BASIC CONDITIONING FACTORS:-.

5 POWER COMPONENTS:
Client Initials: _J.K. Sex: __M Age:_32 Race: White Allergies: Pamelor, Zomig, Skelaxin
________________________________________________________________________________ _A__ Attention Span (Acute Limited attention
Medical Diagnosis: Left Shoulder and Arm Pain span due to anesthesia)
______________________________________________________________________________
Surgical Procedure / Treatment: Left Shoulder Arthroscopy Bicep Tenodoesis Subacromial Bursectomy Removal _A_ Energy Level (Acute decrease in energy
Foreign Body__________________________________________________________________________________ level due to anesthesia)
Client Profile: (reason for hospitalization, chief complaints and/or presenting symptoms) _A__ Control of body movements (Acute control
Patient presenting for preoperative evaluation for left shoulder arthroscopy, Bicep Tenodesis, Subacromial loss due to anesthesia)
Bursectomy, and Removal of foreign body. Patient injured arm/shoulder about one year or more ago at work. Patient
complains of pain in left shoulder area. _A__ Ability to reason (Acute ineffective ability
____________________________________________________________________________ to reason due to anesthesia)
Past Medical/Surgical History of Client(including previous hospitalizations with dates)
_A__ Ability to make decisions (Acute inability
Patient injured his arm about 1year ago at work. Has undergone two surgeries and pt. continues to complain of pain.
to make decisions due to anesthesia)
Labrum repair left shoulder 11/09, Ulnar transposition left elbow 09/09
Patient also experienced seizures as a child but has not experienced any in many years. _A__ Motivation (Acute deficit in motivation due
Patient has history of asthma but has not needed to use his inhaler and cannot remember the last time he needed the to anesthesia)
use for it. Pt. has back pain and has had a facet rhizotomy injection
Pt. also does have anxiety and palpitations. Palpitations are controlled with atenolol and panic is controlled with _A__ Knowledge of health problem (Patients
clonazepam. knowledge deficit in removal of foreign body and
Family History (include three tier genetic history): where it came from is diminished)
Mother: Died at the age of 88 had breast and bladder cancer _A__ Ability to provide for self care (Acute
Father: Died at the age of 72 had cancer of the larynx inability to provide for self-care due to anesthesia
Sister: Age 29 Hyperthyroidism Married daughter 2yrs son 5yrs and surgical incision)
Sister: Age 25 Married___________________________________________________________________________
Support Systems: (family, friends, coworkers etc.) _A__ Skills needed to adapt self-care needs
Wife, Two children (boys 9yr, 1yr), Coworkers, Neighbors, Friends, Family (Patient will difficulty with adapting to self care
_______________________________________________________________________________ needs without the assistance of left arm while
Sociocultural and daily patterns of living: recovering)
Pt. lives in a home with his two children and wife. Pt. son also has asthma. His activities consist of work as a local
truck driver and when he comes home he likes to spend time with kids and family. He is a non-practicing catholic. _A__ Ability to adapt self-care needs to A.D.L.
(Patient will have difficulty with A.D.L.’s due to
limited extremity movement.)
UNIVERSAL / HEALTH DEVIATION
SELF-CARE REQUISITE ASSESSMENT: DEVELOPMENTAL SELF
CARE REQUISITES:
Air (Respiratory, Cardiovascular)-3
Preop: Bp: 109/73, Temp: 98.2, Apical Pulse: 64, regular and strong, Normal EKG, Respirations: 18, Client’s Age: 32 Stage of
Easy on room air. Lung sounds: Bilaterally equal, No secretions, SaO2:98%, Capillary refill: <2 sec. Development:
Heart sounds: normal. Pt does not complain of chest pain but does state that he does have Generativity Vs. Self
hypertension. Mucous membrane: moist, Nail bed color: Pink. Serum Lab results: Glucose: 85 Absorption
Creatinine: 1.0 Serum Calcium: 9.7 Total bilirubin: 0.2 Alanine Aminotransfer: 32 AST: 16 Alkaline
Phosphatase: 63 Chloride: 101 Carbon Dioxide: 28 Granulocyte percentage: 5.3 Granulocyte How might this illness
Absolute: 5.3 Lymph Percent: 26.5 Lymphocyte Absolute: 2.2 Monocyte Percent: 8.3 Monocyte interfere with the client’s
Absolute: 0.7 Eosinophil Percent: 1.4 Eosinophil Absolute: 0.1 Basophil Percent: 0.2 Basophil developmental tasks: How
Absolute: .0 WBC: 8.4 RBC: 4.71 Hemoglobin: 14.5 Hematocrit: 42.4 MCV: 90 MCH: 30.8 MCHC: might the client’s stage of
34.2 Platelets: 220 RDW: 13.2 PT: 10.3 PTT: 27.9 development impact his/her
Pt. had chest x-ray done: Frontal and lateral projections of the chest demonstrate biapical pleural adjustment to the illness?
parenchymal scarring. Lung volumes show large but otherwise clear. Heart size within normal limits.
Postop: Bp: 115/62 Apical pulse: 66 SaO2: 94% on room air, Lung sounds bilaterally equal. Resp:16 Erikson observed that middle-
Radial pulse strong.. Warm temperature normal color of extremities. Sensation: numbness in left arm age is when we tend to be
due to interscalene block. Extremities normal color, cap <2, no edema present. occupied with creative and
Water (Renal, F & E) meaningful work issues
Urine Clear yellow. Urinanalysis: Ph: 7.0 Specific Gravity: 1.003 Glucose: Negative Blood: Negative surrounding out family. The
Ketones: Negative Protein: Negative Urobilinogen: <2.0mg Bilirubin: Negative Leukocyte Esterase: significant task is to contribute
Negative Nitrate: Negative GFR: >=60 Sodium: 139 Potassium: 4.6 Total Protein: 7.9 Albumin: 4.6. to the betterment of society,
Preop:1000ml IV Lactated Ringers, NPO which for the patient is now
Food / Elimination (Gastrointestinal) not able to do. The patient has
Abdomen soft, no masses,. Bowel sounds present in all four quadrants. Patient has crowns. to focus on himself to further
No guarding or rebound. Skin turgor normal. Oropharynx pink and moist. Postop: pt ate 4 oreo increase his health and to
cookies and had 3sips of pepsi. provide an adequate amount of
Activity & Rest (Musculoskeletal, Neurological) time for his surgery incisions
Pt. has limited ROM due to surgery, sleep patterns normal. Sensory and motor intact, PERRLA, pt. to heal.
has pain and limited movement in L. arm due to Surgery. Pt. also complains of previous back pain for This stage of development may
several months. Pt. denies sleep, anxiety, depression problems. impact the patient very easily.
Solitude & Social Interaction The patient is an eager and
(Sensory Perception, Psychosocial) willing man and would to
Pt. does not wear glasses. Interaction with family and friends is close and normal. No issues in anything for his family, even if
communication. Pt. does not use antidepressants or anti-seizure medication. it did include not letting his
Prevention of Hazards (Endocrine Autoimmune, Chemical) shoulder rest after the surgery;
Pt. smokes 1pack in two weeks. Alcohol consumption: 6pk in month, Seizures as child no longer has prolonging the healing time.
episodes. Home environment safe. Anesthesia administered during surgery: Versed, Fentanyl,
Lidocain. Foreign body removed during surgery. Side rails up during transport. Dressings clean.
Incision made at left anterior shoulder. No drainage noticed post operation.
Promotion of Normalcy
(Personal Hygiene, Self Concept, Reproductive, Integument)
Preop: Skin intact no lesions. IV right anterior forearm Postop: patient had a Cuff IC and was unable
to move arm. Pt had incision on left shoulder no drainage present. Patient confirmed of no anxiety
feeling day of surgery. No anxiety was seen in facial expressions. Pain after surgery was at 0 (1-10
scale). Patient is able to complete ADL with assistance due to surgery.
Research of the Medical Diagnosis
Arthroscopic Bicep Tenodesis:
Arthroscopy is a procedure that allows direct visualization of a join to diagnose joint disorders. Treatment of
tears, defects, and disease processes may be performed through the arthroscope. The procedure is performed through the
arthroscope in an operating room, under sterile conditions. Injection of a local anesthetic agent into the joint or general
anesthesia is used. A large bore needle is inserted and the joint is tended with saline. The arthroscope is introduced and
joint structures, synocium, and articular surfaces are visualized. After the procedure the puncture wound is closed with
adhesive strips or sutures and covered with a sterile dressing. Complications are rare but may include infection,
hemarthrosis, neurocascular compromise, thrombophlebitis, stiffness, effusion, adhesion, and delayed wound healing.
(Smeltzer, Bare, Hinkle, & Cheever, 2010)

Bicept tendoesis: A biceps tenodesis is a procedure that cuts the normal attachment of the biceps tendon on the
shoulder socket and reattaches the tendon to the bone of the humerus. By performing a biceps tenodesis, the pressure of
the biceps attachment is taken off the cartilage rim of the shoulder socket (the labrum), and a portion of the biceps tendon
can be surgically removed. Essentially a biceps tenodesis moves the attachment of the biceps tendon to a position that is
out of the way of the shoulder joint. (Smeltzer, Bare, Hinkle, & Cheever, 2010)

Nursing interventions: After the procedure, the joint is wrapped with a compression dressing to control welling. In
addition ice may be applied to control edema and enhance comfort. Frequently, the joint is kept extended and elevated to
reduce swelling. It is important to monitor and document the neurovascular status. Analgesic agents are administered as
needed. The patient is instructed about activities and exercises that may be preformed. The patient and family are
informed of symptoms to watch for in order to determine whether complications are occurring and of the importance of
notifying the physician of this observation. (Smeltzer, Bare, Hinkle, & Cheever, 2010)

Subacromial Bursectomy: is removal of the subscromial bursa sac (a small, fluid-filled sac that acts as a cushion
at a pressure point in the body. near joints where tendons or muscles cross either bone or other muscles). (Smeltzer, Bare,
Hinkle, & Cheever, 2010)

Significance of Normal/Abnormal Diagnostic Tests

Lab work: all levels are normal
Urinanalysis: all levels are normal
Chest X-ray: Frontal and lateral projections of the chest demonstrate biapical pleural parenchymal scarring. Lung
volumes show large but otherwise clear. Heart size within normal limits.

Medical Technologies: Treatments / Medications

Clonazepan: 0.5mg, PRN
Action: Depresses nerve impulse transmission in motor cortex.
Rationale: Patient has anxiety with palpitations.
Side effects: drowsiness, behavioral disturbances
Nursing implications: assess for calm facial expression and decreased restlessness, assess vital signs.
Atenolol: 25mg daily
Action: Blocks beta-adrenergic receptors in cardiac tissue
Rationale: Treatment of hypertension.
Side Effects: Hypotension, dizziness, constipation
Nursing Implications: Monitor B/P and pulse for bradycardia, and respirations for difficulty in
breathing.
Albuterol: 2 puffs q4 hrs PRN
Action: Broncho dilator.
Rationale: Patient has asthma but has not needed medication, and cannot remember the last time he has taken
medication.
Nursing Implications: Monitor rate, depth, rhythm, type of respirations. Assess lungs for abnormal lung sounds.
Fluticasone Propionate: 2 puffs BID
Action: Prevents and controls inflammation.
Rationale: Patient has asthma but has not needed medication, and cannot remember last time he has taken
medication.
Nursing Implications: Monitor rate, depth, rhythm, type of respirations. Assess lungs for abnormal lung sounds.
Post OP ORDERS:
Morphine: 2-4 mg every 2min IV PRN max dose: 20mg
Action: binds with opioid receptors within CNS
Rationale: Pain relief
Nursing Implications: monitor vital signs 5-10 min after IV check for adequate voiding. Assess for clinical
improvement.
Fentanyl: 25-50 mcg every 2min IV PRN max dose: 100mcg
Action: reducing stimuli from sensory nerve endings, inhibits ascending pain pathways
Rationale: Pain relief
Nursing Implications: Asst with ambulation, encourage post op turn, cough deep breathe q2h. Monitor Vital
signs, assess for relief of pain
Prochlorperazine: 10mg IM
Action: Acts to block dopamine receptors in chemoreceptor trigger zone.
Rationale: Relieves nausea/vomiting
Nursing Implications: Monitor BP for hypotension. Monitor WBC count. Assess for therapeutic response.
Onsansteron: 4mg IV
Action: blocks serotonin, both peripherally on vagal nerve terminals, centrally in chemoreceptor trigger zone.
Rationale: Relieves nausea/vomiting
Nursing Implications: Assess for dehydration, assess bowel sounds for peristalsis, and assess mental status
Meperidine: 12.5 IVP May repeat x1
Action: Binds to opoid receptors with in CNS
Rationale: for shivering
Nursing Implications: Monitor vitals 15-30 mins after subQ/IM dose, 5-10 mins after IV dose. Monitor pain
level, bowel activity.

Prioritized List of Nursing Diagnoses (in PES format

Acute pain r/t injury in surgical care AEB pt. verbalization.

Self-Care Deficit related to impaired ability to perform self-care tasks, as evidenced by statements of need for
assistance and observed difficulty in performing activities of daily living

Risk for infection r/t invasive procedure.

Acute pain r/t presence of intubation tube AEB pt. verbalizing a mild sore throat.

Acute back pain related to back injury as evidenced by patient verbalization.

Ineffective health maintenance r/t lack of knowledge regarding prevention of dental disease AEB pt crowns.

Risk for constipation r/t use anesthesia, decrease in fluid and food intake, and pain medication.
Risk for ineffective breathing pattern r/t effects of narcotics and anesthesia.

Risk for Peripheral Neurovascular Dysfunction related to tissue trauma and

Readiness for enhanced Therapeutic regimen management: expresses desire to learn measures to stop smoking.
NURSING DIAGNOSIS
(NANDA)
Acute pain r/t injury in
surgical care AEB pt.
verbalization.
Self-Care Deficit related to
impaired ability to perform
self-care tasks, as evidenced
by statements of need for
assistance and observed
difficulty in performing
activities of daily living
Ok so you would Use self-
care deficit: dressing
Risk for infection r/t invasive
procedure.
SELF-CARE AGENCY-1
Goal (NOC) +
Expected Outcomes (NOC
Indicators)
NOC: Pt. will have a reduction in
pain by discharge.
NOC Indicators: Pt. will
verbalize pain at a level of 3 or
less by the 10/28.
NOCPt. knows an easier method
for dressing .
NOC Indicators: Pt. will verbalize
three types of clothing that are
easier to put on by 10/28.
NOCindicator: Pt. will
demonstrate the ability to dress.
NOC Indicator: Pt. will know to
dress the affected side first by
10/28.
Goal: Prevention of infection
These are all indicators
NOC: Pt. will know signs and
symptoms of infection.
NOC Indicator: Pt. will verbalize $
signs and symptoms of infection.
NOC: Pt. will have surgical area
that shows evidence of healing.at
f/u visit
NURSE AGENCY
(NIC)
Nursing actions (NIC Activities)
(Include rationales, Independent or
Interdependent and S/E, PC, or WC)
Assure patient attentive analgesic care:
Perform a comprehensive assessment of pain, to
include location, characteristics, onset/ duration,
frequency, quality, intensity or severity of pain
and precipitating factors. (Rationale: initial
assessment and documentation provide direction
for the pain treatment plan. Independent PC)
(Ackley and Ladwig pg 604)
Ask the client to describe past experiences with
pain and the effectiveness of methods used to
manage pain, including experiences with side
effects, typical coping responses, and the way the
client expresses pain. (Rationale: many patients
harbor fears and misconceptions regarding the
use of analgesics, management of side effects,
and risk of addiction. Independent PC) (Ackley
and Ladwig pg. 606)
Assess and document the intensity of the pain
and discomfort after surgery. (Rationale: The
clients report of pain is the single most reliable
indicator of pain. Independent WC) (Ackley and
Ladwig [g 605)
Obtain a prescription to administer and opioid.
Rationale: opioid analgesics are indicated for
the treatment of moderate to severe pain
Interdependent PWC) (Ackley and Ladwig pg
607)
Administer opioids orally or IV as ordered when
appropriate and available. (Rationale: the least
invasive route of administration capable of
providing adequate pain control is
recommended. Independent PC )(Ackley and
Ladwig pg 608)
When opioids are administered, assess pain
intensity, sedation, and respiratory status at
regular intervals. (Rationale: Opioids may cause
EVALUATION AND/OR
MODIFICATIONS
Patient had reached goal, by the time
of discharge patient confirmed a
level of 2 out of 10 on the pain scale.
Patient also verbalized the
importance of not waiting till the
pain was intolerable before taking
the medication.
Patient had reached goal: patient
verbalized three easier steps of
dressing that are easier to put on.
(Wide sleeve shirts, sweaters that zip
up in front, and dressing the affected
arm first.)
Patient had reached goal and
indicated 5 signs and symptoms of
infection. (Pain, Redness, Heat,
Fever)purulentdrainage?
Patient had reached goal, by the time
of discharge patient did not show
any signs of redness or swelling in
the surgical area.
Patient had reached goal. Patient
verbalized the steps in correct hand
hygiene, indicated the when time of
surgical dressing had to be changed,
and indicated to whomever was
doing the dressing change required
to wear gloves.
NOC Indicators: Pt. will have no
redness and drainage by 10/30 and
none at f/u visit
NOC: Pt. will know how to change
dressing.
NOC Indicators: Patients will
wash hands, wear gloves and apply
clean band aids to sutures.
respiratory depression because they reduce the
responsiveness of carbon dioxide
chemoreceptors located in the respiratory
centers of the brain. Independent WC) (Ackley
and Ladwig pg. 609)
Teach and implement non-pharmacological
interventions when pain is relatively well
controlled with pharmacological interventions.
(Rationale: non-pharmacological interventions
should be used to supplement, not replace,
pharmacological interventions Independent S/E)
(Ackley and Ladwig pg 609)
Reinforce the importance of taking pain
medications to keep pain under control.
(Rationale: teaching clients to stay on top of
their pain and prevent it from getting out of
control improves the ability to accomplish the
goals of recovery. Independent S/E) (Ackley and
Ladwig pg. 610)
Assess client for symptoms of general weakness,
arm paralysis, and fatigue for planning methods.
(Rationale: General weakness, arm paralysis
and fatigue were reported to be main causes of
being unable to dress oneself. Independent W)
(Ackley and Ladwig pg. 702)
Provide privacy and limit the number of people
in the room. (Rationale: Privacy conveys respect
and increases dressing ability. Independent WC)
(Ackley and Ladwig pg 703)
Select clothing in larger sizes, wide sleeves t-
shirts, or shirts that open in the front. (Rationale:
Simplifying dressing tasks increases self care
and safety, while decreasing exertion.
Independent WC) (Ackley and Ladwig pg. 703)
Teach client to dress affected side first, then the
unaffected side. (Rationale: Dressing the
affected side first allows for easier manipulation
of clothing Independent S/E) (Ackley and
Ladwig pg. 704)
Teach the simplest in a task until mastered, and
then proceed to more complicated steps.
(Rationale: Simplifying dressing and grooming
tasks that consist of many small steps promotes
mastery. Independent S/.E) (Ackley and Ladwig
pg. 705 )

Use careful aseptic technique when caring for

wounds. (Rationale: client safety when
performing aseptic technique is of the highest
importance. Independent WC) (Ackley and
Ladwig pg 497)
Provide client with a complete balanced
therapeutic diet after the immediately
postoperative period. (Rationale: Improvement
in nutritional status can improve outcome of
postoperative period. Independent PC) (Ackley
and Ladwig pg 497)
Observe and report signs of infection such as
redness, warmth, discharge and increase in body
temp. (Rationale: Prospective surveillance study
for nosocomial infection on hematology-
oncology units should include fever of unknown
origin as the single most common and clinically
important entity. Independent WC) (Ackley and
Ladwig pg. 498)
Assess for skin color, moisture, texture and
turgor. (Rationale: The skin is the body’s first
line of defense in protecting the body from
infection. Independent WC) (Ackley and Ladwig
pg 498)
Encourage fluid intake. (Rationale: Fluid intake
helps thin secretions and replaces fluid lost
during surgery. Independent WC) (Ackley and
Ladwig pg 498)
Teach the client risk factors contributing to
surgical wound infection, smoking. (Rationale:
These are some of the factors associated with
risk of surgical wound infection. Independent
S/E) (Ackley and Ladwig pg 499)
Teach the client and family the symptoms of
infection that should be promptly reported to a
primary medical caregiver. (Rationale: two
thirds of wound infections occur after discharge.
Independent S/E) (Ackley and Ladwig, pg 450)
 Discharge Planning-.5
Area of Concern Discharge Preparation Needed
A Instruct Pt to: Do not sign any legal papers or make any legal decisions for 24hrs after surgery.
Activity: Rest the day of surgery. Place a pillow under your elbow: no pillow under your shoulder. Sleep in
a semi-upright position in a recliner or propped up by pillows may also be helpful. Exercises:
Perform early postop exercises as instructed by Dr. Burra. (Remove the strap of sling and
perform range of motion exercises, gently of the elbow and straightening of the elbow, every
hour that pt is awake. After performing exercises, place arm back in the sling and put the sling
straps back on. Pt. may shower after 48hourse. Do not run water directly on the wound. After the
shower remove the band aids, gently dad portal sires dry and apply fresh band aids. Do not
submerge the shoulder in a pool (bathtub, hot tub etc.)Until the suture site has completely healed
and stitches have been removed. Driving should be avoided and pt is not allowed to drive while
wearing the sling, under the influence of pain medication, or when there is lack of sufficient
strength to meet the requirements of driving a motor vehicle. Pt is advised against driving until
further evaluation by Dr. Burra.
M
Medication: No NSAIDS for risk of bleeding. (No Advil/No Aleve)
Norco:1-2 325mg/10mg tabs PO PRN

E Pt. will be going home.any hazards at home need to be addressed, any loss of limb use
Environment: predisposes to fall risk.—sleeping arrangements, task reassignment, etc

T Sling/Brace: The day of the surgery the arm will be placed in a sling/brace for comfort and
Treatment protection. The sling/brace includes a waistband should be worn at all times, especially in bed. It
may be intermittently removed, to shower, dress, and perform exercises.
A cryotherapy (cooling) device or conventional ice pack will provide cold therapy to the shoulder
and reduce pain and swelling. Use the cryotherapy 20min every hour on the first and second
postoperative days. After that, the device may be used about 4-8 sessions per day, 20 min each.
Additional instructions on the use of the device will be provided by Dr. Burra and the physical
therapist. Do not place the cooling pad of the cyrotherapy device or the ice packs directly on the
skin. Please use a barrier between the skin and the cooling device/ice packs.
H
Health Teaching Dressings: remove outer dressings 36-48 hours after surgery. Leave in place any small adhesive
Steri-strips or sutures that are directly on the incision. Apply Band Aids to the portal sites.
Replace the Band aids every 24hrs and after a shower. Do not use bacitracin or any other
ointments, extra dressing materials, sterile gauze and tape can be found at most pharmacy/drug
stores.
Normal Symptoms and findings after surgery: Shoulder pain and warmth is normal, bloody
drainage and limited areas of numbness may be present around the incision, bruising and
swelling distal to the shoulder may occur, low temperature (less 101.5 degrees F) is common
after surgery, deep breathing exercises may be helpful.
Notify Dr. Burra if: you develop fever greater than 101.5 degrees F, chills or night sweats, the
wound turns red and drainage increases, the pain is not tolerable despite the use medication, if
you develop numbness of tingling.
O
Outpatient Referral An appointment should have been scheduled with physical therapy for the first day after surgery.
Be certain that pt. brings a copy of specific physical therapy prescription to your first
appointment. If the therapist is unsure of the protocol to be followed please have him contact Dr.
Burra for appropriate instructions.
Please return to Dr office in 10-14 days to have sutures removed. To call and make an
D
Diet Do not drink anything alcoholic for at least 24hrs after surgery. Gradually increase diet from soft
foods to a regular diet as tolerated. In case of nausea avoid solid foods take only clear liquids as
tolerated if persistent nausea or vomiting please contact your physician. FYI-an increase in
calories aids in healing; malnourishment is a major cause for delayed surgical healing.