UNIVERSITY OF SOUTH FLORIDA



UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

|Fundamental Patient Assessment Tool |Student: Ariel Varela |

|. |Assignment Date: 12/04/2015 |

| ( 1 PATIENT INFORMATION |Agency: Sarasota Memorial Hospital |

|Patient Initials: CDM |Age: 70 |Admission Date: 11/12/2015 |

|Gender: male |Marital Status: married |Primary Medical Diagnosis inpatient surgery, lt hip oa |

|Primary Language: English | |

|Level of Education: Master’s Degree in Fine Arts, Master’s Degree in Child Psychology |Other Medical Diagnoses (new on this admission): |

| |N/A |

|Occupation (if retired, what from?): Retired high school art teacher and wrestling coach for| |

|40 years | |

|Number/ages children/siblings: no children, no siblings | |

|Served/Veteran: no |Code Status: Full |

|If yes: Ever deployed? Yes or No | |

|Living Arrangements: lives with wife in a single-story house |Advanced Directives: yes |

| |If no, do they want to fill them out? |

| |Surgery Date: 11/12/2015 Procedure: It hip oa |

|Culture/ Ethnicity /Nationality: Irish American | |

|Religion: Methodist |Type of Insurance: Medicare Blue Cross |

|( 1 CHIEF COMPLAINT: “My doctor was getting me ready for surgery on both my knees but I told him how awful the pain in my hip had become so he decided to operate |

|on my hip first instead.” |

| |

| |

| |

|( 3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of stay) |

|The patient is a 70 year old male who has undergone inpatient surgery alleviate pain caused by osteoarthritis. The onset of the hip pain was about two to three |

|months ago. The location of the pain was medial the left hip and it lasted “all day every day for about two or three months.” The patient says it started out as a |

|dull ache, “maybe a 1 or 2 just more annoying than anything,” but gradually got more intense until it reached a 9 out of 10 on the pain scale. The patient says |

|once the pain got more noticeable he would try different sleeping positions, applying heat and ice throughout the day, sitting in different furniture throughout |

|the house and changing positions often, and taking over the counter pain relievers such as Aleve. The patient says that after a few weeks his home treatments no |

|longer helped in alleviating his pain. The patient is hopeful that once he heals from surgery and is weaned off his pain medications he will be more functional, |

|though he still needs to have surgery on both his knees soon afterwards to attain more ability to participate in his activities of daily living. |

( 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical illness or operation; include treatment/management of disease

|Date |Operation or Illness |

|Shortly after birth |Bilateral hydrocele |

|When patient was a teenager|Tonsils removed |

|N/A |5 right knee surgeries |

|N/A |2 left knee surgeries |

|N/A |2 sports inguinal hernias |

|N/A |Got steel in left eye from a machine at work, magnet was used and was successful in removing steel |

|N/A |Got steel in right eye from pieces of steel in sweater at work, magnet could not remove steel pieces so drill was used to remove |

| | |

|( 2 FAMILY MEDICAL HISTORY |

|( 1 immunization History |

|(May state “U” for unknown, except for Tetanus, Flu, and Pna) |Yes |No |

|Routine childhood vaccinations | | |

|Routine adult vaccinations for military or federal service | | |

|Adult Diphtheria (Date) U | | |

|Adult Tetanus (Date) Is within 10 years? U | | |

|Influenza (flu) (Date) Is within 1 years? Last month | | |

|Pneumococcal (pneumonia) (Date) Is within 5 years? U | | |

|Have you had any other vaccines given for international travel or occupational purposes? Please List Spinal | | |

|Meningitis | | |

If yes: give date, can state “U” for the patient not knowing date received

|( 1 ALLERGIES OR ADVERSE |NAME of |Type of Reaction (describe explicitly) |

|REACTIONS |Causative Agent | |

|Medications |None | |

| | | |

| | | |

| | | |

| | | |

| | | |

|Other (food, tape, latex, dye, |ragweed |Hay fever, eyes water, roof of mouth itches, nose runs |

|etc.) | | |

| |milk |Skin flakes on face |

| | | |

| | | |

|( 5 PATHOPHYSIOLOGY: (include APA reference and in text citations) (Mechanics of disease, risk factors, how to diagnose, how to treat, prognosis, and include any |

|genetic factors impacting the diagnosis, prognosis or treatment) |

|The patient has osteoarthritis, which is when the cartilage surrounding the joints begins to wear down. (What is Osteoarthritis?) Osteoarthritis most commonly |

|affects the joints of the wrist, hands, knees, hips and spine, and in this patient’s case, it is affecting both of his knees and his left hip. Osteoarthritis can |

|affect people at any age, but it “is most common in people over 65.” (What is Osteoarthritis?) Risk factors for developing osteoarthritis include having a family |

|history of the condition, being overweight, overuse or repetitive injury to a bone, bone and joint disorders and metabolic disorders. The most common symptoms of |

|osteoarthritis is pain and stiffness in a particular joint, “particularly first thing in the morning and after resting.” (Osteoarthritis Symptoms) Symptoms may |

|also include swelling around a joint, limited range of motion and hearing a cracking sound when the joint is bent. (Osteoarthritis Symptoms) In order to diagnose |

|osteoarthritis, a family history will be taken as well as the patient’s symptoms. Then the patient’s range of motion in their joints to find where it may be |

|limited and if there is any swelling or pain that could indicate cartilage damage. Diagnostic tests that can be done include a joint aspiration, an x-ray, and an |

|MRI scan. A joint aspiration is when fluid is removed from the affected joint and then tested for crystals and evidence of deterioration. An x-ray or and a MRI |

|scan can show how much damage the cartilage has sustained. There is no cure for osteoarthritis, but its progression can be slowed. Treatment is focused on reducing|

|the patient’s pain to more manageable levels and improving their mobility. Analgesics, NSAIDS, corticosteroids and hyaluronic acid can be prescribed to alleviate |

|the patient’s joint pain. Natural remedies can be used to provide joint pain relief as well, such as “acupuncture or acupressure, massage, relaxation techniques |

|and hydrotherapy. Increasing the amount of physical activity the patient participates in is important in reducing pain and maintaining a healthy weight, and |

|patients with osteoarthritis are recommended to get “150 minutes of moderate exercise per week.” (Osteoarthritis Treatment) Weight loss is a way to reduce the pain|

|on the joints, as less weight will mean less stress on the joint. Physical and occupational therapists can help patients with their pain management in a number of |

|ways, including “ways to properly use joints, heat and cold therapies, and range of motion exercises.” (Osteoarthritis Treatment) Physical therapists can also |

|assess what assistive devices the patient may need, such as a cane or walker, and show the patient how to properly use them. Surgery can used to “repair or replace|

|severely damaged joints.” (Osteoarthritis Treatment) |

( 5 Medications: [Include both prescription and OTC; hospital, home (reconciliation), routine, and PRN medication (if given in last 48°). Give trade and generic name.]

|Name Triamterene |Concentration 50 milligrams |Dosage Amount 50 milligrams |

|Route PO |Frequency once a day |

|Pharmaceutical class Potassium-Sparing Diuretic | Both |

|Indication To help get rid of all the fluids he received during surgery |

|Adverse/ Side effects hyperkalemia and GI disturbances |

|Nursing considerations/ Patient Teaching Avoid foods rich in potassium, encourage patient not to discontinue without first consulting health care provider |

|Name Tramadol |Concentration 50 milligrams |Dosage Amount 50 milligrams |

|Route PO |Frequency Q6H PRN for pain |

|Pharmaceutical class Narcotic, pain reliever |Both |

|Indication Post-surgical pain |

|Adverse/ Side effects constipation, headache, dizziness, drowsiness |

|Nursing considerations/ Patient Teaching take exactly as prescribed, keep out of reach of children |

|Name Cholecalciferol |Concentration 1000 units |Dosage Amount 1000 units |

|Route PO |Frequency once a day |

|Pharmaceutical class Vitamin D3 | Hospital |

|Indication Improve absorption of calcium to strengthen bones |

|Adverse/ Side effects allergic reaction, nausea/ vomiting, constipation, loss of appetite |

|Nursing considerations/ Patient Teaching do not take vitamin supplements without first consulting provider |

|Name Ondansetron |Concentration 4 milligrams |Dosage Amount 4 milligrams |

|Route IV |Frequency every 12 hours as needed for nausea or vomiting |

|Pharmaceutical class Antiemetic | Hospital |

|Indication prevents vomiting caused by surgery |

|Adverse/ Side effects blurred vision, temporary vision loss, urinary retention, headache |

|Nursing considerations/ Patient Teaching watch for signs of an allergic reaction: fast heartbeat, yellowing of the skin or eyes, blurred vision |

|Name Celecoxib |Concentration 200 milligrams |Dosage Amount 200 milligrams |

|Route PO |Frequency once a day |

|Pharmaceutical class | Hospital |

|Indication |

|Adverse/ Side effects |

|Nursing considerations/ Patient Teaching |

|Name Aspirin |Concentration 325 milligrams |Dosage Amount 325 milligrams |

|Route PO |Frequency once a day |

|Pharmaceutical class Salicylate/NSAID | Hospital |

|Indication Reduce pain and swelling |

|Adverse/ Side effects upset stomach, heartburn, ringing in the ears |

|Nursing considerations/ Patient Teaching limit alcoholic beverages, report any ringing in the ears |

|Name Gabapentin |Concentration 300 milligrams |Dosage Amount 300 milligrams |

|Route PO |Frequency twice a day |

|Pharmaceutical class Anticonvulsant |Hospital |

|Indication Relieve nerve pain |

|Adverse/ Side effects drowsiness, dizziness, loss of coordination, tremors |

|Nursing considerations/ Patient Teaching report any changes in mood such as depression or thoughts of suicide |

|Name Cialis |Concentration 20 milligrams |Dosage Amount 20 milligrams |

|Route PO |Frequency once a day as needed |

|Pharmaceutical class PDE5 Inhibitor |Home |

|Indication Relive symptoms of BPH |

|Adverse/ Side effects headache, upset stomach, muscle pain, back pain, dizziness, lightheadedness |

|Nursing considerations/ Patient Teaching do not drive or operate machinery until you are sure you can do so safely |

|Name Aleve |Concentration 220 milligrams |Dosage Amount 220 milligrams |

|Route PO |Frequency four times a day as needed for pain |

|Pharmaceutical class NSAID |Home |

|Indication Reduces inflammation and pain |

|Adverse/ Side effects indigestion, headache, shortness of breath |

|Nursing considerations/ Patient Teaching report any chest pain or signs of an allergic reaction |

|( 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations. |

|Diet ordered in hospital? Regular diet |Analysis of home diet (Compare to “My Plate” and |

|Diet patient follows at home? Regular diet |Consider co-morbidities and cultural considerations): |

|24 HR average home diet: |[pic] |

|Breakfast: Toast (1 slice) and oatmeal |As the graph shows, the patient is eating more than the recommended amount of |

| |protein and grains. The patient needs to increase his intake of dairy and fruits.|

| |The patient has a hard time eating fruits because he does not like most of them, |

| |but says he’s open to trying new ones when opportunity presents itself. The |

| |patient eats pasta often because it is a staple of Italian culture, and his wife |

| |is Italian. The patient should switch out the refined pasta for whole grain pasta|

| |to increase intake of whole grains. The patient likes to eat vegetables, so |

| |increasing his intake won’t be very hard. In a typical day the patient only eats |

| |1,480 calories when the average allowed is 2,000, so the patient is not in danger|

| |of gaining weight from over eating. The patient also eats 2,183mg of sodium when |

| |the limit is 2,300mg, which will help keep his high blood pressure under control.|

| | |

|Lunch: Sandwich with turkey, low fat cheese, low calorie bread (2 slices) and | |

|vegetables (1 serving) | |

| | |

|Dinner: Sausage, pork, steak or grilled chicken with pasta | |

| | |

|Snacks: Salad, nuts | |

| | |

|Liquids (include alcohol): Sweet tea (8 oz), beer (12 oz) | |

| | |

|[pic] | |

|(1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion) |

|Who helps you when you are ill? “My wife’s been helping through all my knee and hip issues.” |

| |

|How do you generally cope with stress? or What do you do when you are upset? |

|Patient uses meditation and deep breathing exercises to relax, like to paint or sculpt when stressed |

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|Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life) |

|“I just feel a little overwhelmed with this hip issue since my doctor had me all jazzed up to fix my knees then we had to change course at the last minute.” |

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|+2 DOMESTIC VIOLENCE ASSESSMENT |

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|Consider beginning with: “Unfortunately many, children, as well as adult women and men have been or currently are unsafe in their relationships in their homes. I |

|am going to ask some questions that help me to make sure that you are safe.” |

| |

|Have you ever felt unsafe in a close relationship? _No______________________________________________________ |

| |

|Have you ever been talked down to? ___No____________ Have you ever been hit punched or slapped?  ____No____ |

| |

|Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?  |

|________________No___________________ If yes, have you sought help for this?  _____N/A________________ |

| |

|Are you currently in a safe relationship? Yes |

| |

| |

|( 4 DEVELOPMENTAL CONSIDERATIONS: |

|Erikson’s stage of psychosocial development: Trust vs. Mistrust Autonomy vs. Doubt & Shame Initiative vs. Guilt Industry vs. Inferiority Identity vs. |

|Role Confusion/Diffusion Intimacy vs. Isolation Generativity vs. Self absorption/Stagnation Ego Integrity vs. Despair |

|Check one box and give the textbook definition (with citation and reference) of both parts of Erickson’s developmental stage for your |

|patient’s age group: |

|The patient is 70 years old, which places him at Stage 8 of Erikson’s stages of psychosocial development, which is ego integrity vs despair. The goal in this final|

|stage in life is to accept both one’s life and impending death. Ego integrity is demonstrated through “a satisfaction with life and an understanding of one’s place|

|in the life cycle.” (Treas & Wilkinson, 2014) Despair is demonstrated in “a sense of loss, discomfort with life and aging, and a fear of death.” (Treas & |

|Wilkinson, 2014) |

|Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination: |

|My patient exhibits Ego Integrity. He has a very positive outlook on life and loves to talk about his past career as a teacher and wrestling coach, so it is clear |

|he is satisfied overall with how his life turned out. He does not shy away from the topic of death and shows no fear of it. |

|Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life: |

|Due to the patient’s osteoarthritis, he has not been able to be as active as he was once. Being in the hospital has kept him away from his friends, though the |

|patient does state that having a Facebook account has helped him stay in touch with family, friends, and his former students, so he is not too down about his |

|hospital stay. |

|+3 CULTURAL ASSESSMENT: |

|“What do you think is the cause of your illness?” |

|Patient believes that his arthritis is the result of the normal aging process |

|What does your illness mean to you? |

|Patient believes that his arthritis is nothing too difficult for him to handle and considers himself lucky that he doesn’t have more serious health issues given |

|his age |

|+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion) |

|Consider beginning with:  “I am asking about your sexual history in order to obtain information that will screen for possible sexual health problems, these are |

|usually related to either infection, changes with aging and/or quality of life.  All of these questions are confidential and protected in your medical record” |

| |

|Have you ever been sexually active?_Yes________________________________________________________________ |

|Do you prefer women, men or both genders? _Women_____________________________________________________ |

|Are you aware of ever having a sexually transmitted infection? _No___________________________________________ |

|Have you or a partner ever had an abnormal pap smear? __No____________________________________________ |

|Have you or your partner received the Gardasil (HPV) vaccination? __No_____________________________________ |

|Are you currently sexually active?   _______Yes__________________ If yes, are you in a monogamous relationship? _______Yes_____________ When sexually active, what |

|measures do you take to prevent acquiring a sexually transmitted disease or an unintended pregnancy?  __None, wife has reached menopause and can no longer get |

|pregnant, and patient is in a monogamous relationship so patient feels there’s no need to be concerned about STDs__ |

| |

|How long have you been with your current partner?____10 years_____________________________________________ |

| |

|Have any medical or surgical conditions changed your ability to have sexual activity?  ___No______________________ |

| |

|Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy? |

|No |

±1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)

What importance does religion or spirituality have in your life?

Patient believes the mind-body connection is very important and enjoys meditation

Do your religious beliefs influence your current condition?

Patient states that he likes to learn about other religions and doesn’t attend church often, patient does not believe religion influences his health

|+3 Smoking, Chemical use, Occupational/Environmental Exposures: |

|1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? Yes No |

| If so, what? Never smoked |How much?(specify daily amount) |For how many years? n/a |

| |n/a |(age thru ) |

| | | |

|Pack Years: n/a | |If applicable, when did the patient quit? |

| | | |

|Does anyone in the patient’s household smoke tobacco? If so, what, and how much? no|Has the patient ever tried to quit? n/a |

| |If yes, what did they use to try to quit? n/a |

| |

| |

|2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No |

| What? |How much? 2-3 times weekly |For how many years? 40 |

| |Volume: standard drink size |(age 30 thru 70 ) |

| |Frequency: 1-2 a day | |

| If applicable, when did the patient quit? | | |

| n/a |

| |

|3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes No |

| If so, what? n/a |

| |How much? n/a |For how many years? n/a |

| | |(age thru ) |

| | | |

| Is the patient currently using these drugs? Yes No |If not, when did he/she quit? |n/a |

| | | |

| | | |

|4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks |

|Patient worked in a factory and was exposed to chemicals and metals, patient was also potentially exposed to spinal meningitis while working as a teacher when one |

|of his students contracted the disease |

| |

|5. For Veterans: Have you had any kind of service related exposure? n/a |

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( 10 Review of Systems Narrative

|General Constitution (OLDCART anything checked above) |

|How do you view your overall health? |

|“Given my age, I think I’m fairing pretty well.” |

|Integumentary: Patient denies any problems with his nails, dandruff, psoriasis, hives, rashes, or skin infections. Patient reports having flaking skin on his nose |

|when he eats dairy. Patient reports using sunblock when he plans to be outdoors for a long period of time and that he uses whatever SPF sunscreen is on sale. |

|Patient reports he normally bathes at home every night and has been receiving bed baths at the hospital daily. |

|HEENT: Patient denies having cataracts, glaucoma, ear infections, sinus infections, nose bleeds, post-nasal drip, oral/pharyngeal infection, or dental problems. |

|Patient reports having a small blind spot in the right eye where a piece of steel once fell in, patient denies any pain in his eye. Patient reports difficulty |

|hearing in both ears. Patient reports brushing his teeth once a day. Patient reports not having a visual screening or a dental appointment in several years. |

|Pulmonary: The patient denies having any difficulty breathing, coughing, asthma, bronchitis, emphysema, pneumonia or tuberculosis. Patient reports having seasonal |

|allergies to ragweed. Patient reports not recalling if he’s had a chest x-ray done. Patient’s chart says no CXR report is available. |

|Cardiovascular: The patient denies having chest pain, a myocardial infarction, CAD/PVD, CHF, heart murmur, thrombus, rheumatic fever, myocarditis, or arrhythmias. |

|The patient reports having hypertension and hyperlipidemia. Patient reports last EKG screening was on 11/06/2015, reports having sinus rhythm. |

|GI: Patient denies having any nausea, vomiting, GERD, indigestion, hemorrhoids, yellow jaundice, pancreatitis, colitis, diverticulitis, appendicitis, abdominal |

|abscess, irritable bowel, cholecystitis, gastritis/ulcers, blood in the stool or hepatitis. Patient reports being constipated and has not had a bowel movement in |

|two days, which is expected for post-op patients. |

|GU: Patient denies experiencing nocturia, dysuria, hematuria, polyuria, kidney stones or bladder or kidney infection. Patient reports voiding 3-4 times daily. |

|Women/Men Only: Patient denies having an infection of genitalia/prostate or urinary retention. Patient reports mild BPH. Patient reports having prostate exams every|

|few years and does not remember when was his last exam. |

|Musculoskeletal: Patient denies any injuries or fractures, muscle weakness, pain, gout or osteomyelitis. Patient reports having osteoarthritis. |

|Immunologic: Patient denies having any chills with severe shaking, night sweats, fever, HIV or AIDS, lupus, rheumatoid arthritis, sarcoidosis, tumor, life |

|threatening allergic reaction, and enlarged lymph nodes. |

|Hematologic/Oncologic: Patient denies having anemia, bleeding easily, bruising easily, cancer, or having a blood transfusion. Patient reports his blood type is O+. |

|Metabolic/Endocrine: Patient denies having diabetes, hyper/hypothyroidism or intolerance to hot or cold. Patient reports having osteoarthritis. |

|Central Nervous System: Patient denies experiencing CVA, dizziness, severe headaches, migraines, seizures, ticks or tremors, encephalitis, and meningitis. |

|Mental Illness: Patient denies having depression, schizophrenia, anxiety, or bipolar disorder. |

|Childhood Diseases: Patient reports having had mumps and chicken pox. Patient denies having had measles, polio or scarlet fever. |

|Is there any problem that is not mentioned that your patient sought medical attention for with anyone? |

|No |

|Any other questions or comments that your patient would like you to know? |

|No |

|±10 PHYSICAL EXAMINATION: |

|General survey _____________________________________________________________________________________ |

|Height 66.5 inches Weight 232.8 lb. BMI 37 kg/m2 Pain (include rating and location) 2, left hip (surgical site) |

|Pulse 89 Blood Pressure (include location) 139/66 left arm Temperature (route taken) 97.8 F oral |

|Respirations 18 SpO2 95 % Room Air |

|Overall Appearance The patient’s overall appearance is clean, his hair is combed, he is dressed appropriately for the setting and temperature, he maintains eye |

|contact and though he reports being hard of hearing we had no difficulties communicating with each other. His only handicap at the moment is his hip since he just |

|had surgery done on it. |

|Overall Behavior The patient is awake, calm and relaxed. He interacts well with others and his judgement is intact. |

|Speech The patient has clear, crisp dictation. |

|Mood and Affect The patient is pleasant, cooperative, and very talkative. |

|Integumentary The patient’s skin is warm, dry and intact. The skin turgor is elastic, and there are no rashes, lesions or deformities other than the surgical |

|incision site. The patient’s nails are without clubbing, capillary refill is less than 3 seconds, and the patients hair is evenly distributed in a widow’s peak |

|fashion and is clean without vermin. |

|IV Access The patient had just gotten his peripheral IV in his left arm removed by the previous shift, the bandage was still over the site so I did not remove the |

|bandage to assess the site. The bandage is dry and has no dried blood or fluids on it. Patient reports no pain, itchiness or discomfort at the site. |

|HEENT The patient’s facial features are symmetric and the patient denies any pain in his sinus region. The patient denies having jaw pain or clicking of his TMJ. The|

|patient’s trachea is midline and his thyroid gland is not enlarged. The patient does not have palpable lymph nodes His sclera is white and his conjunctiva is clear; |

|both are without discharge. The patient’s eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands are symmetric and without edema or tenderness. The |

|patient’s pupils are equal, round and reactive to light accommodation. His peripheral vision is intact, except for a small blind spot in the right eye. The patient’s|

|EOM is intact through the 6 cardinal fields and without nystagmus. The patient’s ears are symmetric and without lesions or discharge. The patient’s nose is without |

|lesions or discharge. His lips, buccal mucosa, floor of mouth, and tongue are pink, moist and without lesions. |

|Pulmonary/Thorax The patient’s respirations are regular and unlabored. His transverse to AP ratio is 2:1 and his chest expansion is symmetric. Percussion was |

|resonant throughout all lung fields and dull towards posterior bases. The patient has no sputum production. The patient’s lung sounds were clear in all upper areas,|

|however there were diminished sounds bilaterally at the bases, which is to be expected after surgery. |

|Cardiovascular There were no lifts, heaves, or thrills auscultated. The S1 and S2 heart sounds were audible and regular. No murmurs, clicks, or adventitious heart |

|sounds were auscultated. Pulses bilaterally equal in all pulse sites with all of them rated at a 2. No temporal or carotid bruits were auscultated and slight edema |

|was detected on both legs, rated a +1 on both legs. Extremities warm with capillary refill less than 3 seconds. |

|GI Bowel sounds were active x4 quadrants and no bruits were auscultated. The patient has no organomegaly. Percussion was dull over the liver and spleen, and tympanic|

|over the stomach and intestines. The patient’s abdomen was non-tender to palpitation. The patient’s last bowel movement was two days ago, and the patient describes |

|it as being hard, semi-formed and dark brown, not how it usually is. The patient denies having nausea or emesis. The patient’s genitalia was not assessed, patient |

|was alert, oriented and denies having any problems. |

|GU The patient has a bedside urinal with clear yellow urine. The patient has bathroom privileges with assistance for bowel movements, though he has yet to have one. |

|Musculoskeletal Full ROM in upper extremities without crepitus. The patient’s strength is bilaterally equal for both his RUE and LUE and are rated a 5. The patient’s|

|strength is bilaterally equal for his RLE AND LLE and are rated a 3, due to his surgery and the arthritis in both of the patient’s knees. The patient’s vertebral |

|column is without kyphosis or scoliosis. The patient’s neurovascular status is intact. The patient’s peripheral pulses are palpable, the patient reports no pain and |

|he has no pallor, paralysis nor paresthesia. |

|Neurological The patient is awake, alert, and oriented to person, place, time, and date. The patient’s CN 2-12 is grossly intact. The patient’s sense of sensation is|

|intact to touch, pain and vibration. The patient has a very difficult time getting into and out of bed due to the pain in his hip when he moves, so the Romberg test |

|was not performed. His gait was assessed while the patient care technician helped him move from his chair to his bed, which was slow and very unsteady. The patient |

|used both a walker and the help of the PCT to move and he shuffled his feet because it hurt to move his hip. Stereognosis, graphesthesia, and proprioception are all |

|intact. The DTR reflex of the patient’s triceps, biceps, brachioradial are rated at +2, while his patellar and Achilles reflexes were not assessed due to the pain |

|associated with him sitting up and moving his legs over the edge of the bed. The patient’s Ankle clonus reflex is negative and his Babinski reflex is negative. |

| |

|±10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well as abnormals, include rationale and analysis. List dates with all labs and |

|diagnostic tests): |

| |

| |

|Lab |

|Dates |

|Trend |

|Analysis |

| |

|HGB |

|15.8 |

| |

|13.9 |

|Normal 12.1-17.6 g/dL |

| |

|11/06/2015 |

| |

|11/13/2015 |

|Upon admit, the patient’s hemoglobin was on the higher end of the normal range. A day after surgery, the HGB dropped slightly but is still within normal range. |

|A small drop in hemoglobin could be a result of blood loss during surgery, should be monitored to make sure it does not decrease further. |

| |

|Potassium |

|4.4 |

| |

|3.4 |

|Normal 3.7-5.4 mmol/L |

| |

| |

|11/06/2015 |

| |

|11/13/2015 |

|Upon admit, the patient’s potassium was within normal range. A day after surgery, the patient’s potassium dropped closer to the minimum limit. |

|The patient is on a potassium-sparing diuretic, so the potassium levels shouldn’t drop much lower. The potassium needs continuous monitoring as the diuretic could |

|cause hyperkalemia. |

| |

|+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Diet, vitals, activity, scheduled diagnostic tests, consults, accu checks, etc. Also provide rationale and |

|frequency if applicable.) |

|The patient follows a normal diet both at the hospital and at home. A physical therapist comes by three to four times a day to help the patient walk down the hallway|

|and become more comfortable with using his walker. The patient is to send to a rehab facility to help with his recovery from surgery. The patient is to have his |

|Mepilex dressing removed 5-7 days post op. and is to be given an extra Mepilex dressing to take to rehab with him to replace the first one if there is excess |

|drainage. |

| |

|( 8 NURSING DIAGNOSES (actual and potential - listed in order of priority) |

|1. Risk of injury related to post-surgical pain and drowsiness effect of pain medication. |

|2. Impaired physical mobility related to post-surgical pain and osteoarthritis. |

± 15 CARE PLAN

Nursing Diagnosis: Risk of injury related to post-surgical pain and drowsiness effect of pain medication.

|Patient Goals/Outcomes |Nursing Interventions to Achieve Goal |Rationale for Interventions |Evaluation of Goal on Day Care is Provided |

| | |Provide References | |

|Patient will be able to walk without injury |-Patient will walk 3-4 times a day with assistance |-Physical therapy can provide the patient with |-Have the patient demonstrate use of crutches and |

| |during hospital stay |education on techniques for getting out of bed and |other assistive devices |

| |-Physical therapy will assist the patient with |standing up without putting too much pressure on the |-Make sure physical therapy comes to see patient |

| |ambulation |hip joint so the patient can learn to move more |-Ask the patient if they have sustained any injuries |

| |-The patient will be taught how to properly use |independently |while walking |

| |assistive devices for ambulating |-The patient’s wife recently had back surgery so she |-Check with other team members such as the patient’s |

| |-The patient will be provided with non-skid socks |is unable to help him with physical activities. The |Patient Care Technician to see if the patient |

| |-Ask the patient what can be done to help prevent |patient is at a lesser risk for falling if he is able|experienced any injuries |

| |falling |to move around independently and confidently | |

| | |-Non-skid socks will reduce the risk of the patient | |

| | |sliding and falling | |

| | |-Asking the patient what exactly he is struggling | |

| | |with will help determine patient teaching. For | |

| | |example, the patient stated that he could not move | |

| | |his buttocks off the bed, so he had to be taught how | |

| | |to use the bedrails to help push himself off the bed | |

|Patient’s pain will remain at a 2 during hospital |-Patient’s pain medication will be provided as |-If the patient is experiencing pain then he should |-Assess the patients pain level using the 1-10 pain |

|stay |ordered by the provider (every 6 hours) when |be given the pain medication when it is due so that |rating scale during hourly rounds |

| |requested by the patient |the pain does not get worse |-Assess the patient for any signs of pain during |

| |-The patient will be provided with anti-inflammatory |-Reducing inflammation will also help to reduce the |interactions, such as grimacing, labored breathing or|

| |medication as ordered by the provider |pain on the joint |rubbing at the surgical site |

|Patient will not experience excessive drowsiness or |-The patient will receive pain medication only when |-If the patient does not need the pain medication |-Assess the patient’s alertness during hourly |

|tiredness as a side effect of pain medication |requested |right at the six hour mark then it should be held |rounding. If the patient is asleep, any physical |

| |-The patient will be provided with an ice pack for |until he does need it. If the patient is given the |therapy activities will have to be pushed back |

| |his hip and the ice will be replaced as it melts |pain medication when he is not experiencing much |because the patient should not be walking around if |

| | |pain, it could make him drowsy |they are sleepy |

| | |-The ice pack will help reduce the inflammation of |-Try using alternative methods for pain management if|

| | |the joint, which will also reduce the pain. Reducing |the patient is about to engage in physical activity, |

| | |the pain with nonpharmacological methods will reduce |such as relaxation techniques or meditation |

| | |the patient’s need for medication, which will keep | |

| | |him from getting drowsy | |

|±2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching) |

|Consider the following needs: |

|□SS Consult |

|X Dietary Consult |

|X PT/ OT |

|□Pastoral Care |

|X Durable Medical Needs |

|X F/U appointments |

|X Med Instruction/Prescription |

|□ are any of the patient’s medications available at a discount pharmacy? Yes |

|X Rehab/ HH |

|□Palliative Care |

References

(n.d.). Retrieved November 26, 2015, from

Treas, L. S., & Wilkinson, J. M. (2014). Basic Nursing: Concepts, Skills, & Reasoning. Philadelphia: F.A. Davis Company.

Kee, J., Hayes, E., & McCuistion, L. (2014). Pharmacology: A patient-centered nursing process approach (8th ed.). Elsevier.

United States Department of Agriculture. (2015, November 28). MyPlate. Retrieved from :

Instructor feedback:

Very good discussion od the pathophysiology of the disease. Make sure you provide appropriate citation of article or reference.

Vivien Cruz , Dec 5, 2015

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