Nursing Diagnosis (Postoperative)
- Acute pain, related to surgical incision
- Risk for infection, related to disruption in skin integrity
- Impaired physical mobility, related to activity and weightbearing
restrictions - Risk for ineffective tissue perfusion, right leg, related to vascular
disruption and edema.
Exepected Outcomes
- Maintain an adequate level of comfort postoperatively as demonstrated by :
- The ability to move easily within restrictions.
- Compliance with instructions to cough and breathe deeply.
- Verbal expressions of comfort.
- Remain free of adverse consequences of immobility such as pneumonia, pressure areas, thromboembolism, or contracture.
- Remain free of infection.
- Maintain adequate perfusion of affected leg.
- Remain free of injury postoperatively.
Nursing Intervention
- Assess pain at least hourly during first 24 to 48 hours postoperatively, and as needed thereafter.
- Instruct in the use of patient-controlled analgesia (PCA) and monitor its effectiveness.
- Help change position at least every 2 hours; encourage the use of the overhead trapeze to shift positions frequently.
- Maintain sequential compression device and antiembolic stocking as ordered; remove for 1 hour daily.
- Encourage the use of the incentive spirometer hourly for first 24 hours, then at least every 2 hours while awake.
- Assist out of bed three times a day after the first 24 hours.
- Maintain abduction of the right hip with pillows.
- Perform passive ROM exercises of unaffected extremities every shift.
- Encourage frequent quadriceps-setting exercises and plantar and dorsiflexion of feet.
- Assess the surgical site frequently; report signs of excess bleeding or inflammation.
- Monitor temperature every 4 hours.
- Assess pulses, color, movement, and sensation of right foot hourly for the first 24 hours, then every 2 hours for 24 hours, then every 4 hours.
Source : wps.prenhall.com/wps/media/objects/737/755395/osteoarthritis.pdf
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