Osteoarthritis Diagnosis and Care Plan

Osteoarthritis Diagnosis and Care Plan Quiet Initials: JA Unit/Room DOB: 8/17/1926 Code Status Height/Weight 6’1’’/126 lb Allergies: No hypersensitivities Temp (C/F Site) Heartbeat (Site) Breath Heartbeat Ox (O2 Sat) Pulse Agony Scale 1-10 97*F 79 18 160/80 8 History of Present Illness including Admission Diagnosis and Relevant Physical Assessment Findings (typical unusual) Significant Diagnostic Procedures Surgeries/Results (incorporate dates, if not discovered state so) The patient is experiencing general osteoarthritis, muscle shortcoming, strange of lady, spinal stenosis, incessant torment neck, considerate hypertension, Alzheimer, dementia with conduct aggravation, burdensome turmoil NEC, and nearsightedness. The principle manifestation of osteoarthritis is sharp agony, or a consuming sensation in the partner muscles and ligaments, causing solidness and loss of capacity. OA can cause a snapping commotion or crepitus when the influenced joint is moved, and the patient may encounter muscle fit and compressions in the ligaments. Sometimes, the joints may likewise be loaded up with liquid. Muggy and chilly climate builds the torment in numerous patients. OA normally influences the hands, feet, spine, and the enormous weight bearing joints, for example, the hips and knees, in spite of the fact that in principle, any joint in the body can be influenced. As OA propels, the influenced joints seem bigger, are solid and excruciating, and for the most part feel more awful, the more they are utilized for the duration of the day, along these lines recognizing it from rheumatoid joint inflammation. In littler joints, for example, at the fingers, hard augmentations may shape, and however they are not really agonizing, they limit the development of the fingers essentially. OA at the toes prompts the arrangement of bunions, rendering them red or swollen. OA is the most well-known reason for joint emanation, an amassing of abundance liquid in or around the knee joint (Moskowitz, 2007). Bosom medical procedure: Right Tonsillectomy Absolute stomach hysterectomy Past Medical Surgical History, Pathophysiology of clinical findings (with APA references) Appropriate Lab tests/Results (with ordinary reaches) with dates and justifications The patient has a past filled with dementia, hypertension, liquor misuse, UTI, a sleeping disorder, and urinary incontinence. Her reason for dementia is Alzheimer’s malady. This condition every now and again starts with memory misfortune or inconspicuous disabilities in other intellectual capacities. These progressions may at first show as straightforward neglect or absentmindedness or as minor issues with language, judgment, or recognition. As dementia advances, memory misfortune and subjective weakness stretch out in scope until the individual can no longer recollect essential social and ingrained instincts or capacity freely. Language, spatial or transient direction, judgment, observation, and other psychological limits decrease, and character changes may happen (Bourgeois Hickey, 2011). She experiences hypertension whose side effects include: Blood in the pee Extreme migraine Vision issues Weariness or disarray Chest torment Trouble relaxing Unpredictable heartbeat Beating in the chest, neck, or ears (Izzo Black, 2003). Urinary tract contaminations (UTI) don't generally cause signs and manifestations, however they can include: A solid, industrious desire to pee A consuming sensation while peeing Passing incessant, limited quantities of pee Pee that seems overcast Pee that seems red, or brilliant pink shaded, which is an indication of blood in the pee Solid smelling pee Pelvic agony in ladies (Kilmartin, 2002) Heart: Normal in size. Hoist of right stomach. Movement curio include left lung base which cloud distal. No pneumothorax. 1/31/15 Impression: no unmistakable penetrates or masses in spite of the fact that movement relic debases the nature of the picture particularly left lung base. Follow up film as showed. Raise right stomach 1/27/15 Prealbumin 4 Customary eating regimen 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 Egg whites 3.5 baso 0.5 Morphology ordinary Globumin 2.2 A/G proportion 1.6 GFR esteem 83 CBC 7.7 WBC 4.82 7/21/14 Compressibility and patency through the profound venous framework with enlargement noted. Right foot shows no crack or proof of hard pulverization. No positive neoplastic advancement of right foot is demo Erikson’s Developmental Stage with Rationale (APA references) Financial/Cultural/Spiritual Orientation Psychosocial Considerations The patient is more than 80 years of age. In this manner, she fits in the eighth Psychosocial Stage of Integrity versus Depression. The patient is presently a senior resident. She will in general log jam on profitability, and investigate life as a resigned individual. It is during this time she mulls over her achievements and can create respectability on the off chance that she considers herself to be having an effective existence. In the event that she considers her to be as ineffective, feel coerce about her past, or feel that she didn't achieve her life objectives, she will get disappointed with life and create despair, regularly prompting discouragement and misery. Accomplishment in this stage will prompt the righteousness of shrewdness. Insight will empower her to think back on her existence with a feeling of conclusion and fulfillment, and furthermore acknowledge passing unafraid. (Shaffer, 2008) The patient lives with her child who deals with her clinical and money related requirements. The patient has a diminished subjective capacity and can't securely take drug without anyone else. She encounters an elevated level of a sleeping disorder/lack of sleep. She additionally experiences wretchedness exacerbated by an absence of self-viability. 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) Between proficient Consults, Discharge Referrals, Current Orders (incorporate eating routine, test, and medicines) with Rationale With APA references Working out. Exercise could build her perseverance and reinforce the muscles around her joints, making her joint increasingly steady. She can have a go at strolling, yet she should stop on the off chance that she feels new joint agony. New torment that goes on for a considerable length of time after she has practiced presumably implies she has tried too hard, however doesn't mean she should quit practicing out and out. Utilizing hydrotherapy, neighborhood warmth and cold to oversee torment: Both warmth and cold can assuage torment in her joints. Warmth likewise soothes firmness, and cold can calm muscle fits and agony. Applying over-the-counter agony gels/creams. Creams and gels accessible at drugstores may offer transitory alleviation from osteoarthritis torment. A few creams numb the torment by creating a hot or cool sensation though different creams have prescriptions, for example, headache medicine like exacerbates, that get consumed into the skin. Agony creams would work best on joints that are near the outside of her skin, for example, knees and fingers. Utilizing assistive gadgets. Assistive gadgets could make it simpler for her to approach her day without focusing on the excruciating joints. A stick may drop weight from her knees or hips as she strolls. Weight the executives. Being overweight can builds the weight on her weight-bearing joints, for example, her knees and hips. Subsequently, the patient ought to keep up her weight to forestall squeezing her joints, which could build her torment. 1/27/15HPN 4oz TID with dinners for supplement 7/20/14 Regular eating regimen 1/26/15 Ice cream at HS 9/16/14 4.1.1 amiable hypertension. Amlodipine Besylate 2.5mg PO QD. Hold if BP 11/27/14 Colace 250 PO QD gut the executives 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 heartburn 7/20/14 Effexor 37.5 mg PO QD: burdensome, trouble 7/20/14 Monitor energizer sedate symptoms and scene of verbal of pity. Evaluate QS for torment 0-10 4/6/15 Left and right inward butt cheek 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 hack and blockage 7/20/14 May get up on wheelchair as endured. Admitted to Parkview emergency clinic for dx Dementia, discouragement, Alzheimer, hypertension. 11/25/14 Nursing to consolidate ROME during every day ADL care Psych tranquilize: Effexor 37.5mg for discouragement and verbalization bitterness. Result: Resident was conceded assent and request for utilization of medications, will watch and screen conduct 10/31/14 Inhabitant had conduct scene during this quarter will proceed to watch and screen conduct scene. Nursing Diagnosis (in any event 2) Arranging (result/objective) Measurable objective during your day of work (at any rate 1 for each Nursing determination) Organized Independent and community oriented nursing intercessions; incorporate further appraisal, mediation and instructing (in any event 4 for each objective) Basis (use APA references) Assessment Objective Met, Partially met, or not Met and Explanation 1. Extreme agony related with expansion of tissue by the provocative procedure The agony indicated diminished or controlled Looks loose, can rest, rest and capacity to take an interest in suitable exercises. Follow the treatment program. Utilizing the aptitudes of unwinding and amusement exercises in a torment control program. Evaluate agony and note the area and force of torment (scale 0-10). Record the components that quicken and indications of non-verbal torment. Give hard sleeping pad and little cushion. Lift bed when a patient needs to rest or rest. Help the patient take an agreeable position when resting or sitting in a seat. Profundity of bed rest as showed. Help patient to as often as possible change positions. Help the patient to a steaming shower at the hour of waking. Help the patient to a warm pack on the irritated joints a few times each day. Screen temperature pack. Give a mas