Student Name:

Client Initials: IM

Maria Palomera

Professor: Diana Mixon

Gender: Female Age: 57 DOB: 04/24/1955 Marital status: M Religion: unknown Occupation: Stay at home NURSING CARE PLAN #1

CLIENTS MEDICAL DIAGNOSES: BRIEFLY (no more than 90 minutes) review the clients chart. List all client medical diagnoses below. Then, of all medical diagnoses, identify the ONE medical diagnosis/issue that either caused their admission, or keeps them in facility (this can be very difficult to do when clients have multiple co-morbidities; ask your instructor for help determining).

Patients Diagnoses: 1. Obesity 2. osteoarthritis 3. Degenerative joint disease 4. Lumbar spondylosis 5. Hyperlipidemia 6. Dizziness 7. Anxiety 8. Lower extremity edema 9. Hx of GERD The patient was admitted to the hospital for a R hip replacement arthoplasty that was caused by osteoarthritis on her R hip. The patients symptoms upon admission were R hip pain, severe limp and limitation of walking, standing and difficulty performing ADLs.
PATHOPHYSIOLOGY: Of the one medical diagnosis you identified as most clinically significant, write a BRIEF paragraph below describing the pathophysiology of that diagnosis. Use a reputable website (Pub Med, Mayo Clinic, WebMD or other) or your textbooks to support your information, and cite your source. Be sure to include in your paragraph: What populations of patients experience this diagnosis? What is the usual clinical presentation (signs and symptoms) of this diagnosis? What was your assigned patients clinical presentations (how did they show signs or symptoms) of this diagnosis? What is the usual treatment for this diagnosis?

Pathophys: Hip osteoarthritis is known as joint inflammation of the hip. It occurs when the cartilage that protects and cushions the joints breaks down over time. The breakdown of the cartilage causes the bones to now rub against each other, resulting in damage to the tissue and underlying bone and causing pain and swelling in the joints. Demographics: Osteoarthritis is the most common form of arthritis and is a major cause of disability in older adults. More common in obese patients and as patients gets older the disease can progress. Causes: Not known, Factors that contribute include: injury to the joint, increasing age and overweight. Signs & symptoms: joint stiffness that occurs as you are getting out of bed, joint stiffness after you sit for a long time, pain, swelling, or tenderness in the hip joint, a sound or feeling of bone rubbing against bone, inability to move the hip to perform routine activities. Diagnostic findings: There is no single diagnostic test for osteoarthritis. Physician will make diagnosis based on medical history, physical exam, and hip function. They may also order x-rays and blood test like: RF, ESR, ANA, CRP, and HLA-B27. The patients chart did not include copy or record that these tests were performed. Tx: Goal is to improve patients mobility and lifestyle by improving function of hip and controlling pain. Treatment plans: Losing weight, rest and joint care, exercise, use of cane to take weight of hip, physical therapy Pharmacological: acetaminophen, NSAIDS, or prescription pain medication. Surgical: hip replacement surgery- replaces the damaged ball with a metal ball. The hip socket is resurfaces using a metal shell and plastic liner. Hip resurfacing is another surgical option where the diseased hip joint surfaces are surgically removed and substituted with metal. Instead of removing the ball and socket like in replacement surgery it is only covered with a metal cap. Prognosis: About 85% of the hip joint implants will last 20 years. Improvements in surgical technique and artificial joint materials should make these implants last even longer. If the joint does become damaged, surgery to repair it can be successful but is more complicated to do than the original procedure.
Now, document your head to toe assessment findings in appropriate assessment data columns below. Use this table as a working document; when you have collected all assessment data, write your findings in a smooth, system-based narrative assessment note.

Assessment Area

Subjective Assessment Data

Objective Assessment Data

Vital Signs: Weight: Ability to perform ADLs:

Height:

General Survey: Physical development/body build Behavior/mood, Gait/body movement Assistive devices/equipment in use PAIN Integument: Color/temperature Moisture Turgor Lesions/rashes/breakdown

57 y/o female Morbid Obesity Full code. NKA Hx of anxiety Hx of dizziness Reports pain 6/10 Hx of lower extremity edema Hx of breast biopsy Hysterectomy 15+ years ago D & C x 2. Unsure of dates

Wt- 245 lbs, Ht- 54, T- 98.9 F, P-100 2+ bilateral, RR18, B/P 142/76. Patient requires 1 person assist to perform ADLs AAO x 4. Pt is cooperative and can answer all questions clearly and without any problems. Can ambulate with walker and 1 person assist. Gait is a slightly unsteady on R side due to surgery. Skin is warm, pink and dry. Pt has surgical dressing on R outer hip. No drainage on dressing, no redness or irritation noticed around dressing area. Pt has IV saline lock on R forearm with no redness or edema at site. Turgor: skin pinches easily with rapid recoil. No tenting. Mild 1+ edema present on bilateral ankles. Pedal pulses present 1+ bilaterally. Capillary refill less than 2 seconds on fingers and toes. No redness of sore identified on body. AAO x 4. Pt is pleasant, cooperative and answers every question correctly. Speech is clear. Eyes: PERRLA bilaterally. Pupil size 2mm. Pt uses walker and 1 person assist to ambulate. Gait is slightly unsteady on R side due to surgery. Grip strength +5 on bilateral arms. Pt has weak strength on R leg due to surgery. No facial dropping noticed. RR 18. Respiration and even and slightly labored. Breath sounds are diminished in R and L upper lobes and R and L lower lobes. No wheezing heard. Heart sounds heard. Able to identify S1 & S2 on all 5 landmarks. No extra sounds heard. Rhythm regular.

Neurological: Appearance/movement, LOC, concentration/memory, clarity/content of speech, visual acuity near/far, PERRLA, gait, grip strength, extremity movement, facial drooping?

Hx of anxiety Pt denies wearing glasses or contact to correct vision. Last eye exam is unknown.

Respiratory: use diaphragm of stethoscope Inspect clients respiratory effort: Chest rise/fall symmetric? Labored or unlabored? Cardiac: use bell and diaphragm of stethoscope Auscultate for S1/S2, as well as extra heart sounds at all five landmarks:

Reports some SOB and pain in hip with activities. Denies Asthma Denies hx of lung disease. Denies hx or Fhx of heart disease

Vascular: Palpate peripheral pulses bilaterally for presence and quality; Capillary refill time in fingers, toes Skin color/temperature in hands, feet Edema (look especially at dependent areas) Gastrointestinal: Inspect: Mouth/gums/buccal mucosa/teeth/tongue Abdomen contour/symmetry/surface motion Auscultate abdomen: bowel sounds in all 4 quadrants? Palpate abdomen: Distension, tenderness, Masses Last BM? Genitourinary: As appropriate Inspect genitalia: lesions/rashes/breakdown Penile or vaginal discharge Urine color/clarity Musculoskeletal: Range of motion Extremity muscle strength/equality Gait/movement

Hx of lower extremity edema Hx of breast biopsy Hysterectomy 15+ years ago D & C x 2. Unsure of dates Denies hx or Fhx of heart disease Does not wear dentures. Hx of GERD Regular diet. Reports little appetite Last bowel movement was 3 days ago. Reports some flatulence Reports constipation. . Pt is able to ambulate with walker and 1 person assist. Pt can use toilet independently. Hysterectomy 15+ years ago D & C x 2. Unsure of dates Hx of lower extremity edema Obese Hx of osteoarthritis Hx of Degenerative joint disease Hx of Lumbar spondylosis

P 100, 2+ bilateral. Pedal pulses present 1+ weak bilateral. Skin warm, pink and dry. Mild 1+ edema present on bilateral ankles. Capillary refill less than 2 seconds on fingers and toes.

Tongue- pink & moist. Teeth are intact. Abdomen soft and rounded. Striae present on bilateral lower quadrants. Bowel sounds present but diminished in all 4 quadrants. Abdomen is not tender to touch, non-distended. No palpable masses are present. Pt has been given Colace to help with constipation. Bladder not palpable. Genitalia exam was deferred.

Full ROM in bilateral arms and shoulder. Grips strength 5+ on bilateral arms. Full ROM on L leg. Weak limited ROM on R leg due to hip surgery. Strength on L leg 5+ and 2+ on R leg. Can ambulate with walker and 1 person assist. Gait is a slightly unsteady on R side due to surgery

Summary: 57 y/o female. Morbidly obese. Full code. NKA Vital signs: Wt 245 lbs, Ht 54, T 98.9 F, P 100 2+ bilateral, RR 18, B/P 142/76.Pain 6/10 Neuro: AAOx4 Hx of anxiety. Pt is cooperative can answer all question correctly and precise. Eyes are open PERRLA bilaterally. Pupil size 2mm. Resp: Respiration and even and slightly labored. Breath sounds are diminished in R and L upper lobes and R and L lower lobes. Reports some SOB and pain in hip with activities. CV: heart sounds heard able to identify S1 & S2, no extra sounds heard. Rhythm regular. Integument: Skin pink, warm and dry. Pt has surgical dressing on R outer hip. No drainage on dressing, no redness or irritation noticed around dressing area. Pt has IV saline lock on R forearm with no redness or

edema at site. Turgor: skin pinches easily with rapid recoil. Mild 1+ edema present bilateral ankles. Pedal pulses present on weak 1+ bilaterally. Capillary refill less than 2 seconds on bilateral fingers and toes. Hx of lower extremity edema. GI: Hx of GERD. Regular diet. Reports little appetite. Reports some flatulence. Reports constipation. Last bowel movement was 3 days ago. Abdomen soft and rounded. Striae present on bilateral lower quadrants. Bowel sounds present but diminished in all 4 quadrants. Abdomen is not tender to touch, non-distended. No palpable masses are present. Tongue- pink & moist. Teeth are intact. GU: Able to toilet independently. Hysterectomy 15+ years ago. D & C x 2. Unsure of dates Musculo: Hx of Degenerative joint disease. Hx of Lumbar spondylosis Ambulates with walker and 1 person assist. Gait is a slightly unsteady on R side due to surgery. Full ROM in bilateral arms and shoulder. Grips strength 5+ on bilateral arms. Full ROM on L leg. Weak limited ROM on R leg due to hip surgery. Strength on L leg 5+ and 2+ on R leg Focused Assessment Completion: Which or what focused assessments would be clinically relevant, and necessary for this client, and why? Attach your focused assessment findings to back of this worksheet. You arent done yet! Write a brief paragraph describing what your focused assessment findings told you about your client, and how you will change your care plan or concept map as a result. My focus Assesment is the Morse Fall Scale: Item Scale Hx of falls No- 0 Yes - 25 Secondary diagnosis No - 0 Yes -15 Ambulatory aid Bed rest/ nurse aid- 0 Crutches/can/ walker -15 Furniture -30 IV therapy/ IV access No -0 Yes 20 Gait/ transfer Normal/ bed rest- 0 Weak 10 Impaired 20 Mental status Oriented to own ability- 0 Forgets limitations 15 Score 0 15 15 20 10 0 Total score= 60 high risk fall No risk -0-24

Low risk 25-50 High risk 51 and above After performing the Morse Fall scale on my patients I confirmed by belief that she was at a high fall risk because of her recent surgery on her R hip. The assessment did not make me change my plan of care for my patient as I was already going to make fall risk one of my priorities but it did help me identify intervention to help prevent my patient from falling. Some of the interventions that will be used include: access to assistive devices, adequate lighting in room, bed in low position, make sure patients clothing doesnt drag on floor, place call light in reach, keep hourly rounding and keep room clutter free so patient doesnt trip.

LABORATORY & DIAGNOSTIC WORKSHEET Laboratory studies/values: Review your assigned clients chart. Are there relevant, necessary lab studies ordered, reported for this client? If yes, why are those specific laboratory studies relevant, necessary? CLIENT Lab Normal Range
S

Results Hematology: HGB 12.1-15.9 10.7

What Clinical Problem Might Be Present I think the patient might have anemia due to decreased levels of HGB and HCT I think the patient might have anemia due to decreased levels of HCT and HGB.

Nursing Implications

Anemia is most common cause of low HGB. Asses pt for signs of anemia: dizziness, fatigue, and tachycardia. Check HCT level of HGB is low. Blood loss and anemias are most common cause of low HCT. Assess patient for signs & symptoms of anemia: fatigue, paleness and tachycardia.

HCT

40.8-51.9

33.1

PT

10-13

11.6

Purpose is to test anticoagulant Warfarin therapy. Pt was given Warfarin to prevent blood clots due to surgery. Pt is within normal range.

Monitor PT level while pt is taking anticoagulant therapy. Inform provider of results so they can determine if any adjustment in dose need to be made. Assess patient for signs & symptoms of bleeding.

No other lab or diagnostic test performed

Current Medications Medication Administration Profile: Please print blank Medication Administration Profile and bring with you to clinical. While at clinical, review the medication orders for your assigned client, and complete the Medication Administration Profile for each scheduled medication. Your instructor may also ask you to include prn medications on the profile as well, per instructor discretion. Drug Name (Generic and Trade) Classification Dose Route Indications (Why is your client receiving the medication?) Action(s) Adverse Reactions/Side Effects Pt is receiving med to prevent and treat her constipation. Action: Promotes absorption of water into stool to soften stool. Can also promote electrolyte and water secretion into the colon. Therapeutic effects: softens the passage of stool. Side effects: throat irritation, mild cramps, diarrhea and rashes. No life threatening. Nursing Implications: Assessment, Implementation, Teaching, Evaluation as it applies to the care of your client.

Docusate Sodium ( Colace) Therapeutic: laxatives Pharmacologic: stool softeners

200 mg po 2 x a day Can be given po to prevent constipation or rectally as enema to soften fecal impaction.

Assess for abdominal distention and presence of bowel sounds. Medication doesnt stimulate peristalsis and stimulant laxative may also be required since pt is constipated. Pt takes meds po and should be taken with full glass of water. Can administer on empty stomach for more rapid results. Advise pt to increase fluid intake, eat more fiber in meals, and to ambulate as much as possible to decrease constipation. Advise pt to reports any

Protonix (Pantroprazole) Therapeutic: antiulcer Pharmacologic: protonpump inhibitors

40 mg, 1 po daily in the am Can be given po 40 mg once daily IV- 40mg once daily for 7-10 days 10 mg po every 12 hours Can be given po 5-10 mg every 34 hours Rectal: 10-40 mg 3-4 time daily initially

Oxycodone ( Oxecta) Therapeutic: opioid analgesics Pharmacologic: opioid agonists, opioid agonists/nonopioid analgesic combinations

Warfarin (Coumadin) Therapeutic: anticoagulants Pharmacologic: coumarins

PO or IV- 2-5 mg/day for 2-4 days. Then adjust dose by results of INR.

nausea, vomiting, diarrhea or abdominal pain so we can withhold or discontinue med if symptoms are present. Pt has hx of GERD. Assess for abdominal pain and for blood in stool, Action: Lessens accumulation of emesis or gastric aspirate. acid in the gastric lumen. Healing of May be taken with or without food. Do not break, duodenal ulcers and esophagtis. crush or chew tablets. Decreased acid secretion in Advise to take meds as directed and for full course hypersecretory conditions. of therapy even if she is feeling better. Advise pt to Common side effects: headaches, avoid alcohol, aspirin or NSAIDS and foods that abdominal pain. Hyperglycemia. can cause GI irritation. Life threatening: none Patient is taken for pain reliever Assess intensity and location of pain prior to 2 hour after surgery. after administration. Asses B/P pulse and respiration before and regularly while patient is Action: binds to opiate receptors in receiving med. If respiration rate is less than 10 CNS. Decreases pain asses level of sedation. Assess bowel function regularly. Advise pt to Common side effects: confusion, increase fluids and fiber to help with constipation. sedation, constipation. Regular administered doses may be more effective Life threatening: Respiratory than prn administration. PO: can be given with depression. food or milk to lessen GI irritation. Advise patient that med can cause drowsiness or dizziness and should call for help when ambulating to prevent falls. Patient is taking as prophylaxis to Asses to signs of bleeding (bleeding gums, prevent blood clots due to surgery nosebleed, unusual bruising, tarry, black stools; fall in BP) Action: interfere with hepatic Monitor PT labs and advise provider of results to synthesis of Vit K-dependent determine of change in dose is necessary. clotting factors. Prevention of Monitor al meds to for potential interaction. thromboembolic events Advise patient to report any symptoms of unusual Side effects: cramps, nausea, fever. bleeding or bruising immediately.

Life threatening- bleeding

Advise pt to limit foods high in vitamin K and to avoid cranberry juice while on meds.

References Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2011). Nurse's Pocket Guide, Diagnoses, Prioritized Interventions, and Rationales. (12th ed.). Philadelphia, PA: F A Davis Company.

Kee, J. (2010). Laboratory and diagnostic test with nursing implications. (8th ed.). Upper Saddle River, NJ: Pearson Education

Vallerand, A. H., Sanoski, C. A., & Deglin, J. H. (2011). Davis's Drug Guide for Nurses. (13th ed.). Philadelphia : F.A. Davis Company.

Webmd. (2012, May 10). Retrieved from http://webmd.com/osteoarthritis/guide/hip-osteoarthritis-degenerative-arthritis-hip?page=2