Total Knee Arthroplasty (TKA)
UNFOLDING Reasoning
John Roberts, 68 years old
Primary Concept
Infection
Interrelated Concepts (In order of emphasis)
Perfusion
Tissue Integrity
Pain
Clinical Judgment
Patient Education
Communication
NCLEX Client Need Categories Percentage of Items from Each Covered in
Category/Subcategory Case Study
Safe and Effective Care Environment
Management of Care 17-23%
Safety and Infection Control 9-15%
Health Promotion and Maintenance 6-12%
Psychosocial Integrity 6-12%
Physiological Integrity
Basic Care and Comfort 6-12%
Pharmacological and Parenteral Therapies 12-18%
Reduction of Risk Potential 9-15%
Physiological Adaptation 11-17%
, UNFOLDING Reasoning
History of Present Problem:
John Roberts is a 68-year-old Caucasian male who is 6 feet tall (180 cm) and weighs 260 lbs. (118.2 kg) (35.3
BMI). He has a history of diabetes, hypertension, and hyperlipidemia and smokes one pack per day since the age
of 18 (50 pack- years). He has osteoarthritis (OA) in his right knee and the pain has significantly increased over
the past year.
John had a right total knee arthroplasty (TKA) four days ago and refused to go to a rehabilitation center because of
the expense and distance from his home. He decided to have physical and occupational therapy home health
services. You are the home health nurse that will be caring for him, and you have arrived for his first home
visit.
Personal/Social History:
John is a retired lumberjack who enjoys being outdoors. He has become increasingly frustrated because he is not able
to do the outdoor activities he once did. He has been married for 50 years to Mary and lives in the rural
Appalachian Mountains and must travel a long distance for basic medical care.
What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
Diabetic Untreated diabetes, hypertension, and hyperlipidemia can lead to poor
Hypertension peripheral circulation due to plaque build up. This can exacerbate
Hyperlipidemia preexisting conditions like osteoarthritis because without proper blood
50 pack year smoker flow the bones and knee joint will not get the proper nutrients to heal
Total knee arthroplasty 4 days ago Years of smoking also negatively affect the peripheral circulation, smokers
Osteoarthritis in right knee tend to take longer to heal
Osteoarthritis is deteriorative joint condition
RELEVANT Data from Social History: Clinical Significance:
Retired lumberjack, active lifestyle until Lumberjack is a physically demanding job, so he may have developed a
recently high pain tolerance. Might have a tendency to under-report his pain.
Married for 50 years Rural living—access to medical care may be limited, he may choose not
Rural living seek medical help due to long commute and time it takes
Patient Care Begins:
Current VS: P-Q-R-S-T Pain Assessment:
T: 100.1 F/37.8 C (oral) Provoking/Palliative: Movement of the knee increases pain; Ice and pain med relieve
P: 80 (regular) Quality: Constant, dull, throbbing
R: 14 (regular) Region/Radiation: Right Knee
BP: 140/85 Severity: 7/10
O2 sat: 92% RA Timing: Constant ache, but continuous after activity
What VS data are RELEVANT and must be interpreted as clinically significant by the nurse?
RELEVANT VS Data: Clinical Significance:
P: moving right knee increases BP may be elevated due to pain.
pain, RICE and pain med Pain (PQRST) assessment is significant because it lets me know what makes it better and
relieve what makes it worst
Q: constant, dull, throbbing The pain in is his right knee impedes him from being as active as he would normally be
S: 7/10 7/10 suggest that the pain is getting worst not better like it should. 4 days after surgery pain
T: constant ache that is should be well controlled and more mild/less severe
continuous after activity
, BP: 140/85
UNFOLDING Reasoning
John Roberts, 68 years old
Primary Concept
Infection
Interrelated Concepts (In order of emphasis)
Perfusion
Tissue Integrity
Pain
Clinical Judgment
Patient Education
Communication
NCLEX Client Need Categories Percentage of Items from Each Covered in
Category/Subcategory Case Study
Safe and Effective Care Environment
Management of Care 17-23%
Safety and Infection Control 9-15%
Health Promotion and Maintenance 6-12%
Psychosocial Integrity 6-12%
Physiological Integrity
Basic Care and Comfort 6-12%
Pharmacological and Parenteral Therapies 12-18%
Reduction of Risk Potential 9-15%
Physiological Adaptation 11-17%
, UNFOLDING Reasoning
History of Present Problem:
John Roberts is a 68-year-old Caucasian male who is 6 feet tall (180 cm) and weighs 260 lbs. (118.2 kg) (35.3
BMI). He has a history of diabetes, hypertension, and hyperlipidemia and smokes one pack per day since the age
of 18 (50 pack- years). He has osteoarthritis (OA) in his right knee and the pain has significantly increased over
the past year.
John had a right total knee arthroplasty (TKA) four days ago and refused to go to a rehabilitation center because of
the expense and distance from his home. He decided to have physical and occupational therapy home health
services. You are the home health nurse that will be caring for him, and you have arrived for his first home
visit.
Personal/Social History:
John is a retired lumberjack who enjoys being outdoors. He has become increasingly frustrated because he is not able
to do the outdoor activities he once did. He has been married for 50 years to Mary and lives in the rural
Appalachian Mountains and must travel a long distance for basic medical care.
What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
Diabetic Untreated diabetes, hypertension, and hyperlipidemia can lead to poor
Hypertension peripheral circulation due to plaque build up. This can exacerbate
Hyperlipidemia preexisting conditions like osteoarthritis because without proper blood
50 pack year smoker flow the bones and knee joint will not get the proper nutrients to heal
Total knee arthroplasty 4 days ago Years of smoking also negatively affect the peripheral circulation, smokers
Osteoarthritis in right knee tend to take longer to heal
Osteoarthritis is deteriorative joint condition
RELEVANT Data from Social History: Clinical Significance:
Retired lumberjack, active lifestyle until Lumberjack is a physically demanding job, so he may have developed a
recently high pain tolerance. Might have a tendency to under-report his pain.
Married for 50 years Rural living—access to medical care may be limited, he may choose not
Rural living seek medical help due to long commute and time it takes
Patient Care Begins:
Current VS: P-Q-R-S-T Pain Assessment:
T: 100.1 F/37.8 C (oral) Provoking/Palliative: Movement of the knee increases pain; Ice and pain med relieve
P: 80 (regular) Quality: Constant, dull, throbbing
R: 14 (regular) Region/Radiation: Right Knee
BP: 140/85 Severity: 7/10
O2 sat: 92% RA Timing: Constant ache, but continuous after activity
What VS data are RELEVANT and must be interpreted as clinically significant by the nurse?
RELEVANT VS Data: Clinical Significance:
P: moving right knee increases BP may be elevated due to pain.
pain, RICE and pain med Pain (PQRST) assessment is significant because it lets me know what makes it better and
relieve what makes it worst
Q: constant, dull, throbbing The pain in is his right knee impedes him from being as active as he would normally be
S: 7/10 7/10 suggest that the pain is getting worst not better like it should. 4 days after surgery pain
T: constant ache that is should be well controlled and more mild/less severe
continuous after activity
, BP: 140/85
