Question

CHAPTER 3 The Nursing Process 1 tivity G Annwer the following questions related to the nursing process ,. What are the responsibilities of the nurse during the 2. What are the functions served by accurate and thorough documentation in the medical record? What information should a nurse document? assessment of a client? Activity H Think over the following questions. Discuss them with your instructor or peers 1. You are assessing a client with postoperative right hip 5. What would be specific, realistic, measurable, and pain following a total hip arthroplasty. What information client-centered outcomes? What would be appropriate will you need to gather? time frames to measure the client's responses? 6.How would you evaluate the client's responses and compare the actual outcomes to the expected outcon 2. What nursing diagnoses will you consider? What are the types of nursing diagnoses you will list? 7. What information will be included in your 3. What level of priority wil you give the diagnoses? documentation? . How can you actively involve the client in planning and achieving positive outcomes?

Answer 1

Activity G:

1. Nurses responsibility during assessment of a client are

• Identify the correct patient
• Plan and deliver appropriate care to every individual patients.
• Assess the level of consciousness, patient's ability to self care , his ambulation and ability to follow instructions.
• Look for patient's expectations and willingness
• Do a detailed assessment including patient's health history and physical examination
• Analyse psycho social behavior of patients

Activity H:

1. Arthroplasty is replacement of all or a part of the joint surfaces. The replacement of severely damaged hip with an artificial joint is called total hip arthroplasty. It is one of the successful orthopaedic surgeries performed worldwide. Post- operatively when a hip replacement patient complaints of right hip pain the things to be noted are:

• Pain scale assessment and assess the extremity for signs of DVT
• Calf pain,Swelling and tenderness to rule out risk of thromboembolism
• Check for shortening of leg, dislocation of joint which may cause pain
• Check the wound drainage and any signs of infection like redness, swelling and foul smell

2.The first expected signs and symptoms following the surgery is pain, decreased ability to move, wound drainage ,etc

• Acute Pain related to total hip replacement
• Impaired physical mobility related to activity restrictions following total hip replacement
• Impaired skin integrity related to immobility
• Risk for hemorrhage related to surgery
• Risk for infection related to surgery
• Risk for peripheral neurovascular dysfunction related to surgery
• Risk for ineffective health maintenance related to total hip replacement