TARRANT COUNTY COLLEGE DAILY CARE PLAN

CLINICAL FOUNDATIONS FOR NURSING PRACTICE

Student Name: FAYE BARRERAS
Date of Care: 11/17/2011
Patient Initials: D.C.

Rm#: 703-A

Ht.: 51

__

Allergies: PROMETHAZINE HCL RASH, RANITHAZINE HCL HIVES, CIMETIDINE HCL

Wt.: 106 lbs DIARRHEA, SULFANAMIDE RASH, DIAZEPAM RASH, SULFAMETHOXAZOLE RASH,
TRIMETHOPRIM RASH, CIMETIDINE DIARRHEA

Adm. Date: 11/15/2011

Age: 85 Y/O

Gender:
Female

Admitting Diagnosis:

Osteoarthritis Right Hip

Relevant Health History:

Hypothyroid- 1987, TAH/BSO- 1979, GERD, Anxiety, Depression,

Osteoporosis,

Diet: PO/ REGULAR

Activity: UP WITH ASSIST, FALL RISK
Procedures/Treatments:

Check VS q4h, TCDB q2h, Sterile dressing change q shift, Check I/O q shift,
IV L hand
20 G NS 100 ml/hr, Monitor for S/S of DVT, Neurovascular check right foot
q2h

Laparoscopic Sigmoid Resection- 2009, Lap Chole- 1997, General Arthritis,

Difficulty

Swallowing, Constipation, Smoker-1963 (1PPD x 12years) Pneumonia (2010)

Left Kidney Removal
Peg tube placement and Removal
Current
Surgery/Date/Type:

Right total Hip Replacement Level4 11-15-11

Expected Signs and Symptoms for Medical
Diagnosis/Surgery:
Altered lab values (WBC, RBC , HBG, HCT),Fever, Headache,
Inflammation on surgery

area, Immobility, Irritability, Nausea, acute pain, Pulse increase, Respiration

increased,
Temperature increased, Weakness,

Lab:
CBC: WBC 17.4 (5.0-10.0)

PTT 22.6 (25 35)

RBC 3.06 (3.5-5.5)

PT 14.4 (11.2-14.0)

HGB 10.3 (12-16)

INR 1.4 (1-2)

HCT 30.0 (36.-48)

Maslow Needs:
Physiological Need/Pain/Discomfort/ Pain, Acute

Safety and Security/ Physiological level/ Falls, Risk for

Safety and Security/ Physiological level/ Infection, Risk for

Possible Nursing Diagnoses:

Risk for fall R/T musculoskeletal impairment secondary to age

Risk for Infection R/T surgery
Risk for Constipation R/T medication use

Define Admitting Medical DX and/or Surgery:

Hip replacement is a surgical procedure in which the hip joint is replaced by

a prosthetic
implant. total hip replacement (total hip arthroplasty) consists of replacing
both the
acetabulum and the femoral head.
Osteoarthritis right hip also known as degenerative arthritis or degenerative
joint disease,
is a group of mechanical abnormalities involving degradation of joints,
including
articular cartilage and subchondral bone of the hip area.
Report Received From:
Report Notes:

Erikson Developmental Stage for Age:

Integrity VS Despair
Erikson Developmental Stage Actual: Despair AEB her husband died and
lives by herself.