Turb and Kyphoplasty Care Plan
Care Plan: TURB and Kyphoplasty Recovery
Situation and Background E.P. is an 88-year-old Caucasian male. He was admitted on 02/18/13. His code status is full code, and he declines to bring in his advanced directive. He reports that he is 68.5” tall, and his actual weight is 165 pounds. He and his wife are the sources of information, and they are reliable. His blood pressure is 124/62, taken on his right arm in a lying position, his oral temperature is 99.8, his right radial pulse is 74 beats per minute, his respiration rate is 16 breaths per minute and his pulse oximetry reading is 92 on room air. He is allergic to latex, cephalexin and sulfa drugs, with a reaction of hives, and to IV dye, with a reaction of moderate rash. He was admitted for TURB (Trans-Urethral Resection of the Bladder), and left ureteroscopy related to a bladder tumor, and kyphoplasty secondary to compression fractures of the L1 and L3 vertebrae. His significant past medical history includes hypertension, atrial fibrillation, and chronic heart failure. He had a permanent pacemaker placed in 2003, and a history of MRSA over five years ago. E.P.’s fall-risk score is 2; however, he is on fall precautions related to anesthesia recovery, as fall risk is deemed appropriate by clinical judgment. He reports a pain level of 6 out of 10 numeric scale.
Head-to-toe Assessment:
Neurological: E.P.’s Glasgow Coma Scale score is 15. He is awake, alert and oriented to person, place, and time. His speech is clear and understandable, and appropriate to the situation. EENT: E.P.’s pupils are equal, round, reactive to light and accommodative. His sclera is white without drainage, and his nares and mucosa are pink and moist. Cardiovascular: He has +2 pitting edema in lower extremities bilaterally, a right radial pulse of 74 BPM, and blood pressure of 124/62 (right arm, lying). Respiratory: E.P. has diminished lung sounds, with a pulse-ox reading of 92% on room air. Gastrointestinal: He has hypoactive bowel
Situation and Background E.P. is an 88-year-old Caucasian male. He was admitted on 02/18/13. His code status is full code, and he declines to bring in his advanced directive. He reports that he is 68.5” tall, and his actual weight is 165 pounds. He and his wife are the sources of information, and they are reliable. His blood pressure is 124/62, taken on his right arm in a lying position, his oral temperature is 99.8, his right radial pulse is 74 beats per minute, his respiration rate is 16 breaths per minute and his pulse oximetry reading is 92 on room air. He is allergic to latex, cephalexin and sulfa drugs, with a reaction of hives, and to IV dye, with a reaction of moderate rash. He was admitted for TURB (Trans-Urethral Resection of the Bladder), and left ureteroscopy related to a bladder tumor, and kyphoplasty secondary to compression fractures of the L1 and L3 vertebrae. His significant past medical history includes hypertension, atrial fibrillation, and chronic heart failure. He had a permanent pacemaker placed in 2003, and a history of MRSA over five years ago. E.P.’s fall-risk score is 2; however, he is on fall precautions related to anesthesia recovery, as fall risk is deemed appropriate by clinical judgment. He reports a pain level of 6 out of 10 numeric scale.
Head-to-toe Assessment:
Neurological: E.P.’s Glasgow Coma Scale score is 15. He is awake, alert and oriented to person, place, and time. His speech is clear and understandable, and appropriate to the situation. EENT: E.P.’s pupils are equal, round, reactive to light and accommodative. His sclera is white without drainage, and his nares and mucosa are pink and moist. Cardiovascular: He has +2 pitting edema in lower extremities bilaterally, a right radial pulse of 74 BPM, and blood pressure of 124/62 (right arm, lying). Respiratory: E.P. has diminished lung sounds, with a pulse-ox reading of 92% on room air. Gastrointestinal: He has hypoactive bowel
References: “Bladder Cancer”. Retrieved February 20, 2013 from http://www.cancer.gov/cancertopics/types/bladder “Compression Fractures”. Retrieved February 20, 2013 from http://www.nlm.nih.gov/medlineplus/ency/article/000443.htm Deglin, J.H. & Vallerand, A.H. (2011). Davis’ Drug Guide for Nurses (12th ed.). Philadelphia: F.A. Davis Company. Lang, E. V., Benotsch, E. G., & Fick, L. J. (2000). Adjunctive non-pharmacological analgesia for invasive medical procedures: A randomised trial. The Lancet, 355, 1486-90. Smeltzer, S., Bare, B.G., Hinkle, J.L., & Cheever, K.H. (2010). Brunner & Suddarth’s Medical Surgical Nursing (12th ed.) Vol.1 & 2. Philadelphia: Lippincott, Williams & Wilkins. “Vertebral Compression Fractures”. March, 2007. Retrieved February 20, 2013 from http://www.aans.org/Patient%20Information/Conditions%20and%20Treatments/V ertebral%20Compression%20Fractures.aspx