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Gillian Church

Nursing 217

Surgical Rotation

January 8, 2015

Planning/Implementation/Evaluation
Nursing Diagnosis: Risk for peripheral neurovascular dysfunction r/t orthopedic (TKR) surgery and trauma to tissues
Long-Term Goal: Experiences no peripheral vascular dysfunction
Outcome Criteria
1.

Interventions

Pt. will have


adequate peripheral
neuro-vascular
function AEB:
a) 2+ peripheral
pulses
b) extremities
warm/pink
c) able to move
extremities
d) states able to feel
touch/sensation in
extremities

1. Perform neurovascular
assessment q 4 hours

2. Pt. will have no


s&s of DVT AEB:

2. Assess for S&S of DVT


q 4 hours

Assessment

Rationale
1. Perform a neurovascular assessment every 4 hours by
assessing CSMT to assess nerve function and circulatory
status. Assess circulation by finding peripheral pulses
(dosalis pedis & posterior tibial) distal to the trauma/surgical
site to assure blood and oxygen are circulating through the
entire extremity. If the pulses are present, there arent signs
of disruption in circulation to the extremity. Assess sensation
by lightly touching the skin proximal & distal to the surgical
site. Ask the pt. if she has any unusual sensations like
hypersensitivity, tingling, prickling, decreased feeling, or
numbness. If the pt. has any of these unusual sensations,
this may be sign of peripheral neurovascular dysfunction
(compartment syndrome, caused by hemorrhage &/or
edema). Assess movement by asking the pt. to perform
appropriate ROM exercises on the unaffected extremity &
then the affected extremity. If pt. is unable to move
extremities, this can indicate impending muscle, nerve, &
vascular cellular death, &/or compartment syndrome. Lastly,
assess color & temperature below the surgical site. If
extremity is cold &/or bluish, pt. may have arterial
insufficiency or arterial damage. A reddened, very warm-hot
extremity may indicate infection. Any disruption to
circulation, sensation, movement, or temperature to an
extremity indicates peripheral neurovascular dysfunction.
This pt. needs this assessment because of her TKR and
having trauma to her R knee. This surgery could have
potentially disrupted neurovascular function.
Ackley, Ladwig Nursing Diagnosis Handbook

2. Assess the patient for signs and symptoms of deep

Evaluation
1. Pt. fully met
this outcome.
Plan is ongoing.

2. Pt. fully met


this outcome.

a) edema in 1 or both
extremities
b) pt. c/o
cramping/soreness
pain or tenderness in
extremity
c) red, warm
extremity

Plan is ongoing.
Assessment

vein thrombosis. Signs and symptoms to assess for


include edema, red, warm skin, cramping, soreness
or tenderness in legs. This pt. needs to be assessed
for DVT because she is at higher risk d/t having
surgery, and being obese. If the pt. were to develop
a blood clot, this could cause a disruption in
neurovascular function by disrupting blood flow,
resulting in decreased or ceasing circulation and
causing ischemia and cell death.
Ackley, Ladwig Nursing Diagnosis Handbook

3. Pt. will ambulate


with wheeled walker
100 ft. QID

3. Assist pt. to ambulate


with wheeled walker 100
ft. QID

Independent

3. Assist the patient to ambulate with a wheeled walker


for at least 100 feet 4 times per day. This pt. just had a
TKR. Ambulation is encouraged as early as possible to
prevent complications of immobility, build muscle
strength, and reduce risk of DVT formation. Immobility
is a risk factor for DVT, so ambulation will decrease
pt.s risk of a DVT because it can help prevent clot
formation. Ambulation enhances circulation and
reduces pooling of blood, especially in the lower
extremities. Since ambulation helps to prevent clots
and promotes circulation, these factors will help
prevent problems with circulation and motion, thus
help prevent neurovascular dysfunction.

3. Pt. fully met


this outcome.
Plan is ongoing.

Ackley, Ladwig Nursing Diagnosis Handbook


Lewis p. 1616, 1617
4. Pt. will report 01/10 pain after using
ice pack.

4. Apply ice to R knee for


20 min q hour per MD
order

4. Apply ice to pt.s right knee for 20 minutes every


hour. Applying ice packs to operative knee for the first
24-48 hours after surgery will reduce bleeding,
hematoma formation, and edema at the surgical area.

4. Pt. fully met


this outcome.
Plan is ongoing.

Dependent

MD ordered ice machine that is a cooler with ice, and is


connected to a cooling pad. The pad is placed on top of
the surgical dressing. Edema and inflammation can
contribute to vascular insufficiency and nerve
compression. The ice will help with the edema and
prevent the vascular insufficiency and nerve
compression, therefore aiding neurovascular function.
Pain experienced by a patient who has had surgery is
related to inflammation and edema as well. If we use
the ice pack to decrease the edema, there may be less
pain. If there is less pain, the pt. will be more motivated
to ambulate. We want to encourage ambulation to
prevent problems with circulation and movement. If we
prevent this, we would prevent neurovascular
dysfunction.
Lewis 1598-1600

5. Pt. will report 01/10 when operative


extremity is
elevated, at all
times

5. Elevate operative
extremity with 2-3 pillows
under calf/ankle to keep
above heart level per MD
order

Dependent

5. Elevate the operative extremity with 2-3 pillows


under the calf or ankle to keep the knee above heart
level, keeping the knee in full extension. Elevation after
surgery will help lessen the edema at the surgical site.
Elevation of the extremity will also help circulation by
promoting venous return, and the decreasing edema
may help reduce the pain. Since elevating the
extremity helps to improve circulation, this will help
prevent neurovascular dysfunction.

5. Partially met
this outcome.
Times during
shift, pt. c/o 7/10
pain in extremity.
Plan is ongoing.

Lewis p. 1598
6. Pt. will have H&H
WNL (Hgb 12-16,
Hct 37-47) by 1/9/15

6. Obtain order to assess


pt.s CBC diff. by 1/9/15

6. Monitor hemoglobin, hematocrit, coagulation studies


like prothrombin time levels. These tests assist in

6. Unsure if pt.
met this outcome.
No order for CBC

Monitor/Dependent

calculation of blood loss. Coagulation deficits may


occur secondary to major trauma, presence of fat
emboli, or anticoagulant therapy. If there is blood loss,
hemorrhaging, or emboli present, these factors can
cause decreased circulation. If circulation is disrupted,
neurovascular function is disturbed as well.

diff for 1/9/15.


Based on 1/8/15
CBC, pt. did not
meet this
outcome. Plan is
ongoing.

Ackley, Ladwig Nursing Diagnosis Handbook

7. Pt. will consume


75-100% of meal at
each meal time

7. Provide a regular diet


to pt. at every mealtime
until d/cd

Dependent

7. Provide a regular diet to the patient at every


mealtime per MD order. Good nutrition is needed to
promote healing and prevent complications. Proteins
are needed to keep good vascular tone, which is
needed to provide the body with adequate systemic
circulation. Good nutrition also provides energy to the
pt., which is necessary to motivate her to ambulate.
Ambulation is needed to promote circulation of blood
flow, and good movement of extremities. We want to
promote both circulation and movement to decrease
the patients risk of neurovascular dysfunction.

7. Pt. fully met


this outcome.
Plan is ongoing.

Ackley, Ladwig Nursing Diagnosis Handbook

8. Pt. will consume


at least 1.5L of H2O
every day until d/cd

8. Provide pt. 1.5-2L of


H2O to drink per day

Independent

8. Provide the patient at least 1.5-2L of water to drink


every day while in the hospital. Emphasize to the
patient the importance to consume fluids. The patient
would need to replace fluids from her surgery. Also,
along with good nutrition, sufficient fluids are needed
to promote healing and prevent complications.
Maintaining adequate hydration will prevent increased
blood viscosity. Adequate fluids help to Maintain
circulating volume, and enhance tissue perfusion.

8. Pt. fully met


this outcome.
Plan is ongoing.

Lewis 1598
9. Pt. will have no
s&s of DVT AEB:
a) edema in 1 or both
extremities
b) pt. c/o
cramping/soreness
pain or tenderness in
extremity
c) red, warm
extremity

9. Apply foot pumps to


pt.s feet BIL at all times

Dependent

9. Apply foot pumps to patients feet bilaterally at all


times when patient is in bed or sitting in a chair. Foot
pumps are a mechanical method for DVT prophylaxis.
They increase venous outflow and reduce stasis within
the leg veins. In regards to prevention of VTE, foot
pumps have an advantage because they lack the
bleeding potential. Foot pumps are beneficial to this
patient because of their ability to reduce stasis and
promote venous return. This promotes circulation,
which will decrease the patients risk of neurovascular
dysfunction.

9. Pt. fully met


this outcome.
Plan is ongoing.

Ackley, Ladwig Nursing Diagnosis Handbook

10. Pt. will have no


s&s of DVT AEB:
a) edema in 1 or both
extremities
b) pt. c/o
cramping/soreness
pain or tenderness in
extremity
c) red, warm
extremity

10. Apply TEDS onto pt.s


LE BIL at night, and take
off during the day per MD
order

11. Pt. will have no

11. Administer Lovenox

Dependent

10. Apply TED stockings to patients legs when they go


to sleep, and take them off when they wake up per the
MDs order. TEDs are compression stockings that help
prevent the occurrence of venous disorders such as
edema, phlebitis and thrombosis. TEDs compress the
leg, exert pressure, and cause an increase in venous
blood flow velocity. They help decrease venous
pressure, prevents venous stasis and impairments of
venous walls. They will prevent blood clots to form. We
want to prevent blood clot formation because, if a clot
forms, it will disrupt circulation. If circulation is
disrupted, there is an increase risk for peripheral
neurovascular dysfunction.

Ackley, Ladwig Nursing Diagnosis Handbook


11. Administer 30mg of lovenox to the patient

10. Pt. fully met


this outcome.
Plan is ongoing.

11. Pt. fully met

s&s of DVT or PE
aeb:
a) pain, tenderness,
edema, warmth,,
erythema in
extremities
b) dyspnea,
tachypnea, pleuritic
chest pain,
hemoptysis, cough,
syncope,
tachycardia

30 mg SC q12h per MD
order

Dependent

subcutaneously every 12 hours. Lovenox potentiates


the inhibitory effect of antithrombin on factor Xa and
thrombin. It prevents the formation of thrombus. We
want to prevent venous thromboembolism, deep vein
thrombosis, and/or pulmonary embolism. This patient is
at a higher risk because she just had TKR surgery on
1/6/15. We want to prevent any kind of thrombus
formation because if a thrombus were to form, it could
disturb blood flow circulation. If circulation is disrupted,
there is an increase risk for peripheral neurovascular
dysfunction.

this outcome.
Plan is ongoing.

Davis Drug Guide


12. Pt. will have no
parasthesia aeb no
c/o:
a) tingling
b) numbness
c) hyperesthesia
d) hypoesthesia
that indicate nerve
compression

12. Assist pt. in proper


body
positioning/alignment q
hour

13. Pt. will have pain


0-1/10 after
ambulating

13. Administer
oxycodone-APAP (5325mg) PO PRN q4h 30
minutes prior to
ambulating

Independent

12. Assist the patient to position themselves in proper


body alignment every hour. Proper positioning will
prevent compression of blood vessels and nerves,
therefore reduce pressure on nerves and tissues. We
want lessened pressure on nerves and tissues to
promote adequate circulation and sensation. If
circulation and sensation are adequate, there is less
risk of peripheral neurovascular dysfunction.

12. Pt. fully met


this outcome.
Plan is ongoing.

Lewis 1598, 1600


13. Administer 5-325mg of oxycodone-APAP to patient
30 minutes prior to ambulation. Oxycodone binds to
opiate receptors in the CNS. It alters the perception of
and response to painful stimuli, while producing

13. Pt. fully met


this outcome.
Plan is ongoing.

Dependent

generalized CNS depression. If the patient is in less


pain, she will be more motivated to ambulate and it will
enhance her participation. We want to encourage the
patient to ambulate and understand that ambulation
will strengthen her muscles, and promote systemic
blood flow to circulate. If there is improved circulation,
and movement, there is a decreased risk for peripheral
neurovascular dysfunction.

Davis Drug Guide


14. Pt. will verbalize
5 s&s of
neurovascular
dysfunction prior to
d/c

14. Teach pt. s&s of


neurovascular dysfunction
prior to d/c

Teaching

14. Teach the patient the signs and symptoms of


neurovascular dysfunction. Since the patient just had
orthopedic surgery and has had recent trauma to her R
knee, she is at risk for peripheral neurovascular
dysfunction. Teach the patient the signs and symptoms
to monitor for including increasing pain, pulselessness,
decreased sensation including tingling, numbess, or
decreased feeling, loss of movement or decreased
ROM, and feelings of tightness and pressure in her
extremity. If the patient knows what to monitor for, she
can know when to seek medical assistance.

14. Pt. fully met


this outcome.
Plan is ongoing.

Lewis 1598, 1600

15. Pt. will


demonstrate proper
body mechanics to
ambulate by
discharge

15. Collaborate with


physical therapist to
assist pt. with ambulation
prior to discharge

15. Collaborate with the physical therapist to establish


an exercise program and discuss safety measures.
Physical therapists can help to demonstrate exercises
to maintain and strengthen muscles and improve
function. PTs can help to develop, execute, and

15. Pt. fully met


this outcome.
Plan is ongoing.

Collaborate

reinforce an exercise plan and provide a unified


approach to the patient. If the pt. learns the proper
ways and amount to ambulate/exercise, they may be
more motivated to do so. We want to encourage
ambulation to prevent DVT, which would disrupt
circulation. Ambulation will help improve muscle tone,
and movement. It will also help prevent blood stasis
and improve blood circulation. If we prevent disruption
in movement and circulation, were preventing
neurovascular dysfunction.
Lewis p. 1600