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Having trouble with care plan

First care plan. I cannot figure out what information is pertinent for this assessment, and I'm also worried i will come up with too much or too little info. i'm lost!

Assessment:

Case Study: 72 y/o male, hospitalized for surgery on R. knee.

past 5 yrs experienced pain and decreased mobility preop

Now 2 days postop following total knee replacement

Incision is healing no signs of edema or erythema

He rates pain as a 6-7 on a scale of 0-10.

Using patient-controlled analgesia pump allows him to receive pain meds by pressing button

He uses continued passive motion machine to maintain flexion and extension

He is able to amb from bed to bathroom with aid of walker

The problem I'm having is all the missing information i may have gained by a hands on direct assessment. I would start with the most important, in my thought process, would be: Nursg dx

Acute pain r/t incision site of surgical procedure

Risk of infection r/t surgical incision, and age

impaired physical mobility r/t limited ROM

I wanted to put constipation r/t opiates taken for pain. don't think its in my book.

And possibly risk for injury r/t to implementing immobilization to R. leg.

Do I have anything worth while here or bag it and start all over. Any help would be greatly appreciated!!:loveya:

Daytonite, BSN, RN

Has 40 years experience. Specializes in med/surg, telemetry, IV therapy, mgmt.

diagnosing is based upon abnormal assessment data--not what is normal. so, when you are presented with these scenarios, go through them and pick out what is abnormal (if it helps, think about yourself. . .are you in pain? do you have a pca pump? use a walker?) you also need to do a little reading about the patients medical condition or the surgical procedure that was done. with knee replacements the patient's are not supposed to put full weight on the surgical limb for a while (see http://www.surgeryencyclopedia.com/fi-la/knee-replacement.html and http://www.nlm.nih.gov/medlineplus/tutorials/kneereplacement/htm/index.htm):

  • rates pain as a 6-7 on a scale of 0-10.
  • ambulates from bed to bathroom with aid of walker (unable to bear full weight on right leg)

the above is evidence of actual problems:

  • acute pain r/t surgical procedure aeb rates pain as a 6-7 on a scale of 0-10.
  • impaired physical mobility r/t knee surgery aeb unable to bear full weight on right leg

there are also complications of the procedure to be considered as well as complications of general anesthesia that could happen.

  • risk for ineffective breathing pattern r/t effects of anesthesia [risk for pneumonia]
  • risk for injury r/t altered peripheral tissue perfusion [risk for dvt]
  • risk for infection r/t invasive procedure [risk for wound infection]

FlyingScot, RN

Has 28 years experience. Specializes in Peds/Neo CCT,Flight, ER, Hem/Onc.

Hey, I just wanted to tell you thanks for all the work you did coming up with a care plan and then typing it here. So many students seem to expect us to do the work for them but you did your part. That's the kind of work ethic that will make you an excellent student and nurse. Sorry I didn't comment on your care plan. I literally have not done one since 1986 so I wouldn't have been much help. Thanks to Daytonite for her response...this student really deserved some help!

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