Nursing Care Plan for Left Knee Replacement (2022)

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Student Name­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­: Elizabeth (Beth) Andrews

Brief Patient History including medical diagnosis and summary of assessment findings:

The patient is a 59 year old female, widowed, who entered the Braintree Rehabilitation Center for transitional care after left knee arthroplasty due to osteoarthritis. She has a history of COPD; obstructive sleep apnea; spinal stenosis; degenerative joint disease; depression; obesity; fibromyalgia; dyslipidemia; hypothyroidism; lymphedema; tachycardia; and idiopathic tremors. She experienced a pulmonary embolism in 2009.

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The total knee replacement (TKR) was conducted at Metrowest/Leonard Morse Hospital on 5/21/12. The patient was transferred to Braintree Rehabilitation Center on 5/24/12. She had difficulty emerging from anesthesia and experienced urinary retention. She subsequently emerged from anesthesia and the urinary retention resolved. A neurological consult was ordered to assess the patient’s difficulty emerging from anesthesia; no source of this difficulty was identified during examination. The consultation suggested that her lethargy might be attributable to oxycodone (patient is allergic to milnapricine and several other drugs) which the patient takes for ongoing pain and fibromyalgia.

The patient has otherwise experienced good recovery with physical therapy 1-2 hours per day/5 days per week. She continues to experience edema of the left operative extremity; no thromboembolus was identified and her physician ordered an additional diuretic. Her incision was healing well with no local swelling, warmth, or exudates and the wound erythema was receding from the marking drawn around the incision. Staples remained intake.

The patient is a former smoker with COPD; she quit smoking just prior to the current surgery and seems to be managing this well. She is obese and indicates that she struggles with this and is aware of the relationship of her obesity to her osteoarthritis and current procedure as well as to other current and potential diagnoses. Her past medical history is noteworthy for fibromyalgia from which the patient experiences considerable disability. She associates the onset of fibromyalgia subsequent to being involved in a physically and emotionally abusive intimate adult relationship and to self-described post traumatic stress disorder relative to childhood sexual abuse. In addition, her past medical history is noteworthy for obstructive sleep apnea; patient uses a CPAP.

The patient is widowed and lives alone in Natick. She has four children who live locally and whom she indicates are very supportive. One son comes to her home everyday to cook her dinner. The patient does not cook for herself and is maintained during the day with tea until her son comes to make her dinner. The patient is very focused on understanding and accessing information about her conditions/diagnoses and treatments. When I first met her, she was reviewing information provided to her by the transitional care unit pertaining to difficulties in emerging from anesthesia and about her medications. The patient’s life appears to revolve around her illnesses and conditions; she describes herself as a multiply disabled person. She does not leave her home very much except to attend medical appointments and is highly dependent upon her family for her needs and care. The patient reports that depression is a significant factor in her life related to prior physical, emotional and sexual abuse and to her general state of disability. The patient is noteworthy for high level of health seeking behavior and a high degree of medicalization. According to the patient, her home is outfitted with multiple assistive devices which include a CPAP, a walker, a cane, an electronic chair to take her upstairs and a bidette to help her with personal hygiene.

In spite of her many disabilities, the patient is progressing well and will be discharged in about a week.

Additional Nursing Diagnosis without Care Planning Specification

Activity Intolerance

Acute Pain

Anxiety

Chronic Low Self Esteem

Chronic Pain

Deficient Diversional Activity

Depression

Disturbed Body Image

Disturbed Sleep Pattern

Disuse Syndrome

Fatigue

Health Seeking Behaviors

Hopelessness

Imbalanced Mobility: Greater than Body Requirements

Impaired Bed Mobility

Impaired Comfort

Impaired Communication

Impaired Gas Exchange

Impaired Individual Resilience

Impaired Physical Mobility

Impaired Social Isolation

Impaired Transfer Ability

(Video) How to care for your knee after Total Knee Replacement

Impaired Walking

Ineffective Activity Planning

Ineffective Breathing Pattern

Ineffective Coping

Post Trauma Syndrome

Powerlessness

Readiness for Additional Health Seeking Behavior

Risk for Cardiac/Vascular Complications

Risk for Caregiver Role Strain

Risk for Complications of Deep Vein Thrombosis

Risk for Complications of Musculoskeletal Dysfunction

Risk for Constipation

Risk for Falls

Risk for Hypothermia

Risk for Impaired Cellular Regulation

Risk for Impaired Skin Integrity

Risk for Ineffective Respiratory Function

Risk for Infection

Risk for Injury

Risk for Loneliness

Risk for peripheral Neurovascular Dysfunction

Sedentary Lifestyle

Self Care Deficit

NANDA Approved Nursing Diagnosis I Impaired Physical Mobility

Client’s Medical Diagnosis: Osteoarthritis, degenerative joint disease, spinal stenosis, status post total left knee replacement, fibromyalgia, obstructive sleep apnea, obesity, dyslipidemia, hypothyroidism, lymphedema, tachycardia, idiopathic tremors

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 75th 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

(Video) Nursing Care Plan: Easy and Simple

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?

(Video) CAREPLAN: POSTOPERATIVE HIP FRACTURE

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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).

(Video) Arthroplasty - Medical-Surgical (Med-Surg) - Musculoskeletal System - @Level Up RN

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

References

Ackley, B.J. & Ladwig, G.B. (2011). Nursing diagnosis handbook-an evidence-based guide to planning care. Ninth Edition. Mosby Elsevier, St. Louis, Missouri, 2011

Carpenito-Moyet, L.J. (2010) Handbook of nursing diagnosis, 13th Edition, Used by arrangement with Wiley-Blackwell Publishing, a company of John Wiley & Sons, Inc, Publisher Wolters Kluwer Health/Lippincott Williams & Wilkins, Philadelphia, Baltimore, New York, London, Buenos Aires, Hong Kong, Sydney, Tokyo

Dell, D.D. (2007) Getting the point about fibromyalgia. Nursing 2007, February 2007, 61-64. Retrieved from: http://web.b.ebscohost.com.mbcproxy.minlib.net/ehost/pdfviewer/pdfviewer?vid=4&sid=2a85447c-cc47-4b86-8e31-250d1b9e754d%40sessionmgr111&hid=114

Janke, E.A., Collins, A. & Kozak, A. T. (2007) Overview of the relationship between pain and obesity: what do we know? Where do we go next? Journal of Rehabilitation Research & Development, Vol 44, No 2, 245-261. Retrieved from: http://web.b.ebscohost.com.mbcproxy.minlib.net/ehost/pdfviewer/pdfviewer?vid=5&sid=2a85447c-cc47-4b86-8e31-250d1b9e754d%40sessionmgr111&hid=114

Hall, V.L., Hardwick, M., Reden, L., Pulido, P. & Colwell, C. (2004) Unicompartmental knee arthroplasty –an overview with nursing implications. Orthopaedic Nursing, Vol 23, No 3, May/June 2004, 163-173. Retrieved from: http://web.b.ebscohost.com.mbcproxy.minlib.net/ehost/pdfviewer/pdfviewer?vid=6&sid=2a85447c-cc47-4b86-8e31-250d1b9e754d%40sessionmgr111&hid=114

Hindle, L. & Mills, S. (2012) Obesity self-care and illness prevention. Practice Nursing, Vol 23, No 3, 130-134. Retrieved from: http://web.b.ebscohost.com.mbcproxy.minlib.net/ehost/pdfviewer/pdfviewer?vid=10&sid=2a85447c-cc47-4b86-8e31-250d1b9e754d%40sessionmgr111&hid=114

Moon, L.B. & Backer, J. (2000) Relationships among self-efficacy, outcome expectancy, and postoperative behaviors in total joint

replacement patients. Orthopaedic Nursing, 19 (2) 77-85. Retrieved from: http://web.b.ebscohost.com.mbcproxy.minlib.net/ehost/detail?vid=7&sid=2a85447c-cc47-4b86-8e31-250d1b9e754d%40sessionmgr111&hid=114&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=rzh&AN=2000051848

Possley. D. et al. (2009) Relationship between depression and functional measures in overweight and obese persons with osteoarthritis of the knee. Journal of Rehabilitation Research & Development, Vol 46, No 9, 1091-1097. doi:10.1682/JRRD.2009.03.0024

Seed, S.M., Dunican, K.C., & Lynch, A.M. (2009) Osteoarthritis: a review of treatment options. Geriatrics, Vol 64, No 10, 20-28.

Retrieved from: http://web.b.ebscohost.com.mbcproxy.minlib.net/ehost/pdfviewer/pdfviewer?vid=9&sid=2a85447c-cc47-4b86-8e31-250d1b9e754d%40sessionmgr111&hid=114

Turk, D.C. (2009). Fibromyalgia syndrome: a guide for the perplexed. Psychiatric Times, 26(2), 50-54. Retrieved from: http://web.b.ebscohost.com.mbcproxy.minlib.net/ehost/detail?vid=8&sid=2a85447c-cc47-4b86-8e31-250d1b9e754d%40sessionmgr111&hid=114&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=cin20&AN=2010211647

Yilmaz, J. et al. (2011) Adopting a psychological approach to obesity. Nursing Standard, Vol 25, No 21, 42-46. http://dx.doi.org/10.7748/ns2011.01.25.21.42.c8289

FAQs

What are 3 nursing interventions for a postoperative patient? ›

A. Nursing interventions that are required in postoperative care include prompt pain control, assessment of the surgical site and drainage tubes, monitoring the rate and patency of IV fluids and IV access, and assessing the patient's level of sensation, circulation, and safety.

How do you write a nursing care plan? ›

To create a plan of care, nurses should follow the nursing process: Assessment. Diagnosis. Outcomes/Planning.
...
  1. Assess the patient. ...
  2. Identify and list nursing diagnoses. ...
  3. Set goals for (and ideally with) the patient. ...
  4. Implement nursing interventions. ...
  5. Evaluate progress and change the care plan as needed.
3 Mar 2020

How do you write a surgical care plan? ›

Then in step two you're going to look at your assessment. Data which is your subjective. And

What are nursing interventions for care plan? ›

What Are Nursing Interventions? Nursing interventions are actions a nurse takes to implement their patient care plan, including any treatments, procedures, or teaching moments intended to improve the patient's comfort and health.

What do nurses do after surgery? ›

Post-anesthesia care units are where patients are taken after their surgery is complete. These nurses help patients come out of their anesthesia, helping them stabilize and prepare for transfer to another unit of the hospital, or for discharge for out-patient procedures.

How do you write a nursing diagnosis? ›

A nursing diagnosis has typically three components: (1) the problem and its definition, (2) the etiology, and (3) the defining characteristics or risk factors (for risk diagnosis). BUILDING BLOCKS OF A DIAGNOSTIC STATEMENT. Components of an NDx may include problem, etiology, risk factors, and defining characteristics.

What are the 5 components of nursing care plan? ›

The nursing process functions as a systematic guide to client-centered care with 5 sequential steps. These are assessment, diagnosis, planning, implementation, and evaluation.

What makes a good nursing care plan? ›

A plan that describes in an easy, accessible way the needs of the person, their views, preferences and choices, the resources available, and actions by members of the care team, (including the service user and carer) to meet those needs.

How long does it take to write a nursing care plan? ›

average time to write up a careplan? 4 hours. It takes me what seems like forever. It takes me about 2 hours to do the prelabbing part of it (meds, labs, etc) and about 2 hours to write up the the other part (Gordon's, nursing dx, etc).

What should be in a care plan? ›

Your care plan should cover:
  • outcomes you wish or need to achieve.
  • what your assessed needs are.
  • which needs your local council will meet and how they will meet them.
  • information and advice on how to prevent, reduce or delay your future needs for social care.
28 Apr 2022

What is diagnosis in nursing care plan? ›

Diagnosis. The nursing diagnosis is the nurse's clinical judgment about the client's response to actual or potential health conditions or needs.

What are the three types of care plans? ›

They include; "nursing plan", "treatment plan", "discharge plan" and “action plan". While these terms refer to aspects of the care planning process, they do not include the concept of patient involvement and shared decision making, which is key to the care planning process.

Do nurses make care plans? ›

Yes every patient admitted to a hospital has a nursing care plan. We dont necissarily have to sit and write out the long detailed plan. Most are generated by the computer after we put in their nursing diagnosis.

What is a three part nursing diagnosis? ›

The nursing diagnosis is comprised of three parts: problem/definition, etiology, characteristics and risk factors.

What are the 4 key steps to care planning? ›

Here are four key steps to care planning:
  • Patient assessment. Patient identified goals (e.g. walking 5km per day, continue living at home) ...
  • Planning with the patient. How can the patient achieve their goals? ( ...
  • Implement. ...
  • Monitor and review.

What is the first responsibility of the nurse when preparing a client for surgery? ›

The nurse's role in the preoperative assessment is that of advocate who identifies the patient's needs and risk factors that may be affected by the surgical experience.

What nurses assist in surgery? ›

A surgical nurse, also known as a Perioperative nurse, Operating Room nurse (OR), or scrub nurse, is a Registered Nurse that's been trained to assist during surgeries. They care for patients before, during, and after surgical procedures and work on everything from life-saving procedures to elective ones.

What is the nursing responsibility? ›

Nurses are responsible for recognizing patients' symptoms, taking measures within their scope of practice to administer medications, providing other measures for symptom alleviation, and collaborating with other professionals to optimize patients' comfort and families' understanding and adaptation.

Which is the best example of a nursing diagnosis? ›

Which is the best example of a nursing diagnosis? Ineffective Breastfeeding related to latching as evidenced by non-sustained suckling at the breast. The formulation of nursing diagnoses is unique to the nursing profession.

What are the 4 nursing diagnosis? ›

There are 4 types of nursing diagnoses: risk-focused, problem-focused, health promotion-focused, or syndrome-focused.

Which is an example of an actual nursing diagnosis? ›

An example of an actual nursing diagnosis is: Sleep deprivation. Describes human responses to health conditions/life processes that may develop in a vulnerable individual/family/community. It is supported by risk factors that contribute to increased vulnerability.

What are 3 important elements of an effective care plan? ›

A care plan consists of three major components: The case details, the care team, and the set of problems, goals, and tasks for that care plan.

Who writes a care plan? ›

The professional writes the care plan with little or no input from the person or their representative. The person is supported to express how they would like their care and support to be delivered. The professional provides information about what the service can offer.

What are the 3 components of nursing care? ›

ANA describes three basic nursing activities that explicitly include issues related to the environment and health, a preventive approach to health, and concern for populations as well as individuals: 1.

How do you write a care plan for the elderly? ›

How do you develop a care plan?
  1. Start a conversation about care planning with the person you take care of. ...
  2. Talk to the doctor of the person you care for or another health care provider. ...
  3. Ask about what care options are relevant to the person you care for. ...
  4. Discuss any needs you have as a caregiver.
15 Nov 2017

What is a care plan assessment? ›

An assessment is a conversation about your needs, how these affect your wellbeing and what you want to be able to do in your daily life. It should also: Promote your interests and independence.

What are the seven main steps in care planning? ›

Advance Care Planning: Seven Steps to Maximize Effectiveness
  • Advance Care Planning: Seven Steps to Maximize Effectiveness. ...
  • Assess your policies and procedures. ...
  • Train the entire IDT on their specific roles. ...
  • Pick a team lead. ...
  • Give the facility lead dedicated time to work. ...
  • Ensure the team lead is able to work with physicians.
14 Jul 2020

How do you add problems and goals to your patient's care plan? ›

You can also add components to document additional treatment that the patient needs. To add a problem to the Care Plan, click New Problem. To add a goal to a care plan problem, click New Goal next to the corresponding problem. To add a task to a goal, click New Task next to the corresponding goal.

What is the difference between nursing care plan and nursing process? ›

A computerised nursing care plan is a digital way of writing the care plan, compared to handwritten. Computerised nursing care plans are an essential element of the nursing process. Computerised nursing care plans have increased documentation of signs and symptoms, associated factors and nursing interventions.

How do you determine priority of a nurse? ›

Nurses should apply the concept of ABCs to each patient situation. Prioritization begins with determining immediate threats to life as part of the initial assessment and is based on the ABC pneumonic focusing on the airway as priority, moving to breathing, and circulation (Ignatavicius et al., 2018).

How do I write a care plan report? ›

Every care plan should include:
  1. Personal details.
  2. A discussion around health and well being goals and aspirations.
  3. A discussion about information needs.
  4. A discussion about self care and support for self care.
  5. Any relevant medical information such as test results, summary of diagnosis, medication details and clinical notes.
14 Feb 2022

Can I write my own care plan? ›

Some people feel they need help from their nurse or doctor to fill in an ACP, but you can also complete one yourself. You can write your own or use the document provided by Dying Matters. Once completed you should keep a copy yourself and give a copy to anyone who's involved in your care.

Should care plans be written in the first person? ›

Use first person when the person wrote the plan (or section of the plan) or when you are quoting the person whose plan it is and you are comfortable the person meant what they said.

What is NANDA approved nursing diagnosis? ›

A nursing diagnosis is defined by NANDA International (2013) as a clinical judgment concerning a human response to health conditions/life processes, or vulnerability for that response, by an individual, family, group, or community.

What is an individual care plan? ›

Individualised care plans, or support plans, are legal documents that outline the agreed treatment for each client. They cover both routine and emergency situations, and as such, you might have one or several care plans for each client.

How do you write a smart goal in nursing? ›

SMART is an acronym for the guidelines nurses should use when setting their goals:
  1. Be specific. Setting broad nursing goals allows them to be open for interpretation. ...
  2. Keep it measurable. For goals to be effective, there must be some way to measure your progress. ...
  3. Keep it attainable. ...
  4. Be realistic. ...
  5. Keep it timely.
3 Aug 2018

What are care and support plans? ›

A care and support plan is a detailed document setting out what services will be provided, how they will meet your needs, when they will be provided, and who will provide them.

What are the 3 postoperative phases? ›

The recovery from major surgery can be divided into three phases: (1) an immediate, or post anesthetic, phase; (2) an intermediate phase, encompassing the hospitalization period; and (3) a convalescent phase.

What is the priority nursing intervention for a patient during the immediate postoperative period? ›

During the postoperative period, reestablishing the patient's physiologic balance, pain management and prevention of complications should be the focus of the nursing care.

What are the responsibilities of the post anesthesia care nurse in the prevention of immediate postoperative complications? ›

PACU Nurse Responsibilities:

Monitoring post-operative patients' levels of consciousness during recovery from anesthesia. Measuring and recording patients' vital signs. Closely observing patients for signs of side effects of anethesia medication.

When caring for a postoperative patient what should be included in the postoperative assessment? ›

This assessment should include the intraoperative history and post-operative instructions, circulatory volume status, respiratory status and cognitive state. Common causes of confusion in the postoperative period include infection, hypoxia, sedatives and other medications such as anticholinergics [22].

What does Phase 2 mean in surgery? ›

Phase 2 is a transitional period between intensive observation and either the surgical ward or home. The concept of bypassing or “fast-tracking” phase 1 is becoming more common as fast-offset anesthesia agents and practices are emerging.

What are post op complications? ›

Nausea and vomiting from general anesthesia. Sore throat (caused by the tube placed in the windpipe for breathing during surgery) Soreness, pain, and swelling around the incision site. Restlessness and sleeplessness.

What is postoperative assessment? ›

The goal of a postoperative evaluation is to recognize and manage issues that arise in the immediate postoperative period. Generally, right after any procedure requiring anesthesia, individuals are monitored in a post-anesthesia care unit or PACU for things like respiratory distress or cardiac complications.

What is the nursing diagnosis for post op? ›

Nursing Diagnosis: Risk for Altered Tissue Perfusion related to post-operative nursing care. Desired Outcome: The patient will exhibit adequate tissue perfusion as evidenced by normal vital signs, presence of strong peripheral pulses, warm and dry skin, and acceptable urine output.

Why do you monitor vital signs after surgery? ›

The purpose of frequent vital sign collection during this post-operative period is to rapidly identify any physiological change in condition. Timing of these intervals are typically determined by a standardized formula developed by individual institutions rather than based on patient need.

How often should vital signs be taken after surgery? ›

Background: Current protocol for post-operative patients admitted to medical-surgical/telemetry units from post anesthesia care units states vital signs are taken every 15 minutes for 1 hour, every 30 minutes for 2 hours and then, every 4 hours for 24 hours.

What are 5 responsibilities of a recovery room nurse? ›

The practical nurse responsibility for the care of a patient in the recovery room is to prevent complications, detect early complications, relieve patient's discomfort, support patients through their state of dependence to independence, and closely monitor the patient's condition.

How do you care for a post operative patient? ›

Take medications as prescribed, watch out for potential complications, and keep your follow-up appointments. Don't overdo things if you've been instructed to rest. On the other hand, don't neglect physical activity if you've been given the go ahead to move around.

What is the nursing responsibility? ›

Nurses are responsible for recognizing patients' symptoms, taking measures within their scope of practice to administer medications, providing other measures for symptom alleviation, and collaborating with other professionals to optimize patients' comfort and families' understanding and adaptation.

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