Question

Pt is a 52 yr old male. He was admitted for Right Total Hip Arthroplasty and had surgery for hip replacement. He's on telemetry. He has hx of hyperlipedemia, sleep apnea, HTN, PTSD, osteoarthritis, chronic back pain, narcotic dependence. He's allergic to Gabapentin and bee sting (anaphylaxis reaction). Past surgical hx are appendectomy, arthroscopy of left knee, left knee surgery, and tonsillectomy. His vital signs were stable yesterday, afebrile. No bowel movement since his surgery 10/26/20. Dressing to his right hip tegaderm and gauze CDI, no breakthrough drainage. Pt reported continuous 8/10 "burning, tightness, throbbing, radiating" pain to his incision site, lower back, right knee, and groin. Medicated hydromorphone dilaudid 2x and oxycodone 2x as needed. His pain didn't decrease at the end of my shift. Physical therapy came in to ambulate him and transfer him to reclining chair with an abduction pillow. Lidocaine patch to his right leg, using ice pack for comfort. He was not able to take a nap due to the pain. Getting discharge today.

MEDICATIONS:

Mag-Tab Sr tablet 84 mg PO daily

Morphine Sulf ER tablet 15 mg PO BID

Tylenol Tab 975 mg PO TID

Norvasc tab 5 mg PO daily

Protonix tab 40 mg PO daily

Senna 8.6/50mg tab PO daily

Lovenox Inj. 40 mg SQ 0.4mL

Miralax packet 17gm PO daily

Oxycodone 5mg PO Q4HP PRN

Hydromorphone HCL 1mg IVP Q2HP PRN

LAB TEST:

RBC 3.65L

Hgb 11.4L

Hct 35.6L

Neutrophils 76.8H

Lympocytes 12.9L

Creatinine 0.76L

Glucose 162H

- What is the most important nursing diagnosis for this patient?

- What is one biggest problem or biggest concern for this patient? Include "related to" and "as evidenced by".

- What are the goals presented for priority problems listed with measurable outcomes?

- What are the interventions (at least one education intervention) Relationships apparent between interventions and each goal/outcome and problem. Be concise and clear, achievable, relates to the stated diagnosis and client outcome.

- Evaluation: States how client outcome was met, what might have helped or hinder attainment of the outcome, analyzes the care given. If needed, revisions in the care plan done; interventions, assessment, state if should have done something differently in retrospect.

- Labs: (discussed how the labs relates to the patient’s specific condition).

Answer 1

Nursing diagnosis : Deep Vein Thrombosis

• Swelling of the calf, thigh, or the entire leg
• Redness, warm and hard flesh, low-grade fever, and chills
• Asymmetrical enlargement of one leg relative to the other
• Increased leg spasms and cramping
• Abdominal pain

The biggest concern is that he has low haemoglobin and haematocrit levels which is making it difficult for his blood to clot normally. As evidenced by : In patients with deep vein thrombosis, thrombus formation and consequent vein wall damage induce a systemic inflammatory reaction which is reflected by significantly increased levels of white blood cells and plasma C-reactive protein. So as seen in his reports, his neutrophil and WBC count are very high

Nursing interventions:

• Bed rest to prevent clot dislodgment
• Elevate affected or both legs
• Turn the patient every 2 hours without crossing legs
• Range-of-motion exercises to the unaffected leg
• Warm compresses to help reduce swelling
• Monitor vital signs every 4-6 hours
• Assess patient for complications of PE, such as shortness of breath, chest pain, apprehension, cough, hemoptysis, tachypnea, crackles, tachycardia, diaphoresis, and fever