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Indiana University School of Nursing Baccalaureate of Science in Nursing Program Nursing Care Plan - Example Care Plan Care Planning, Implementation, and Evaluation From the Comprehensive Nursing Diagnosis list, select one Nursing Diagnosis: Actual or problem statement, related to etiological factors or Risk for problem, related to presence of risk factors (list) NURSING DIAGNOSIS 1. Acute pain related to surgical procedure AEB by pain level 8-10/10, grimacing and guarding. 2. Impaired physical mobility related to surgical procedure on left knee AED pain in ambulation and swelling. 3. Risk of infection related to inflammation of wound surgery State a measurable patient outcome that is achievable within a clinical time frame: 1. Patient will report a decreased in pain (0-1/10 and shows no grimacing or guarding at the end of hospitalization. 2. Patient will demonstrate use of adaptive equipment (walker) to increase mobility at the end of hospitalization. 3. Patient will state the symptoms of which to be aware at the end of hospitalization NURSING RATIONALE : IMPLEMENTATION: Describe effectiveness INTERVENTIONS State rationale for individual intervention Select appropriate Include source Ex (Ackley and of interventions done in assessment, therapeutic Ladwig,2008) clinical and patient education interventions to achieve patient outcome: Assess client’s pain and vital signs every 4 hour. Administer scheduled pain management medications and PRN medications as needed to reduce pain. “Pain assessment is as important as physiological vital signs and pain is considered as the fifth vital sign. Routine monitoring of the effects of the pain management regime results in improved pain management and decreased risk of adverse effects” (Ackley & Ladwig, 2008, p. 611) Consult with the physical therapist to begin an exercise program post surgery “Exercise has been shown to be beneficial in arthirits” (Ackley & Ladwig, 2008, p. 551) Assess client’s pain before physical exercise. “Pain limits mobility and is often exacerbated by movement” (Ackley & Ladwig, 2008, p. 550). Obtain any assistive devices needed for the activity.. Educate patient about sign and symptoms of infection, such as: fever (101 F), redness, warmth, and discharge on surgical wound and the need to call her health care provider “Assistive devices can help increase mobility” (Ackley & Ladwig, 2008, p. 550). “Fever is often the first sign of an infection (Ackley & Ladwig, 2008, p. 492). “Clinical manifestations of infection include redness, swelling, pain, fever, and increased white blood cell count” (Ackley & Ladwig, 2008, p. 379). Assess client’s pain and vital signs every 4 hours: intensity, location, & duration and signs & symptoms. Inform the patient that she can resume her pain medication at home, especially before and after activity. Consult with the physical therapist to begin an exercise program that includes aerobic exercise, resistance exercise and gentle stretching. Assess pain level and administer pain medications as prescribed before and after activity. Obtain any assistive devices needed for the activity, such as gait belt and walker before activity and consult with the physical therapist about assistive device teaching. Discharge teaching will include the the signs and symptoms of infection, which including: fever (101 F), redness, warmth, and discharge on surgical wound and the need to call her health care provider. EVALUATION OF PATIENT OUTCOME: (outcome met, not met, partially met) Problem resolution? Outcome Met: Goals was met - Patient reported decreased pain level (3/10) and verbalized understanding to resume her pain medication at home. -Patient verbalized understanding about the sign and symptoms of infection and the need to contact her health care provider if infection occurs - Patient verbalized understanding about the benefits of exercise post knee surgery. -Patient was able to do return demonstration of exercise and how to use the walker. Reference: Ackley, B.J., & Ladwig, G.B. (2008). Nursing diagnosis handbook (8 th ed). St.Louis: C.V. Mosby.