Nursing Care Plan
This Nursing Care Plan is designed for the management of postoperative care for a patient recovering from a knee replacement surgery in a hospital setting. The care plan includes nursing diagnoses, goals, interventions, and evaluation to ensure a comprehensive and patient-centered approach to recovery.
Date | Nursing Diagnosis | Goal | Nursing Interventions | Evaluation/ Outcome |
|---|
May 10, 2050 | Risk for infection related to surgical incision | Patient will remain free from infection during hospital stay | 1. Monitor wound site for redness, swelling, and discharge. 2. Perform sterile dressing changes as per protocol. 3. Administer prescribed antibiotics. | Wound site remains clean, no signs of infection present by May 15, 2050. |
May 10, 2050 | Acute pain related to postoperative surgical site | Patient will report pain at a level of 3 or below on a 0-10 scale | 1. Administer prescribed pain medications (opioids/NSAIDs). 2. Encourage the use of non-pharmacologic pain management (e.g., relaxation techniques). | Pain level decreased to 3 or below by May 12, 2050. |
May 10, 2050 | Impaired physical mobility related to surgical procedure | Patient will demonstrate increased mobility by walking 10 feet with assistance by May 15, 2050 | 1. Assist with ambulation exercises as tolerated. 2. Provide physical therapy consultation. 3. Encourage use of assistive devices (walker/crutches). | Patient successfully walked 10 feet with assistance on May 14, 2050. |
May 10, 2050 | Risk for impaired skin integrity related to immobility | Patient will maintain intact skin without pressure ulcers | 1. Reposition patient every 2 hours. 2. Use pressure-relieving devices on bed. 3. Ensure proper nutrition to support skin healing. | No signs of pressure ulcers noted during skin assessments on May 12, 2050. |
Conclusion:
This care plan provides a comprehensive approach for managing postoperative recovery, focusing on pain control, mobility, infection prevention, and skin integrity. Regular evaluation ensures the patient’s progress toward recovery and helps guide any necessary adjustments in care.
Prepared by: [YOUR NAME]
Email: [YOUR EMAIL]
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