A nurse is assessing an older adult client who is postoperative following a right knee arthroplasty.
History and Physical
Day 1 0800:
75-year-old client who has osteoarthritis of the knees. Reports increased pain to the right knee following their daily walk of 3 miles.History of type 2 diabetes mellitus, GERD, hyperlipidemia, and hypothyroidism.No known allergies.
Nurses' Notes
Day 3 0800: Client is postoperative day three from right knee arthroplasty. Currently with operative knee in the continuous passive motion (CPM) machine but attempting to take knee out of device. States, "I've had enough of this mess. I'm going home." Client is disoriented to time and place, oriented to self. Refuses to answer simple questions, rambles incoherently when spoken to. Will not follow simple commands. Client's family is at bedside and reports the client began displaying behavior changes the prior evening. States that client was awake most of the night and was restless when they did fall asleep, appeared to be having nightmares. Attempted to get out of bed without assistance during the early morning hours.
Surgical dressing to right knee dry and intact. No sign of redness or edema around the dressing. Client refuses to answer questions about surgical pain or respond to prompts using pain scales. According to client's family, client has not received pain medication since before physical therapy yesterday afternoon and has not reported pain.
Requested client's family to please remain at the bedside and to call for any needs or if the client attempts to get out of bed without assistance.Placed call to provider to report findings. Awaiting call-back.
Graphic Record
Day 3 0800:
Heart rate 115/min
Respiratory rate 20/min
Blood pressure 90/48 mm Hg
Temperature 38.6° C (101.5° F)
Oxygen saturation 96% on room air
Weight 63.5 kg (140 lb)
Intake and Output (I&O)I = 750 mLO = 2,500 mL
Provider Prescriptions
Day 1:
Enoxaparin 30 mg subcutaneously twice daily
Levothyroxine 75 mcg PO once daily
Omeprazole 20 mg PO once daily
Pravastatin 40 mg PO once daily at bedtime
Morphine 2 to 4 mg intermittent IV bolus every 4 hr PRN pain
Hydrocodone 5 mg PO every 6 hr PRN pain
Acetaminophen 325 mg PO every 6 hr PRN pain or temperature greater than 38.3° C (101° F)
Diagnostic Results
Day 3 0800: Capillary blood glucose 92 mg/dL (82 to 115 mg/dL)
For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.
1) Melatonin
2) Apply restraints
3) Urinalysis with culture and sensitivity
4) MRI of the head
5) Insert indwelling urinary catheter
6) IV fluids
A) Anticipated
B) Nonessential
C) Contraindicated
