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Patient Name: F  K

Date of Birth: 09/25/1933

History/Information:

An older widowed female adult was brought into the Emergency Care Center (ECC) after slipping and falling at the grocery store. She underwent a total right hip replacement two days ago. The client lives alone in a two-story house with her dog, Renny, which she adores. Her medical history includes: Congestive Heart Failure (CHF) and Hypertension (HTN). Three months ago she was diagnosed with Atrial Fibrillation and began Warfarin (Coumadin). Her INR is checked every 2 weeks. She has Cataracts and is Hard of Hearing (HOH) but unable to purchase any hearing devices due to the cost. Ms. Knight is on her second post-operative day.

Healthcare Provider’s Orders:

Low Sodium Diet as tolerated

IV D5 0.45% Sodium Chloride with 20 meq Potassium Chloride (KCL) at 75 ml/hour

Up with assist

Physical therapy for hip rehabilitation

Abduction pillow

Sequential Compression Device (SCD)                                                               

Change surgical dressing once a day

Foley catheter to continuous drainage. Discontinue Foley catheter on second post-operative day

Vital Signs and O2 Saturation every 4 hours

Intake and Output every shift

Incentive Spirometer x 10 every 1 hour while awake

INR/PT daily and call healthcare provider with results

Digoxin (Lanoxin) 0.125 mg po once a day at 1400

Metoprolol Tartrate (Toprol) 12.5 mg PO twice a day

Enoxaparin (Lovenox) 40 mg SQ every 12 hours

Warfarin (Coumadin) 2 mg PO once a day at 1800

Hydrocodone 5 mg/Acetaminophen 500 mg 1 tab PO every 6 hours prn pain for a pain level less than 6

Hydromorphone Hydrochloride (Dilaudid) 0.5 mg PO every 6 hours prn pain for a pain level greater than 6

Laboratory Tests

Laboratory Results

Normal Value Range

White Blood Cell (WBC)

7,500 /mm3

Hemoglobin (Hgb)

9 gm/dl

Hematocrit (Hct)

32%

Platelet Count

198,000/cu mm

International Normalized Ratio (INR)

2.9

Prothrombin (PT)

17 seconds

Sodium (Na+)

140 mEq/L

Potassium (K+)

4.0 mEq/L

Creatinine (Cr)

1.1 mg/dL

Blood Urea Nitrogen (BUN)

21 mg/100 ml

Glucose

118 mg/dL

  1. Performs a basic physical assessment of the client (APPLICATION).
  2. Do Nursing Care Plan
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