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    2care Plan n360

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    This patient recently underwent a right total hip replacement surgery and is experiencing pain at the surgical incision site, lower back, and right groin. Additional problems include bleeding from the incision, nausea from pain medications, fever, and impaired mobility. The patient requires assistance with activities of daily living, uses an incentive spirometer and breathing treatments for a history of respiratory issues, and needs education on post-operative hip precautions and care.

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    2care Plan n360

    Uploaded by

    api-302732994
    130 views1 page
    This patient recently underwent a right total hip replacement surgery and is experiencing pain at the surgical incision site, lower back, and right groin. Additional problems include bleeding from the incision, nausea from pain medications, fever, and impaired mobility. The patient requires assistance with activities of daily living, uses an incentive spirometer and breathing treatments for a history of respiratory issues, and needs education on post-operative hip precautions and care.

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    2care plan n360

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    This patient recently underwent a right total hip replacement surgery and is experiencing pain at the surgical incision site, lower back, and right groin. Additional problems include bleeding from the incision, nausea from pain medications, fever, and impaired mobility. The patient requires assistance with activities of daily living, uses an incentive spirometer and breathing treatments for a history of respiratory issues, and needs education on post-operative hip precautions and care.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    130 views1 page

    2care Plan n360

    Uploaded by

    api-302732994
    This patient recently underwent a right total hip replacement surgery and is experiencing pain at the surgical incision site, lower back, and right groin. Additional problems include bleeding from the incision, nausea from pain medications, fever, and impaired mobility. The patient requires assistance with activities of daily living, uses an incentive spirometer and breathing treatments for a history of respiratory issues, and needs education on post-operative hip precautions and care.

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    1.

    Pain
    Right Hip surgical incision
    Osteoarthritis
    Hx of Rheumatoid Arthritis
    Hx of Systemic Lupus Erythematous
    Hx Fibromyalgia
    lower back
    Right groin
    Right hip with touch
    Percocet
    Ice packs
    Reposition
    Pelvis X-ray

    8. Self Care Deficit


    Right Hip Surgery
    Surgical incision pain
    Lower back and groin pain
    Minimal assist needed with ADLs

    7. Ineffective Airway Clearance


    Hx Bronchiectasis
    Hx Reactive Airway Disease
    Hx GERD
    Incentive spirometer
    Advair
    Ventolin HFA
    Pepcid

    2. Bleeding
    Right Hip surgical incision drainage
    Hx Anemia
    RBC 2.81 L
    Hemoglobin 8.6 L
    Hematocrit 25.4 L
    Platelet 132 L
    2 PRBC Blood transfusion
    Estimated Blood Loss during surgery
    Hemovac

    Chief Medical Diagnosis:


    Right Hip Osteoarthritis
    Post op
    Right Total Hip Replacement
    Priority Assessments: Surgical site
    (CMS, DVT, infection & bleeding),
    pain, vitals (fever, hypovolemia,
    tachycardia), respiratory
    (pneumonia, atelectasis), mobility
    and assessment with ADLs.

    6. Knowledge Deficit
    Right Hip Surgery
    Total Hip Precautions
    Proper positioning
    Proper movement
    Activity Restriction
    S/Sx of surgical site infection

    3. Nausea
    Due to Percocet
    Zofran
    Rest

    4. Fever
    Temp 37.7C and 37.5 C
    Incentive spirometer
    Deep breath and cough
    Ice pack
    Acetaminophen

    5. Impaired Physical Mobility


    Right Hip surgery/ surgical incision
    Osteoarthritis
    Hx Rheumatoid arthritis
    Hx Systemic Lupus Erythematous
    Hx Herniated disc (5-7)
    Hx Fibromyalgia
    Fall precautions
    Use of front wheel walker
    Partial weight bearing right leg
    OOB with assistance
    Pain
    Hydrochloroquine
    Cholecalciferol
    Flexeril
    PT/OT
    ROM

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