You are on page 1of 11

PART A COMPLETE EVERYTHING IN BLUE BEFORE CLINICAL DAY.

BRING TO CLINICAL,
Student Name: Brian Sandman Clinical Date: 2/28/17

Height/Weight Age: Gender: F Admission date:2/27/17


5’ 3” 72
*****STARRED ITEMS ARE FOR PEDIATRIC PATIENTS ONLY
**OFC **Height/Weight Growth percentile

Resuscitation Status: Full Code


Reason for Hospitalization:
Full Hip replacement

Past medical history: Chronic Bronchitis, Type 2 diabetes, Hypertension, ARDS

Past surgical history:


Hip replacement today
Current surgeries, procedures, treatments and diagnostic tests: (ie: X-Ray, CT, endoscopy )

R Hip x-ray: 2/27/17- pre-procedure test to verify DJD in R hip

Pathophysiology: Provide a description of the PATHOPHYSIOLOGY OF THE CONDITION FOR


WHICH THE PATIENT WAS ADMITTED. The description should include pertinent
signs/symptoms and complications of the disease process.
Medical condition Signs/symptoms Complications
Full Hip replacement -Pain upon movement -Loss of cartilage(irreversible)
Degenerative Joint Disease:
-No cartilage or little left in -Chronic/acute pain
-The joint cartilage begins to the Joint
breakdown due to decreased -Bone damage/ fractures
proteoglycans -Difficulty ambulating
-Nerve damage
-Osteoclasts are responsible -Full thickness cartilage loss
for bone resorption and with synovitis.
osteophytes cause a change -Crepitus
in bone. -Limited ROM

-an inflammatory response


happens.

-Proteoglycans and collagen


are broken down more and
more and resorption
continues till there is no
collagen left.

-Normal wear and tear of the


cartilage of the hip.

Citation:

Johns Hopkins Arthritis Center. (n.d.). Retrieved February 22, 2017, from
https://www.hopkinsarthritis.org/

Hinkle, J. L., Brunner, L. S., Cheever, K. H., & Suddarth, D. S. (2014). Brunner & Suddarth's textbook of
medical-surgical nursing. Philadelphia: Lippincott Williams & Wilkins.

TEST NORM DATE/ Resul REASON FOR Effect of abnormal value


AL TIME t ABNORMAL on patient (potential problems)
VALUES VALUE
White blood cells (WBC) 3.2-10.6 2/27/17 6.2 Normal
0407
Red blood cells (RBC) 3.98-5.8 “ 4.48 Normal

Hemoglobin (Hgb) 12.5-18.0 “ 12.8 Normal

Hematocrit (Hct) 37-52 “ 42.7 Normal

Platelets 140-440 “ 255 Normal


Prothrombin time (PT) 10-13 2/27/17 10.8 Normal Therapeutic range is 2-3
0400 This was the first Initial Protime
before establishing coumadin
therapy. The bleeding time needs
to be longer to prevent clots
International normalized ratio N/A
(INR)

Partial thromboplastin time N/A


(PTT)

Calcium (Ca) 8.5-10.1 2/26/17 8.9 Normal


1707
Sodium (Na) 136-145 “ 138 Normal

Potassium (K) 3.5-5.1 “ 4.7 Normal

Chloride (Cl) 98-107 “ 98 Normal

Glucose 70-110 2/20/17 163 Uncontrolled type 2 Can cause high urinary output.
diabetes Protein in the urine.
Body begins to metabolize itself if
Glucose cannot enter the cells for
food
Hemoglobin A1C N/A Oddly no A1C was done in the past
Year and a half in EPIC
Cholesterol N/A

Blood Urea Nitrogen (BUN) 7-18 1/23/17 9 Normal

Creatinine 0.6-1.3 “ 0.7 Normal

Pre-albumin N/a

Albumin 3.4-5 1/23/17 4.2 Normal

ABG: N/a
pH
CO2
HCO3
Other important labs Blood 2/27/17 + Strep infection Can lower immune response
significant for this patient: culture strepto At risk for nosocomial infection
cocci

Allergies:
Allergies: Aspirin Type of Reaction: Rash

Medications:
Medication Dose/Route/ Why this Major Side Nursing
generic and Frequency patient is Effects Implications &
trade names **Pediatric receiving this Special
calculations medication Precautions
Safe?
Tylenol 650 mg P.O. Fever reducer Liver toxicity Do not exceed 4
acetaminophen g a day

Ascorbic Acid 1000mg daily Repair body N/A Give at same


Vitamin C PO tissue/HTN time, 1000mg
max dose daily
Cefazolin 2G/100ML Strep/ potential Diarrhea, N/V, Give every 8
Kefzol surgical rash hours in 100ml
infection solution
Humalog
Lispro Type 2 diabetes Monitor glucose
Sliding scale Hypoglycemia, levels
altered LOC

Coumadin 3mg mg PO 2x Blood clots Hemorrhage, Protect from


Warfarin time daily bruising falls/ injury,
Monitor PT for
therapeutic
Demerol 30MG Via PCA Acute Severe LOC, range 2-3
Meperidine pain Drowsiness,
Respiratory Monitor RR,
(discontinued) depression assess pain
level, teach pt
about PCA
allow only the
PT to touch it
Albuterol 2.5 mg SOB, Dyspnea, Headache, RT gives
proventil nebulized Bronchitis dizziness, cough, treatment if
tremor, N/V necessary,
teach about
using the
breathing
treatment for 3-
5 minutes
Toradol 15 mg IV Pain, Swelling of the Push slowly(can
Ketorolac inflammation surgical site, cause burning
Pain 6-10 sensation),
Monitor pain
relief
Tramadol 50mg PO Pain Nausea, altered Assess for
Ultram LOC, weakness, dizziness before
Vomiting sitting up or
standing
Oxycodone 10-15 mg PO Pain N/V, dizziness, Assess LOC,
Roxicondone Sedation watch for
respiratory
suppression
Pantoprazole 40 mg PO Decreases N/V, GI distress, Assess for GI
Protonix stomach acid Joint pain, relief,
production Insomnia

Ordered Treatment(s):
Dressing changes (wounds) YES NO NA
yes
Ice X

Foley X

NG x

Position changes q2h x

Ted hose x

SCDs X

Incentive spirometer q1h X

Cough and deep breath X

Intake/Output X

Additional consults ordered:

O2 therapy NC 3L
Diet/Fluids:
Diet Order: Diabetic Restrictions: N/A Precautions: N/A Gag Reflex Intact: yes

Appetite (good, fair, poor): Breakfast % Lunch %100 Dinner %


Good 100 I was gone for dinner
Total Oral Fluid Intake: N/A Total IV Fluid Intake: Total Output: N/A
1350
Enteral Feeding: n/a Rate: Type of tube: n/a
n/a
Problems swallowing YES NO

Problems chewing YES NO

Dentures YES NO

Needs assistance with feeding YES NO

Nausea YES NO

Vomiting YES NO

Fluid volume excess YES NO

Fluid volume deficit YES NO

Intravenous Therapy:
IV Fluid Type: 5% dextrose
IV rate: 144 ml/hr

Location/Gauge Site Assessment YES NO


IV site and catheter IV dressing dry, no edema, redness of x
gauge: PICC 20 gauge left site: No redness
brachial vein

IV site and catheter IV dressing dry, no edema, redness of


gauge: site:

IV site and catheter IV dressing dry, no edema, redness of


gauge: site:
Elimination:
Last bowel movement: 2/27/17

Constipation YES NO

Diarrhea YES NO

Flatus YES NO

Incontinence-bowel YES NO

Urinary hesitancy YES NO

Urinary frequency YES NO

Burning YES NO

Incontinence-urinary YES NO

Unusual odor YES NO

Activity:
Type of activity ordered: Ability to walk (gait): PT came Morse Falls scale score:
2x today to walk with her down 50
What kind of bath will you the hall
plan to do: CNA did a bed
Oral care, how often: Bed bath
bath
via CNA

Use of assistive devices:


Cane YES NO
Crutches YES NO
Walker YES NO
Crutches YES NO
Prosthesis YES NO

Physical Assessment Data:


BP: Temp/Method: Pulse: Respiratory rate: SpO2: Height/Weight (kg):
147/68 97.9 87 16 94 5’3” 95kg

Neurological: Additional detail


LOC: Alert and oriented x3 YES NO
Confused YES NO
PEERLA YES NO
Able to follow commands YES NO
Grip equal, bilateral YES NO
Sensation intact to all extremities YES NO Lower extremities were numb after
surgery but returned by 10 am
Speech clear YES NO
Sensory deficit (hearing, vision, taste, YES NO Wears glasses
smell
Dizziness, vertigo YES NO
Use of assistive device (glasses, hearing YES NO Specify: glasses
aids)
**Additional detail required for abnormal findings**

Cardiovascular: Additional detail


Pulses (radial, pedal) palpable, equal, YES NO
strong
Normal heart tone (S1, S2), regular YES NO
Capillary refill (<3 seconds all YES NO
extremities)
Extremity temperature warm to touch YES NO
No edema present-all extremities YES NO
**Additional detail required for abnormal findings**

Respiratory: Additional detail


Respiration pattern regular without YES NO
effort
Use of accessory muscles YES NO
Productive cough YES NO
Nonproductive cough YES NO
Lungs clear to auscultation, all fields YES NO
Use of oxygen YES NO Specify mode and flow rate of oxygen:
NC 2L
Oxygen humidification YES NO
Smoker YES NO Specify current or past hx:
**Additional detail required for abnormal findings**

Gastrointestinal: Additional detail


Abdomen soft, nontender, all quadrants YES NO

Bowel sounds present x4 quadrants YES NO Specify: active, hypoactive, absent


RUQ, RLQ hypoactive

Nausea YES NO
Vomiting YES NO Description:
NG tube YES NO Describe drainage:

Stool YES NO Describe consistency:


Brown, soft, easy to pass
Ostomy YES NO Describe stoma site and output:

Additional GI tubes YES NO Specify:


**Additional detail required for abnormal findings**

Urinary: Additional detail


Continent, voiding without difficulty YES NO
Incontinent YES NO Interventions:

Foley catheter, patent, down drain YES NO


Urine clear, light yellow to amber, no YES NO
odor
Additional GU tubes YES NO Specify
**Additional detail required for abnormal findings**

Musculoskeletal: Additional detail


Normal muscle tone without weakness YES NO Weakness on L side due to surgery
Able to transfer independently YES NO L Hip pain, needs help to transfer
Purposeful movement, all extremities YES NO
Normal skeletal alignment/structure YES NO
Altered gait YES NO Specify: Walks with walker and help of a
therapist

Orthopedic device (cast, splint, brace) YES NO Specify

Fall risk YES NO Specify rationale


r sided surgery
**Additional detail required for abnormal findings**

Skin: Additional detail


Skin dry, intact, color within patient YES NO
norm
Mucous membranes moist YES NO
Evidence of skin breakdown YES NO Specify location:

Rashes or bruising YES NO Specify location:

Sutures, staples, steri-strips YES NO Specify:


Sutures
Wound drainage YES NO Describe drainage:
serosanguinous
Wound drain YES NO Specify:
R hip hemavac
Braden Score:
10
**Additional detail required for abnormal findings**

Psychosocial and Cultural


Marital status/children/social support:
Married/ 3 children/ live here in town.

Religious preference:

N/A
Occupation: Retired

Pain
Pain Score ____6_________ out of 10 (10 being severe pain, 1 minimal pain)
Characteristics Dull ache
Onset Post Surgery

Location R hip

Duration 30 minutes after we administered pain meds

Exacerbation Ambulating/ moving in bed

Radiation Down the R thigh above the knee

Relief Rest

Associated
symptoms n/a
*****Complete this table for pediatric patients only
**Developmental Milestones

**Developmental Level: Erickson/Piaget

**PATHOPHYSIOLOGY AND NURSING CARE: Provide a description of the pathophysiology of


all conditions for which the patient is receiving treatment, YOUR patient’s signs/symptoms
AND THE TREATMENT THAT WAS GIVEN FOR EACH CONDITION.
Medical condition Signs/symptoms Treatment given
1 type 2 diabetes Hyperglycemia, Ulcers Insulin given on a sliding
scale, Humalog
2 HTN Headache, fatigue, vision Diet with low NA+ intake, PT
blurriness, chest pain was instructed to give
exercise and treatment
3 Chronic bronchitis Respiratory Distress, SOB, Breathing treatment given/
Dyspnea albuterol
4. Acute respiratory Distress Difficulty breathing, anxiety, No treatment was given
decreased lung sounds, today, but she would receive
labored breathing albuterol breathing
treatment 2.5 mg via
nebulizer
5 Pain Increased BP, Increased RR, Pt has PCA with Demerol
Verbalization of pain early in the morning but she
did not like how it made her
feel so she was then given
other options to treat her
pain.

You might also like