Question

Please help

Patient with

Primary admission diagnosis

Left knee DJD. Then she has surgery in her legs, she has orthostatic hypotension, hypertension, sleep apnea, GERD, memory loss

Base on this patient please answer these question below

Please give three Nursing Diagnosis for this patient. Please answer

Nursing Interventions and Rationale separate

I. Nursing Diagnosis 1

1. Nursing Diagnosis

R/t:

AEB

2. Goals/ Expected Outcomes

3. Nursing Interventions

4. Rationale

5. Evaluations

II. I. Nursing Diagnosis 2

1. Nursing Diagnosis

R/t:

AEB

2. Goals/ Expected Outcomes

3. Nursing Interventions

4. Rationale

5. Evaluations

III. I. Nursing Diagnosis 3

1. Nursing Diagnosis

R/t:

AEB

2. Goals/ Expected Outcomes

3. Nursing Interventions

4. Rationale

5. Evaluations

Answer 1

1.Nursing Diagnosis

Acute pain in the left knee related to surgery as evidence by incision , dressing ,verbalisation

Goals/Expected Outcomes

The patient will have decreased or no pain

Nursing intervention and rationale

• Assess the level of pain to plan for care
• Administer analgesics as per order to relieve pain
• Provide relaxation therapy to divert the patient mind from pain
• Monitor vital signs
• Encourage patient to maintain position while standing up to prevent orthostatic hypotension while standing or walking

Evaluation

The patient verbalized of reduced pain

2.Nursing Diagnosis

Impaired sleep pattern related to obstruction in the airway as evidenced by snoring, difficulty in breathing, lack of continuity in sleep

Goals

• The patient will have a normal sleep pattern

Nursing intervention and rationale

• Monitor vital signs, to get tte baseline data
• Assess for any signs of cyanosis due to disturbed breath pattern
• Provide propped up position to ensure airway latency during sleep
• Relieve any congestion or secretion post operatively to prevent obstruction
• Encourage patient to do breathing exercises to enhance the lung function

Evaluation

The patient exhibits a normal sleep pattern

3.Nursing diagnosis

Risk for fall related to decreased cardiac function as evidenced by orthostatic hypotension

Goals

The patient will be normotensive

Nursing intervention and rationale

• Monitor vital signs, baseline data to plan for care
• Encourage patient to sit for some time before getting up from supine or sitting position
• Restrict any antihypertensive drug, to prevent further lowering of blood pressure

Evaluation

The patient will be exhibiting a nitmal blood pressure