Concept Map
Problem #1: Acute Pain r/t R TKR Revision
Goal/Outcome: Patient will have pain no > 3/10 on my shift.
Nursing Intervention
Rationale
Patient Responses
Assess pt’s sx & sx of pain and administer pain meds as prescribed. Monitor and record the Rx effectiveness and adverse effects.
Assessment allows for care plan modification, as needed. (Potter & Perry, 965)
Patient denies pain and discomfort, but stats pain is around a 4/10 at 11 am. (Last pain med given at 6 am)
Plan Activities with pt to provide distraction, such as reading, crafts, tv, and visits to help pt focus on non pain related subjects.
Keeping the patient occupied with activities helps relieve and subside the pain, even if only a few moments. (Potter & Perry, 967)
Patient is intrigued to partake in conversation. Watches television when alone. Appears happy and content.
Perform comfort measures to promote relaxation, such as massage, bathing, repositioning, and relaxation techniques.
These measures reduce muscle tension or spasm, redistribute pressure on body parts, and help pt focus on non pain related subjects. (Lehne, 256)
Patient is very happy after a bath. We repositioned her to relieve pressure on specific extremities.
Help pt into a comfortable position and use pillows to split or support painful areas, as appropriate.
Reduces muscle tension or spasm and to redistribute pressure on body parts. (Lehne, 256)
Patient remains comfortable.
Collaborate with pt in administering prescribed analgesics when alternative methods of pain control are inadequate. Teach patient to ask for pain relief before pain > 4/10.
Gaining pt’s trust and involvement helps ensure compliance and may reduce medication intake. (Ignativicius, 9)
Patient does not ask for medication for pain. She is able to distract herself by talking to people and watching tv.
Evaluation: Patient states that her pain is about a 3/10 on my shift.
Problem #2: Risk for Infection 2° R TKR Revision
Goal/Outcome: Patient will
Goal/Outcome: Patient will have pain no > 3/10 on my shift.
Nursing Intervention
Rationale
Patient Responses
Assess pt’s sx & sx of pain and administer pain meds as prescribed. Monitor and record the Rx effectiveness and adverse effects.
Assessment allows for care plan modification, as needed. (Potter & Perry, 965)
Patient denies pain and discomfort, but stats pain is around a 4/10 at 11 am. (Last pain med given at 6 am)
Plan Activities with pt to provide distraction, such as reading, crafts, tv, and visits to help pt focus on non pain related subjects.
Keeping the patient occupied with activities helps relieve and subside the pain, even if only a few moments. (Potter & Perry, 967)
Patient is intrigued to partake in conversation. Watches television when alone. Appears happy and content.
Perform comfort measures to promote relaxation, such as massage, bathing, repositioning, and relaxation techniques.
These measures reduce muscle tension or spasm, redistribute pressure on body parts, and help pt focus on non pain related subjects. (Lehne, 256)
Patient is very happy after a bath. We repositioned her to relieve pressure on specific extremities.
Help pt into a comfortable position and use pillows to split or support painful areas, as appropriate.
Reduces muscle tension or spasm and to redistribute pressure on body parts. (Lehne, 256)
Patient remains comfortable.
Collaborate with pt in administering prescribed analgesics when alternative methods of pain control are inadequate. Teach patient to ask for pain relief before pain > 4/10.
Gaining pt’s trust and involvement helps ensure compliance and may reduce medication intake. (Ignativicius, 9)
Patient does not ask for medication for pain. She is able to distract herself by talking to people and watching tv.
Evaluation: Patient states that her pain is about a 3/10 on my shift.
Problem #2: Risk for Infection 2° R TKR Revision
Goal/Outcome: Patient will