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Nursing Case Study I. ASSESSMENT 1. Description of client The patient I am using for my nursing case study is a 53 year old white female. She weighs 210 pounds and her height is 67” tall. She is a well-developed, well nourished female. My patient had been a smoker for ten years; she is currently a social drinker, and wears glasses for driving. She is not very active and has difficulty walking for long distances. Her father had a myocardial infarction (MI) and rheumatic fever. Her mother has hypertension (HTN), cancer, arthritis, and asthma. My patient is a homemaker, married to a police officer, and has grown children that are out of the house. Her medications were Prozac 20mg/PO/QD for depression, Hydrochlorothiazide Hydrochlorothiazide 25mg/PO/OD for HTN, and a multivitamin 1 dose PO/QD. My patient was admitted to the hospital for degenerative joint disease (DJD), otherwise known as osteoarthritis (OA) in both knees, and she had gotten to the point where she felt she needed needed to have right total total knee replacement (TKR) surgery. She had a cortisone injection 2 weeks ago, and was taking prednisone last summer for knee pain. She had right knee arthroscopy in 2005, but she has not had much relief from the pain. She said her knee was painful enough on a daily basis that she wanted to proceed with right TKR surgery. The surgeon explained to her the risks and benefits, problems with phlebitis and she desired to proceed. My client’s TKR surgery was scheduled for 1/30/06. 2. Assessment of client A summary of my patient’s initial interview by an RN includes the following. My patient has a drug allergy to codeine, and develops a rash from adhesive tape. She has known food allergies. She has motion sickness, only in the back seat. She has arthritis arthritis in her knees and back. She has has a chronic cough in the the morning usually productive. She currently has an eleven year old nephew living with her and her husband. She is concerned about his behavior because is bipolar. My patient’s preoperative laboratory values were; Hematology: White blood cells (WBC): 11,700/mm² 11,700/mm² (high), Neutrophils: Neutrophils: 82.5% (high), Lymphocytes: Lymphocytes: 11% (low), Monocytes: 1.5% (low). Prothrombin time: 13.3 seconds (high), International normalized ratio (INR): 1.3 seconds (low). Urinalysis: Color: yellow, Appearance: clear, Specific gravity: 1.020, pH: 7.5, Leukocytes: negative, Nitrite: negative, Protein: negative, Glucose: negative, Ketones: negative, Urobilirubin: 0.2, Bilirubin: negative, Occult blood: trace A, WBC: 1-3, Red blood cell (RBC): 3-5, the urine source was via Foley catheter.
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3 & 4. Medical/surgical diagnoses & Pathophysiology My patient also has a history of degenerative joint disease (DJD), otherwise known as osteoarthritis, hypertension, obesity, depression, and rheumatoid arthritis. She has had the following surgeries; arthroscopy in 2005, pneumonia in 2004, left foot bone spur removed, bilateral carpal tunnel surgery, breast reduction surgery in 1997, and a hysterectomy in 1995. “Osteoarthritis is a disorder of a synovial joint characterized by loss of joint function, shape, and stability due to erosion of the articular cartilage and weakening of viscous and shock absorbing properties of the synovial joint fluid. As the cartilage deteriorates, areas of bone are often left unprotected, causing further deterioration of articular cartilage that comes in contact with the rough bony surface (causing significant pain).” “Clinically, OA can be diagnosed most conclusively with a simple x-ray.” “In the later stages, some of the joint space may completely collapse, resulting in direct bone on bone contact.”(visco article) Taber’s states, that “ risk factors include aging, obesity, overuse or abuse of joints as in sports or strenuous occupations, and trauma. Treatment is supportive, using exercise balanced with rest, heat, weight reduction if needed, and analgesics. Joint replacement surgery may be required if these measures were unsuccessful in controlling pain, depending on the joint involved. Patient care includes activities that are paced to prevent excessive fatigue or irritation of the joints, and rest is provided after the activity.” Hypertension (HTN), Taber’s states, “is a condition in which the blood pressure (BP) is higher than 140 mm Hg systolic or 90 mm Hg diastolic on three separate readings recorded several weeks apart. Hypertension is one of the major risk factors for coronary heart disease (CAD), congestive heart failure (CHF), stroke, peripheral vascular disease (PVD), and kidney failure.” “Hypertension results from many different conditions, many are not curable. Excess alcohol consumption (more than two drinks per day) is a common cause of high BP; abstinence or drinking in moderation effectively lowers BP in these cases. Pregnancy, aortic valve stenosis, and the use of “recreational drugs” may also lead to hypertension. The goal of treatment is to reduce BP to below the normal range of 120/80 in all patients with hypertension. Lifestyle modification are usually required to help lower BP. Patients are restricted to a diet that is low in sodium diet, low in fat and in cholesterol. Patients should also quit smoking, reduce their alcohol consumption, and begin an exercise regimen. In conjunction with these lifestyle modifications, medications can be used. “Drug therapy may include low-dose thiazide diuretics; beta-blockers, and calcium-channel blockers. Patient care
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includes BP being checked at every health care visit. Positive lifestyle changes should be encouraged, and adherence to medical regimen is emphasized.” “ Depression is a cluster of psychological and physiological symptoms that may be episodic or contiguous, ranging from mild depression to dysthymia (a chronically depressed mood that is present more than 50% of the time for at least 2 years in adults.” (Depression article, p.519) Taber’s states that, “depression is one of several mood disorders marked by loss of interest or pleasure of living.” (p.563) “Depression results in decreased quality of life through impairment of work and daily activities, is associated with significant morbidity and mortality, and results in economic costs that rival those from heart disease.” (Depression article, p.519) 5. Progress of client My patient was admitted to the hospital on 1/30/06 for her right TKR surgery. Preoperative care included inserting a Foley catheter, medication for pain, Venodyne boots, and Ted stockings. The surgery was explained to my client. My patient’s baseline preoperative vital signs were; temperature (T) 36.2C, pulse (P) 64 radial, respirations (R) 18, blood pressure (BP) 126/79 lying, and oxygen saturation (O2 sat) 96% room air. Involved during the intraoperative care there was a surgeon, anesthesiologist, a physician’s assistant, nurses, who else was involved in surgery??? Surgery summary “ The surgeon will make an incision above the affected area and move the patella out of the way. The ends of the femur and tibia are shaved off to fit the prosthesis. The two parts of the prosthesis are implanted onto the ends of the femur and tibia using bone cement. The backside of the patella must be cut to allow for the prosthetic. The patient will leave surgery with a large dressing on the knee. A small drainage tube will be placed during surgery to drain excess fluid. The patient may be placed into continuous passive (CPM) device to help speed recovery, decrease pain, bleeding, and infection. The patient will control pain using a PCA machine for about 3-5 days after surgery. Patient will have IV lines in place to provide fluid and nutrition. Patient will be encouraged to start moving and walking as early as the first day after surgery. Patient will be instructed to use incentive spirometry, and cough and deep breathing exercises to increase the depth of breaths in order to prevent lung collapse and pneumonia. Total knee replacement surgery results are very often excellent. Most prostheses last about 10 to 15 years before loosening and requiring revision surgery. A hospital stay generally lasts 3-5 days, but the total recovery period varies from 2-3 months to a year. Walking and range-of-motion (ROM) exercises will be started immediately after surgery.”(Medline plus)
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The results of my patient’s right TKR surgery according to the surgeon’s operative findings are as follows, summarized from the surgeon’s report. There was indeed severe DJD of the patellofemoral joint with more wear laterally than medially, and she could had possibly suffered a little while longer in regards to the actual weight bearing surface of the joint. The patellofemoral joint was causing her enough trouble that she would have definitely come to have needed total knee replacement surgery with a year or two if she had waited. Total tourniquet time was 93 minutes with estimated blood loss 100cc. Patient tolerated quite well and had no complications. The surgeon installed a Hemovac at the surgical site to remove drainage and to aid in healing. The surgery lasted just under three hours. Postoperative care included spending 45 minutes in the post-anesthesia care unit (PACU). My patient still had a Foley catheter in place, a Hemovac for drainage, a cryocuff on right knee, and patient-controlled analgesic (PCA) pump for pain medications. “Benefits of a PCA pump include the following: patients having control over pain, pain relief does not depend on nurses’ availability, patients tend to take less medication, and small doses of opioids delivered at short intervals stabilize serum drug concentrations for sustained pain relief.”(Potter & Perry, p.725) The surgeon assessed my patient postoperatively in her room, and gave the following medical orders: vital signs Q2HR, then Q4x4, and then Q shift; when OOB right knee in immobilizer; Ted stockings, Venodyne off 30 minutes Q shift; and in isolation room to minimize the chances of getting a nosocomial infection.
6. Role of LPN in the Assessment phase of patient care “Surgical patients enter health care facilities in different stages of health.” (Potter & Perry, p.906) My patient was admitted to the hospital for major reconstructive surgery of her right TKR. One of the many responsibilities of the LPN in nursing care is to getting a detailed medical and family history from the patient and family members. This history is very important in establishing a picture of the patient’s, and helps to alert the health care team to any special needs or potential complications during and/or after surgery. The patient history will include asking questions regarding; “ previous surgeries, medication history, allergies, smoking habits, alcohol and controlled substance use and abuse, family support, occupation, feelings, cultural and spiritual factors, coping resources, and body image.” (Potter & Perry, p. 907-909) A complete physical examination is usually required prior to surgery. “Knowledge of patient risk factors will enable the nurse to take necessary precautions in planning care.” (Potter & Perry, p.911) Diagnostic screening will be done depending on the reason for hospitalization and surgery.
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II. PLANNING 1. Nursing diagnoses My patient’s first diagnosis is Anxiety: related to actual or perceived change in environment secondary to hospitalization and surgery . “Anxiety is the state in which an individual or group experiences feelings of uneasiness (apprehension) and activation of the autonomic nervous system in response to a vague, nonspecific threat.”(Nsg. Dx, p.11) My patient was anxious about the pain from having physical therapy the day after her surgery, but she knew it was important to start physical therapy soon after surgery. My second nursing diagnosis is: Disturbed self-concept related to immobility manifested by ambulatory pain . “Disturbed self-concept is the state in which an individual experiences, or is at risk of experiencing, a negative state of change about the way he or she feels about himself or herself.”(Nsg. Dx, p.403) My patient is obese and has depression. My third nursing diagnosis is: Acute pain related to tissue trauma and reflex muscle spasms secondary to surgery manifested by right total knee replacement. “Acute pain is the state in which an individual experiences and reports the presence of severe discomfort or an uncomfortable sensation lasting 1 second to less than 6 months.”(Nsg. Dx, p.55) My fourth nursing diagnosis is: Activity intolerance related to inactivity secondary to surgery, lack of motivation, and sedentary lifestyle. “Activity intolerance is a diagnostic judgment that describes a person with compromised physical conditioning.” (Nsg. Dx, p.3) My patient is obese, and prior to surgery said that she lives a sedentary lifestyle, and has difficulty walking long distances. My fifth nursing diagnosis is: Ineffective health maintenance related to intake in excess of metabolic requirements . “Obesity is a complex condition with sociocultural, psychological, and metabolic implications. This diagnosis, when used to describe obesity or overweight conditions, focuses on them as nutritional problems. The focus of treatment is behavioral modification and lifestyle changes.” (Nsg. Dx, p.307) 2. Expected outcomes/goals, discharge planning Short-term goals for my patient:
Long-term goals: 3. Role of the LPN in the planning phase of patient care
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III. IMPLEMENTATION
1. Nursing actions, postoperative care During my first clinical day with my patient, one day postoperatively, I started the day getting vital signs; T 97.7F, P 83, R 20, BP 136/80, O2 96RA, lung sounds were clear and unlabored, bowel were inactive. Her pain was aching at the surgical site, and her pain level was a five out of 10 when laying still, and a fifteen when she tried to move in bed. She said she had slept pretty well the night before. She was in pretty good spirits considering she had just had surgery the day before. She ate 100% of her breakfast. I administered my patient’s medications. I checked the IV site, and there were not any signs of edema or pruritis. The surgeon assessed the patient, and discontinued the Hemovac. The patient was on a PCA pump for pain, and had Venodynes on her lower legs to increase circulation. I emptied the Foley which had 200cc and was yellow in color. I obtained a urine sample to the lab for testing. The results came back with no growth in 48 hours. My patient had forgotten her medication for depression at home, so my co-assigned asked the physician for Prozac 20mg/PO/one time. My patient was in a great deal of pain, and was moved to tears during her first session with physical therapy. She was upset with herself for crying. I tried to sympathize with her saying it is certainly OK to cry because of the pain. Next time I would have asked my co-assigned about giving her an extra dose of pain medication 30 minutes before physical therapy. My patient had less pain during the second day with her. The PCA pump had been discontinued by the co-assigned nurse at 0900. I administered her medications. An order was given for Percoset 10mg, 30 minutes prior to physical therapy. She tolerated physical therapy much better the second day. 2. Scientific rationale
3&4. Medications administered with rationale My patient’s was received Morphine sulfate 30mL/IV via the PCA pump. The indication is for severe pain. Nursing implications are: assess level of consciousness (LOC), BP, pulse, and respirations before, during, and after administration. Also, the nurse must assess type, location, and intensity of the pain prior to administration. My patient received Cefazolin 1000mg/NS 50mL over 30 minutes Q6HR IV piggyback. Indications are treatment of bone and joint infections and perioperative prophylaxis. Nursing implications were, observe
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patient for rash, pruritis; administer of 30-60 minutes; and monitor IV site for thrombophlebitis. My patient received Docusate sodium 100mg/PO/BID. Indication is for prevention of constipation. Nursing implications were, assess for presence of bowel sounds; and assess color, consistency, and amount of stool produced. My patient also received Lactated Ringers 1000mL/IV/continuous. Indications are supplying water and electrolytes to the body, and a mixing solution for other IV medications. Nursing implications were to give medications as ordered, and closely follow instructions for mixing with other medications. 5. Diet prescribed My patient was on a clear liquid the first day postoperatively, because she had been NPO the day of the surgery. She was nauseous from the medications she was receiving. She was changed to a regular diet on my second day with her. 6. Role of the LPN in the Implementation phase of patient care
IV. EVALUATION 1. Effectiveness/modification, client teaching Postoperatively interview w/ PT (Prior to discharge) My patient was interviewed by a physical therapist at the hospital, prior to discharge. The physical therapist reported that the client was upset and tearful. My client shared some concern. One concern was regarding her rehabilitation and dietary requirements once she was discharged. A bigger concern was related to her finances. She stated that she and her husband have several medical bills which they are trying to pay on just her husband’s paycheck. The physical therapist requested that a gentleman from the hospital speak with her about my patient’s financial concerns.
2. Role of the LPN student in the Evaluation phase of patient care
