NURSING CARE PREPARATION
Student Name:
Sue Mathews
Unit/Room Number: PSU/386
Age: 81
Gender: Male
Erikson’s Developmental Level: Integrity vs. Despair
Date of Care: 10/09/14
Date of Admission: 10/08/2014
Ethnic/Cultural Preferences: Caucasian/NonHispanic/Christian
Allergies: ASPIRIN
Code Status: No orders/Full Code
Primary Diagnosis:
Degenerative osteoarthritis, left hip with total hip arthroplasty
Co-morbidities:
Hypertension
Discharge Plan (add day of clinical):
Home with wife
Integrated Pathophysiology (what is going on with your patient at the cellular level for the health condition, no more than
three pages in length)
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): Transitional (jello, broth, pudding),
advance as tolerated
I&O (MD order/Nursing Order/Frequency): Nursing
order/every shift
Fall Risk/Safety Precautions (Yes/No): Yes, Morse score
70; yellow gown/yellow wristband in place
Wound Care (Yes/No): No, may reinforce left hip
dressing PRN
Drains (Yes/No, Type): Foley catheter
Other Tubes: No
IV (Fluid type, rate, access type): Peripheral IV Right
forearm, 18 gauge catheter, Sodium Chloride via
pump and Hydromorphone via PCA
CBG (Yes/No, frequency): No
Activity (What is ordered): LLE weight bearing as
tolerated post op to be started after PT evaluation;
hip sling for 2 hours BID morning and evening shift as
tolerated; Offload heels, encourage ankle pumps,
turn every 2 hours
Oxygen (Yes/No, Delivery method, how much): No
Last BM: 10/07/14
ASSESSMENTS
(Include Subjective & Objective Data)
Integumentary:
skin is warm, dry, tan
no clubbing or discoloration of nails, nail bed pale;
oral mucosa is pink, moist, without lesions or
tenderness; dressing of the incision was found to
have shadowing but was not increasing or coming
through
Head and Neck:
neck is soft without lumps, lesions, or bruising
hair distribution even; facial features symmetrical
Ear/Nose/Throat:
facial movement is symmetrical and expressions
appropriate without drooping of mouth, eyes, or
eyelids; nares are patent with no reported
tenderness; no drainage, redness, or irritation noted
Sclera white with minimal appearance of blood
vessels; conjunctiva pink and moist
Thorax/Lungs:
Lungs clear in all lobes; skin is warm, smooth, dry
respirations regular in depth
Cardiac:
no JVD; capillary refill less than 3 seconds; pedal
pulses equal palpable and strong; radial pulses
consistent with apical pulse regularly irregular
rhythm; S1, S2 noted
Musculoskeletal:
BLE 2-3
BUE 4
able to lift feet against resistance, and push against
resistance; decreased muscle tone noted bilateral
lower extremities; no loss of balance noted on
ambulation with front wheeled walker; no decrease in
length of lower or upper extremities
Genitourinary:
urine yellow clear, with no foul odor, without
discomfort on urination (catheter D/C’d early 10/9/14
prior to beginning of shift)
Gastrointestinal:
Bowel sounds in all 4 quadrants, no distention or
tenderness noted; no discoloration; umbilicus
midline; patient reports passing flatus; last BM
10/7/14; abdomen is soft warm
Other (Include vital signs, weight):
Ht: 74 inches
Wt: 82 kg
BP: 148/72
P: 96
SpO2: 95%
R: 18
T: 100.3 F
Pain: 5/10
Neurological:
A&O x 3; answers appropriately; cranial nerves intact;
jaw movement intact; affect appropriate; patient
cooperative; no anxiety noted
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
Intended
Action/Therapeutic use.
Why is this client taking
med?
Adverse reactions (1
major side effect)
Nursing Implications for this client. (No more than
one)
Rivaroxaban
(Xarelto)
Anticoagulant;
Antithrombotic;
Selective Factor
XA inhibitor
10 mg/1 tab PO;
start on 10/09/14
09:00
P: 2-4 H
VTE Prophylaxis
Monitor VS closely for S/Sx of
bleeding/internal hemorrhage
(epidural, intracranial) such as
significant drop in BP or H&H
Terazosin
(Hytrin)
Alpha-Adrenergic
Receptor
Antagonist;
Antihypertensive
Bile Acid;
Gallstone
Solubilizing agent
Stimulant Laxative
2mg/1 cap PO
QHS; start
10/08/14 21:00
P: 1-2 H
Hypertension
Bleeding
complications
(especially after
surgery and
spinal
anesthesia)
Syncope
300 mg/1 cap PO
BID; start
10/08/14 21:00
8.6/50 2 tab PO
BID; start on
10/08/14 20:00
P: 1-3 H
Gallstone
Prevention
Peptic Ulcer
O: 6-10 H
May take up
to 24 H
Bowel regulation
Excessive fluid
loss
Monitor BP prior to administration for
effectiveness; teach patient regarding
postural drop in BP; monitor position
changes for safety
Monitor for onset of GI
distress/bleeding (nausea, severe pain,
dark stools)
Maintain fluid balance and hold if
watery diarrhea develops
Ursodiol
(Actigal)
Senna/
Docusate
(Senokot-S)
Metoprolol
Succinate- XL
(Toprol
Metoprolol
Succinate-XL)
Cardioselective
Beta-adrenergic
antagonist
antihypertensive
100 mg/1 tab PO
QPM
P: 1.5 H
Hypertension
Shortness of
breath,
bradycardia
Do not give if HR less than 50, and/or
SBP less than 90; Notify physician
Monitor for respiratory distress
Acetaminoph
en IV
Non-narcotic
analgesic
100mL IV Q 6 H
for 3 doses; MAX
4 GM IV per day;
start 10/08/14
18:00; NO OTHER
Acetaminophen
while on IV
P: 0.5-2 H
Pain
Hepatotoxicity
with chronic use
Monitor for abdominal pain, diarrhea,
elevation of ALT, AST
Acetaminophen
Cefazolin/D5
W Duplex
1gm
(Ancef/D5W
Duplex 1 gm)
1st Generation
Cephalosporin
antibiotic
Ascorbic Acid
(Vitamin C)
Vitamin
supplement
Multivitamin
(Theragran)
50 mL IV Q 8 H for
2 doses start 8 H
after Operative
dose; must be
complete within
24 hours
1000mg/2 tab PO
daily 18:00; start
on 10/08/14
18:00
P: 5 min IV
Prophylactic
against infection
peri-operatively
Renal
insufficiency
Monitor for onset of severe diarrhea
associated with colitis/monitor renal
output and BUN
Readily
absorbed
PO
Dysuria
Monitor for salicylate toxicity- Ascorbic
acid may decrease elimination of
salicylates and can also reduce effect of
anticoagulant
Multivitamin
1 tab PO daily
18:00
Unknown
Increases
protective
mechanism of
immune systemsupporting healing
Vitamin
supplement
Vitamin/mineral
overload/
overdose
Finasteride
(Proscar)
Antiandrogen; 5=
Alpha reductase
inhibitor
5mg/1 tab PO
daily
O: 3-6 H
Benign prostatic
hypertrophy
Postural
hypotension
Saline Flush
(Sodium
Chloride
Flush)
FS-Dextrose
5%-Lactated
Ringers
1052 ml bag
FS-Sodium
Chloride
0.9%
541 ml bag
Saline Flush
2 mL IV Q shift
flush with 2-5ml ;
saline lock when
PO tolerated
IV @ 125mL/hour
over 8.5 H
N/A
IV patency
Redness/
irritation
N/A
Fluid loss
replacement and
maintenance
Fluid volume
excess
Monitor for signs of hypervitaminosisexcessive itching, dry skin, nausea,
vomiting, hives, sore mouth, foul taste,
skin discoloration, flushing
Monitor position changes and
ambulation for signs of hypotensiondizziness, increased pulse, sweating,
balance
Flush IV line every shift and as needed
before and after accessing IV; monitor
for signs of irritation, blockage,
infiltration
Monitor I/O, weight, and signs of fluid
excess ( constant irritated cough,
dyspnea, vein engorgement)
IV @ 22mL/hour
over 24.5 H
TKO with PCA if
no other
maintenance IV
N/A
Fluid loss
replacement and
maintenance
Fluid volume
excess
Isotonic
Crystalloid Fluid
Isotonic
Crystalloid fluid
Monitor I/O, weight, and signs of fluid
excess ( constant irritated cough,
dyspnea, vein engorgement)
fluid is running
Mupirocin
2%
Ointmentnasal
(Bactroban
2% ointmentnasal)
Magnesium
Hydroxide
(Milk of
Magnesia)
Pseudomonic
acid antibiotic
1 gm nasal bid for
4 days
Not
systemically
absorbed
Infection
Contact
dermatitis
Hold drug and notify physician if
dermatitis or pus production increases
Saline Cathartic;
antacid
30 ml PO daily
PRN constipation,
if no BM by End of
Post op day 3,
start on 10/11/14
1 enema rectal
daily PRN
constipation if
MOM ineffective
and no BM by end
of Post op day 3
1 suppository
rectal daily PRN
constipation if
MOM ineffective
O: 3-6 H
Constipation
Bradycardia
Unknown
Constipation
Abdominal pain
Monitor for Hypermagnesemia
(profound thirst, flushing, sedation,
confusion, depressed deep tendon
reflexes, hypotension, depressed
respirations)
Assess bowel sounds prior to
administration- do no use if obstructed
O: 15-60
min
Constipation
Cramping
O: 2 min
Reversal of
narcotic depression
(sedation,
respiratory
depression,
hypotension)
Tachycardia,
Hypertension
Phosphates
enema
(Fleet
enema)
Stimulant Saline
laxative
Bisacodyl
(Dulcolax,
Bisac-Evac)
Stimulant laxative
Naloxone
1mg/1ml
(Narcan
1mg/ml)
Opiate antagonist
narcotic
0.1 mg dose IV
titrate PRN
unable to
arouse/resp rate;
dilute Naloxone
2mg/2ml w/8ml
NS to yield 10ml
*conc: 0.2mg/ml*
give 0.1mg Q 2-3
min until resp rate
greater than 8 or
Ensure adequate fluid intake 6-8
glasses/day unless fluid restriction;
antacids will cause early dissolution of
enteric coating- resulting in increased
abdominal cramping (teach)
Watch patient closely as some opiates
may have longer duration of action than
Naloxone’s; watch for changes in
respiration
Oxycodone
immediate
release
(Roxicodone
Immediate
release)
Ondansetron
(Zofran)
Opiate Analgesic
Antiemetic
Metaxalone
(Skelaxin)
arousable; may
repeat x 3 per 24
hour; monitor Q
15 min for at least
2 hours
5 mg/1 tab PO Q 4
H PRN pain for 1
day; STOP order
after 24 hours
O: 10-15
min
Pain management
Respiratory
depression
Monitor response closely for pain relief;
do not give if respirations less than 12;
have Narcan readily available
4mg/2ml IV Q 4 H
PRN
P: 1-1.5 H
Nausea
Diarrhea,
sedation
Give over 2-3 minutes IV; monitor
tachycardia
Skeletal muscle
relaxant
800 mg/1 tab PO
Q 8 H PRN
O: 3 H
Muscle Spasm
Anaphylaxis
Hydromorph
one/NS
0.2mg/ml
Narcotic analgesic
(opiate agonist)
O: 15 min
Pain management
Respiratory
depression
Zolpidem
(Ambien)
Anxiolytic;
sedative hypnotic,
nonbenzodiazepine
Anesthetic;
antianxiety;
sedative-hypnotic
short acting
PCA; Demand: 0.2
mg every 10 min;
limit: 3mg/4 HRS;
Loading dose= 0.2
mg IV PRN Pain
for 4 days; May
increase PCA dose
by 0.1 mg every
30 minutes up to
max dose of
0.4mg per
injection
5mg/1 tab PO HS
PRN for 7 days
Monitor for allergic reaction ( rash
around chest and neck, SOB, itching,
tachycardia)
Document # of mg infused every shift;
monitor baseline respiratory rate; hold
if respiratory rate less than 12; watch
for signs of miosis (abnormal
constriction of pupils)
O: 7-27 min
Insomnia
Confusion/falls
O: 1-5 min
IV
Preoperative
sedation/anxiety
Tachypnea
Midazolam
(Versed)
1mg/1ml IV x 2
PRN Preop- may
repeat 1mg dose
one time PRN
Give directly before sleep to avoid
impaired cognition/risk for falls; assess
for vision changes and report to
provider if present
Monitor injection site continuously for
signs of extravasation; monitor
respirations for changes in rhythm
depth, effort, as well as signs of
benzodiazepine
Oxycodone/
APAP
Opiate analgesic
Oxycodone/
APAP
Opiate analgesic
Acetaminoph
en
(Tylenol)
Non-narcotic
analgesic
continued confusion
5/325
1 tab PO Q 4 H x 1
day
Delay start x 24
HR while on
Acetaminophen
IV. Around the
clock. Change to
PRN Post op day 2
Start on
10/09/2014
10/325 1 tab PO Q
4H for 1 day,
delay start while
on
Acetaminophen
IV. Around the
clock until post op
day 2, then PRN
Start on 10/09/14
14:00
650 2 tab PO Q 4H
for 1 day, delay
start while on
Acetaminophen IV
around the clock
post op day 2,
then PRN Start on
10/09/14 14:00
O: 10-15
min
Pain
Level 4-6
Sedation
Monitor/assist with ambulation;
monitor respiratory status frequently;
monitor pain level/ relief; assess for
bowel elimination
O: 10-15
min
Pain
Level 7-10
Sedation
Monitor/assist with ambulation;
monitor respiratory status frequently;
monitor pain level/ relief; assess for
bowel elimination
P: 0.5-2 H
Pain
Level 1-3
Hepatotoxicity
with chronic use
Monitor for abdominal pain, diarrhea,
elevation of ALT, AST
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
Normal Values
10/09/14
Sodium
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
Uric Acid Plasma
4.4-7.6 mg/dL
Calcium
8.2-10.2 mg/dL
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
SGOT or AST
10 – 48 IU/L
LDH
70-185 IU/L
CPK
38-174 IU/L
WBC
4.5 – 11.0
RBC
10/09/14
HGB
10/09/14
HCT
male: 43-49%
female: 38-44%
MCV
85-95 fL
MCH
28 – 32 Pg
MCHC
33-35 g/dL
RDW
11.6-14.8%
Platelet
150-450
10/09/14
10/09/14
10/09/14
10/09/14
10/09/14
10/09/14
10/09/14
10/09/14
10/09/14
10/09/14
10/09/14
10/09/14
10/09/14
10/09/14
10/09/14
10/09/14
10/09/14
10/09/14
10/09/14
10/09/14
10/09/14
10/09/14
10/09/14
10/09/14
Patient Values/
Date of care
Interpretation as related to Pathophysiology –cite reference & pg #
male: 4.7-5.14 x 10
female: 4.2-4.87 x 10
male: 12.6-17.4 g/dL
female: 11.7-16.1 g/dL
DIAGNOSTIC TESTING
Date
10/09/14
10/09/14
10/09/14
10/09/14
10/09/14
10/09/14
10/09/14
UA
Interpretation as related to
Pathophysiology –cite reference & pg #
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Normal
Range
Results
Interpretation as related to
Pathophysiology –cite reference & pg #
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Color/Appearance
pH
Spec Gravity
Protein
Glucose
Ketones
Blood
Date
Other
(PT, PTT, INR, ABG’s,
Cultures, etc)
10/09/14
10/09/14
10/09/14
10/09/14
10/09/14
10/09/14
10/09/14
10/09/14
Date
Results
Normal
Range
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Radiology
10/08/14 X-Rays
10/09/14 Scans
10/09/14 EKG-12 lead
10/09/14 Telemetry
Results
Interpretation as related to
Pathophysiology –cite reference & pg #
Hip 1 view left
Well aligned unipolar left hip
prosthesis without suspicious lytic or
sclerotic bone lesions; soft tissue
swelling and surgical staples
consistent with immediate
postoperative status
N/A
N/A
N/A
N/A
N/A
N/A
DAR NURSING PROGRESS NOTE
Include the same note that was written in the client record for the priority nursing diagnostic statement.
Include the date/time/signature.
10/9/14 17:05
Grimacing, guarding, moaning with movement, increased irritability. Rates pain at 7 on 0-10 pain
scale. Administered oxycodone/apap 10/325 per pain scale (see MAK). Able to swallow PO
medication without incident, Pt reports no further needs at this time, call light in reach, door closed
per patient request
10/9/14 17:34
Pt reports pain at 2-3 on 0-10 pain scale, verbalizes satisfaction with pain control, medication
effectiveness documented (see MAK), no further needs reported, call light on bed, PCA pump control
on bed; door closed per patient request
PATIENT CARE PLAN
Patient Information: 81 y.o. male; degenerative osteoarthritis; hypertension; benign prostatic hypertrophy
Nursing Diagnosis should include Nanda Nursing Diagnostic statement, related to (R/T), as evidenced by (AEB).
Problem #1 Acute Pain R/T loss of integrity of bone and surrounding structures due to surgical procedure AEB
patient reports pain using pain scale, demonstrates protective gestures during positioning, and sleep
disruption
Desired Outcome: Patient will report that pain is well-controlled at a level that is acceptable for the patient
and demonstrate improved sleep pattern, and a decrease in guarding or protective behavior during
positioning and patient care
Nursing Interventions
Client Response to Intervention
1. Assess pain and comfort level frequently to ensure
1.Pt verbalized understanding of teaching and
effectiveness of therapy- teach regarding the
regarding pain management, discussed his
importance of round the clock management
concerns regarding “getting hooked”
postoperatively to maintain better control of pain
2. Provide pillows and blankets to position patient
comfortably and correctly to avoid hip flexion,
rotation, or dislocation, while alternating weight in
bed. Utilize the help of NT to ensure fluid
movement of the patient and minimize discomfort
2.Pt was refusing wedge at beginning of shift
and continued to refuse wedge throughout
shift, he declines hip sling, and was able to
reposition self in bed, alternating weight.
3. Administer pain medications as ordered- before
pain level is unacceptable for patient and assess
within 15-20 min after administration to ensure
adequate relief is achieved- contact physician as
soon as possible if pain is not adequately controlled
3.Pt verbalized needs for pain control on when I
entered room; patient was able to report
adequate control on reassessment
Evaluation (evaluate goal & interventions, what worked/what didn’t, what would you adapt if needed):
Maintained adequate control of pain as this was his priority issue, although his pain increased throughout the
shift due to the patient’s increasing independence and refusal to call for help in getting in and out of bed or
ambulating around the room; I think in the future in this type of intervention, I will just continue with
teaching, emphasizing importance of exercising limitations but it is also important that the patient be able to
have his independence as he wishes; he verbalized understanding the risks for falls, incisional dehiscence, and
trauma; I could be more “aggressive” with teaching and it may help to have another nurse with me just to help
emphasize importance to the patient, but not make them feel patronized
Problem #2 Risk for Injury R/T decreased mobility, invasive procedure, and decreased perfusion AEB
immobilization of left leg/hip, limited activity, and inability to reposition independently in bed
Desired Outcome: Patient will demonstrate adequate perfusion of tissues, be free from development of
infection or further impairment of the skin AEB intact skin (not including surgical site), will maintain clean dry
dressing over incision
Nursing Interventions
Client Response to Intervention
1. Assess and monitor patient’s skin especially on the
1.Patient was able to reposition self but allowed
back and heels at least every 2 hours with
SN to assess heels each time pain/safety
positioning
checks/rounding were done
2. Continue to monitor circulation of all extremities,
sensation, and movement- watch for signs of
swelling, irritation, redness, or pain; ensure asceptic
technique with all patient care especially of
catheter and IV site
2.IV remained intact, noted slight elevation of
skin proximal to the sorbaview dressing of the IV
and increased blood from insertion around IV
cannula; patient reported no pain, warm, or
irritation, and none noted on all aspects of the
forearm, hand and up the arm
3. Assess V.S. at least every 4 hours; teach patient the 3.Continued to teach incentive spirometry use;
importance of incentive spirometry every 2 hours to patient reports “yes I have been using it so you
prevent respiratory infection
can put that in your report”
Evaluation: A full skin audit was difficult to do given the independent nature of the patient and refusal for
some care or assistance. Patient was very modest and it was very important to respect that and also report to
the oncoming NOC nurse to protect patient’s rights; I was able to assess his back intermittently as well as the
back of his legs; VS were assessed, and increasing amounts of teaching done; continued to monitor
positioning, movement, and any factors of friction or pressure against the skin. Mainly though his risk for
injury continues to be an issue regarding refusal for assistance.
Problem #3 Potential complication of surgery: joint dislocation or displacement of prosthesis, infection, and
venous thromboembolism
Desired Outcome: Patient will not have dislocation or displacement of prosthesis , infection, or VTE
throughout hospital admission
Nursing Interventions
Client Response to Intervention
1.Keep left leg slightly abducted; assess for pain and
1.Patient refused use of hip sling or wedge
extremity shortening- report immediately if noted
2. Monitor appearance of dressing, note any changes in
appearance, odor, swelling, or increased signs of
inflammation of surrounding skin and tissue; monitor
patient’s temperature, LOC, and vital signs at least every 4
hours ( or more if changes are noted)
2.shadowing noted; no odor noted;
Temperature increased over shift. Reported to
primary nurse and also NOC Nurse; LOC
remained A&O x3; patient reported no concerns
outside of pain
3.Apply sequential compression devices, teach the patient
regarding the importance and encourage heel pumps;
teach leg exercises as indicated by orders or PT (patient
was to be evaluated 10/09/14 ~07:00 by PT, will address
orders at beginning of shift); administer anticoagulant
medication as prescribed- teach regarding importance and
3.SCDS used, teaching done, patient was
cooperative with teaching; continually offered
fluids and discussed heel pumps with patient;
patient nodded with appropriate eye contact;
refused to demonstrate heel pumps
signs of adverse effects; encourage fluid intake
Evaluation: patient was receptive to teaching, tolerating SN continued attempts at demonstration and return
demonstration; again, with this patient just continued teaching and perhaps in his home environment, after
he has had time to reduce ongoing pain to his tolerable level of 4 or less, he would be more interactive with
teaching