- Acute Pain Related to Surgical intervention and Presence of prosthesis as evidenced by altered physiological and parameters facial expressions of pain
- Impaired Physical Mobility Related to Musculoskeletal impairment and Joint pain or discomfort as evidenced by Altered gait and Decreased range of motion
- Risk for Infection related to Impaired skin integrity and Implantation of a foreign body or prosthesis as evidenced by symptoms of infection
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective data: -Verbal reports from the patient -Expressions of pain, such as crying -Unpleasant feeling (such as a prick, burn, or ache) Objective data: -Significant changes in vital signs -Changes in appetite or eating patterns -Changes in sleep patterns | Acute Pain Related to Surgical intervention and Presence of prosthesis as evidenced by altered physiological and parameters facial expressions of pain | Patient will report decreasing pain relief following surgery. Patient will effectively demonstrate interventions to relieve pain and discomfort. | 1. Ensure proper positioning of the affected joint. Proper positioning of the affected joint after knee replacement can help reduce muscle spasms and prevent tension on the new knee prosthesis. The nurse can use pillows and wedges to keep the knee straight. Elevating the knee for short periods can reduce swelling. 2. Monitor for any sudden and severe joint pain following knee replacement surgery. Sudden and severe joint pain after knee replacement can indicate a developing complication like blood clots, infection, or prosthesis dislocation. 3. Administer pain medication as indicated. Opioid analgesics are prescribed to help relieve surgical site pain, while NSAIDs help with inflammation and are often prescribed together. 4. Encourage non-pharmacologic pain relief interventions. Nonpharmacologic pain relief interventions can help reduce muscle tension, enhance coping abilities, and refocus attention, relieving overall discomfort. Encourage rest, distraction, and alternating ice and heat. 5. Premedicate prior to physical therapy. Ambulation and physical therapy start immediately. Movement will be painful at the beginning, and the nurse can help the patient adhere to treatment by premedicating prior. | Patient reported decreasing pain relief following surgery. Patient effectively demonstrated interventions to relieve pain and discomfort. |
| Subjective data: -Expression of pain and discomfort with movement -Refusal to move Objective data: -Limited range of motion -Uncoordinated movements -Poor balance -Inability to turn in bed, transfer, or ambulate -Postural instability -Gait disturbances -Reliance on assistive devices -Contractures -Decreased muscle strength | Impaired Physical Mobility Related to Musculoskeletal impairment and Joint pain or discomfort as evidenced by Altered gait and Decreased range of motion | Patient will demonstrate independence in ambulating and positioning. Patient will participate in physical therapy as ordered. | 1. Ensure that the affected joint is positioned as prescribed. Proper positioning of the knee joint after knee replacement surgery can ensure the stabilization of the prosthesis, promote recovery, and reduce the risk of injuries. 2. Utilize continuous passive motion. Continuous passive motion (CPM) is a machine that moves the knee joint passively to prevent stiffness and pain and improve mobility. 3. Assist the patient in ambulating with the use of assistive devices. Assistive devices like walkers, crutches, canes, and wheelchairs can help the patient ambulate independently as their mobility improves. 4. Refer the patient to a physical therapist. Physical therapy is required after knee replacement surgery as this can help strengthen affected muscle groups and promote recovery. PT may be inpatient, outpatient, or at the patient’s home. 5. Encourage the patient to adhere to rehabilitation interventions. Early initiation of postoperative exercises and ambulation promotes early recovery and healing and prevents complications. | Patient demonstrated independence in ambulating and positioning. Patient participated in physical therapy as ordered. |
| Subjective data: Verbalizes difficulty to manage the wound Objective data: -Invasive procedure -Implantation of a foreign body or prosthesis -Decreased mobility | Risk for Infection related to Impaired skin integrity and Implantation of a foreign body or prosthesis as evidenced by symptoms of infection | Patient will remain free from any symptoms of infection and demonstrate timely wound healing. Patient will demonstrate interventions that can help prevent infection. | 1. Use a strict aseptic technique when dressing the surgical site. Aseptic technique prevents contamination and infection of the surgical site. 2. Instruct on symptoms of infection to be alert for. Educate the patient and their family to monitor for fever, increased swelling, redness, or drainage at the incision site. Contact the healthcare provider if this is observed. 3. Assess for any signs of increased surgical site pain. Increased surgical site pain described as deep, dull, constant, and aching can indicate a developing joint infection. 4. Administer antibiotics as ordered. Antibiotic therapy is often given prophylactically after knee replacement surgery. 5. Emphasize the importance of follow-up consultations. Follow-up consultations are important in monitoring patients after knee replacement surgery to ensure they are not developing complications like infection. | Patient remained free from any symptoms of infection and demonstrate timely wound healing. Patient demonstrated interventions that can help prevent infection. |