NURSING DX: ‡Acute pain r/t surgical incision ‡Impaired mobility r/t activity and weight bearing restrictions ‡Risk for infection

r/t to surgical incision ‡Risk for thromboembolismr/t immobility ‡Risk for pneumonia r/t immobility GOALS: ‡Pain will be managed to an adequate level as evidenced by verbal expressions of comfort ‡Patient will be able to ambulate easily within restrictions ‡Will remain free of infection as evidenced by no swelling, redness or fever ‡Will not develop thromboembolism ‡Will not develop pneumonia as evidenced by clear lung sounds bilaterally

Medical DX: Osteoarthritis

PATHOPHYSIOLOGY: Osteoarthritis is the degeneration of articular cartilage and hypertrophy of underlying bone. When bone surfaces become less protected from cartilage, bone may become exposed and damaged. As a result of decreased movement secondary to pain, the muscles may atrophy.

PATIENT HEALTH HISTORY: 73 year old female admitted 3 days ago after a right sided total hip replacement surgery. Prior to surgery, she had difficulty ambulating because of extreme pain.

INTERVENTIONS: ‡Assess pain frequently during first 24-48 post-op, and administer pain medication as needed ‡Assist with repositioning Q 2 hrs ‡Will maintain use of sequential compression device and stockings ‡Use of incentive spirometer will be encouraged Q 2hrs while awake ‡Maintain abduction with abuductor pillow ‡Perform passive ROM ‡Moniter temperature spikes for signs of infection ‡Monitor pulse, sensation and color in the right foot ‡O2 will remain above 90%

ASSESSMENT: V/S: T- 96.7 BP- 136/78 P-72 R-12 O2-98% Alert and oriented x 4; skin around incision clean and dry with no redness; lung sounds clear bilateral with no labored breathing ; bowel sounds active in all 4 quadrants, soft on palpation with no distention

MEDICATIONS: ‡Morphine sulfate, 0.8 mg IV via PCA pump for pain ‡Azithromycin (Zithromax), 500 mg IV to prevent infection ‡Ondansetron (Zofran) 4 mg for nausea ‡Dalteparin (Fragmin) 5000 units inj. to prevent clot formation

OUTCOME: ‡Patient states pain level is 5/10. Pain is tolerable ‡Patient is able to ambulate with assistance ‡No signs of infection present; no signs of redness, swelling, or drainage over area of incision present, and no fever. ‡Lung sounds clear bilateral with O2 sat of 98%

PERTINANT LABS: ‡WBC 5,000- within normal limits; indicative of no signs of infection ‡PT 1.5 (inidication of therapuetic dosage of heparin)

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