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NURSING CARE PREPARATION

Student Name: Daniel Gaudette, SN

Unit/Room Number: PSU 363


Age:65
Gender: M
Eriksons Developmental Level: Integrity vs. Despair

Date of Care: November, 13 2014

Date of Admission: 11-10-2014


Ethnic/Cultural Preferences: Hispanic, Pentecostal
OTH
Allergies: none
Code Status: Full Code

Primary Diagnosis: left total hip revision arthroplasty

Co-morbidities: HTN, osteoarthritis and chronic pain. History of paralytic ileus and gastroenteritis.

Discharge Plan (add day of clinical): Discharge to home with wife. He would like to have home health.

Data Collection (Record exactly what is written on the personal information sheet [aka Kardex]. Any
assessment/elaboration should be made on the assessment sheet):
Diet (Type): Regular ADAT, Benifiber in applesauce
IV (Fluid type, rate, access type): Yes, Peripheral IV,
with each meal per physician.
forearm, right, 18G, dressing: sorbaview. Pump and
PCA.
HYDROMORPHONE/NS 0.2 MG/ML PCA PCA
;Basal:0.5 MG/h ;Demand:0.3 MG every 10
MINS;Limit:12 MG/4 HRS;Loading dose =1 MG IV
PRN PAIN for 4 Days
FS-LACTATED RINGERS IV (1052 ML bag) IV
@100mL/Hour Over 10.5H
I&O (MD order/Nursing Order/Frequency): nursing
CBG (Yes/No, frequency): no
order, monitor I & O throughout shift.
Fall Risk/Safety Precautions (Yes/No): yes. Check on
Patient often and Orient Pt as needed, Patient Safety
Precautions in place Wrist band, gown, etc. as
indicated, Safety Protocol in Place Call light in place,
upper side rails up, bed low & locked.
Wound Care (Yes/No): Yes, wound reinforcement
PRN, Dressing change on POD #2
Drains (Yes/No, Type):
NO
Other Tubes: N/A

Activity (What is the patient activity level):


Trapeze on bed, LLE: Partial weight bearing, 50% or
up to 50 lbs, encourage ankle pumps, off load heels

Oxygen (Yes/No, Delivery method, how much): yes,


O2 NC at 2 - 4 Lpm OR FM at 6 - 8 Lpm to keep O2
sats greater than / equal to 92%
Last BM: 11-10-14

ASSESSMENTS
(Include Subjective & Objective Data)
Integumentary:
Head and Neck:
Skin was uniform in color.
Head is symmetrical, facial movement is symmetrical.
Skin had good turgor, no tenting on back of hand or
Neck is symmetrical and larynx and trachea rise with
clavicle. Extremities were warm to touch and capillary swallowing. Thyroid and lymph nodes are normal in
refill occurred at less than 3 seconds on pointer finger size. Slight alopecia on the head. No lice noted. Range
and great toe. Wound on left hip from total hip
of motion for the neck is not limited. 45 degree
revision arthroplasty. Wound not observed due to
rotation from center on either side. No JVD noted.
bandaging. No drainage from bandage noted. Right
wrist was edemous due to infiltrated IV. Edema
dissipated in about an hour after D/C the IV.
Eyes/Ear/Nose/Throat:
Thorax/Lungs:
Pupils 2mm equal, round, and reactive to light. Eyes
Chest cavity is symmetrical and slightly barrel
were tracking pen light through all six fields. Eyes are chested. Respirations at 16 per min. Chest is not
symmetrical. No tenderness to palpation around the
sensitive to palpitation. Lung sounds presented were
ocular cavity. Ears have no tenderness to palpitation.
clear inspiratory and expiratory sounds in all lobes. No
Hearing is diminished and equal bilaterally. Ears are
complaints of labored breathing or shortness of breath.
symmetrical. Nose is midline and symmetrical, nasal
Cough was not productive of sputum in the morning
mucosa pink, moist, and not draining. Oral mucosa is
pink, intact, and dry. No bleeding or lesions evident,
most Teeth were present and slightly yellow, mild
gingivitis.
Tongue is pink, moist and free of lesions.
Cardiac:
Musculoskeletal:
Dorsal pedal and radial pulses were regular and strong Left and right arm strength was equal bilaterally. Left
bilaterally, extremities are cool to touch, and cap refill and right dorsal extension and flexion strength was
at less than 3 second on pointer finger and great toe
unequal bilaterally. Left lower leg strength 2 on 0/5
bilaterally. No chest pain reported. S1, S2 heard at
scale, right leg 5/5. Pt. was able to sit up on bedside,
right and left base and Erbs point. Regular rate and
stand and rotate to sit on bedside chair with assistance
rhythm no murmurs, gallops, or rubs. Hypertension
from Physical therapist.
noted.
Genitourinary:
Gastrointestinal:
No redness, swelling or drainage noted from Penis,
Bowel sounds normoactive in all four quadrants, no
anus or perianal area. No reported pain from urination, sensitivity to palpitation, percussion reveals no
passing flatus, or bowel movements. Last BM reported diminished sounds in the four quadrants. Abdomen
Morning of 11-10-14 Urine output of 340mL on
was obese and distended, and soft to palpitation. Last
bedside urinal. Yellow clear and no foul odor.
BM afternoon of 11-10-14 and is currently passing
gas. No gastric reflux noted. Nausea experienced 2
times today with no incidence of vomiting.
Neurological/Psychosocial:
Other: BP= 102/64 Temp= 98.4 Pulse= 62 Res= 16
Patient is alert and oriented to place and time. Speech
O2= 96%
is clear and coherent. Pt. reported being in pain most
Pain: 6-8/10
of the day. He was on the phone with family several
Frequency: Chronic or continuous
times during the shift and he was waiting for his wife
Description: Throbbing and aching
when I left.
Tolerable Level: 6/10

CURRENT MEDICATIONS
List ALL regularly scheduled and prn medications scheduled on your client.
(Due morning of clinical)
Generic &
Trade Name

Classification

Dose/Route/
Rate if IV

Onset/Peak

ACETAMINO
PHEN
(TYLENOL)

Antipyretic

0.5-1hr/1060min

MULTIVITA
MIN
(MULTIVITA
MIN,
THERAGRA
N)
MAG
HYDROX/AL
HYD/SIMET
H 30 ML
(MAG-AL
PLUS,
MAALOX)
NALOXONE
1 MG/ML
(NARCAN 1
MG/ML)

Multivitam
in
supplemen
t

650 MG = 2
TAB PO Q4H
PRN
HEADACHE
1 TAB = 1
TAB PO
DAILY 1800

ONDANSET
RON INJ
(ZOFRAN
INJ)

Antiemetic

OXYCODON
E/APAP
10/325
(PERCOCET
10/325)

narcotic

antacid
30 ML = 30
ML PO Q2H
PRN
INDIGESTIO
N
opioid
antagonist

0.1 MG
DOSE MG IV
TITRATE
PRN
UNABLE TO
AROUSE/RE
SP RATE
4 MG = 2 ML
IV Q4H PRN
NAUSEA/VO
MITING
1 TAB = 1
TAB PO Q4H
PRN PAIN
LEVELS 7-10
for 7 Days

Intended
Action/Therapeutic
use. Why is this
client taking med?
Headache or fever

Adverse
reactions (1
major side
effect)
Liver damage

Nursing Implications for this client.


(No more than one)

Unknown

Prevent vitamin
deficiency

Allergic reaction

Monitor for rash, itching/swelling

3-6 hrs/
unknown

Treats too much


stomach acid

tachycardia

Monitor for slow/shallow breathing,


slow/irregular heartbeat,.

Rapid/
unknown

Unable to arouse/ resp


rate <8

N/V

Monitor respiratory rate, rhythm, and depth

rapid/ 1-1.5
hr

10-20min/
4hr

N/V

Pain 7-10/10

Headache

Hallucinations

Monitor for signs and symptoms or


liver damage

Monitor for effectiveness, ask the patient if


nauseous or headache.

Monitor for mental/mood changes

ZOLPIDEM
(AMBIEN)

sedativehypnotics

CELECOXIB
(CELEBREX)

Nonsteroid
al antiinflammat
ory
SENNA/DOC Stimulant
USATE
laxative
8.6/50
(SENOKOTS 8.6/50)
HYDROMOR
PHONE/NS
0.2 MG/ML
PCA
methadone
(METHADO
NE)
METOPROL
OL
(LOPRESSO
R)
RIVAROXAB
AN
(XARELTO)
CYCLOBEN
ZAPRINE
(FLEXERIL)
PROMETHA
ZINE *IV*
(PHENERGA
N *IV*)
LACTATED
RINGERS IV
(1052 ML
bag)

narcotic
(opiate)
analgesics
narcotic
(opiate)
analgesics
beta
blocker
Anticoagul
ant
Skeletal
muscle
relaxant
Antihistam
ine

Carbohydr
ate

5 MG = 1
TAB PO HS
PRN
INSOMNIA
for 7 Days
200 MG = 1
CAP PO BID

5-30min/
0.5-2.3 hrs

insomnia

Thoughts of
suicide

Monitor for memory loss,


mental/mood/behavior changes

Unknown/
3hrs

Reduce swelling

Edema

Monitor for unexplained weight gain

2 TAB = 2
TAB PO BID

6-10hrs/
unknown

Prevents
constipation

Rectal bleeding

Monitor for persistent


nausea/vomiting/diarrhea

PCA
;Demand:0.3
MG every 10
MINS;Limit:1
2 MG/4 HRS
20 MG = 2
TAB PO TID
for 7 Days

20min/
unknown

Pain 7-10

Hallucinations

Monitor for mental/mood changes

10-20min/
4hr

Pain

Dizziness

Watch for orthostatic hypotension

50 MG = 1
TAB PO ACBRK

15min/1hr

Decrease BP

Heart failure

Monitor BP for hypotension

10 MG = 1
TAB PO
DAILY
10 MG = 1
TAB PO Q8H
PRN SPASM

30-60min/24hr

Prevent DVT

Hemorrhage

Monitor for bleeding gums and


excessive bruising.

1hr/4-6hr

Prevent spasm

CNS depression

Monitor for drowsiness, dizziness, and


LOC

25 MG = 1
ML IV Q6H
PRN
NAUSEA/VO
MITING
IV
@25mL/Hour
Over 42H
STAT

3-5min/
unknown

N/V

Respiratory
depression

Monitor for effective breathing


patterns.

Rapid/rapid

Dehydration

hyperglycemia

Assess the hydration status, monitor


I/O and electrolyte concentrations.

DIAGNOSTIC TESTING
Include pertinent labs [ABGs, INRs, cultures, etc.] & other diagnostic reports [X-rays, CT, MRI,
U/S, etc.]
NOTE: Adult values indicated. If client is newborn or elder, normal value range may be
different.
Date
Lab Test
Patient Values/
Interpretation as related to Pathophysiology cite
Normal Values
Date of care
reference & pg. #
Sodium
11-12
136
N/A
11-12
11-12
11-12
11-12
11-12
11-12
11-12

N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
11-12
11-12

11-12

11-12

135 145 mEq/L


Potassium
3.5 5.0 mEq/L
Chloride
97-107 mEq/L
Co2
23-29 mEq/L
Glucose
75 110 mg/dL
BUN
8-21 mg/dL
Creatinine
0.5 1.2 mg/dL
Calcium
8.2-10.2 mg/dL

4.1

N/A

104

N/A

28

N/A

99

N/A

N/A

0.54

N/A

7.9L

Phosphorus
2.5-4.5 mg/dL
Total Bilirubin
0.3-1.2 mg/dL
Total Protein
6.0-8.0 gm/dL
Albumin
3.4-4.8gm/dL
Cholesterol
<200-240 mg/dL
Alk Phos
25-142 IU/L

N/A

May be related to the citrate preservative in


blood product that binds to calcium and removes
it from circulation.
Laboratory diagnostic tests with nursing
implications. Pg.292
N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

SGOT or AST
10 48 IU/L
LDH
70-185 IU/L
CPK
38-174 IU/L
WBC
4.5 11.0
RBC
male: 4.7-5.14 x 10
female: 4.2-4.87 x 10

N/A

N/A

N/A

N/A

N/A

N/A

9.0

N/A

2.92L

Decrease related to acute loss during surgery


Laboratory diagnostic tests with nursing
implications. Pg.428
Decrease related to acute loss during surgery
Laboratory diagnostic tests with nursing
implications. Pg.411
Decrease related to acute loss during surgery

HGB
male: 12.6-17.4 g/dL
female: 11.7-16.1
g/dL
HCT

9.7L

27.4L

male: 43-49%
female: 38-44%

11-12
11-12
11-12
11-12
11-12
N/A

MCV
85-95 fL
MCH
28 32 Pg.
MCHC
33-35 g/dL
RDW
11.6-14.8%
Platelet
150-450
Other:

94

Laboratory diagnostic tests with nursing


implications. Pg.411
N/A

33.1

N/A

35.3

N/A

13.2

N/A

155

N/A

N/A

N/A

DIAGNOSTIC TESTING
Date
11-06
11-06
11-06
11-06
11-06
11-06
11-06
Date

11-06
11-06
11-06
Date

UA

Normal
Range
Color/Appearance
N/A
pH
5-8
Spec Gravity
1.0011.029
Protein
Neg
Glucose
Neg
Ketones
Neg
Blood
Neg-Tr
Other
(PT, PTT, INR, Normal
Range
ABGs,
Cultures, etc)
INR
0.9-1.1
Protime Sec
11.513.8
PTTS
24.435.3
Radiology

N/A
N/A
N/A
N/A
11-10

EKG-12 lead
Telemetry
CT
MRI
X-ray

11-10

X-ray

Results
Yellow, Clear
7.0
1.010
Neg
Neg
Neg
Neg
Results

Interpretation as related to Pathophysiology cite reference &


pg. #
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Interpretation as related to Pathophysiology cite reference &
pg. #

1.0
12.8

N/A
N/A

26.8

N/A

Results
N/A
N/A
N/A
N/A
Hip complete LT

Hip 1 view LT

Interpretation as related to Pathophysiology cite reference &


pg. #
N/A
N/A
N/A
N/A
1. Interval left hip prosthesis revision.
2. Fracture at the middle third of the femur. Hardware is intact.
3. Femoral component extends past the fracture and lies with
its tip near the posterior inner cortical surface.
This image shows the proximal to mid-shaft of the left femur.
There is a subtle crack seen in the proximal to mid-shaft of the
left femur, in the region of glue in the shaft.

DAR NURSING PROGRESS NOTE

11-13-14 0800. Order ankle pumps not implemented. Placed pumps and programmed. Alarm
sounded after start. Repositioned the pumps and started again. Alarm sounded within 5 min.
changed out the tubing and started again. No alarm sounded for duration of shift. Nursing order
enforced and maintained.________________________________________Daniel Gaudette, SN

PATIENT CARE PLAN


Patient Information: 65 year-old-male admitted on 11-10-14 for a left hip replacement/revision
arthroplasty. HeShe has comorbidities of: Hypertension, osteoarthritis, and chronic pain..

Nursing Diagnosis should include Nanda Nursing Diagnostic statement, related to (R/T), as
evidenced by (AEB).
Problem #1 Acute Pain R/T Inflammation AEB Grimace, moaning, shifting, verbal confirmation
of pain on 0-10 scale.
Desired Outcome: Maintain a level of pain that is acceptable to patient throughout shift. Patient
states this level to be a 3 on 0-10 scale.
Nursing Interventions
Client Response to Intervention
1. Administer medication on schedule to maintain
1. The client stated pain level of 6-9/10
therapeutic effect verbalized as 3 on 0/10 by pt.
through shift.
2. Evaluate effectiveness of medication by Vital
2. The medication was effective but he
signs, reduction in symptoms, nonverbal
was weaning off the PCA at the same
communication and verbal confirmation of scale 0time.
3/10
3. Teach on therapeutic pain management
3.He was not really receptive to any other
techniques of deep breathing, imagery, and
technique except for distraction by the TV
distraction.
Evaluation: This was the best Dx for this pt. because he was in pain all day and it was his
primary concern. The effect of the medication was adequate because his acceptable level was
6/10. He spent most of the day in this range.
Problem #2: Impaired skin integrity R/T surgical incision AEB total left hip replacement, wound
reinforcement PRN, Dressing change on POD #2, measurement, appearance, and dressing.
Desired Outcome: Patients skin integrity will be maintained or improved through shift AEB
wound remaining well approximated between wound checks and no new skin breakdown.
Nursing Interventions
Client Response to Intervention
1. Pt. will be kept clean and free from moisture, or
1. The client had maintained or

fecal matter to encourage health and promote


improved skin integrity by keeping
healing.
it clean and dry
2. Encourage adequate nutrition and hydration, to
2. He was eating 50% of his meals
decrease skin breakdown and promote healing.
and drinking 480mL per meal
3. Provide incision site care noting any drainage
3. Incision care was not necessary, but
color, consistency and volume. Also provide
he was receptive to wound care
teaching on care of incision when returning home.
teaching.
Evaluation: Dx was good, pt. was receptive to the interventions and wanted to get better.
Problem #3 Impaired physical mobility RT Total left hip replacement, secondary to DJD AEB
Decreased muscle strength and limited ability to perform ambulation.
Desired Outcome: Client will show satisfaction of functional assistance through nursing
assistance to achieve mobility and self-care throughout shift.
Nursing Interventions
Client Response to Intervention
1. Asses baseline level of mobility
1. He could shift his weight in bed and
reposition with the trapeze. He tolerated
50% weight bearing with the PT well and
was able to get up out of bed and walk 8
steps forward and back to bed.
2. Encourage patient to perform ADLs and provide 2.He was able to perform most of his
assistance to complete ADLs as needed.
ADLs himself but he requested that I
dont do his pericare because his wife
would help him.
3. Teach on the importance of proper body
3. He understands that he is now at a
mechanics with walkers, canes, WC, or crutches to increased risk for falls and He stated that
prevent injury.
he understood.
Evaluation: This dx was a good one but I really need to work on creating some better
interventions. I wanted to make sure that this is a priority because it is very important for
recovery. I hope that I can really improve with this dx in the future.

Osteoarthritis
Daniel E. Gaudette, SN
Southwestern Oregon Community College
11-13-2014

Patient
The client is a 65 year-old-male that was admitted on 11-10-14 for left total hip revision
arthroplasty. Co-morbidities for the patient are hypertension, osteoarthritis and chronic pain. He
is Hispanic and of Pentecostal OTH faith. His Family is very involved in his care and has
constant visits from his wife and children. He wants to be discharged to home with his wife and
have his physical therapy at home.
Osteoarthritis
Osteoarthritis or degenerative joint disease is the most common form of arthritis, often
referred to as wear and tear arthritis. Osteoarthritis occurs when the protective cartilage on the
ends of the bones deteriorates in one or more joints (Ignatavicius, 2013). Most often the
deterioration occurs at synovial joints that are load bearing points, like hands, hips, and spine.
Osteoarthritis involves low grade inflammation, calcification of articular cartilage, genetic
alterations, and metabolic disorders (Huether, 2012). Although both sexes are affected greatly by
this, it occurs more in women. Persons that have had additional stress on the joints are
predisposed to an earlier onset of the disease. Additional stress could be caused by sports,
obesity, or previous knee injuries (Huether, 2012).
Pathophysiology
Osteoarthritis is the loss of articular cartilage. Early on, the cartilage changes from an
opaque glisten to a yellow-grey or brownish-grey color (Huether, 2012). As time passes the
cartilage begins to flake off becoming thin and eventually absent in some areas leaving the bone
exposed and unprotected. This unprotected bone then becomes dense and hard (sclerotic). As the
cartilage deteriorates, bone spurs (osteophytes) develop and grow into the synovial area where
cartilage has been broken down. The bone spurs then enlarge until the break off into the synovial

cavity. The broken off pieces of bone are known as joint mice (Lozada, 2014). The bone pieces
irritate the joint capsule and cause it to become thickened and adhere to the deformed bone. The
adherence to the deformed bone may be the major contributing factor to limited range of motion
(Huether, 2012).
Tests and Diagnosis
Osteoarthritis is typically diagnosed on the basis of clinical and radiographic evidence.
Most commonly a plain radiography is done because it is cost effective and quick to obtain. This
was not the case with my patient because he had already had a hip replacement on 12-29-11. His
x-ray showed that he had a subtle non-displaced fracture in the proximal to mid-shaft of
the left femur, in the region of glue in the shaft. Post operation his x-ray showed a fracture at the
middle third of the femur, and his hardware from the previous hip replacement was still intact.
Also, the femoral component extended past the fracture and lied with its tip near the posterior
inner cortical surface. Computed tomography (CT) scanning can be used but it is rare. Magnetic
resonance imaging (MRI) is not a necessary procedure in most patients unless there is a link to
surgical repair. Ultrasonography is not used at this time for diagnosis. Bone scanning can
differentiate osteoarthritis from osteomyelitis and bone metastases (Lozada, 2014).
Treatment
Conservative treatment of osteoarthritis is to rest the joint that is afflicted until the
inflammation goes away. Use range of motion (ROM) exercises to prevent the joint mice from
becoming lodged and limit mobility. Use mechanical aides such as walkers or canes to decrease
the weight bearing load on the joints, Weight loss can be a major factor in contributing to the
management of the disease.

Medications are used regularly to reduce inflammation, swelling and pain. Drug
manufacturers are developing inhibitors of cytokines and may be more effective in treating
osteoarthritis in the near future.
For the more invasive treatment, surgery is used. The most common surgery is to replace
the joint with an artificial one. 250,000 hips are replaced in the United States alone every year
(Huether, 2012). This was the case for my patient on 12-29-11. Unfortunately there was a
complication of aseptic loosening at the left hip surgical site on 9-24-14 and he had to have a left
hip revision arthroplasty on 11-10-14 to repair it.
Medications he is currently taking consist of the joint replacement cocktail which
includes Hydromorphone for high levels of pain, Methadone for pain, Oxycodone/APAP for
pain, Acetaminophen for mild pain or fever, Celebrex for inflammation, Cyclobenzaprine for
muscle spasms, Ondansetron for N/V, Promethazine for N/V, Zolpidem for insomnia,
Rivaroxaban to prevent DVT, Senna/Docusate for constipation, Maghydrox/alhyd/simeth for
GERD, Theragra for vitamins, lactated ringers for fluid balance and Naloxone for opioid
overdose. Additionally he is taking Metoprolol for his high BP.
His lab values post-surgery that are outside of normal range are Calcium, RBC, HGB,
and HCT. Calcium is low at 7.9mL/dL which may be caused by the citrate preservative in blood
products that binds with calcium and removes it from circulation (Van leeuwen, 2011). Red
blood cell count is low at 2.92x10, HGB is low at 9.7g/dL, and HCT is low at 27.4%. These low
values can be attributed to the significant acute loss of whole blood during surgery (Van
leeuwen, 2011). These labs have been trending over the last few days back to normal and will
continue to be monitored during his stay.

His culture and ethnicity are of note, I have been researching on the internet and most
sites suggest to be open, accepting, and modify teaching as necessary with an interpreter,
Spanish forms, reinforce medications, etc. For his religious beliefs I should provide privacy for
prayer, expect to have groups of visitors at a time for prayer, be prepared for speaking in
tongues, and the possibility of strong belief in miraculous healing (Ehman, 2012).

References

Ehman, J. (2012, May 8). Religious diversity: practical points for health care providers.
Retrieved from
http://www.uphs.upenn.edu/pastoral/resed/diversity_points.html#pentecostalpoints
Huether, S. E., & McCance, K. L. (2012). Understanding pathophysiology. St. Louis, MO:
Elsevier.
Ignatavicius, D. D., & Workman, M. L. (2013). Medical-surgical nursing: Patient-centered
collaborative care. St. Louis, MO: Elsevier Saunders.

Lozada, C. J., (2014, February 3). Osteoarthritis. Retrieved from


http://emedicine.medscape.com/article/330487-overview#a0104

Van leeuwen, A. M., & Poelhuis-Leth, D., & Bladh, M. L. (2011). Laboratory diagnostic tests
with nursing implications. Philadelphia, PA: F.A. Davis.

Wilson, B. A., & Shannon, M. T., & Shields. K. M. (2014). Nurses drug guide. Upper Saddle
River, NJ: Pearson.