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DATA COLLECTION TOOL

Student Name: Sarah Reyner


Patient Initials:

College of Nursing
DATE OF ADMISSION: 10/28

Age: 85

Gender: F

DATE OF CARE: 10/31

Race: African American

Medical Diagnoses ( Current and Past History):

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

ROOM NO: 344

Educational Level: High school diploma Occu


Lives in: nursing home Caregiver: Other
Code Status: A
Safety concerns: Fall risk, restraints, seizure prec
monitor, side rails 1, 2, 3,4
_________________________________________
Activity Level: Ambulate Hall
Equipment: Walker, Wheelchair, Cane
Assistance needed: Self
_________________________________________
Type of Diet: Regular
Assistance needed: Self
Appetite: good % Meal eating 100%
Supplements:
Height:
Weight:
Recent Gain or
Loss:_none____
Hygiene: Shower, Bedside chair, Bed-bath, Tub b
Assistance needed: Self, one person, two person_
Elimination: Void, Foley, Ostomy, Dialysis
Uses: Bedpan, Urinal, BSCC, Toliet Last BM D
Usual pattern:
Needs Laxatives: Yes

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.

Report from Nurse:

Concept Care Map

NSG DX: Acute pain R/T


Pt. Goals (AEB):
Support Data:
Nursing Interventions:
1.
2.
3.
4.
Evaluation (AEB):

NSG DX: Impaired physical mobility R/T surgical procedure, discomfort,


pain AEB limited ability to ambulate or move in bed, limited ROM, inability
to perform action as desired
Pt. Goals (AEB): Patient performs physical activity within limitations of
prescribed mobility restrictions. Patient demonstrated use of adaptive
techniques that promote ambulation and transferring.
Support Data: Reports of a pain level of 8 that is worsened with
movement, limited ROM, decreased muscle strength
Nursing Interventions:
1. Assess the patients fear and anxiety about transferring or
ambulating, their level of understanding of postoperative
restrictions, and the postoperative ROM and compare with
preoperative statuses.
2. Assist and encourage the patient to perform quad sets, gluteal
sets, and ROM to both legs.

NSG DX : Ineffective peripheral tissue perfusion R/T HTN, heart murmur,


and poor peripheral circulation AEB prolonged elevated BP,
Pt. Goals (AEB):
Support Data:
Nursing Interventions:
1.
2.
3.
4.
Evaluation (AEB):

NSG DX: Impaired tissue integrity R/T


Pt. Goals (AEB):
Support Data:
Nursing Interventions:
1.
2.
3.
4.
Evaluation (AEB):

Diagnostic Tests:

Abnormal Diagnostic Lab:


(10/30/14)
N-(5,000- 10,000)
H- (20,000)
Pneumonia
eGFR African American:
(10/30/14)
N-(5,000- 10,000)
H- (20,000)
Pneumonia
PT
(10/30/14)
N-(5,000- 10,000)
H- (20,000)
Pneumonia
INR
(10/30/14)
N-(5,000- 10,000)
H- (20,000)
Pneumonia
WBC
(10/30/14)
N-(5,000- 10,000)
H- (20,000)
Pneumonia
RBC
(10/30/14)
N-(5,000- 10,000)
H- (20,000)
Pneumonia
HCT
(10/30/14)
N-(5,000- 10,000)
H- (20,000)
Pneumonia
MCH
(10/30/14)
N-(5,000- 10,000)
H- (20,000)
Pneumonia
MCV
(10/30/14)
N-(5,000- 10,000)
H- (20,000)
Pneumonia
hgb

Pathophysiology/ Textbook Overview


Degenerative Joint Disease (DVD) :

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.

Symptoms to assess for: pain, stiffness, and functional impairment

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.

Symptoms to assess for: pain and limited mobility

Diagnostic lab and tests

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 :

Pathophysiology: defined as a systolic BP>140 mmHg and a diastolic BP>90 mmHg.

Causes: Can result from increases in CO

Symptoms to assess for

Diagnostic lab and tests


st

Medications: diuretic agents and beta blockers are 1 line medications

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.

Loratadine Antihist Tabamine EC, po,


daily,
routine

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

Metoprolol Antihyp Tab,


(Metoprolo ertensiv
po,
l tartrate)
e, beta
BID,
blocker routine

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

give with full


glass of water or
juice.
Assess for
abdominal
distention,
presence of
bowel sounds,
and usual
pattern of bowel
function.
Assess color,
consistency, and
amount of stool
produced.
Monitor BP, ECG,
and pulse
frequently during
dose adjustment
and periodically
during therapy.

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.

Dicyclomi Antispa Cap,


ne
smodics
po,
,
TID,
antichol routine
inergic

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

acetamino antipyre tab,


325 mg
phen
tics,
po,
(Tylenol) nonopio q4H-int
id
analgesi
cs

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

Assess BP, pulse,


and respirations
before and
periodically
during
administration.
If respiratory
rate is <10/min,
assess level of
sedation. Dose
may need to be
decreased by
2550%. Initial
drowsiness will
diminish with
continued use

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

Assess for signs


of bleeding and
hemorrhage
(bleeding gums;
nosebleed;
unusual
bruising; tarry,
black stools;
hematuria; fall
in hematocrit or
BP; guaiacpositive stools,
urine, or
nasogastric
aspirate).
Monitor stool
and urine for
occult blood
before and
periodically
during therapy.

Computer Work List


Complete this form the day you pick up your patient assignment- Scroll ahead to tomorrows schedule to see what is
ordered for your patient and at what time.

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

Work List Example


Day before care: Access your patients computer chart work cue. Scroll ahead to tomorrows schedule to see what is
ordered for your patient and at what time. Record ordered Activities and time on this form. Click on the activity to see
what you will be recording and make a note in the procedure column. You can look ahead but do not accept anything,
just cancel to get back out. If you do not know what kind of bath or activity is ordered, see the physicians orders then
ask the nurse or tech if you are still not sure.
Day of care: Record time completed on this sheet so you will be able to document the correct time in the computer.
TIME

ACTIVITY

MEDICATION

PROCEDURE

TIME
Completed
0920

Scheduled
8:00 am

Hygiene

Shower with
assistance,
Change linens

8:30 am

Turn pt

Turn side, back,


side

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

Assess side rails


Bed position
Call light

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