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Assessment On this clinical day, I had a 67-year-old man who came in the hospital for a hip replacement surgery.

Besides the osteo-arthritis his past history of this man was a diagnosis of type 2 diabetes Mellitus and coronary artery disease, in which he had 3 bypass surgeries. During his surgery it had been reported that his heart rate slowed down. Upon assessment the patients is alert and oriented x 3, blood pressure is up and down after surgery 86/49 and in my assessment 105/76 other then that his Vital signs are stable, however he has a dysrythmia in his pulse. His bowel sounds are present at this time, and his air entry is clear and adequate. His skin color is normal however pale upon his walk to the washroom where he reported feeling dizzy, pedal pulses are present and capillary refill is fairly slow in a 3 second period. During my assessment the patient states that he does not have type 2 diabetes and his blood sugar just like his blood pressure is always up and down. During this day his wife came to visit. He is in his second marriage. 2. Clients Strengths (personal & support system that promote client wellness) Family support, and optimism. The client is in high spirits and has his wifes support. 3. Nursing Diagnoses 1. Ineffective peripheral tissue perfusion related
to decreased blood flow/venous stasis AEB tissue slow capillary refill, skin color change (pallor)

2. Knowledge deficient regarding condition of


diabetes mellitus type 2 AEB patient stated he does not have diabetes mellitus.

Rationale for Selection 1. Patient has pallor skin and a slow capillary refill. This may be a risk for DVT and should be monitored regularly. In addition, studies show that male patient that have hip replacement surgery are at higher risk of developing a DVT. 2.for reason being that the patient feels he does not have diabetes mellitus is an important nursing diagnosis because if he is in denial about his condition he is probably not taking care of himself in a way that an individual with diabetes

should. Nursing interventions Rationale to support nursing interventions 1. Evaluate circulatory and neurologic 1. Symptoms help distinguish between studies involved extremity, both sensory thrombophlebitis and DVT. Redness, and motor. The skin colour was heat, tenderness and localized edema are inspected for skin color and temperature characteristic of superficial involvement. was monitored but was adequate. The Calf involvement is associated with symmetry of the calves measure and absence of edema, femoral vein record calf circumference. And pain was involvement is associated with mild to noted. Capillary refill was also noted. moderate edema. Thrombosis is The examination of obvious prominent characterized by edema. Diminished veins will be noted and palpated gently capillary usually present in DVT is a for local tissue tension, stretched skin, classic but unreliable sign because many knots bumps along course of vein. clients with DVT. Elevating legs will Elevate legs in bed or chair, as indicated, reduce tissue swelling and rapidly however the patient will remain in a 90 empties superficial and tibial veins. degree angle to prevent any dislocation Anticogulants will be given to reduce the of the hip. AntiCoagulants will be risk of developing DVT. Monitoring or administered promptly. PT, PTT apt will PTTs will monitor anticoagulant be monitored. therapy and presence of risk factors e.g. hemoconcentration and dehydration, 2. The patient should be assessed for his which potential clot formation, understanding of the disease and reason he believes he does not have it. The nurse 2. This assessed understand would build would provide a trusting environment a rapport and respect the client allowing where she would listen to the patients the nurse to better his learning process concerns. The nurse would state that she and willingness to learn. Return understands his reason believing he does demonstration would assess the patients not have this diagnosis for it is difficult understanding and perhaps reevaluate to see but that said he should take the areas that are missed. Information necessary precautions to prevent further provided to the patient will be what is complications. The nurse would then necessary so the patient can absorb more educate the patient on the disease and information. Awareness of the how to care for himself. She would also information given will help the client be get the patient to repeat what she had more consistent with care and may told him. Teaching would include (a prevent delay onset complications. normal glucose range and how it Information on symptoms of hypo and compares with clients level, she would hyperglycemia will promote early also a description of the type of diabetes detection and treatment preventing and in relationship between insulin limiting occurance. deficiency and high glucose levels. The nurse would insure that the patient understand his medication in relation to monitoring his blood sugar. Dietary plan should also be introduced limiting fats,

salts, sugar and alcohol intake and include the ability to identify symptoms of hypo/hyper glycemia. 5. Evaluation Strategies 1) Patient verbalizes understanding of the disease process, potential complications. 2) Identify relationship of signs/symptoms to the disease process and correlate symptoms with causative factors. 3) Patient initiate necessary lifestyle changes and participate in treatment regiment. 4) Patient demonstrates improved perfusion as evidence by peripheral pulse present/equal skin color and temperature normal, absence of edema. 5) Display increase tolerance to activity.

Timeframe for each strategy 1) Prior to discharge. 2) During the teaching session patient provides positive understanding of signs and symptoms. 3) During the shift patient will elevate his knee and participate in movements and exercises. He will further implement exercises after discharge. 4) By the end of my shift patient will demonstrate improved capillary refill and maintain the presents of pedal pulses. 5) Patient will participate in physical activity to understand the benefit to increase circulation.

References Doenges, M., Moorhouse, M. & Murr, A. (2006). Nursing Care Plan. Guidelines for Individualizing Client Care Across the Life Span. (7th Ed.). Davis Company. Lewis, S., Heitkemper, M., OBrien, P., Dirksen, S., & Butcher, L. (2010). Medical Surgical Nursing in Canada: Assessment and Management of Clinical Problems. (2nd Ed.). Mosby: Elvesier.

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