Gemma is a 75 yr old female patient. She had her first Total Hip Replacement (THR) surgery due to arthritis. Although Gemma’s pathway appears to be quite normal according to the transition record, she has some issues need to be addressed. She is old, had a major surgery of trauma score 5 orthopedic, history of Asthma and hypertension, and high BMI. She needs to be monitored for complications since she is not only a surgical patient but also an orthopedic patient. The shift started at 1600 on post operation day one. The care plan for Gemma for the PM shift will employ clinical reasoning cycle: including nursing problems in order of priority, interventions with rationales and evidences, evaluations on Gemma’s performance. This nursing diagnoses and care plan is to focus on early detection and prevention of complications associated with post operation of THR. PART A: Nursing Diagnosis
Diagnosis: Breathing problems related to effect of anesthesia and narcotics. a)
Cue/Data: Observation at 1630-Resps26, O2Sats 95%, Oxygen maintained via Hudson at 6 liters a minute: Previous history of Asthma: X-ray on day one PM: Exercise deep breathing & coughing: Note Pre-Medication Gabapentin Orally 600 mg: Temazepam Orally 10 mg: Fentanyl IV 10 mg 4 times in PACU: Oxycontin PO 20 mg BD withheld on day one. b)
AEB(as evidenced by): A side effect of all anesthetics is to decrease ventilation, decrease metabolism and hence CO2 production(Ahrens et al, 2009) 2.
Diagnosis: Impaired balance of fluid volume related to losses secondary to surgical procedures with recent wound drainage appliance. a)
Cue/Data: Note dry skin: intake exceeding output: increased body temperature: lower Hb count after surgery: PreOp Hb 146/ WCC 8.1/ Platelets 322 , PostOp Hb 106/ WCC 10.8/ Platelets 223: Pre-Medication Na Citrate Orally 30 mLs b)
AEB: Fluid can collect within the tissues of the body during surgery causing dramatic losses in fluid levels which must be restored intravenously.(Scales & Pilsworth, 2008) 3.
Diagnosis: Risks of Kidneys or Urinary system Infection
Cue/Data: Note Urine Microscopy-14x10(6) White Blood Cells: U&E’s change: PreOp Na 141 K+4.2 Chloride 105 PostOp Na 139 K+3.6 Chloride 105: Bacteria not detected: Administered Endone PO 10 mg this AM.: Avapro PO 300mg Mane. b)
Urinary tract infections associated with urinary catheters are the leading cause of secondary nosocomial bacteremia. Approximately 20 percent of hospital acquired bacteremias arise from the urinary tract, and the mortality associated with this condition is about 10 percent. (O’Farrell et al, 2011). 4.
Diagnosis: Nausea/ vomiting related to the side effects of general anesthesia a)
Cue/Data: Experienced mild nausea & complained about feeling like to vomit.: Tropisetron IV 2mg daily PRN b)
AEB: Recognition of complications of N&V is critical to prevent and manage untoward complications of dehydration and electrolyte imbalance (Steele & Carlson, 2007) 5.
Diagnosis: Acute pain related to surgical incision
Cue/Data: Medi Pain Management: PCA: Pain Score 6 (0-10): Elevated B/P: Nausea and vomiting: Administered Paracetamol IV 1 gram 6/24: Gabapentin PO 300 mg Daily b)
AEB: Chronic postsurgical pain is common but may lead to significant disability.(APS,2008) 6.
Diagnosis: Thrombophlebitis in the lower extremity related to hip replacement a)
Cue/Data: Specific order for abduction pillow: Pneumatic compression device: Administered Clexane SC 40 mg daily: Mildly obese/ BMI 29: Age 75 yr old b)
AEB: Complication of thrombophlebitis is progression to the deeper veins, with development of DVT, and increased risk of pulmonary embolism. (Tudor-Locke et al, 2008) 7.
Diagnosis: Bathing, Hygiene or toileting self care deficit Related to mobility restrictions a)
Cue/Data: Mildly obese/ BMI 29: Age 75 yr old: No more than 45 degree hip flexion: Limb exercises: Rest in bed when not with physio: Slide out of bed and stand in rollator assist x 2 on day one. b)
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