A 23-year-old male patient was brought to the ER with a compression bandage on his right knee

and was assisted by his peers during ambulation. His presented signs and symptoms were:
tenderness on his right knee and 8/10 pain. His vital signs were BP 130/80mmHg, RR of 19,
and HR was 95bpm and a temperature of 37.0 degrees celsius. He verbalized that he heard
something "snap" in his right knee when he landed from a jump whilst playing basketball. CT
Scan was done, and ACL grade 3 tear was diagnosed. He was then put on a knee brace upon
discharge and was scheduled for ACL reconstruction after a week.
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1. Patient Discharge

ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSI
S

OBJECTIVE Deficient After 4 hours 1. Examine patients' 1. A baseline of the After a series of
DATA: Knowledge of nursing existing knowledge of patient's knowledge is nursing
- Patient is related to interventions the new diagnosis. a great technique to interventions, the
seen confused new health the patient will 2. Examine the build a teaching plan patient verbalized
when explained diagnosis verbalize the willingness to learn that isn't overwhelming understanding of
about ACL or accurate new knowledge to the patient. As a his condition and
grade 3 tear treatment information regarding the result, the nurse will be the upcoming ACL
and ACL about condition. able to tell which reconstruction.
reconstruction condition and 3.Determine the issues to cover first.
treatment by patient’s learning style 2. Sudden changes in
SUBJECTIVE discharge 4. Provide different a person’s health and GOAL MET.
DATA: learning material such hospitalization are
- Patient as paper, factors that affect the
verbalized that demonstration or ability to absorb and
““I have no idea video process information. It
what the doctor 5.Encourage the is important to
is telling me. It patient to ask consider timing in the
is too much questions teaching process and
information.” 6.Provide time to adapt to the patient’s
process learned situation and their
material and use a perception of that.
step by step approach 3.The same
knowledge may be
learned in a variety of
ways. The utilization of
specialized teaching
and learning resources
to assist learning is
determined by your
patient's learning type.
4.As previously said,
 several learning
resources will assist
the patient in better
absorbing knowledge.
It's easier to remember
material when you
study with varied
media and perceive it
in multiple ways.
5.The patient is able to
engage in the learning
process by asking
questions. It indicates
that the patient is
paying attention to the
topic and is eager to
learn. By asking
questions, the patient
takes an active role in
his or her care and
informs the healthcare
team on the next steps
to take.
6.Teaching too much
material at once might
overwhelm the patient
and subsequently
discourage the
individual. A step by
step approach allows
for time to review the
content and practice. It
also provides for
clarifying questions
before moving on to
the next step.

2. Postoperative
ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSI
S

OBJECTIVE Acute Pain After 8 hours 1. Evaluate the 1.To establish and After a series of
DATA: related to of nursing patient's condition compare any changes nursing
- Facial ACL intervention, and pain on a scale of in patients pain. Pain interventions, the
Grimace and reconstruc the patient will one to ten and the scale may indicate the patient
Wincing tion on manifest a location of the pain effectiveness of the Verbalized relief
- Guarding right knee. decrease in 2.Look for any interventions. from pain with a
behavior pain scale symptoms of infection 2.To rule out the pain scale of 2/10.
from 8/10 at the surgery site. possibility of infection
down to a 0-3 / 3.Keep an eye on V/S which may also cause GOAL MET.
SUBJECTIVE 10 pain scale. for symptoms of pain.
DATA: stress. 3.To monitor internal
- Patient 4. Teach clients how signs of discomfort
verbalized pain to divert their 4.To keep patient’s
of 8/10 . attention away from mind off pain
- “my knee is in pain 5.To relax any elevated
so much pain, 5.Recommend signs of stress and
Nurse” relaxation and pain
breathing exercises 6.To reduce pain
and techniques perception and
6. Administer pain discomfort
medicines as ordered 7.To further relax the
by the physician. patient
7.Reposition the 8. To determine if the
patient as necessary. interventions are
8.Encourage vocal effective in alleviating
responses to nursing pain.
interventions and
movements both
while and after they
occur.