Download Dawn Krauskopf

Dawn Krauskopf
4/19/04
PERSON
Name: C. J. R
Current Medical/Surgical Diagnosis: Total Knee Replacement
Admitted date: x/xx/xx
Age: 50
Date of Care: x/xx/xx
Code Status: Full Leo
P NEED: My client is a 50 year old, 175 pound, 5’8”, married, Hispanic female who was admitted on
XXX XX XXXX, for surgery. 2nd day post op total knee replacement. Spanish speaking only, so special
considerations were taken when caring for her. Very pleasant, oriented X3, and accompanied by her
Spanish speaking daughter, and numerous visitors throughout the day that are supportive. She is a
homemaker.
She has been educated about the wound care, and the TED hose. Her past medical & surgical history
includes: degenerative joint disease, bilateral knees osteoarthritis treated with methotrexate and prednisone.
She recently started taking accupril for possible HTN. She also, has had kidney stones, a history of
hypothyroidism, and type II diabetes that is controlled only by diet. She is being assisted with ADLs by her
daughter, and she needs little to no assistance with her care, however, she has been educated on the
importance of calling the nurse for all other needs (using the restroom). She does not use tobacco or
alcohol.
Meds: Novolin R, Prednisone, Levothroid, Accupril, & Methotrexate
E NEED: No history of GI or urinary track problems
Using a foley catheter, urine clear, amber. Last 8 hours, 1250 output and 2040 input including IV &
IVPB.
Abdomen soft, non distended, active bowel sounds; last BM was 4/12/04. No complaints or
abnormalities stated or noted.
Meds: Potassium Chloride (K-dur), Ferrous Sulfate, & Senokot
Creatinine 0.4 (0.6-1.3)
R NEED: My client denies pain most of the time, however, when physical therapy worked with her, she
grimaced a lot. Wound care was done with little to no complaints. Otherwise, she states that she is
comfortable. She ambulated often with physical therapy. The activities were tolerated well.
Dilaudid ordered prn for pain.
S NEED: Moderate to low risk for falls. Assisted bath while lying in bed by her daughter. She did not
have orders to shower independently yet. She did her own oral hygiene, brushed her hair. Her skin appeared
intact without any reddened areas. She has no known drug or food allergies. She is receiving IV antibiotics and
diluadid prn for pain;
IV site at the right forearm. TED hose to prevent DVT. Wearing non skid socks to prevent falls, and her call
light is within reach. Aware of the importance of calling when assistance is needed.
Meds: Lovenox, & Diluadid (PCA)
ALLERGIES: NKDA
CODE STATUS: Full Leo
O NEED: Vital sounds are stable. BP 122/77; pulse 80, resp. 17. Strong, regular pulses, respiratory rate is
regular and unlabored. Blood pressure is within normal limits, and her skin is warm and dry to the touch. Her
breath sounds are clear in all lobes. No oxygen in use. She has no complaints of SOB, or difficulties at this
time.
HCT 36.9 (37.0-47.0)
PLT 468 (150-450)
N NEED: Regular diet and eats well, without any complaints of nausea. No known food allergies, and
teeth are in good condition. Independently feeds self, and is at a low risk for aspiration. Glucose 117 (70-110).
MEDICAL DIAGNOSIS
Total knee replacement is a surgical procedure in which injured or damaged parts of the knee joint are replaced
with artificial parts. The procedure is performed by separating the muscles and ligaments around the knee to
expose the knee capsule (the tough, gristle like tissue surrounding the knee joint). The capsule is opened,
exposing the inside of the joint. The ends of the thigh bone (femur) and the shin bone (tibia) are removed and
often the underside of the kneecap (patella) is removed. The artificial parts are cemented into place. Your new
knee will consist of a metal shell on the end of the femur, a metal and plastic trough on the tibia, and if needed,
a plastic button in the kneecap. Total knee replacements are usually performed on people suffering from severe
arthritic conditions. Most patients who have artificial knees are over age 55, but the procedure is performed in
younger people. The prosthesis may be metallic or polyethylene (or a combination) implanted with a
methylmethacrylate cement, or it may be a porous, coated implant that encourages bony ingrowth.
Medications given for this diagnoses: adequate pain medicine, either orally or through an IV line. Oxygen may
need to be delivered through a nasal tube or facemask.
Diagnostic Studies:
Complete physical exam, blood and urine tests, X-rays, and cardiogram (EKG).
X-rays: May reveal destruction of articular cartilage, bony demineralization, fractures, soft-tissue swelling;
narrowing of joint space, joint subluxations or deformity.
Bone scan, CT/MRI: Determine extent of degeneration and rule out malignancy.
LIST OF APPLICABLE NURSING DIAGNOSES
1. Acute pain r/t bilateral total knee replacement
2. Disturbed body image r/t bilateral total knee replacement scars
3. Ineffective tissue perfusion r/t bilateral total knee replacement
4. Risk for infection r/t bilateral total knee replacement
5. Mobility, impaired physical
6. Peripheral Neurovascular, risk for dysfunction
7. Knowledge, deficient regarding condition, prognosis, treatment, self-care, and discharge
needs
MEDICATIONS
Name – Potassium Chloride (K-dur)
Dosage: - 20 meq bid po
Class – electrolytic and water balance agent; replacement solution
Actions – Principal intracellular cation; essential for maintenance of intracellular isotonicity, transmission of
nerve impulses, contraction of cardiac, skeletal, and smooth muscles, maintenance of normal kidney function,
and for enzyme activity. Plays a prominent role in both formation and correction of imbalances in acid–base
metabolism.
Indications – My patient is taking 20meq po qd to prevent a deficit in potassium possibly depleted from severe
vomiting, diarrhea, or intestinal drainage.
Side effects – nausea, vomiting, flaccid paralysis, respiratory distress, cardiac depression, arrhythmias, or arrest,
ECG changes in hyperkalemia, deterioration of QRS contour and finally ventricular fibrillation and death.
RN Indications – Give while patient is sitting up or standing (never in recumbent position) to prevent drug–
induced esophagitis. Some patients find it difficult to swallow the large sized KCl tablet. Do not crush or allow
to chew any potassium salt tablets. Observe to make sure patient does not suck tablet (oral ulcerations have
been reported if tablet is allowed to dissolve in mouth). Swallow whole tablet with a large glass of water or
fruit juice (if allowed) to wash drug down and to start esophageal peristalsis. Dilute liquid forms as directed
before giving it through nasogastric tube. Monitor I&O ratio and pattern in patients receiving the parenteral
drug. If oliguria occurs, stop infusion promptly and notify physician. Monitor for and report signs of GI
ulceration (esophageal or epigastric pain or hematemesis). Monitor patients receiving parenteral potassium
closely with cardiac monitor. Irregular heartbeat is usually the earliest clinical indication of hyperkalemia. Be
alert for potassium intoxication; may result from any therapeutic dosage, and the patient may be asymptomatic.
The risk of hyperkalemia with potassium supplement increases (1) in older adults because of decremental
changes in kidney function associated with aging, (2) when dietary intake of potassium suddenly increases, and
(3) when kidney function is significantly compromised.
Lab – Frequent serum electrolytes are warranted.
Name: Prednisone
Dosage: 5 mg bid po
Classification: Hormones and Synthetic Substitutes; Adrenal Corticosteroid; Glucocorticoid
Action: Immediate-acting synthetic analog of hydrocortisone. Effect depends on biotransformation to
prednisolone, a conversion that may be impaired in patient with liver dysfunction. Less mineralocorticoid
activity than hydrocortisone, but sodium retention and potassium depletion can occur.
Indication: May be used as a single agent or conjunctively with antineoplastics in cancer therapy; also used in
treatment of myasthenia gravis and inflammatory conditions and as an immunosuppressant.
Side Effects: Leukocytosis, Hypokalemia, N, V, and HA
Nursing Considerations:
1.
Establish baseline and continuing data regarding BP, I&O ratio and pattern, weight, and sleep pattern.
Start flow chart as reference for planning individualized pharmacotherapeutic patient care.
2.
Check and record BP during dose stabilization period at least 2 times daily. Report an ascending pattern.
3.
Monitor patient for evidence of HPA axis suppression during long-term therapy by determining plasma
cortisol levels at weekly intervals.
4.
Be aware that older adult patients and patients with low serum albumin are especially susceptible to
adverse effects because of excess circulating free glucocorticoids.
5.
Be alert to signs of hypocalcemia. Patients with hypocalcemia have increased requirements for
pyridoxine (vitamin B6), vitamins C and D, and folates.
6.
Be alert to possibility of masked infection and delayed healing (anti-inflammatory and
immunosuppressive actions). Prednisone suppresses early classic signs of inflammation. When patient is
on an extended therapy regimen, incidence of oral Candida infection is high. Inspect mouth daily for
symptoms: white patches, black furry tongue, painful membranes and tongue.
7.
Monitor bone density. Compression and spontaneous fractures of long bones and vertebrae present
hazards, particularly in long-term corticosteroid treatment of rheumatoid arthritis or diabetes, in
immobilized patients, and older adults.
8.
Be aware of previous history of psychotic tendencies. Watch for changes in mood and behavior,
emotional stability, sleep pattern, or psychomotor activity, especially with long-term therapy, that may
signal onset of recurrence. Report symptoms to physician.
9.
If a patient is receiving aspirin concomitantly with a corticosteroid, salicylism may be induced when the
corticosteroid dosage is decreased or discontinued.
10. Be aware that long-term corticosteroid therapy is ordinarily not interrupted when patient undergoes
major surgery, but dosage may be increased.
11. Monitor for withdrawal syndrome (e.g., myalgia, fever, arthralgia, malaise) and hypocorticism (e.g.,
anorexia, vomiting, nausea, fatigue, dizziness, hypotension, hypoglycemia, myalgia, arthralgia) with
abrupt discontinuation of corticosteroids after long-term therapy.
Lab: Obtain fasting blood glucose, serum electrolytes, and routine laboratory studies at regular intervals during
long-term steroid therapy.
Name: Novolin R
Dosage: sliding scale – subcutaneous route
Classification: Short-acting insulin
Action: Decrease blood glucose levels – used to treat hyperglycemia
Indications: My client is taking this to treat Type II diabetes – insulin required only while sick/post surgery
Side Effects: Hypoglycemia – most probably 2-3 hrs after administration
Nursing Considerations: Monitor for signs of hypoglycemia, rotate sites, administer at room temperature, No
air bubbles in syringe.
Sliding Scale for my patient: Accuchecks AC & HS
<150 – none
151-200 – 2 units
201 – 250 – 4 units
251 – 300 – 6 units
301 – 350 – 8 units
351 – 400 – 10 units
>400 – CALL MD.
Name: Ferrous Sulfate
Dosage: 325mg bidwm (twice daily with meals)
Classification: BLOOD FORMERS, COAGULATORS, AND ANTICOAGULANTS; IRON PREPARATION
Action: Standard iron preparation against which other oral iron preparations are usually measured. Corrects
erythropoietic abnormalities induced by iron deficiency but does not stimulate erythropoiesis. May reverse
gastric, esophageal, and other tissue changes caused by lack of iron. Ferrous gluconate: Claimed to cause less
gastric irritation and be better tolerated than ferrous sulfate.
Indication: To correct simple iron deficiency and to treat iron deficiency (microcytic, hypochromic) anemias.
Also may be used prophylactically during periods of increased iron needs, as in infancy, childhood, and
pregnancy.
Side Effects: Nausea, heartburn, constipation, black stools, shock, cardiovascular collapse, liver necrosis,
death.
Nursing Considerations: *Give on an empty stomach if possible because oral iron preparations are best
absorbed then (i.e., between meals). Minimize gastric distress if needed by giving with or immediately after
meals with adequate liquid. * Do not give tablets or capsules within 1 h of bedtime. * Continue iron therapy
for 2–3 mo after the hemoglobin level has returned to normal (roughly twice the period required to normalize
hemoglobin concentration). * Monitor bowel movements as constipation is a common adverse effect. * Do not
to crush tablet or empty contents of capsule when administering. * Consult physician about prescribing a liquid
formulation or a less corrosive form, such as ferrous gluconate, if the patient experiences difficulty in
swallowing tablet or capsule. * Dilute liquid preparations well and give through a straw or placed on the back
of tongue with a dropper to prevent staining of teeth and to mask taste. Instruct the patient to rinse mouth with
clear water immediately after ingestion.
Lab: Monitor Hgb and reticulocyte values during therapy. Investigate the absence of satisfactory response after
3 wk of drug treatment.
Name: Enoxaprin (Lovenox)
Dosage: 30mg q12h SQ
Classification: Blood Formers, Coagulators, and Anticoagulants, Low Molecular Weight Heparin
Action: Low molecular weight heparin with antithrombotic properties. Does not affect PT. Does effect
thrombin time (TT) and activated thromboplastin time (aPTT) up to 1.8 times the control value.
Indication: Prevention of deep vein thrombosis (DVT) after hip, knee, or abdominal surgery, treatment of
DVT and pulmonary embolism, management of acute coronary syndrome.
Side Effects: angioedema, & hemorrhage.
Nursing Considerations: * Alternate injections between the left and right anterolateral abdominal wall. *
Hold the skin fold between the thumb and forefinger and insert the whole length of the needed into the skin
fold. Hold skin fold throughout the injection. Do not rub site post injection. * Monitor platelet count closely.
Withhold drug and notify physician if platelet count less than 100,000/mm3. * Monitor closely patients with
renal insufficiency and older adults who are at higher risk for thrombocytopenia. * Monitor for and report
immediately any sign or symptom of unexplained bleeding.
Lab: Baseline coagulation studies; periodic CBC, platelet count, urine and stool for occult blood.
Name: Senna (Sennosides, Senokot)
Dosage: 1 UDtab q12h po
Classification: Gastrointestinal Agent, Stimulant Laxative
Action: Prepared from dried leaflet of Cassia acutifolia or Cassia angustifolia. Similar to cascara sagrada but
with more potent action. Senna glycosides are converted in colon to active aglycone, which stimulates
peristalsis. Concentrate is purified and standardized for uniform action and is claimed to produce less colic than
crude form.
Indication: Acute constipation and preoperative and preradiographic bowel evacuation.
Side Effects: Abdominal cramps, flatulence, nausea. watery diarrhea, excessive loss of water and electrolytes,
weight loss, melanotic segmentation of colonic mucosa (reversible).
Nursing Considerations: Reduce dose in patients who experience considerable abdominal cramping.
Lab: none listed
Name: Levothyroxine Sodium (t4) (Levothroid)
Dosage: 0.025 mg qd po
Classification: Hormone and Synthetic Substitute, Thyroid Agent
Action: Synthetically prepared monosodium salt and levo-isomer of thyroxine, with similar actions and uses
(thyroxine, principal component of thyroid gland secretions, determines normal thyroid function).
Indication: Specific replacement therapy for diminished or absent thyroid function resulting from primary or
secondary atrophy of gland, surgery, excessive radiation or antithyroid drugs, congenital defect. Administered
orally for hypothyroid state; administered IV for myxedematous coma or other thyroid dysfunctions demanding
rapid replacement, as well as in failure to respond to oral therapy.
Side Effects: insomnia,
Nursing Considerations: * Monitor pulse before each dose during dose adjustment. If rate is >100, consult
physician. * Monitor for adverse effects during early adjustment. If metabolism increases too rapidly,
especially in older adults and heart disease patients, symptoms of angina or cardiac failure may appear. *
Levothyroxine may aggravate severity of previously obscured symptoms of diabetes mellitus, Addison's
disease, or diabetes insipidus. Therapy for these disorders may require adjustment. * Monitor bone age,
growth, and psychomotor function in children are recommended. * Closely monitor PT/INR and assess for
evidence of bleeding if patient is receiving concurrent anticoagulant therapy. A decrease in anticoagulant
dosage may be needed 1–4 wk after concurrent levothyroxine is started. * Some children have partial hair loss
after a few months; it returns even with continued therapy. * Synthroid 0.1 and 0.3 mg tablets contain
tartrazine, which may cause an allergic-type reaction in certain patients; particularly those who are
hypersensitive to aspirin.
Lab: Baseline and periodic tests of thyroid function.
Name: Quinapril Hydrochloride (Accupril)
Dosage: 5mg qd po
Classification: Cardiovascular Agent, Angiotensin-converting Enzyme (ace) Inhibitor
Action: Potent, long-acting second-generation ACE inhibitor that lowers BP by interrupting the conversion
sequences initiated by renin to form angiotensin II; a vasoconstrictor. Inhibition of ACE also decreases
circulating aldosterone, a secretory response to angiotensin II stimulation. Reduces pulmonary capillary wedge
pressure, systemic vascular resistance, and mean arterial pressure, with concurrent increases in cardiac output,
cardiac index, and stroke volume.
Indication: Mild to moderate hypertension, CHF.
Side Effects: Angioedema
Nursing Considerations: * Discontinue diuretics 2–3 d before initiation of quinapril. Do NOT exceed initial
dose of 5 mg if diuretics cannot be discontinued. *Monitor BP at time of peak effectiveness, 2–4 h after dosing,
and at end of dosing interval just before next dose. * Report diminished antihypertensive effect toward end of
dosing interval. Inadequate trough response may indicate need to divide daily dose. * Monitor for first-dose
hypotension, especially in salt- or volume-depleted clients. * Observe for S&S of hyperkalemia.
Lab: Monitor BUN and serum creatinine periodically. Increases may necessitate dose reduction or
discontinuation of drug. Monitor serum potassium values.
Name: Methotrexate
Dosage: 20mg Th (Thursday) po
Classification: Antineoplastic, Antimetabolite, Immunosuppressant
Action: Antimetabolite and folic acid antagonist. Blocks folic acid participation in nucleic acid synthesis,
thereby interfering with mitotic process.
Indication: Principally in combination regimens to maintain induced remissions in neoplastic diseases.
Effective in treatment of gestational choriocarcinoma and hydatidiform mole and as immunosuppressant in
kidney transplantation, for acute and subacute leukemias and leukemic meningitis, especially in children. Used
in lymphosarcoma, in certain inoperable tumors of head, neck, and pelvis, and in mycosis fungoides. Also used
to treat severe psoriasis nonresponsive to other forms of therapy, rheumatoid arthritis.
Side Effects: Headache, Hepatotoxicity, ulcerative stomatitis, glossitis, gingivitis, hepatic cirrhosis,
Leukopenia, thrombocytopenia, marked myelosuppression, aplastic bone marrow, sudden death, pneumonitis,
pulmonary fibrosis.
Nursing Considerations: * Prolonged treatment with small frequent doses may lead to hepatotoxicity, which
is best diagnosed by liver biopsy. * Monitor for and report ulcerative stomatitis with glossitis and gingivitis,
often the first signs of toxicity. Inspect mouth daily; report patchy necrotic areas, bleeding and discomfort, or
overgrowth (black, furry tongue). * Keep patient well hydrated (about 2000 mL/24 h). * Monitor I&O ratio
and pattern. Severe nephrotoxicity (hematuria, dysuria, azotemia, oliguria) fosters drug accumulation and
kidney damage and requires dosage adjustment or discontinuation. * Prevent exposure to infections or colds
during leukopenia periods. Be alert to onset of agranulocytosis (cough, extreme fatigue, sore throat, chills,
fever) and report symptoms promptly. Therapy will be interrupted and appropriate antibiotic drugs prescribed.
* Be alert for and report symptoms of thrombocytopenia (e.g., ecchymoses, petechiae, epistaxis, melena,
hematuria, vaginal bleeding, slow and protracted oozing following trauma). * Monitor blood glucose and
HbAlc periodically in diabetics.
Lab: Obtain baseline liver and kidney function, CBC with differential, platelet count, and chest x-rays. Repeat
weekly during therapy.
Nursing Dx & Support Data
Goal/Outcome &
Outcome
Attainment
1) Maintain position of
Mobility, impaired physical r/t
bilateral TKR
Support Data
Reluctance to attempt
movement, difficulty
purposefully moving
within the physical
environment
Reports of pain/discomfort
on movement
Limited ROM; decreased
muscle strength/control
function, as evidenced
by absence of
contracture.
Outcome
Attainment
Nursing
Interventions
Scientific Rationale
Evaluation
1A) Maintain affected
joint in prescribed
position and body in
alignment when in bed.
1A) Provides for stabilization
of prosthesis and reduces risk
of injury during recovery
from effects of anesthesia.
1a) Client remains
in alignment while
resting.
1B) Medicate before
procedures/activities.
1B) Muscle relaxants,
narcotics/analgesics decrease
pain, reduce muscle
tension/spasm, and facilitate
participation in therapy.
1b) Client presses
PCA button prior to
ambulating, and
wound care.
Client’s legs remain in
a position of function
2)
Displays
increased
strength and
function of
affected joint
and limb.
Outcome
Attainment
Client ambulates with
PT
2a) Promote
participation in
rehabilitative exercise
program.
2a) Strengthens muscle
groups, increasing muscle
tone and mass; stimulates
circulation; prevents
decubitus. Active use of the
joint may be painful but will
not injure the joint.
Continuous passive motion
(CPM) exercise may be
initiated on the knee joint
postoperatively.
2a) Client feels an
increase in
strength and
stability
SEE ABOVE
3) Participate in
ADLs/rehabilitation
program.
Outcome
Attainment
Client does self care
with daughters
assistance
3a Encourage
participation in ADLs.
3a) Enhances self-esteem;
promotes sense of control
and independence.
3a) Client
partakes in all
ADLs that she can
do on her own,
and leaves the rest
to her daughter.
(i.e. legs)
Nursing Dx &
Support Data
Infection r/t surgery
sites
Support Data
Inadequate
primary
defenses
(broken skin,
exposure of
joint)
Invasive
procedures;
surgical
manipulation
;
implantation
of foreign
body
Decreased
mobility
Goal/Outcome
& Outcome
Attainment
1) Achieve
timely wound
healing, be free
of purulent
drainage or
erythema, and
be afebrile.
Outcome
Attainment
Client shows no
S&S of infection.
Nursing Interventions
1A) Use strict aseptic or
clean techniques as
indicated to
reinforce/change
dressings and when
handling drains. Instruct
patient not to
touch/scratch incision.
Scientific Rationale
1a) Prevents contamination and risk of wound
infection, which could require removal of
prosthesis. Reduces risk of infection by
preventing accumulation of blood and
secretions in the joint space (medium
for bacterial growth). Purulent,
nonserous, odorous drainage is
indicative of infection, and continuous
drainage from incision may reflect
developing skin tract, which can
potentiate infectious process.
Evaluation
1a) Client remains
afebrile, free of drainage,
redness, & swelling.