707A

NURS 2645L Professional Nursing 1

WEEKLY WORKSHEET

STUDENT NAME ______Daelyn Lazor________DATE OF CARE_4/19/18______PATIENT INITIALS___JS___

DNR STATUS__FULL___SAFETY CONCERNS_Medium fall risk____ ALLERGIES___NONE____
DIET (Type/Assistance needed) GENERAL_INTAKE _800_ OUTPUT __600mL_BKFT__75__% LUNCH__50__%
ACTIVITY ORDER_Full weight bearing, up as tolerated__# OF ASSIST_1 _ANY DEVICES___Walker, PCDs__
IV’s__NS LOCK_____Bp___125/83__ Temp_98.4_Pulse__ 78 Resp___17__ Pain Rating___6_
TEACHING NEEDS – Identify and State Reason (Cultural, Spiritual, Sexual, Psychosocial, Knowledge Deficit)

fall prevention- plan of care care___

PRIMARY MEDICAL DIAGNOSIS: *HIGHLIGHT ALL SIGNS/SYMPTOMS YOUR PATIENT EXHIBITS

ETIOLOGY/PATHOPHYSIOLOGY

Primary osteoarthritis of Rt knee

Pathophysiology= cartilage undergoes a remodeling process, stimulated by joint mvt or use, process is
altered by an abnormal reparation of cartilage, and an increase in cartilage degradation

Etiology= previous joint injury; biologic and mechanical factors play a role n its development (age,
hereditary , gender- female and obesity)

ALL SIGNS/SYMPTOMS OF DIAGNOSIS

Limited Rom and stiffness- goes away after movement

Clicking or cracking sound when joints bends

Mild swelling around joint

Tenderness of palpation

Pain worse at ED

Bony enlargement around joint

CAUSE OR EFFECT ON PATIENT’S PRESENT CONDITION.

Discomfort and dyspnea during ADLS

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SURGERICAL HX:

Breast surgry- right cyst removal

Colonoscopy- 9/24/13

Echo compl with drop color flow – 2/15/13

Eye surgery- bilateral

PR total knee arthroplasty right – 4/17/18

Tonsillectomy

SECONDARY MEDICAL DIAGNOSIS: LIST ALL ON BACK OF PAGE.

Viral myositis, Unspecified cerebral artery occlusion with cerebral infraction , Rhabdomyolysis, Myositis,
Moderate tricuspid regurgitation, Pure hypercholesterolemia, Left leg weakness, HT, Elevated
transaminase levels , Elevated CK,CVA, asthmatic bronchitis, Arthritis, Anemia ,Gait abnormality

LABORATORY DATA

TEST DATE NORMAL RESULTS REASON FOR ABNORMAL VALUES

VALUES
WBC’S 4/18 4.5-11 15.5 INC DT INJURY OR STRESS RELATED /
TRAUMA/SURGERY

HEMOGLOBIN 4/18 11.5-15.5 10.4 DEC, SURGERY, ANEMIA AND BLOOD LOSS

HEMATOCRIT 4/18 34-48% 30.7 DEC, ANEMIA, SURGERY, BLOOD LOSS

GLUCOSE 4/10 74-109 109 WNL

(FBS/BS)
Other (Especially
related to meds)
4/10 8-23 12 WNL
CREATININE
BUN
4/10 0.5-1.0 0.6 WNL
GFR 4/10 >60ML >60 WNL

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 DIAGNOSTIC TESTS: Chest x-ray, EKG, sputum, blood culture, etc.

TEST DATE NORMAL RESULTS REASON FOR ABNORMAL VALUES

VALUES
XRAY R KNEE 4/17/18 RT TOTAL KNEE ARTHROPLASTY WITH AIR
WITHIN SOFT TISSUE, SOFT TISSUE
SWELLING, SUSPCTED SURGCIAL DRAIN
- THERE IF QUESTIONABLE LUCENCY
SEEN IN LATERAL TIBIAL PLATEAU
REGION, THEY COULDN’T EXCLUDE
PATENCY OF FRACT8RE IN THIS AREA
BASED ON THIS IMAGE CLINICA;
CORRELATION RECOMMENDED

TREATMENTS (INTERVENTIONS): INCLUDE ELIMINATION, RESTRAINTS, DRESSINGS, O2 THERAPY

Treatment (Intervention) How Often Times Rationale

Q8hrs Assess fluid status and circulating volume needing
Monitor I&O- call if urine replaced – heart issues
<120mL in 4hrs
Incentive spirometry Every 2hrs Need to keep lings healthy after surgery- open airways ,
while prevent fluid or mucus from building up in lungs
awake
PRN Help decrease pain, swelling and inflammation (reduce
Elevated operative BF to injury)
affected extremity
once MRSA- needs to be treated immediate and prevent the
MRSA culture spreading for it to others (make sure not HA)
Q4hrs Monitor overall health (heart functioning) and assess
VS for red flags regarding VS
Q4hrs 5 P’s Assess for adequate nerve function and blood
Neurovascular checks circulation throughout body
Q2hrs Hel- breathing, clear lungs and lower risk of pneumonia
Encourage deep while
breathing & coughing awake

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 PRN Help pt with performing ADLs and improve pts ability to
OT &PT perform movement
PRN Provide comfort when unable to take more pain meds
Ice therapy and promote healing and decrease swelling
PCDS Always on Prophylaxis for DVT due to limited mobility
while in
bed
Continuous PROM (0-70 daily Improve ROM on right knee, regain strength and
degrees increase as mobility (prevent contractures)
tolerated 2hrs/shift)

Assess peripheral IV left PRN Make sure no signs of infection , irritation or

antecubital 20g inflammation
Wound care (dressing PRN Prevent complications such as a infection and promote
chang and apply) healing

TARGET ASSESSMENT (Hospital Only)

What body system(s) Musculoskeletal system

Why did you choose

Patient got an arthroplasty of the right knee

Document assessment of that system

Incision was pink, dry and intact, minimum amount of drainage, sanguineous

Dry sterile dressing clean dry and intact

No signs of infection

Handwashing and sterile procedures to prevent spread of infection

Pillows strategically placed to support the affected leg and make sure its in proper alignment

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 HEAD TO TOE ASSESSMENT DATA

HIGHLIGHT ABNORMAL DATA

NEURO/MENTAL: Alert and oriented to person, place & time . hand grasp equal bilaterally. No PERRL-
Rt pupil 4mm & left pupil 3mm. Pt claims of severe dizziness & overwhelming rush of nausea

CARDIOVASCULAR:

S1 and S2 present, apical pulse , irregular rhythm

PERIPHERAL/VASCULAR

Pedal pulse +1 bilat, scale 0-3+, capillary refill <3 sec in all extremeities . Edema +2 on Rt foot and edema
on Left foot

RESPIRATORY:

Lungs clear to ausuclatation in bilateral nterior, posterior and lateral lungs. Respirations even and non
laboed, AP = transverse. No cough

GASTROINTESTINAL:

Nasal mucosa intact, oral mucosa pink, moist. Bowel sounds in all 4 quadrants. No pain or masses when
palpated no N/V/D. continent of bowel. Last BM 4/17/18 in morning.

GENITOURINARY:

Continent or urine, yellow clear, no sediment or odor.

SKIN:

Skin warm, dry , intact, color flesh tone. Skin turgor tenting . both ears w/o drainage. Hearing aids used.

MUSCULOSKELETAL:

Limited ROM in right knee. Full ROM in all Other extremities. Strength able to resist in all extremities
and neck. Ambulated with walker and is a 1 assist. Gait is steady with walker, unsteady without walker.

PSYCHOSOCIAL:

Calm, pleasant and content

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PAIN/DISCOMFORT:

Patient describes pain a 6 on 0-10 pain scale. Patient explained pain as “aching” feeling (right above
patella to top of tibia – area of pain), facial grimacing , exertional dyspnea, irritability and guarding.

EXPLAIN HIGHLIGHTED ABNORMAL ASSESSMENT DATA FROM HEAD TO TOE ASSESSMENT

(IF HIGHLIGHTED ON PREVIOUS PAGE, MUST BE EXPLAINED HERE)

NEURO/MENTAL:

Aging, impaired vision- no PERRL, Dizziness / nausea – orthostatic hypotension due to tricupsid
regurgitation and medication anesthesia

CARDIOVASCULAR:

PERIPHERAL/VASCULAR

Pedal pulse +1= dt edema and moderate tricupsid regurgitation (heart problems), Edema= on righ foot
due to heart/ tricuspid problem and swelling from surgery Left foot= due to HTN poor blood flow

RESPIRATORY:

GASTROINTESTINAL:

GENITOURINARY:

SKIN:

Hearing aids used- aging / impaired hearing

MUSCULOSKELETAL:

Limited ROM – surgery (arthroplasty of Rt knee)

Ambulate and gait = need walker due to surgery as well

PSYCHOSOCIAL:

PAIN/DISCOMFORT:

6 on 0/10 pain scale  due to surgical pain of right knee arthroplasty

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 Katz Index of Independence in Activities of Daily Living

ACTIVITIES INDEPENDENCE: DEPENDENCE:

POINTS (1 OR 0) (1 POINT) (0 POINTS)

BATHING (1 POINT) Bathes self completely (0 POINTS) Needs help with

or needs help in bathing only a bathing more than one part of the
single part of the body such as the body, getting in or out of the tub
DRESSING (1 POINT)
back, Gets
genital clothes
area from
or disabled (0
or POINTS) Needs help
shower. Requires with
total bathing.
closets and drawers and puts on dressing self or needs to be
clothes and outer garments completely dressed.
TOILETING (1 POINT) with
complete Goesfasteners.
to toilet, gets
Mayonhave (0 POINTS) Needs help transferring
and off, arranges clothes, cleans to the toilet, cleaning self or uses
genital area without help. bedpan or commode.
TRANSFERRING (1 POINT) Moves in and out of bed (0 POINTS) Needs help in moving
or chair unassisted. Mechanical from bed to chair or requires a
transferring aides are acceptable. complete transfer.
CONTINENCE (1 POINT) Exercises complete self (0 POINTS) Is partially or totally
control over urination and incontinent of bowel or bladder.
defecation.
FEEDING (1 POINT) Gets food from plate (0 POINTS) Needs partial or total
into mouth without help. help with feeding or requires
Preparation of food may be done parenteral feeding.
by another person.

TOTAL POINTS = 6 = High (patient independent) 0 = Low (patient very dependent)

3 patient moderately dependent

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 Fulmer SPICES: An Overall Assessment Tool for Older Adults

Date: 4/19/18
SPICES EVIDENCE
No Yes
Sleep Disorders NONE

Problems with Eating or NONE

Feeding

Incontinence NONE

Confusion NONE

Evidence of Falls Secondary diagnosis

Left leg weakness;

gait abnormality, Fell
at home at 4/01/18
Skin Breakdown NONE

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  
SENSORY Completely Limited:
PERCEPTION Unresponsive (does not
Ability to respond moan, flinch, or grasp) to
meaningfully to painful stimuli, due to
pressure-related diminished level of
discomfort consciousness or sedation,
OR
limited ability to feel pain
over most of the body
surface.
MOISTURE Constantly Moist:
Degree to which Skin is kept moist almost
skin is exposed to constantly by perspiration,
moisture urine, etc. Dampness is
detected every time patient is
moved or turned.
ACTIVITY Bedfast:
Degree of physical Confined to bed.
activity
MOBILITY Completely Immobile:
Ability to change Does not make even slight
and control body changes in body or extremity
position position without assistance.
NUTRITION Very Poor:
Usual food intake Never eats a complete meal.
pattern Rarely eats more than 1/3 of
any food offered. Eats 2
servings or less of protein
(meat or dairy products) per
day. Takes fluids poorly.
Does not take a liquid dietary
supplement,
OR
Is NPO and/or maintained on
clear liquids or IVs for more
than 5 days.
FRICTION AND Problem:
SHEAR Requires moderate to
maximum assistance in
moving. Complete lifting
without sliding against sheets
is impossible. Frequently
slides down in bed or chair,
requiring frequent
repositioning with maximum
assistance. Spasticity,
contractures, or agitation
leads to almost constant
friction.
N2645 Assessment: Directions: Add up the total points, a perfect score is 23. A high score means lower risk for
developing a pressure ulcer. A low score means higher risk.
BRADEN SCALE - PRESSURE ULCER RISK- Assess Prior to and during clinical.
Very Limited:
Responds only to painful
stimuli. Cannot
communicate discomfort
except by moaning or
restlessness,
OR
has a sensory impairment
which limits the ability to
feel pain or discomfort
over ½ of the body.
Moist:
Skin is often but not
always moist. Linen must
be changed at least once
a shift.
Chairfast:
Ability to walk severely
limited to nonexistent.
Cannot bear own weight
and/or must be assisted
into chair or wheelchair.
Very Limited:
Makes occasional slight
change in body or
extremity position but
unable to make frequent or
significant changes
independently.
Probably Inadequate:
Rarely eats a complete
meal and generally eats
only about ½ of any food
offered. Protein intake
includes 3 servings of
meat or dairy products per
day. Occasionally will take
a dietary supplement,
OR
Receives less than
optimum amount of liquid
diet or tube feeding.
Potential Problem:
Moves feebly or requires
minimum assistance.
During a move skin
probably slides to some
extent against the sheets,
chair, restraints, or other
devices. Maintains
relatively good position in
chair or bed most of the
time but occasionally
slides down.
 
Slightly Limited:
Responsive to verbal
commands but cannot
always communicate
discomfort or need to be
turned,
OR
has a sensory impairment
which limits ability to feel
pain or discomfort in 1 or
2 extremities.
Occasionally Moist:
Skin is occasionally moist,
requiring an extra linen
change approximately
once a day.
Walks Occasionally:
Walks occasionally during
day but for very short
distances, with or
assistance. Spends
majority of each shift in
bed or chair.
Slightly Limited:
Makes frequent though
slight changes in body or
extremity position
independently.
Adequate:
Eats over half of meals.
Eats a total of 4 servings
of protein (meat, dairy
products) each day.
Occasionally will refuse a
meal, but will usually take
a supplement if offered,
OR
Is on a tube feeding or
TPN regimen, which
probably meets most of
nutritional needs.
No Apparent Problem:
Moves in bed and in chair
independently and has
sufficient muscle strength
to lift up completely during
move. Maintains good
position in bed or chair at
all times.
No Impairment:
Responds to verbal
commands. Has no
sensory deficit which
would limit ability to
feel or voice pain or
discomfort.
Rarely Moist:
Skin is usually dry;
linen requires
changing only at
routine intervals.
Walks Frequently:
Walks outside the
room at least twice a
day and inside room
at least once every 2
hours during walking
hours.
No Limitations:
Makes major and
frequent changes in
position without
assistance.
Excellent:
Eats most of every
meal. Usually eats a
total of 4 or more
servings of meat
and dairy products.
Occasionally eats
between meals.
Does not require
supplementation.
Total Points:
Clinical
Judgment
____21___
No risk for
pressure
ulcers__
9
 0
0
0
1

Pt is a
potential high
fall risk

10
 4/19/18
J..S.

Daelyn Lazor

0-10 scale, rated a 6

Ache

continuous

Grimacing, guarding, exertional dyspnea, irritability

Morphine, Tylenol, Percocet

Movement aggravates

Emotions & physical activities are affected by this pain

Control pain 0 on 0-10

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