Bundley1

Kimberly R. Bundley
Helene Fuld
School of Nursing
Care plan

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Nursing Care Plan

NAME: Kimberly Bundley

CLIENT INITIALS:

RT

CURRENT MEDICAL DX:

1. Bilateral OA Rt. Knee

CURRENT MEDICATIONS:
1. Atonolol 50 mg daily
2. Celebrex 200 mg po bid
3. Wellbutin XL 300 mg po daily
4. Lexapro 10 mg po daily
5. Lipitor 10mg po q evening
6. Dilaudid PCA Bolus 2 q10 min.
7. Docusate 100mg daily

DATE: 05/ 19/ 2006

CLIENT AGE: 54
PAST MEDICAL HX:
1. Smoker
2. CAD
3. Depression
4. Arthritis
5. HTN
6. Degenerative Joint Disease

GENDERS:

Male

ALLERGIERS: NKDA

8. Methoclophamide (raglan) 10 mg IV Q6h

9 .Diphenhydramine 25mg po Q4h for itching
10.Oxycodone 5mg po Q4h for pain less than 5/10
11.Oxycodone 10 mg po Q4h for pain more than 5/10
12.Zofran 4 mg IV Q6h for nausea
13.Atacand 16mg po daily
14.Ambieu 5mg orally @ bedtime for sleep

15.Cefazolin IV
2gm q6h

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Medication List
1. Atonolol:
Action: Predominately beta-1 blocking activity. Has no membrane stabilizing activity or intrinsic sympathomimetic
activity. Low lipid solubility.
Peak blood level: 2-4 hr. t 6-9 hr. eliminated unchanged in the feces.
Side effects: Dosage not established in children.
2. Celebrex:
Action:

release of signs symptoms of rheumatoid arthritis and osteoarthritis in adults.

Side effects: Abdominal pain, N/V, dry mouth.

3. Metoclopramide (raglan):
Action:

Increases the rate at which the stomach and intestines move during digestion. It also increases the rate at

which the stomach empties into the intestines and increases the strength of the lower esophageal sphincter (The muscle
between the stomach and esophagus).
Side effects: Gastrointestinal hemorrhage, obstruction, or perforation.
4. Diphenhydramine:
Action: High sensitivity, anticholinergenic and antiheroic effects.

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Side effects: increased risk if cognitive decline in the elderly.

6. Lexapro:
Action: Inhibits CNS neuronal reuptake of serotonin. Minimal effects on norepinephrine and dopamine reuptake.
Side effects: Insomnia, dry mouth, dizziness.
8. Lipitor:
Action: Undergoes first-pass metabolism by CYP3A4 enzymes to active metabolites.
Side effects: Headache, leg pain, sinusitis
9. Zofran:
Action: Prevent N&V.
Side effects: Constipation, diarrhea, abdominal pain.
10. Dilaudid PCA:
Action: 7-10 times more analgesic than morphine, with shorter duration of action. Induce respiratory depression onset.
Peak effect 30-60 min. duration 4-5 hrs. T 2-3 hrs. Give rectally for prolonged activity.
Side effects: Migraines headaches, increase CNS, and respiratory depression. Nystagmus.
11. Atacand:

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Action: Is rapidly and completely bioactivatied to candesartan by ester hydrolysis during absorption for the GI tract. T
elimination: 9hr excreted mainly unchanged in the urine and feces.
Side effects: N/V, abdominal pain, diarrhea, dyspepsia, headache, fatigue impaired renal function, rash, back pain.
12. Docusate:
Action: Act by lowering the surface tension of the feces and promoting penetration by water and fat thus increasing the
softness of the fecal mass.
Side effects: N/V, abdominal pain ns intestinal obstruction.
13. Oxycodone:
Action: Semi synthetic opiate causing mild sedation.
Side effects: Addiction, chewing or injecting can lead to death.
14. Wellbutrin XL:
Action: Treatment for depression. Aid to stop smoking.
Side effects: Dizziness, tachycardia UTI, seizers.
16. Ambien:
Action: Short term treatment of insomnia.
Side effects: Fatigue, stomach cramps, headache.

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Nursing Care Plan

Assessment
Data
Bilateral knee
replacement
Sharp severe
pain, during
movement rated
9/10
B/P 170/80
T:99.7
HR: 100
RR:25
Pain: 9/10

Nursing Diagnosis
Activity
intolerance R/T
chronic pain
secondary to
bilateral knee
surgery.

Outcome Criteria

Plan

Implementation

Evaluation

1. Client will
understand and use
the pain intensity
scale appropriately.
2. Client and nurse
will agree mutually
pain intensity goal.
3 Clients will rate
pain at or below
pain intensity goal.

1. Teach client to
report and explain
pain as soon as it
starts.
2. Have client rank
pain on a scale of
0-10.
3. Request the
client to share
thoughts and
feelings prior to
onset of pain.
4. Administer pain
medication as
ordered.
4. Give massage
immediately
following
administration of
pain medication.

1. Ask client to rate

pain intensity using
appropriate pain scale
both at rest and with
activity.
2. Evaluate PQRST
aspect of pain.
3. Observe clients
position, mobility,
relaxation, and
ability to participate
in ADL's.

1. Client
explains and
demonstrates how
to change
dressings.
2. No signs of
infection around
suture site.
3. Client keeps
right leg
elevated.

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Assessment
Data

Nursing
Diagno
sis
Surgical
Risk of
staples in
infection
both knees. R/T
surgical
staples in
both knees.

Outcome
Criteria

Plan

Rationale for
Plan

Implementation

Evaluation

1. Client will
remain free of
infection prior to
discharge.
2. Client will
experience normal
wound healing during
hospitalization.
3. Clients wound
will become patent
and intact. Skin
around surgical
sutures is free of
irritation.
4. Client will keep
right leg elevated
to prevent swelling.

1. Teach the
client the
proper to
change
surgical
dressings
2. Have client
assist with
change
dressing every
shift
3. Asses
clients pain
before, during
and after
dressing
change
according to
pain scale of
0-10
4. Administer
pain meds for
comfort
prior to
dressing
change.

1. Inflammation is
evidenced by pink
area and slight
swelling, which
confirms increased
circulation to
enhance healing
(Perry-Potter, 539).
2. Incisions edges
should be well
approximate and may
be stapled or closed
with visible or
subcutaneous sutures
(Perry-Potter, 539).
3. Avoid introducing
microorganisms from
surrounding skin
into the incision
(Perry-Potter, 539).

1. Assist client
and demonstrate
sterile technique
while performing
dressing change.
2. Assess vital
signs every 2-4
hours.
2. Assess and
document size,
color depth of
wound noting any
unusual conditions
skin surrounding
the external
fixation device.
3. Elevate leg 30
degrees above heart
to prevent
swelling.

1. Client
explains and
demonstrates
how to change
dressings.
2. No signs of
infection
around suture
site.
3. Client
keeps right
leg elevated.

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Nursing Care Plan

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References
Darlene Como. (Ed.). (2002). Mosby's Medical, Nursing, & Allied Health Dictionary (6th Ed.). St. Louis, Missouri: Mosby
An Affiliate of Elsevier.
Helen C. Cox. (2002). Clinical Applications of Nursing Diagnosis (4th Ed.) [Adult, child, Women's, Psychiatric,
Geronic, and Home Health Considerations]. Philadelphia: F. A. Davis.
Lynda Juall Carpenito- Moyet. (2006). Nursing Diagnosis Application to Clinical Practice. Philadelphia: Lippincott
Williams & Wilkins.
Perry-Potter. (2005). Fundamentals of Nursing (6th Ed.). St. Louis, Missouri: Mosby.

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