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Patient Name: VBM

ASSESSMENT Subjective: My knee is in pain. It is hard to bare sometimes as verbalized by patient. Pain scale is a 7 out of 10 as verbalized by patient.

Age: 58

Sex: F

Final Diagnosis: ACL Tear


PLANNING After 8 hours of nursing intervention, the patient will manifest a decrease in pain scale from 7/10 to a pain free level of 0/10. 1.

Procedure: Total Knee Arthroplasty R knee


RATIONALE 1. To document and compare any changes To rule out infection To monitor internal signs of discomfort To keep patients mind off pain To relax any elevated signs of stress To reduce pain perception To further relax the patient To find provide a more comfortable position for the patient To determine if interventions are effective in reducing symptoms. EVALUATION After 8 hours of nursing intervention, the patient was able to report a decrease in pain scale from 7/10 to 0/10.

NURSING DIAGNOSIS Acute Pain related to surgical intervention on right knee

INTERVENTIONS Assess patients pain scale and location of pain Check surgical site for any signs of infection. Monitor V/S for signs of stress Teach client diversion activities Advise breathing exercises and relaxation techniques Give pain medications as ordered Give a back massage Reposition patient Encourage verbal response during and after nursing interventions and movements

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3. 4. 5. Objective: Facial grimace Guarding behavior of right knee

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ASSESSMENT Subjective: I am unable to move my right leg. It feels very week and it hurts when I make sudden movements as verbalized by the patient. I am scared to try to move my leg as verbalized by patient. Objective: Facial grimace Guarding behavior of right knee Patient is unable to move right leg purposefully Limited ROM

NURSING DIAGNOSIS Impaired Physical Mobility related to immobilization therapy.

PLANNING After 8 hours of nursing intervention, the patient will perform ROM exercises and express a willingness for continued compliance. 1.

INTERVENTIONS Assess degree of immobility produced by injury/treatment and note patients perception of immobility. Encourage participation in diversional/recreat ional activities. Maintain stimulating environment. Instruct patient and assist with passive ROM exercises to R leg Encourage use of isometric exercises with unaffected limbs Assist with and encourage selfcare activities Provide and assist with mobility with assisted devices 1.

RATIONALE To determine the extent of immobility To provide opportunity for release of energy and refocus of attention. Enhances patients sense of selfcontrol. To increase blood flow to muscles and improve muscle tone, maintain joint mobility. To help maintain muscle strength and mass To improve muscle strength and circulation by having patient move their extremities while promoting selfcontrolled wellness Early mobility reduces complications of bed rest and promotes healing

EVALUATION After 8 hours of nursing intervention, that patient was able to perform ROM exercises and expressed a willingness to continue to do them in order to strengthen her knee.

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