NURSING CARE PREPARATION



NURSING CARE PREPARATION

Student Name: Sue Mathews Date of Care: 10/09/14

|Unit/Room Number: PSU/386 |Date of Admission: 10/08/2014 |

|Age: 81 |Ethnic/Cultural Preferences: Caucasian/Non-Hispanic/Christian |

|Gender: Male |Allergies: ASPIRIN |

|Erikson’s Developmental Level: Integrity vs. Despair |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 |IV (Fluid type, rate, access type): Peripheral IV Right forearm, 18 gauge |

| |catheter, Sodium Chloride via pump and Hydromorphone via PCA |

|I&O (MD order/Nursing Order/Frequency): Nursing order/every shift |CBG (Yes/No, frequency): No |

|Fall Risk/Safety Precautions (Yes/No): Yes, Morse score 70; yellow gown/yellow |Activity (What is ordered): LLE weight bearing as tolerated post op to be started|

|wristband in place |after PT evaluation; hip sling for 2 hours BID morning and evening shift as |

| |tolerated; Offload heels, encourage ankle pumps, turn every 2 hours |

|Wound Care (Yes/No): No, may reinforce left hip dressing PRN |Oxygen (Yes/No, Delivery method, how much): No |

|Drains (Yes/No, Type): Foley catheter |Last BM: 10/07/14 |

|Other Tubes: No | |

ASSESSMENTS

(Include Subjective & Objective Data)

|Integumentary: |Head and Neck: |

|skin is warm, dry, tan |neck is soft without lumps, lesions, or bruising |

|no clubbing or discoloration of nails, nail bed pale; oral mucosa is pink, moist,|hair distribution even; facial features symmetrical |

|without lesions or tenderness; dressing of the incision was found to have | |

|shadowing but was not increasing or coming through | |

| | |

|Ear/Nose/Throat: |Thorax/Lungs: |

|facial movement is symmetrical and expressions appropriate without drooping of |Lungs clear in all lobes; skin is warm, smooth, dry |

|mouth, eyes, or eyelids; nares are patent with no reported tenderness; no |respirations regular in depth |

|drainage, redness, or irritation noted | |

|Sclera white with minimal appearance of blood vessels; conjunctiva pink and moist| |

|Cardiac: |Musculoskeletal: |

|no JVD; capillary refill less than 3 seconds; pedal pulses equal palpable and |BLE 2-3 |

|strong; radial pulses consistent with apical pulse regularly irregular rhythm; |BUE 4 |

|S1, S2 noted |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: |Gastrointestinal: |

|urine yellow clear, with no foul odor, without discomfort on urination (catheter |Bowel sounds in all 4 quadrants, no distention or tenderness noted; no |

|D/C’d early 10/9/14 prior to beginning of shift) |discoloration; umbilicus midline; patient reports passing flatus; last BM |

| |10/7/14; abdomen is soft warm |

|Neurological: |Other (Include vital signs, weight): |

|A&O x 3; answers appropriately; cranial nerves intact; jaw movement intact; |Ht: 74 inches |

|affect appropriate; patient cooperative; no anxiety noted |Wt: 82 kg |

| |BP: 148/72 |

| |P: 96 |

| |SpO2: 95% |

| |R: 18 |

| |T: 100.3 F |

| |Pain: 5/10 |

CURRENT MEDICATIONS

List ALL regularly scheduled and prn medications scheduled on your client.

(Due morning of clinical)

|Generic & Trade Name |Classification |Dose/Route/ |Onset/Peak |Intended Action/Therapeutic |Adverse reactions (1 major |Nursing Implications for this client. (No more than one) |

| | |Rate if IV | |use. Why is this client taking|side effect) | |

| | | | |med? | | |

|Rivaroxaban |Anticoagulant; |10 mg/1 tab PO; start on |P: 2-4 H | VTE Prophylaxis |Bleeding complications |Monitor VS closely for S/Sx of bleeding/internal hemorrhage |

|(Xarelto) |Antithrombotic; |10/09/14 09:00 | | |(especially after surgery |(epidural, intracranial) such as significant drop in BP or |

| |Selective Factor XA inhibitor| | | |and spinal anesthesia) |H&H |

|Terazosin |Alpha-Adrenergic Receptor |2mg/1 cap PO QHS; start |P: 1-2 H |Hypertension |Syncope |Monitor BP prior to administration for effectiveness; teach |

|(Hytrin) |Antagonist; Antihypertensive |10/08/14 21:00 | | | |patient regarding postural drop in BP; monitor position |

| | | | | | |changes for safety |

|Ursodiol |Bile Acid; Gallstone |300 mg/1 cap PO BID; start |P: 1-3 H |Gallstone Prevention |Peptic Ulcer |Monitor for onset of GI distress/bleeding (nausea, severe |

|(Actigal) |Solubilizing agent |10/08/14 21:00 | | | |pain, dark stools) |

|Senna/ |Stimulant Laxative |8.6/50 2 tab PO BID; start on|O: 6-10 H |Bowel regulation |Excessive fluid loss |Maintain fluid balance and hold if watery diarrhea develops |

|Docusate | |10/08/14 20:00 |May take up to 24 H | | | |

|(Senokot-S) | | | | | | |

|Metoprolol Succinate- |Cardioselective |100 mg/1 tab PO QPM |P: 1.5 H |Hypertension |Shortness of breath, |Do not give if HR less than 50, and/or SBP less than 90; |

|XL |Beta-adrenergic antagonist | | | |bradycardia |Notify physician |

|(Toprol Metoprolol |antihypertensive | | | | |Monitor for respiratory distress |

|Succinate-XL) | | | | | | |

|Acetaminophen IV |Non-narcotic analgesic |100mL IV Q 6 H for 3 doses; |P: 0.5-2 H |Pain |Hepatotoxicity with chronic|Monitor for abdominal pain, diarrhea, elevation of ALT, AST |

| | |MAX 4 GM IV per day; start | | |use | |

| | |10/08/14 18:00; NO OTHER | | | | |

| | |Acetaminophen while on IV | | | | |

| | |Acetaminophen | | | | |

|Cefazolin/D5W Duplex |1st Generation Cephalosporin |50 mL IV Q 8 H for 2 doses |P: 5 min IV |Prophylactic against infection |Renal insufficiency |Monitor for onset of severe diarrhea associated with |

|1gm |antibiotic |start 8 H after Operative | |peri-operatively | |colitis/monitor renal output and BUN |

|(Ancef/D5W Duplex 1 | |dose; must be complete within| | | | |

|gm) | |24 hours | | | | |

|Ascorbic Acid |Vitamin supplement |1000mg/2 tab PO daily 18:00; |Readily absorbed PO |Increases protective mechanism |Dysuria |Monitor for salicylate toxicity- Ascorbic acid may decrease |

|(Vitamin C) | |start on 10/08/14 18:00 | |of immune system- supporting | |elimination of salicylates and can also reduce effect of |

| | | | |healing | |anticoagulant |

|Multivitamin |Multivitamin |1 tab PO daily 18:00 |Unknown |Vitamin supplement |Vitamin/mineral overload/ |Monitor for signs of hypervitaminosis-excessive itching, dry |

|(Theragran) | | | | |overdose |skin, nausea, vomiting, hives, sore mouth, foul taste, skin |

| | | | | | |discoloration, flushing |

|Finasteride |Antiandrogen; 5= Alpha |5mg/1 tab PO daily |O: 3-6 H |Benign prostatic hypertrophy |Postural hypotension |Monitor position changes and ambulation for signs of |

|(Proscar) |reductase inhibitor | | | | |hypotension-dizziness, increased pulse, sweating, balance |

|Saline Flush |Saline Flush |2 mL IV Q shift |N/A | IV patency |Redness/ |Flush IV line every shift and as needed before and after |

|(Sodium Chloride | |flush with 2-5ml ; saline | | |irritation |accessing IV; monitor for signs of irritation, blockage, |

|Flush) | |lock when PO tolerated | | | |infiltration |

|FS-Dextrose |Isotonic Crystalloid Fluid |IV @ 125mL/hour over 8.5 H |N/A |Fluid loss replacement and |Fluid volume excess |Monitor I/O, weight, and signs of fluid excess ( constant |

|5%-Lactated Ringers | | | |maintenance | |irritated cough, dyspnea, vein engorgement) |

|1052 ml bag | | | | | | |

|FS-Sodium Chloride |Isotonic Crystalloid fluid |IV @ 22mL/hour over 24.5 H |N/A |Fluid loss replacement and |Fluid volume excess |Monitor I/O, weight, and signs of fluid excess ( constant |

|0.9% | |TKO with PCA if no other | |maintenance | |irritated cough, dyspnea, vein engorgement) |

|541 ml bag | |maintenance IV fluid is | | | | |

| | |running | | | | |

|Mupirocin 2% |Pseudomonic |1 gm nasal bid for 4 days |Not systemically |Infection |Contact dermatitis |Hold drug and notify physician if dermatitis or pus |

|Ointment-nasal |acid antibiotic | |absorbed | | |production increases |

|(Bactroban 2% | | | | | | |

|ointment-nasal) | | | | | | |

|Magnesium Hydroxide |Saline Cathartic; antacid |30 ml PO daily PRN |O: 3-6 H |Constipation |Bradycardia |Monitor for Hypermagnesemia (profound thirst, flushing, |

|(Milk of Magnesia) | |constipation, if no BM by End| | | |sedation, confusion, depressed deep tendon reflexes, |

| | |of Post op day 3, start on | | | |hypotension, depressed respirations) |

| | |10/11/14 | | | | |

|Phosphates enema |Stimulant Saline laxative |1 enema rectal daily PRN |Unknown |Constipation |Abdominal pain |Assess bowel sounds prior to administration- do no use if |

|(Fleet enema) | |constipation if MOM | | | |obstructed |

| | |ineffective and no BM by end | | | | |

| | |of Post op day 3 | | | | |

|Bisacodyl |Stimulant laxative |1 suppository rectal daily |O: 15-60 min |Constipation |Cramping |Ensure adequate fluid intake 6-8 glasses/day unless fluid |

|(Dulcolax, Bisac-Evac)| |PRN constipation if MOM | | | |restriction; antacids will cause early dissolution of enteric|

| | |ineffective | | | |coating- resulting in increased abdominal cramping (teach) |

|Naloxone 1mg/1ml |Opiate antagonist narcotic |0.1 mg dose IV titrate PRN |O: 2 min |Reversal of narcotic depression|Tachycardia, Hypertension |Watch patient closely as some opiates may have longer |

|(Narcan 1mg/ml) | |unable to arouse/resp rate; | |(sedation, respiratory | |duration of action than Naloxone’s; watch for changes in |

| | |dilute Naloxone 2mg/2ml w/8ml| |depression, hypotension) | |respiration |

| | |NS to yield 10ml *conc: | | | | |

| | |0.2mg/ml* give 0.1mg Q 2-3 | | | | |

| | |min until resp rate greater | | | | |

| | |than 8 or arousable; may | | | | |

| | |repeat x 3 per 24 hour; | | | | |

| | |monitor Q 15 min for at least| | | | |

| | |2 hours | | | | |

|Oxycodone immediate |Opiate Analgesic |5 mg/1 tab PO Q 4 H PRN pain |O: 10-15 min |Pain management |Respiratory depression |Monitor response closely for pain relief; do not give if |

|release | |for 1 day; STOP order after | | | |respirations less than 12; have Narcan readily available |

|(Roxicodone Immediate | |24 hours | | | | |

|release) | | | | | | |

|Ondansetron |Antiemetic |4mg/2ml IV Q 4 H PRN |P: 1-1.5 H |Nausea |Diarrhea, sedation |Give over 2-3 minutes IV; monitor tachycardia |

|(Zofran) | | | | | | |

|Metaxalone |Skeletal muscle relaxant |800 mg/1 tab PO Q 8 H PRN |O: 3 H |Muscle Spasm |Anaphylaxis |Monitor for allergic reaction ( rash around chest and neck, |

|(Skelaxin) | | | | | |SOB, itching, tachycardia) |

|Hydromorphone/NS |Narcotic analgesic (opiate |PCA; Demand: 0.2 mg every 10 |O: 15 min |Pain management |Respiratory depression |Document # of mg infused every shift; monitor baseline |

|0.2mg/ml |agonist) |min; limit: 3mg/4 HRS; | | | |respiratory rate; hold if respiratory rate less than 12; |

| | |Loading dose= 0.2 mg IV PRN | | | |watch for signs of miosis (abnormal constriction of pupils) |

| | |Pain for 4 days; May increase| | | | |

| | |PCA dose by 0.1 mg every 30 | | | | |

| | |minutes up to max dose of | | | | |

| | |0.4mg per injection | | | | |

|Zolpidem |Anxiolytic; sedative |5mg/1 tab PO HS PRN for 7 |O: 7-27 min |Insomnia |Confusion/falls |Give directly before sleep to avoid impaired cognition/risk |

|(Ambien) |hypnotic, non-benzodiazepine |days | | | |for falls; assess for vision changes and report to provider |

| | | | | | |if present |

|Midazolam |Anesthetic; antianxiety; |1mg/1ml IV x 2 PRN Preop- may|O: 1-5 min IV |Preoperative sedation/anxiety |Tachypnea |Monitor injection site continuously for signs of |

|(Versed) |sedative-hypnotic |repeat 1mg dose one time PRN | | | |extravasation; monitor respirations for changes in rhythm |

| |short acting benzodiazepine | | | | |depth, effort, as well as signs of continued confusion |

|Oxycodone/ |Opiate analgesic |5/325 |O: 10-15 min |Pain |Sedation |Monitor/assist with ambulation; monitor respiratory status |

|APAP | |1 tab PO Q 4 H x 1 day | |Level 4-6 | |frequently; monitor pain level/ relief; assess for bowel |

| | |Delay start x 24 HR while on | | | |elimination |

| | |Acetaminophen IV. Around the| | | | |

| | |clock. Change to PRN Post op | | | | |

| | |day 2 | | | | |

| | |Start on 10/09/2014 | | | | |

|Oxycodone/ |Opiate analgesic |10/325 1 tab PO Q 4H for 1 |O: 10-15 min |Pain |Sedation |Monitor/assist with ambulation; monitor respiratory status |

|APAP | |day, delay start while on | |Level 7-10 | |frequently; monitor pain level/ relief; assess for bowel |

| | |Acetaminophen IV. Around the | | | |elimination |

| | |clock until post op day 2, | | | | |

| | |then PRN Start on 10/09/14 | | | | |

| | |14:00 | | | | |

|AcetaminophenAcetamino|Non-narcotic analgesic |650 2 tab PO Q 4H for 1 day, |P: 0.5-2 H |Pain |Hepatotoxicity with chronic|Monitor for abdominal pain, diarrhea, elevation of ALT, AST |

|phen | |delay start while on | |Level 1-3 |use | |

|(Tylenol) | |Acetaminophen IV around the | | | | |

| | |clock post op day 2, then PRN| | | | |

| | |Start on 10/09/14 14:00 | | | | |

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 |Patient Values/ |Interpretation as related to Pathophysiology –cite reference & pg # |

| |Normal Values |Date of care | |

|10/09/14 |Sodium | | |

| |135 – 145 mEq/L | | |

|10/09/14 |Potassium | | |

| |3.5 – 5.0 mEq/L | | |

|10/09/14 |Chloride | | |

| |97-107 mEq/L | | |

|10/09/14 |Co2 | | |

| |23-29 mEq/L | | |

|10/09/14 |Glucose | | |

| |75 – 110 mg/dL | | |

|10/09/14 |BUN | | |

| |8-21 mg/dL | | |

|10/09/14 |Creatinine | | |

| |0.5 – 1.2 mg/dL | | |

|10/09/14 |Uric Acid Plasma | | |

| |4.4-7.6 mg/dL | | |

|10/09/14 |Calcium | | |

| |8.2-10.2 mg/dL | | |

|10/09/14 |Phosphorus | | |

| |2.5-4.5 mg/dL | | |

|10/09/14 |Total Bilirubin | | |

| |0.3-1.2 mg/dL | | |

|10/09/14 |Total Protein | | |

| |6.0-8.0 gm/dL | | |

|10/09/14 |Albumin | | |

| |3.4-4.8gm/dL | | |

|10/09/14 |Cholesterol | | |

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