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

Answer: The most important nursing diagnosis is Acute pain related to surgical procedure and preexisting history of chronic back pain,osteo arthritis and narcotic dependence.

Evidenced by repotting of pain 8/10,not able to sleep

Desired outcomes

• Client will report relieved / controlled of pain
• Client will appear relaxed,able to rest/sleep appropriately.

Nursing interventions:

• Assess reports of pain,noting intensity ( scale 0-10) duration and location
• Maintain a proper position of operated extremity
• Provide comfort measures( frequent repositioning,back rub) and diverse all activities.Encourage stress management techniques ( progressive relaxation,guided imagery,visualization,meditation).Provide therapeutic touch as appropriate
• Medicate on a regular schedule and before activities.
• Investigate reports of sudden,severe Joint pain with spasms and changes in joint mobility,sudden severe chest pain with dyspnea and restlessness
• Administer narcotics,and muscle relaxants as needed.
• Apply ice packs as indicated
• Initiate and maintain extremity mobilization,ambulation,physical therapy,exercise and/ or CPM device
• Health teaching : Identify signs and symptoms requiring medical evaluation e.g fever and chills,incisional inflammation,unusual wound drinage,pain in the calf or upper thigh,or development of strep throat or dental infections
• Encourage intake of balanced diet,including roughage and adequate fluids.