Nursing Diagnosis For TKR

Mtaraj · Jul 6, 2011

Hi to whoever is reading this. THis is my first time on this site and I am in need for finding three nursing diagnosis and one goal for each one of them and three interventions for each one of them on the following case.

This is the first time for me dealing with nursing diagnosis and I am not sure about it. i know one of them which is pain acute so i have exhausted that one. But for the other ones I am confused.

here is the case:

72 year ol male

Admiting Dx: DJD (degenerative joint disease) L knee; TKR (total knee replacement)

MD Orders: VS q 4 hrs; BR; up c PT; CPM(continuous, passive motion) Except during sleep @noc

Bilateral SCD (sequential compression device ) Bilateral antiemboltic stockings (TEDs)

Regular Diet

Dressing change L Knee: clena w/ betadine;apply DSD

Bactrim DS po BID

Demerol 75 mg IM q 4h prn pain

Vistaril 50 mg IM q4h prn (give c Demerol)

Nursing Assessment: A&O *2 , hand grips equal &strong; Leg Pushes: weak L, strong R

B/P 140/82; apical pulse 82&regular; Homan's negative bilaterally ; BLE pulses present

Lungs clear to auscultation; RR 22&unlabored

Bowel sounds + *4 quads; LBM Today; 75% of meals

Voiding qs clear, amber urine via urinal

L Knee incision c staple intact well approximated, serosanguineous drainage; minimal redness, edema noted; c/o stabbing pain, 7/10 c ambulation &repositioning

Please help.