Reference no: EM133250260

Question: Mr.John Wright is a 78 year old male, married, presents with chief complaints of right knee pain to right knee, radiating to right leg rating pain level 10/10" on the numeric scale 0 - 10. report right knee and feet feel " very heavy and numb, drowsy with frequent wave of nausea" . client reports a job that requires long periods of standing. Client is currently admitted with a medical diagnosis of right Total Knee Arthropl;asty. On this admission, client reports medical h/o HTN, CAD, Obesity, DM,

chronic osteoarthritis, Hyperlipidemia (HLD), client denies elicit drugs, alcohol, and tobacco used Client Denies Claudication and paresthesia symptoms at the affected site.

Pre OP Medication: Regional anesthesia, and and Epideral

Current medications: Atenolol 25 mg 1 tab oral two time (BID)

Heparin injectable 5,000 unit subcutaneous every 12 hours (q12 hours)

Metformin 500 mg 1 Tab oral twice a day (BID)

Pantoprazole 40 milligrams 1 tablet oral every day (OD)

Simvastatin 10 my 1 tab oral daily at bedtime (OD at HS)

Gabapentin 300 mg 1 Tab oral two times a day (BID)

Cyclobenzaprine 10 mg 1 tab Two times a day (BID)

Meds PRN

Acetaminophen 325 mg 2 tabs oral every 6 hours as PRN (needed )(1 - 3)

Morphine injectable 1 mg IVP every 6 hours PRN (as needed) (7 - 10)

Oxycodone 5mg 1 tab oral every 4 hours PRN (as needed) 4 - 6.

Physical assessment findings: Mr. JW appears anxious,

CP: Denies any SOB

C/o Nausea, vomiting, and headache, muscle weakness

Color WNL for ethnicity

Vital signs (V/S) B/P 130/80, HR. 90, R. 22. oxygen oxymetry: 96%

ABG: PC02 40, PAO2 96%, PH 7.38

Weight: 168 Lbs, height: 5.4

Labs: On admission Peak Flow Rate (PFR) 80% which indicates WNL. Lungs clear on auscultation

Right Knee

CBC: Hemoglobin 14 and Hematocrit 45 (H/H) 16/49, WBC: 6,000.

Review of system information (ROS):

Neurological: Alert and oriented to time, place, and person. Good historian

Respiratory: No adventious sounds

Breath sounds: inspiratoty = expiratory, and on auscultation

Adventitious sounds: None findings bilaterally

Cardiovascular: Heart rate 90 strong and regular

Jugular venous distention: Negative on assessment

Peripheral edema 2 +

Elimination Pattern

Gastro intestinal (GI): Abdominal soft. Mildly distended

Bowel sounds present in all four quadrants

Bowel habits: Consistent. Last BM: 9/22/2022: Stools characteristics: Firm

Genitourinary (GU): 18 French Catheter connected to Foley bag at bedside drining clear amber urine. No clot or sedimentation noted in the foley bag.

Mobility: Mobile with unsteady gait

Integumentary (skin): Dry, warm, and intact

Incision: Right knee incision with surgical aquacel dressing intact

Keep initial DSD in place to change by surgeon

Skin color: WNL for etchnicity

Diet: NPO

IV Fluids Ringer Lactate at 75cc/hour

Assignment requirements

Develop a patient Plan Of Care (POC) on Surgical incision- using Concept Map Tamplate on the case scenario listed above
Identify subjective and objective data
Define three nursing diagnosis/problems
Define one short term and long term goals
Define six nursing interventions, briefly explain your rational for each
intervention

Evaluate the outcomes of your treatment plan
Complete a medication list using medication template include Name, dose, route, frequency, class, indications, side effects, and adverse effects (complications)
How is the medical diagnosis associated with the nursing diagnosis.
What atre the probable causes of Osteoarthritis result findings What factor contribute to the result finding: ? What interventions can you anticipate for patient with osteoarthritis?

Lastly: Complete Cyclobenzaprine medication and Systems Disorder of Active Learning Template to complete assignment on Post Sugical Incision.