NURS-330N6-Medical Surgical Nursing-I-CP-08-2020
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NURS-330N6-Medical Surgical Nursing-I-CP-08-2020
While utilizing the provided CARE PLAN template, which was given to you in week one, write a care plan on a newly admitted patient with
1. A total hip arthroplasty
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Nursing Care Plan Form (NURS-330N6-Medical Surgical Nursing-I-CP-08-2020)
Student Name: Date:
Patient Identifier: M.N, 66-year-old A.A male Patient Medical Diagnosis: A total hip arthroplasty
Nursing Diagnosis (use PES/PE format): Impaired Physical Mobility related to Surgery therapy as evidence by difficulty purposefully moving within the physical environment.
Assessment Data
(Include at least three-five subjective and/or objective pieces of data that lead to the nursing diagnosis)
Goals & Outcome
(Two statements are required for each nursing diagnosis. Must be Patient and/or family-focused; measurable; time-specific, and reasonable.)
Nursing Interventions
(List at least three nursing or collaborative interventions with rationale for each goal & outcome.)
Rationale
(Provide reason why intervention is indicated/therapeutic; provide references.)
Outcome Evaluation & Replanning
(Was goal met? How would you revise the plan of care according to the patient’s response to current plan ?)
1.
Difficulty purposefully moving within the physical environment.
2.
Reluctance to attempt movement
3.
Reports of discomfort and pain on movement
4.
Limited ROM of the operated limb
5.
Decreased muscle strength/control
Statement #1
The patient will demonstrate increased muscle strength and function of affected hip joint and limb within 24 hours.
Statement #2
The patient will report controlled pain and discomfort on the affected limb within 12 hours.
1.
Maintain affected hip joint in prescribed position and body in alignment when in bed (Ignatavicius & Workman, 2013).
2.
Perform and assist with range of motion exercises to the unaffected hip joint.
3.
Initiate the patient in a rehabilitative exercise program involving the quadriceps and gluteal muscle, isometrics, leg lifts, dorsiflexion, and plantar flexion of the foot (Ignatavicius & Workman, 2013).
1.
Maintain a proper position of the operated limb (Ignatavicius & Workman, 2013).
2.
Initiate and maintain limb mobilization by ambulation, physical therapy, and ARM exercise (Ignatavicius & Workman, 2013).
3.
Administer analgesics and muscle relaxants as prescribed (Ignatavicius & Workman, 2013).
1.
This provides for the stabilization of prosthesis and lowers the risk of injury during recovery from the effects of anesthesia (Ignatavicius & Workman, 2013).
2.
To avoid losing the joint function of the unaffected joint during periods of restricted activity (Ignatavicius & Workman, 2013).
3.
To strengthen muscle groups, which increase muscle tone and mass and stimulate circulation to prevent decubitus (Ignatavicius & Workman, 2013).
1.
Proper limb positioning reduces muscle spasm and undue tension on the new prosthesis and surrounding tissues (Ignatavicius & Workman, 2013).
2.
Limb mobilization increases circulation to affected muscles, minimizes joint stiffness and relieves muscle spasms (Ignatavicius & Workman, 2013).
3.
Analgesics relieve surgical pain while muscle relaxants reduce muscle tension and spasm, contributing to an increased overall comfort (Ignatavicius & Workman, 2013).
Outcome #1
The goal was met since the patient exhibited increased muscle strength and enhanced hip joint function within 24 hours.
Outcome #2
The goal was met as the patient reported decreased pain and discomfort on the operated limb.
Reference
Ignatavicius, D. D., & Workman, M. L. (2013). Medical-surgical nursing: Patient-centered collaborative care (7th Ed.). Elsevier Health Sciences.
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Nursing Care Plan Form
Student Name: Date:
Patient Identifier: Patient Medical Diagnosis:
Nursing Diagnosis (use PES/PE format):
Assessment Data
(Include at least three-five subjective and/or objective pieces of data that lead to the nursing diagnosis)
Goals & Outcome
(Two statements are required for each nursing diagnosis. Must be Patient and/or family focused; measurable; time-specific; and reasonable.)
Nursing Interventions
(List at least three nursing or collaborative interventions with rationale for each goal & outcome.)
Rationale
(Provide reason why intervention is indicated/therapeutic; provide references.)
Outcome Evaluation & Replanning
(Was goal met? How would you revise the plan of care according to the patient’s response to current plan ?)
1.
2.
3.
Statement #1
Statement #2
1.
2.
3.
1.
2.
3.
1.
2.
3.
1.
2.
3.
Outcome #1
Outcome #2
NURS-330N6-Medical Surgical Nursing-I-CP-08-2020
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