11/3/2020 Clinical debriefing tool Background: Mrs. M was an 81yo female in for an elective total right knee replacement that has been aggravated by OA. She lives at home with her husband who is a retired family doctor. Her expected d/c date was 10/29 so SNF because husband is not well enough to provide her the care she needs at home. PMHx of smoking, hearing loss in both ears, RA, obesity, HTN, urinary incontinence, diverticulitis and IBS. Assessment: Vitals: 133/66, 95 (spO2), 74 (HR), 36.7c, 18 (RR) Pain: 9 out of 0-10 pain scale. Reported constant severe pain at incisional site and behind right knee. Alleviating factors; sleep and pain meds. Pain meds were given at 5 am so she could not get any more at the time so in the mean time ice was given, pillows under knee and repositioning. HEENT: WNL, A&Ox3- but was agitated by pain, facial grimacing. Lungs: RRR, lung sounds clear, unlabored. Absence of any cough, SOB, or dyspnea Heart: RRR, heart sounds clear, to murmurs present. Absence of any chest pain R UE & LUE: radial pulses +2 bilaterally, cap refill <3seconds, sensation intact, hand grasp moderate, no edema RLE & LLE: pedal pulse +2 bilaterally, post tibial +1 bilaterally, sensation intact, cap refill <3 seconds, warm to touch, slight erythema and edema (+1) on right leg. GI: rounded, soft, bowel sounds hypoactive. No BM yet, passed gas. GU: voids without pain, slight incontinence Mobility: very limited, weak on right side. Uses front wheel walker plus 1-2 assist. Should use apex Would site: dressing dry, clean and intact. No signs of drainage. Slight erythema at site. Nursing diagnosis: #1 Risk for impaired skin integrity r/t surgery and level of pain #2 Risk for impaired healing r/t hx of smoking, obesity and inadequate nutrition #3 Risk for pneumonia r/t immobility d/t surgery Planning: #1 - Reposition patient Q2 hours to prevent any pressure ulcers Work on better pain management so patient is able to ambulate without excruciating pain - Assess patients eating habits at home and any attempts of smoking cessations Educate patient on importance of healthy, balanced diet with high protein for healing - Educated patient DB&C, maybe using IS? Work with PT and OT to encourage ambulation and help to decrease any fears patient has about ambulating. #2 #3 Implementation: - New pain management plan was created to provide longer lasting pain relief in hopes that patient would feel better when ambulating Patient was given ensure with every meal. I made sure to educate Mrs. M on the importance of adequate nutrition and high protein is for healing Ambulation was encouraged, patient ambulated to bathroom Evaluation: - We were able to have her pain better under control and patient was not experiencing pain any higher than a 4. Patient’s mobility was still an issue. An apex was used for patient safety when ambulating back from bathroom and into chair. Mrs. M still was not eating an adequate amount of food. Highest priorities: - - - Pain management o At first, Mrs. M was getting tordol every 6 hours which was not providing adequate pain relief. The Health care team decided to decrease her dose but have it dose every 4 hours, hoping that this would provide better pain relief, which it seemed to that. Mobility o Because after surgery you are at an increased risk for pneumonia, DVT, constipation, urinary retention and many other issues, getting Mrs. M up and moving was important, especially because of her hx of smoking and having a high BMI puts her at a greater risk of developing DVTs.