CSU, STANISLAUS B.S.N.
CLINICAL PLAN OF CARE
Student:
Jillian Rohde
Date of Care:
12/5/14
Room Number:
Patient Data
Admitting Diagnosis
Right total knee arthroplasty
Age
60 years old
Spiritual Focus
Not specified
Culture
Caucasian; married
Patient Initials
ME
Gender
Male
Height
170.1 cm
Weight
74.8 kg
Admitting Date
12/4/12
Vital Signs
T
36.6 (98)
P
80
R
19
B/P
122/71
O2Sat
96 on room air
Pain Scale
2/10
Past Medical History
MRSA; HTN
Surgical History
Right total knee arthoplasty
Diet:
Regular
Activity:
Crutches, cane, walker, passive ROM q2h, trapeze bed
Foley:
NG/Feeding Tube:
None
Advance Directives:
Yes. Clear yellow
urine output
Yes- wife
Code Status:
Full code
VS Freq:
Q4h
TEDs/SCDs:
Compression stockings
bilateral
Drains/
Tubes:
Glucose
Monitoring:
Foley catheter
Right knee hemovac
Q4h
PCA/Epidural:
None
Telemetry
Continuous cardiac
monitoring
Vascular Access:
IV Site:
Safety Considerations:
Fall precaution; MRSA
Dressing Changes:
Surgical dressing change at 48 hours post op- not color, size, exudate, odor, temperature
Labs to be Drawn:
CBC w Differential
Scheduled Procedures:
Notes on Pathophysiology:
Left forearm
IV Solution: Sodium Chloride 0.9% 1000mL continuous
infusion
Total knee arthroplasty is better known as total knee replacement. It is used as a last resort to relieve pain and
restore function in severely damaged knee joints. Under general anesthesia, the surgeon removes damaged bone and
cartilage from the knee, thigh bone, kneecap, and shin bone and replaces it with an artificial joint made often of high
grade plastic or polymers. This patient was experiencing arthritic pain in his knee prior to the surgery that was caused
by the wearing away of the cartilage in his knee. This caused the bones to rub together as he put pressure on the
knee-walking, jogging, climbing, etc. which caused him pain.
All Lab values WNL except..
Lab and Diagnostic Test Data
Test type
(date)
Blood
Hgb
Normal
Range
13-16
Pt Results
11.1
Trends ↑
L
Rationale
(specific to pt)
Nursing implications related to patient
care & teaching
Could be due to anemia or dietary
deficiency. There was no hemorrhaging
Test type
(date)
Normal
Range
Pt Results
Hct
37-49
32.0
Platelets
130-400
184
Medication Allergies:
Trends ↑
Rationale
(specific to pt)
L
Nursing implications related to patient
care & teaching
during the surgery. Implications would be
to watch for dehydration, fatigue,
dizziness, and headache and lab results
for all RBC, Hemoglobin, Hematocrit and
liver enzymes.
Could be due to anemia or dietary
deficiency. There was no hemorrhaging
during the surgery. Implications would be
to watch for dehydration, fatigue,
dizziness, and headache and lab results
for all RBC, Hemoglobin, Hematocrit and
liver enzymes.
WNL
None
Medications
Generic & Trade Name
Drug Classification
Dose/Route
Frequency
(Therapeutic &Pharmacologic)
Hydromorphone
(Dilaudid)
1 mg IV push prn
for pain 1-3 q4h
Lipitor
(Atorvastatin)
Drug class: Statin
80 mg PO at
bedtime
Action of drug and
Rationale
(specific to Pt)
This medication is used
to treat pain in this
patient as related to
knee pain from surgery
Significant Side Effects
Nursing implications related to
patient care & teaching
Peripheral edema, pruritis,
abdominal pain, xerostomia,
dizziness, UTI, upper
respiratory infection,
fatigue
Monitor pt for respiratory
depression, monitor for nausea,
fatigue, constipation, avoid sudden
discontinuation of drug
Ensure pain is being controlled with
medication by assessing pain on a
0/10 scale
Administer slowly
Monitor this patient’s blood
pressure and ensure they take it
every night before bed
This medication is used
May cause fever or muscle
to lower high cholesterol weakness
and triglyceride levels for
this patient due to his
hyperlipidemia
Tylenol
(Acetaminophen)
Drug class: Analgesic
650 mg q6h PO
prn for pain (1-3)
or temperature
>101
maximum daily
dose of 4000 mg
per day
This drug treats minor
aches and pains and
reduces fever. This
patient currently has
pain due to the wounds
on his legs
Pruritis, Constipation,
Nausea, Vomiting,
Headache, Insomnia,
Agitation, Atelectasis
Temazepam
Drug class: Benzodiazepine
7.5 mg (I cap) po
prn at bedtime for
insomnia
This medication is used
to induce sleep as
needed for the patient
while they are in the
hospital
Somnolence, dizziness
Zofran
(Ondansetron)
Drug class: Antiemetic
4 mg IV q6h prn
for nausea and
vomiting
This medication is used
as needed in the case
that the patient is
Tachypnea, Tachycardia,
fever, headache, SOB
Ensure the patient’s cholesterol
levels are within normal range
Ensure patient’s blood pressure is
within normal range (90-120)/(6080)
Have patient rate pain 1-10 to
determine whether Tylenol is
appropriate. Record patient’s
temperature q4h or as needed when
patient’s skin feels warm, wet, or
consciousness is altered. Monitor
patient’s pain level or temperature
thereafter and for any adverse
effects
Patient must state that they need
the medication for the induction of
sleep.
Advise that pt will be sleepy and
might be altered or dizzy upon
standing so pt should remain in bed
Monitor respiration level and o2
saturation
Monitor the pt for nausea and
vomiting and administer as needed
Monitor the patient’s vitals
Hydromorphone
(Dilaudid)
2 mg IV push prn
for pain 4-7 q4h
This medication is used
to treat pain in this
patient as related to
knee pain from surgery
Peripheral edema, pruritis,
abdominal pain, xerostomia,
dizziness, UTI, upper
respiratory infection, fatigue
Hydromorphone
(Dilaudid)
4 mg IV push prn
for pain 8-10 q4h
Peripheral edema, pruritis,
abdominal pain, xerostomia,
dizziness, UTI, upper
respiratory infection, fatigue
Docusate Sodium
Drug class: Stool Softener
100 mg/1 Tablet,
NG, Daily
This medication is used
to treat pain in this
patient as related to
knee pain from surgery
nauseous or vomiting to
block the chemicals that
trigger it
This medication is used
to treat Constipation
Flu-like syndrome, fatigue,
pain, edema, hypertension,
thrombocytopenic purpura,
Monitor pt for respiratory
depression, monitor for nausea,
fatigue, constipation, avoid sudden
discontinuation of drug
Ensure pain is being controlled with
medication by assessing pain on a
0/10 scale
Administer slowly
Monitor pt for respiratory
depression, monitor for nausea,
fatigue, constipation, avoid sudden
discontinuation of drug
Ensure pain is being controlled with
Carefully monitor for and
immediately report S&S of GI
bleeding.
Vancomycin HCl in
Sodium Chloride 0.9%
Drug class: Antibiotic
250 mL @ 125
mLs/hr IVPB Q12H
This medication is used
to prevent infection
(Antibacterial)
dyspepsia, diarrhea, nausea,
hypercholesterolemia,
headache, dizziness,
depression, URI rash,
pruritus, cough, rhinitis
Nephrotoxicity leading to
uremia, shock-like state,
anaphylactoid reaction with
vascular collapse, leukopenia
– all life-threatening effects
Report any unusual bleeding. Avoid
omeprazole, esomeprazole, or other
over the counter acid reducing
drugs. Only take aspirin or NSAID if
approved by prescriber.
Monitor BP and heart rate
continuously during drug
administration.
Notify prescriber immediately of
ringing in ears. The full course of
prescribed medication must be
completed.
Evaluate Effects of Nursing Actions – Patient Response/Outcomes
Chief Medical Diagnosis:
Priority Assessments:
1. Nursing Care: Risk for infection
Nursing Actions:
Assess incision wound every shift and document size,
color, redness, warmth, and healing stage
Maintain sterile dressing for the first 48 hours and then
leave open to air while still assessing edges of wound
for healing process
Assess for signs of infection, redness, swelling, heat
Collaborate with dietician to develop meal plan to
promote tissue healing
Maintain good handwashing technique
Patient Response and Outcome:
2. Nursing Care: Pain r/t post operation
Nursing Actions:
Administer pain medication as indicated
Assess pain level frequently
Maintain patient in comfortable position in bed
Maintain adequate pain medication administration
before procedures and activities
Apply ice packs as indicated
Patient Response and Outcome:
Patient’s pain level reduce to 2/10 from 6/10
Patient able to maintain bedrest without excessive
pain or discomfort
Patient responding well to pain medication-no sideeffects
3. Nursing Care: Decreased mobility r/t total knee
arthroplasty
Nursing Actions:
Maintain affected knee in prescribed position and body
in alignment while in bed
Support position while in bed with pillows
Demonstrate and assist with mobility using trapeze
device
Inspect skin, observe for reddened areas. Keep linens
dry and wrinkle-free. Massage skin and bony
prominences routinely. Protect operative heel,
elevating whole length of leg with pillow
Perform and assist with ROM exercises q2h
Ensure foley catheter is in place
Patient Response and Outcome:
Patient’s right knee is immobilized and cushioned
with pillows between the extremity and the bed
Patient’s affect leg raised on pillow
Patient used trapeze device to assist with mobility
Patient has foley in place with clear, yellow urine and
adequate output
Patient presents with no reddened areas of skin
Patient has crutches at bedside to assist with
ambulation
Patient’s wound clean and dry
No evidence of drainage or signs of infection
Patient maintaining high protein diet and ingesting
>70% for increased tissue healing
Patient’s temperature is normal at 36.6