Medical Diagnosis/Reason for Admission __Post-operative _pain____ Admitting Diagnosis: RIGHT KNEE REVISION
Describe (Brief Pathophysiology in your own words, including HPI)__Patient is a 74 years female with right knee revision due to acute post-operative pain came in for surgical consultation due to continued pain and a valgus deformity after having cast removed. She is on hinged knee brace for stability.
Allergies: Ancef, Tolectin 600, Cephalosporins
Social Hx Patient is a retired pharmacist, married with children. She is alert and oriented x4; uses tobacco before but quitted 20years ago.__________________________________________________________
HOW ARE THE ABOVE ITEMS RELATED? (Preparation – Add on by Clinical week 3)
Treatments (Accuchecks, dressing changes, PT, OT, RT, activity order, diet, Isolation, I/O)
Medications (See Medication Summary)
Systematic & Concise Summary of Physical Assessment findings (See Checklist for Routine Bedside Assessment)
General: (includes vital signs) BP: 119/69, P: 93, T: 73.3, R: 18, SaO2: 95, Pain: 8/10
Neuro: Alert and oriented x4, Pupils dilated and face expression is symmetry.
Cardiac: Clear on S1 and S2. No extra heart sounds, murmurs, or ribs.
Respiratory: Breathing is unlabored, chest movement is symmetric.
Integumentary: (include wounds) Skin is normal, warm and moist, no skin discoloration. Wound dressing on the right knee and right femur edema.
GI: Normal bowel sounds hyperactive in all quadrants.
GU: Clear yellow urine
Musculoskeletal: Active range of motion on upper extremities, impaired range of motion on lower extremities with brace on right leg. Right foot is dissented.
Safety Concerns Fall risk, Pressure sore risk.
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
DIAGNOSIS: *Radiology results; lab; micro; orders
Pertinent Diagnostic Tests This includes abnormal and significant normal.
Test
Date
Findings/Results
Implications/Nursing care
X-RAY knee 1or 2 view right
11/17/2014
Degeneration joint disease
Revision of the tibia and femoral
X-ray chest 1or 2 view
11/12/2014
Cardiomegaly, Tortuous descending aorta, left basilar atelectasis.
Surgery
Lab Tests with Rationale for Abnormals and Implication of Findings:
Name of lab
Reference Range
Level at Admit
Level on Last Lab
Nursing Implications
Reason for level
S&S
Date
Level
Date
Level
Red blood cell count
3.93- 5.22mmol/L
11/17/2014
2.8210E6/mcl
11/20/2014
2.6410E6/mcl
Due to Surgery
Hemoglobin
11.4-14.4 mmol/L
11/17/2014
7.9gm/dl
11/20/2014
7.4gm/dl
Due to Surgery
Hematocrit
33.3-41.4 mEq/L
11/17/2014
25.0%
11/20/2014
24.4%
Due to Surgery
mEq/L
mg/dL
Nursing Plan of Care
Nursing Plan of Care
NANDA NURSING DIAGNOSTIC LABEL (Choose #1 priority problem for patient)
RELATED FACTORS Secondary to a Disease or Condition
DEFINING CHARACTERISTICS*
(As evidenced by signs or symptoms)
* Remember “Risk For” Diagnoses do not yet have defining characteristics!
Acute pain
Related to knee replacement surgery
Subjective: As evidence by pain rate of 10/10
Objective: Lower extremity weakness.
Nursing Diagnosis Statement: Acute Pain______________________________________________
PATIENT EXPECTED OUTCOMES/GOALS
(Specific, Measurable, Achievable, Realistic, Timely)
PLANNED NURSING INTERVENTIONS & RATIONALE
EVALUATION
(Not Met, Partially Met or Met)
Patient Goal
Patient will indicate pain level decrease to less than 5/10
Your Intervention:
Administer pain medication
Evaluation of Goal
Goal partially met, Patient pain level was managed to a level of 6/10.
Your Intervention:
Facilitate Rest
Your Intervention:
Provide relaxation and guided imagery.
Nursing Plan of Care
Nursing Diagnosis Statement_____Ineffective coping ______________________________________________
NANDA NURSING DIAGNOSTIC LABEL (Choose #1 priority problem for patient)
RELATED FACTORS Secondary to a Disease or Condition
DEFINING CHARACTERISTICS*
(As evidenced by signs or symptoms)
Ineffective coping
Related to pain due to ineffective function
Subjective: patient report of anxiety
Objective: patient appears withdrawn
PATIENT EXPECTED OUTCOMES/GOALS
(Specific, Measurable, Achievable, Realistic, Timely)
PLANNED NURSING INTERVENTIONS & RATIONALE
EVALUATION
(Not Met, Partially Met or Met)
In patient terms only, summarize response to intervention
Patient Goal (may have several)
Patient will learn two coping skills
Your Intervention:
Encourage family support
Evaluation of Goal
Goal met, patient was able to relax by listening to , and daughter was there to give a moral support
Your Intervention:
Administer antidepressant /antianxiety medication
Your Intervention:
Involve relaxation therapy
Nursing Plan of Care
Nursing Diagnosis Statement: Risk for ineffective peripheral tissue perfusion.
NANDA NURSING DIAGNOSTIC LABEL (Choose #1 priority problem for patient)
RELATED FACTORS Secondary to a Disease or Condition
DEFINING CHARACTERISTICS*
(As evidenced by signs or symptoms)
Risk for ineffective peripheral tissue perfusion.
Related to coagulating factors released by bone during surgery.
Subjective:
Objective:
PATIENT EXPECTED OUTCOMES/GOALS
(Specific, Measurable, Achievable, Realistic, Timely)
PLANNED NURSING INTERVENTIONS & RATIONALE
EVALUATION
(Not Met, Partially Met or Met)
In patient terms only, summarize response to intervention
Patient Goal (may have several)
Prevent clotting
Your Intervention:
Give anticoagulant medication
Evaluation of Goal
Goal met,
Your Intervention:
Encourage ambulation
Your Intervention:
Give compression stockings
Nursing Plan of Care
Nursing Diagnosis Statement: Risk for fall _________________________________________________
NANDA NURSING DIAGNOSTIC LABEL (Choose #1 priority problem for patient)
RELATED FACTORS Secondary to a Disease or Condition
DEFINING CHARACTERISTICS*
(As evidenced by signs or symptoms)
Risk for fall
Related to lower extremity weakness
Subjective:
Objective:
PATIENT EXPECTED OUTCOMES/GOALS
(Specific, Measurable, Achievable, Realistic, Timely)
PLANNED NURSING INTERVENTIONS & RATIONALE
EVALUATION
(Not Met, Partially Met or Met)
In patient terms only, summarize response to intervention
Patient Goal (may have several)
Prevent patient from falling
Your Intervention:
Assist with ambulation
Evaluation of Goal
Met, patient was able to ambulate to bedside Commode.
Your Intervention:
Make sure bed is in low position with the rails at the top of the bed up
Your Intervention:
Involve physical therapy
References for your entire clinical worksheet:
Ruth F. Craven, Constance J. Hirnle, Sharon Jensen, (2013) Fundamental of nursing: human health and function,
(7th Ed). Philadelphia, PA: Lippincott Williams & Wilkins Inc.
Gulianick, M. and Myers, J. (2003). Nursing Care Plans: Nursing Diagnosis and Interventions. Mosby: St Louis
Pearson Education http://wps.prenhall.com/
Nursing Central (200-2014) Using web sources in writing, Retrieved from http://www.unboundmedicine.com/
Schedule: *Pt Care Summary; Med list; Pt schedule; task list
7am
Visit with patient and getting report from night shift staff.
8am
Perform vital signs
9am
Giving medication
10am
Assist with morning care, mouth care, assist with bath.
11am
Head to toe Assessment
12pm
Assist to bathroom, Accu-check.
State1 personal learning goal for this clinical day: ________Be able to give IV push and make my patient more comfortable. _________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
Did you meet your personal goal for the day?
_____________________________________________Goal Met, I was able to give IV push of 5% dextrose to my patient after noticing low level of glucose. _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Checklist for Routine Bedside Nursing Assessment
Mental/Neuro Status
LOC
Alertness/Orientation
PERRLA
Mood
Behavior
Check Patient ID Band
Cardiopulmonary
Heart Sounds
Apical Rate/rhythm
Lung sounds
Breathing pattern
Peripheral pulses
Edema
Capillary refill
Hemodialysis Access – Graft/Fistula – bruit/thrill
Oxygen Equipment
Vital Signs
BP
P
R
Temp
Pain
SaO2
Gastrointestinal
Bowel sounds
Abdominal palpation
Degree of ABD distension
Bowel elimination problems (diarrhea/constipation/flatulence)
Nausea/vomiting
Genitourinary
I & O (quantity)
Quality (color, clarity, burning)
Continence/incontinence
(Assistive devices)
Reproductive problems/sexual concerns
Motor Sensory Function
ROM
Paralysis
Weakness_______________________________________________________________________________________________________________________________/Numbness/Tingling
Assistive Devices
Ambulation
Wound
Cleanliness
Swelling/redness.infection
Drainage
Bandage dressing
Integumentary
Color
Temp
Turgor
Moisture
Integrity
Braden Scale Score (Mon, Thurs: rescore at EUH)
Invasive Tubes (IV’s, NGT, Wound drains, Catheters, etc..)
Device and location
IV Line(s): Fluids, Meds, Date of insertion/dressing/tubing
Patency and position
Redness, swelling, tenderness at site
Drainage/Infusion rate
Modified by Erin Poe Ferranti, 2005, 2007; Corrine Abraham, 2007
Adapted From: Elkin, Potter & Perry (2004) Nursing Interventions & Clinical Skills (3rd ed.) Mosby: St. Louis
Medications MAR; MAR Summary: Medication Profile*
Medication: Name/Dose/Route
Time
Classification
Purpose
Side Effects/Nursing Considerations
OxyCODONE(10mg=1tab)
1 tablet PO
9:00 am
Opioid analgesics
Reduce pain
Respiratory Depression
May cause drowsiness
Exenatide (10mcg injection)
1 each BID
PRN
Antidiabetics
Lower blood sugar
Pancreatitis, weakness
Insulin aspart (BG > 150)
(BG -100) /40= unit
Antidiabetics
Lower blood sugar
Anaphylaxis, hypoglycemia
Atorvastin (liptor) 20mg=1 tab, 1 tablet PO
9:00 am
Antilipidemia
Reduce Cholesterol level
Chest pain, Rhabdomyolysis
BuPRion 300mg=1tab
1tablet PO
9:00 am
Antidepressant
Treatment for depression
Seizure, anxiety, dry mouth, depression
ClonazePAM (0.5mg=1tab)
1mg=2tablets PO
9:00 am
Anticonvulsant
Prevention of seizure
Fatigue, constipation, suicidal thought
Docusate sodium (100mg=1cap) 1capsule PO
9:00 am
laxative
Prevent constipation
Mild cramps, diarrhea, rashes
Enoxaparin 30mg =0.3ml subq
9:00 am
anticoagulant
Blood thinner
Constipation, urinary retention
Levothyroxine (25mcg=1tab) 1tablet PO
7:00 am
hormonal
Treatment for hypothyroidism
Tachycardia. Abdominal cramps
Alprazolam (0.25mg=1tab)
9:00 am
antianxiety
Relief of anxiety
Constipation, blurred vision
Venlafaxine (75mg=1cap )150mg= 2capsule
PRN
Antidepressant
antianxiety
Decrease depression, anxiety and panic attack
Chest pain, anorexia, itching, epistaxis
Hydrocodone (10mg-1tab)
1tablet PO
9:00 am
opioid
Decrease pain
Respiratory depression, apnea, anaphylaxis
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