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Sex: __M Age:_32 Race: White Allergies: Pamelor, Zomig, Skelaxin ________________________________________________________________________________ Medical Diagnosis: Left Shoulder and Arm Pain ______________________________________________________________________________ Surgical Procedure / Treatment: Left Shoulder Arthroscopy Bicep Tenodoesis Subacromial Bursectomy Removal Foreign Body__________________________________________________________________________________ Client Profile: (reason for hospitalization, chief complaints and/or presenting symptoms) Patient presenting for preoperative evaluation for left shoulder arthroscopy, Bicep Tenodesis, Subacromial Bursectomy, and Removal of foreign body. Patient injured arm/shoulder about one year or more ago at work. Patient complains of pain in left shoulder area. ____________________________________________________________________________ Past Medical/Surgical History of Client(including previous hospitalizations with dates) Patient injured his arm about 1year ago at work. Has undergone two surgeries and pt. continues to complain of pain. Labrum repair left shoulder 11/09, Ulnar transposition left elbow 09/09 Patient also experienced seizures as a child but has not experienced any in many years. Patient has history of asthma but has not needed to use his inhaler and cannot remember the last time he needed the use for it. Pt. has back pain and has had a facet rhizotomy injection Pt. also does have anxiety and palpitations. Palpitations are controlled with atenolol and panic is controlled with clonazepam. Family History (include three tier genetic history): Mother: Died at the age of 88 had breast and bladder cancer Father: Died at the age of 72 had cancer of the larynx Sister: Age 29 Hyperthyroidism Married daughter 2yrs son 5yrs Sister: Age 25 Married___________________________________________________________________________ Support Systems: (family, friends, coworkers etc.) Wife, Two children (boys 9yr, 1yr), Coworkers, Neighbors, Friends, Family _______________________________________________________________________________ Sociocultural and daily patterns of living: Pt. lives in a home with his two children and wife. Pt. son also has asthma. His activities consist of work as a local truck driver and when he comes home he likes to spend time with kids and family. He is a non-practicing catholic.
POWER COMPONENTS: _A__ Attention Span (Acute Limited attention span due to anesthesia) _A_ Energy Level (Acute decrease in energy level due to anesthesia) _A__ Control of body movements (Acute control loss due to anesthesia) _A__ Ability to reason (Acute ineffective ability to reason due to anesthesia) _A__ Ability to make decisions (Acute inability to make decisions due to anesthesia) _A__ Motivation (Acute deficit in motivation due to anesthesia) _A__ Knowledge of health problem (Patients knowledge deficit in removal of foreign body and where it came from is diminished) _A__ Ability to provide for self care (Acute inability to provide for self-care due to anesthesia and surgical incision) _A__ Skills needed to adapt self-care needs (Patient will difficulty with adapting to self care needs without the assistance of left arm while recovering) _A__ Ability to adapt self-care needs to A.D.L. (Patient will have difficulty with A.D.L.’s due to limited extremity movement.)
6. Seizures as child no longer has episodes. Solitude & Social Interaction (Sensory Perception. Normal EKG.2.4 Eosinophil Absolute: 0.4 MCV: 90 MCH: 30. Nail bed color: Pink. Promotion of Normalcy (Personal Hygiene. Pt. sleep patterns normal. prolonging the healing time. Neurological) Pt. Integument) Preop: Skin intact no lesions.0mg Bilirubin: Negative Leukocyte Esterase: Negative Nitrate: Negative GFR: >=60 Sodium: 139 Potassium: 4. Activity & Rest (Musculoskeletal. Bowel sounds present in all four quadrants. The significant task is to contribute to the betterment of society.4 RBC: 4. Home environment safe. Lung volumes show large but otherwise clear. Dressings clean. anxiety. SaO2:98%. has pain and limited movement in L.9 Pt. Lidocain. smokes 1pack in two weeks. no edema present.3 Lymph Percent: 26. Reproductive. Serum Lab results: Glucose: 85 Creatinine: 1. does not wear glasses. depression problems.3 Monocyte Absolute: 0.7 Eosinophil Percent: 1.8 MCHC: 34. Extremities normal color. . Easy on room air. The patient is an eager and willing man and would to anything for his family. Respirations: 18. Pt.003 Glucose: Negative Blood: Negative Ketones: Negative Protein: Negative Urobilinogen: <2. Incision made at left anterior shoulder. pt. Temp: 98. Prevention of Hazards (Endocrine Autoimmune.. Heart size within normal limits.3 Granulocyte Absolute: 5. Foreign body removed during surgery. IV right anterior forearm Postop: patient had a Cuff IC and was unable to move arm. Capillary refill: <2 sec. Sensory and motor intact. Mucous membrane: moist.. No drainage noticed post operation.2 Platelets: 220 RDW: 13.1 Basophil Percent: 0. had chest x-ray done: Frontal and lateral projections of the chest demonstrate biapical pleural parenchymal scarring. Patient is able to complete ADL with assistance due to surgery. regular and strong. Interaction with family and friends is close and normal. Oropharynx pink and moist. Anesthesia administered during surgery: Versed. no masses. Sensation: numbness in left arm due to interscalene block. Postop: Bp: 115/62 Apical pulse: 66 SaO2: 94% on room air. NPO Food / Elimination (Gastrointestinal) Abdomen soft. Psychosocial) Pt. Side rails up during transport. also complains of previous back pain for several months. Pt.0 WBC: 8. No anxiety was seen in facial expressions. which for the patient is now not able to do. Pt does not complain of chest pain but does state that he does have hypertension.2 PT: 10. This stage of development may impact the patient very easily. does not use antidepressants or anti-seizure medication. Lung sounds: Bilaterally equal.7 Total bilirubin: 0. has limited ROM due to surgery. Urinanalysis: Ph: 7. Cardiovascular)-3 Preop: Bp: 109/73.0 Specific Gravity: 1.6 Total Protein: 7.UNIVERSAL / HEALTH DEVIATION SELF-CARE REQUISITE ASSESSMENT: Air (Respiratory.71 Hemoglobin: 14. F & E) Urine Clear yellow. Heart sounds: normal. Patient confirmed of no anxiety feeling day of surgery.2 Alanine Aminotransfer: 32 AST: 16 Alkaline Phosphatase: 63 Chloride: 101 Carbon Dioxide: 28 Granulocyte percentage: 5. Water (Renal. Apical Pulse: 64. arm due to Surgery.0 Serum Calcium: 9. Resp:16 Radial pulse strong. Self Concept. cap <2. Preop:1000ml IV Lactated Ringers. Pain after surgery was at 0 (1-10 scale).5 Hematocrit: 42. No guarding or rebound.5 Lymphocyte Absolute: 2. Pt had incision on left shoulder no drainage present. PERRLA. Postop: pt ate 4 oreo cookies and had 3sips of pepsi. Lung sounds bilaterally equal. The patient has to focus on himself to further increase his health and to provide an adequate amount of time for his surgery incisions to heal.9 Albumin: 4. No issues in communication. DEVELOPMENTAL SELF CARE REQUISITES: Client’s Age: 32 Stage of Development: Generativity Vs. Patient has crowns. even if it did include not letting his shoulder rest after the surgery. Self Absorption How might this illness interfere with the client’s developmental tasks: How might the client’s stage of development impact his/her adjustment to the illness? Erikson observed that middleage is when we tend to be occupied with creative and meaningful work issues surrounding out family. Chemical) Pt. Alcohol consumption: 6pk in month. Skin turgor normal. Warm temperature normal color of extremities.3 PTT: 27.2 Monocyte Percent: 8. No secretions.2 Basophil Absolute: . Fentanyl. denies sleep.
type of respirations. and respirations for difficulty in breathing.Research of the Medical Diagnosis Arthroscopic Bicep Tenodesis: Arthroscopy is a procedure that allows direct visualization of a join to diagnose joint disorders. defects. Side effects: drowsiness. Hinkle. Nursing Implications: Monitor rate. Analgesic agents are administered as needed. and a portion of the biceps tendon can be surgically removed. hemarthrosis. effusion. Heart size within normal limits. (Smeltzer. & Cheever. under sterile conditions. depth. (Smeltzer. Rationale: Patient has anxiety with palpitations. synocium. the joint is kept extended and elevated to reduce swelling. . Complications are rare but may include infection. A large bore needle is inserted and the joint is tended with saline. The arthroscope is introduced and joint structures. and articular surfaces are visualized. Bare. Albuterol: 2 puffs q4 hrs PRN Action: Broncho dilator. rhythm. After the procedure the puncture wound is closed with adhesive strips or sutures and covered with a sterile dressing. thrombophlebitis. and disease processes may be performed through the arthroscope. Essentially a biceps tenodesis moves the attachment of the biceps tendon to a position that is out of the way of the shoulder joint. behavioral disturbances Nursing implications: assess for calm facial expression and decreased restlessness. Medical Technologies: Treatments / Medications Clonazepan: 0. & Cheever. adhesion. Bare. stiffness. Injection of a local anesthetic agent into the joint or general anesthesia is used. Atenolol: 25mg daily Action: Blocks beta-adrenergic receptors in cardiac tissue Rationale: Treatment of hypertension. Hinkle. The patient and family are informed of symptoms to watch for in order to determine whether complications are occurring and of the importance of notifying the physician of this observation. The patient is instructed about activities and exercises that may be preformed.5mg. Rationale: Patient has asthma but has not needed medication. the pressure of the biceps attachment is taken off the cartilage rim of the shoulder socket (the labrum). Bare. By performing a biceps tenodesis. Hinkle. Bare. and cannot remember the last time he has taken medication. 2010) Bicept tendoesis: A biceps tenodesis is a procedure that cuts the normal attachment of the biceps tendon on the shoulder socket and reattaches the tendon to the bone of the humerus. Lung volumes show large but otherwise clear. (Smeltzer. It is important to monitor and document the neurovascular status. Assess lungs for abnormal lung sounds. fluid-filled sac that acts as a cushion at a pressure point in the body. & Cheever. neurocascular compromise. & Cheever. In addition ice may be applied to control edema and enhance comfort. Treatment of tears. PRN Action: Depresses nerve impulse transmission in motor cortex. The procedure is performed through the arthroscope in an operating room. Hinkle. 2010) Significance of Normal/Abnormal Diagnostic Tests Lab work: all levels are normal Urinanalysis: all levels are normal Chest X-ray: Frontal and lateral projections of the chest demonstrate biapical pleural parenchymal scarring. 2010) Nursing interventions: After the procedure. (Smeltzer. Frequently. near joints where tendons or muscles cross either bone or other muscles). 2010) Subacromial Bursectomy: is removal of the subscromial bursa sac (a small. Side Effects: Hypotension. dizziness. and delayed wound healing. assess vital signs. constipation Nursing Implications: Monitor B/P and pulse for bradycardia. the joint is wrapped with a compression dressing to control welling.
centrally in chemoreceptor trigger zone. Risk for constipation r/t use anesthesia. Monitor pain level. Assess for therapeutic response. Ineffective health maintenance r/t lack of knowledge regarding prevention of dental disease AEB pt crowns. Acute pain r/t presence of intubation tube AEB pt. Rationale: Relieves nausea/vomiting Nursing Implications: Assess for dehydration. bowel activity. rhythm. encourage post op turn. Monitor Vital signs. decrease in fluid and food intake. Assess for clinical improvement. Post OP ORDERS: Morphine: 2-4 mg every 2min IV PRN max dose: 20mg Action: binds with opioid receptors within CNS Rationale: Pain relief Nursing Implications: monitor vital signs 5-10 min after IV check for adequate voiding.Fluticasone Propionate: 2 puffs BID Action: Prevents and controls inflammation. and pain medication. Self-Care Deficit related to impaired ability to perform self-care tasks. Nursing Implications: Monitor rate. assess for relief of pain Prochlorperazine: 10mg IM Action: Acts to block dopamine receptors in chemoreceptor trigger zone. Monitor WBC count. . depth. assess bowel sounds for peristalsis. Risk for Peripheral Neurovascular Dysfunction related to tissue trauma and Readiness for enhanced Therapeutic regimen management: expresses desire to learn measures to stop smoking. inhibits ascending pain pathways Rationale: Pain relief Nursing Implications: Asst with ambulation. type of respirations. as evidenced by statements of need for assistance and observed difficulty in performing activities of daily living Risk for infection r/t invasive procedure. and cannot remember last time he has taken medication. Rationale: Relieves nausea/vomiting Nursing Implications: Monitor BP for hypotension. Prioritized List of Nursing Diagnoses (in PES format Acute pain r/t injury in surgical care AEB pt. both peripherally on vagal nerve terminals. Onsansteron: 4mg IV Action: blocks serotonin. and assess mental status Meperidine: 12. Fentanyl: 25-50 mcg every 2min IV PRN max dose: 100mcg Action: reducing stimuli from sensory nerve endings. verbalizing a mild sore throat. Assess lungs for abnormal lung sounds. verbalization. Risk for ineffective breathing pattern r/t effects of narcotics and anesthesia. cough deep breathe q2h.5 IVP May repeat x1 Action: Binds to opoid receptors with in CNS Rationale: for shivering Nursing Implications: Monitor vitals 15-30 mins after subQ/IM dose. Rationale: Patient has asthma but has not needed medication. Acute back pain related to back injury as evidenced by patient verbalization. 5-10 mins after IV dose.
including experiences with side effects. will demonstrate the ability to dress. will verbalize three types of clothing that are easier to put on by 10/28. will verbalize pain at a level of 3 or less by the 10/28. and indicated to whomever was doing the dressing change required to wear gloves. (Rationale: Opioids may cause EVALUATION AND/OR MODIFICATIONS Patient had reached goal. will have a reduction in pain by discharge. typical coping responses. NOC Indicators: Pt. frequency. to include location. Independent or Interdependent and S/E. and the way the client expresses pain. Fever)purulentdrainage? Patient had reached goal. Redness. and dressing the affected arm first. and risk of addiction. (Rationale: many patients harbor fears and misconceptions regarding the use of analgesics. NOC Indicators: Pt. indicated the when time of surgical dressing had to be changed. will verbalize $ signs and symptoms of infection. Patient verbalized the steps in correct hand hygiene. Independent WC) (Ackley and Ladwig [g 605) Obtain a prescription to administer and opioid. verbalization. will have surgical area that shows evidence of healing. Patient also verbalized the importance of not waiting till the pain was intolerable before taking the medication. NOC: Pt. intensity or severity of pain and precipitating factors. (Rationale: the least invasive route of administration capable of providing adequate pain control is recommended. or WC) Assure patient attentive analgesic care: Perform a comprehensive assessment of pain. Heat. Independent PC )(Ackley and Ladwig pg 608) When opioids are administered. Independent PC) (Ackley and Ladwig pg 604) Ask the client to describe past experiences with pain and the effectiveness of methods used to manage pain. NURSE AGENCY (NIC) Nursing actions (NIC Activities) (Include rationales. and respiratory status at regular intervals.NURSING DIAGNOSIS (NANDA) SELF-CARE AGENCY-1 Goal (NOC) + Expected Outcomes (NOC Indicators) NOC: Pt. quality. characteristics. NOC Indicator: Pt. Independent PC) (Ackley and Ladwig pg. Rationale: opioid analgesics are indicated for the treatment of moderate to severe pain Interdependent PWC) (Ackley and Ladwig pg 607) Administer opioids orally or IV as ordered when appropriate and available. by the time of discharge patient confirmed a level of 2 out of 10 on the pain scale. sweaters that zip up in front. (Rationale: The clients report of pain is the single most reliable indicator of pain. PC. NOCPt. by the time of discharge patient did not show any signs of redness or swelling in the surgical area. Patient had reached goal. Acute pain r/t injury in surgical care AEB pt. as evidenced by statements of need for assistance and observed difficulty in performing activities of daily living Ok so you would Use selfcare deficit: dressing Goal: Prevention of infection These are all indicators NOC: Pt. (Rationale: initial assessment and documentation provide direction for the pain treatment plan. 606) Assess and document the intensity of the pain and discomfort after surgery. will know to dress the affected side first by 10/28. will know signs and symptoms of infection. NOC Indicator: Pt. assess pain intensity. management of side effects. .at f/u visit Risk for infection r/t invasive procedure. (Wide sleeve shirts. sedation. (Pain. Self-Care Deficit related to impaired ability to perform self-care tasks. Patient had reached goal: patient verbalized three easier steps of dressing that are easier to put on. knows an easier method for dressing .) Patient had reached goal and indicated 5 signs and symptoms of infection. NOCindicator: Pt. onset/ duration.
609) Teach and implement non-pharmacological interventions when pain is relatively well controlled with pharmacological interventions. respiratory depression because they reduce the responsiveness of carbon dioxide chemoreceptors located in the respiratory centers of the brain. will have no redness and drainage by 10/30 and none at f/u visit NOC: Pt. 610) Assess client for symptoms of general weakness. arm paralysis . Independent S/E) (Ackley and Ladwig pg. and fatigue for planning methods. wear gloves and apply clean band aids to sutures. not replace.NOC Indicators: Pt. arm paralysis. (Rationale: General weakness. NOC Indicators: Patients will wash hands. pharmacological interventions Independent S/E) (Ackley and Ladwig pg 609) Reinforce the importance of taking pain medications to keep pain under control. will know how to change dressing. Independent WC) (Ackley and Ladwig pg. (Rationale: teaching clients to stay on top of their pain and prevent it from getting out of control improves the ability to accomplish the goals of recovery. (Rationale: non-pharmacological interventions should be used to supplement.
(Rationale: Simplifying dressing tasks increases self care and safety. discharge and increase in body temp. Independent WC) (Ackley and . (Rationale: Improvement in nutritional status can improve outcome of postoperative period. (Rationale: Prospective surveillance study for nosocomial infection on hematologyoncology units should include fever of unknown origin as the single most common and clinically important entity. Independent W) (Ackley and Ladwig pg.E) (Ackley and Ladwig pg. warmth. (Rationale: Simplifying dressing and grooming tasks that consist of many small steps promotes mastery. (Rationale: client safety when performing aseptic technique is of the highest importance. (Rationale: Dressing the affected side first allows for easier manipulation of clothing Independent S/E) (Ackley and Ladwig pg. 705 ) Use careful aseptic technique when caring for wounds. and then proceed to more complicated steps. 702) Provide privacy and limit the number of people in the room. Independent WC) (Ackley and Ladwig pg 497) Provide client with a complete balanced therapeutic diet after the immediately postoperative period. or shirts that open in the front. while decreasing exertion. wide sleeves tshirts. 703) Teach client to dress affected side first. 704) Teach the simplest in a task until mastered. Independent PC) (Ackley and Ladwig pg 497) Observe and report signs of infection such as redness. Independent WC) (Ackley and Ladwig pg. Independent WC) (Ackley and Ladwig pg 703) Select clothing in larger sizes.and fatigue were reported to be main causes of being unable to dress oneself. Independent S/. (Rationale: Privacy conveys respect and increases dressing ability. then the unaffected side.
498) Assess for skin color.Ladwig pg. moisture. pg 450) . (Rationale: Fluid intake helps thin secretions and replaces fluid lost during surgery. (Rationale: two thirds of wound infections occur after discharge. Independent S/E) (Ackley and Ladwig. smoking. Independent WC) (Ackley and Ladwig pg 498) Encourage fluid intake. Independent S/E) (Ackley and Ladwig pg 499) Teach the client and family the symptoms of infection that should be promptly reported to a primary medical caregiver. (Rationale: The skin is the body’s first line of defense in protecting the body from infection. (Rationale: These are some of the factors associated with risk of surgical wound infection. texture and turgor. Independent WC) (Ackley and Ladwig pg 498) Teach the client risk factors contributing to surgical wound infection.
Do not run water directly on the wound. especially in bed. After that. Do not submerge the shoulder in a pool (bathtub. brings a copy of specific physical therapy prescription to your first appointment. Burra. if you develop numbness of tingling. Driving should be avoided and pt is not allowed to drive while wearing the sling. or when there is lack of sufficient strength to meet the requirements of driving a motor vehicle. Do not place the cooling pad of the cyrotherapy device or the ice packs directly on the skin. gently of the elbow and straightening of the elbow.)Until the suture site has completely healed and stitches have been removed. 20 min each. the wound turns red and drainage increases. Do not use bacitracin or any other ointments.any hazards at home need to be addressed. Please return to Dr office in 10-14 days to have sutures removed. Place a pillow under your elbow: no pillow under your shoulder. bruising and swelling distal to the shoulder may occur. etc Sling/Brace: The day of the surgery the arm will be placed in a sling/brace for comfort and protection.Discharge Planning-. After the shower remove the band aids. task reassignment. under the influence of pain medication. low temperature (less 101.5 Area of Concern A Activity: Discharge Preparation Needed Instruct Pt to: Do not sign any legal papers or make any legal decisions for 24hrs after surgery. Please use a barrier between the skin and the cooling device/ice packs. dress. may shower after 48hourse. Pt is advised against driving until further evaluation by Dr. Use the cryotherapy 20min every hour on the first and second postoperative days. Notify Dr. to shower. No NSAIDS for risk of bleeding. any loss of limb use predisposes to fall risk. If the therapist is unsure of the protocol to be followed please have him contact Dr. Burra for appropriate instructions. Additional instructions on the use of the device will be provided by Dr. A cryotherapy (cooling) device or conventional ice pack will provide cold therapy to the shoulder and reduce pain and swelling. To call and make an Do not drink anything alcoholic for at least 24hrs after surgery. extra dressing materials. Burra and the physical therapist. hot tub etc. Apply Band Aids to the portal sites. (Remove the strap of sling and perform range of motion exercises. It may be intermittently removed.—sleeping arrangements. bloody drainage and limited areas of numbness may be present around the incision. place arm back in the sling and put the sling straps back on. After performing exercises. gently dad portal sires dry and apply fresh band aids. Leave in place any small adhesive Steri-strips or sutures that are directly on the incision.5 degrees F. Burra. In case of nausea avoid solid foods take only clear liquids as tolerated if persistent nausea or vomiting please contact your physician. Exercises: Perform early postop exercises as instructed by Dr. the pain is not tolerable despite the use medication. (No Advil/No Aleve) Norco:1-2 325mg/10mg tabs PO PRN Pt. deep breathing exercises may be helpful. Burra if: you develop fever greater than 101. Dressings: remove outer dressings 36-48 hours after surgery. chills or night sweats. Sleep in a semi-upright position in a recliner or propped up by pillows may also be helpful. FYI-an increase in calories aids in healing. Be certain that pt. Pt. M Medication: E Environment: T Treatment H Health Teaching O Outpatient Referral D Diet .5 degrees F) is common after surgery. Replace the Band aids every 24hrs and after a shower. and perform exercises. sterile gauze and tape can be found at most pharmacy/drug stores. the device may be used about 4-8 sessions per day. Gradually increase diet from soft foods to a regular diet as tolerated. will be going home. Rest the day of surgery. malnourishment is a major cause for delayed surgical healing. The sling/brace includes a waistband should be worn at all times. An appointment should have been scheduled with physical therapy for the first day after surgery. every hour that pt is awake. Normal Symptoms and findings after surgery: Shoulder pain and warmth is normal.
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