Question

Please help Patient with Primary admission diagnosis Left knee DJD. Then she has surgery in her...

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

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

0 0
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Answer #1

1.Nursing diagnosis

Risk for infection related to surgery as evidenced by surgical incision, verbalisation secondary to degenerative joint disease

Goal/Expected outcome

To prevent infection

Nursing intervention and rationale

  • Assess the surgical site for any redness,swelling, pain ,tenderness, discharge are tte indicators of infection
  • Administer antibiotics as per order to prevent infection
  • Administer analgesics as per order to relieve pain
  • Meticulous handwashing to prevent cross infection
  • Surgical dressing as per order

Evaluations

The patient will exhibit no infection and have a faster healing

2.Nursing Diagnosis

Risk for fall related to alternated cardiac function as evidenced by dizziness , standing up from supine or sitting position

Goals/Outcome

The patient will have normal blood pressure

Nursing intervention and rationale

  • Monitor vital signs, baseline data to plan for care
  • Inform patient to sit for some time after getting up from lying down patient and then stand up
  • In case of feeling dizzy make the patient to lye down ,this helps to increase the blood pressure
  • Stop medication in case of any hypertensive medication to prevent lowering of blood pressure

Evaluation

The patient will have a normal blood pressure

3.Nursing Diagnosis

Impaired memory related to age ,medical conditions as evidenced by loss of cognitive function

Goals/outcome

The patient will be able to remember things or improve in cognitive function

Nursing intervention and rationale

  • Assess the mental status examination to plan for care
  • Remind the patient before doing any procedure to get cooperation and confidence of patient
  • Provide psychotherapy to relieve any stress or anxiety
  • Administer medication as per order to prevent further deterioration

Evaluation

The patient will be able to exhibit normal thinking abilities

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