Case Study: Osteoarthritis with a Total Knee Arthroplasty Essay

DN is a 68 year old Caucasian male who lives in Pomona, Missouri. On September 14, 2009, DN underwent a scheduled left organic genu arthroplasty at Baxter County Regional Medical Center. A consultation appointment about a summarise knee arthroplasty was scheduled when DN had increasing bother in his knees composition doing chores and working on his dairy farm. The increasing trouble oneself DN was having been due to a history of osteoarthritis and the wear-and-tear on his joints end-to-end his purport, no specific injury was renowned. Depending on the outcome of the left knee, DN was consulted on having his right knee do in the future due to his active modus vivendi as a dairy farmer. DN is concisely in very good wellness despite his sufferful sensation from osteoarthritis. Osteoarthritis is ca implementd from wear and tear on the joints. The b angiotensin converting enzymes between a joint is cushioned by cartilage which after mevery years of use fall downs. When th e bones no longer father the cushion, pain and stiffness develops when the bones rub unitedly (Total Knee Replacement, 2009). His health history includes over access prostate cancer approximately six years ago. subsequently a prostatectomy to re ladder his cancer, DN continues to vex erectile dysfunction flush after meeting some(prenominal) specialists and trying many treatment options. In 1999, DN had his appendix removed at Ozark Medical Center. DN has a herniorrhaphy and cataract surgical number prior to this infirmaryization. DN has no known totally toldergies to drugs, food, or surroundingsal allergens. The forbearing lives at home with his married woman on a dairy farm. He handles about 170 head of dairy cattle that ar milked twice a day. He retired from Ho well up-Oregon County Electrical approximately five years ago to servicing manage his farm on a full clock basis. DN and his wife raised three children and prolong several(prenominal) grandchildren who come and visit frequently. DN does not have any significant history of nicotine, alcohol, or drug use. His diet has consisted of fresh fruits and ve stick to able-bodieds from the garden throughout his life. These factors have all played a part in tendinging DN stay well-informed without any underlying chronic disease processes.Physical appraisementMy corporal surveyment was performed on September 16, 2009. DNs vital signs consisted of an apical pulse of 98, a internal respiration set of 20, a temperature of 99.1 degrees Fahrenheit, an oxygen saturation of 96%, a lying blood pressure of 117/78, a sitting blood pressure of 116/75, and a stand blood pressure of 116/74. enduring was alert and oriented to person, place, time, and situation. patient was able to spell WORLD forward and backwards. PERLA and noted cardinal field of gaze were inherent. eyeball were clear with conjunctiva pink and no loss noted. unhurrieds head and face was symmetrical with no apparent skin breakdow n. Patient had dentures intact in mouth with healthy, pink gums with no lesions present inside 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 hear upon auscultation in all four cardiac areas with normal rhythm. Abdomen is soft, symmetrical with hypoactive intestine sounds present in all four quadrants. Last bowel movement was on Sunday, September 13. Patient was passing flatus.No masses, distention, or lesions noted on the abdomen. No tenderness was noted in the abdomen. No edema was noted in the upper or lower 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, slight erythemateous around incision, no odor present, and dressing was dry and intact. Pulses w ere strong and equal bilaterally- including carotid, brachial, radial, femoral, popliteal, dorsalis pedis, and bet onerior tibialis. Skin was sore and pink with no signs of cyanosis, rash, or skin breakdown. Gait was symmetrical and coordinated when utilize a walker, without the supportive device there is some unsteadiness due to the left total knee arthroplasty. There was no hearing shortage noted with normal conversation. Patient only had complaints of pain at surgical site after ambulation, physical therapy or the CPM. Patient was taught he could quest for the pain medical specialty prior to these events to hopefully avoid intense pain.Current MedicationsThroughout DNs hospital stay he was prescribed medicine to alleviate the pain caused from the total knee arthroplasty, help prevent any infection that had potentiality to be a problem, and prevent any complications. DNs urrent medicinal drugs while in the hospital were as follows 1.) Docusate-Senna (Trade Name Peri-Colace ) 1 tablet by mouth, twice a day used for softening and passage of s alsol for the championship of constipation caused by post operative anaesthesia and decreased employment (Deglin & Vallerand, 2007). 2.) Enoxaparin (Trade Name Lovenox) 40 mg by subcutaneous injection, once every morning used for the prevention of thrombosis makeup (Deglin & Vallerand, 2007). 3.) Psyllium (Trade Name Metamucil) 1 tablespoon by mouth, twice a day used for relief and prevention of constipation (Deglin & Vallerand, 2007).4.) Acetaminophen-Oxycodone (Trade Name Percocet 5/325) 1-2 tablets by mouth, every four hours used for decreasing pain as well as decreasing a temperature (Deglin & Vallerand, 2007). 5.) Magnesium Hydroxide (Trade Name Milk of Magnesia) 30 mL by mouth as needed used for replacement in a deficient state or evacuation of the colon (Deglin & Vallerand, 2007). 6.) morphia (Trade Name Astramorph) 8 mg by intravenous piggyback, every three hours as needed used for a decrease in the sev erity of pain (Deglin & Vallerand, 2007). 7.) Promethazine (Trade Name Phenergan) 12.5 mg by intravenous piggyback, every four hours as needed used for diminishing nausea and vomiting, as well as provide some sedation (Deglin & Vallerand, 2007).Diagnostic TestsDN had diagnostic tests prior to being admitted to the hospital for his total knee arthroplasty to determine the best treatment option for his osteoarthritis. After his surgery, more diagnostic tests were done to monitor for complications of the affair. The results were compared to normal and were as follows for the diligent 1.) White Blood Cells (Normal Value 5,000-10,000/mm3) Patients white blood stallphone count was 12,800/mm3, which is a high value. This value indicates the stress on the body and inflammation around the knee involved after the operation. The value is as well a possible indicator of infection, which would require continued monitoring (Pagana & 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 common conclusion after an invasive surgery.A decreased level whitethorn indicate a hemorrhage, overhydration, or a dietary deficiency, which may need to be corrected (Pagana & Pagana, 2006). 3.) hemoglobin (Normal Value 14-18 g/dL) Patients hemoglobin was 11.8 g/dL, which is a low value. This value is a common finding after surgery due to the blood loss, moreover the value may withal indicate anemia or nutritional deficiency (Pagana & Pagana, 2006). 4.) Hematocrit (Normal Value 42-52%) Patients hematocrit was 34.4%, which is a low value. This is a normal finding after surgery, only if may indicate anemia, malnutrition, or a dietary deficiency that may need to be corrected (Pagana & Pagana, 2006). 5.) Mean Corpuscular Hemoglobin (Normal Value 27-31 pg) Patients mean corpuscular hemoglobin was 31.8 pg, which is just slightly overhead railway. This value could possibly indicate a macrocytic anemia, but is not elevated enough to be a significant concern (Pagana & Pagana, 2006).Basic Conditioning Factors and Power ComponentsDorthea Orem identifies ten basic conditioning factors that identify the diligent and help assess the need for tending in her Self-Care famine Theory of nursing. The basic conditioning factors identified by Orem consist of age, gender, Eriksons developmental state, health state, sociocultural orientation, health carry on system factors, family system factors, patterns of life-time, environmental factors, and availability 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 relocated to Pomona at the age of nineteen. DN has three grown children and several grandchildren. DNs family remains very close and visit often to where DN lives. DN quit his job at Howell- Oregon Electric in 1980 to become a full time farmer. DN and his wife own approximately 300 acres to operate a dairy and beef cattle farm with 170 head of cattle.They milk the kine twice a day keeping them very active throughout the day. DN considers himself to be in the middle-class sparingally, but with the unpredictable cattle market economic status can tilt throughout the year. DN has Medicare as primary insurance with supplements. Before his admission to the hospital, DNs health state was good. DNs health care system factors consist of a medical diagnosis of osteoarthritis. The treatment of choice for DN was a left total knee replacement. After discharge, home health leave behind help organize physical therapy closer to home. DN does not have any underlying diseases, such as hypertension or diabetes, which can cause complications or alter the ability of DN to have a speedy recovery.He has a primary physician in Willow Springs for yearly check-ups and minor problems. DNs pa tterns of living include hunting and fishing, going to church, and taking care of the farm. DN does not smoke or drink alcohol. According to Erikson, he is in a developmental set up of ego integrity versus despair (Berman et al., 2007). DN belongs in this psycho affable developmental stage because he is at a stage where he is content with his life and satisfied with everything that has happened in his life thus far. He is able to reflect on his past without regret. DN feels as if he has lived a life full of happiness.Orem identifies ten power components that are important in evaluating how much nursing care is needed by the patient. The ten power components consist of attention span and vigilance, laterality of physical force, control of body movements, ability to reason, motivation for action, decision making skills, knowledge, repertoire of skills, ability to order self-care actions, and ability to integrate self-care actions into patterns of living (Caton, 2008). DNs attentio n span ad vigilance is a chroma because throughout the physical assessment and health history, he remained very attentive and honest when answering the questions. His control of physical energy is a potential weakness due to the fatigue DN could experience after his knee replacement. After surgery, neat fatigued is easier due to the pain and inability to get a good darknesss serenity in the hospital. DN seemed to know his limits with what kind of physical energy he had to use throughout his stay.The patients control of body movements is a strength. Even though DN is recovering from a total knee replacement, he maintains good control over his movements. He alike has a steady gait when walking with a supportive device. The patients ability to reason is a strength. When he needed help, he knew to ask his wife, a moderate, or an aide for help. He understood that Home Health would be a benefit once he was complete from the hospital. Motivation for action is definitely a strength. DN was very motivated to get back on his feet as soon as he could. He knew physical therapy was what would help the virtually so he was always score to go when physical therapy came to take him to the Joint Club. After returning after a trip to physical therapy, the patient stated, The physical therapist said I did better than all of the other patients with knee replacements.The patients decision making skills were strength because he took all options into consideration prior to getting his knee replacement. He knew it would be the best option with the active lifestyle that he has. Knowledge was a potential shortfall for the patient because he had never had a knee replacement surgery before. The patient was informed of all the procedures, hospital stay, and expected outcomes during consultation appointments, but all the information at once can be overwhelming for the patient. Even after the surgery, the patient still questioned the health care team members throughout the hospital stay to refresh his memory. Repertoire of skills is a strength because the patient 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 more or less important and follow through with them. He decided to have his knee surgery to benefit his lifestyle and made it a priority to get it done as soon as he could. The ability to integrate 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 lead have to integrate into his lifestyle for full recovery.Universal Self-Care RequisitesOrems General Theory of Nursing involves self-care, self-care deficit, and nursing systems. Orems definition of self-care is what people plan and do on their own behalf to maintain life, health, and wellness. The nursing systems that Orem identifies are wholly compensatory, partly compensatory, and supportive-educative. The universal self-care essentials that patient may be deficient, potentially deficient, or a strength in consists of air, water, food, elimination, activity and rest, solitude and social interaction, prevention of hazards to human life, and normalcy (Berman et al., 2007).Air Potential DeficitAir is a potential deficit for this patient. Upon assessment, his respiratory rate was within normal range at 20 breaths per minute. Normal respirations for the age group of the client range from fifteen to twenty per minute (Berman et al., 2007). The patient has a stable respiration rate between this level, but with decrease red blood cells, hemoglobin, and hematocrit the patients oxygen level may profit to compensate for the l ack of cells that can carry the oxygen, especially 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 minutes causing a deficit (Deglin & Vallerand, 2007).Water mediumWater is a strength for DN. No edema was noted upon assessment. Good skin turgor was indicative that there was adequate hydration for the patient. DNs average intake was 2000 mL of fluids, usually water and ice tea. This was within normal range with the requirements being set at a minimum of 1500 mL of fluids chance(a) (Berman et al., 2007).Food long suitFood 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 die t usually consists of very lean beef from home grown cattle. DN consumed enough calories to aid in recovery of his surgery.Elimination DeficitElimination is a problem for the patient. He has not had a bowel movement since the day before he had the surgery. DN had an epidural anesthesia until the first day post-op and is taking narcotic analgesics for pain control, which both contributed to the impaired elimination. The side cause 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 important nursing interventions (Lemone & Burke, 2008).Activity and Rest DeficitThe patient had a deficit in both activity and rest. The patient stated he was not getting adequate rest in the hospital due to the different 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 times a day, but normal activities were limited for DN. At home DN does not have activity or rest deficit, he participates in an active lifestyle with lots of walking and occasional 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 room majority of the time and he also had many people drop in and see him throughout his hospital stay. DN also interacted with people 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. Adeq uate 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 pretend for infection due to all the invasive procedures done. safety 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 muddy vein thrombus due to the surgery, which could be a fatal complication if not prevented. Compression stockings and devices were used to decrease the chance of venous stasis.Promotion of Normality DeficitPromotion of normality is a deficit for the patient. He has only been hospitalized two other tim es in his life and feels un cozy. Since DN is not used to being in the hospital, he is hesitant 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 recognizes the pain coming back. DNs normal routine at home will be changed to accommodate for the knee surgery he underwent. He will have to prepare to the limitations on his activities until he is fully recovered. For example, he will 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, productive life and many life changing events have occurred throughout his life. He graduated high school and worked multiple jobs which gave him the experience he needed to no w be a self-employed farmer. He and his wife raised a family with three children, and now have several grandchildren. all(prenominal) 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 acceptance 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 still works and provides for his family. He is not ready to leave his family at this point in his life.Health Deviation Self-Care RequisitesAccording to Orem, there are six health excursus self-c are requisites. The health care deviation self-care requisites consist of seeking and securing medical help when needed, responsibly attending to the effects and results of pathologic conditions, effectively carrying out prescribed interventions, responsibly attending to the regulation of effects resulting from prescribed interventions, accepting the fact that sometimes self or others need medical help when faced with certain life challenges, and learning to live fruitfully 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 realized 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 pathologic conditions. The patient is aware of the physical therapy regime he needs to complete for full recovery, as well as the incumbrance measures he needs to take to protect his right knee. The third health deviation self-care requisite is to effectively carry out prescribed interventions, which is a strength for the patient.DN realizes he will continue with physical therapy after discharge on the hospital and will be on a few prescription medications. former(a) interventions, such as wearing TED hoses, limiting activities, and allowing home health to help with his care, will all be followed by the patient. The fourth 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 will do the interventions asked of him, the caper of depending on others for help may be difficult. As a farmer, it is difficult to let someone else do the chores the patient is usually doing on a daily basis. The fifth health deviation self-care requi site 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 realized his knee was not functioning at the level he needed it too, he desire 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 forward to having better function in his knee to live a more productive life. The chores he does on the farm were bonnie difficult with the increasing pain in his knee prior to the surgery. The patient now talks evangelistically about getting back out on the farm to do the things he loves to do.Nursing DiagnosisI. Nursing Diagnosis 1 Acute Pain related to to create from raw stuff trauma caused by surgery and intense physical therapy regime as testify by patient verbalizing his pain an 8 on a 1-10 scale. a. anticipate Outcome Patient verbalizes relief of pain as less than a 3 on a 1-10 scale at least thirty minutes after administration of pain medication. i. Intervention 1 Assess the patients description of pain and effectiveness of pain-relieving interventions. 1. rationale 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. Intervention 2 Instruct the patient to request pain medication before the pain becomes severe. 2. rule Relief will take longer if the patient waits until the pain is too severe (Gulanick & Vallerand, 2007).The best pain control is proactive, not reactive. iii. Intervention 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 needs analgesics (Gulanick & Vallerand, 2007). a. Implementation/Evaluation value assessed the patients description of pain to adequately treat the pain symptoms. Nurse taught the patient the request the pain medication at the onset of pain to reduce the amount of time it takes to surface working. The goal was met because the patient verbalized his pain less than a 3 on a 1-10 scale within 30 minutes of administration of pain medication. b. Expected Outcome Patient appears comfortable as evidenced by absence of facial grimacing and use of stress management techniques between doses of pain medication and throughout hospital stay. iv. Intervention 1 Nurse will teach patient to use manoeuver imagery and progressive relaxation. 4. rationale Use of guided imagery and progres sive relaxation will distract patient from the pain he is experiencing (Gulanick & Vallerand, 2007). v. Intervention 2 Nurse will teach patient to change position frequently.5. Rationale Changing positions (within limits) will relieve pressure and pain on bony prominences, reduce muscle spasm, and undue tension (Gulanick & Vallerand, 2007). vi. Intervention 3 Nurse will apply ice packs as ordered. 6. Rationale Applying ice packs may decrease edema and enhance comfort (Gulanick & Vallerand, 2007). b. Implementation/Evaluation Nurse taught the patient different comfort measure to relieve pain in between doses of pain medication. Using repositioning and relaxation measures helped the patient stay comfortable between doses of pain medication. The goal was met. II. Nursing Diagnosis 2 Impaired physical mobility related to pain after surgical procedure as evidenced by limited ability to ambulate. c. Expected Outcome Patient will maintain optimal mobility within limitations throughout hosp ital stay. vii. Intervention 1 Assess postoperative range of motion in affected and unaffected joints.7. Rationale Assessment of range of motion will give a baseline to see if the patient is improving. Range of motion exercises are important to strengthen 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 encourage the patient to move from the bed to the chair as tolerated, as well as ambulate in the room three times a day. 9. Progress will be monitored toward normal activities patient will do once discharged from the hospital (Gulanick & Vallerand, 2007). c. Implementation/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 political program throughout hospital stay. x. Intervention 1 Assess the patients fear 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 encouraged to go to physical therapy as ordered. More tilt bearing will progress throughout the use of walker (Gulanick & Vallerand, 2007). xii. Intervention 3 Nurse will reinforce instructions for rehabilitative activities as ordered. 12. Rationale Rei nforcing instructions will help the patient achieve mobility throughout the hospital stay and adhere to the physical therapy program (Gulanick & Vallerand, 2007). d. Implementation/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. Rationale 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). xi v. Intervention 2 Assist 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 habituation on people or supportive devices may be necessary temporarily (Gulanick & Vallerand, 2007). xv. Intervention 3 Nurse will implement measures to facilitate independence, but be available to help patient when needed.15. Rationale Giving the patient independence will help encourage patient to attempt 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, but to recognize 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 dischar ge. 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 liberty 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 (Gulanick & 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 fr ustration 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 put on the line for ineffective tissue perfusion related to surgical procedure and impaired physical mobility. g. Expected Outcome Patient maintains adequate tissue perfusion and remains free from deep vein thrombosis, as evidenced by warm extremities, good capillary refill, bilaterally equal pulses, negative 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 deep 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 compression devices as prescribed. 20. Antiembolic devices, such as TED hose and SCDs, increase venous blood flow to the heart and decrease venous stasis, which could prevent a blood clot (Gulanick & Vallerand, 2007).xxi. Intervention 3 Nurse will administer thrombolytic and anticoagulant agents as ordered. 21. Rationale Prophylactic anticoagulants will reduce the risk of deep vein thrombosis and 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 neurov ascular 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 teaching 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 according to what the patient does not already know, for example, using the walk er, maintain proper body weight, and when to notify the physician. 23. Rationale Reviewing the information will reinforce devotion 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 inactivity and medication use as evidenced by patient having frequent but nonproductive desire to defecate. VII. Nu rsing Diagnosis 7 Risk for infection related to invasive procedure. VIII. Nursing Diagnosis 8 Risk for falls related to unsteady gait and pain in left leg.ReferencesBerman, A., Snyder, S., Kozier, B., & Erb, G. (2007). fundamental principle 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 Critical thinking in client care(3rd Ed.). Upper Saddle Road, NJ Pearson.Pagana, K.D., & Pagana, T.J. (2006). Mosbys manual of diagnostic and laboratory tests(3rd ed.). St. Louis, MO Mosby.Total Knee Replacement (2009). American Academy of Orthopaedic Surgeons. RetrievedOctober 19, 2009, from http//orthoinfo.aaos.org/topic.cfm?topic=A00389.