Isabelle O.

Parcon BSN 3-E

Defining Characteristics Nursing Diagnosis Outcome Identification Nursing Intervention Rationale Evaluation

INDEPENDENT:

Subjective Impaired physical SHORT TERM: *Begin bedrest on a firm *Rest reduces pressure on nerve roots, Goal is met as evidenced by patient’s verbalize
mobility related to joint mattress. And use a pillow relieves muscle spasm, and promote relief of joint pain and comfort.
“My right knee stiffens for 5- After an hour of nursing
stiffness secondary to under the knees. comfort during the healing process.
10 minutes most mornings intervention the patient
osteoarthritis as
and often feels stiff after exhibits increased comfort
evidenced by limited
prolonged sitting.” As lessen joint stiffness.
range of motion * Educate the patient about  Instructing the patient to exercise
verbalized by the patient *Goals met as evidence by the client perform
Long term the active range of motion will help the physically inactive range of motion exercise with confidence and
Objective: exercise and encourage the patient to maintain muscle strength, stronger muscle.
After a week of nursing
Temperature- 36.8’C patient’s participation in joint ROM, and exercise tolerance.
intervention will show and
planning the activities that will
Pulse rate- 83 beats oer Nursing Diagnosis verbalize the increase in
gradually build endurance.
minute Handbook comfort that is evidence by
relaxed knee.
Respiration- 17 cycle per An Evidence-based guide
minute to planning care 12th  Instruct the patient to
* Pain may reduce by heat and *Goals met
Edition apply a hot or cold pain to improves blood flow. Cold packs will
Blood pressure- the painful area. help reduce pain, and inflammation.
Betty J. Ackley, MSN, EdS,
140/90mmHg
RN Gail B. Ladwig, MSN, DEPENDENT:
Popliteal bulging at the RN Mary Beth Flynn -To relieve muscle spasms in painful
 Orphenadrine 35
right posterior knee. Makic, PhD, RN, CCNS, musculoskeletal conditions. Used to
mg/Paracetamol 450 Goals Met as evidenced by compliance to
FAAN, FNAP Marina relieve mild to moderate pain
mg 2 tablets 3 times a medication and patient demonstrated relief of
Mild effusion felt on the Reyna Martinez-Kratz,
day when necessary. pain to both knees and slightly capable to
left knee. MS, RN, CNE Melody - This NSAID reduces
inflammatory symptoms and perform activities of daily living.
Zanotti, BA, RN, LSW
 Ketoprofen SR capsule relieves pain
100mg 1 capsule twice
a day - Used to treat gastroesophageal
reflux disease (GERD)
 Famotidine 20mg 1
 tablet twice a day
- To treat acute and chronic
 Topical Piroxicam osteoarthritis and rheumatoid
0.50% gel 30 gram arthritis

 Caltrate Plus 1 tablet - Relief of mild to moderately

once a day severe pain, with or without
accompanied inflammation
 Vitamin B complex
1000mg/tab. OD
As ordered - help find the causes of pain,
tenderness, swelling, or
- Bilateral knee xray
deformity of the knee, and
detect broken bones or a
dislocated joint.
- Lachman maneuver
- passive accessory movement
test of the knee performed to
identify the integrity of the
- Anterior drawer test anterior cruciate ligament (ACL)

- knee assessment that checks

- Pivot shift test for ACL. Injury

- used to assess the combined

tibio-femoral internal rotation
and anterior tibial translation
- McMurray Test when the ACL is deficient.
- used to determine the presence
of a meniscal tear within the
 Isabelle O. Parcon BSN 3-E
knee

Defining Characteristics Nursing Diagnosis Outcome Identification Nursing Intervention Rationale Evaluation

INDEPENDENT:

Subjective Risk for injury related to SHORT TERM: *Instruct the client regarding *Helps prevent accidental injuries and Goal is met as evidenced by the client
mobility changes safety measures: falls. demonstrates behaviors, lifestyle changes to
“I have knee pain for a few After 3 hours of nursing
secondary to reduce risk factors and protect self from
years but it has progressively intervention the client will Raised chairs and toilet seat,
osteoarthritis injury.
got worse.” As verbalized by identify measures to Use of handrails, Accurate use
the patient prevent injury of mobility equipment and
wheelchair safety.
Objective:
Temperature- 36.8’C
Nursing Diagnosis Long term
*Goals met as evidence by the client
Pulse rate- 83 beats oer Handbook * Instruct the use of adaptive * This will keep the joints mobile,
After 12 hours of nursing identifying measures to prevent injuries.
minute mobility equipment such as promote safety, and maintain a high
An Evidence-based guide intervention the client will
walkers, canes, and crutches quality of life.
Respiration- 17 cycle per to planning care 12th demonstrate behaviors,
as indicated.
minute Edition lifestyle changes to reduce
risk factors and protect self  Instruct the patient to
Betty J. Ackley, MSN, EdS,
Blood pressure- from injury. apply a hot or cold pain to
RN Gail B. Ladwig, MSN, - This will reduce possible injury from
140/90mmHg the painful area.
*Goals met
RN Mary Beth Flynn falling during sleep.
Popliteal bulging at the Makic, PhD, RN, CCNS, *Use a buffer bed and
right posterior knee. FAAN, FNAP Marina positioning the bed as low
Reyna Martinez-Kratz, when sleeping.
Mild effusion felt on the MS, RN, CNE Melody
DEPENDENT: - This NSAID reduces
left knee. Zanotti, BA, RN, LSW
 Orphenadrine 35 inflammatory symptoms and
Goals Met as evidenced by compliance to
mg/Paracetamol 450 relieves pain medication and patient demonstrated relief of
mg 2 tablets 3 times a pain to both knees and slightly capable to
day when necessary. - Used to treat gastroesophageal perform activities of daily living.
 Ketoprofen SR capsule reflux disease (GERD)
100mg 1 capsule twice
a day - To treat acute and chronic
osteoarthritis and rheumatoid
 Famotidine 20mg 1
arthritis
tablet twice a day

- Relief of mild to moderately

 Topical Piroxicam
severe pain, with or without
0.50% gel 30 gram
accompanied inflammation
 Caltrate Plus 1 tablet
once a day
- help find the causes of pain,
tenderness, swelling, or
 Vitamin B complex deformity of the knee, and
1000mg/tab. OD detect broken bones or a
As ordered
dislocated joint.
- Bilateral knee xray
- passive accessory movement
test of the knee performed to
- Lachman maneuver identify the integrity of the
anterior cruciate ligament (ACL)

- Anterior drawer test - knee assessment that checks

for ACL. Injury

- Pivot shift test - used to assess the combined

tibio-femoral internal rotation
and anterior tibial translation
when the ACL is deficient.
- McMurray Test
- used to determine the presence
of a meniscal tear within the
knee