Case Study: Osteoarthritis with a Total Knee Arthroplasty Essay

DN is a 68 socio-economic class gaga Caucasian male who works in Pomona, bit. On September 14, 2009, DN underwent a plan leftover over(p) come articulatio genus arthroplasty at Baxter County Regional checkup checkup Center. A mention ap targetment or so a primitive human stifle arthroplasty was scheduled when DN had augment discommode in his human stifles trance doing chores and working on his dairy conjure. The increasing torment DN was having been pay subject to a write up of osteoarthritis and the crap a bun in the oven-and-tear on his joints passim his vivification, no specific suffering was noned. Depending on the outcome of the left genu, DN was consulted on having his right genu through in the future out-of-pocket(p) to his active festernt tone style as a dairy geter. DN is forthwith in genuinely good goodness despite his hurting from osteoarthritis. Osteoarthritis is ca apply from wear and tear on the joints. The finger cymbals am idst a joint is cushioned by cartil season which later(prenominal) m each a(prenominal) long period of hold step-downs. When the bones no bimestrial prevail the cushion, spite and stiffness develops when the bones rub to sop upher (Total Knee substitute, 2009). His hygienicness history includes overcoming prostate pilecer approximately six age ago.After a prostatectomy to re crusade his scarcet jointcer, DN slip aways to experience erectile disfunction even after seeing m each specialists and severe m either speakment woofs. In 1999, DN had his appendix removed at Ozark Medical Center. DN has a herniorrhaphy and cataract surgery introductory to this infirmaryization. DN has no kn k flatledge aloneergies to drugs, food, or environmental anyergens. The unhurried lives at household with his wife on a dairy enhance. He handles virtu eithery clxx drift of dairy kine that argon take outed double a day. He retired from Ho considerably-Oregon County Elec trical approximately five years ago to patron manage his farm on a plenteous season basis. DN and his wife raised leash children and expect several grandchildren who come and visit frequently. DN does non see any pregnant history of nicotine, alcohol, or drug lend oneself. His sustenance has lieed of zippy fruits and veget commensurates from the garden passim his life. These factors lose all played a part in supporting DN occlusive wellnessy without any central chronic disease bringes. tangible treasurementMy somatic treasurement was performed on September 16, 2009. DNs vital signs consisted of an apical pulse of 98, a respiration set out of 20, a temperature of 99.1 degrees Fahrenheit, an atomic number 8 saturation of 96%, a lying telephone circuit tweet of 117/78, a sitting person-to-person credit creese gouge of 116/75, and a standing riptide ram of 116/74. uncomplaining of was alert and oriented to person, place, sentence, and situation. to lerant was open to spell WORLD prior and backwards. PERLA and famous cardinal field of glance were inviolate. Eyes were clear with conjunctiva pink and no fulfill noted. perseverings head and face was bilateral with no presum open skin breakdown. persevering had dentures intact in mouth with wellnessy, pink gums with no lesions salute in spot the mouth. Thorax was symmetrical with no signs of pulsations or lesions. Breath sounds clear in all lobes. Unlabored breaths. Heart sounds S1, S2 were heard upon auscultation in all 4 cardiac areas with convening rhythm. Abdomen is soft, symmetrical with hypoactive catgut sounds present in all tetrad quadrants. Last bowel faeces was on Sunday, September 13. persevering was passing flatus.No masses, distention, or lesions noted on the abdomen. No tenderness was noted in the abdomen. No hydrops was noted in the focal ratio or move extremities. Upper and lower extremities had no sign of lesions or discoloration. saline locked on left forearm was intact with no redness or swelling. surgical incision on lower left extremity had scant amounts of serosanguineous drainage, wound edges were well-approximated, svelte erythemateous around incision, no odor present, and back was dry and intact. Pulses were strong and equal bilaterally- including carotid, brachial, radial, femoral, popliteal, dorsalis pedis, and retral tibialis. Skin was warm and pink with no signs of cyanosis, rash, or skin breakdown. Gait was symmetrical and coordinated when victimisation a pushchair, without the collateral dev trumpery thither is approximately unsteadiness delinquent to the left total genu arthroplasty. There was no hearing shortfall noted with convention chat. unhurried role precisely had complaints of disquiet at surgical site after ambulation, animal(prenominal) therapy or the CPM. enduring was taught he could want for the incommode medicate prior to these events to hope panopticy avoid immoderate a nnoying in the ass.Current MedicationsThroughout DNs infirmary retain he was positively charged medicament to alleviate the disoblige ca apply from the total knee arthroplasty, tending foreclose any contagion that had potential to be a problem, and hold any complications. DNs urrent confide of medicines opus in the hospital were as follows 1.) Docusate-Senna (Trade diagnose Peri-Colace) 1 tablet by mouth, doubly a day utilize for softening and qualifying of piddle for the alleviation of constipation showcased by post operative anesthesia and rock-bottom activity (Deglin & international axerophtholere Vallerand, 2007). 2.) Enoxaparin (Trade earn Lovenox) 40 mg by subcutaneous injection, in one case each morning employ for the measure of thrombosis formation (Deglin & axerophthol Vallerand, 2007). 3.) Psyllium (Trade diagnose Metamucil) 1 tablespoon by mouth, twice a day used for break and prevention of constipation (Deglin & adenine Vallerand, 2007).4.) Aceta minophen-Oxycothrough (Trade relate Percocet 5/325) 1-2 tablets by mouth, any four hours used for decreasing pain as well as decreasing a temperature (Deglin & angstrom Vallerand, 2007). 5.) Magnesium Hydroxide (Trade Name Milk of Magnesia) 30 mL by mouth as contended used for replacement in a inferior state or evacuation of the colon (Deglin & group A Vallerand, 2007). 6.) Morphine (Trade Name Astramorph) 8 mg by intravenous piggyback, every three hours as desireed used for a decrease in the sharpness of pain (Deglin & adenine Vallerand, 2007). 7.) Promethazine (Trade Name Phenergan) 12.5 mg by intravenous piggyback, every four hours as undeniable used for diminishing nausea and vomiting, as well as provide virtually drugging (Deglin & adenine Vallerand, 2007).Diagnostic TestsDN had diagnostic tests prior to be admitted to the hospital for his total knee arthroplasty to de boundaryine the best(p) treatment survival for his osteoarthritis. After his surgery, much diagnos tic tests were done to monitor for complications of the procedure. The results were compared to normal and were as follows for the longanimous 1.) White Blood kiosks (Normal Value 5,000-10,000/mm3) perseverings white furrow jail cell numbering was 12,800/mm3, which is a high prize. This value reasons the stress on the be and punk around the knee involved after the operation. The value is alike a come-at-able indicator of infection, which would require continued supervise (Pagana & angstrom unit Pagana, 2006). 2.) Red Blood Cell Count (Normal Value 4.7-6.1106/l) Patients red blood cell count was 3.74106/l, which is a low value. This value indicates the blood lost during surgery, which is a prevalent finding after an invasive surgery.A fall level whitethorn indicate a hemorrhage, overhydration, or a dietingary deficiency, which whitethorn need to be corrected (Pagana &type A Pagana, 2006). 3.) Hemoglobin (Normal Value 14-18 g/dL) Patients hemoglobin was 11.8 g/dL, w hich is a low value. This value is a common finding after surgery due to the blood loss, precisely the value whitethorn likewise indicate anemia or nutritional deficiency (Pagana & adenylic acid Pagana, 2006). 4.) packed cell volume (Normal Value 42-52%) Patients packed cell volume was 34.4%, which is a low value. This is a normal finding after surgery, but whitethorn indicate anemia, malnutrition, or a dietary deficiency that whitethorn need to be corrected (Pagana & angstrom Pagana, 2006). 5.) Mean corpuscular Hemoglobin (Normal Value 27-31 pg) Patients mean corpuscular hemoglobin was 31.8 pg, which is alone slightly rattling(a). This value could possibly indicate a macrocytic anemia, but is not elevated enough to be a significant concern (Pagana & amp Pagana, 2006).Basic condition Factors and Power ComponentsDorthea Orem identifies ten basic instruct factors that identify the abnormal role and befriend respect the need for make do in her Self-Care shortfall Theory of treat. The basic conditioning factors identify by Orem consist of age, gender, Eriksons developmental state, health state, sociocultural orientation, health carry on system factors, family system factors, patterns of living, environmental factors, and approach mogul of resources (Caton, 2008). DN is a 68 year old Caucasian male who lives in Pomona, Missouri where he and his wife own a house. DN grew up in Dora, Missouri where he graduated high school, then resettled to Pomona at the age of nineteen. DN has three pornographic children and several grandchildren. DNs family remains very close and visit often to where DN lives. DN abdicate his job at Howell-Oregon Electric in 1980 to become a full judgment of conviction farmer. DN and his wife own approximately three hundred acres to operate a dairy and crab cattle farm with 170 head of cattle.They milk the cows twice a day keeping them very active end-to-end the day. DN considers himself to be in the middle-class economically , but with the unpredictable cattle market economic status can change passim the year. DN has Medi commission as primitive insurance with supplements. Before his admission to the hospital, DNs health state was good. DNs health negociate system factors consist of a health check diagnosis of osteoarthritis. The treatment of superior for DN was a left total knee replacement. After bump off, home health entrust help organize tangible therapy close set(predicate) to home. DN does not entertain any underlying diseases, such as hypertension or diabetes, which can cause complications or depart the world power of DN to cast a stool recovery.He has a primary medical student in Willow Springs for yearly check-ups and nestling problems. DNs patterns of living include run and fishing, going to church, and winning care of the farm. DN does not smoke or drink alcohol. agree to Erikson, he is in a developmental represent of ego integrity versus discouragement (Berman et al., 2007). DN belongs in this psychosocial developmental stage because he is at a stage where he is content with his life and satisfied with everything that has make passed in his life thus far. He is able to reflect on his past without regret. DN tones as if he has lived a life full of happiness.Orem identifies ten personnel components that are grave in evaluating how much nursing care is need by the long-suffering. The ten power components consist of attention deny and vigilance, hold in of forcible life force, control of body causas, ability to reason, motivation for action, conclusion making skills, k nowledge, repertoire of skills, ability to localise self-care actions, and ability to ruffle self-care actions into patterns of living (Caton, 2008). DNs attention span ad vigilance is a dexterity because passim the natural assessment and health history, he remained very attentive and transparent when answering the questions. His control of personal energy is a poten tial weakness due to the fatigue DN could experience after his knee replacement. After surgery, change state fatigued is easier due to the pain and softness to get a good nighttimes await in the hospital. DN seemed to know his limits with what kind of somatogenic energy he had to use end-to-end his stay.The perseverings control of body movements is a strength. even off though DN is get from a total knee replacement, he take notes good control over his movements. He excessively has a steady tread when walking with a supportive device. The diligents ability to reason is a strength. When he infallible help, he knew to ask his wife, a entertain, or an upholde for help. He understood that main office Health would be a emolument once he was discharged from the hospital. Motivation for action is in spades a strength. DN was very actuate to get back on his feet as presently as he could. He knew somatogenetic therapy was what would help the most so he was invariably rea dy to go when physical therapy came to take him to the Joint Club. After reverting after a trip to physical therapy, the forbearing stated, The physical therapist verbalise I did better than all of the an opposite(prenominal) uncomplainings with knee replacements.The endurings decision making skills were strength because he took all options into consideration prior to acquire his knee replacement. He knew it would be the best option with the active lifestyle that he has. experience was a potential famine for the diligent of because he had never had a knee replacement surgery in the beginning. The enduring was apprised of all the procedures, hospital stay, and anticipate outcomes during audience accommodations, but all the selective information at once can be arouse for the touch role. Even after the surgery, the diligent take over questioned the health care team members throughout the hospital stay to refresh his memory. repertoire of skills is a strength becaus e the persevering has a high school education, as well as the same occupation throughout his life.He is able to retain information and repeat skills if needed. DNs ability to order self-care actions is a strength because he is able to decide what actions are most strategic and follow through with them. He contumacious to have his knee surgery to advance his lifestyle and made it a precedency to get it done as shortly as he could. The ability to commingle self-care actions into his patterns of living is a strength for DN. He integrates a healthy diet and active lifestyle to prevent complications of his osteoarthritis. After trying minor treatment options to control pain and discomfort from the osteoarthritis, DN opted for surgical treatment and he realizes the physical therapy he give have to integrate into his lifestyle for full recovery. habitual Self-Care RequisitesOrems General Theory of Nursing involves self-care, self-care deficit, and nursing systems. Orems definition of self-care is what hoi polloi plan and do on their own behalf to maintain life, health, and wellness. The nursing systems that Orem identifies are in all compensatory, partly compensatory, and supportive-educative. The universal self-care undeniables that diligent may be deficient, potentially deficient, or a strength in consists of air, water, food, elimination, activity and equaliser, purdah and social interaction, prevention of hazards to human life, and normalcy (Berman et al., 2007). contrast voltage famineAir is a potential deficit for this patient. Upon assessment, his respiratory rate was abstruse down normal locate at 20 breaths per minute. Normal respirations for the age group of the client invest from xv to twenty per minute (Berman et al., 2007). The patient has a invariable respiration rate mingled with this level, but with decrease red blood cells, hemoglobin, and hematocrit the patients oxygen level may increase to chasten for the lack of cells that c an carry the oxygen, peculiarly during physical therapy. DNs lung sounds when auscultated were clear in all lobes, bilaterally. A critical side effect of morphine, one of the medications DN was taking while in the hospital, is respiratory depression, which can happen in a matter of legal proceeding ca exploitation a deficit (Deglin & Vallerand, 2007).Water vividnessWater is a strength for DN. No edema was noted upon assessment. Good skin turgor was indicative that there was becoming hydration for the patient. DNs average inlet was 2000 mL of fluids, usually water and ice tea. This was within normal range with the requirements being set at a marginal of 1500 mL of fluids daily (Berman et al., 2007).Food StrengthFood is a strength for the patient. The patient was on a regular diet and had no trouble eating. On some occasions, his wife brought meals to the patient. DN consumes a healthy diet, full of fruits and vegetables from his own garden when home. Protein consumed in his diet usually consists of very lean beef from home grown cattle. DN consumed enough calories to aid in recovery of his surgery.Elimination shortageElimination is a problem for the patient. He has not had a bowel movement since the day earlier he had the surgery. DN had an epidural anesthesia until the first day post-op and is taking soporiferous analgesics for pain control, which both contributed to the price elimination. The side make from the medication cause the intestines to decrease peristalsis. Monitoring bowel functions, as well as administer the stool softeners and laxatives that are ordered, are two chief(prenominal) nursing interventions (Lemone & Burke, 2008).Activity and bide DeficitThe patient had a deficit in both activity and alight. The patient stated he was not get adequate rest in the hospital due to the assorted environment and the pain he was experiencing from his surgery. In the hospital, the patient was also put on activity restrictions due to his total knee arthroplasty. He was able to go to physical therapy three measure a day, but normal activities were contain for DN. At home DN does not have activity or rest deficit, he participates in an active lifestyle with a lot of walking and daily physical labor. He also gets approximately 7 or 8 hours of sleep a night which is adequate for a man his age (Berman et al., 2007).Solitude and Social Interaction Potential DeficitThe patient did not have a deficit with social interaction. His wife was in the manner majority of the time and he also had many a(prenominal) battalion drop in and see him throughout his hospital stay. DN also interacted with wad on the health care team, whether it was the nurses or physical therapists, he was always having a conversation with someone. Due the many visitors and activities DN had during the day, solitude was a potential deficit. The physical therapists and nurses that came in the room consistently make it difficult for the patient to get any time to rest and relax by himself. Adequate rest is easier to obtain when there are no interruptions in the rest period and some solitude is allowed.Hazard Prevention DeficitHazard prevention is a deficit for DN. The total knee arthroplasty causes the patient to be at an increased risk for infection due to all the invasive procedures done. refuge antibiotics were being considered to help prevent any infection that may develop. The patient is also at risk for falls. The intravenous line and pole make it difficult for the patient to walk on his own while dealing with his surgery. The medications DN were taking could cause confusion, dizziness, and sedation which could lead to a fall. The patient is also at risk for a abstruse vein thrombus due to the surgery, which could be a fatal complication if not prevented. muscular contraction stockings and devices were used to decrease the chance of venous stasis. advancement of Normality DeficitPromotion of normality is a deficit for the patient. He has tho been hospitalized two other measure in his life and feels un homey. Since DN is not used to being in the hospital, he is indecisive to ask for pain medication until the pain is already present. Teaching DN to ask for the pain medicine prior to activities and when he manages the pain coming back. DNs normal ordinary at home go away be changed to accommodate for the knee surgery he underwent. He depart have to castigate to the limitations on his activities until he is fully recovered. For example, he result have to depend on his wife and other family members to help milk the cows and take care of the farm until he has full range of movement so he does not damage his newly replaced knee.Developmental Self-Care RequisitesDevelopmental self-care requisites are associated with conditions that result in maturation (Berman et al., 2007). DN has lived a long, robust life and many life changing events have occurred throughout his life. He graduated high scho ol and worked duple jobs which gave him the experience he needed to now be a self-employed farmer. He and his wife raised a family with three children, and now have several grandchildren. exclusively of these different aspects in DN life have helped DN mature, which puts him in a developmental stage of ego integrity versus despair. According to Erikson, people in this stage should have betrothal of their life and self-worth (Berman et al., 2007).DN seems very satisfied with everything that has happened in his life. He is able to reminisce about the things that have happened in his life with a smile. He does not have any regrets about his life. At this point in DNs life, he is always thinking of others and enjoying the small things in life. Even though DN is in this developmental stage, he has not fully completed this stage. DN is in a position where he free works and provides for his family. He is not ready to leave his family at this point in his life.Health Deviation Self-Car e RequisitesAccording to Orem, there are six health leaving self-care requisites. The health care discrepancy self-care requisites consist of seeking and securing medical help when needed, responsibly attendance to the effects and results of pathologic conditions, in effect carrying out prescribed interventions, responsibly tending to the regulation of effects resulting from prescribed interventions, evaluate the fact that some generation self or others need medical help when face up with certain life challenges, and learning to live productively with the effects of pathologic conditions and treatments while promoting continued personal development (Caton, 2007). The patient is strong in seeking and securing medical help when needed. As soon as the patient know his pain was increasing in his knee, he scheduled an appointment with his family doctor who referred him to Dr. Know the orthopedic surgeon. The patient is also responsible in attending to the effects and results of p athologic conditions. The patient is conscious of the physical therapy regime he require to complete for full recovery, as well as the preventive measures he take to take to protect his right knee. The third gear health deviation self-care requisite is to effectively carry out prescribed interventions, which is a strength for the patient.DN realizes he get outing continue with physical therapy after discharge on the hospital and pull up stakes be on a few prescription medications. separate interventions, such as wearing TED waters, confining activities, and allowing home health to help with his care, pull up stakes all be followed by the patient. The poop health deviation self-care requisite is to responsibly attend to the regulation of effects resulting from prescribed interventions is a potential deficit. Even though the patient stated he depart do the interventions asked of him, the task of depending on others for help may be difficult. As a farmer, it is difficult t o let someone else do the chores the patient is usually doing on a daily basis. The fifth health deviation self-care requisite is accepting the fact that sometimes self or others need medical help when faced with certain life challenges.This health deviation self-care requisite is a strength for the patient. When DN established his knee was not functioning at the level he needed it too, he sought help from professionals after trying alternative treatments. When DN had his prostate removed due to prostate cancer, he also pursued help from many specialists to deal with the many complications a prostatectomy can cause. The sixth health deviation self-care requisite is learning to live productively with the effects of pathologic conditions and treatments while promoting continued personal development. This is a strength for the DN because he looks onward to having better function in his knee to live a more productive life. The chores he does on the farm were becoming difficult with th e increasing pain in his knee prior to the surgery. The patient now talks yearningally about getting back out on the farm to do the things he loves to do.Nursing diagnosingI. Nursing diagnosis 1 cracking Pain cogitate to meander distress caused by surgery and intense physical therapy regime as attest by patient verbalizing his pain an 8 on a 1-10 scale. a. expect issuing Patient verbalizes relief of pain as little than a 3 on a 1-10 scale at least xxx minutes after administration of pain medication. i. preventive 1 evaluate the patients description of pain and persuasiveness of pain-relieving interventions. 1. precept Assessing pain description leads to the best interventions to control the pain, as well as assess for any complications with a different pain description. Every patient has a right to effective pain relief (Gulanick & Vallerand, 2007). ii. intercession 2 give lessons the patient to signal pain medication before the pain becomes severe. 2. precept r est pull up stakes take longer if the patient waits until the pain is too severe (Gulanick & Vallerand, 2007).The best pain control is proactive, not reactive. iii. interjection 3 Administer narcotic analgesics as ordered by the doctor. 3. rule With all of the tissue damage done during surgery, the nurse should assume the patient is in pain and needfully analgesics (Gulanick & Vallerand, 2007). a. instruction execution/ military rank carry assessed the patients description of pain to adequately treat the pain symptoms. curb taught the patient the request the pain medication at the oncoming of pain to dress the amount of time it takes to start working. The finishing was met because the patient talk his pain less than a 3 on a 1-10 scale within 30 minutes of administration of pain medication. b. Expected government issue Patient appears comfortable as manifest by absence of facial grimacing and use of stress centering techniques between doses of pain medication an d throughout hospital stay. iv. handling 1 admit entrust hear patient to use guided imagery and forward-moving relaxation. 4. rationale Use of guided imagery and progressive relaxation will distract patient from the pain he is experiencing (Gulanick & Vallerand, 2007). v. hitch 2 Nurse will teach patient to change position frequently.5. rule Changing positions (within limits) will relieve nip and pain on bony prominences, deoxidize muscle spasm, and undue tension (Gulanick & Vallerand, 2007). vi. Intervention 3 Nurse will apply ice packs as ordered. 6. principle Applying ice packs may decrease edema and enhance comfort (Gulanick & Vallerand, 2007). b. death penalty/ valuation Nurse taught the patient different comfort measure to relieve pain in between doses of pain medication. utilise repositioning and relaxation measures helped the patient stay comfortable between doses of pain medication. The goal was met. II. Nursing diagnosis 2 stricken physical mobility tie in to pain after surgical procedure as evidenced by limited ability to ambulate. c. Expected Outcome Patient will maintain optimal mobility within limitations throughout hospital stay. vii. Intervention 1 Assess operative range of motion in affected and unaffected joints.7. rationale Assessment of range of motion will give a service line to see if the patient is improving. black market of motion exercises are important to sanction affected joint (within limitations) and unaffected joints need to maintain current mobility in periods of decreased activity because joints with arthritis lose function more rapidly (Gulanick & Vallerand, 2007). viii. Intervention 2 Nurse will assist patient to ambulate with less assistance as tolerated. 8. rationale This will allow for patient to become more independent before discharge (Gulanick & Vallerand, 2007). ix. Intervention 3 Nurse will uphold the patient to move from the bed to the chair as tolerated, as well as ambulate in the r oom three times a day. 9. Progress will be monitored toward normal activities patient will do once discharged from the hospital (Gulanick & Vallerand, 2007). c. effectuation/Evaluation Nurse assessed postoperative range of motion to have a baseline of function. Improvement was noted throughout shift that the patient was able to move more independently. d. Expected Outcome Patient participates in rehabilitation plan throughout hospital stay. x. Intervention 1 Assess the patients dismay or anxiety in ambulating and going to physical therapy.10. Rationale If the patients fear and anxiety is too great, the patient may not get the full benefit of physical therapy and is at a greater risk for falls or other injuries (Gulanick & Vallerand, 2007). xi. Intervention 2 Nurse will encourage use of supportive walking devices, such as a walker. 11. Rationale Use of a walker will help the patient feel more independent and support to go to physical therapy as ordered. More pack bearing will progress throughout the use of walker (Gulanick & Vallerand, 2007). xii. Intervention 3 Nurse will beef up instructions for rehabilitative activities as ordered. 12. Rationale Reinforcing instructions will help the patient achieve mobility throughout the hospital stay and adhere to the physical therapy program (Gulanick & Vallerand, 2007). d. slaying/Evaluation The patient was enthusiastic about physical therapy and gaining full mobility of affected leg. He participated in the rehabilitation program and was able to go home on schedule, so the goal was met.III. Nursing diagnosis 3 Self-care deficit related to impaired mobility as evidenced by inability to perform activities of daily living, such as dressing, bathing, and ambulate independently. e. Expected Outcome 1 Patient will safely perform all self-care activities of daily living independently before discharge. xiii. Intervention 1 Nurse will assess the patients ability to perform activities of daily living. 13. Rat ionale This will provide a baseline to know where the priority deficits in the patients performance of ADLs and help nurse assist with the patients needs (Gulanick & Vallerand, 2007). xiv. Intervention 2 take care the patient in accepting help from others. 14. Rationale The patient may need to realize after a total knee replacement, some assistance may be needed and dependence on people or supportive devices may be necessary temporarily (Gulanick & Vallerand, 2007). xv. Intervention 3 Nurse will implement measures to facilitate liberty, but be available to help patient when needed.15. Rationale Giving the patient freedom will help encourage patient to travail ADLs on his own, but with assistance when needed will prevent falls or other injuries (Gulanick & Vallerand, 2007). e. Implementation/Evaluation Nurse assessed the patients ability to perform activities of daily living and realized where the patient needed assistance. Patient was encouraged to do ADLs on his own, b ut to cut and ask for help if he needed it. Patient was able to ambulate on his own the bathroom, perform most activities independently, but required some help from his wife by discharge. This goal was met because the patient realized when he needed help and performed all ADLs safely by discharge. f. Expected Outcome 2 Resources are identified that are useful in optimizing the autonomy and independence of the patient by discharge from the hospital. xvi. Intervention 1 Nurse will assess what assistance will be needed when the patient is discharged.16. Rationale This will be helpful to the patient and other caregivers to recognize deficits until they are overcome (Gulanick & Vallerand, 2007). xvii. Intervention 2 Nurse will encourage patient to use assistive devices until no longer needed, and reassure patient that use of them can prevent falls and injuries. 17. Rationale This allows patient to know total independence is not expected just because the patient is being discharged (G ulanick & Vallerand, 2007). xviii. Intervention 3 Nurse will help the patient set short term goals to becoming more independent. 18. Rationale setting short term goals will decrease the frustration the patient may have in not being able to do activities he could do before surgery (Gulanick & Vallerand, 2007). f. Implementation/Evaluation Nurse assessed what assistance may be needed to help with activities of daily living. Patient used assistive devices and help from others when he recognized he could not do them independently. Short term goals were set and patient was able to be discharged with a walker and home health services. This expected outcome was met.IV. Nursing Diagnosis 4 Risk for ineffective tissue perfusion related to surgical procedure and impaired physical mobility. g. Expected Outcome Patient maintains adequate tissue perfusion and remains free from obscure vein thrombosis, as evidenced by warm extremities, good capillary refill, bilaterally equal pulses, nega tive Homans sign, and stable vital signs. xix. Intervention 1 Assess neurovascular status of affected limb preoperatively and postoperatively, as well as assess for signs and symptoms of abstruse vein thrombosis. 19. Rationale Preoperatively a baseline should be established and assessing for changes postoperatively will be indication of a problem. Signs and symptoms could be an early indication of a blood clot which leads to early intervention (Gulanick & Vallerand, 2007). xx. Intervention 2 Nurse will assist patient in using thromboembolic disease support hoses and sequential compaction devices as prescribed. 20. Antiembolic devices, such as TED hose and SCDs, increase venous blood hightail it to the heart and decrease venous stasis, which could prevent a blood clot (Gulanick & Vallerand, 2007).xxi. Intervention 3 Nurse will administer clot buster and anticoagulant agents as ordered. 21. Rationale Prophylactic anticoagulants will reduce the risk of deep vein thrombosis an d thrombolytic drugs may decrease the complications if a blood clot does develop (Gulanick & Vallerand, 2007). g. Implementation/Evaluation Patient was assessed preoperatively and postoperatively for neurovascular status. Patient was monitored closely for any signs of ineffective tissue perfusion. Nurse encouraged use of antiembolic devices and patient adhered to regimen. The goal was met because ineffective tissue perfusion was not a problem and not deep vein thrombosis developed. V. Nursing Diagnosis 5 Deficient knowledge related to a new procedure and unfamiliar with the discharge plan as evidenced by patient questioning health care team members about the process. h. Expected Outcome Patient verbalizes understanding of procedure and discharge instructions.xxii. Intervention 1 Assess the patients current understanding of process in hospital and discharge instructions. 22. This will allow the nurse the individualize the dogma plan for the patient and teach only what the patient does not understand (Gulanick & Vallerand, 2007). xxiii. Intervention 2 Nurse will review total knee arthroplasty precautions tally to what the patient does not already know, for example, using the walker, maintain proper body weight, and when to rede the physician. 23. Rationale Reviewing the information will strengthen adherence to the rehabilitation program (Gulanick & Vallerand, 2007). xxiv. Intervention 3 Nurse will explain the discharge follow up instructions, and reinforce the need to continue with home health for physical therapy.24. Rationale Home health and physical therapy will increase the patients strength to have a full recovery. When the patient understands the process, he will be more motivated to continue with the program (Gulanick & Vallerand, 2007). h. Implementation/Evaluation This goal was met. The patient had a full understanding of the limitations of a knee arthroplasty, in the hospital and after discharge. He understood the follow-up appointments and how home health would assist in his recovery. VI. Nursing Diagnosis 6 Constipation related to inaction and medication use as evidenced by patient having frequent but nonproductive desire to defecate. VII. Nursing Diagnosis 7 Risk for infection related to invasive procedure. VIII. Nursing Diagnosis 8 Risk for falls related to insecure gait and pain in left leg.ReferencesBerman, A., Snyder, S., Kozier, B., & Erb, G. (2007). bedrock of nursing Concepts, process, and practice (8th ed.). Upper Saddle Road, NJ Pearson. Caton, B. (2007). Orems self care requistes. Handout for NUR100 Fundamentals of Nursing. Missouri State University-West Plains, Fall 2007. Deglin, J.H., & Vallerand, A.H. (2007). Daviss drug guide for nurses (10th ed.). Philadelphia F.A. Davis. Gulanick, M., & Myers, J.L. (2007). Nursing care plans Nursing diagnosis and intervention. St. Louis MO Elsevier. LeMone, P., & Burke, K.M. (2004). Medical-surgical nursing tiny thinking in client care(3rd Ed.). Upper Saddle Road, NJ Pearson.Pagana, K.D., & Pagana, T.J. (2006). Mosbys manual of diagnostic and lab tests(3rd ed.). St. Louis, MO Mosby.Total Knee Replacement (2009). American Academy of Orthopaedic Surgeons. RetrievedOctober 19, 2009, from http//orthoinfo.aaos.org/ melodic theme.cfm?topic=A00389.