Nrsg Dx for total hip replacement

Bklyn_RN · Mar 12, 2009

Hope these are of help;

1) Risk for altered respiratory function related to immobility.

2) Acute pain related to surgical incision.

3) Fluid volume deficit related to losses secondary to surgical procedures with recent wound drainage appliance (or fever).

4) Bathing/Hygiene (or toilteing) self care deficit related to mobility restrictions.

5) Risk for constipation related to activity restriction (or pain meds).

6) Activity intolerance related to fatigue, pain and impaired gait.

7) Risk for injury related to altered gait and assistive devices (when your pt begins to ambulate, which i guess will be soon).

8) Risk for altered body temperature related to...

Daytonite, BSN, RN · Mar 12, 2009

see https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans for how to construct a care plan.

step 1 assessment - assessment consists of:

a health history (review of systems)
performing a physical exam
assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming)
reviewing the pathophysiology, signs and symptoms and complications of their medical condition - why was the total hip replacement done? trauma? or, because of joint disease? this information is needed for the etiology of your nursing diagnostic statements.
[*]reviewing the signs, symptoms and side effects of the medications they are taking
[*]since he had general anesthesia, he needs to be monitored for the following side effects of general anesthesia (some of these should be a part of your care plan):
- breathing problems (atelectasis, hypoxia, pneumonia, pulmonary embolism)
- hypotension (shock, hemorrhage)
- thrombophlebitis in the lower extremity
- elevated or depressed temperature
- any number of problems with the incision/wound (dehiscence, evisceration, infection)
- fluid and electrolyte imbalances
- urinary retention
- constipation
- surgical pain
- nausea/vomiting (paralytic ileus)

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data - all you posted is listed below. i would have taken a list of his medications. i can't believe that he wasn't getting something for pain and that he didn't need assistance with some of his adls. that's what we nurses do. also, he had general anesthesia. he needs to be monitored for complications. did no one have this man deep breathe and cough during your clinical day? this is a surgical patient as well as an orthopedic patient.

hgb, hct, wbc were low - this is blood loss anemia, a fluid deficit
bp was 90/52
pain assessment ???
lung assessment ???
mobility issues ???
self care deficits ???
teaching needs ???

step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use

acute pain - maybe. . .you have no pain assessment information.
- assessment and description of pain includes the following (you might want to copy these down):
  - where the pain is located
  - how long it lasts
  - how often it occurs
  - a description of it (sharp, dull, stabbing, aching, burning, throbbing)
    - have the patient rank the pain on a scale of 0 to 10 with 0 being no pain and 10 being the worst pain
    [*]what triggers the pain
    [*]what relieves the pain
    [*]observe their physical responses
    - behavioral: changing body position, moaning, sighing, grimacing, withdrawal, crying, restlessness, muscle twitching, irritability, immobility
    - sympathetic response: pallor, elevated b/p, dilated pupils, skeletal muscle tension, dyspnea, tachycardia, diaphoresis
    - parasympathetic response: pallor, decreased b/p, bradycardia, nausea and vomiting, weakness, dizziness, loss of consciousness
[*]impaired physical mobility
[*](toileting) (bathing/hygiene) self-care deficit
[*]deficient knowledge, discharge care
[*]risk for ineffective airway clearance
[*]risk for ineffective breathing pattern

surviving · Mar 12, 2009

I guess I was pretty vague with my first post - this is all new to me. First semester student and new to this site....

Reason for surgery - arthritis, other hip done previously.

Meds: Morphine PCA (he only hit it once all day while PT was doing ROM on leg), Lovenox 30 mg q12h, Celebrex 200 mg q day, Ancef 1 gm Duplex x 4 doses, PRN pain meds - did not give because he never complained.

Pain Assessment: Everytime I checked on him, he said he did not have any pain. He complained of level 5 when PT was working with him - he hit PCA pump once. He said it eased off within 10 minutes.

I instructed and monitored deep breathing and coughing, as well as incentive spirometer q2h all day.

Lungs clear, respirations 16. Active bowel sounds x 4 qdts, HR 80 and regular, 02 100%.

I prepared his food tray and he feed himself. He was given a bed bath. He had a catheter and had not had a bowel movement since before surgery. He was NPO until the morning after surgery (which is when I got him as a pt). His electrolytes were within normal ranges, his U/A was normal. His incision is very clean - his drain only had 40 cc total before they removed it. He was getting D5NS at 200 cc/hr. He has a history of hypertension - went hypo after surgery.

I am thinking Impaired Physical Mobility r/t ___________________.

I also want to address the hypotension. Not sure exactly how yet....

Daytonite, BSN, RN · Mar 12, 2009

I gave you a lot of information to think about. Before I do anymore of this assignment for you, especially since you said that you used other diagnoses (so you must have done a previous care plan), what ideas do you have for the nursing problems (nursing diagnoses) that this patient might have now?

surviving · Mar 14, 2009

In my assessment, my main concern is safety - I am thinking Risk for Injury r/t Impaired Gait. My instructor stressed that I need to include items such as monitoring for s/s of DVT, his turning schedule, post-op teaching, incentive spirometer, etc. I know what I need to do as a nurse, but I have a hard time matching an approved NANDA diagnosis to it. I am using Taylor and Sparks Nursing Diagnosis Reference Manual, and I just have a very difficult time matching my assessment and nursing interventions to an approved diagnosis. Would Risk for Injury r/t postoperative complications work as a nursing diagnosis? And the following interventions: monitor for s/s of anesthesia complications (I could address the hypotension here), turn schedule, incentive spirometer, ambulation, etc. I just can't seem to focus on one diagnosis.

This is my 3rd care plan - I am struggling to match assessment data, and interventions with NANDA.

Daytonite, BSN, RN · Mar 14, 2009

my instructor stressed that i need to include items such as monitoring for s/s of dvt, his turning schedule, post-op teaching, incentive spirometer, etc.

your instructor is absolutely correct and that is why, in my first post, i brought up the issue almost immediately that he needs to be monitored for the side effects of general anesthesia and that some of them need to be made a part of your care plan. that is what your instructor was hinting at. respiration complications are a big one. i'm guessing you have never had surgery. i've had 13.

i can tell you quite a lot about what major anesthesia does to the respiratory track. they put an et (endotracheal tube) down the patient's throat and then proceed to paralyze the person so the muscles relax and the surgeon can work. while paralyzed, the anesthesiologist places the patient on a ventilator and makes sure the patient keeps breathing. these are not like normal breaths because the patient is so relaxed. secretions begin to build up in the alveoli. fluid depletion occurs during surgery because the person has already been npo for some hours, the body is incised into and fluid escapes through the open body areas into the atmosphere. iv fluids will be given, but replacement doesn't catch up for many hours. when the patient is awakened and recovering from anesthesia, the lungs are being asked to come back to full use again after a period of sluggishness and dehydration. sputum, particularly dried sputum caught up in the alveoli, is a sticky mess and it takes a lot of effort to get it moved out. so much so that it takes up to 3 days, let me repeat that, 3 days, for that sticky sputum stuck in the alveoli of the lungs to get hydrated and moving. if it doesn't, bacteria come along and find a home in it and the patient gets a full-blown case of pneumonia. by deep breathing and coughing, even if the cough is dry and nonproductive, the patient is inflating the most distal alveoli and un-sticking the sputum which is stuck down there and gluing those air sacks shut. every deep breath works at loosening that sticky gunk. my most productive coughing was almost always done on day 3 or 4 after my surgeries and the sputum was always thick, sticky, nasty tasting stuff. and i've had surgeries on my legs, back, neck and abdomen. if you don't have a respiratory diagnosis, where are you going to put your nursing interventions for the deep breathing and coughing and the lung assessments?

turning and moving have to do with respiration and circulation. prevention of a dvt is dependent on maintaining circulation in the lower extremities. people are stationary during surgery. they are drowsy when recovering from anesthesia and not moving normally. even during our normal sleep we make movements, but not when we are drugged up with anesthetics. and, the operative limb isn't going to be doing much independent movement because it

hurts

and is swollen from the inflammatory response that kicked in because of tissue trauma.

i gave you the weblinks about hip replacements so you could see information in there about what needs to be taught to the patient after surgery and about their recovery.

i just can't seem to focus on one diagnosis.

when you are going to write a care plan, you need to sit down, assemble all the data that you collected and go through a rational process to sort it out--the nursing process as i started to demonstrate it for you. in time you will become familiar with the different nursing diagnoses. many of them are used commonly and over and over again. these two websites list the most commonly used ones and you can also get the nanda information about them:

if you have your own copy of

taber's cyclopedic medical dictionary

you will find all the diagnoses listed in the appendix along with the nanda taxonomy information (definition, related factors and defining characteristics) as well as a cross reference with some medical diagnoses.

diagnosing is a skill. it is mastered with experience over time. you will learn to work with nursing diagnoses the same way medical students learn to work with medical diagnoses--on a case by case basis and reading about them when they come up against a case.

this is what i would diagnose for this patient. i think i covered everything. they are prioritized by maslow. "risk for" diagnoses (anticipated problems) are never sequenced before actual problems. if i missed something, you can fill it in. my cats are pawing at my leg for breakfast at the moment. the next step is to take each diagnosis and bring in goals and nursing interventions (this is treatment)--that is step #3 planning (write measurable goals/outcomes and nursing interventions of the nursing process, the meat of your care plan (problem solving).

acute pain r/t surgical invasion aeb patient's ranking of pain at 5 on a 0 to 10 scale
impaired physical mobility r/t musculoskelatal impairement and inflammation of ___ hip aeb ["impaired gait" is not specific enough. what can't he do? can he get in and out of bed by himself or does he need assistance? say that. does he need one or two people to transfer to a chair? say that.] see these websites that list the defining characteristics (symptoms) of this diagnosis just below the title:
- impaired physical mobility
- http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=35 - impaired physical mobility

[*]deficient knowledge, self-care and discharge needs r/t lack of information aeb [evidence you have that patient didn't know specific information about what would be needed at home to help with his recovery]

[*]risk for ineffective airway clearance r/t effect of anesthesia and narcotics

[*]risk for constipation r/t decreased activity

[*]risk for vascular injury r/t altered peripheraltissue perfusion and immobility [this is a diagnosis i would use to monitor for a dvt]

[*]risk for infection r/t surgical invasion [this is a diagnosis i would use to monitor the wound and specifically to monitor for signs and symptoms of a wound infection]

[*]risk for falls r/t age, receiving postop narcotic analgesics, hypotensive state and blood loss

i am struggling to match assessment data, and interventions with nanda.

you need to keep all three of these things clear in your mind.

assessment data

is information. assessment is an activity where you are specifically looking for evidence--clues--of nursing problems. it's a hunt. you never know what you are going to find. you may have an idea because you know what the person's medical diagnoses are, but because we ask about their adls we could find anything that is out of the norm. that's why you learn about normal anatomy and physiology and what normal adls are. if something is abnormal it is a symptom, a defining characteristic (this is nanda language), evidence (as in aeb-as

evidenced

by), proof that something isn't right. think of yourself, nursing student surviving, as a detective with your antenna up and always on the alert for clues, clues and more clues--that is your mission. you can't have problems without clues and patients would not be in the hospital if they didn't need nursing help. these clues will not always be as simple as something that has gone wrong with their anatomy and physiology. they could be weird behavior, not acting right in society or not accomplishing simple (or more complex) adls.

a nanda, as you are using it, is a nursing diagnosis, or nursing problem identification. the nursing diagnosis is actually just a shortened label that stands in place of a much longer definition. this is why you want to see a nursing diagnosis reference so you understand exactly what you are calling something such as

acute pain

(unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months--

page 354

,

nanda international nursing diagnoses: definitions and classifications 2009-2011

)

or

impaired physical mobility

(limitation in independent, purposeful physical movement of the body or of one or more extremities

--page 124,

nanda international nursing diagnoses: definitions and classifications 2009-2011

). a care plan is a

compiled list

of the patient's nursing problems.

interventions are the strategies you will employ to do something about the nursing problems. you can't perform any interventions (strategies) until (1) you identify the problem and (2) the evidence that supports the existence of the problem. one of the analogies i use is taking a car to a mechanic. if your car is making a knocking sound in the rear end, you take it to a mechanic and the mechanic opens the hood of your car and starts pulling stuff out, does that make sense? are you going to pay the bill when the knocking sound is still there as you start to drive the car away? what did he do wrong? he didn't

assess

the situation. how could he apply interventions that pertained to the right problem, the knocking sound in the rear end? what i am saying is that you can't start coming up with interventions until you know what you need to target. in care planning you are also being asked to name (nursing diagnosis) the problem that goes with the evidence. that is why you need to follow the steps of the nursing process which helps keep you on the logical road in doing that. interventions actually target the abnormal data that got collected back during assessment. those abnormal things are really what we would like to correct and many times there are things within our scope of nursing practice that we can do for them.

example:

acute pain r/t surgical invasion aeb patient's ranking of pain at 5 on a 0 to 10 scale

goal:
patient will be comfortable
interventions:
- assess and document patient's level and intensity of pain using the 0 to 10 rating scale with 0 being no pain and 10 being the worst possible pain
- assess and document where the pain is located and what, if anything, makes it worse or better
- observe and document any of the following physical responses: frequent changing of body position, moaning, sighing, grimacing, crying, restlessness, dyspnea, tachycardia, diaphoresis, pallor
- give pain medication as ordered
- provide emotional support by spending time talking to the patient and reassuring them that measures are being taken to relieve their pain
- reposition the patient
- give a back massage
- use short, simple relaxation exercises to distract the patient's attention
- dim the lights in the room and keep noise down
- play soft, soothing music
- have the patient perform slow deep breathing and concentrate on feeling weightless with each breath
- reassess and evaluate the patient's response to each method employed. ask the patient which techniques work better for them.
- monitor for side effects of narcotic therapy: respiratory depression, constipation, nausea/vomiting
- teach the patient about prescriptions they will be going home with including the dosage, how they should be taken and any side effects

surviving · Mar 15, 2009

Thanks! I wish you were my instructor!!!!! You make this so clear - as if I am sitting here carrying on a one-on-one conversation with you. You have really helped me resolve my issues. I know this will all come in time. I have a much better grasp on it now.

msAnneRN11 · Oct 29, 2009

My patient tonight was a post op total hip replacement too and this is what I assessed:

Male, 72 years old, NKDA retired physicist, surgery procedure: THR on 10/26/2009 - assessed during 10/27/09 and 10/28/2009

1. Pain - 5(severe) - hip - stabbing - everytime the patient moves - relieved by pain meds

2. Wound - left hip -clean, skin is intact, no redness or swelling

3. Respiratory - lungs are clear to ascultate - no adventitious breath sounds - resp rate 15 - pulse ox 96 - able to use the incentive spirometer properly

4. Cardiovascular - s1,s2 - no wheezing or murmurs - BP 108/60 - capillary refill time less than 3 sec - radial/pedal pulse palbale, strong.

5. Musculoskeletal - A-ROM upper extremeties strong, lower extremeties weak (due to surgery), able to walk with walker/crutches, on physical therapy

6. Nutrition/Electrolytes: On a regular diet, lab values are normal except for an elevated glucose 115 (10/27), on 10/27 patient started vomiting, gave meds, tolerated 4 crackers without vomiting. on 10/28 patient was constipated, was not able to eliminate bowel, bowel sounds are hyperactive, he is now on stool softener and vomited 7pm 10/28.

7. Neurological - alert x3, cranial nerves intact, left pupil contricted but right eye pupil did not - patient states having a problem with his right eye, patient uses eye glasses, had a history of brain injury

8. Knowledge: patient knows about hospital procedures, about therapy, about deep breathing, patient is aware and mind is intact.

9. Psychosocial: Patient is very cooperative, wife is caring for her, he is glad to have a student nurse to take care of him.

Initial diagnosis: Acute Pain r/t surgical incision AEB patient states pain of 5 everytime he moves

Imbalanced nutrition r/t ??? AEB patient ?? (no bowel movement? vomiting?)

(I NEED 4 ACTUAL DIAGNOSIS AND SOME RISKS!!)

Daytonite, BSN, RN · Oct 29, 2009

maflores84 said:
My patient tonight was a post op total hip replacement too and this is what I assessed:
Male, 72 years old, NKDA retired physicist, surgery procedure: THR on 10/26/2009 - assessed during 10/27/09 and 10/28/2009
1. Pain - 5(severe) - hip - stabbing - everytime the patient moves - relieved by pain meds
2. Wound - left hip -clean, skin is intact, no redness or swelling
3. Respiratory - lungs are clear to ascultate - no adventitious breath sounds - resp rate 15 - pulse ox 96 - able to use the incentive spirometer properly
4. Cardiovascular - s1,s2 - no wheezing or murmurs - BP 108/60 - capillary refill time less than 3 sec - radial/pedal pulse palbale, strong.
5. Musculoskeletal - A-ROM upper extremeties strong, lower extremeties weak (due to surgery), able to walk with walker/crutches, on physical therapy
6. Nutrition/Electrolytes: On a regular diet, lab values are normal except for an elevated glucose 115 (10/27), on 10/27 patient started vomiting, gave meds, tolerated 4 crackers without vomiting. on 10/28 patient was constipated, was not able to eliminate bowel, bowel sounds are hyperactive, he is now on stool softener and vomited 7pm 10/28.
7. Neurological - alert x3, cranial nerves intact, left pupil contricted but right eye pupil did not - patient states having a problem with his right eye, patient uses eye glasses, had a history of brain injury
8. Knowledge: patient knows about hospital procedures, about therapy, about deep breathing, patient is aware and mind is intact.
9. Psychosocial: Patient is very cooperative, wife is caring for her, he is glad to have a student nurse to take care of him.
Initial diagnosis: Acute Pain r/t surgical incision AEB patient states pain of 5 everytime he moves
Imbalanced nutrition r/t ??? AEB patient ?? (no bowel movement? vomiting?)
(I NEED 4 ACTUAL DIAGNOSIS AND SOME RISKS!!)

Are you asking for help in determining what this patient's nursing diagnoses are?

msAnneRN11 · Oct 29, 2009

Yup! I have some in mind; Acute pain rt surgical incision aeb.. Patient states 5 when ever he moves

Imbalanced nutrition rt bowel obstruction, adverse effect of pain meds aeb vomiting, inability to eliminate

Impaired physical mobility r/t surgery, pain aeb patient prefers not to move bec of pain

Hmm.. Risk for infection

Risk for ineffective breathing pattern/clearance

Anymore?

Daytonite, BSN, RN · Oct 30, 2009

you are not putting your assessment data together correctly. you need to be able to recognize what is normal and abnormal about a physical assessment. you need to know what surgical procedure was done for your patient, why it was done, the pathophysiology of the underlying medical problems and what complications the patient is at risk for.

the construction of the 3-part diagnostic statement follows this format:

p (problem) - e (etiology) - s (symptoms)

problem - this is the nursing diagnosis. a nursing diagnosis is actually a label. to be clear as to what the diagnosis means, read its definition in a nursing diagnosis reference or a care plan book that contains this information. the appendix of taber's cyclopedic medical dictionary has this information.
etiology - also called the related factor by nanda, this is what is causing the problem. pathophysiologies need to be examined to find these etiologies. it is considered unprofessional to list a medical diagnosis, so a medical condition must be stated in generic physiological terms. you can sneak a medical diagnosis in by listing a physiological cause and then stating "secondary to (the medical disease)" if your instructors will allow this.
symptoms - also called defining characteristics by nanda, these are the abnormal data items that are discovered during the patient assessment. they can also be the same signs and symptoms of the medical disease the patient has, the patient's responses to their disease, and problems accomplishing their adls. they are evidence that prove the existence of the nursing problem. if you are unsure that a symptom belongs with a nursing problem, refer to a nursing diagnosis reference. these symptoms will be the focus of your nursing interventions and goals.

- - - - - - - - - - - - - - -

acute pain rt surgical incision aeb.. patient states 5 when ever he moves

"patient states 5 when ever he moves" isn't complete enough. it's 5 on a scale of 0 to 10.

imbalanced nutrition rt bowel obstruction, adverse effect of pain meds aeb vomiting, inability to eliminate

imbalanced nutrition is not a proper nanda diagnosis. there are 2 choices and you must identify the correct one:
- imbalanced nutrition: less than body requirements
- imbalanced nutrition: more than body requirements
[*]the related factor (r/t) of the diagnostic statement for either diagnosis must explain why the patient has been unable to ingest or digest less or more food than normal
- a bowel obstruction is a medical diagnosis. medical diagnoses cannot be used in nursing diagnostic statements. when was he diagnosed with a bowel obstruction? what are the symptoms?
- if he is having adverse effect of pain meds what are they? name them.
[*]symptoms: must be the evidence that proves the problem (imbalanced nutrition: altered intake of nutrients) exists.
- vomiting - vomiting is not a symptom of eating too little food (imbalanced nutrition: less than body requirements) or eating too much food (imbalanced nutrition: more than body requirements)
- inability to eliminate - not being able to urinate is not a symptom of eating too little food (imbalanced nutrition: less than body requirements) or eating too much food (imbalanced nutrition: more than body requirements)

impaired physical mobility r/t surgery, pain aeb patient prefers not to move bec of pain

if you read the earlier post for the op you would have seen that a more appropriate related factor for this would be musculoskelatal impairment.
symptoms: patient prefers not to move bec of pain is not specific enough and you will run into problems with this when you start to write your nursing interventions for it. your assessment stated his lower extremities were weak and that should be included here. how is his balance?

there is a sensory problem that you missed. look at your assessment data again.