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John Kelly is a 77-year-old male with a history of osteoarthritis, asthma, early stage dementia, and heart failure who had a right total hip arthroplasty and is post-operative day one. Since surgery he has been on path, resting comfortably and his pain has been controlled with oxycodone 5 mg PO. When the nurse enters the room to do his morning assessment, John is agitated, combative and resistive to staff. He pulled out his Foley urinary catheter, his IV catheter and removed his surgical dressing. His legs are swung over the side rails and is trying to get out of bed. John does not know where he is and oriented to self only. He insists that he is at home and yells out, “You get the hell out of my home or I am going to call the police!” His wife is visibly upset and states that she has never seen him behave like this before. With tears in her eyes she asks you, “What is happening to my husband! Please do something to help him!” Personal/Social History: John is a retired high school math teacher who lives at home with his wife and lives independently. He is active at the senior center where he attends social activities 3-4 times a week. He attends Catholic Mass every Sunday with his wife. He is a nonsmoker and has a glass of wine 2-3 times a week with dinner. What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential) RELEVANT Data from Present Problem: Clinical Significance: RELEVANT Data from Social History: Clinical Significance: Patient Care Begins: What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance) RELEVANT VS Data: Clinical Significance: Current VS: P-Q-R-S-T Pain Assessment: T: 99.1 F/37.3 C (oral) Provoking/Palliative: Pain in his right hip but unable to give details P: 102 (regular) Quality: Tenderness to palpation over incision site R: 18 (regular) Region/Radiation: Right hip BP: 155/65 Severity: Unable to verbalize due to confusion, tenderness to palpation but does not appear to be in acute discomfort based on assessment O2 sat: 95% room air Timing: Unable to verbalize Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved. What assessment data is RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion & Maintenance) RELEVANT Assessment Data: Clinical Significance: Radiology Reports: CT Head What diagnostic results are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation) RELEVANT Results: Clinical Significance: No evidence of acute infarction, intracranial hemorrhage, or masseffect seen. Lab Results: What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation) RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Current Assessment: GENERAL APPEARANCE: Agitated, attempting to climb out of bed, pulled out Foley catheter and IV catheter, is not grimacing as if he is in pain but does grimace when incision site is palpated RESP: Breath sounds clear with equal aeration bilaterally ant/post, nonlabored respiratory effort CARDIAC: Pink, warm & dry, slight edema present at incision site, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill, no diaphoresis present NEURO: Alert & oriented to person only, very agitated, unable to maintain focus when asked questions, PERRL, emotionally labile, not easily re-directed, face is symmetrical, speech is

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NURSING
NURSING MEDICAL SU

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