CAN SOMEONE HELP ME REVISE CARE PLAN ?
Nursing Diagnosis #1: Risk for impaired tissue perfusion
R/T: interruption in blood flow, immobility
AEB: Patient status is total hip arthroplasty, and mobility restrictions.
Short term Goal: Patient will show no sign of shortness of breath by the end of the shift.
Long term Goal: Patient will maintain adequate peripheral perfusion as evidenced by strong pedal pulses, and skin without edema by discharge.
Interventions: minimum of (4)
1. Intervention: Assess for the signs and symptom of DVT
Rationale: DVT is a serious complication after joint replacement surgery (Gulanick & Myers, 2022, p.614)
Implementation: nurse applied stocking on both legs for the patient.
Evaluation: Patient have stocking on both legs while in bed.
2. Intervention: assess motor and sensory function
Rationale: problems with loss of sensation, and numbness indicate neurovascular dysfunction or tissue ischemia
Implementation: nurse instructed the patient to raise both legs.
Evaluation: Patient is unable to perform straight leg raises without an assistant.
3. Intervention: assess capillary refill, temperature, and color of lower extremities
Rationale: inadequacy of systemic circulation indicates circulation problems.
Implementation: nurse assesses lower extremities by palpating legs, and checking capillary refill.
Evaluation: capillary refill less than 2 seconds.
4. Intervention: Assess skin integrity for signs of redness and tissue ischemia
Rationale: a regular examination of the skin over bony prominences will allow for the prevention or early recognition and treatment of pressure injuries (Gulanick & Myers, 2022, p.90)
Implementation: nurse assesses skin over the sacral area.
Evaluation: there was no sign of skin integrity and tissue ischemia.
Nursing Diagnosis #2: Risk for infection
R/T: incision lateral hip right
AEB: Patient reported of pain 7/10, change in respiratory rate
Short term Goal: Patient will show sign of comfort and relaxation by the end of the 12-hour shift.
Long term Goal: Patient will show no sign of edema and erythema by discharge.
Interventions: minimum of (4)
1. Intervention: use sterile technique for all dressing changes
Rationale: sterile technique is essential during dressing changes to prevent the transmission of pathogens (Gulanick & Myers, 2022, p.592).
Implementation: nurse avoided touching any open wounds with non-sterile hands
Evaluation: There was no sign of contamination or wound infection
2. Intervention: assess vital signs, especially HR and temperature
Rationale: report an HR greater than 100 beats per minute or temperatures greater than 38.0 degree as these may be signs of developing infection (Gulanick & Myers, 2022, p.592).
Implementation: nurse instructed the UAP to monitor vital signs
Evaluation: nurse reassess vital signs every 15 minutes, 30 minutes, 1 hour, every 2 hours, or every 4 hours for 24 hours for sign of infection.
3. Intervention: Identify patient who are at high risk for infection such as patient with obese and diabetes
Rationale: obesity can alter immune response which then increase risk of infection
Implementation: nurse calculate patient’s body mass index.
Evaluation: patient’s BMI is 34 which indicate obesity
4. Intervention: Encourage foods high in protein and vitamin C
Rationale: adequate nutrition facilitates immune system function to prevent infection (Gulanick & Myers, 2022, p.592).
Implementation: nurse offers high protein diet to patient to order for dinner
Evaluation: Patient ordered chicken, salad, and milkshake
Nursing Diagnosis #3: Impaired physical mobility as evidence by pain, discomfort, and inability to ambulate
R/T: musculoskeletal impairment
AEB: Inability or difficulty to move legs purposefully, need assistant to reposition
Short term Goal: Patient will demonstrate techniques that promote mobility by the end of 12-hour shift.
Long term Goal: Patient will demonstrate an increased strength on the hip as evidenced by improved movement by discharge.
Interventions: minimum of (4)
1. Intervention: Administer medications as appropriate
Rationale: antispasmodic medications may reduce muscle spasms or spasticity that interferes with mobility; analgesics may reduce pain that impedes movement (Gulanick & Myers, 2022, p.92).
Implementation: nurse administered 0.2 mg IV Hydromorphone (DILAUDID)
Evaluation: goal was met. Patient reported pain 0/10.
2. Intervention: instruct the patient in maintaining total hip arthroplasty precautions during position changes
Rationale: these precautions prevent hip dislocation by limiting ROM of the hip joint. The precautions need to be maintained for up to 6 weeks during the healing process. These precautions may include using an abductor wedge while in bed to prevent joint adduction. The patient should not flex the hip more than 90 degrees and should not bend from the waist (Gulanick & Myers, 2022, p.612).
Implementation: nurse apply foam wedge between thighs prevents hip adduction after surgery. Legs must never be crossed
Evaluation: The foam wedge keeps hip straight while patient is in bed.
3. Intervention: teach the patient how body weight affects joints
Rationale: excessive weight may add stress to painful joints, contribute to further degeneration of joint cartilage, and limit the patient’s mobility (Gulanick & Myers, 2022, p.620).
Implementation: nurse implemented lifestyle modification which included nutritional counseling and weigh loss programs.
Evaluation: Patient demonstrated an understanding of reducing weight.
4. Intervention: Instruct the patient about how to perform isometrics, and active and passive ROM exercises; leg lifts, dorsiflexion or plantar flexion of the foot
Rationale: muscular exertion through exercise promotes circulation and free joint mobility, strengthens muscle tone, develops coordination, and prevents nonfunctional contracture (Gulanick & Myers, 2022, p.620).
Implementation: Coordinated with the physiotherapist to assist patient with exercise
Evaluation: Patient reported stabbing pains. Goal was not met. Patient stops the exercises.