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Mr. Joseph Lawrence (J.L.) is a 74-year-old Caucasian English-speaking male. He currently resides in a small rural community where he has lived with his family for over 50 years. Client’s date of birth is February 2, 1947. He was born just outside the rural community in southern Illinois that he currently lives, and his ethnic roots go back “a few” generations to family that emigrated to the U.S. from Ireland. â–º J.L has been married to the “love of his life” for 52 years, Mrs. Mary Ellen Lawrence. Together they had two children, Justin, who is 48; and Colleen, who is 46; and four grandchildren, Rebecca (24), Thomas (22), Carleen (12) and Andrew (25). Although they consider themselves a “tight knit” family, Justin lives in California, and Colleen resides in Arizona along with their spouses and children. They can visit approximately twice per year. Mrs. Lawrence was diagnosed with Alzheimer Disease approximately 2 years ago, and Joseph has now become her primary caregiver as her health is declining. â–º J.L. has a high school diploma and worked as a local business owner in a sporting goods store until his retirement 9 years ago. He currently has Medicare with a supplemental policy. He is a reliable source. He describes his general health as “not bad for a man my age with arthritis, diabetes and heart disease, I keep up with the best of them.” â–º J.L.’s past medical history includes a history of osteoarthritis, diabetes mellitus type II, coronary artery disease, and coronary artery bypass surgery 9 years ago (his only previous hospitalization). He is up to date on his immunizations (Influenza, pneumococcal, shingles, and T-dap). He is allergic to penicillin: he stated he had it as a child and developed a severe rash. His current medications are Ibuprofen two tabs every 4 hours as needed for joint pain, Metformin 500 mg two tabs daily for diabetes, Metoprolol succinate extended-release tablet 200 mg daily for heart disease/hypertension, and one multivitamin daily. He states that currently he is 5″11″ and weighs 190 lbs. â–º J.L. has no “regularly scheduled” exercise, however during a typical day he walks up and down the stairs about 3 times daily and takes short walks in the driveway while caring for his wife, who currently cannot be left alone. He feels he sleeps approximately 4-5 hours per night, as he is up frequently caring for his wife. â–º The 24-hour diet recall includes the following: A piece of toast and bran cereal for breakfast, a turkey and salami sandwich with American cheese for lunch, and a Stouffer’s frozen meatloaf with mashed potatoes and carrots for dinner, with 2 chocolate chip cookies for dessert. He reports moving his bowels daily, with occasional difficulty in starting a stream and frequent urination. He drinks 2-3 cups of caffeinated coffee during the day with generally one more cup with dinner. The only alcohol he reports consuming is one glass of wine daily prior to bed. He denies taking any street drugs or un-prescribed medications, smoked 1 pack of cigarettes per day for 35 years, which he was successful at quitting approximately 10 years ago. â–º J.L. reports feeling safe in the neighborhood he has lived in for many years, and reports adequate heat, electricity, and water in the home. He currently drives, with the nearest store 6 miles away, which he generally visits twice per month to “store up on frozen and canned goods.” He reports his wife was a great cook, and they enjoyed making traditional “Irish meals of meat, potatoes, bacon and vegetables such as cabbage, carrots and celery” for many years prior to her diagnosis. â–º He is in Erik Erikson’s state of “Ego Integrity vs. Despair.” His collaborative resources include friends in the community, family (by phone or FaceTime), connections with the local parish with home visitations from the priest of the parish and a close relationship with his primary healthcare provider and nursing staff. The nurse gives a full report to the healthcare provider who completes the physical examination, renews the client’s prescriptions, and orders yearly bloodwork and health promotion screenings appropriate to the client. Phase II: ER Visit Case Study â–º J.L. presents to the Emergency Department late in the afternoon stating, “I have extreme pain in my right knee.” He reports that he “slipped and fell directly on my right knee” in the bathroom yesterday while giving his wife a shower, and he has used a cane that he borrowed from his neighbor to help him get around since the fall. He is anxious to be discharged; however, he is looking for relief of the pain in his knee. While waiting for further imaging, the nurse gathers the following data: â–º Vital Signs: T 98.6 (tympanic), P 92 (regular), R 22 (unlabored), BP 148/92, SpO2 97% on RA â–º Client history includes progressive osteoarthritis in the right knee, with client having previously seen an orthopedic physician who recommended total knee replacement (knee arthroplasty). J.L. is discharged from the Emergency Department with instructions to follow up with the orthopedic surgeon. Phase III: First Day Postoperative Following Total Knee Replacement Surgery â–º J.L. was readmitted to the hospital two weeks following the ER Visit for total knee replacement surgery. As family were unavailable to come care for the client’s wife, a caregiver was hired full time for the extent of the client’s hospitalization. â–º Postoperative Day #1 Assessment: Client is alert and oriented x 4. He reports pain of 6/10 described as “sharp” and “in the right knee.” Vital signs: T 99.2 (tympanic), P 94 (regular, 2+), R 20 (shallow and unlabored), SpO2 96% on 2L/NC. He has a heparin lock in place to his left forearm. Skin is warm and dry, tenting skin turgor, mucous membranes pink and dry, no areas of skin breakdown noted, dressing to right knee dry and intact with immobilizer splint in place. â–º Patient c/o nausea after taking a small amount of lunch (soft diet) and had a 125 mL emesis. â–º Lungs are clear anteriorly, crackles noted posteriorly in upper lobes, however they clear with cough. Incentive spirometer is in use, with an order to repeat 10 times every hour. Apical heart rate is 94 bpm and regular. Capillary refill < 3 seconds. 1+ pitting edema is noted to right lower extremity. Patient denies pain on passive movement, skin pink, pulse 2+, denies numbness or tingling, skin warm, moves right lower extremity freely. SCD device in use when client in bed. No redness, warmth, or swelling of calf bilaterally. â–º Abdomen is distended with hypoactive bowel sounds throughout, last BM was 2 days prior to admission. â–º Client is anxious stating "I need to get home to my wife." â–º Patient is using a urinal to void, with output for the last 4 hours as follows: 1600 - 1700 ​125 mL​​​1800 - 1900 ​90 mL 1700 - 1800​100 mL​​​1900 - 2000​50 mL With this scenario, there are three questions I need answered. 2. Identify assessment data related to J.L.'s assessment that may indicate dehydration. 3. Is Mr. J.L. at risk for impaired urinary elimination? Why or why not? 4. What is the normal urine output for an adult client for 24 hours? SCIENCE HEALTH SCIENCE NURSING NURSING NR 302

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