PLAN
IHUMAN
OF
CARE
PATIENT ASSESSMENT
Age: ____52______ Gender: ____M______
Resuscitation Status _ Full code ________ Allergies__Shellfish____________________
Reason for Admission: ______Total Knee replacement surgery, an elective
surgery.____________________________________________________________________________
Medical Diagnoses: ___Chronic Osteoarthritis___________________________________________________________
________________________________________________________________________________________________________
Surgeries/Procedures and Dates: ____________________________________________________________________________
Past medical history__Chronic osteoarthritis
______________________________________________________________________________________
________________________________________________________________________________________________________
Current Orders:
Diet________NPO until after surgery____________________ Activity________ OOB with assistance
________________________
Intake ___________________ Output_________________ Accu Cheks__no____________________________
Vital signs____ Oral temperature 98.6, BP:122/76, pulse 72 with no diminished pulses to the right lower extremity. Respirations 24,
and 98% oxygen saturation on room
air.___________________________________________________________________________________________
Drsg changes/wound care_________________Dressing changes:_Incision site on right
knee________________________________________________________________
Foley___________________________ NG/G-tube/PEG?PEJ______________________________________________________
IV _______ R forearm, NS 75 mL/hr ; 5 mL q8h _________________ Reason for
IV____________________________________________
Other orders:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
1
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______________________________________________________________________________________________________
______________________________________________________________________________________________________
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Most recent Imaging Findings: (CXR? CT? MRI?)
Type of Imaging
(X-Ray, CT, MRI,
etc)
X-ray
Body Area Imaged
Reason for testing and results of test
Upper and Lower extremity
Musculoskeletal fractures, structural
abnormalities, location of emboli and thrombi,
heart and lung abnormalities.
Most Recent Significant /Recent Lab Results: (Chemistry? Hematology? Drug Levels? Coagulation tests?)
Date
Lab Test
Glu
BUN
Creat
Na
K
Cl
Ca
CO2
Hct
PT
INR
ABO
WBC
RBC
Hgb
MCV
Platelets
Results
108
18
0.7
135
4.5
99
9.5
22
47
15
0.9
AB Negative
5660
5.2
16
87
296
Norms
70-110
8-21
0.6-1.3
138-145
3.5-5.1
95-102
8.7-10.7
22-29
42-54
11-15
0.8-1.1
Comments
Fast blood glucose
Kidney fx
4,000-10,000
4.5-5.9
14-18
82-103
150-399
Immune fx
Electrolytes
ABGs
Blood Viscosity
Clotting fx
O2 carrying capacity of blood
Other recent, significant procedures or tests (EKG, etc)
Date
Test
ECG
Reason for testing and results of test
Pt is overweight and recently stopped smoking a week ago
Based on the information on these pages and your assessment of this patient, what is your FIRST or
PRIORITY concern and why?
2
Medications
You may copy and paste these tables onto the next sheet if you have more medications
Brand Name and Generic Name
Normal Dosage Ranges
500 mg to 1 gram
cefazolin
Pharmacotherapeutic Class
cephalosporin
Dosage Ordered
2 g IV
Why is patient receiving this med? (Can list
related diagnosis, symptom, or need)
Route and Frequency
treat certain infections caused by
bacteria from joint pain
PO every morning
Brand Name and Generic Name
Normal Dosage Ranges
Lactated Ringers
25-50 mg deep IM or
slow IV/IO; maximum dose 100
mg
Pharmacotherapeutic Class
Dosage Ordered
Alkalinizing Agents
Why is patient receiving this med? (Can list
related diagnosis, symptom, or need)
used as a source of electrolytes,
calories and water for hydration
Brand Name and Generic Name
74 mL/hr
Route and Frequency
During surgery
Normal Dosage Ranges
400 to 3000 mg
Calcium Carbonate
Pharmacotherapeutic Class
antacids
Dosage Ordered
600
Contraindications
patients who have a history of
immediate hypersensitivity reactions
Adverse Reactions
Swelling, redness, pain, or soreness at
the injection site may occur
Nursing Considerations and Teaching
Watch for seizures: Monitor signs of
pseudomembranous colitis
Contraindications
contraindicated where the
administration of sodium, potassium,
calcium, chloride or lactate could be
clinically detrimental.
Adverse Reactions
localized or generalized hives
and itching, swelling of the eyes, face,
or throat, coughing, sneezing, or
difficulty breathing
Nursing Considerations and Teaching
Administer only in high acuity areas. For
short-term use to correct critical
electrolyte abnormalities. Monitor
electrolytes and assess for hypervolemia
Contraindications
hypersensitivity, renal calculus, high
urine calcium levels, elevated
serum calcium
Adverse Reactions
upset stomach, vomiting,
stomach pain, belching.
Medications
Why is patient receiving this med? (Can list
related diagnosis, symptom, or need)
Route and Frequency
Nursing Considerations and Teaching
may cause cardiac arrest and
arrhythmias; Do not continue this
medication beyond 1–2 week, since it
may cause acid rebound
PO qAM
relieve heartburn, acid indigestion,
and upset stomach.
Brand Name and Generic Name
Normal Dosage Ranges
50 to 400 mg
Contraindications

Docusate

Pharmacotherapeutic Class
Dosage Ordered
100 mg
Colace
Why is patient receiving this med? (Can list
related diagnosis, symptom, or need)
stool softener.
Brand Name and Generic Name
Normal Saline (0.9%)
Pharmacotherapeutic Class
Crystalloid Fluid
Why is patient receiving this med? (Can list
related diagnosis, symptom, or need)
For Extracellular fluid replacement
Route and Frequency
PO BID
Normal Dosage Ranges
recommend aiming for a
correction of 8 mEq/L/day;
serum sodium should not
increase by more than 10 to
12 mEq/L in the first 24 hours
Dosage Ordered
Normal Saline (0.9%) 75 mL/hr
Normal Saline (0.9%) 5 mL IV q8
hours
Hypersensitivity reaction to
any of the docusate ingredients.
Avoid concomitant use of
mineral oil; Nausea or vomiting
Adverse Reactions
Abdominal cramping, Stomach pain,
Diarrhea, excessive bowel activities,
ntestinal obstruction
Nursing Considerations and Teaching
cause of constipation Evaluate
therapeutic response
Contraindications
patients with congestive heart failure, severe
renal impairment, conditions of sodium
retention, oedema, liver cirrhosis and irrigation
during electrosurgical procedures. Do not use
unless the solution is clear
Adverse Reactions
Fever, injection site swelling, redness,
and infection
Route and Frequency
Nursing Considerations and Teaching
75 mL/hr
5 mL IV q8 hours
May worsen existing hypovolemia and
hypotension causing cardiovascular
collapse. Monitor for signs of fluid
volume deficit, such as confusion in
older adults and dizziness. Never
administer to patients at risk for
increased ICP as the potential fluid shift
may cause cerebral edema.
Medications
Brand Name and Generic Name
Normal Dosage Ranges
Contraindications
Oxycodone
Orally 5 to 15 mg every 4 to
6 hours
Before using this medication, tell your
doctor or pharmacist your medical
history, especially of: brain disorders
(such as head injury, tumor, seizures),
breathing problems (such as asthma,
sleep apnea, chronic obstructive
pulmonary disease-COPD), kidney
disease, liver disease, mental/mood
disorders
Pharmacotherapeutic Class
Analgesic, Opioid
Why is patient receiving this med? (Can list
related diagnosis, symptom, or need)
Pain management related to
chronic osteoarthritis
Dosage Ordered
Oxycodone ER 10 mg PO BID
Oxycodone IR 5 mg q4 hours score
pain of 4/10 or less
Oxycodone IR 10 mg q4 hours
score pain of 5/10 or greater
Route and Frequency
IR 5 mg q4 hours
IR 10 mg q4 hours
Adverse Reactions
Nausea, vomiting, constipation, dry
mouth, weakness,
sweating, lightheadedness, dizziness,
or drowsiness may occur
Nursing Considerations and Teaching
CNS depression
Constipation
Respiratory depression
May cause severe hypotension
Routine Findings
Skin –Skin warm and dry. Incision site well approximated
with no redness, swelling, or drainage. Area
of warmth, redness, and 1+ pitting edema on medial aspect
of R calf. R calf is 3 cm wider in
girth than L calf. Pt complains of pain upon palpation of R
leg
Head and neck –
Head
Normocephalic, atraumatic
No deformities
Facial feature symmetric
Temporal arteries non- tender to palpation
Frontal and maxillary sinuses non- tender
Eyes
Eyes H – Test normal
Right pupil normal reactive
Left pupil normal reactive
External auditory canals clear, hearing intact
Eyelids- no ptosis erythema or swelling
Conjunctiva- pink, no discharge
Sclerae- anicteric
Orbital area- no edema, redness, tenderness or lesions noted
Mouth/pharynx
No hoarseness
Clear mucosa, tonsils without exudate
Tongue normal color, symmetrical
No swelling or ulcerations
No unusual smell in mouth
Nose
No discharge or polyps.
No edema or tenderness over4 the frontal or maxillary sinuses
Ears
Tympanic membrane translucent, pinkish-gray in color
Normal landmarks
Hearing intact in both ears
Neck
Trachea is midline and freely mobile
No nodes present
No asymmetry or accessory respiratory muscle use with quiet
breathing
Patient Variations/Abnormals
1+ pitting edema on medial aspect of R calf. R
calf is 3 cm wider in
girth than L calf. Pt complains of pain upon
palpation of R leg
None to note
Respiratory –
Clear breath sounds in all lobes. Tachypnea. Breathing
unlabored.
Cardiovascular
S1S2. No adventitious sounds. Pulses regular in all
extremities. Cap refill 2 seconds in fingers
RR is 24 and normal respiration rate is between 12-20
therefore the patient has tachypnea
and toes. No JVD present. 1+ pitting edema in R calf. No
diminished pulses in R lower
extremity.
1+ pitting edema in R calf
Abdomen –
Abdomen soft and non-tender. Normoactive bowel sounds
in all quadrants. .
Bowel continence? normal Last BM? Last night
Bowel Plan? n/a
Neurological AAO x4. PERRLA.
Musculoskeletal - .
Upper extremities strength is 5/5 bilaterally.
Right lower extremity strength 3/5 bilaterally
Left Lower extremity strength 5/5
Right lower extremity strength 3/5 bilaterally
Genitourinary –
Urinary continence? normal Toileting plan? n/a
Voiding clear yellow urine
Nursing Diagnosis #1:
Ineffective peripheral infusion
Related to (RT):
Venous spacious, decrease blood flow
As evident by (AEB):
Swelling, redness, 1+ pitting edema on lower right leg
Planning/Desired Outcome(s):
Patient identifies factors that improve circulation.
Patient identifies necessary lifestyle changes.
Patient exhibits growing tolerance to activity.
Patient shows no further worsening/repetition of deficits.
Implementation/Nursing intervention(s): Rationale
Assist with position changes.
Gently repositioning patient
from a supine to
sitting/standing position can
reduce the risk for orthostatic
BP changes. Older patients are
more susceptible to such drops
of pressure with position
changes.
Promote active/passive ROM
exercises.
Exercise prevents venous stasis and
further circulatory compromise.
Administer medications as
prescribed to treat underlying
problem. Note the response.
These medications facilitate
perfusion for most causes of
impairment.
Evaluation/Patient
Response
Assess the site of the
problem, patient noted
that the pain in his calf
has decreased. The was
no presents of DVT.
Nursing Diagnosis #2:
Impaired Physical Mobility
Related to (RT):
Pain and discomfort, musculoskeletal impairment
As evident by (AEB):
Limited ROM; decreased muscle strength/control
Planning/Desired Outcome(s):
Client will display increased strength and function of affected joint and limb. Participate in
ADLs/rehabilitation program.
Implementation/Nursing intervention(s):
Rationale
Perform and assist with the range of
motion exercises to unaffected joints.
Patient with degenerative joint
disease can quickly lose joint
function during periods of restricted
activity.
Medicate before procedures and
activities.
Muscle relaxants, narcotics,
analgesics decrease pain, reduce
muscle tension and facilitate
participation in therapy.
Maintain affected joint in prescribed
position and body in alignment when in
bed.
Provides for stabilization of
prosthesis and reduces the risk of
injury
Evaluation/Patient
Response
Nursing Diagnosis #3:
Acute Pain
Related to (RT):
Pain/discomfort
As evident by (AEB):
Reports of pain, spasm, tingling, numbness
Planning/Desired Outcome(s):
Patient will report satisfactory pain control at a level less than 3 to 4 on a scale of 0 to 10.
Patient will exhibit increased comfort such as baseline levels for HR, BP, respiration, and
relaxed muscle tone or body posture.
Patient will engage in desired activities without an increase in pain level.
Implementation/Nursing intervention(s):
Rationale
Evaluation/Patient
Response
Provide for adequate rest periods
Fatigue impairs the ability to
cope with discomfort.
Assess the patient’s description of
pain.
Pain may manifest as an ache,
progressing to sharp pain when
the affected area is brought to
full weight-bearing or a full
range of motion (ROM).
Medicate for pain before activity
and exercise therapy.
Exercise is necessary to maintain
joint mobility, but patient may be
reluctant to participate in exercise if
they are in too much pain.
Problem#__1_______
To Do:
Problem#______2___
ND: immunity, Risk for allergic
reaction
ND: Impaired Physical
Mobility
RT Pain and discomfort,
Medical Diagnoses:
Total right knee replacement
secondary to osteoarthritis.
musculoskeletal impairment
AEB Reports of pain, spasm,
tingling, numbness
assess the pt pain on a
pain scale of 0-10 , ten
being the worse pain
after they finish the
exercise therapy to see if
the medication work
effectively
RT pt allergic reaction to shellfish
Key Assessments:
1. Knee pain that is
gradual in onset and worse with
activity
AEB the appearance of rashes on
his body after consuming the
shellfish
2. Knee stiffness and
swelling
3. Pain after prolonged
sitting or resting.
Problem#_____3____
ND: Impaired Physical Mobility
Problem#____5_____
Problem#______4___
ND: Lack of activity
ND: Behavior changes