1.

Pain
Right Hip surgical incision
Osteoarthritis
Hx of Rheumatoid Arthritis
Hx of Systemic Lupus Erythematous
Hx Fibromyalgia
lower back
Right groin
Right hip with touch
Percocet
Ice packs
Reposition
Pelvis X-ray

8. Self Care Deficit

Right Hip Surgery
Surgical incision pain
Lower back and groin pain
Minimal assist needed with ADLs

7. Ineffective Airway Clearance

Hx Bronchiectasis
Hx Reactive Airway Disease
Hx GERD
Incentive spirometer
Advair
Ventolin HFA
Pepcid

2. Bleeding
Right Hip surgical incision drainage
Hx Anemia
RBC 2.81 L
Hemoglobin 8.6 L
Hematocrit 25.4 L
Platelet 132 L
2 PRBC Blood transfusion
Estimated Blood Loss during surgery
Hemovac

Chief Medical Diagnosis:

Right Hip Osteoarthritis
Post op
Right Total Hip Replacement
Priority Assessments: Surgical site
(CMS, DVT, infection & bleeding),
pain, vitals (fever, hypovolemia,
tachycardia), respiratory
(pneumonia, atelectasis), mobility
and assessment with ADLs.

6. Knowledge Deficit
Right Hip Surgery
Total Hip Precautions
Proper positioning
Proper movement
Activity Restriction
S/Sx of surgical site infection

3. Nausea
Due to Percocet
Zofran
Rest

4. Fever
Temp 37.7C and 37.5 C
Incentive spirometer
Deep breath and cough
Ice pack
Acetaminophen

5. Impaired Physical Mobility

Right Hip surgery/ surgical incision
Osteoarthritis
Hx Rheumatoid arthritis
Hx Systemic Lupus Erythematous
Hx Herniated disc (5-7)
Hx Fibromyalgia
Fall precautions
Use of front wheel walker
Partial weight bearing right leg
OOB with assistance
Pain
Hydrochloroquine
Cholecalciferol
Flexeril
PT/OT
ROM