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Care Map

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by

Miranda Summitt

on 28 April 2014

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Transcript of Care Map

Care Map
By: Miranda Summitt
NURS 2240

Nursing Diagnosis
Impaired physical mobility r/t musculoskeletal impairment, surgery, and prosthesis aeb pt's inability to mobilize independently
(Ackley, 2014, p. 114)
Key
Pt Information
V.L.B.
Room #459
Age: 65
Gender: Female
Race: Caucasian
Date & Time of Care: 8:00 a.m. April 15th, 2014
Ht: 5'1
Wt: 270.6 lb
Pt reliable
Allergies: NKA
Developmental Stage: Generativity vs. Stagnation
Normal diet while in hospital
Vitals
Pain: 3/10 dull and aching
BP: 149/83 mmHg
O2 Sat: 95%
P: 90 beats/min
Temp: 99.2 degrees F
Resp: 18 breaths/min
Hx

Endometriosis- 2005
Two total knee replacements- 2007 and 2010
Mother had a stroke
Mother, aunts and uncles had hypertension and diabetes
Safety Check
Level 2 fall risk
call for assistance
unsteady on own
on narcotics and BP medications
Side rails up
Bed in lowest position
Can reach phone and call light
No hazards or messes
Chief Concern
Total ankle joint replacement
Pathophysiology
Total ankle replacement is a surgery done to replace damaged bone in the ankle joint using prosthetic joint parts. Plastic is generally inserted in between the prosthetic parts. It is stitched up and a splint, cast, or brace may be worn to prevent movement of the ankle. Some reasons for a damaged ankle bone would be arthritis, bone fracture, infection, osteoarthritis, and rheumatoid arthritis. Foot will need to be elevated and physical therapy may be ordered ("Ankle replacement," 2014).
Pt ADLs/Abilities
Pt must have assistance when walking or going to the bathroom because of the inability to put weight on her affected ankle. She uses bedside commode. She can eat on her own.
Physical Assessment/Review of Systems
General: WNL
Skin: WNL except for redness on left upper arm from pneumonia vaccine
HEENT: WNL except for stuffiness in nose, no hearing aids, wears glasses, no dentures
Cardiovascular/PV: WNL except for edema on both feet, pitting edema 1 or 2 in non-affected ankle, swelling in affected ankle, anterior heart sounds faint, foot pulses strong
Hematology: WNL except for bruise on right thigh of unknown origin
Respiratory: WNL except for slightly diminished in anterior bases d/t rest from surgery, history of sleep apnea, uses an incentive spirometer 10 times/hr
GI: WNL, last BM 2 days prior
Hepatic/accessory GI: WNL
Renal: WNL
Endocrine: WNL
Musculoskeletal: multiple different joint issues d/t arthritis, both knees replaced, first ankle replacement and other is set to be replaced as well, uses walker temporarily to get around
Neuro: WNL
Psychiatric: WNL
No incidence of infectious disease
IV access in left hand
Short Term Goal
Pt will walk to the bathroom 3 times a day using walker with limited assistance by the end of the clinical day (4/15/14).
Long Term Goal
Pt will be able to walk and perform ADLs independently upon discharge.
Short Term Interventions
Nurse will explain to the pt the need to try and do it independently to the best of their ability.
Nurse will encourage the pt to walk using the walker and pt will use call light when they need to go to the bathroom.
Long Term Interventions
Nurse will provide less assistance each day when pt is ambulating.
Pt will engage in resistance exercises 2-3 days/week and flexibility/stretching exercises 2 days/week
(Ackley, 2014, p. 537).
Other possible diagnosis:
Risk for Peripheral Neurovascular Dysfunction r/t immobilization aeb limited movement of affected ankle
(Ackley, 2014, p. 114)
Evaluation
Possible medication:
Hydrocodone (Lorcet, Lortab, Norco, Vicodin)
-Pt will be in a lot of pain after a total ankle joint replacement. Narcotics are a possible pain reliever.
Other NANDA problem statements:
Disturbed Body Image
Risk for Injury
Ineffective Peripheral Tissue Perfusion
(Ackley, 2014, p. 114)
If the goals are met by the pt, no further implementations are needed. If the goals are not met, the nurse and the pt need to reassess the situation and come up with new, more realistic goals and implementations. For this pt specifically, observe the pt's ability to walk and perform ADLs independently. If the pt is not able to do so, keep the same goals and interventions and add more time or change the goals and interventions to something that may possibly be more successful.
This diagnosis would be of highest priority because the pt's ability to go home after surgery depends on their ability to ambulate independently
The priority with this dx is to get the pt moving around. Pt will have to use the bathroom so that would be a good time to practice ambulating with assistance.
Some pt's will try and use their surgery as an excuse to need help with everything when it would be more beneficial for them to try and do it independently.
Other pt's will be used to doing everything independently and not recognize the risk of falling.
Before pt is able to go home, they must be able to perform ADLs independently to reduce the risk for falling.
It is necessary for pt to be able to perform ADLs independently.
Resistance exercises will strengthen muscles around the affected joint. Flexibility/stretching exercises will prevent the muscles around the affected joint from getting tight and causing pain.
Pain is the most common side effect after total joint replacement surgery.
Pt Information/Assessment Data
Short/Long Term Goals
Interventions
Evaluation
Crosslink
References
References
Ackley, Betty J., and Gail B. Ladwig.
Nursing Diagnosis Handbook: An
Evidence-based Guide to Planning Care
.
Maryland Heights, MO: Mosby, 2014. Print.

(2014). "Ankle replacement."
Medline Plus,
Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/007254.htm.
Full transcript