Mr.John Wright is a 78 year old

Mr.John Wright is a 78 year old male, married, presents with chief complaints of right knee pain to right knee, radiating to right leg rating pain level 10/10″ on the numeric scale 0 – 10. report right knee and feet feel ” very heavy and numb, drowsy with frequent wave of nausea” . client reports a job that requires long periods of standing. Client is currently admitted with a medical diagnosis of right Total Knee Arthropl;asty. On this admission, client reports medical h/o HTN, CAD, Obesity, DM, chronic osteoarthritis, Hyperlipidemia (HLD), client denies elicit drugs, alcohol, and tobacco used Client Denies Claudication and paresthesia symptoms at the affected site. Pre OP Medication: Regional anesthesia, and and Epideral Current medications: Atenolol 25 mg 1 tab oral two time (BID) Heparin injectable 5,000 unit subcutaneous every 12 hours (q12 hours) Metformin 500 mg 1 Tab oral twice a day (BID) Pantoprazole 40 milligrams 1 tablet oral every day (OD) Simvastatin 10 my 1 tab oral daily at bedtime (OD at HS) Gabapentin 300 mg 1 Tab oral two times a day (BID) Cyclobenzaprine 10 mg 1 tab Two times a day (BID) Meds PRN Acetaminophen 325 mg 2 tabs oral every 6 hours as PRN (needed )(1 – 3) Morphine injectable 1 mg IVP every 6 hours PRN (as needed) (7 – 10) Oxycodone 5mg 1 tab oral every 4 hours PRN (as needed) 4 – 6. Physical assessment findings: Mr. JW appears anxious, CP: Denies any SOB C/o Nausea, vomiting, and headache, muscle weakness Color WNL for ethnicity Vital signs (V/S) B/P 130/80, HR. 90, R. 22. oxygen oxymetry: 96% ABG: PC02 40, PAO2 96%, PH 7.38 Weight: 168 Lbs, height: 5.4 Labs: On admission Peak Flow Rate (PFR) 80% which indicates WNL. Lungs clear on auscultation Right Knee CBC: Hemoglobin 14 and Hematocrit 45 (H/H) 16/49, WBC: 6,000. Review of system information (ROS): Neurological: Alert and oriented to time, place, and person. Good historian Respiratory: No adventious sounds Breath sounds: inspiratoty = expiratory, and on auscultation Adventitious sounds: None findings bilaterally Cardiovascular: Heart rate 90 strong and regular Jugular venous distention: Negative on assessment Peripheral edema 2 + Elimination Pattern Gastro intestinal (GI): Abdominal soft. Mildly distended Bowel sounds present in all four quadrants Bowel habits: Consistent. Last BM: 9/22/2022: Stools characteristics: Firm Genitourinary (GU): 18 French Catheter connected to Foley bag at bedside drining clear amber urine. No clot or sedimentation noted in the foley bag. Mobility: Mobile with unsteady gait Integumentary (skin): Dry, warm, and intact Incision: Right knee incision with surgical aquacel dressing intact Keep initial DSD in place to change by surgeon Skin color: WNL for etchnicity Diet: NPO IV Fluids Ringer Lactate at 75cc/hour Image transcription text ACTIVE LEARNING TEMPLATE: System Disorder STUDENT NAME DISORDER/DISEASE PROCESS REVIEW MODULE CHAPTER Alterations in Pathophysiology Related Health Promotion and Health (Diagnosis) to Cli… Show more

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