KENNESAW STATE UNIVERSITY
WellStar School of Nursing
Baccalaureate Nursing Program
CLINICAL PLANNING SHEET
NUR 3313
Instructor: Susan Selman
Student Name:
Patient age:
70
Sex: F
Allergies: Latex/Rash
Admission Diagnosis: LOC PRIM Osteoart – L/Leg
I.
CLIENT HISTORY (Describe pre-hospitalization issues that led to this admission - as
well as pertinent facts relating to diagnosis). List other diagnoses.
This patient is a 70 year old married female with progressive knee pain in the left knee that has not
been responsive to nonopertive management. Until shortly before the surgery the patient was
employed as a librarian in Gwinnett county and recently retired from that position. The pain is
starting to limit her quality of life and was having difficulty with ambulation. Before surgery patient
presented with a limp (antalgic gait) and ambulates with a cane. The present knee is postive for
chronic severe compartmental degenerative changes meaning all compartments of the knee have
been affected – resulting in a total knee replacement. Examination shows varus deformity of about
5 degress of the left knee resulting in the distal part of the leg below the knee is deviated inward,
resulting in a bowlegged appearance. Crepitation with passive flexion and extension is noted as
well. Surgery was performed on November 3rd in an effort to help relieve pain and improve function
of the hip.
Patient has a medical history of hypertension, Type II DM, obesity, stress incontinence, and
hypercholesterolemia. There is a past surgical history of a right knee replacement in 2002, spine
surgery in 2008, gallbladder surgery in 1980, breast augmentation and bladder tack in the past.
II.
PATHOPHYSIOLOGY (Describe the pathophysiology of the primary diagnosis).
List two potential complications of the disease process.
Type II Diabetes is the most common form of diabetes affecting 90% - 95% of the 21 million people
with diabetes. Unlike people with Type 1 diabetes, people with Type 2 diabetes produce insulin;
however either the pancreas does not produce enough insulin or the body cannot use the insulin
adequately. This is called insulin resistance. When there isn’t enough insulin or the insulin is not
used as it should be, glucose cannot get into the body’s cells. When glucose builds in the blood
instead of going into the cells, the body’s cells are not able to function properly. When consuming
food, the body breaks down all of the sugars and starches into glucose, which is the basic fuel for
the cells in the body. When glucose builds up in the blood instead of going into cells, it can cause
two problems: Right away, the cells may be starved for energy, Over time, high blood glucose levels
may harm the eyes, kidneys, nerves or heart.
Anyone can get type 2 diabetes. However, those at highest risk for the disease are those who are
obese or overweight, women who have had gestational diabetes, people with family members who
have type 2 diabetes and people who have metabolic syndrome (a cluster of problems that include
high cholesterol, high triglycerides, low good 'HDL' cholesterol and a high bad 'LDL' cholesterol, and
high blood pressure). In addition, older people are more susceptible to developing the disease since
aging makes the body less tolerant of sugars. In addition, people who smoke, have inactive
lifestyles, or have certain dietary patterns have an increased risk of developing type 2
diabetes. www.diabetes.org, Lewis, Heitkemper, Dirksen, et al. (2007) Medical-Surgical Nursing
Revised 3/25/09 NURS 3313 K. Lishman
III.
PROCEDURES (Current/recent surgical/other invasive done during this admission
and describe rationale for procedures). e.g. surgeries, cardiac catheterization, etc.
The severe destructive deterioration of the knee joint indicated for total knee arthroplasty. Patient
had left Total Knee Replacement surgical on 11/3/2009. The patient received spinal anesthesia.
TheOsteophytes and soft tissues were debrided and removed as appropriate. The surgery involves
exposure of the front of the knee, with detachment of part of the quadriceps muscle (vastus
medialis) from the patella. The patella is displaced to one side of the joint allowing exposure of the
distal end of the femur and the proximal end of the tibia. The ends of these bones are then
accurately cut to shape using cutting guides oriented to the long axis of the bones. The cartilages
and the anterior cruciate ligament are removed; the posterior cruciate ligament may also be
removed but the tibial and fibular collateral ligaments are preserved. Metal components are then
impacted onto the bone or fixed using polymethylmethacrylate (PMMA) cement. A round ended
implant is used for the femur, mimicking the natural shape of the bone. On the tibia the component is
flat, although it often has a stem which goes down inside the bone for further stability. A flattened or
slightly dished high density polyethylene surface is then inserted onto the tibial component so that
the weight is transferred metal to plastic not metal to metal. During the operation any deformities
must be corrected, and the ligaments balanced so that the knee has a good range of movement and
is stable. In some cases the articular surface of the patella is also removed and replaced by a
polyethylene button cemented to the posterior surface of the patella. In other cases, the patella is
replaced unaltered. www.nlm.nih.gov
IV.
CURRENT/RECENT DIAGNOSTIC TESTS/PROCEDURES (Dates and results:
CXR, 12-lead ECG, scans.
12 lead ECG show normal, vital signs show normal
V.
LIST THREE NURSING DIAGNOSIS FOR THIS CLIENT IN ORDER OF IMPORTANCE
OR PRIORITY. EXPLAIN THE RATIONALE FOR THE PRIORITY.
1. Acute Pain related to trauma caused by surgery
a. Assessment of pain, noting pain level (0 - 10)
b. Administer medication on a regular schedule
c. Monitor effects of analgesic
Goal: maintain pain control
2. Risk for Infection related to invasive procedure
a. Monitor for signs and symptoms infection (fever, joint swelling, redness, warmth),
neurovascular compromise and compare finding with the unaffected limb (diminished
pedal pulses; capillary refill. cool and pale extremity)
b. Monitor WBC count
c. Monitor vital signs, increased pulse, increased respirations, decreased oxygen
saturation.
Goal: Patient will remain free of infection as evidenced by normal vital signs and absence of
purulent drainage
3. Impaired Physical Mobility
a. Encourage ROM will all unaffected extremities
b. Maintain proper position in CPM machine
c. Assist patient in position changes and monitor for skin breakdown
Goal: Patient maintains strength in unaffected joints
Revised 3/25/09 NURS 3313 K. Lishman
CURRENT NURSING INTERVENTIONS (check, describe or quantify):
Explain why the intervention is appropriate/necessary for your client. What other
intervations did you do based on the clients pathophysiology, history, and current
condition? Why?
____ Nasogastric Suction
____ Pacemaker Wires/Monitor
____ Feeding Tube (NG/GT/JT)
size _____ suction _____
____ Baseline Vital Signs _____________
____ Glucose check times _____/_____
____ Neuro Checks
____ Colostomy/Ileostomy
____ I & O
____ Foley Catheter
____ Dressing Change (describe)
______________________________
____ Nephrostomy tubes/stents/supra
pubic tubes
____ Mobility/ADL Level
____ Chest Tubes ________/________
____ ROM Exercises
____ O2
____ TED Hose
____ Oximetry(pulse oximetry)
____ Special Bed/Mattress (describe)
______________________________
____ CPT
____ Restraints
____ Traheostomy _________________
____ Drains - Constavac, JP, ________
Intercranial, etc.
____ Central Line(s). What type?_____
What's infusing?______________
____ Precautions (what type?)
______________________________
____ Other
______________________________
______________________________
____ Peripheral Line(s): What's _____
infusing?________________
____ Saline/Heparing Lock
location ____________________
____ Casts
____ Traction ______________________
Revised 3/25/09 NURS 3313 K. Lishman
VII.
LABORATORY RESULTS (Remember to look at "trends in labs values". Circle abnormal value and state why this
lab is abnormal specific to your patient) [dx, hx, meds, etc.]
DATES:
11/4/2009
PURPOSE OF LAB TESTS
TIMES:
03:48
Lab
Glucose
BUN
Normal
65-105
7-21
Creatinine
0.5-1.04
WBC
4.8-10.8
RBC
4.20-5.40
Reasons for Abnormal
↑ 149
↑ 23
↑ 1.12
↑ 12.3
↓ 3.08
Hgb
12.0-16.0
↓ 9.9
Hct
37.0-47.0
↓ 29.3
Revised 3/25/09 NURS 3313 K. Lishman
Determined in new patients to
monitor closely the insuline
dosage to be administered / or if
need
Measures amount of urea
nitrogen in the blood. In
conjunction with creatinine test is
measurement of kidney and liver
function
Measure amount of creatinine in
the blood. Part of measurement of
renal function
Measure total number of WBC in
venous blood, function is to fight
infection and react to foreign
bodies
Counts the number of circulating
red bloods, routinely performed
as part of complete blood
count.Within each RBC are
molecules of hemoglobin that
permit the transpot and exhange
of oxygen to the tissues
Measure as part of complete
blood count, Hgb serves as a
vehicle of oxygen and carbon
disoxide transport.
Measure of the percentage of
total blood volume that is made
up by the red blood cells
Stress can cause increased serum
glucose levels
Hypovolemia, dehydration can
cause increased level (possiblity r/t
NPO of surgery)
Dehydration can cause increased
level, in addition to urinary tract
obstruction
Increased level can indicate
infection, stress, inflammation
Decreased level may indicate
hemorrage, anemia
Decreased levels indicate anemia
Decreased levels indicate anemia
VIII. Medications: List all medications, including IV, IM, PO, SC and prn. FOR ALL IV PIGGYBACKS, please calculate flow rate
and know if the medication is compatible with the rest of the IV drugs/ IV fluids which are listed for your patient. FOR IV PUSH
DRUGS, please know push rate, compatibility with other IV meds/IV fluids and if they need to be diluted and with what.
Medication (Brand and generic as
listed on patient profile), dose,
route and frequency. If IV, include
info. from directions above
Classification (general and
pharmacologic)
Nursing Implications (crossover
allergies, vital sign check
before giving, max dosage per
24 hours,etc.)
Possible side effects
Colace/docusate sodium
100mg capsule
PO
Qday
Therapeutic: Laxative
Pharmacologic: stool softner
Assess for abdominal distention,
bowel sounds, bowel function.
Max dosage 50-400mg in 1-4
divided doses
Lovenox/enoxaparin sodium
30mg
SQ
Q 12 hours
Therapeutic: anticoagulant
Pharmacologic: antithrombotic
Assess for signs of bleeding,
thrombosis. Max dosage 30mg q
12 hours
Dizziness, headache, insomia,
bleeding, anemia
Lipitor/atorvastatin
40mg
PO
HS
Therapeutic: lipid-lowering
Pharmacologic: Reductase
Inhibitor (statin)
Evaluate serium cholesterol and
triglyceride level,monitor liver
function test, if muscle tenderness
monitor CK level; avoid grapefruit
juice, may be administered
anytime of day; do not skip doses.
Max dosage 80mg/day
Dizziness, headache, insomian,
weakness, abdominal cramps,
constipation
Actos/pioglitazone
15mg
PO
QD8
Therapeutic: antidiabetic
Pharmacologic: thiazolidinediones
Observe for s/s hypoglycemic
reaction (sweating, hunger,
weakness, dizziness,
tachycardia). Max dosage
45mg/day
Edema, hepatits, ↑ liver enzymes,
anemai
Amaryl/glimepiride
1mg
PO
QD8
Therapeutic: antidiabetic
Pharmacologic: sulfonyureas
Novolg
(BS-100)/30 for >160 BS
SQ
Q6H
Therapeutic: antidiabetic
Pharmacologic: pancreatic
Low weight Heparin/prevent DVT
Decrease insulin resistance
Stimulate release of insuline from
pancrease and increase sensitivity
of receptor sites
Rapid acting, lower blood glucose
by stimulating uptakein skeletal
muscle and fat
Revised 3/25/09 NURS 3313 K. Lishman
Observe for s/s hypoglycemic
reaction (sweating, hunger,
weakness, dizziness,
tachycardia). Assess for allergy to
sulfaonamides, monitor CBC. Max
dosage 8mg/day
Observe for s/s hypoglycemia
(sweating, hunger, weakness,
dizziness, tachycardia) and
hyperglycemia (confusion,
drowsiness, flushed, dry skin, fruity
breath, poluria, n/v) Max dosage
depends on sliding scale.
Throat irritation, mild cramps
Dizziness, drowsiness, headache,
photsensitivity, aplastic anemia
Hypoglycemia, anaphylaxis,
Onset 10-20 min, peak 1-3 hr,
duration 3-5 hour
Revised 3/25/09 NURS 3313 K. Lishman