported pain of “4”related to current acute pain “4” and “6” for chronic pain at home prior to admission based on scale of from “0” to “10”

Patient reported that she uses assistive devices at home: walker, cane, electronic chair for climbing stairs while seated, bidette to assist with personal care; CPAP for sleep

Patient reported that she engages in little social activity when at home, going out only for medical appointments

Patient reported that she often sleeps during the day and has difficulty sleeping at night

Patient reported that she is frequently fatigued and that movement around the home is difficult even with assistive devices

Patient reported that chronic pain is related to osteoarthritis and fibromyalgia

Patient reported that she is dependent upon family member for meals

Patient reported that she is able to manage some dressing and bathing, but is dependent upon bidette for some of her perianal care

Patient self-reports depression, PTSD, and fibromyalgia related to past physical, emotional and sexual abuse and to current status of general disability

Objective Data Entry

Vital signs: Temp: Oral 97.3, HR, 105, Respirations, 20, BP: r: 121/75; L 123/79

Pulses: Radial 105, L and R pedal pulses present

Height: 4 ft 11 inches Weight 259 lbs

Cognition: Alert and Oriented to person place and time X3

Affect: Pleasant, conversant, but subject to inattention due to dozing during conversation

Integumentary: Hair: clean, gray color, neat haircut, no lesions on scalp

Nasal: moist, pink

Oral: mucosa : moist, pink, tongue: moist, pink, no oral lesions. Skin Color: Pink

Skin: Color: pink Temp: warm to touch Texture: smooth Moisture/Hydration: moist, turgor positive at sternum Breakdown: the only current manifestation of breakdown is skin rashes in groin area and under breasts. Operative incision is erythmetous, but erythema is receding as evidenced by line drawn around erythema. No swelling, warmth or exudate at the operative incision

Respiratory: Respirations: 20, depth even and rhythm even, O2 saturation 94% at rest on room air. Observed patient fatigue upon walking a short distance from bed to bathroom,

Cardiovascular:Apical Pulse: 105; Rhythm: regular; Radial pulses: left and right present Pedal Pulses: left and right present

Capillary refill observed L X 5 fingers and R X 5 fingers; L X 5 toes and R X 5 toes < 3 seconds LE: 2+ edema left operative extremity lower calf

Musculoskeletal: poor mobility. Left hand slightly weaker than right; tremors appeared in left when squeezing fingers

General: Patient experiences generalized pain chronically and current acute pain at operative site. Patient used ice pack and lidocaine strips to moderate localized pain (in addition to pain medications). Patient experiences chronic sleep disturbances, in particular, chronic obstructive sleep disorder. Sleep is only moderately relieved by use of CPAP Objective evidence includes patient frequent dozing during interview. Patient is obese: weight 259 lbs/height 4 feet, 11 inches BMI 52.3

Evaluate

Student Instructions: To be sure your client diagnostic statement written below is accurate you need to review the defining characteristics and related factors associated with the nursing diagnosis and see how your client data match. Do you have an accurate match or are additional data required, or does another nursing diagnosis need to be investigated?

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Diagnostic Statement

Nursing Diagnosis (specify) Impaired Physical Mobility (Carpenito-Moyet , 2010, p. 285) related to pain, fatigue, obesity and sleep disturbances as evidenced by patient fatigue upon walking a short distance, patient report of limited mobility, patient dozing during interview, patient pain reports of “4” and “6” on scale of from “0” to “10” , patient BMI 52.3

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Desired Outcome The Client will:

and Client Criteria:

Reduce weight by 20% after one year compared to baseline of 259 lbs

Reduce feelings of depression by 20% as measured by the PHQ-9 questionnaire after one year

Improve mobility by 20% after one year compared to baseline determined by physical therapist assessment

Reduce pain by 50% after one year compared to baseline of “6” on scale of from “0”to“10”

Improve feelings of self esteem and self-efficacy by patient report after one year

Evaluate

The desired outcome must meet criteria to be accurate. The outcome must be specific, realistic, measurable, and include a time frame for completion. Does the action verb describe the client’s behavior to be evaluated? Can the outcome be used in the evaluation step of the nursing process to measure the client’s response to the nursing interventions listed below?

Interventions

Referral to mental health counseling to identify and treat depression, issues of self-esteem and self efficacy

Referral and active participation in physical therapy to improve mobility

Undertake regular exercise that includes ambulation for longer distances, higher frequency and increased repetition of performing ankle pumps, gluteal sets and quadriceps sets.

Use heat and cold, stretching and range of motion exercises to manage symptoms of fibromyalgia

Referral to pulmonologist for sleep disturbance assessment.

Referral to pain management specialist for assessment, planning and treatment related to various sources of patient pain

Referral to nutritionist for assessment and planning related to nutrition and weight reduction. Set realistic goals for weight reduction, encourage patient to keep food diaries, provide patient with information about the relationship of weight management to pain reduction and mobility improvement, identify stress issues related to obesity and support systems that can help patient in weight reduction.

Rationale for Selected Intervention and References

Research indicates that attention to psychosocial issues and mental health counseling can have a positive impact on reduction in obesity (Yilmaz et al, 2011). Depression has been related to weight control in patients with osteoarthritis (Possley et al, 2009). Mood disorders are related to fibromyalgia (Dell, 2007).

Research has shown that active participation in physical therapy is important to improved mobility post TKR (Hall, Hardwick, Reden, Pulido,& Colwell, 2004).

Research indicates that behaviors such as ambulation for longer distances, higher frequency and increased repetition of performing ankle pumps, gluteal sets and quadriceps sets are related to greater self-efficacy in patients who have had total joint replacement (Moon & Backer, 2000). Regular exercise improves pain, physical function and contributes to weight reduction in patients with osteoarthritis (Seed, Dunican & Lynch, 2009). Active physical exercise has achieved modest positive results in reduction of signs and symptoms of fibromyalgia (Turk, 2009).

Research has shown that heat and cold, stretching and range of motion exercises improves symptoms of fibromyalgia ((Turk, 2009).

Research has shown that sleep disturbances should be evaluated and treated as a component of treatment of fibromyalgia (Dell, 2007).

Patient has pain related to many sources and may influence the patient’s approach to obesity and mobility. Pain has been related to obesity (Janke, Collins, Kozak, 2007).

Realistic goals, food diaries/monitoring/ understanding of the relationship between pain and mobility, stress issues and support systems have been shown to support successful obesity self care and illness prevention (Hindle & Dell, 2012).

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Evaluate

Do your interventions assist in achieving the desired outcome? Do your interventions address further monitoring of the client’s response to your interventions and to the achievement of the desired outcome? Are qualifiers: when, how, amount, time, and frequency used? Is the focus of the action’s verb on the nurse’s actions and not on the client? Do your rationales provide sufficient reason and directions?

What was your client’s response to the interventions? (theoretic)

Weight is reduced by 20% after one year (evaluation outcome 200 lbs)

Feelings of depression are reduced by 20% as measured by the PHQ-9 questionnaire after one year

Mobility is improved by 20% after one year compared to baseline established by physical therapist assessment

Pain is reduced by 50% after one year (evaluation outcome “3” on a scale of from “0” to “10”

Feelings of self esteem and self-efficacy are improved by patient report after one year