Name of Patient: Medical Diagnosis: Right knee internal injury, horizontal tear of posterior horn of medial meniscus Arthroscopic

menisectomy Nursing Diagnosis: Alteration in comfort: pain r/t injury in the knee Short Term Goal: After 8 hrs of nursing intervention, the patient will verbalize decrease rate of pain. Long Term Goal: After hospitalization, the patient will report absence of pain.

CUES
Subjective: >verbalization / Complain of pain by the patient Objective: > facial grimace >immobilizati on of affected area (knee)

PROBLEM pain

NURSING INTERVENTION Joint cartilage is a Independent: layer of tissue > Obtain clients present at the joint assessment of pain to surfaces that include location, sustains joint characteristics, quality loading and allows and intensity. motion. It is gel-like, Reassess each time porous, and elastic. pain occurs. Note and Normal cartilage investigate changes provides a durable, from previous reports. low-friction, loadbearing surface for joints.

BACKGROUND KNOWLEDGE

RATIONALE > To rule out worsening of underlying condition or development of complications.

EVALUATION After 8 hrs of nursing intervention, the patient was able to verbalize decrease rate of pain. After hospitalization, the patient reported absence of pain.

> Monitor vital signs. > Provide comfort measures (e.g., touch, repositioning), quiet environment, and calm activities. > Encouraged

> Which are usually altered when in pain. > To promote nonpharmacological pain management.

> To prevent fatigue

adequate rest period.

and stress that could aggravate the symptoms. >Prevents general fatigue and joint stiffness.

>Encourage frequent changes position. Assist client to move in bed, supporting affected joints above and below avoiding jerky movements.

Dependent: > Administer analgesics as prescribed. >Note the patients response to medication.

> To decrease the level of pain and emotional response to pain. >To know if the regimen is adequate to meet pain control goal.

Name of Patient: Medical Diagnosis: Right knee internal injury, horizontal tear of posterior horn of medial meniscus Arthroscopic menisectomy Nursing Diagnosis: Anxiety r/t upcoming surgical procedure Short Term Goal: After 8 hrs of nursing intervention, the patient will be able to relax and lessen his anxiety Long Term Goal: After hospitalization, the patient will be free from anxiety.

CUES
Subjective: >verbalization of anxiousness

PROBLEM Anxiety

BACKGROUND KNOWLEDGE
A vague uneasy feeling of discomfort or dread accompanied by an automatic response; the source often nonspecific or unknown to the individual; a feeling of apprehension caused by anticipation of danger. It is an altering signal that warns of impending danger and enables the individual to take measures to deal with threat.

NURSING INTERVENTION
>Maintain frequent contact with the client. Talk with and touch client. > Make arrangements

RATIONALE
>It provides assurance that client is not alone and rejected.

EVALUATION After 8 hrs of nursing intervention, the patient was able to relax and lessen his anxiety After hospitalization, the patient was freed from anxiety.

with someone else such as relatives to stay with the client.

>Provide open environment in which client feels safe to discuss feelings or to refrain from talking

> Providing client with

usual/desired support persons can diminish feelings of anxiety.

>Helps client feel accepted in present condition without feeling judged. It promotes sense of dignity and control. >Acceptance of

>Permit expressions of fear, anger and despair without confrontation. Give information that feelings are normal and are to be appropriately expressed. > Explain procedures, providing opportunity for questions and honest answers.

feelings allow client to begin to deal with present situation.

>Accurate information allows client to deal more effectively with the reality of situation, thereby reducing anxiety (fear of the unknown).

Name of Patient: Medical Diagnosis: Right knee internal injury, horizontal tear of posterior horn of medial meniscus Arthroscopic menisectomy Nursing Diagnosis: Risk for infection r/t post-surgical incision Short Term Goal: After 8 hours of nursing intervention, the patient will be able to demonstrate proper techniques in wound care to achieve timely wound healing. Long Term Goal: After hospitalization, the patient will be able to timely wound healing, free from infection.

CUES
Objective: >post-surgical incision on the right knee

PROBLEM Risk for infection

BACKGROUND KNOWLEDGE
Arthroscopy is a surgical procedure in which an arthroscope is inserted into a joint. The surgeon makes small incisions ( of an inch), around the joint area. Each incision is called portal. This incisions result in very small scars which in many cases are unnoticeable.

NURSING INTERVENTION Independent: >Monitor vital signs. >Observe for localized signs of infection at surgical incisions. >Stress proper hand hygiene by all caregivers between therapies and clients. > Change wound dressings, as indicated, using proper technique for changing/ disposing of contaminated

RATIONALE > To establish baseline data. >For immediate action if theres any presence of infection. > A first line defense against healthcare associated infection. > To prevent infection and contamination.

EVALUATION
After 8 hours of nursing intervention, the patient was able to demonstrate proper techniques in wound care to achieve timely wound healing.

After hospitalization, the patient was able to timely wound healing, free from infection.

materials. Dependent: >Administer antibiotic as prescribed by the physician. > Note the patients response to medication. > For prevention of infection.

>>To know if the regimen is adequate to meet pain control goal.