Care Plan
| ASSESSMENT | NURSING DIAGNOSIS | CLIENT CENTERED OUTCOMES | NURSING INTERVENTION | RATIONALE AND REFERENCE | EVALUATION |
| Subjective:
Patient stated, “ The patient complained of pain and numbness in the left leg after about twenty hours after having extensive surgery on their knee. –
Objective: the patient has had extensive surgery on their left knee. The incisions have been approximated by biodegradable sutures and the wound bandaged. As at now, the wounds look good. Patient has an IV line and bed rest has been prescribed along with medications for pain and postoperative antibiotics.
Client Vital Signs: BP-119/74 Pulse-78 SpO2-97% Respiratory rate 18 Temperature98.0 Pain- 2
Laboratory: BUN-14 Sodium- 137 Potassium-4.1 PT-11.4 NR-1.1
| High risk of peripheral neurovascular dysfunction in the operative extremity. | The patient should report decreased pain, better comfort, and functionality in the affected limb within 4 hours of care. 1. Palpable peripheral pulses – posterior tibial, dorsalis pedis and popliteal. 2. Capillary refill of three seconds in the toes of the affected limb. The time of capillary refill should ideally be the same in toes of both limbs. 3. The affected limb should be warm on palpation and should be the same temperature when compared to the other limb. The temperatures should be compared below the knees. 4. The color of the operative extremity should be consistent with the normal complexion of the patient. Pallor or darker tinges should be recorded as abnormal color which could be an indicator of reduced perfusion. 5. The patient should have the ability to flex and extend the affected foot and the toes on the foot. This will prove that the nerves in the leg and foot are functioning properly. 6. There should be no numbness or a tingling sensation in the left foot and the left toes. Such sensations would indicate nerve dysfunction as a result of traumatic damage to a nerve either during the surgery or in the traumatic events that led to the surgery. 7. The absence of foot pain, especially during passive movements of the foot and toes. Nerve entanglement as a result of trauma can lead to pain in the affected limb that increases on slight movement in a particular direction. 8. There should be generally no increase in pain in the left extremity. | Monitoring of vital signs every thirty minutes
Assessment for and reporting of signs of neurovascular damage in the affected limb This will include checking for peripheral pulses; checking for the time required for capillary refill in the toes of the affected limb and comparing it to that of the other toe; checking for pallor, cyanosis, blanching or coolness in the operative extremity distal to the point of operation; checking for ability of the patient to flex and extend the toes of affected limb; inquiring about numbness and tingling sensation in affected limb; and checking for pain or paresthesia in the foot during passive and active movements.
Application of ice packs around the operative knee
Maintenance of the limb in proper alignment
Positioning the leg correctly to ensure that the immobilizing device and the CPM are placed correctly so that the leg does not suffer from undue pressure
Loosening the straps of the knee immobilizer which seemed to be a bit tight
| Measurement of vital signs. It remains the surest way of determining the state and well-being of a patient at a glance. The vital signs look to establish the functioning of the most critical body systems at a glance. Vital signs will tell the nurse whenever there is a problem and that the patient’s condition is deteriorating. Moreover, this signs will reveal to a nurse the best interventions for the particular patients. after going ahead with the chosen intervention, monitoring of vital signs is the only thing that will aid the nurse in finding out whether their chosen intervention is working or not.
Damage to nerves may lead to pain on active and passive movements of the whole or parts of the affected limbs; inability to flex toes, extend toes or do both; paresthesia, numbness and or tingling sensation in the affected limb; and the general increase in pain in the limb (Potter et al, 2017 p. 809). On the other hand, damage to blood vessels would cause a range of symptoms on the affected limb including an increase in pain sensation; pallor; cyanosis; coldness of the limb, swelling; and inability to flex and/or extend the toes of the affected limb.
Ice packs reduce pain, bleeding and edema in a surgical site or in any other form of injury (Potter et al, 2017 p. 809).
This was meant to reduce the chances of inadvertent movement of the limb which could lead to further damage of neurovascular damage and excess pain in the limb.
Undue pressure on a limb with suspected neurovascular bundle damage will cause real damage to neurovascular bundles in the distal parts of the affected limb (Potter et al, 2017 p. 809).
Excess tightness in the knee immobilizer straps has the same effect of applying pressure to the affected limb. It enhances the application of pressure on the limb which interferes with the function of nerves and blood vessels. Excess strap pressure will thus lead to pallor and/or cyanosis in the affected limb, reduced temperature, excess swelling in the limb, tingling sensation, numbness and excessive pain on movement of the limb and/or inability to flex and extend the toes of their left leg.
| Throughout the four hours of evaluation, the patient’s vital signs remained stable. As the day went by and environmental temperatures increased, the blood pressure of the patient increased but remained within the normal ranges of adult blood pressure. The patient’s PaO2 also improved from the initial reading of 97% to 98% as probably because of the improved respiration in the patient as the pain got better controlled. At a temperature of 98.0, the patient was not febrile or hypothermic (Pagana et al., 2013). The patient reported pain in the entire limb but the pain got better as the patient was managed. The patient was able to flex and extend their toes without any difficulties, did not feel pain on passive movement of the limb and had neither numbness, paresthesia nor a tingling sensation in the affected limb. The color of the limb was also normal when compared to the rest of the body.
The pain that the patient initially felt throughout the limb subsided gradually after the use of icepacks on the affected knee.
The patient did not report any pains on limb movement in any direction.
The patient did not report any undue pressure on the affected limb or any other things that tended to cause a feeling of paralysis or increase the pain that the patient felt in the limb. The patient reported a feeling of relief in their operative knee after the straps of the immobilizer were loosened and the pain that the patient initially felt reduced markedly.
|
| INTERVENTION | RATIONALE AND REFERENCE | EVALUATION |
| Notification of the attending physician who operated on the patient about the patient’s state of pain and the dressing o the wound which seemed too tight
Ensuring that the patient took their pain medications in the right dosages
Checking for and controlling any further bleeding at the surgical site
Assessment of breathing by use of a spirometer.
Keeping the surgical site hygienic and teaching patient about prevention control.
Providing more pillows to make the patient comfortable
Teaching the patient about the importance of the call bell in the room.
Maintaining the patency of the wound drainage system.
Prevention of stress fracture of tibia and femur especially, by assessing for and inquiring about muscle spasms
| Postoperative pain is an important clinical finding which must be treated and controlled effectively (Potter et al, 2017).It is thus important for nurses to report cases of persistent pain in the patient being managed to attending physicians so that the best control method for the pain may be devised. The patient, in this case, was already on some pain medications but the persistence of pain is evidence of their ineffectiveness. The attending physician thus has to determine the best pain medications for the patient. A wound dressing may look perfect after dressing but will turn tight some hours after surgery due to the associated edema. Extreme wound tightness interferes with the process of wound healing and encourages thriving of anaerobic bacteria in the wound. The patient’s pain medications were hydrocodone and acetaminophen to be given PRN (Delgin et al, n.d). Excess bleeding during or after surgery can be a big problem for surgical patients. Silent bleeding under dressings can be detrimental thus nurses should be on the lookout. Patients in pain may be forced to take rapid shallow breaths which can lead then to respiratory alkalosis hence the importance of checking depth of respiration after surgery (Potter et al, 2017). One of the surest ways of preventing surgical site infection is by maintaining proper hygiene of the surgical site (Potter et al., 2017).
Maintaining a patient’s comfort and satisfaction is one of the key roles of a nurse. Pillows and their arrangement can help in giving a patient more comfort in bed.
The call-bell in a patient’s room should be used by the patient whenever they think they are in a situation that requires nursing or medical intervention (Potter et al, 2017). Draining of wounds effectively keeps them dry. Wet or moist wounds are more likely to get infected that dry wounds. Apart from causing pains, muscles spasms, which can result due to pain or neurovascular damage after surgery, can be severe enough to cause stress fracture, especially of the femur. | The physician Was expected to make a decision of whether to change the patient’s pain medications or not. The physician was also to confirm if the wound dressing was harmful to the patient or not.
By 0900 hours on 4/7/2016, the patient had taken their morning dose and know what PRN drug administration was all about. There was no real bleed but spots of blood were seen on the underside of the dressing
Between 0700 hours and 1300 hours, the depth of breathing of the patient had been adequate.
This patient’s surgical site was still clean but the area around it needed to be cleaned. By 1000 hours on 4/7/2016, all the patient’s questions on infection prevention had been answered sufficiently. The patient reported being a bit more comfortable after the pillows were provided.
By 1400 hours on 4/7/2016, the patient was competent in the use of the call-bell.
Although the patients wound did not require much draining, the patency of the drainage system was still intact. Patient did not report any episode of muscle spasms. On assessment, no muscles spasms were noticed. |
The patient-centered outcomes were appropriate and were achieved exactly three and half hours after the above-described nursing care was initiated. The patient felt more comfortable and was in much lesser pain, the situation of the wound had also been reviewed and confirmed to be in the right state by the physician.
References
Delgin, J. H., Vallerand, A. H., & Sanoski, C. A. (n.d.). Davis’s drug guide for nurses (15th ed.) [Mobile application software]. Retrieved
nursing (9th ed.). St. Louis, MO: Mosby Elsevier.
Pagana, K., Pagana, T. & Pagana, T. (2013). Mosby’s diagnostic and laboratory
Potter, P., Perry, A., Stockert, P. A. & Hall, A. M. (2017). Fundamentals of
test references (12th ed.). St. Louis, MO: Mosby Elsevier.
