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RNSG 1260 Level 2 Homework Template Student Name: Danielle Honea Date of Care: 7/13 & 7/14 Patients

Diagnosis: Total R knee replacement Day of Admission: 7/12 Post-operative Day: 7/13 Age: 61

Brief Description of Hospital Stay: 61 yowf admitted for a total R knee arthroplasty (7/12). History of RA, which appears to be genetic as her mother and sister, has RA. Medical procedures include seven joint fusions (last one 2003). Patients sister and patients daughter at bedside at all times. Patient resides in San Marcos with her daughter and daughters husband. Appears to have plenty of support during recovery. Very pleasant, smiling and cooperative. Responds appropriately, speech clear, maintains good eye contact. Very happy with the care received during current hospital stay. Also appears to be highly motivated to participate in her recovery. As well, as understands and follows directions regarding post op care. MEDICAL DIAGNOSIS DISEASE NAME: Rheumatoid arthritis (RA) PATHOPHYSIOLOGY RA is a chronic inflammatory autoimmune disorder. Unlike osteoarthritis that results from wear and tear associated with aging, RA affects the lining of the joint. Eventually, swelling results in bone erosion and joint deformity. RA occurs when your immune system mistakenly attacks your own body's tissues. In addition to causing joint problems, RA can also affect your whole body with fevers and fatigue. RA occurs when your immune system attacks the synovium, the lining of the membranes that surround your joints. The inflammation thickens the synovium, eventually invading and destroying the cartilage and bone within the joint. The tendons and ligaments that hold the joint together weaken and stretch. Gradually, the joint loses its shape and alignment. RISK FACTORS

Women more likely to develop rheumatoid arthritis than men are. Occurs at any age, but it most commonly begins between the ages of 40 and 60. If a member of your family has rheumatoid arthritis, you may have an increased risk of the disease. (Doctors do not believe you can directly inherit rheumatoid arthritis. Instead, it is believed that you can inherit a predisposition to rheumatoid arthritis). Smoking cigarettes increases your risk of rheumatoid arthritis. (Quitting can reduce your risk).

CLINICAL MANIFESTATION Signs and symptoms may vary in severity and may even come and go. A period of increased disease activity called flare-ups or flares alternate with periods of relative remission, during which the swelling, pain, difficulty sleeping, and weakness fade or disappear. Joint pain

Joint swelling Joints that are tender to the touch Red and puffy hands Firm bumps of tissue under the skin on your arms (rheumatoid nodules) Fatigue Morning stiffness that may last for hours Fever Weight loss

DIAGNOSTIC STUDIES No single test or physical finding confirms the diagnosis of RA. It can be difficult to diagnose in its early stages because its early signs and symptoms mimic those of many other diseases. Initial diagnostic study: H & P, followed by lab and blood work. Elevated erythrocyte sedimentation rate (indicates the presence of an inflammatory process in the body). RA factor and anti-cyclic citrullinated peptide (anti-CCP) antibodies on blood work. TREATMENTS There is no cure for RA. Medications (NSAIDs, Steroids, Immunosuppressants) can reduce inflammation in your joints in order to relieve pain, and prevent or slow joint damage. Occupational and physical therapy can teach you how to protect your joints. If your joints are severely damaged by RA, surgery may be necessary. Surgery may help restore joint mobility. It can also reduce pain and correct deformities. RA surgery may involve one or more of the following procedures:

Total joint replacement (arthroplasty): Removal of the damaged parts of the joint and prosthesis made of metal and plastic is inserted. Tendon repair: Repair of loosened tendons around the joint. Removal of the joint lining (synovectomy): Lining around your joint (synovium) is inflamed and causing pain, surgery may be performed to remove the lining of the joint. Joint fusion (arthrodesis): Surgically fusing a joint to stabilize or realign a joint and for pain relief when a joint replacement is not an option.


Use assistive devices to minimize joint stress during ADLs. Verbalize a plan to reduce responsibilities for home maintenance. Express a willingness to plan rest breaks during the day. Demonstrate understanding of the prescribed therapeutic regimen and its importance for both short- and long-term benefit.

Please underline all information that pertains to your patient.

MEDICATIONS DRUG NAME AND DOSAGE CLASSIFICATION ACTION Ciprofloxin / Cipro 100 mg q 12 Anti-infective-broad spectrum antibiotic Interferes with conversion of intermediate weight DNA in bacteria; DNA gyrase inhibitor


MY PATIENT IS TAKING THIS FOR: Urinary tract infection (clean catch urine specimen 7/13, initial dose 7/14) WHAT I NEED TO KNOW BEFORE GIVING: Do Not confuse Cipro with Cephalexin Seizures Pseudomembranous colitis Bone marrow depression Tendon rupture Steven Johnsons Syndrome Monitor WBC Record I &O



Give 2 hours before or 6 hours after antacids, zinc, calcium or iron


Protonix/ Pantoprazole 40mg SID Proton Pump Inhibitor Suppresses gastric secretion by inhibiting hydrogen/potassium ATPase enzyme in gastric parietal cell; gastric pump inhibitor since it blocks final step of acid production MY PATIENT IS TAKING THIS FOR: Prevention of gastric reflux post-op WHAT I NEED TO KNOW BEFORE GIVING: Decrease absorption with Vit. B12 Increase bleeding with Warfarin Headache Diarrhea Abdominal pain Rash Assess Vit. B12 deficiency in those on long term therapy Teach patient to report severe diarrhea Assess bowel sounds


DRUG NAME AND DOSAGE Niferex-150 100 mg PO BID (Ferrous sulfate 150mg/Vit. B12 25mcg/folic acid 1mg) CLASSIFICATION ACTION INDICATION Iron Supplement Essential nutrient, component of heme & nonheme iron proteins MY PATIENT IS TAKING THIS FOR: Iron deficiency WHAT I NEED TO KNOW BEFORE GIVING: Give either 2 hrs. before or 6 hr. after antibiotics or antacids Nausea Vomiting Constipation Dark stools Diarrhea



For max absorption, give on an empty stomach


DRUG NAME AND DOSAGE Docusate sodium/Colace 100 mg PO BID CLASSIFICATION ACTION Laxative, emollient; stool softener Facilitates mixture of stool fat and water


MY PATIENT IS TAKING THIS FOR: Prevention of constipation post-op WHAT I NEED TO KNOW BEFORE GIVING: Avoid mineral oil use Abdominal cramps Rash Electrolyte d/o Assess for bowel sounds Assess for abdominal cramping Asses for diarrhea


DRUG NAME AND DOSAGE Celebrex 100 mg PO BID CLASSIFICATION ACTION INDICATION NSAID; anti-rheumatic Selectively inhibits cyclooxygenase-2 and reduces prostaglandin synthesis (COX-2 inhibitor) MY PATIENT IS TAKING THIS FOR: Musculoskeletal pain WHAT I NEED TO KNOW BEFORE GIVING: Do Not confuse with Celexa; Cerebra; Cerebyx; Clarinex
GI bleed MI HTN CHF Stevens-Johnson syndrome anemia insomnia


rash flatulence peripheral edema


CBC, chemistry profile if long-term tx Cr if severe renal diagnosis coagulation tests if systemic onset JIA BP

DRUG NAME AND DOSAGE Neurontin/gabapentin CLASSIFICATION ACTION INDICATION Seizure Disorders; Other Neurologics Exact mechanism of action unknown MY PATIENT IS TAKING THIS FOR: Neuropathic pain WHAT I NEED TO KNOW BEFORE GIVING: Avoid/use of ginkgo biloba
dyskinesia depression suicidality dizziness somnolence ataxia fatigue peripheral edema nystagmus nausea/vomiting Cr at baseline s/sx depression, behavior changes, suicidality



DRUG NAME AND DOSAGE trazodone CLASSIFICATION ACTION INDICATION Other antidepressants; Insomnia exact mechanism of action unknown; inhibits serotonin reuptake, antagonizes alpha-1 adrenergic and serotonin 5HT2A/C receptors MY PATIENT IS TAKING THIS FOR: Difficulty falling asleep and remaining asleep

WHAT I NEED TO KNOW BEFORE GIVING: Do Not confuse with tramadol;terazosin;Thorazine SIDE EFFECTS (LIST MAJOR SIDE EFFECTS.) NURSING CONSIDERATIONS serotonin syndrome hypotension, orthostatic syncope HTN MI neuroleptic malignant syndrome SIADH hyponatremia sx suicidality, clinical worsening, and/or unusual behavior changes, especially during initial tx or after dose changes monitor WBC, if count falls below normal d/c trazadone

Lab Results Norm Lab Day 1 Day 2 (7/13 (7/14) ) 9.8 9.0 Analysis

4.511.0 4.66.2 14.018.0


WNL Included in CBC panel, which provides an overall indication of current health status. Performed routinely as part of general exam and upon hospital admission prior to surgery.

3.17 3.14 9.8 9.7

40-54 HCT

29.7 29.2

Decreased: anemia nutritional deficit Nursing Intervention: assess dietary intake administer isotonic fluids monitor for signs of bleeding WNL WNL WNL WNL WNL

150450 55-70 135145 9-11

PLTs Neutr Na+


274 65.9

135 4.6 102


3.5-5.0 K+ 70-120 Glu

Ca++ 8.4 93


10-30 95105 >2.5 200900


18 1.2 104 105

WNL WNL (high end of normal) Increased levels of blood chloride (called hyperchloremia) usually indicate dehydration Measured with Vitamin B12 levels, assists in determining megaloblastic anemia increased in vitamin B12 deficiency or pernicious anemia dietary deficiency Nursing Interventions instruct pt. to include foods such as meat, eggs, grains, veggies, fish, chicken and milk, which are high in iron and vitamin B12 as well as include multi-vitamin containing iron

0.5-1.4 Creat

Folate 7.6 Vit. B 309 12

NURSING DIAGNOSES -Write down TOP 3 Nursing Diagnoses FOR YOUR PATIENT NURSING DIAGNOSIS RELATED TO AS EVIDENCED BY (YOU WILL NOT FILL OUT THIS COLUMN IF YOUR NURSING DIAGNOSIS IS A RISK FOR. Increase in BP 160/93 Reports of difficulty ambulating Pt.s verbal report, pain scale rating 8 (0-10)

Acute pain Impaired physical mobility Activity intolerance

Tissue disruption s/t total R knee arthroplasty Limited ROM, s/t surgical procedure Post-op pain

Nursing Care Plan Nursing Diagnosis and Support data Acute pain: knee r/t disruption of skin integrity, s/t total R knee replacement Goal 1. Patient will verbalize adequate relief of pain AEB pain scale rating of a 3 to 4 prior to end of shift, 1300. Interventions 1. Assess pain level using a valid and reliable selfreport tool, such as 0-10 numerical pain rating scale. 2. Assess for s/s of pain (verbalization of pain, grimacing, diaphoresis, increase in BP, tachycardia) Scientific Rationale 1. First step in pain assessment is to determine if pt. can provide a self-report. Evaluation 1. Patient used pain scale rating correctly to provide self -report of pain level.

Support data:

Increased BP 160/93 7/14 0300 Pt.s verbal report of 8 on pain scale, 0-10 Expressive behaviors such as moaning when ambulating

2. Early recognition of stages and symptoms of pain allow prompt intervention and improved pain control.

2. Patient moaned in discomfort when rising to use bedside commode and reported pain-rating 7.

2. Patient will report that pain management regimen relieves pain to satisfactory level with acceptable and manageable side effects by discharge, day 3 postop (7/15).

3. Administer supplemental opioid doses as ordered to keep the client's pain level at or below the comfortfunction goal.

3. An order for prn supplementary opioid doses between regular doses is an essential backup.

3. Norco 10/325, 2 tablets PO administered 0700 & 1100 (7/14), q 4h as ordered.

4. Research shows the


4. Assess & evaluate patient's response to pain & effectiveness of medication, (1 hour after administration) at frequent intervals.

Outcome: 1. Goal Met Patient reported a pain rating of a 4 and expressed increase in comfort prior to end of shift. 2. Goal Met No c/o medication side effects Reported satisfaction in management and pain relief; incorporating PRN Norco 10/325 q 4h, as ordered helps manage pain immensely, prior to d/c (7/15). 5. Provide rest periods to facilitate comfort, sleep, and relaxation.

most common reason for unrelieved pain is failure to assess pain relief frequently (some will tolerate slight pain if not asked). In addition, monitoring pain relief displays genuine concern and helps build trust for a therapeutic relationship. 5. The patient's experiences of pain may become exaggerated as the result of fatigue.

4. Reassessed 1 hour following PRN medication (Norco 10/325) administration: patient reported pain scale rating 4.

5. Room darkened and door shut allowing patient periods of rest and relaxation throughout shift.

6. Apply cold gel pack (cryotherapy) first 72 hr and as necessary.

6. Cold reduces pain, inflammation, and muscle spasticity by decreasing the release of paininducing chemicals and slowing the conduction of pain impulses. 7. Therapeutic management of pain relief can be modified to promote more satisfactory comfort levels.

6. Frozen gel pack applied to R knee as needed (thawed) throughout shift.

7. Instruct patient to evaluate and report effectiveness of measures used.

7. Instructed patient to evaluate and report effectiveness of pain management; modification may be necessary.