Beruflich Dokumente
Kultur Dokumente
College of Nursing
DATE OF ADMISSION: 10/28
Age: 85
Gender: F
Surgery/Date:
Wounds/Drains: incision and hemovac above right knee
Dressing Change Orders:
______________________________________________
Pain level (0-10): 8
Location: Right knee
Pain meds ordered:
IV Type: Peripheral
Location: hand over needle left 20 guage
Fluid infusing/Rate: 75 ml/hr
Hep locked: none
Site change due: 11/3/14
Dressing change due: 11/1/14
Oxygen: Room air
L/Min: n/a
O2 Sat %: 96
Admit V/S: 98.2, 72, 18, 216/86
Last Recorded V/S: 100, 76, 18, 141/73
Patient Summary:
Patient is an 82 year old female with end stage degenerative joint disease of the right knee. All previous non-surgical
modalities failed to provide any significant benefit. The patient complained of persistent pain that was constant. Her
pain limited performing activities of daily living and weight bearing and walking worsened the pains intensity. X rays
were taken showed evidence of degeneration. On 10/28/14 the patient was admitted with vitals of 98.2, 72, 18, 216/86
and a right knee arthroplasty and full knee replacement was performed. There was no complications were noted post
procedure and diagnostics showed positive signs of bone degeneration and ruled out any other diagnosis. Current
concerns are possible infection related to an elevated temp. of 100 and lab abnormalities. Physician progress notes order
full weight bearing with the assistance of a walker.
Diagnostic Tests:
Pathophysiology: The progressive degeneration of articular cartilage in synovial joints. This leads to the inability of
the cartilage to withstand the normal weight bearing stress in the joint.
Causes: Primary DVD is idiopathic and secondary DVD is usually a result of joint trauma or repetitive joint injury.
Diagnostic lab and tests: X rays show narrowing of joint space and osteophytes (spurs) at the joint margins and on the
subchondral bone.
Medications: Acetaminophen and NSAIDs; COX-2 enzyme blockers; opioids and intra-articular corticosteroids; and
topical analgesics.
Medical Treatment:
o
Conservative measures-Height and weight reduction, joint rest, orthotic devices (splints, braces), isometric and
postural, and aerobic exercises , and occupational and physical therapy.
o
Surgery-osteotomy and joint arthroplasty
:Knee arthroplasty
Pathophysiology: The replacement of deteriorated femoral, tibial, and patellar articular surfaces with
prosthetic metal and plastic components. The prosthetic devices are held in place through the use of
cement or the device is porous, which is secured by bio-ingrowth.
Causes: Treatment for advanced osteoarthritis in older adults and rheumatoid arthritis in young and older
patients.
Medications
Medical Treatment: hospitalization is usually required for about 5 days after the procedure followed by
rehabilitation and recovery from 6 weeks to 3 months.
HTN :
Medical Treatment: Lifestyle modifications such as weight reduction, reduced alcohol and Na+ intake, and regular
physical exercise are encouraged.
Allergies (reaction):
Times
Med
Class
Route
&
Freq
Dosage
Diluted
UnDilut
Dil amt
Min
Why is this
pt taking?
Medical DX
NSG DX
Assessment
Lab
Side Effects
Before
Giving
Hold if:
After Giving
Assess SE
&
Expected
Outcomes (what
should the med
do)
Aspirin
GI BLEEDING,
antipyre Tab- 650 mg
Mild to
dyspepsia,
tics
EC, po,
moderate
epigastric
nonopio daily,
pain.
distress,
id
routine
Fever.
nausea,
analgesi
cs,
Osteoarthritis. abdominal
pain, anorexia,
salicylat
Mild to
hepatotoxicity,
es
moderate
vomiting,
pain.
ALLERGIC
Fever.
REACTIONS
INCLUDING
ANAPHYLAXIS
AND
LARYNGEAL
EDEMA
Atorvastin
Lipid
lowerin
g agent,
Tab,
po,
daily,
hmg coa routine
reductas
e
inhibitor
s
10 mg
abdominal
cramps,
constipation,
diarrhea,
flatus,
heartburn,
RHABDOMYAL
SIS
Patients who
have asthma,
allergies, and
nasal polyps or
who are allergic
to tartrazine are
at an increased
risk for
developing
hypersensitivity
reactions.
Monitor hepatic
function before
antirheumatic
therapy and if
symptoms of
hepatotoxicity
occur
If patient
develops muscle
tenderness during
therapy, CPK
levels should be
monitored.
10 mg
confusion,
drowsiness
(rare),
paradoxical
excitation,
blurred vision,
dry mouth, GI
upset,
photosensitivit
y, rash, weight
gain
Assess allergy
symptoms
(rhinitis,
conjunctivitis,
hives) before
and periodically
during therapy.
Assess lung
sounds and
character of
bronchial
secretions.
Maintain fluid
intake of 1500
2000 mL/day to
decrease
viscosity of
secretions.
40 mg
Headache,
PSEUDOMEM
BRANOUS
COLITIS,
abdominal pain,
diarrhea,
eructation,
flatulence
Assess patient
routinely for
epigastric or
abdominal pain
and for frank or
occult blood in
stool, emesis, or
gastric aspirate.
Multivitam
in
Pantaprazo Antiulce Table
r, proton EC, po,
pump
daily,
inhibitor routine
Sertraline
(Zoloft)
prn
docusate
(Colace)
Antidep
ressant,
SSRI
Tab,
po,
daily,
routine
NEUROLEPTIC
MALIGNANT
SYNDROME,
SUICIDAL
THOUGHTS,
dizziness,
drowsiness,
fatigue,
headache,
insomnia,
diarrhea, dry
mouth, nausea,
sexual
dysfunction
100 mg
laxative, cap,
100 mg constipation
throat
stool
po,
Softening and
irritation,
softener BID,
passage of
mild cramps,
s
routine
stool
diarrhea,
rashes
50 mg
hypertension
Assess for
suicidal
thoughts,
Monitor appetite
and nutritional
intake. Weigh
weekly. May
cause
hyperglycemia
and diabetes
mellitus; monitor
serum glucose if
clinical symptoms
occur.
hold if
within 2
hours of
another
laxative
fatigue,
Take apical
weakness,
pulse before
BRADYCARDIA, administering
HF,
. If <50 bpm
PULMONARY
or if
EDEMA,
arrhythmia
hypotension,
occurs
peripheral
vasoconstrictio
n, erectile
dysfunction,
libido, urinary
frequency
PRN
ondansetr
anti
on (Zofran) emetics,
five ht3
antagon
ists
SolnInj, IV
push,
q8h
PRN
4 mg
nausea/vomit
ing
headache,
dizziness,
drowsiness,
fatigue,
weakness,
TORSADE DE
POINTES,
constipation,
diarrhea,
abdominal
pain, dry
mouth,
liver enzymes
Assess patient
for nausea,
vomiting,
abdominal
distention, and
bowel sounds
prior to and
following
administration.
Monitor ECG in
patients with
hypokalemia,
hypomagnesemi
a, HF,
bradyarrhythmi
as, or patients
taking
concomitant
medications
that prolong the
QT interval.
10 mg
GERD
PARALYTIC
ILEUS,
constipation,
heartburn,
salivation, dry
mouth,
nausea,
vomiting
Assess for
symptoms of
irritable bowel
syndrome
(abdominal
cramping,
alternating
constipation and
diarrhea, mucus
in stools) before
and periodically
during therapy.
Assess patient
routinely for
abdominal
distention and
auscultate for
bowel sounds.
famotidine
(Pepcid)
20 mg
GERD
confusion,
dizziness,
drowsiness,
ARRHYTHMIA
S,
AGRANULOC
YTOSIS,
APLASTIC
ANEMIA
Assess for
epigastric or
abdominal pain
and frank or
occult blood in
the stool,
emesis, or
gastric
aspirate.
anti
tab,
ulcer
po,
agents
BID,
(histami routine
ne h2
antagon
ists)
PRN
hydromorp opioid
hone
analgesi
(dilaudid)
c
soln- 1/2 mg
inj, IV
push,
q3Hint,
PRN,
routine
Fever, pain
HEPATOTOXI
CITY (
DOSES), CUTE
GENERALIZED
EXANTHEMA
TOUS
PUSTULOSIS,
STEVENSJOHNSON
SYNDROME,
TOXIC
EPIDERMAL
NECROLYSIS,
rash, urticaria
Assess amount,
frequency, and
type of drugs
taken in patients
self-medicating,
especially with
OTC drugs.
Painbreakthrough
confusion,
sedation,
hypotension,
constipation
promethaz
ine
(phenerga
n)
antieme tab po
tics
q4H
antihist
PRN
amines
sedative
/hypnot
ics
25 mg
Treatment
NMS,
and
confusion,
prevention of disorientation
nausea and
, sedation,
vomiting.
dizziness,
Adjunct to
EPS, blurred
anesthesia
vision,
and analgesia
diplopia,
tinnitus
Monitor for
development of
neuroleptic
malignant
syndrome
(fever,
respiratory
distress,
tachycardia,
seizures,
diaphoresis,
hypertension or
hypotension,
pallor, tiredness,
severe muscle
stiffness, loss of
bladder control).
warfarin
(coumadin
)
Oxycodon
e
(Roxicodo
ne)
anticoa
gulant
po tab
daily
5 mg
Tab, 5/10 mg
po,
q4Hint/as
indicat
ed
PRN,
routine
Prevention of
thromboemb
olic events.
AEB:
Prolonged PT
(1.32.0
times the
control; may
vary with
indication) or
INR of 24.5
without signs
of
hemorrhage.
Pain-mild to
severe
BLEEDING
draw blood
for PT/INR in
patients
receiving
both heparin
and warfarin
at least 5 hr
after the IV
bolus dose,
4 hr after
cessation of
IV infusion,
or 24 hr
after subcut
heparin
injection.
Before
administerin
g, evaluate
recent INR
or PT results
and have
second
practitioner
independent
ly check
original
order
TIME
ACTIVITY
Scheduled
8:00 am
8:30 am
9:00 am
9:30 am
10:00 am
10:30 am
11:00 am
11:30 am
12:00 pm
12:30 pm
1:00 pm
1:30 pm
2:00 2:30 pm
Post-conference
MEDICATION
PROCEDURE
TIME
Completed
ACTIVITY
MEDICATION
PROCEDURE
TIME
Completed
0920
Scheduled
8:00 am
Hygiene
Shower with
assistance,
Change linens
8:30 am
Turn pt
9:00 am
Incentive Spirometry
10 breaths
Record ML
9:30 am
Activitiy
Ambulate in hall
10:00 am
AE hose maintenance
10:30 am
Wound Care
Clean with NS
Apply gauze
11:00 am
Safety
11:30 am
12:00 pm
12:30 pm
Vital Signs
Lasix
Maxipime
Remove hose,
assess ext,
reapply hose
10 am
1:00 pm
1:30 pm
2:00 2:30 pm
Post-conference