Osteoarthritis Diagnosis and Care Plan

Osteoarthritis diagnosis and C are PlanPatient InitialsJAUnit/Room DOB8/17/1926 Code Status Height/ tilt 61 / 126 lbAllergiesNo allergies Temp (C/F Site)Pulse (Site)RespirationPulse Ox (O2 Sat)Blood PressurePain Scale 1-1097*F7918160/808History of Present Illness including Admission Diagnosis and pertinent Physical Assessment Findings (normal abnormal)Relevant Diagnostic Procedures Surgeries /Results(include dates, if non found state so)The forbearing is suffering from general osteoarthritis, muscle weakness, abnormal of gal, spinal stenosis, chronic distress neck, benign hypertension, Alzheimer, dementia with demeanour disturbance, depressive disorder NEC, and myopia.The main symptom of osteoarthritis is sharp disoblige, or a burning sensation in the associate muscles and tendons, causing stiffness and loss of ability. OA undersurface origin a crackling noise or crepitus when the affected joint is moved, and the patient may experience muscle spasm and contr exertions in the tendons. Occasionally, the joints may overly be filled with changeable. Humid and cold weather increases the nuisance in many patients.OA commonly affects the hands, feet, spine, and the large weight bearing joints, much(prenominal) 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 pure tone worse, the more they are used throughout the day, thus distinguishing it from rheumatoid arthritis. In smaller joints, such as at the fingers, hard raddled 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 RightTonsillectomyTotal abdominal hysterectomyPast Medical Surgical History , Pathophysiology of medical diagnoses (with APA citations) tending(p) Lab tests/ Results (with normal ranges)with dates and rationalesThe patient has a history of dementia, hypertension, alcohol abuse, UTI, insomnia, and urinary incontinence.Her cause of dementia is Alzheimers disease. This condition frequently begins with memory loss or subtle impairments in other cognitive routines. 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 friendly 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 includeBlood in the urineSevere headache lot problemsFatigue or confusionC hest painDifficulty breathingIrregular heartbeatPounding in the chest, neck, or ears (Izzo Black, 2003).Urinary tract infections (UTI) do not always cause signs and symptoms, but they can includeA strong, persistent urge to urinateA burning sensation when urinatingPassing frequent, small amounts of urineUrine that appears cloudyUrine that appears red, or bright pink colored, which is a sign of line of credit in the urineStrong-smelling urinePelvic pain in women (Kilmartin, 2002)Heart Normal in size. Elevate of right diaphragm. Motion artifact involve left lung brutal which obscure distal. No pneumothorax.1/31/15Impression no definite infiltrates or masses although motion artifact degrades the quality of the image in particular left lung base. Follow up film as indicated. Elevate right diaphragm1/27/15Prealbumin 4Regular diet11/17/14Glucose 79BUN 22Creatinine 0.74 RBC 4.82Phosphate 97 hemoglobin 13.7SGot 15 MCV 85.3SGPT 0.5 MCH 28.5Calcium 8.6 MCHC 33.4Sodium 140 RDW 13.8Potassiu m 3.9 blood platelet 216Chloride 105 monocyte 7.9Co2 28 lymph 28Protein 5.7 eos 2.5Albumin 3.5 baso 0.5Morphology normalGlobumin 2.2A/G ratio 1.6GFR value 83CBC 7.7WBC 4.827/21/14Compressibility 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 demoEriksons Developmental Stage with Rationale (APA citations)Socioeconomic/Cultural/Spiritual druthers Psychosocial ConsiderationsThe 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 stamp 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 feel 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 drop Health Deviations, Predisposing Related Factors Interventions to Assess or Prevent Potential Health Deviations At Risk for nursing dx (AT LEAST TWO)Inter-professional Consults, Discharge Referrals, Current Orders (include diet, test, and treatments) with Rationale With APA citationsExercising. representative 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. bare-ass 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/ figure outs. Creams and gels available at drugstores might dischargeer temporary relief from osteoarthritis pain. Some creams numb the pain by generating a hot or chill 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 stressin g 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 bear on her weight to prevent pose pressure on her joints, which could increase her pain.1/27/15HPN 4oz TID with meals for supplement7/20/14 Regular diet1/26/15 ice rink cream at HS9/16/14 4.1.1 benign hypertension. Amlodipine Besylate 2.5mg PO QD. Hold if BP 11/27/14 Colace 250 PO QD bowel management7/20/14 Namenda 5mg PO BID7/20-7/21/14 Donepezil 10mg PO QHS for Alzheimer. Tylenol 325mg 2tabs Q4H if temp 10110/18/14-11/2/14- Mylanta 30cc PO QD as required for indigestion7/20/14 Effexor 37.5 mg PO QD depressive, sadness7/20/14 Monitor antidepressant drug side make and episode of verbal of sadness. Assess QS for pain 0-104/6/15 Left and right inner buttock redness clean with NS, pat dry, Baza cream7/31/14 RNA ambulation with FWW with QD 6x/week10/4/14 Half left side rail up1/31/14 CXR for cough and congestion7/20/14 May get up on wheelchair as tolerated. Admitted to Parkview hospital for dx Dementia, depression, Alzheimer, hypertension.11/25/14 care for to incorporate ROME during daily ADL carePsych drugEffexor 37.5mg for depression and verbalization sadness.Outcome Resident was admitted consent and order for use of med, will chance on and monitor behavior10/31/14Resident 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 preventives include further assessment, intervention and teaching (at least 4 per goal)Rationale(use APA citations)EvaluationGoal Met, Partially met, or not Met and Explanation1. Severe pain associated with distention of tissue by the inflammatory processThe pain showed reduced or controlledLooks r elaxed, can rest, sleep and ability to participate in appropriate activities.Follow the treatment program.Using the skills of residuum and amusement 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. pull hard mattress and small pillow. Elevate bed when a patient needs to rest or sleep.Help the patient take a comfortable fructify when sleeping or sitting in a chair. Depth of bed rest as indicated.Help patient to frequently change slips.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 respecti ve(prenominal) situations.Give the drug before activity or exercise that is planned as directed.Assist patients with physical therapy.Rest of systemic, recommended during the not bad(p) aggravation 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 osteal deformitie s, 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.attest techniques or behaviors enabling activitiesMonitor the level of inflammation / pain in jointsMaintain bed rest / sit if necessarySchedule 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 aid / 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 strengthMaintain / 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 mobilityAvoiding injury due to accidents / fallsUseful 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 LISTMedications(with APA citations)Class/PurposeRouteFrequencyMechanism of action /Onset of actionCommon side effectsNursing considerations specific to this patientNamendaNMDA receptor antagonist, 5-HT3 antagonist .Oral5mg 2times a dayNamenda reduces the actions of chemicals in the brain that may contribute to the symptoms of Alzheimers disease.Diarrhea, dizziness or headache.Donepezil HCLParasympathomimeticOral1tab/day at bed timeThis medication is an enzyme blocker that works by restoring the balance of immanent substances (neurotransmitters) in the brain.Nausea, vomiting, diarrhea, loss of appetite/weight loss, dizziness, drowsiness, weakness, trouble sleeping, shakiness (tremor), or muscle crampsAmlodipineCalcium channel blockerOral2.5mg POAmlodipine relaxes (widens) blood vessels and improves blood flow.Dizziness, lightheadedness, swelling ankles/feet, headaches, or flushingHydrochlorothiazideThiazide diureticOral12.5 mg 1tab PO QDHydrochlorothiazide helps prevent the body from absorbing too much salt, which can cause fluid retention.Stomach upset, dizziness, or headacheEffexorAntidepressantOral37.5mg 1x a dayVenlafaxine affects chemicals in the brain that may become unbalanced and caus e depression.Vision changesnausea, vomiting, diarrhea, changes in appetite or weight, dry mouth, yawningdizziness, headache, anxiety, feeling nervous, fast heartbeats, tremors or shaking, insomnia, strange dreams, tired feeling, increased sweating, and decreased sex drive.BibliographyBourgeois, 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 Pe rsonality Development. Boston Cengage Learning.