NUR 304: CLIENT INFORMATION SHEET (CIS)

Student Name Date

Patient Initials M X __ F Age 58 Religion Catholic Primary Language Spanish

Allergies peanuts, shrimp DNR AD None X Height 5’11” Weight 229.3 lbs

Admission Date 9/5/18 Admission Diagnosis Failed total right knee replacement

Current Diagnosis [reason for admit/chief complaint] He continued to complain of bilateral knee pain after having
undergone bilateral total knee arthroplasties that are now loose. He described the pain being much worse in the right knee
than the left which had progressively worsened to the point of no longer being able to ambulate without pain.

Surgical/Invasive Diagnostic Procedures [this admit] Right total knee arthroplasty revision

Concurrent Medical History [past] Hypertension; hyperlipidemia; MI; GERD; asthma; arthritis of knee

Past Surgeries Carpal tunnel release; bilateral knee replacements

Course of Hospitalization [what happened during stay] After a failed knee replacement, the patient returned complaining
of pain in the right knee. The pain continued to worsen until he was no longer able to ambulate without constant pain.
After several evaluations, it was determined that the knee implant parts became loose and that the patient needed to
undergo a right total knee arthroplasty revision surgery to correct it. He had the surgery on 9/05 and is now rehabilitating
and proactively recovering. He made good progress with physical therapy today getting out of the bed and walking from
the bed to the door of the room with the assistance of a walker.

Precautions/Special Needs [isolation, fall, restraints] Fall risk / fall precautions – need for walker and assistance;
pressure sore risk due to infrequent mobility – need for frequent repositioning; risk for infection

Activity Order Patient may only ambulate or be out of bed with assistance. Weight bearing on the right lower extremity
as tolerated with a hinged knee immobilizer locked in extension. First physical therapy out of bed progress on 9/6, walked
to door and back to bed with use of walker.

External Devices [orthopedic, SCD/IPC] Knee immobilizer brace; Standard walker; 3-in-1 commode

Treatments [wound care, 02] Right knee surgical incision site with post-op Aquacel dressing dry and intact along with
a knee immobilizer brace

Vital Signs: frequency q4h BP 100/52 T 37.1 C P 91 R 17 Baseline BP 130/74 T 36.7 C HR 90 RR 16

Diet Regular Tube Feeding: type, rate/frequency, site none

Intake: Output:
Oral 1100 ml Urine/Foley/Incontinent/Voids 3130 ml  (foley catheter removed @ 8 am
and voided 4 hrs after)
Parenteral 3175 ml (IV fluids, meds) Drainage tubes [specify]               

Tube Feed none Other: estimated blood loss: 250 ml

Q 8 H or Q 12 H or Q 4 H Total Input 4275 ml Total Output 3380 ml

Venous Access Devices:
[type, solution, rate/saline lock, site] BS Glucose: AM n/a PM n/a

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PIV Peripheral IV right hand 20 gauge 9/5/18

CVC none

Other:                                                                                                                                                                                            

Pathophysiology of Medical Problem [describe etiology, progression, treatment-specific to client]:

Following a previous surgery for bilateral knee arthroplasties that have now become loose, the patient continued to
complain of bilateral knee pain, that he described as being much worse on the right knee than the left. Patient reports that
the pain got progressively worse to the point where he was no longer able to ambulate without any pain. “Persistent post-
surgical pain (PPSP) is reported in a significant number of patients after total knee replacement with loosening being the
number one cause of failed procedures” (Drosos, Triantafilidou, et al, 2015). As recommended, he decided to undergo a
revision of the right total knee arthroplasty on 9/5/18 to correct the failed one. Total knee replacement is a treatment of
knee osteoarthritis used to alleviate pain symptoms and improve mobility and physical functioning. Loosening of the
implant can commonly occur. In the revision procedure, the doctor removes some of or all parts of the original prosthesis.
The revision surgery is more complex than the original and requires extensive planning to execute a successful outcome.

Consultations [type, date, results] Physical Therapy (walking) on 9/6/18

Current Lab Results: Note Additional Diagnostic Studies Below (Radiographs, Scans, etc.)
Normal Pt. Results Significance of Abnormals: [indicates kidney failure, anemia, etc.]
Na+ 135-145 136
K+ 3.5-5 4.3
Cl` 95-105 96
CO2 22-26 31 (H) May be evident of inadequate fresh gas flow as a delayed side effect in
relation to having been under anesthesia
Glu 65-139 112
Ca2+ 8.5-10.5 8.5
BUN 8-21 10
Cr 0.6-1.2 0.52 (L) May be evident of muscle loss, which decreases with age but too small a
difference from the norm to really be a concern
Mg2+ 1.6-2.6
WBC 4.5-11 6.4
HgB 11.7-17.3 10.4 (L) May be evident of postoperative mild anemia as result of blood loss
during the surgery and should resolve on its own with time as the body
makes more
HcT 33-39 33.9
Plt 150-450x109/L 155
Bedside Glucose
Other:
Other:

Medications: List only [complete on medication form]

Gabapentin 100 mg, 1 cap, oral, t.i.d.; Rosuvastatin 20 mg, 1 tab, oral, daily; aspirin 325 mg, 1 tab, oral, b.i.d.; Percocet
5/325, 2 tab, oral, q6h, PRN: pain – moderate; Ropivacaine 0.2% - adult 500 ml, 10 ml/hr

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Nursing Diagnosis: [list 3 & prioritize]
1. Acute pain related to right total knee arthroplasty revision surgery as evidenced by patient verbalizing his discomfort.
2. Impaired physical mobility related to related to right total knee arthroplasty revision surgery as evidenced by the
presence of a knee immobilizer brace.
3. Risk for infection related to surgical incision.

All Nursing interventions/actions:

1. Assess patient’s signs and symptoms of pain and monitor changes, including location, quality, intensity on a scale of 1 to 10,
temporal factors, sources of provocation, and relief. Rationale: Assessment forms the basis of an effective treatment plan.
2. Administer pain medications as prescribed. Monitor and record the medication’s effectiveness and adverse effects. Rationale:
Assessment allows for care plan modification, as needed.
3. Perform comfort measures to promote relaxation, such as massage, bathing, repositioning, and relaxation techniques. Rationale:
These measures reduce muscle tension or spasm, redistribute pressure on body parts, and help patient focus on non-pain-related
subjects.
4. Turn and position patient every 2 hours. Rationale: This prevents skin breakdown by relieving pressure.
5. Provide progressive ambulation up to the limits imposed by patient’s condition (must wear knee brace). Rationale: Knee
immobilizers are often used after surgery to help prevent unwanted movement that could re-injure the leg or cause harm to the
healing area.
6. Encourage patient to follow physical therapy program to promote walking. Rationale: Rehab exercises will help patient walk,
climb stairs, and return to other normal activities more quickly.
7. Document and report results of preoperative nursing assessment. Identify risk factors predisposing patient to infection. Rationale:
A complete nursing assessment allows development of an individualized care plan.
8. Monitor wound and incision to make sure it is clean, pink, and free from purulent drainage. Rationale: Joint replacement
infections may occur in the wound or deep around the artificial implants.
9. Use strict sterile technique when inserting or changing IV catheters and providing wound care. Rationale: To avoid spreading
pathogens.

Anticipated Discharge Needs: [equipment; include teaching]

 Wound care: Keep dressing clean and dry, remove Aquacel after 7 days, and replace with daily dry gauze dressings
for 7 more days
 Follow up with physician in 6 weeks for post-operative check
 Home health evaluation and daily treatment for 2 weeks:
o Patient to receive evaluation and education regarding wound care and dressing changes in which the patient
will be able to demonstrate after.
o Medication management
o Outpatient PT evaluation and treatment. Work on gait training and transfers for ADLs.
 Patient should continue wearing knee brace according to doctor’s instructions.
 Patient will continue taking medications as prescribed by doctor after surgery.
 Patient should follow doctor’s instructions regarding safe movement for walking and exercising the knee.
 Patient should call doctor right away if they think they might have an infection (redness, inflammation, pus, swelling)
 Patient should maintain a healthy weight, as added body weight puts stress on the knee and can also further the risk
for infection.

References [APA]

Drosos, G. I., Triantafilidou, T., Ververidis, A., Agelopoulou, C., Vogiatzaki, T., & Kazakos, K. (2015, August 18). Persistent
postsurgical pain and neuropathic pain after total knee replacement. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4539476/

Phelps, L., Ralph, S. & Taylor, C. (2017). Sparks & Taylor's nursing diagnosis reference manual. Wolters Kluwer.

Sanoski, C., & Vallerand, A. (n.d.). Davis's drug guide for nurses (16th ed.). Retrieved September 7, 2018, from
https://nursing.unboundmedicine.com/nursingcentral/index/Davis-Drug-Guide/All_Entries/A