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Student Name:
Client Initials:
Key Problem # 1
Impaired physical mobility r/t surgical incision aeb limited
range of motion.
-1 day post right total knee arthroplasty
- Reports no pain, but grimaces during ambulation and
hesitates when flexing right knee.
- Limited range of motion in LRE
- Walker use when ambulating.
1/22/2015
Key Problem # 2
Activity intolerance level II r/t sedentary lifestyle, chronic
pain in LRE aeb patient statememtns
- Patient reports fatigue after activity
- Patient grimaces during ambulation
- Refused transfer to a chair, or a sitting position.
- VSs increased after moderate ambulation, pulse increased
from 78 at rest to 98, respirations increased from 17 to 22
Key Problem # 3
Acute and chronic pain r/t right knee arthroplasty aeb
facial expression when ambulating
-1 day post op
-Grimacing when moving right leg
-Surgical incision on right knee
- Ice applied to affected limb
- Medication for pain with PRN orders
Key Problem # 4
Readiness for enhanced family processes r/t role performance
aeb changing family dynamics
-Husband was present during surgery and recovery
-Both showed an understanding of each others restrictions
-They both showed a willingness to work together
-Husband recently retired due to disability
-They showed a mutual respect for each other
Nick Haislip
Client Initials:
K.W.
Clinical Dates:
1/22/2015
Problem #1 (Nursing Diagnosis) Impaired physical mobility r/t surgical incision aeb limited range of motion.
General Goal: Patient will ambulate with minimum assistance
Expected Outcome
Behavioral, measurable, observable, realistic & time-limited
Patient will move from bed to walker and ambulate 250 feet on two separate occasions by the end of my shift on 1/22/2015
Nursing Interventions/Rationale
The patient stated that she could never lift her leg up before, due to
the pain, and that she always had to use her hands to move her leg.
She was hesitant to try now due the her history.
Activities were scheduled around one hour after medications were
administered; patient reported a low level of pain prior to and during
activities.
Patient would do foot pump exercises every hour, this was noted on
several occasions.
Clinical Dates:____________
Problem #2 (Nursing Diagnosis): Activity intolerance level II r/t sedentary lifestyle, chronic pain in LRE aeb patient statements
General Goal: Patient will increase activity tolerance
Expected Outcome
Behavioral, measurable, observable, realistic & time-limited
Patient will identify ways to increase activity tolerance by her discharge date of 1/23/2015.
Nursing Interventions/Rationale
Will alert the patient when she needs to rest or limit exertion.
Teach patient methods to conserve energy
Reduces fatigue
Encourage participation in recreation, social activities, and hobbies
Provides activity and socialization.
Evaluate patients actual and perceived limitations and severity of
deficit in light of usual status
Patient states that she will take breaks regularly during activity.
Patient expressed interest in weekly activities at her church that she
will look in to joining.
Patient was afraid to move her right leg due to a habit of having to
use her hands to move it, and prior pain. After ambulating and
stretches she realized that she had more mobility than prior to her
Limitations may have changed after surgery
surgery.
Evaluation: Goals met, patient identified ways to increase her activity tolerance, and how to monitor her exertion to conserve energy.
Clinical Dates:____________
Problem #3 (Nursing Diagnosis) Acute and chronic pain r/t right knee arthroplasty aeb facial expression when ambulating
General Goal: Patient will remain within tolerable levels of pain.
Expected Outcome
Behavioral, measurable, observable, realistic & time-limited
Patient will report tolerable levels of pain, less than 4/10, during my shift on 1/22/2015
Nursing Interventions/Rationale
Patient reported low levels of pain, 1/10 throughout the day, some
grimacing and grunting was noted during ambulation
Clinical Dates:____________
Problem #4 (Nursing Diagnosis) Readiness for enhanced family processes r/t role performance aeb changing family dynamics
General Goal: Patient will verbalize a desire for enhanced family dynamics
Expected Outcome
Behavioral, measurable, observable, realistic & time-limited
The patient and her husband will demonstrate the desire for open communication, and expressing their needs and abilities by their discharge date.
Nursing Interventions/Rationale
The patient and her husband understood that they both have
limitations, and that they needed to tell each other when there were
Facilitates ongoing expression or open, honest, feeling, and
problems with their ability. They know each others limitations, and
effective problem solving
will stay involved.
Evaluation: Goals met, the patient and her husband are comfortable with communicating with each other and expressing their needs and
abilities.