Michael Smith is an 18-year-old African American male who presents to your floor after repair of his right anterior cruciate ligament (ACL).
PMH:
- Denies medical history
- Previous tonsillectomy at age 5 due to recurrent strep infections. No complications from that procedure.
- Family history positive for lung cancer in maternal grandfather.
HPI:
Michael is an 18-year-old high school senior who tore his right anterior cruciate ligament (ACL) playing soccer. Earlier today at 1000, he underwent an ACL repair under general anesthesia and will stay overnight in your facility. He will work with physical therapy to learn crutch walking, and the plan is to discharge him to home tomorrow. Provider orders allow for partial weight-brearing on the RLE as tolerated.
Michael has not been out of bed since surgery.
1500 Shift Assessment:
- Vital signs: Temp 98.6 F, HR 74 bpm, RR 16 breaths/min, BP 120/74, SaO2 99% room air
- General: Appears stated age; speech clear; c/o feeling “tired”; denies pain
- Skin: warm and dry; appropriate skin tone for race; no evidence of pressure injuries
- HEENT: Noncontributory
- Respiratory: lungs clear to auscultation bilaterally (CTAB); denies cough.
- Cardiovascular: S1 and S2 auscultated, no murmurs present. Denies chest pain.
- Gastrointestinal: bowel sounds auscultated in all quadrants; abdomen soft and nontender; denies nausea
- Genitourinary: Denies dyruria; last void was 2 hours ago
- Musculoskeletal: Surgical incision is covered by a large pressure dressing. Immobilization brace is present. Strength 5/5 in all joints except right knee strength and ROM not assessed.
- Neurological: alert and oriented x 4; PERRLA; denies numbness and tingling in right lower extremity
solution
Patient Summary
Patient: Michael Smith
Age/Sex/Race: 18-year-old African American male
Diagnosis: Right ACL repair (postoperative, general anesthesia)
Past Medical History: Tonsillectomy at age 5; otherwise negative
Family History: Lung cancer in maternal grandfather
Surgical History: Right ACL repair today at 1000
Current Status:
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Postoperative day 0, currently stable, vital signs within normal limits.
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Complains of mild fatigue, denies pain.
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Not yet ambulated since surgery.
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Partial weight-bearing on RLE as tolerated per provider.
Focused Assessment Findings (1500 shift)
| System | Findings | Notes |
|---|---|---|
| Vital Signs | T 98.6°F, HR 74 bpm, RR 16, BP 120/74, SpO2 99% RA | Within normal limits |
| General | Appears stated age, speech clear, tired | Postoperative fatigue |
| Skin | Warm, dry, appropriate color, no pressure injuries | Good perfusion, low risk for skin breakdown |
| HEENT | Noncontributory | No abnormalities |
| Respiratory | Lungs clear bilaterally; denies cough | No respiratory compromise |
| Cardiovascular | S1, S2 normal; no murmurs | No acute cardiac concerns |
| Gastrointestinal | Bowel sounds present, abdomen soft | Normal GI function |
| Genitourinary | Last void 2 hours ago, denies dysuria | Adequate urinary output |
| Musculoskeletal | Surgical incision with dressing; RLE brace; right knee ROM/strength not assessed | Postoperative immobilization; risk for stiffness |
| Neurological | Alert, oriented x4; PERRLA; denies numbness/tingling | Neurovascular intact distal to surgery |
Nursing Diagnoses (Priority Focus)
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Impaired Physical Mobility related to postoperative status and right lower extremity surgery.
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Risk for Impaired Skin Integrity related to immobilization brace and pressure from limited mobility.
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Acute Pain (potential) related to surgical intervention (currently minimal but monitor).
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Risk for Infection related to surgical incision.
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Activity Intolerance / Fatigue related to post-anesthesia recovery.
Nursing Interventions & Rationale
| Nursing Diagnosis | Intervention | Rationale |
|---|---|---|
| Impaired Physical Mobility | Assist with ambulation using crutches as tolerated; collaborate with PT for safe transfer and mobility | Promotes early mobilization, prevents deconditioning, and supports functional recovery |
| Risk for Impaired Skin Integrity | Inspect skin under brace and pressure points at least every 4 hours; reposition patient every 2 hours | Early detection of pressure areas reduces risk of pressure injuries |
| Acute Pain | Assess pain using standardized pain scale every 2–4 hours; administer analgesics per provider orders; provide comfort measures (elevation, ice, repositioning) | Pain control facilitates mobility and improves recovery |
| Risk for Infection | Monitor incision site for redness, swelling, drainage, or warmth; maintain sterile dressing; educate patient/family on incision care | Prevents postoperative infection and promotes wound healing |
| Activity Intolerance / Fatigue | Encourage rest periods, provide nutrition and hydration, gradually increase activity | Supports recovery from anesthesia and surgery, prevents overexertion |
Patient Education Priorities
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Proper use of crutches and partial weight-bearing instructions.
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Incision care and signs of infection to report (redness, drainage, increased pain).
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Importance of physical therapy and gradual return to activity.
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Pain management strategies (medications and nonpharmacologic methods).
Expected Outcomes
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Michael will ambulate with crutches safely with partial weight-bearing by discharge.
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Surgical incision remains intact with no signs of infection.
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Patient reports pain controlled ≤ 3/10 on the pain scale.
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Patient demonstrates understanding of postoperative care and PT exercises before discharge.
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