Care Plan

Student: Evelina Balzhyk Date: 09.20.19

Course: NSG320CC Instructor: Alyx Fergus

Clincial Site: Chandler Regional Client Identifier: DA Age: 66

Reason for Admission:

DA was admitted for severe hip pain in her right hip after her total hip replacement surgery on 09.19.2019.

Medical Diagnoses: (Include Pathophysiology and Risk Factors): Clinical Manifestation(s):

Patient was diagnosed with hip surgical site infecction status post right DA’s clinical manifestations include: increased pain/stiffness, and
total hip arthoplasty. wound drainage, and chills.
Pathophysiology: Joint replacement infections may occur in the wound or Potential clinical manifestations include swelling, warmth and
deep around the artificial implants (“Joint Replacement Infection”, 2019). redness around the wound, fevers, and fatigue (“Joint Replacement
Any infection in the body can spread to a joint replacement. These Infection”, 2019).
infections are caused by bacteria. Because joint replacements are made of
plastic, it is difficult for the immune system to attack bacteria that make it
to the implant (“Joint Replacement Infection”, 2019). If bacteria gain
access to implants, they may multiply and cause an infection. Bacteria
may enter the body through breaks or cuts in the skin, during major
procedures, or through wounds.

Risk factors for this diagnosis include “host immunity, nutritional status,
diabetes, age, use of steroids or immunosuppressive drugs, rheumatoid
arthritis, and urinary tract or other infections” (Seibert, 2017).

© 2018. Grand Canyon University. All Rights Reserved. Rev 2.17.18

 Assessment Data

Subjective Data: DA rates her pain in the right hip on a level of 8/10. She also says that she is very cold.
VS: T : 36.8 C Labs: Diagnostics:
BP: 102/58 DA’s labs were performed on 09.20.19. DA’s diagnostics were performed on 09.20.19 at 9:36.
HR: 73 bpm RBC 2.16 (normal 4.2-5.4) XR Hip w Pelvis 1 View
RR: 16 bpm Hgb 6.9 (normal 12-15.5) Results:
O2 Sat: 97 on room air Hct 21.2 (normal 37%-48%) 1. Multiple rounded densities consistent w antibiotic
pellets are seen throughout the proximal stem
Glucose 136 (70-100)
2. Left hip arthroplasty remains intact.
BUN 21 (normal 7-20)
3. Visualized portions of the bony pelvis show osteoporoic
Creatinine 1.05 (normal 0.6-1.2)
changes, but no evidence of acute fracture.

Assessment:
General: acute distress due to new diagnosis and many people involved
in treatment.
Pt History: patient has a history of recurrent right hip dislocation,
HTN, MRSA prosthetic right hip infection
Neuro: LOC alert and oriented to person and place, and time. Patient
seems to be fatigued and lethragic.
Orders:
Q1h vital sign checks due to blood transfusion and low BP.
Check vitals 15 minutes and 30 minute after blood transfusion.
Keep on monitoring BP. If low, isotonic solution saline will be
anticipated
Keep pain under control

Respiratory: Monitor input and output due to IV saline fluids.

Normal breath sounds are auscultated bilaterally. Good inspiratory Monitor wound vac and wound on right hip
effort.

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Respirations are regular, non-labored and even.
Chest is symmetrical, rising and falling of chest is symmetrical
Cardiovascular:
Regular rate and rhythm, no lower extremity pitting edema bilaterally to
upper and lower extremities
S1 and S2 sounds noted, no S3/S4 sounds noted
Most recent BP is 102/58; HR is 73 bpm. Patient’s blood pressure has
been ranging low since her surgery. I do not have the exact numbers.
Skin: no rash
Right thigh wound appears to be intact. Without redness or warmth.
Wound vac is in place
No upper body swelling noted bilaterally.
Musculoskeletal: Ambulates independently
GU: voids without difficulty
GI: soft, non-tender, non-distended, bowel sounds are normal.
Continent urination
Diet: regular diet

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 Medications
ALLERGIES:
Gabapentin, Vancomycin, Augmentin, Lisinopril, Morphine

Name Dose Route Frequency Indication/Therapeutic Adverse Effects Nursing

Effect Considerations
Calcium Carbonate 1250 mg PO TID Treatment and prevention CNS: headache, tingling. Observe patient
of hypocalcemia. Adjunct CV: arrhythmias, closely for
in the prevention of bradycardia. GI: symptoms of
postmenopausal constipation, nausea, hypocalcemia
osteoporosis. Relief of vomiting. GU: calculi, (paresthesia, muscle
acid indigestion or hypercalciuria. twitching,
heartburn (Vallerand, 2017). laryngospasm,
(Vallerand, 2017). colic, cardiac
arrhythmias,
Chvostek’s or
Trousseau’s sign).
Notify physician or
other health care
professional if these
occur. Protect
symptomatic
patients by
elevating and
padding siderails
and keeping bed in
low position
(Vallerand, 2017).
2000 mg IV push Q8hr Treatment of the CNS: SEIZURES (high Assess for infection
Cefazolin following infections due doses). GI: (vital signs;
to susceptible organisms: PSEUDOMEMBRANOUS appearance of
Skin and skin structure COLITIS, diarrhea, nausea, wound, sputum,
infections (including burn vomiting, cramps. Derm: urine, and stool;
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 wounds), Pneumonia, STEVENS-JOHNSON WBC) at beginning
Urinary tract infections, SYNDROME, rash of and throughout
Biliary tract infections, (Vallerand, 2017). therapy
Genital infections, Bone (Vallerand, 2017).
and joint infections
(Vallerand, 2017).
15 mL topical BID Antiseptic antibacterial Blistering, burning, itching, Rinse the skin
Chlorhexidine Topical agents. It is used to clean peeling, skin rash, redness, before applying
the skin after an injury, swelling, or other signs of chlorhexidine
before surgery, or before irritation on the skin, topical. Apply only
an injection. swelling of the face, hands, enough medicine to
(Vallerand, 2017). or feet, trouble breathing cover the area you
are treating. Do not
(Vallerand, 2017). apply this medicine
to deep cuts,
scrapes, or open
skin wounds.
(Vallerand, 2017).
100 mg PO BID Prevention of constipation EENT: throat irritation. GI: Assess for
Docusate (in patients who should mild cramps, diarrhea. abdominal
avoid straining, such as Derm: rashes. distention, presence
after MI or rectal surgery) (Vallerand, 2017). of bowel sounds,
(Vallerand, 2017). and usual pattern of
bowel function
(Vallerand, 2017).
50 mg PO BID Treatment of HTN; blocks CNS: fatigue, weakness, Hold dosage if SB
Metoprolol beta 1 stimulation anxiety, depression, <110, HR<55
(Vallerand, 2017). dizziness, drowsiness, Monitor BP, ECG
insomnia, memory loss and pulse
Resp: bronchospasm frequently. Side
Derm: rash (Vallerand, effects: fatigue,
2017). dizziness, anxiety
(Vallerand, 2017).

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 10 mL IV push Q12hr Hydration and provision Pulmonary edema, edema, Assess fluid
Sodium Chloride 0.9% of NaCl in deficiency hypernatremia, balance (intake and
states, maintenance of hypovolemia, hpokalemia, output, daily
electrolye and fluid status. irritation at IV site weight, edema, lung
Reconstitue or dilute other (Vallerand, 2017). sounds) throughout
medications. therapy. Assess
(Vallerand, 2017). patients for
symptoms of
hyponatremia
(headache,
tachycardia, muscle
cramps, N/V) or
hypernatremia
(edema, weight
gain, hypertension)

(Vallerand, 2017).
220 mg PO qday
Zinc Sulfate

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 Nursing Diagnoses and Plan of Care
Goal Expected Outcome Intervention(s) Rationale Evaluation
Client or family focused. Measurable, time-specific, Nursing or interprofessional Provide reason why Was goal met? Revise
reasonable, and attainable. interventions. intervention is the plan of care
indicated/therapeutic. according the client’s
Provide references. response to current plan
of care.
Priority Nursing Diagnosis (including rationale for choosing this as the priority diagnosis)
Cardiac disturbance related to post-op infection as evidenced by hypotension.

This has been selected as the primary diagnosis because risk for falls is a concern for safety which is the second tier in Maslow’s Hierarchy of
Needs.
Patient will verbalize Patient will verbalize 1. Report complaints of 1. These may indicate Goal was met.
understanding of reportable understanding of dizziness or syncope. cerebral hypoxia resuslting
signs and symptoms. reportable signs and 2. explain all procedures from a cardiac rhythm Patient verbalizes
symptoms by discharge. and tests disturbance. understanding of
3. measure and record 2. to enhance reportable signs and
(Phelps, Ralph, & Taylor, intake and output accurately understanding and reduce symptoms by discharge.
2017). anxiety
(Phelps, Ralph, & Taylor, 3. decreased urine output
2017). without lowered fluid
intake might indicate
decreased renal perfusion,
possibly from decreased
cardiac output.

Secondary Nursing Diagnosis: Risk for falls related to hypotension.

This has been selected as the secondary diagnosis because risk for falls is a concern for safety which is the second tier in Maslow’s Hierarchy of
Needs.

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Patient will relate the DA will point out things in 1. Identify factors 1. To enhace the Goal was met.
intent to use safety the environment that puts that may cause or patient, faily, caregiver
measures to prevent falls. her at risk for falls by the contribute to injury awareness of the risks DA pointed out things in
end of the shift from a fall 2. Doing frequent the environment that put
2. Improve assessments of the her at risk for falls by the
environmental patient’s environment end of the shift
safety factors as is necessary to make
needed sure new risks have
3. Review not occurred
medications with 3. Two or more
(Phelps, Ralph, & Taylor, patient and family. medications taken by a
2017). Help the patient patient put the patient
understand which at greater risk. Many
medications put the medications takken by
patient at greater the elderly can cause
risk for falls. dizziness, sleepiness,
Knowing the risk lowered blood
may help the pressure, and
patient take more confusion. Without
care in moving sufficient instructions,
about. It may also the patient may at a
call for reviewing higher risk for falls.
with the primary
care physician.
(Phelps, Ralph, &
(Phelps, Ralph, & Taylor, Taylor, 2017).
2017).
Definition of Client-Centered Care: Care that is unique to the age/developmental stage, gender, race, ethnicity, socio-economic
status, cultural and spiritual preferences of the individual and focused on providing safe, evidence based care for the achievement of
quality client outcomes.”
References

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Joint Replacement Infection - OrthoInfo - AAOS. (2019). Retrieved from https://orthoinfo.aaos.org/en/diseases--conditions/joint-
replacement-infection/
Phelps, L., Ralph, S., & Taylor, C. (2017). Sparks & Taylors nursing diagnosis reference manual (10th ed.). Philadelphia, PA:
Wolters Kluwer.
Seibert, D. J. (2017, December). Pathophysiology of surgical site infection in total hip arthroplasty. Retrieved from
https://www.ncbi.nlm.nih.gov/pubmed/10586159
Vallerand, A., Sanoski, C., & Deglin, J. (2017). Davis’s drug guide for nurses (15th ed.). Philadelphia, PA: F.A. Davis.

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