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Client’s Initials KB Adm. Date 9/24/09 Date Surgery 9/24/09 Type

Client’s Initials KB Adm. Date 9/24/09 Date Surgery 9/24/09 Type

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Published by: Mags on Dec 15, 2009
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Client’s Initials _KB__ Adm. Date _9/24/09___ Date Surgery _9/24/09__  Type of Surgery _Right total knee arthroplasty_ Diagnosis & Relevant History Dx: osteoarthritis Rt knee s/p Rt TKA (total kneearthroplasty); arthritis; joint replacement surgery left knee 4/03, revision left knee 10/03;plantar fasciatis surgery ; Diabetes Mellitus Type 2 ; Sleep apnea, uses CPAP;hypertension; hx of bronchitis, pneumonia; hypothyroidismSocial History Pt is retired construction worker. Lives at home with wife.Non-smoker.Pathophysiology: Attach and cite source with APA format (USE SEPARATE SHEET)Analysis of Assessment: (use only abnormal and significant normal findings)0800 VS: T 99.0 axi P 80 R 18 B/P 156/72 LLA saO
2
96% RAI.Psychological Variables pt feels nervous about using his weakened s/p TKA leg, he statesthat he has to learn how to trust using his left leg since his newly operated leg was alwaysthe “good leg”. He is very motivated, during physical therapy, he completes his workouts,states that he knows they are important and that he needs to be compliant in order for himto recover properly. This is his second surgery to his right knee and has had two othersurgeries to the left knee also several years ago (joint replacement and a revision).Although pt discussed his difficulties and frustrations with his condition, he states that herealizes that after this surgery he will be be “in better condition to live his life.”II.Sociocultural Variables retired construction worker, lives with wife. Split level house with 5-6 steps to front door and ~6 steps down to lower level and ~6 steps up to upper level. There aresiderails and carpeting on the stairs.III.Developmental Variables , list current Erickson Integrity Despairstage & “X” task line and explain reason Xopen about life and life experiences, discusses life as lived well, discussed childrenin good tone and spoke of their accomplishmentsIV.Spiritual Variables Roman Catholic; very spiritual, very active in church. Relies on faith as acoping strategy. Receives daily communion at hospital. Speaks to hospital chaplain and is visitedby own parish members.V.Physiologic VariablesA.Respiratory airway patent; lung sounds clear in all areas bilaterally; 18RR, regular,eupnea, unlabored breathing, symmetrical chest movement, no cough. 96% onroom air. Instructed to use incentive spirometer , coughing and deep breathingexercises. Uses CPAP q night for sleep apnea.B.Cardiovascular Apical 80; regular. On telemonitor- sinus rhythm. No pacemaker.Peripheral pulses palpable 2+ in all extremities. Skin pink, warm and dry to touch.No generalized edema. Capillary refill <2sec in all extremities. BP 156/72 LLA;current treatment of hypertension. Temp 99.0 axillary.C.Neurological awake/alert. Oriented to person, place, time, situation. Languagenormal for age. Speech clear. Judgment appropriate. No hx of seizures. Symmetrical
9/09
Male
  _X_ Married __ Single __ Divorced __ WidowedAge _ 
62
 __ 
 
facial movements. Full sensation in all extremities, denies numbness or tingling.Extremity movement present. Emotion: calm, coping. Behavior: cooperative.D.Musculoskeletal Right and left hand grasps strong, symmetrical. Right and leftplantar flexion strong. Pt s/p right total knee arthroplasty, post-op day 4, walks usingwalker to support right leg. Uses trapeze mounted to bed. C/o pain in right knee,4/10, “tolerable, aching, feel bone on bone”, not radiating, aggravating: ADLs,movement, alleviating: ice, meds, rest. Performs good active range of motion andstrength of bilateral UE for ADL. LE decreased AROM. CPM 60 degrees, q4h for 1hr.E.Gastrointestinal abd soft non-tender, BSx4, normal, no abd discomfort, passingflatus, no constipation, no diarrhea, last BM 9/27/09, no nausea or vomiting.F.Genitourinary toileting: BRP and urinal at bedside, urine: yellow, clear. No voidingproblems. No bladder distension. (2300 9/27-700 9/28: 800 mL)G.Integumentary warm, color normal for ethnicity, elastic/no tenting, dry to touch.Mucous membranes pink, moist. 1 surgical incision: right knee, medial, ~7 incheslong, well approximated, by staples, covered with ABD pad and knee wrapped inACE wrap. Dressing dry/intact, small amount of serous discharge (clear, yellow) fromsite. Skin around incision warm, pink. Pt denies direct wound pain. Dressing changed900.
VI.
Discharge Planning Assessment POD 4, pt being discharged today.D/c with home health: PT 5x/wk x1wk. then 3x/wk. dressing changes onMonday and Thursdays. PT/INR levels q Monday and Thursdays.VII. Neuman Wheel
M
EDICATIONS
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OSAGE
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ONSIDERATIONS
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ADMINISTRATION
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ADMINISTRATION
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REACTIONS
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ADMINSTRATION
sennosides/ducosate sodium(Senna-S Tab)09001800Post-opconstipation-c/d/n/v [
]-last BM [9/24/09 normal]-usual bowel habits-s electrolytes-diarrhea-abd cramping
9/09
 
Key for Neuman wheel:Phy-PhysiologicalPsy-PsychologicalSoc-SocioculturalDev-DevelopmentalSpi-Spiritual
 
Phy psysocdevspi
 
-1 tab-BID-PO-adequate fluid intake,exercise, dietwarfarin(Coumadin)-1 dose-daily-PO1600Prophylactically post-op againstDVT, PE-draw labs prior toadministration-bleeding gums, bleedingskin abrasion, excessive bruising, nose bleeds,melena, hematuria,hematemesis [
]-fever, rash (adv rxn) [
]-INR (therapeuticlevel: 2-3xnorm)CNS: fever GI: cramps, diarrhea, melena,nausea, vomitingGU: excessive menstrual bleeding, hematuria, priapismHeme: hemorrhageHepatic: hepatitisSkin: rashIf INR is:<1.40 – give 5mg Coumadin1.41-1.90 – give 2.5mg Coumadin1.91-2.50 – give 1mg Coumadin>2.51 – hold Coumadinallopurinol(Zyloprim300mg tab)-300mg-daily-PO0900antigout-joint stiffness [in knees,can be contributed also tohis OA]-joint pain [in knees, can be contributed also to hisOA and TKA]-monitor I/O’s-uric acidlevels-CBC-hepaticfunction-renal function-may inc alk  phosphatase,AST, ALT,BUN,creatinine-may dec hgbhct-may decgranulocyteand plateletcountsCNS: drowsiness, headacheEENT: retinopathyGI: abd pain, d/n/vGU: renal failure, uremiaHeme: anemia,thrombocytopeniaHepatic: hepatitisSkin: erythema multiforme,exfoliative lesions, rash,levothyroxine(Synthroid)-300mg-daily-PO0700hypothyroidism-assess for adv effects [
]-pulse for rate and rhythm[80 strong]-tremors, anxiety [
]-appetite, sleep pattern-tsh levels-Excessive dosage producess/s of hyperthyroidism (wtloss, palpitations, inc appt,tremors, anxiety, tachycardia,htn, headache, insomnia,menstrual irregularities).Cardiac arrhythmias occur rarely
9/09

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