Assessment Subjective:

Nursing Diagnosis

Objectives Short Term Objective 1: By the end of shift, the patient will do passive range of motion for 2hrs with the help of a CPM device at 100 degrees.

Interventions Care Plan

Rationales

Evaluations STO 1: The outcome was not fully met. The CPM device was in place on patients left knee for 2 hours at 72 degree on 9/27. This outcome was appropriate but needed to be modified. I adjusted the angle to 55 degrees instead of 100. I monitored the patients pain and increased the CPM to 72 degrees as tolerate by patient. The patient was not able to tolerate past 72 degrees because c/o pain. This outcome could also be modified by encouraging the pt to ask for pain medication 30 minutes before CPM devices is used. I could have had nurse administer 2 percocet tabs Q4HPRN. I could also encourage the patient to press the PCA device,

Impaired physical S: 1100 rating mobility r/t pain as a 9 on a removal of scale of 1-10 femur and tibia and replaced S: 0100 pain is with artificial now a zero parts AED knee S: describes pain replacement as sore on my procedure, c/o knee cap pain of 9 S: I had the same surgery on this knee before S: My arthritis got worse, so I needed the surgery again Objective: O: 64yr old female had left total knee replacement 9/26/11 O: lift left leg off bed about 1 inch O: able to walk 36 steps down the hall while monitored by PT O: TED hose