Osteoarthritis Diagnosis and Care Plan

Osteoarthritis Diagnosis and Care Plan Patient Initials:  JA  Unit/Room DOB:  8/17/1926 Code Status Height/Weight 6’1’’ / 126 lb Allergies:  No allergies Temp (C/F Site) Pulse (Site) Respiration Pulse Ox (O2 Sat) Blood Pressure Pain Scale 1-10 97*F 79 18 160/80 8 History of Present Illness including Admission Diagnosis and Relevant Physical Assessment Findings (normal abnormal) Relevant Diagnostic Procedures Surgeries /Results (include dates, if not found state so) The patient is suffering from general osteoarthritis, muscle weakness, abnormal of gal, spinal stenosis, chronic pain neck, benign hypertension, Alzheimer, dementia with behavior disturbance, depressive disorder NEC, and myopia. The main symptom of osteoarthritis is sharp pain, or a burning sensation in the associate muscles and tendons, causing stiffness and loss of ability. OA can cause a crackling noise or crepitus when the affected joint is moved, and the patient may experience muscle spasm and contractions in the tendons. Occasionally, the joints may also be filled with fluid. Humid and cold weather increases the pain in many patients. OA commonly affects the hands, feet, spine, and the large weight bearing joints, such as the hips and knees, although in theory, any joint in the body can be affected. As OA advances, the affected joints appear larger, are stiff and painful, and usually feel worse, the more they are used throughout the day, thus distinguishing it from rheumatoid arthritis. In smaller joints, such as at the fingers, hard bony enlargements may form, and though they are not necessarily painful, they limit the movement of the fingers significantly. OA at the toes leads to the formation of bunions, rendering them red or swollen. OA is the most common cause of joint effusion, an accumulation of excess fluid in or around the knee joint (Moskowitz, 2007). Breast surgery: Right Tonsillectomy Total abdominal hysterectomy Past Medical Surgical History, Pathophysiology of medical diagnoses (with APA citations) Pertinent Lab tests/ Results (with normal ranges) with dates and rationales The patient has a history of dementia, hypertension, alcohol abuse, UTI, insomnia, and urinary incontinence. Her cause of dementia is Alzheimer’s disease. This condition frequently begins with memory loss or subtle impairments in other cognitive functions. These changes might initially manifest as simple forgetfulness or absentmindedness or as minor problems with language, judgment, or perception. As dementia progresses, memory loss and cognitive impairment extend in scope until the person can no longer remember basic social and survival skills or function independently. Language, spatial or temporal orientation, judgment, perception, and other cognitive capacities decline, and personality changes may occur (Bourgeois Hickey, 2011). She suffers from hypertension whose symptoms include: Blood in the urine Severe headache Vision problems Fatigue or confusion Chest pain Difficulty breathing Irregular heartbeat Pounding in the chest, neck, or ears (Izzo Black, 2003). Urinary tract infections (UTI) do not always cause signs and symptoms, but they can include: A strong, persistent urge to urinate A burning sensation when urinating Passing frequent, small amounts of urine Urine that appears cloudy Urine that appears red, or bright pink colored, which is a sign of blood in the urine Strong-smelling urine Pelvic pain in women (Kilmartin, 2002) Heart: Normal in size. Elevate of right diaphragm. Motion artifact involve left lung base which obscure distal. No pneumothorax. 1/31/15 Impression: no definite infiltrates or masses although motion artifact degrades the quality of the image especially left lung base. Follow up film as indicated. Elevate right diaphragm 1/27/15 Prealbumin 4 Regular diet 11/17/14 Glucose 79 BUN 22 Creatinine 0.74 RBC 4.82 Phosphate 97 hemoglobin 13.7 SGot 15 MCV 85.3 SGPT 0.5 MCH 28.5 Calcium 8.6 MCHC 33.4 Sodium 140 RDW 13.8 Potassium 3.9 platelet 216 Chloride 105 monocyte 7.9 Co2 28 lymph 28 Protein 5.7 eos 2.5 Albumin 3.5 baso 0.5 Morphology normal Globumin 2.2 A/G ratio 1.6 GFR value 83 CBC 7.7 WBC 4.82 7/21/14 Compressibility and patency through the deep venous system with augmentation noted. Right foot demonstrates no fracture or evidence of bony destruction. No definite neoplastic progress of right foot is demo Erikson’s Developmental Stage with Rationale (APA citations) Socioeconomic/Cultural/Spiritual Orientation Psychosocial Considerations The patient is over 80 years old. Therefore, she fits in the 8th Psychosocial Stage of Integrity vs. Despair. The patient is now a senior citizen. She tends to slow down on productivity, and explore life as a retired person. It is during this time that she contemplates her accomplishments and is able to develop integrity if she sees herself as leading a successful life. If she sees her life as unproductive, feel guilt about her past, or feel that she did not accomplish her life goals, she will become dissatisfied with life and develop despair, often leading to depression and hopelessness. Success in this stage will lead to the virtue of wisdom. Wisdom will enable her to look back on her life with a sense of closure and completeness, and also accept death without fear. (Shaffer, 2008) The patient lives with her son who takes care of her medical and financial needs. The patient has a decreased cognitive ability and is not able to safely take medication by herself. She experiences a high level of insomnia/sleep deprivation. She also suffers from depression exacerbated by a lack of self-efficacy. Potential Health Deviations, Predisposing Related Factors; Interventions to Assess or Prevent Potential Health Deviations â€Å"At Risk for†¦Ã¢â‚¬  nursing dx (AT LEAST TWO) Inter-professional Consults, Discharge Referrals, Current Orders (include diet, test, and treatments) with Rationale With APA citations Exercising. Exercise could increase her endurance and strengthen the muscles around her joints, making her joint more stable. She can try walking, but she should stop if she feels new joint pain. New pain that lasts for hours after she has exercised probably means she has overdone it, but does not mean she should stop exercising altogether. Using hydrotherapy, local heat and cold to manage pain: Both heat and cold can relieve pain in her joints. Heat also relieves stiffness, and cold can relieve muscle spasms and pain. Applying over-the-counter pain gels/creams. Creams and gels available at drugstores might offer temporary relief from osteoarthritis pain. Some creams numb the pain by generating a hot or cool sensation whereas other creams have medications, such as aspirin-like compounds, that get absorbed into the skin. Pain creams would work best on joints that are close to the surface of her skin, such as knees and fingers. Using assistive devices. Assistive devices could make it easier for her to go about her day without stressing the painful joints. A cane might take weight off her knees or hips as she walks. Weight management. Being overweight can increases the stress on her weight-bearing joints, such as her knees and hips. Therefore, the patient should maintain her weight to prevent putting pressure on her joints, which could increase her pain. 1/27/15HPN 4oz TID with meals for supplement 7/20/14 Regular diet 1/26/15 Ice cream at HS 9/16/14 4.1.1 benign hypertension. Amlodipine Besylate 2.5mg PO QD. Hold if BP 11/27/14 Colace 250 PO QD bowel management 7/20/14 Namenda 5mg PO BID 7/20-7/21/14 Donepezil 10mg PO QHS for Alzheimer. Tylenol 325mg 2tabs Q4H if temp >101 10/18/14-11/2/14- Mylanta 30cc PO QD PRN for indigestion 7/20/14 Effexor 37.5 mg PO QD: depressive, sadness 7/20/14 Monitor antidepressant drug side effects and episode of verbal of sadness. Assess QS for pain 0-10 4/6/15 Left and right inner buttock redness clean with NS, pat dry, Baza cream 7/31/14 RNA ambulation with FWW with QD 6x/week 10/4/14 Half left side rail up 1/31/14 CXR for cough and congestion 7/20/14 May get up on wheelchair as tolerated. Admitted to Parkview hospital for dx Dementia, depression, Alzheimer, hypertension. 11/25/14 Nursing to incorporate ROME during daily ADL care Psych drug: Effexor 37.5mg for depression and verbalization sadness. Outcome: Resident was admitted consent and order for use of med, will observe and monitor behavior 10/31/14 Resident had behavior episode during this quarter will continue to observe and monitor behavior episode. Nursing Diagnosis (at least 2) Planning (outcome/goal) Measurable goal during your shift (at least 1 per Nursing diagnosis) Prioritized Independent and collaborative nursing interventions; include further assessment, intervention and teaching (at least 4 per goal) Rationale (use APA citations) Evaluation Goal Met, Partially met, or not Met and Explanation 1. Severe pain associated with distention of tissue by the inflammatory process The pain showed reduced or controlled Looks relaxed, can rest, sleep and ability to participate in appropriate activities. Follow the treatment program. Using the skills of relaxation and entertainment activities in a pain control program. Assess pain and note the location and intensity of pain (scale 0-10). Write down the factors that accelerate and signs of non-verbal pain. Give hard mattress and small pillow. Elevate bed when a patient needs to rest or sleep. Help the patient take a comfortable position when sleeping or sitting in a chair. Depth of bed rest as indicated. Help patient to frequently change positions. Help the patient to a warm bath at the time of waking. Help the patient to a warm compress on the sore joints several times a day. Monitor temperature compress. Give a massage. Encourage the use of stress management techniques such as progressive relaxation bio-feedback therapeutic touch, visualization, self-hypnosis guidelines imagination, and breath-control. Engage in activities of entertainment that is suitable for individual situations. Give the drug before activity or exercise that is planned as directed. Assist patients with physical therapy. Rest of systemic, recommended during the acute exacerbation phase of disease and all that is important to retain the power to prevent fatigue. Eliminates pressure on the tissue and increase circulation. Facilitate patient self-care and independence. Proper removal techniques can prevent skin abrasion tear. Increasing the stability (reduce the risk of injury) and necessary joint position and body alignment, reduced contractor. To maximize joint function and maintain mobility. It may be necessary to suppress the acute inflammatory system. Useful in formulating training programs / activities based on individual needs and in identifying the tool (Moskowitz, 2007). The patient met this outcome. Her worst pain reduced to 6 and her tolerance increased to 5 with less verbal and facial expression. 2. Impaired Physical Mobility associated with skeletal deformities, pain, discomfort, and decreased muscle strength. Maintain a function of position in the absence / restrictions contractures. Maintain or improve strength and function of compensation of the body. Demonstrate techniques or behaviors enabling activities Monitor the level of inflammation / pain in joints Maintain bed rest / sit if necessary Schedule of activities to provide a rest period of continuous and uninterrupted nighttime sleep. Assist patients with range of motion active / passive and resistive exercise and isometric if possible. Slide to maintain an upright position and sitting height, standing, and walking. Provide a safe environment, for example, raise the chair / toilet, use a high grip and tub and toilet, the use of mobility aids / wheelchairs rescue. Collaboration physical therapist / occupational and specialist visional. The level of activity / exercise depends on the development / resolution of the inflammatory process. Systemic Rest is recommended during acute exacerbations, and all phases of the disease is important to prevent exhaustion maintain strength Maintain / improve joint function, muscle strength and general stamina. Eliminates stress on the network and improves circulation. Facilitate patient self-care and independence. Proper removal techniques to prevent tearing skin abrasion. Increase stability (reducing the risk of injury) and maintain the necessary joint position and body alignment, reducing contractor. To maximize joint function and maintain mobility Avoiding injury due to accidents / falls Useful in formulating training programs / activities based on individual needs and identifying tools (Grifka Ogilvie-Harris, 2012). The patient met this outcome because she is able to walk without any appliance and her mobility is independent. MEDICATION LIST Medications (with APA citations) Class/Purpose Route Frequency Mechanism of action / Onset of action Common side effects Nursing considerations specific to this patient Namenda NMDA receptor antagonist, 5-HT3 antagonist. Oral 5mg 2times a day Namenda reduces the actions of chemicals in the brain that may contribute to the symptoms of Alzheimers disease. Diarrhea, dizziness or headache. Donepezil HCL Parasympathomimetic Oral 1tab/day at bed time This medication is an enzyme blocker that works by restoring the balance of natural substances (neurotransmitters) in the brain. Nausea, vomiting, diarrhea, loss of appetite/weight loss, dizziness, drowsiness, weakness, trouble sleeping, shakiness (tremor), or muscle cramps Amlodipine Calcium channel blocker Oral 2.5mg PO Amlodipine relaxes (widens) blood vessels and improves blood flow. Dizziness, lightheadedness, swelling ankles/feet, headaches, or flushing Hydrochlorothiazide Thiazide diuretic Oral 12.5 mg 1tab PO QD Hydrochlorothiazide helps prevent the body from absorbing too much salt, which can cause fluid retention. Stomach upset, dizziness, or headache Effexor Antidepressant Oral 37.5mg 1x a day Venlafaxine affects chemicals in the brain that may become unbalanced and cause depression. Vision changes; nausea, vomiting, diarrhea, changes in appetite or weight, dry mouth, yawning; dizziness, headache, anxiety, feeling nervous, fast heartbeats, tremors or shaking, insomnia, strange dreams, tired feeling, increased sweating, and decreased sex drive. Bibliography Bourgeois, M. S., Hickey, E. (2011). Dementia: From Diagnosis to Management A Functional Approach. New York: Taylor Francis. Grifka, J., Ogilvie-Harris, D. (2012). Osteoarthritis: Fundamentals and Strategies for Joint-Preserving Treatment. New York: Springer Science Business Media. Izzo, J. L., Black, H. R. (2003). Hypertension Primer: The Essentials of High Blood Pressure. New York: Lippincott Williams Wilkins. Kilmartin, A. (2002). The Patients Encyclopaedia of Urinary Tract Infection, Sexual Cystitis and Interstitial Cystitis. Boston: Angela Kilmartin. Moskowitz, R. W. (2007). Osteoarthritis: Diagnosis and Medical/Surgical Management. New York: Lippincott Williams Wilkins. Shaffer, D. (2008). Social and Personality Development. Boston: Cengage Learning.