Published Jul 6, 2011
Mtaraj
2 Posts
Please help,
I am new on this site and nursing field. I have a case study which requires three nursing diagnosis one goal for each of them and three interventions.
I thought one of them would be acute pain r/t surgery aeb pt stating stabbing pain, 7/10 c ambulation &repositioning.
Anyway the following is the case. Please help
72 year ol male
Admiting Dx: DJD (degenerative joint disease) L knee; TKR (total knee replacement)
MD Orders: VS q 4 hrs; BR; up c PT; CPM(continuous, passive motion) Except during sleep @noc
Bilateral SCD (sequential compression device ) Bilateral antiemboltic stockings (TEDs)
Regular Diet
Dressing change L Knee: clena w/ betadine;apply DSD
Bactrim DS po BID
Demerol 75 mg IM q 4h prn pain
Vistaril 50 mg IM q4h prn (give c Demerol)
Nursing Assessment: A&O *2 , hand grips equal &strong; Leg Pushes: weak L, strong R
B/P 140/82; apical pulse 82®ular; Homan's negative bilaterally ; BLE pulses present
Lungs clear to auscultation; RR 22&unlabored
Bowel sounds + *4 quads; LBM Today; 75% of meals
Voiding qs clear, amber urine via urinal
L Knee incision c staple intact well approximated, serosanguineous drainage; minimal redness, edema noted; c/o stabbing pain, 7/10 c ambulation &repositioning