1 NURSING CARE PLAN FOR THE PERIOPERATIVE PATIENT 2003 Elmhurst College Deicke Center for Nursing Education

Name Amanda Malmstrom Faculty Barb Zak

GENERAL DIRECTIONS Select a preoperative patient that you took care of for 2 days. Apply the nursing process and theoretical concepts to create an individualized nursing care plan. An optional draft may be submitted prior to the due date. A paper submitted on the due date cannot be revised and resubmitted. In addition to utilizing your texts, you will need to incorporate a professional journal article published within the last 5 years that relates to your patient's care. The article must be from a professional nursing journal. Lay oriented journals or magazines are not acceptable. This article must be cited within the paper. This paper must be word-processed. The text boxes are not meant to imply how much information you need to include in each section. They are designed to expand as you type in your data. You cannot work on the nursing care plan at Blackboard Web Site. Any data that you put on the form at the site will be lost. You must first save the document to your hard drive or USB storage device. If you must save the document to a floppy disk, work on it on the hard drive and transfer the finished product to an empty disk when you are done for the day. Otherwise, you may run out of disk space because of the large amount of formatting in this document. If you will be using your computer at home, see if it is compatible with your word processing program. If you have any problems with compatibility, ask for assistance in CSTC 107. If you work on the document in the CSTC, saving directly to a USB storage device is recommended to avoid losing all of your data if the computer freezes or needs to be rebooted. 16 MB devices are available for approximately $20-25. The computers in Room 110 have USB ports that are located on the front of each computer. GENERAL POINTS Demonstrate a professional level of writing. (2 pts.) Reference citations are incorporated within the nursing system design in APA format (Author, year) in designated sections. (1 pts.) Turn in the word-processed medication profiles for ALL routine and prn medications prescribed for this patient. (2 pts.) There will be a 10% deduction per day if the paper is not turned in on the date due.

2 THEORETICAL CONCEPTS List the health condition for which surgery was performed and the name of the surgery. (1/4 pt.) Health condition for which surgery was Prosthesis loosening of Right knee performed Surgical procedure performed Total Right knee replacement List the significant preexisting health conditions. (1/4 pt.) BILATERAL kNEE REPLACEMENTS 3 TOTAL MI HISTORY OF ULCERS Home Medications (dose and schedule) (1/4 pt.) Lopressor 50 mg BID Smitriptlin 25 mg 2 QHS Saw Palmetto 1000mg QD Pravachol 40 mg QHS ASA QD Tylenol PM PRN Nitro-Dur Patch 0.2 mg 12HR QD

All Hospital Medications (dose and schedule, including prn medications) (1/4 pt.) Ancef 1 gm IVPB Q8 HR Colace 100 mg PO BID Lovenox 30 mg SC Q12 HR Lopressor 25 mg PO BID Lactated Ringers 1000ml IV Q10HR Nitro-Dur 1 each TOP QD Tylenol 650 mg PO Describe the pathophysiology of the current health condition including signs, symptoms, usual diagnostic tests and treatments. Include citations in APA format. (3 pts.) The patient was admitted into the hospital for pain in the right knee. He was admitted on 11/03. He had a total knee replacement on his right knee in 97 and now six years later there is loosening of the prosthesis and damage to the polyethylene. The patient claims that the knee replacements that were used in 97 are being recalled and his might be that type. The patients surgery was a total knee replacement. A KNEE PROTHESIS KNEE REPLACED THE OLD PROTHESIS KNEE, WHICH IS AN IMPLANT OF METAL, HIGH-DENSITY POLYTHELENE, CERAMIC, AND OTHER SYTHETIC MATERIALS. For this surgery, the placement of the prosthesis knee was cemented in place. The patient was feeling pain in his right knee due to the surgery. it was rated a 9 on Tuesday and AN 8 on Wednesday out of 10. There was some tingling and burning on the right knee on Tuesday, which subsided on Wednesday. Briefly explain the pathophysiology of preexisting health conditions. Include citations in APA format. (3 pts.)

3 The patients preexisting health conditions included the following, bilateral knee replacements, myocardial infarction, and history of ulcers. The bilateral knee replacements are surgical insertion of a hinged prosthesis. Diseased surfaces are removed and a two piece metallic hinge is inserted into the medullary cavities of the femur and tibia. This was the patients third total knee replacement, the second in his right knee. a myocardial infarction is necrosis of cardiac muscle caused by an obstruction in a coronary artery THROUGH atherosclerosis, a thrombus, or SPASM, WHICH then triggers a heart attack. the patients history of ulcers is described as a circumscribed, craterlike lesion of the skin or mucous membrane resulting from necrosis that accompanied some inflammatory infectious or malignant process. Explain how the preexisting health conditions may impact upon the patients preoperative, intraoperative or postoperative course and each other. Include citations in APA format. (3 pts.) The patients preexisting health conditions could have impacted the patients recovery in minimal to extensive complications. The best preexisting health condition this patient had was past total knee replacements. The patient then knew what he had to do to minimize his stay and decrease infection and more complications. This patient was though a little on the difficult side in means of not fully cooperating. Example would be that he was asked to do his incentive spirometer and he would put of a fight to not have to do it, but in the end he knew it was in the best interest of his health and would decrease his stay. With some assertiveness and aggressiveness the patient did do what he was told and cooperated. Due to a past myocardial infarction, medication WAS given to him to aide in increased cardiac output and decrease BP, WHICH would help maintain prevention of an anginal attack. These medications were the Nitro-dur patch and lopressor. Also, the history of ulcers could increase the patients risk of having one due to the stress and inflammation from the trauma of having this surgery. Explain the surgical procedure performed to treat the patient's health condition. Include citations in APA format. (1 pt.) The surgical procedure performed was a revision of the right knee prosthesis. The patient was under general anesthesia, while the right knee and leg were prepped and draped properly. A tourniquet was placed on the upper right thigh to help keep blood loss minimal. The tourniquet was inflated to 350mm Hg. The incision was a midline through the medial parapatellar, which then opened exposed the knee. The tibial component was addressed and the polyethylene was removed. The acetabular and femoral components were also removed due to them being loose. Then a trial and error approach was needed to find the parts that would fit the knee well to maintain patency. In order for the parts to fit right, addressing certain components to fit right were tried, then the trial components were removed and the final components were inserted and cemented into place. The knee was able to perform ROM and had good alignment and stability. The patellar was intact and left alone, irrigation was performed and then closure to the incision was done over a hemovac-solcotrans drain. Staples were used to keep the skin intact and a pressure bandage was applied with also cold pad therapy.

DATA COLLECTION, ANALYSIS & NURSING DIAGNOSIS

4 Include data for both days of care. When data does not change from day 1 to day 2, there is no need to rewrite the data. If the assessment is abnormal, (Abn) place an X in the first column. ASSESSMENT OF SOCIOCULTURAL, PSYCHOLOGICAL, DEVELOPMENTAL, AND SPIRITUAL VARIABLES Focus on the clients discharge as well as the inpatient stay
Abn

DEVELOPMENTAL ASSESSMENT (2 pts.) Assessment Category Data Specific to this Patient Age 59 Gender Male Developmental Stage Patient's stage according to Erikson is Erikson's Stage Generativity versus Stagnation Discuss the patient's ability to In this stage it includes adults from ages 25-65 years old. meet the tasks of this stage. There are positive tasks such as creativity, productivity, and Describe how the health concern for others. The negative tasks would be selfcondition has or has not altered indulgence, self-concern, and lack of interests and the patient's ability to meet commitments. The patient has no problem meeting these these tasks? tasks since there was not any health alterations that could affect him in any different way that he has not experienced before. Cognitive Developmental This patient is able to process reactions, problem solve, and Stage according to Piaget has the ability to learn. His memory and perception are also Educational data very well. His cognitive and intellectual level does not seem Literacy affected by his age or from surgery. According to Piagets Primary language phases of cognitive development, he has successfully carried out all stages. Formal operations phase which the use of rational thinking and reasoning is deductive and futuristic. This patients rational thinking and reasoning is presented and expressed in a positive way. He understands that the future does not hold a complete recovery with out sign or symptoms related to his knee, but is positive in looking ahead. He wants to get better not only for himself, but to enjoy his life and partake in ADLs.

How has the patient's health condition/surgery affected his ability to meet developmental tasks? This patients ability to meet developmental tasks in not affected from his surgery. The only impact this patient could be feeling is that he has been off of work for 20 years due to a fall at work and has not returned since. He has had many operations performed in relation to his knee, so I believe that the only real affect this could have on him is that it is an ongoing problem and has impacted his career.

SOCIOCULTURAL & SPIRITUAL ASSESSMENT (2 pts.)

5
Abn

Assessment Category Family dynamics: Family Members Clients role in family Family communication pattern Clients support system

Occupational data Employment Health benefits Ability to meet economic needs after discharge

Living environment prior to hospitalization Housing Neighborhood Support/Resources Culture/Ethnicity Affiliation Practices/beliefs Impact on illness Spiritual practices Religious affiliation Practices Impact on illness

Data Specific to this Patient The patient has a wife that was there both days and helped him and myself in assessment. She bathed him on Tuesday and helped feed him. She also helped encourage and tell him to listen to me. The communication between them was very well, and they seemed to have a very good relationship. His wife is his big supporter and encourager, while also two men came to visit and also were very polite and encouraging to the patient to get better and do what he was supposed to. My patient had respect for all three of these visitors and listened to what they had to say about getting better and doing the little things that would help increase his return to home and recovery. My patient was retired for 20 years due to a fall at work in 1983. He is on workmans comp and has Medicare. He was an electrician prior to his fall. In being retired he does not have any real economic needs to get back to since he has not been working for so long. But in reality, we all have our own economic needs and feel as if certain things we do help out and are needed. I am sure him and his wife have needs economically and the sooner he is discharged and recovery fine, those needs will be met sooner. My patient was living in a rural neighborhood in a comfortable house with his wife and his bird.

Not available

My patient was catholic and was affiliated with a church in his hometown. He had communion when I was there and was very excited about it and shared it with everyone who walked into his room. He thought it was a neat thing. I know that he has strong feelings about praying due to having so many complications with his knees that he prays that one day this mess will get better and not have to worry about them getting bad and going through more pain

How are the sociocultural and/or spiritual variables affected by the client's health condition/surgery? The clients sociocultural assessment has positive affects on his health with the increasing help and assistance from his wife and friends. His moods were much better and he was more willing to listen when visitors were there. He showed more emotion such as excitement with them in the room, but at the same time he really liked the attention from his wife and made sure she was babying him. He made comments to me that he wishes he could still be working instead of going through all of the

6 knee surgeries and complications and wish he could go back, but knows it can not happen. I believe that if he were still working that would give him a little more motivation to get better and have something extra to look forward too.

Abn

PSYCHOSOCIAL ASSESSMENT (2 pts.) Assessment Category Data Specific to this Patient Behavior Appearance He was alert, orientated, speech was clear and understandable. He was a little crabby and uncooperative to with some things, but eager to get well and liked to talk. Healthy appearance, a little overweight though. Skin color was normal. Once bathed his hair was combed and he felt better. No distinct body odor. No irregular body movements. In pain, but otherwise everything else was fine. High spirited with wife there and had good coping skills. Patient was a little overweight, but overall no signs of abnormalities. Was able to make decisions on own, he knew what he wanted to do and when PT came in he wanted to walk to the bathroom and knew he was capable to do so. If he needed something he would always ask. His coping was fine, which I believe had a lot do with his previous knee surgeries. He was even educating me on his surgery and was not hesitant on showing me his other knee and talking about it. His wife was very supportive and her coping ability pushed him also to do better and cooperate.

Emotional status & Affect Body image Decision making ability

Individual coping

Family coping

How are the psychosocial variables affected by the client's health condition/surgery? The clients psychosocial variables are not too much affected by the surgery. This was his third total knee replacement surgery, which helped prepare him for the preoperative, intraoperative, and postoperative care. He also has nothing to lose out on since he not working any more and his wife was there with him and his friends were in and out also. He has a lot of support and being in otherwise fairly good health helps him cope easier.

HEALTH ASSESSMENT
Abn

MENTAL STATUS (2 pts.) Assessment Category Level of consciousness Orientation Thought processes Attention span

Data Specific to this Patient Patient is alert, orientated, responds appropriately and asks and answers questions. Patient is orientated to time, place, date, everything. No complications with this. Able to cognitively process thoughts, feelings, and concerns. Could put together sentences and communicate efficiently. Full attention was on me when I was in there. He was curious of what I was doing. He was able to concentrate on other things and me. Ability to comprehend and communicate well. No problems gathering thoughts or if he had questions he would ask. He was appropriate in most cases, with some things though he was inappropriate in ways to ask me to leave when I was assessing him. For example, I was emptying his foley bag and he asked me rudely to leave his room as I was in the middle of doing emptying it because he wanted to tell his visitors a story and could not wait to do so. His judgment was fine; he made good choices on what he should be doing and not doing. He knew exactly what needed to be done to help benefit his health. Some judgments with not cooperating were not adequately right, but that is just his personality. Full attention on me or whoever was in there. Had full attention on his knee and would favor his other leg and be protective of his bad one. He had perfect hearing and had glasses. I did not see him wear his glasses while I was with him.

Ability to comprehend & communicate Appropriateness

Judgment

Attention Span Vision & hearing including assistive devices VITAL SIGNS (1 pt.) Assessment Category Vital signs during days of care

Abn

Data Specific to this Patient Tues 130/60, 90, 20, 101.1

Wed 132/64, 90, 18, 99.4

PAIN ASSESSMENT (2 pts.) Assessment Category X Location & Characteristics (Describe)

Abn

Pain rating Scale (e.g. 0-10) Presence of PCA Epidural /Intravenous

Data Specific to this Patient The patient expressed there was a tingling and burning sensation right above his knee. There was pressure on it when he would sit up and it felt very uncomfortable for him. Tues Wed 9 or 10/10 8/10 Dose Basal rate= Morphine 1.5 mg/ 6 min. None

Site Assessment

Frequency= 4 hour lockout 1 hour maximum

8 # of mg used on your shift # of attempts on your shift

Pharmaceutical Interventions last 24 hours Nonpharmaceutical Interventions

Morphine PCA 1.5 mg/ 6 min Polar ice pack, pillows, CPM, also having visitors distracted him from his pain. PT came in BID to do exercises and ambulate him.

Abn

INTEGUMENT (2 pts.) Assessment Category Skin color, Temperature, Moisture Skin integrity

Data Specific to this Patient Skin color was normal, pinkish tan. Temperature was elevated and skin was warmer than normal. Moisture was normal Texture feels smooth and firm with even surface. According to the surgical report, there was a midline incision across the knee. I was unable to assess the incision due to the dressing and ace wrap applied. 17/23 with some risk due to age. The location of the incision was on the right knee, midline parapatellar. There was an ace wrap over it with the polar ice wrap on top of that. There was no drainage on the dressing from what I assessed. There was a drain that was intact. The location of the drain was on the right knee. It was a Hemovac-Soloctrans. There were serasanginous fluids irrigating from the intact drain, which collected about 40 cc. This was reported on a 24-hour shift.

Braden score & Level of Risk Wound Location Description Wound Dressing Drainage type & amount Drain Location Type Drainage type Drainage amount per shift /24h

Abn

RESPIRATORY (2 pts.) Assessment Category Respiratory rate (12-20), rhythm, breath sounds Pulse oximetry (94-100%) results: Include type and amount of oxygen in use when pulse oximetry was done

Data Specific to this Patient 20 bilateral and clear, deep and regular. Pulse oximeter was 89% on Tuesday with out oxygen. A nasal cannula was used at 2 L. The pulse oximeter then went up to 95%. He was not keeping it for the full time either. He was putting it on and taking it off all the time, but it helped maintain his percent with in normal limits. On Wednesday it was not done due to not being able to fine one for the time I was there. There were not any signs of respiratory distress that were of any serious complications. He did do deep breathing and coughing, which he showed minimal distress in.

Signs of respiratory distress

9 Sputum: Amount, Color, Consistency Ability to deep breathe & cough effectively Ability to use incentive spirometer Not available He was able to deep breathe and cough effectively. He was able to do this efficiently, but I needed to be persistent with him to do and when he did do it he said it felt better and cleared his lungs out. He was able to use the incentive spirometer effectively as well. He also was not very cooperative with this, but when he did do it, his lungs cleared and it was more comfortable for him. On his first few breaths there was coughing, but with the last few, it was clear. Volume achieved= Volume predicted= 250 250 Waterseal Drainage type Type/amt of suction Air leak Yes No Tues Drainage in cc's/shift= Wed Drainage in cc's/shift= Tues Drainage in cc's/24 hours= Wed Drainage in cc's/24 hours= Total drainage since surgery=

Volume achieved on incentive spirometer. Chest tube N/A

SQ emphysema Yes No Fluctuation Yes No Clamps & Vaseline gauze taped above bed Yes No My patient did smoke

Smoking history (packs/day for # of years)

Abn

CARDIOVASCULAR (2 pts.) Assessment Category Heart rate & rhythm (60-100) Heart sounds BP Peripheral pulses in extremities Radial P edal Capillary refill (<3 sec)

Data Specific to this Patient Rate is 90, rhythm is regular, and s1-s2 are normal, no diminishing, no extra sounds or murmurs for both days when doing 1200 VS on Tuesday and 1100 on Wednesday. Strong and easily auscultated. Tues. 130/60 Wed 132/64 L R Present and 2+ bilaterally Present, 2+ bilaterally L R Strong, present, 2+ Strong, present, 2+ bilaterally bilaterally. Wednesday 1+ due to weaker pulse LUE LLE Immediate return of color < 3 Immediate return of color < 3 seconds on Tuesday and seconds on Tuesday and Wednesday. Wednesday. RUE RLE Immediate return of color < 3 Immediate return of color < 3 seconds on Tuesday and seconds on Tuesday and

10 Wednesday. Edema including site, 0-4+scale & pitting JVD at 30-45 degree HOB elevation DVT assessment: Unilateral leg edema, calf pain, or positive Homan's sign DVT prophylaxis in use: TED's, SCD's, Plexipulse, Heparin or Lovenox SQ Wednesday. On Tuesday it was +2 and on Wednesday it was +1 on the right foot. There was no degree to the HOB. The patient could not tolerate the pressure that it radiated to the knee. No calf pains when asked to wiggle, flex, extend feet and move toes around. Edema was either a +1 or +2 on the right foot. Lovenox SQ 30 mg/0.3 ml syringe q 12 hr. was administered to prevent DVT after surgical procedures, such as knee surgery.

Abn

GASTROINTESTINAL/NUTRITION (2 pts.) Assessment Category Data Specific to this Patient Oral Cavity Pink, moist, no lesions, soft and symmetric contour Nausea or vomiting Ability to swallow Abdominal contour Bowel sounds None present His ability to swallow was not altered. He was on a clear, soft diet and was able to swallow pills with out a problem. Rounded, symmetric bilaterally. Skin surface was smooth, and even. Good color and pigmentation. Bowel sounds were active, and high pitched due to not having any solid food for a couple of days. The sounds were gurgling and a whooshing sound. Type & amt of suction Tues Output in cc/shift = Tues Output in cc/24h= Type of drainage Wed Output in cc/shift= Wed Output in cc/24h=

NG/GT to gravity/suction Description of drainage N/A

Nutrition
X Ideal body weight Height & weight Usual diet at home Hospital Diet Appetite (% consumed) Tolerance of diet NG ,GT, JT N/A 160 lbs. Is the ideal body wt. And with calculating the percent of IBW it shows that this patient is obese. 5 ft 9 in. and 268 lb. He is not on any diet to decrease intake or watch what he eats. He eats normal meals and snacks through out the day. Currently, the patient prefers to be on a soft, liquid diet because he wants to be able to ambulate to the bathroom if he has to have a BM. He was intaking 100% of his meals and on Wednesday he was going to try a general diet. Feeding formula & rate

11 Placement= TPN Intralipids Stress ulcer Prophylaxis Rate Residual=

Bowel Elimination
Usual home bowel elimination pattern Passage of flatus Date of last BM (<2days) Color, amount, & consistency Ostomy: Type and condition of stoma and peristomal skin Type, color, & amount of drainage or flatus Every day or every other day Yes, depends on diet for an increase or decrease. 11/03 the day of surgery. N/A

Abn

URINARY (2 pts.) Assessment Category Usual urinary elimination pattern Current urinary elimination pattern Catheterization: # of days: Foley, Suprapubic, or Straight Signs of retention: Inability to void, Dribbling Incontinence(Describe type and management) Signs of UTI: Burning, Frequency, Urgency, Odor, Cloudiness, Hematuria

Data Specific to this Patient His elimination patterns are normal. He has a foley catheter so it is continuous drainage Has had a Foley catheter for 3 days Not available due to foley catheter Not available due to continuous foley catheter irrigating the bladder There is not any burning, odor, and frequency and urgency are not recorded due to foley. There is neither cloudiness nor hematuria in the urine. It is clear, yellow. Data Specific to this Patient Intake Mon in cc/24h= Output Mon in cc/24h= Not available Not available Intake Tues in cc/24h= Output Tues in cc/24h= Intake Tues in cc/shift= 500 cc Intake Wed in cc/shift= 380 cc Tues Edema is +2 on right foot. Output Tues in cc/shift= 1500 cc Output Wed in cc/shift= 775 cc Wed

Abn

FLUID BALANCE (2 pts.) Assessment Category I&O

Weight, if on daily weights Edema Location

12 Grade (1+ 4+) IV Fluids : Type & rate X Peripheral IV Access Site # of days Central IV Access Site Type # of days IV Assessment Site Appearance (infiltrate/phlebitis) Patency Dressing The IV fluid is a Lactated Ringers Solution bag of 1000 mL, 100 ml/hr The IV is inserted on his right hand and has been present for 3 days Not available

There is no redness, tenderness, or swelling present at the IV site. It is patent and there is tape on it to keep it in place

Abn

NEUROMUSCULAR (2 pts.) Assessment Category Usual pattern of ambulation Usual ability to perform ADLs

Ability to ambulate & transfer postop Evaluate risk for falls using fall risk assessment tool (Attach results. See Elkin, Potter & Perry, 2004, page 82.)

Ability to perform ROM Musculoskeletal deformities, paralysis (Describe) Numbness, tingling, sensory loss, Impaired motion (Describe) Physical Therapy: Type, tolerance

Data Specific to this Patient Uses a cane to ambulate with when his knees are bothering him, but can also walk with no problem with out it. Has difficulty walking for long periods of time. Can perform with out a problem, but does experience stiffness in his knees and sometimes swelling. He was able to ambulate 2nd day post op with PT. He walked to the bathroom with a walker and sat up in a chair for about 15 minutes and then complained of an increase in throbbing, so we moved back to the bed. Using the risk for falls assessment tool, this client is at risk. He has 4 elements checked, two under general data which are postoperative surgery and smoker. The other two are under medications and he is taking an antihypersensitive and a medication that increases gastrointestinal motility, a laxative. These medications are Lopressor, and Colace. Also, the fall in 1983 at work is what has caused his knees so much damage is a risk with an asterisk by it which means that with that checked alone, he is at risk for falls. Was able to perform with assistance. When PT came they helped him do ROM of his lower extremities. He felt pain, but was able to tolerate it with out complaint. N/A On Tuesday there was tingling and a burning sensation above his right knee. This did subside by Wednesday. PT came in BID, he had some pain with ROM, but was very cooperative and was appreciative of them helping him ambulate to the bathroom. The right knee was in pain, which made it difficult for his right leg to be moved. There was no fatigue or dyspnea,

Difficulty moving d/t pain, stiffness, weakness, fatigue,

dyspnea (Describe) X X Use of assistive devices: walkers, canes, etc. Orthopedic postop assessment: CMS, cast, traction, braces, CPM, weight bearing status

13 some stiffness though since his leg had not been moved for 2 days. He did use a walker when ambulating at the hospital, and uses a cane at home for extra help and to take pressure off of his knee. He had a CPM machine and his knee was covered in an ace wrap bandage.

Abn

SLEEP AND REST (1 pt.) Assessment Category Usual sleep pattern & routines Postop sleep pattern & quality

Data Specific to this Patient Sleeps fine through the night at home and when he has pain in his knees, he does have difficulty sleeping. On Monday night he did not sleep very well do to the pain, but on Tuesday he slept much better and slept a lot during the morning too.

14 EVALUATION OF ABNORMAL ASSESSMENT RESULTS (3 pts.) List each abnormal clinical manifestation found during your health assessment. Explain the reasons for the abnormal clinical manifestation based on the patients health condition(s) and pathophysiology. Clinical Manifestation Rationale Pulse Oximeter Pulse oximeter was abnormal on Tuesday with a reading of 89%. This has to do with lying supine in bed after surgery. Unable to sit up allows for development of hypoxia, low oxygen in the blood. Lying on your back also allows one to accumulate fluid and contract infection due to poor lung aeration. Temperature Temperature was elevated and skin was warmer than normal due to surgery. This could be in relation to the surgery, stress from the surgery, environment, or even infection. Employment My patient was retired for 20 years due to a fall at work in 1983. He is on workmans comp and has Medicare. He was an electrician prior to his fall. Usually, retirement is not until the mid 50s-early 60s. So this is kind of abnormal since he has been retired for so long. Edema Edema is +2 on right foot. With the surgery this is normal due to the impact on the knee and swelling post-op. this being abnormal is a sign for the nurse to monitor the feet to make sure the edema does not increase due to risk for DVT. Dressing The location of the incision was on the right knee, midline parapatellar. There was an ace wrap over it with the polar ice wrap on top of that. There was no drainage on the dressing from what I assessed and there was a drain intact from the incision site. This is normal due to the surgery to help with irrigation, preventing clotting and swelling of the area. IV The IV is inserted on his right hand and has been present for 3 days. Lactated Ringers solution was used and this is an alkalinizing solution that may be given to treat metabolic acidosis. It contains sodium, chloride, potassium, calcium, and lactate. This solution remains in the vascular compartment, expanding vascular volume. The use of IVs is to supply the client effectively with electrolytes that they are losing due to not consuming the electrolytes in food or drink. CPM He had a CPM machine that helped with flexion of theknee. This is abnormal for anyone who has not had traumatic damage or surgery to the knee. This increased the patients ROM and increased the ability to ambulate faster. Walker He did use a walker when ambulating at the hospital, and uses a cane at home for extra help and to take pressure off of his knee. These devices increase ambulation and decrease risk of falls. These are used as assistant devices to decrease the risks. This is a good way of practicing safe mobility for the patient. Pain The right knee was in pain, which made it difficult for his right leg to be moved. The patient expressed there was a tingling and burning sensation right above his knee. There was pressure on it when he would sit up and it felt very uncomfortable for him. Due to the

15 surgery these findings are normal, but will also diminish. The surgery is a painful, and unpleasant. The amount of sawing and pounding at the bone and tearing of the joint, tissue, and skin is a painful healing process. 268 lb. This weight is abnormal even preoperatively. According to what his ideal weight should be, 160 lb, his IBW percentage is over 120%, which qualifies him as obese. This could also initiate the pain and problems he has with his knees. The more weight there is, the more pressure and trauma to the area. On Monday night he did not sleep very well do to the pain, but on Tuesday he slept much better and slept a lot during the morning too. Using the risk for falls assessment tool, this client is at risk. For having this kind of surgery, it is normal to be at risk for falls due to the balance, immobility postop, and medications. It takes time and practice, and with a lot of therapy to get the knee (joint) back to what is was. Using assisstive devices will decrease the risk of this assessment.

Weight

Sleep patterns Risk for falls

16 ASSESSMENT OF LABORATORY AND DIAGNOSTIC TESTS (1 pt.) List all laboratory and diagnostic tests completed for this client. Include numerical results. If the admission result is significantly different than the postop results, include both values. DIAGNOSTIC TESTS X-Ray of MRI of EKG Ultrasound of Endoscopy of Nuclear Scan of Other: H&H RBC were low pre-op and within normal level postop. Hemoglobin and hematocrit were normal preop and post op they were low. The values of the Hgb were 9.1 and Hct was 27.4. These tests were done on 10/28 preop and 11/05 postop. Glucose level was high at 250 on 10/28. No organisms were seen and no WBC were present INR was tested on 10/28 and was 1.0. it was low pre-op and was not done again after that date.

Gram Stain Smear of wound INR

17 ASSESSMENT OF LABORATORY AND DIAGNOSTIC TESTS (CONTINUED)

X 11/05 X 11/05

HEMATOLOGY/CBC WBC ( 3.8-10.1x103/mm3) RBC (3.9-5.2-million/mm3) Hgb (12.0-15.6g/dl ) Hct (35-46) Platelets (150-400 x 103/mm3) MCV (80-100%) MCH (27-33 pg) MCHC (32-36 g/dl) WBC DIFFERENTIAL Polys, PMN, Neut, Seg (40-75%) Bands (0-8%) Lymph (18-47%) Monos (0-10%) Eosin (0-5%) Baso (.5-1%) Metamyelocytes (0) Myelocytes ( 0) Other COAGULATION PT (11-14.2 sec) INR (Coumadin 2-3) APTT (22-32 sec) ARTERIAL BLOOD GASES ABG's on __________%O2 PH (7.35-7.45 PCO2 (35-45 mm Hg PO2 (80-100 mm Hg) HCO2 (22-26 mmEq/1 Base (+2) SAT ( 94-99%) K+ (3.5-5.3 mEq/1

X 10/28

X 10/28

CHEMISTRY Glucose ( 70-110 mg/dl) Sodium (135-145 mEq/1) Potassium (3.5-5.3 mEq/1) Chloride (97-107 mEq/1) BUN (10-20 mg/dl) Creatinine (0.1-1.2 mg/dl) BUN/Creat ratio (10-20/1) CO2 Content (24-32 m/Eq/1) Anion gap (8-16) Magnesium (1.8-2.4 mg/dl) Phosphorus (2.7-4.5 mg/dl) Amylase Calcium (8.2-10.2) mg/dl) Phos ( 2.5-4.5 mg/dl) Bilirubin (.2-1.3 mg/dl) Total Protein ( 6.2-8.2 g/dl) Albumin ( 3.5-5 g/dl) Globulin (2.0-3.5 g/dl) Uric Acid (2.1-8.5 mg/dl) Alk Phos (50-130 U/l) AST(SGOT) (5.35 U/l) LDH (45-90 U/ml) CPK (CK) (5-75 mU/ml) CARDIAC TESTS Cholesterol (<200 mg/dl) Triglycerides (40-150 mg/dl) CPK mb Troponin Myoglobin DRUG LEVELS Digoxin level ( 0.5-2.0 mg/dl) Theophylline Dilantin ANTIBIOTIC LEVELS Drug Peak ( ) Trough ( )

URINALYSIS/URODIPSTICK Color (Amber-Yellow) Clarity (Clear) Spec. Gravity (1.003-1.030) pH (5-8) Protein (N) Glucose (N) Ketones (N) Bilirubin (N) Blood (N) Nitrite (N) Urobilinogen (0.1-1.0 ng) Leukocyte esterase (N) WBC (0-5) RBC ( 0-2) Epith Cells (N) Bacteria (N) Casts (N) Crystals (N) Mucous (N) OTHER TESTS CEA CA-125

BEDSIDE DIAGNOSTIC TESTS Hemoccult ( N) Gastroccult (N)

X 11/04 89% Nasal 2L

Pulse Oximetry Result Type/amt of oxygen Result Type/amt of oxygen Result Type/amt of oxygen

CULTURES Site Organism Sensititivity Site Organism Sensititivity

Bedside Glucose Monitoring Date/Time Insulin Date/Time Insulin Date/Time Insulin Date/Time Insulin Date/Time Insulin Date/Time Insulin Date/Time Insulin Date/Time Insulin

18 ANALYSIS OF LABORATORY AND DIAGNOSTIC TEST RESULTS (3 pts) List each abnormal laboratory or diagnostic test result. Describe the purpose of each laboratory and diagnostic test. Explain the reason for your patient's abnormal results based on the patient's health condition(s), surgical procedure, and pathophysiology. Abnormal Test Purpose of the Diagnostic Test Value Hgb Hgb is a component of RBCs. Hgb binds with oxygen and is released into the blood. The amount of Hgb in the blood changes the blood volume. Hct Hematocrit is measured to find out the volume of the cell. Measure the percentage of blood that is erythrocytes. Glucose in the urine indicates high blood glucose levels. Glucose should not be present. This is also test for Diabetes Mellitus. This is used to assess the oxygenation in the blood. The normal value is from 95-100% This test is to find out the ratio of the patients PT to the normal PT. This is used to monitor anticoagulant therapy. Explanation of Patient's Result This could be a risk for hemorrhage, or hemodilution due to fluid retention. In this patient case it is not detrimental, but needs to be monitored incase of hemorrhaging or infection. A low value means that there is not enough hemoglobin in the blood forming. The Glucose level was 250 on 10/28, preop. This value was high which means that the urine had high levels of glucose. This patient is tested with the pulse oximeter to get the value of oxygen in his blood. Due to surgery and immobility, this can decrease the oxygen in the lungs that will decrease the oxygen in the blood. This patient had a low INR on 10/28 which was 1.0. this means that with low INR, his bloods ability to clot is high. This then can increase the risk of DVT and PE.

Glucose

Pulse oximeter

INR

19 RISK ASSESSMENT FOR IMPAIRED WOUND HEALING - (1 pt.) On the assigned clinical patient assess for factors which could inhibit wound healing.
Abn

Assessment Category Low hemoglobin/hematocrit Low WBC count or total lymphocyte count(Must be calculated even if numbers are normal) TLC=WBC count x %of Lymphs Degree of TLC deficiency: mild = 1500 - 1800, moderate = 900 - 1500, severe = <900 Low albumin level Degree of deficiency: mild = 3.0-3.5, moderate = 2.5-3.0, severe = <2.5 Less than ideal body weight or obese

Data Specific to this Patient Hgb = 9.1 Hct = 29.7 WBC count= % of lymphs= Total Lymphocyte count= Degree of TLC deficiency=

Albumin (serum)= Degree of deficiency= % over or under ideal body weight Age=

Age (>65) Physiologic stressor in addition to surgery NPO, eats poorly or eats poorly balanced meals (Describe) Diabetes, peripheral vascular disease, COPD or other chronic disease (list) Disease of immune system (list) Takes Immunosuppressant or corticosteroid drugs (list) Decreased tissue oxygenation Impaired tissue perfusion (Describe) Presence of infection (Describe) Positive wound culture/sensitivity results Disruption of suture line (Describe) Wound caused by accident/trauma or contaminated d/t bowel perforation (Describe) Wound requires packing (Describe) Wound exposed to feces or urine (Describe) Copious wound drainage (Describe)

Pulse oximetry= 89% Site Organism

20 NURSING DIAGNOSES: ACTUAL & RISK FOR (6 PTS.) To obtain the nursing diagnoses: Analyze all data. (Include past history, medications, admitting diagnosis, surgical procedure, developmental, psychosocial and health assessment, laboratory and diagnostic tests.) List and cluster abnormal findings (Data may be used to support more than one nursing diagnosis.) Look up possible nursing diagnoses in your nursing diagnosis book to determine which ones fit your data. Don't forget to include psychosocial nursing diagnoses. Assign the appropriate NANDA nursing diagnosis to each cluster of data. Write nursing diagnoses in PES format (Problem, Etiology, Symptom). Prioritize list of nursing diagnoses. # 1 Clusters of abnormal data Patients pain rate was 8-9/10 Some tingling above knee on Tuesday. With ambulation and sitting for a while increased throbbing sensation. Patient had morphine PCA due to pain. 2nd day post op was out of bed with PT. Did not ambulate on own, nor get out of bed with out assistance. Needed a walker for balance and to help with ambulating. Laying supine in bed most of the day, low hemoglobin, hematocrit, elevated temperature, moderate edema, pulse oximeter on Tuesday was low with a 89%. Nursing Diagnosis in PES Format Pain related to surgery.

Impaired physical mobility and postop management related to surgery

Risk for infection related to immobility, wound care, and foley catheter due to surgery

Was not cooperating with incentive Knowledge deficit related to incentive spirometer, spirometer. Had some fluid in lungs DB&C, wound care, CPM, ambulation, and when coughing and deep breathing. assisstive devices. Had elevated temperature and pulse oximeter reading was 89% on Tuesday. Used a walker with ambulation. Needed emphasis on explanation of not using it to keep his balance. It used as a guide to help with ambulation and to make it easier and safer.

21

Based on theoretical concepts, develop a list of "Risk for" nursing diagnoses specific to your client. # 1 Risk For Nursing Diagnosis in PE Format Risk for wound infection related to surgical procedure, and exposure to pathogens. Rationale for Nursing Diagnosis Due to patient lying down after surgery for approximately 24 hr. the patient has an increase of contracting an infection. The patient is showing a slight fever and has been doing deep breathing and coughing (incentive spirometer), but there is fluid when he coughs. The patient has low hemoglobin and hematocrit levels, and a risk for hemorrhaging is increased. With lying down and having a surgery in the lower extremity the patient is at risk for having a DVT and could travel up which would result in a Pulmonary embolus. The patient just had knee surgery and with that is a lot of swelling and inflammation because of damaged or destroyed tissue. This could increase the risk of blocking blood flow to the lower extremity; his foot and cause unilateral edema. Edema was +2 on Tuesday and +1 on Wednesday, but Wednesday the pedal pulses were weaker. Due to surgery, my patients fall risk is increased because his leg is immobilized and in pain. He has to favor his other leg that could put him off balance and he could reach for something unsteady or just fall due to lack of balance. Patient did not want to eat solid food due to not being able to ambulate to bathroom, so monitoring for constipation, diarrhea, and impaction is important. With not ambulating he is at risk for constipation. His bowels are not as active when he is lying down. He is at risk for this and has been a laxative to soften stools. Colace was given.

Risk for fluid volume deficit related to increase blood loss from OR

Risk for decreased tissue perfusion related to immobility due to surgical procedure.

Risk for fall related to knee surgery

Risk for constipation related to immobility and decrease food intake.

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NURSING CARE PLAN FOR THE 1ST PRIORITY NURSING DIAGNOSIS Write the 1st priority nursing diagnosis in PES format. Pain related to knee surgery Write 1 discharge-related outcome (long term goal) for this nursing diagnosis. (1 pt.) Client will be able to perform ADLs with minimal pain after recovery. There will be less swelling and pain once the patient recovers fully from surgery. Write 2-3 expected outcomes (short term goals) for this nursing diagnosis appropriate to the days of care. The outcomes must be specific to the patient, measurable and realistic. (2 pts.) Client will rate his pain lower each day in the hospital and will go home with a pain level that is comfortable for him to mobilize. Client will have PCA discontinued and will be on oral medications. Client will be able to tolerate ROM easier and with out so much discomfort. Complete a comprehensive list of specific individualized nursing interventions and rationales for the nursing diagnosis. The nursing interventions should relate to the problem, as stated. The interventions should include all interventions that would be appropriate for this patient whether you had the opportunity to implement them or not. Document your sources in APA format. (5 pts.) Nursing Intervention Assess pain q 2-4 hr. Rationale Client will rate pain on the scale out of 10 to assess the level of pain and make sure it is being controlled well enough with the medication or if needs to be increased. What we really want is the pain to be decreasing, to show inflammation is subsiding and that infection rate is going down. Client will report location, intensity, and quality of pain. The patients report on pain is the most important and reliable indicator of his pain. Unrelieved pain can result in immune function, which can lead to infection. Cold therapy will help decrease the inflammation, which goes hand in hand with decreasing the throbbing pain. Nonpharmacological interventions should be used to supplement, not replace, pharmacological interventions. This helps decrease the inflammation also. May also provide a more comfortable position for the knee. Watch for how many times the patient is attempting the medication and how much is

Apply polar ice pack and change ice continuously as needed.

Elevating the knee with pillows Monitor PCA and encourage to use PCA prior to activity and hr before PT.

23 actually being administered. Monitoring this will help show if the pain is increasing, leveled out, or decreasing. The IV site is the preferred route for rapid control of severe pain. Write a nursing progress note for this nursing diagnosis. Your note may be in Focus (Data, Action, Response) , SOAP (Subjective, Objective, Assessment, Plan), or PIE (Problem, Intervention, Evaluation) format. (2 pts.) D= Pain was rated an 8, polar ice pack was cold and applied to knee. Patient was comfortable with pillows underneath and the PCA attempts were minimizing. Emptied foley bag. A= I filled the polar ice pack with ice and made sure the patient was comfortable and the pain was not intolerable. R= patient was doing well and respectful to my assistance in making his stay as comfortable as possible related to his pain.

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NURSING CARE PLAN FOR THE 2ND PRIORITY NURSING DIAGNOSIS Write the 2nd priority nursing diagnosis in PES format. Impaired mobility related to surgery Write 1 discharge related outcome (long term goal) for this nursing diagnosis. (1 pt.) Client will be able to walk smoothly with out complaints of pain or soreness Write 2-3 expected outcomes (short term goals) for this nursing diagnosis appropriate to the days of care. The outcomes must be specific to the patient, measurable and realistic. (2 pts.) Client will be able to move right leg with little assistance and decreased pain Client will be able to walk to the bathroom and sit up in a chair. Complete a comprehensive list of specific individualized nursing interventions and rationales for the nursing diagnosis. The nursing interventions should relate to the problem, as stated. The interventions should include all interventions that would be appropriate for this patient whether you had the opportunity to implement them or not. Document your sources in APA format. (5 pts.) Nursing Intervention Explain how to use assisstive device, such as walker Encouraged ROM of all extremities due to immobility BID. Rationale Patient was told not to use the walker inappropriately; such as leaning over too much could increase risk of patient to fall. Express ROM is extremely beneficial with the surgery he had done due to keeping the joint loose and strong. Tightening of the joints and muscle around the knee can make it more painful. ROM will maintain muscle movement and strength. It also prevents contracture. Reason for doing this is because he is lying down for a lengthy amount of time and when he gets up he could be feeling faint or dizzy. The medications can also trigger this response. This will help with maintaining movement of muscles and keep strength. Also motivate the person to get better. Will help to decrease this patients temperature and increase pulse oximeter.

When getting out of bed, instruct client to sit for a couple of minutes Encourage getting up in chair qid for 15-30 min.

25

Write a nursing progress note for this nursing diagnosis. Your note may be in Focus (Data, Action, Response) , SOAP (Subjective, Objective, Assessment, Plan), or PIE (Problem, Intervention, Evaluation) format. (2 pts.) D= PT assisted him to the bathroom, and in the chair. Did ROM exercises with him while he was in bed and in the chair. BP was fine before PT came and after, so was respirations and pulse. A= Check BP, for edema in right foot, ask about pain rate. Made sure client was feeling good, not feeling sick or short of breath. Kept doing his incentive spirometer to decrease the fluid in his lungs from lying down so much. Helped patient back into bed from the chair. R= patient felt fine on the second day. Was happy that he got up to the bathroom and sat for a while.

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NURSING CARE PLAN FOR THE 1ST PRIORITY PSYCHOSOCIAL OR DEFICIENT KNOWLEDGE NURSING DIAGNOSIS Write the 1st priority psychosocial or deficient knowledge nursing diagnosis in PES format. Knowledge deficit: Risk of post-op infection. Write 1 discharge related outcome (long term goal) for this nursing diagnosis. (1 pt.) Client will not have an infection, pneumonia, or respiratory distress. Write 2-3 expected outcomes (short term goals) for this nursing diagnosis appropriate to the days of care. The outcomes must be specific to the patient, measurable and realistic. (2 pts.) Clients fever will go down and be in the normal ranges. Client will have an increased pulse oximeter reading within normal ranges. Client will use the incentive spirometer less or not at all. Complete a comprehensive list of specific individualized nursing interventions and rationales for the nursing diagnosis. The nursing interventions should relate to the problem, as stated. The interventions should include all interventions that would be appropriate for this patient whether you had the opportunity to implement them or not. Document your sources in APA format. (5 pts.) Nursing Intervention Teach use of Incentive Spirometer. Rationale Teaching the use of the spirometer will decrease the likelihood of infection. Maintaining a check on this will allow one to notice if his oxygen in the blood is decreased which could increase his risk for infection. Address wife to see if she is willing to help increase and encourage use of incentive spirometer. Also, how important it is to get him up in bed and in the chair. With his wife there encouraging, might have a bigger success with utilizing the spirometer. Watch patient demonstrate the use of the incentive spirometer to make sure he has the right understanding and knows the correct way of using it. If he does not use it correctly, encourage and assist him with it. A demonstration back is more successful than providing information alone.

Assess willingness of family to incorporate new information, and modifications in support of client.

Evaluate clients understanding through demonstrations, and verbalizations.

27

Write a nursing progress note for this nursing diagnosis. Your note may be in Focus (Data, Action, Response) , SOAP (Subjective, Objective, Assessment, Plan), or PIE (Problem, Intervention, Evaluation) format. (2 pts.) D= pulse oximeter was 89% on Tuesday. Clients deep breathing and coughing and use of incentive spirometer helped clear his lungs out. On Tuesday his voice was raspy in the morning and by the time I was leaving his voice was clear from doing his exercises. A= enforced the incentive spirometer every time I was in the room. Made sure he got up to 250 on all inhalations. Did pulse oximeter q 2-4 hr, and auscultated his lungs sounds to make sure they were clear bilaterally. Also checked pedal pulses to make sure those were still strong. R= he did not like to do the incentive spirometer, but every time he did do it, he said he felt much better. He stated that he would use it more while I was out of the room because he understood that he needed to do it more to decrease his fever and decrease his stay.

28

NURSING CARE PLAN FOR A PRIORITY RISK FOR NURSING DIAGNOSIS Write a priority Risk For nursing diagnosis in PE format. Risk for infection related to immobility of knee surgery Write 1 discharge related outcome (long term goal) for this nursing diagnosis. (1 pt.) Client will demonstrate no evidence of infection. Write 2-3 expected outcomes (short term goals) for this nursing diagnosis appropriate to the days of care. The outcomes must be specific to the patient, measurable and realistic. (2 pts.) Client will have a lower fever than 99 Client will have a higher pulse oximeter reading that will be within normal range Client will maintain clear lungs sounds Complete a comprehensive list of specific individualized nursing interventions and rationales for the nursing diagnosis. The nursing interventions should relate to the problem, as stated. The interventions should include all interventions that would be appropriate for this patient whether you had the opportunity to implement them or not. Document your sources in APA format. (5 pts.) Nursing Intervention Monitor temperature q 4 hr or prn Monitor pulse oximeter q 4 hrs Rationale Make sure it does go up, if it goes up it can be a response to an infection Make sure it is within normal ranges, if not he needs to be on oxygen due to the chance of hemorrhaging and infection. Auscultate lungs to Make sure lungs stay clear bilaterally, if not then there is fluid, which increases risk of infection. If any are out of normal ranges, the risk for infection increases Keep these exercises up due to decreasing likely hood of infection. If fluid sits in lungs could result in pneumonia. Make sure client uses these properly to decrease the risk and time of using it and doing them. Monitoring this is just to make sure that the drainage is not showing any forms of infection and that it is not excessive.

Monitor vital signs Encourage DB&C q 1 hr- 3 repetitions

Instruct client on Incentive Spirometer q 1hr, 10 inhalations Assess Hemovac drain for abnormal drainage.

29 Write a nursing progress note for this nursing diagnosis. Your note may be in Focus (Data, Action, Response), SOAP (Subjective, Objective, Assessment, Plan), or PIE (Problem, Intervention, Evaluation) format. (2 pts.) D= VS were 132/62, 90, 18, 99.4 and pulse oximeter was at 89%. Edema was present with +1 or +2. Pedal pulses were strong on Tuesday but a little weaker on Wednesday. The incentive spirometer reached 250 with every inhalation. DB&C were still assessed and there was less coughing on Wednesday with that exercise. Lungs were clear bilaterally. A= Checked vital signs q 2-4hr, including pulse oximeter. Had patient wear nasal cannula at 2 L to increase oxygen in the blood. Monitored the Hemovac drain, which was serasanginous fluid. R= client was uncooperative with incentive spirometer even though he knew that it was in his best interest to maintain healthy and not increase his risk for infection. He felt better with inhalations and DB&C and started to cooperate by Wednesday with them. But he was a little more tired Wednesday so I believe he did not want to put up a fight.

30 PROFESSIONAL JOURNAL ARTICLE (2 pts.) Attach a copy of a professional journal article published within the last 5 years that relates to some aspect of your patient's care. The article must be from a professional nursing journal. Foreign nursing journals or lay oriented magazines are not acceptable. This article should be cited in one of the previous sections of this paper. In the space below, explain how the information in the article could be used to improve the nursing care provided. In reading the article on total hip replacement rehabilitation, it educated me in finding out that this surgery and the postoperative care have not been fully studied. Experiments and studies still need to go underway to actually find out more information regarded to the specific areas that are being questioned along with what therapies are good, how long therapy should last, what activities can induce more problems on the replacement. In this article many studies addressed did not have enough or adequate information to make a factual statement, or outcome on the findings. Total hip replacement is one of the most common and successful surgeries. In this procedure, the hip is resected and replaced with a prosthetic bone. This procedure is meant for long-lasting function and to decrease pain. The real question is not the preoperative care or intraoperative, but the postoperative. Many studies investigated the use of PT after surgery and all came up with different outcomes. In doing this procedure, posteroperatively the main concerns are restoring normal function back to the hip, with mobility, strength, and flexibility. An in other procedures, reducing and preventing complications such as pain, DVT, ROM, and weight-bearing precautions. With total hip replacement, the postoperative restrictions are based primarily on the patient. With weight bearing activities the surgeon usually assesses the status as well as looking at what type of implant was used, the bone integrity, and strength and structure of the tissues. With cemented stems, partial body weight is allowed usually. With uncemented stems, only allows minimal pressure for 6-12 weeks postop. Some ROM is prohibited depending on what kind of surgery was performed. With posterior and lateral surgical approaches, hip flexion, adduction, and rotation are avoided past the midline. With anterior approach, hip extension, external rotations are not allowed. In the first week postoperatively, dislocation is at the greatest risk. There has been notable leg length discrepancy after total hip replacement. Those that do have one can wear a shoe lift to help with gait training, but those cannot be worn until 6 months postop. Exercise is important in recovery from this surgery. Lower extremity range of motion exercises is encouraged, with strengthening of the hip abductors. In doing proper exercise it should maximize strength and flexibility. In managing pain, analgesics and cold packs are the best form of nonpharmacological and pharmacological treatments so far. As with most surgeries, patient and family education is a key part in recovery. Discussing postoperative care and therapy with the patient along with home exercise programs and outpatient therapy are part of the discharge care. There are some long term physical impairments associated with hip surgery such as, decreased muscle strength, limited hip ROM, and abnormalities in gait. Long-term activities recommended are diving, cycling, golfing. While discouraged sports are soccer, football, baseball, hockey due to impact and reinjury. With experiments and studies performed on total hip replacement, it shows that there still needs to be experiments done in areas addressing therapy, strength, ROM, reliability of the hip. Also, with the most cost-efficient and safe therapies that can be performed with maximum recovery.

31 REFERENCE LIST List references in APA format. Include at least one professional journal article. (2 pts.) Ackley, B.J. & Ladwig, G.B. (2002). Nursing diagnosis handbook: A guide to planning care. (5th ed.), St. Louis: C.V. Mosby. Anderson, K.N., Anderson, L.E., & Glanze, W.D. (Eds.). (2002). Mosbys medical, nursing, and allied health dictionary. (6th ed.). St. Louis: C.V. Mosby. Brader, B.A., Mullarkey Fitzgerald, C. (2002). Rehabilitation after total hip replacement for osteoarthritis. Physical Medicine and Rehabilitation. 6 (3), 415-433. Kozier, B., Erb, G., Berman, A.J., & Wilkinson, J. (2000). Fundamentals of nursing: Concepts, Process, and Practice (6th ed.). New York: Addison-Wesley. Phipps, W.J., Monahan, F., Sands, J.K., Neighbors, M. & Marek, J.F. (2003). Medical-surgical nursing: Health and Illness Perspectives. (7th ed.). St. Louis: C.V. Mosby.