Just follow the rubric
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| Nursing Note: Client presents to surgical center, uses a cane. Last oral intake yesterday at 1900. Rates 5/10 right knee pain. 20 gauge peripheral IV to L hand. |
| VITAL SIGN TREND | ||||||
| Date | Temp | HR | RR | BP | SpO2 | O2 |
| 5/9 0610 | 97.3 °F | 98 | 18 | 156/88 | 98% | RA |
| PROVIDER PRESCRIPTIONS & NOTES | |
| 5/9 0615 | Prescriptions:
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| 5/9 0600 | Medical History: Hypertension, anemia, osteoarthritis, anxiety Surgical History: L knee arthroplasty (age 67) Home Medications:
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The use of epoetin assists with increasing red blood cells by stimulating erythropoiesis. Due to a history of anemia, this client is using epoetin to reduce the risk of needing a blood transfusion after surgery. Risks associated with epoetin therapy include clot development, so the client should monitor for deep venous thrombosis, stroke, or pulmonary embolism symptoms. Loss of coordination, along with facial drooping, may indicate stroke. In addition, Epoetin can cause an increase in blood pressure.
The nurse needs to know more information before intervening. Assessing the client’s pain will provide insight. The client cannot receive more hydromorphone yet. Lorazepam is used as an anxiolytic and will not address surgical pain. The oxycodone/acetaminophen prescription is a contraindication due to an allergy. The nurse will need to notify the provider of a need for a new prescription due to the client’s uncontrolled pain, given the record of medications that have already been administered.
Per manufacturer instructions, enoxaparin is only to be administered in the abdominal wall for best absorption. The air bubble should not be expelled due to the risk of loss of medication. In addition, ringing in the ears is a sign of ototoxicity associated with vancomycin administration and requires discontinuation of the antibiotic.
| 5/9 0600 | Medical History: Hypertension, anemia, osteoarthritis, anxiety Surgical History: L knee arthroplasty (age 67) Home Medications:
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5/9 0615Prescriptions:
Peripheral IV start
0.9% NS 1000 mL IV over 10 hours
Midazolam 5 mg (2.5 mg/mL) IV push once
Fentanyl 50 mcg (200 mcg/2 mL) IV push once
Cefazolin 2 g/50 mL D5W over 30 minutes
5/9 1300Prescriptions:
TED hose
Sequential compression devices
Vitals q4h
CBC daily
Oxygen 4L PRN for SpO2 >94%
Enoxaparin 40 mg subcutaneous injection daily x 7 days
Oxycodone/acetaminophen 5 mg/325 mg by mouth q6h PRN for moderate pain
Hydromorphone 0.5 mg IV push q4h PRN for severe pain
Lisinopril 20 mg by mouth daily
Naproxen 500 mg by mouth twice daily PRN
Lorazepam 0.25 mg by mouth PRN for anxiety
Discontinue 0.9% NS 1000 mL IV over 10 hours
0.9% NS 1000 mL IV continuous – 75 mL/hr
5/11 0825 Prescriptions:
Acetaminophen 650 mg by mouth q6h PRN fever > 100.4°F
Cefazolin 2 g/50 mL D5W IV infusion q8h - administer over 30 minutes
Vancomycin 1 g/250 mL NS IV q12h - administer over 90 minutes
MEDICATION ADMINISTRATION RECORDMedication5/09 1315Hydromorphone 1 mg IV pushRTHLisinopril 20 mg by mouthRTHNaproxen 500 mg by mouthRTHLorazepam 0.25 mg by mouthRTH0.9% NS 75 mL/hr IV continuousRTH
| Date | Lab | Normal | Result |
| 5/11 0745 | RBC | 4.2-5.9 cells/L | 3.8 L |
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| Hgb | 12-17 g/dL | 10.1 L |
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| Hct | 36-51% | 35 L |
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| WBC | 4,000 - 10,000 mm3 | 13,800 H |
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| Platelets | 150,000-350,000 mm3 | 199,000 |
| 5/9 0600 | Nursing Note: Client presents to surgical center, uses a cane. Last oral intake yesterday at 1900. Rates 5/10 right knee pain. 20 gauge peripheral IV to L hand. |
| 5/9 1240 | Situation: This is Wudnesh Beyene. She’s coming back from PACU after having a right knee arthroplasty completed. Background: She has a history of knee pain for several years. She has a complete knee replacement in the left knee already. Assessment: She has steri-strips covering the incision, a nonadherent dressing, 4x4 gauze pads, and ace wrap. We gave her 100 mcg of fentanyl in recovery, and she seems to be doing better. Recommendation: Continue to monitor her pain. She seems to get restless quickly. |
| 5/11 0800 | Neuro/Cognitive: Alert, oriented x 4. Cooperative. Obeys commands. Reports feeling chilled. Cardiovascular: +2 pedal pulses bilat. Musculoskeletal: 4/5 strength in right lower extremity, 5/5 in all other extremities. Limited active range of motion. Non pitting edema to R lower leg. Integumentary: +bruising to lower abdomen. Steri-strips intact. Small amount of dried sanguineous drainage on dressing. Peri wound area appears red. Hot to palpation. Pain: Reports 7/10 sharp, aching pain to R knee. |
| 5/11 0940 | Client Education:
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