Christopher Collins: Plan of Care for Surgical Patient in Healthcare

This assignment presents a detailed plan of care for Christopher Collins, a 54-year-old male admitted for a left high tibia knee osteotomy. The plan addresses several patient problems, including sepsis and surgical infection, pain, deep vein thrombosis (DVT), pulmonary embolism, compartmental syndrome, and risk of falls. Each problem includes patient assessment data (objective and subjective), such as vital signs, pain scores, and physical examination findings. The plan outlines optimal patient outcomes or goals using the SMART (Specific, Measurable, Attainable, Realistic, Time-oriented) framework, such as reducing tachycardia, controlling infection, managing pain, preventing DVT and pulmonary embolism, and ensuring patient safety. The assignment demonstrates the application of nursing knowledge to assess patient needs, develop interventions, and set realistic goals for improved patient outcomes. The provided solution focuses on the care of the surgical patient, including assessment, planning, and evaluation of patient care.

PLAN OF CARE
PATIENT or NURSING ORIENTED PROBLEM OR
PATIENT NEED
PATIENT ASSESSMENT DATA OPTIMAL PATIENT OUTCOME or GOAL
Patient problem/issues/need - which is related to
<insert>
Patient problems/issues/needs can be actual
present and occurring now
Or potential when the patient is considered to be ‘at
risk of’.
As evidenced by (or how do we know this problem
exists)
Objective patient data
Subjective patient data
Lab and other test results
What do we (patient and nurse) want to achieve:
Specific, measurable, attainable, realistic and time
orientated (SMART goals)
1.
Sepsis and surgical infection
1. Redness, pain, swelling
2. Formation of pus.
3. Wbc elevated
4. Lactate 2.8, ph- 7.3
5. Paco 21, RR- 27, Spo2-94%
6. Blood pressure- 98/57
7. Tachycardia- 125bpm
 Reducing the Tachycardia
 Reducing the pus by antibiotic
 WBC will be between 4.5-11.0×109/ L
 Aiming for BP between 110-80
 Reducing the temperature
2.
Pain
1. Heat beat- 135beats per minute.
2. The pain score was 7/10.
3. Reduced mobility
 The nurse can encourage the patient to sleep
which will relax the body and will decrease the
pain score to 3/10.
 Effective communication will provide support
to the patient.
 Adverse condition of pain can be reduced by
physiotherapy.
3.
Deep Vein thrombosis
1. high heart rate that is 135bpm
2. swelling, redness
3. pus.
4. Age more than 50
5. Hospitalisation
 This condition can be reduced by enoxaparin
and dalteparin will be thin the blood clot.
 The nurse can also assist the patient in
changing lifestyle to reduce the development
of this condition.
 Patient will be free from DVT
 Patient will be mobilized

 Patient anti thrombin III will remain normal and
D-dimmer will be negative.
4. Pulmonary embolism 1. breathing shortness
2. rapid heart rate- 135bpm
 The condition can be resolved and prevented
by adhering to light exercise.
 The blood clot can be prevented by
anticoagulant therapy.
 The heart rate will be between 60-100bpm
 Breathing will be normal
5.
Compartmental syndrome
1. Pain score 7/10
2. swelling, weakness, redness in skin.
3. restricted mobility
4. Pus
 The nurses can assist the patient after the
supervision of the doctors to consume non-
steroidal anti-inflammatory drug along with
paracetamol which will reduce the pain and
also remove the damaged platelets.
 Pus will be reduced
 Nil dehiscene
6. Risk of fall 1. Reduced Mobility
2. Pain in leg
3. Infection
4. Low bp- 98/57
 Patient will have no fall
 Nurse will guide the patient
 Blood pressure aimed to be risk up to 120-
70mmHg.
One row per problem
Up to 6 prioritised problems (minimum 4)