Sunday, June 20, 2010

CP for knee replacement

Hello Victoria, please excuse the late response. I do not regularly do the message center and I overlooked this request. Dr. A sent me a reminder..

Ms. Vicki Ledel is a 52 y/o female admitted four days ago for a right knee replacement due to aseptic necrosis of the lateral condyle. Her surgical procedure was uneventful. She is currently on a continuous passive range of motion machine (CPM). Ice is being applied to her right knee for 30 minutes three times a day. Her dressing remains intact with no new drainage. Her IV antibiotic has been discontinued and she is now receiving oral antibiotics. She is on a regular diet and tolerating food well. She is taking in adequate fluids and urinary output is quantity sufficient. She is presently having regular BMs, but her elimination is being monitored closely, as she is taking Lortabs 5mg po Q4 hours prn for pain (and has been taking them Q4 hours while awake). Physical therapy has made an initial assessment. Two-person transfer and limited weight-baring with a walker has been initiated.
Overriding/Required Areas of Care:
* Safety/Other (SR up X2, eyeglasses, dentures, TED hose bilateral lower extremities continuous)
* Mobility (Transfer OOB to chair with assist of 2 and walker, limited weight-bearing of right leg; elevate RLE while OOB)
* Vital Signs (BP, AP, RR, T, Pain)
Selected Areas of Care:
* Peripheral Vascular Assessment (lower extremities)
* Muskuloskeletal Management (AROM of LLE, PROM of RLE; CPM to bilat legs while in bed; Cold application to right knee X 20 minutes)
* Pain Management
* Respiratory Management (cough/deep breathing)

Care Plan:

#1 Ineffective Airway Clearance

R/t retained secretions this is a sign and symption - on page 174 under related factors, obstructed airway retained secretions is listed as r/t. Due to intubation a post op patient most likely has some retained secretions? I am confused as to why this is not have correctly stated this, and the text supports your choice

AEB ineffective cough this is a restatement of the NrDx review this diagnosis in the text( ackley) on page 174 defining characteristics “absent or ineffective cough” is written. Aren’t the defining characteristics the AEB? Abnormal breath sounds are the next grouping on that page. - What you are hearing is abnormal breath sound – which is the most objective data to support that the coughing is ineffective. And your interventions also support this as your evidence ( defining character istic) and your evaluation of the whether the coughing was effect would be if the breath sounds clear – otherwise there is no objective data.


Patient will demonstrate effective cough during PCS this is anevaluation of the intervention not a goal that will assist the phyisological function of the patient. You would also have to measure “ effective”.. how would you do this? Thinking about this may actually give you your outcome. Once again on page 174 Client outcomes “demonstrate effective coughing and clear breath sounds” If I add the clear breath sounds would that suffice? As to how to measure effective? A strong vs weak cough?


1. Assess lungs

2. Have patient perform deep breathing and coughing exercised

#3 Impaired physical Mobility

R/t loss of integrity of bone structure

AEB limited range of motion

This one is stated correctly


Patient will have complete ROM of lower extremities during PCS- not realistic for this patient/ what type of ROM/ how do you measure ‘complete” I intended to say - the patient will have the prescribed range of motion exercises completed during the PCS, poor wording


1. Encourage patient to perform AROM of LLE

2. Perform PROM of RLE

I selected #1 as my priority – this is good – as oxygen is important According to Maslow an effective airway clearance Oxygen exchange is a basic physiological need, effective airwary clearance is needed to support this exchange. Without adequate clearance of the air way the paitent may ...................with an effective airway the patient will progress towards healing as the tissue will have adequate oxygenation thus promoting regeneration.

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