Plan of Care

Patient or Nursing oriented proble or patietn need

Patient Assessment data

Optimal Patient Outcome or Goal

1.

The primary assessment of the patient was the problem at the knee due to osteoarthritis. The patient was not able to stand the pain.

The patient was suffering from osteoarthritis in the left knee therefore this caused pain and affected the mobility of the patient. After operation he was suffering from pain at the incision site.

GCS 15, PERL. Pain score – left knee 5/10

The disease osteoarthritis is a disease of the bones which most of the time leads to the elevation of the risk of the fractures. There are situations where the patient often suffers a chance of breaking a bone, therefore the patient is often considered to be fragile. There are chances of typical fragility especially in the knee in the given situation.

Actions should be taken to verbalise the decrease or the absence of the pain. It should be decreased from 5/10 to 0/10.

 It was required to verbalise the understanding of the importance of the significance of both the pharmacological and the pharmaceutical therapies in order to decrease the pain.

It is important to maintain the integrity of the skin around the wound area which is evidenced by the lack of the pressure ulcer development (Gulanick & Myers 2016).  Being free from any kind of injury.

Making the patient verbalize regarding the absence of the pain which is experienced upon moving.

It is important to demonstrate the relaxation techniques along with the activities of diversion for the aim of decreasing the pain.  

It is important to increase the comfort of the patient and to decrease the pain experienced by the patient.

2.

He felt nauseated and was shivering out of the pain.

RR 27, Sp02 94% on 60% oxygen, equal air entry – chest is clear. Verbal report of feeling a little breathless. Glucose 5.1. Nil hx diabetes.

Due to the surgery there was a pain at the incision site since there were plates and screws inserted in order to stabilise the tibia which is a part of the procedure.

The patient will be able to participate in the activities of daily life along with the other desired activities.

The patient will be made to show willingness to participate in the interventions which will help the patient in improving the conditions of mobility.

The patient needs to verbalize the absence of the back pain.

It is important to verbalize about the significance of the both pharmacological and the non-pharmacological therapies in order to reduce the prevalence of the pain.

The patient should stay safe from any injury.

3.

The wound site appeared to be sutured and the skin at the wound site appeared.  

The assessment showed that wound site is left knee, sutures in situ, skin appears ‘tight’, swollen, shiny and red. Warm to touch. Several areas of dehiscence with pus present.  

It is important to report the increase in the comfort along with the reduction of the pain at the injury site.

It is important to verbalize the patient regarding the education and the health teachings that needs to be imparted to the prevention of the additional injury (Dunphy et al. 2015).

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4.

The patient was not able to stand up without any provided assistance.

Impairment of the physical mobility and prevalence of discomfort in the knee area. Pain was experienced on any movement. There was some kind of guarding behaviour as well.

IV cannula inserted.  After the surgery, there was occurrence of an uneventful post-operative period after which the patient was discharged after two days.

The patient was also given anti-inflammatory medication for pain relief.

The patient is able to participate in the activities which are applicable to the real life situations in order to enhance the change.

It is also required to show the changes in the behavior in order to restore a positive self-image.  

5.

The patient was perceived to be unhealthy since the scale showed 5/10. Risk for development of any injury like a fracture due to the impact of the change in the structure of the bone that is secondary to the osteoarthritis.

There was altered ADL which was shown by the patient.

 It is important to make sure to report the lack of the complications that occurs due to the lack of the mobility. After a few hours of nursing interventions, it was required to the maintainence the lack of the chances of the additional fractures.

6.

Deficit of self-care. Deficit of the activities like the toileting and bathing as a result of the pain along with the discomfort on moving the body.

Problem in mobility, was fitted with a supportive knee brace. There are non-weight bearing on crutches which were also provided to the patient.

The patient must try to perform the self-care activities while keeping the level within one’s own identity.

It is required to express positive feelings towards the patient while one is trying to carry out the activities.

Within few hours of the nursing interventions the patient must be able to verbalize the elevation of the level of sense of the self-worth that is in relation to the current situation of the patient (Eliopoulos 2013).

Implementation 

Rationale

Evaluation

It is important to assess the pain experienced by the patient which needs to include the location of the pain along with the characteristics and the intensity of the pain. The frequency, quality along with the aggravating factors of pain is also important. This requires the use of the pain scale 0-10.

It is important to assess the description of the pain.

 It is important to obtain the subjective data related to the pain which includes the feelings of the patient. It also rules out the underlying condition and the conditions that are related to the development of the complications.

For the purpose of obtaining the baseline data, it is required to alter the data during the acute pain.

For the aim to decrease the pain sensation by implementing the non-pharmacological approaches.

In order to provide comfort to the patient and to decrease the pain.

In order to distract the attention of the patient from the pain and also to reduce the pain.

For reducing the pain and to prevent any other injury from occurring.

For making the patient mobilise and to support the lumbar portion of the patient while the patient is moving.

Client might report pain present in the fingers, the hips and the knees along with the vertebrae.  This pain is most of the time provoked by activity and then it is relieved by the rest. There is also joint pain and aching which might be present (Dziedzic et al. 2014).

The evaluation involves to see whether the goals are partially met or fully met.

The evaluation showed that patient was able to verbalize the reduction in the sensation of pain while the patient was taking the medication.

The patient was able to show the techniques which are non-pharmacological in nature with the assistance from the S.O.

The skin colour of the wound area also needs to be monitored.

The supplements like the calcium and vitamin D is important for the process of bone formation and also to increase the bone density and the bone mass.

In order to prevent the patient from having any pressure from ulcers.

 For the purpose of aiding a faster healing of the patient.  

Assisting the patients with the activities of the daily life which will allow the conservation of the energy.  It is required to provide balance carefully along with the provision of assistance, thereby facilitating the endurance which will ultimately help in enhancing the tolerance activity of the patient along with self-esteem.

Exercises might help in the maintaining the strength of the muscle thus increasing the tolerance of the exercise.

The patient was able to implement the activities along with the help and assistance received from the nurses and when there is absence of the pain.

It is important to provide measures of comfort to the patient like providing backrubs, also the provision of heat packs and cold packs to the area that is affected.

The patient should be encouraged to have a complete bed rest. He should be provided with linens along with a non-sagging and form mattress to sleep on.

The patient should also be encouraged to perform activities related to relaxing or exercises like the deep breathing exercises.

The patient should also be suggested to move his trunk as a whole unit in order to avoid twisting. Assistance should be given to the patient during turning sides.

The patient should be encouraged to take adequately balanced diet which is rich in calcium and phosphorous along with vitamin D. food items like milk, egg and others needs to be given to the patient.

Medication therapies are required to be provided which included the medications like NSAID, Ventolin, Seretide accuhaler.

Additionally it is required to determine the degree of immobility that is related to the assessment of the pain.

The emotional and the behavioural response of the patient towards the problem of immobility is also important.

The patient should be encouraged to increase the fluid intake 2000-3000ml a day which is within the cardiac tolerance.

Provides stability to the reduction of the possibility of disturbing alignments along with muscle spasms and therefore enhance healing.

However excessive bed rest might lead to more complications including problems like constipation and contractures. Providing a firm mattress might help in increasing the comfort of the patient.

Helps to maintain the adequate the urine output and therefore the following should be avoided like hypercalcluria, renal calculi and hypercalcemia.

Application of a lumbosacral corset or binder is also suggested.

Prevents the patient from developing pressure ulcers.

When the patient is present at home, additional injuries can be avoided. Provide balance to the patient and prevent injuries.

The vitamin, calcium and others are essential for the patient.

It is important to encourage the patient to perform a knee flexion in order to avoid injury.

The patient should also be encouraged to install the safety devices like the grab bars and the side rails and railings at home after the discharge in order to avoid falls and other additional injuries.

A liberal intake of calcium and fluid intake is suggested along with the intake of the supplements.

The patient should be assisted to turn the sides every 2 hours.

It is also important to evaluate the indicators like the reduction in the ability to ambulate and to move purposefully keeping shorter keeps and making the appearance of the gait. There is also uneven weight bearing along with an observable limp due to the injury in the knee (LeMone et al. 2015).

Promotes the patient to trust a given situation in which the patient is able to exist freely and to be open and honest with one’s self. Helps the patient to identify the underlying reasons of dependency and help the patient to cope with it. Increases the likelihood of receiving an appropriate support to the patient. This also helps to make the patient feel better while they are able to present an outer appearance that is positive in nature.

The patient was free from any kind of signs of pressure ulcers and which was free from any other injuries.

The patient was able to maintain an intact skin integrity in the wound area.

The patient was successful in verbalising the reduction in the sensation of pain while he was feeling comfortable.

Whether the patient was able to express his feelings without hesitation.

Was the patient able to accept the present condition or not and identify the problems that he was going through (Brand, Ackerman & Tropea 2014).