Nursing Care Plan - Assignment Example

Nursing Care Plan Student’s Name Institutional Affiliation Task 1 During preparation for surgery, it is important to educate the patient on postoperative care. The aim is to ensure understanding and participation during care. Among the areas of education include breathing exercises and movement restriction post-operatively. The goal of breathing exercises is to ensure the lungs are adequately inflated keeping them healthy. The exercises play a role in the prevention of complications such as pneumonia. The procedure can be through a device known as incentive spirometer or just by mouth. If the practice is via the mouth, it involves her being in an upright position. Gill is then instructed to take a few normal breaths followed by slow breaths before she can finally take deep breaths. Advice Gill to hold the deep breaths for 2-5 seconds and with her lips ‘O’ shaped, blow out the retained air. If she decides to use a spirometer, instruct her to hold it upright. Ensure her mouth is covering the mouthpiece completely and then slowly but deeply breathe in. Ensure the piston is raised towards the top of the column. She can hold the breath as long as possible before breathing out (Restrepo et al., 2011).The procedure is repeated 10-15 times for every one hour to prevent dizziness and lightheadedness. Coughing in between the exercises ensures the lungs are free. Education on movement restriction following total hip arthroplasty is necessary to prevent complications and ensure a positive outcome. The learning involves movements Gill is allowed to do and those she cannot do. First, she is only allowed to sleep in the supine position for a minimal of eight weeks postoperatively and use a pillow between her legs. Secondly, advice her to move the operated leg that is the left backward while bending to avoid flexing beyond 90 degrees. Thirdly, Gill should ensure not to cross legs, squat, sit on a low chair, flex the left hip beyond 90 degrees or internally rotate the left hip beyond 45 degrees. Full weight bearing is only allowed under a physiotherapist’s care and is practiced within the first 24 hours postoperatively (Mikkelsen et al., 2014). Task 2 Following the arthroplasty postoperatively, the priority nursing problems include pain and restricted mobility. The priority is due to the contributing factor to Gill’s comfort and ability to rest. The pain is about the surgical procedure, inflammation, and restricted mobility. Pain management is by the prescribed analgesics: paracetamol, diclofenac, and oxycodane (Oppermann et al, 2016). Painkillers work by blocking pain receptors in the brain hence preventing pain perception. Oxycodane classification is in the dangerous drugs hence prescribed only when need be to avoid addiction (Kuchálik et al, 2013). Postoperatively, Gill should lie in bed in a supine position to prevent putting pressure on the operated left hip causing dislocation. Application of pressure on the operated hip predisposes to swelling that leads to pain or increases the chances of poor outcome following possible dislocation or breaking of possibly used the prosthesis. Instruct her to avoid reaching down on blankets while lying down in bed, picking items from the floor while sitting or raising the knee above the hip on the affected left limb. Avoid turning feet of affected limb inward to prevent dislocation. Gill is allowed to restricted mobility following the orthopedic consultant's instructions. Restricted movement is to ensure correctly guided weight bearing and prevent flexing beyond the allowed angles predisposing to poor outcome. Task 3 Gill’s prescription treatment is inclusive of oral diclofenac, oral glucosamine, and subcutaneous enoxaparin. Diclofenac is a Nonsteroidal anti-inflammatory drug (NSAID). Its mode of action is it inhibits prostaglandin synthesis preventing pain perception. The adult dosage following osteoarthritis is a maximum of 150 milligrams daily in divided doses for the diclofenac potassium immediate-release. The diclofenac extended-release tablet is 100 milligrams once daily. The nurse is responsible for monitoring effectiveness via patient’s verbal communication hence scaling the pain. The nurse is responsible for overseeing for side effects inclusive of allergy, breath shortness, high blood pressure, headache nausea & vomiting and constipation among others (Karlsen et al, 2015). Glucosamine is a monosaccharide used as a diet supplement used to promote joints function and structure. The most associated side effects include a risk of diabetes, constipation, heartburn, headache and rash among others. The dosage is 1500 milligrams within 24 hours as a single or divided dosage. The nurse is responsible for monitoring blood glucose levels frequently during use of glucosamine to detect early signs of diabetes occurrence and manage appropriately (Hochberg et al, 2012). Enoxaprin is a low molecular weight heparin. It is an anticoagulant hence administered to prevent the formation of blood clots and deep venous thrombosis incidence. Gill is using enoxaprin prophylactically to prevent blood clots and deep venous thrombosis. The mode of action is it binds to antithrombin to form a complex inactivating the clotting factor. The adult dosage for prophylaxis is 40 milligrams once daily. The common side effects include dyspnea, purple spots under the skin, palpitations, bleeding, nausea, diarrhea and pain on injection site among others. It is administered either intravenously or subcutaneously depending on the physician’s instructions. For Gill, the enoxaprin is subcutaneous hence injections under the skin on the fatty regions like the stomach (Januel et al., 2012). The nurse is responsible to identify the occurrence of side effects and act promptly. In cases of the side effects, the nurse collaborates with the physician to change to a suitable drug with a similar mode of action. During administration ensure the practice of the five R’s: right patient, right drug, right route, and right dosage at the right time. Diclofenac and anti-coagulants have a tendency of drug reactions hence the nurse monitors for signs of bleeding (Hinkle J. & Cheever K, 2014). Task 4 Care plan Nursing problem Goal of care Nursing intervention Rationale Expected outcome Risk for peripheral neurovascular dysfunction related to swelling, constricting devices Maintain adequate neurovascular function Assess the skin color and temperature Assess the toes’ capillary refill Assess for numbness and sensation Elevate the hip higher than the legs Assess the legs for edema Examine movement of foot and toes Feel for pedal pulses The skin is bluish and cold with poor tissue perfusion Pink refill indicates good capillary perfusion Numbness and loss of sensation indicate nerve damage Dorsiflexion of ankle and extension of toes ensure the functioning of the peroneal nerve. Plantar flexion of ankle and flexion of toes show presence of tibial nerve Presence of pedal pulse assures good circulation Normal skin color and warm Normal capillary refill of the toes Gill verbalizes sensation on her extremities and no numbness Gill verbalizes absence of numbness and presence of sensation No paralysis Impaired physical mobility related to weight bearing, restricted mobility and positioning Achieve a pain-free, functional and stable hip Use of analgesics Maintain proper hip joint position Maintain off heel pressure Instruct on positioning To inhibit pain perception To prevent dislocation of hip prosthesis Prevent ulcers formation on the heel Encourage Gill’s participation without causing dislocation of the prosthesis The nurse administers prescribed analgesics: paracetamol, diclofenac and oxycodane prn No pressure sores on heel She helps during position changing Anxiety related to fear of the outcome Allay anxiety Reassurance Explain the surgery in details allowing her to ask questions Involve multidisciplinary during her care like orthopedic consultant, psychiatrist, and physiotherapist Promotes hope for positive outcome Allows her to raise concerns providing opportunity to come down Ensures care from all angles Allay anxiety Risk for prosthesis dislocation Maintain prosthesis in position Use of pillow or abductor splint Avoid acute and extreme flexion Avoid crossing legs Maintain the hips in a higher position than the knees Assess for dislocated prosthesis Position like only lies on side if on the unaffected limb Keep the prosthesis in a neutral position Shortened extremity indicate a dislocation Avoid dislocation The prosthesis remains in position Risk for deep venous thrombosis Prevent deep venous thrombosis Gill can wear elastic compression stockings Use of prophylactic anti-coagulants Encourage fluid intake Avoid pressure on popliteal blood vessels from things like pillows or the abductor splint (Levitan et al., 2014). Promotes venous return Prevents formation of clots Fluids increase blood viscosity Diminishes blood flow The venous return will be sufficient No formation of clots Ensure continuous blood flow Risk for low self-esteem secondary to the Maintain positive self-esteem Clarify misconception Involve her in the care and management Promote a friendly environment where she can express her feelings To prevent confusion To promote her understanding of the changes occurring in her body and care She is able to tell reality from misconceptions She participates and acknowledges her body changes Risk of Ineffective health maintenance related to total hip replacement Care for self at home Assess home environment Teach caregiver home care instructions Identify physical barriers and remove them Ensure the caregiver understand the rehabilitative guide and need for compliance (van der Weegen, W., Kornuijt, A., & Das, D, 2016). Home environment is easily assessable to Gill Ensure compliance per the rehabilitative measures (van der Weegen, W., Kornuijt, A., & Das, D, 2016). Risk of hemorrhage secondary to the total hip arthroplasty Prevent hemorrhage Monitor the wound site for color, and amount of bleeding Repeat hemoglobin levels Monitor vitals: temperature, pulse rate, blood pressure and respiration rate The drainage is bright red with active bleeding Identify anemia Detect signs of shock like fever and bradycardia In case of bleeding early diagnosis and management Commence supplements for low hemoglobin Normal vitals: temperature (36.3-37.7 degrees celcious), pulse rate (60-100 beats per minute), respiration (15-21 breaths per minute) and blood pressure (100-140/60-90 millimeters of mercury) Risk of infection secondary to the surgery wounds Prevent infection Give prophylactic antibiotics Practice prevention infection Monitor early signs of infection like fever, pus formation, and inflammation Ask for presence of pain on the wound Take vitals Kill any bacteria preventing infection Prevent spread of disease from one patient to another Ensure early diagnosis and management Wound is indicative of hematoma that needs surgical removal Elevated temperature, respiration rates, and pulse rate are a sign of presence of infection Gill will not present with signs of infection Risk of knowledge deficit Ensure understanding Explain pre and post-operative management Encourage her participation during management Encourage questions of concern Promote understanding of her care Gill demonstrates understanding of her care Task 5 Identify Name: Gill Age: 63years Handing over staff: nurse Situation Gill's admission is following a diagnosis of osteoarthritis in both hips. On X-ray, there was bone spurring and severe joint space narrowing in both hips due to complicated osteoarthritis. Her admission is to perform surgical management via total hip arthroplasty of the left hip. The performing of the surgery was five days ago, and she was receiving postoperative management. The catheter removal was on the third postoperative day. The surgical wound is clean, and sutures removal is on the thirteen postoperative days. Background She was previously on a prescription of oral glucosamine and chrodroitin. Gill is a smoker until recently following medical advice in preparation for the surgery. Prior the surgery, she was mobile using single prong walking stick. Assessment Gill is currently able to sit out of bed into a commode chair and shower. Today she is reporting moderate pain and swelling on her left lower limb but has denied taking enoxaprin due to injection bruises. There is an elevation in the pulse rate and blood pressure beyond normal. Recommendation Gill's transfer is for rehabilitative management. Following my nursing care, the recommendation is the psychological support to reassure Gill. Persuade her to recommence enoxaprin to prevent deep venous thrombosis. Encourage her to elevate the lower left limb with consideration the hips is higher than the leg. Involve her two children in her care to prevent loneliness and promote hope. Monitor the vitals regularly and the left lower limb for signs of DVT and manage promptly. Following pain, persuade Gill to take oxycodane reasonably if the pain is severe. During her continued care, ensure regular physiotherapist reviews (Hashmi et al., 2016). Reference Cherubino, P. (January 01, 2012). Total hip arthroplasty. Orthopedics, 35, 12, 1039-41. Hashmi, F., Kogan, A., Gallo De Moraes, A., Elmer, J., Capels, S., Oeckler, R. A., & Jensen, J. (2016). Standardizing And Improving The Hand-Off Process During Rapid Response Team Activations. In D104. 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