Question: Jonathon Jackson Patient Information Initials: JJ Age: 68 Weight: 170 Lbs Height: 6’0” Gender: M Living Arrangements: House With Wife Allergies Drugs: NKA Reaction: Environment: Seasonal Reaction: Itchy Eyes, Nasal Congestion Food: Strawberries Reaction: Rash Medical Information Chief Complaint: Left Knee Pain; Total Left Knee Arthroplasty X 1 Day …

Patient Information

Initials: JJ

Age: 68   Weight: 170lbs   Height: 6’0”

Gender: M

Living Arrangements: House with wife

Allergies

Drugs: NKA

Reaction:

Environment: Seasonal

Reaction: Itchy eyes, nasal congestion

Food: Strawberries

Reaction: Rash

Medical Information

Chief Complaint: Left knee pain; Total left knee arthroplasty x1 day ago

History of present illness: Osteoarthritis left knee (unknowntime of dx, approximately 2-3 years).

Past medical history: Anxiety

Family history: CAD (m/f), HTN,(f), Breast cancer (m)

Social History

Tobacco use:

Yes: X

No:

Packs per day:

Duration:

Previous history: 2 ppd x 15 years, quit 10 years ago

Alcohol use:

Yes: X

No:

Number per week: 1-2

Previous history:

Caffeine use:

Yes: X

No:

Number of cups per day: 3-4

Previous history:

Other recreational drug use:

Yes:

No: X

List:

Immunization

Comments: Refused Influenza andPneumovax 23 vaccine

Medication List: Include OTC &Vitamins/Herbal/Supplements

Name: Celecoxib 100 mg twice daily

Indication: Knee pain

Name: Diazepam 2 mg PO every 6 hours as needed for anxiety

Indication: Anxiety

Name: Enoxaparin 30 mg subcut q12h for 10 days

Indication: DVT prophylaxis

Name: Morphine 2.5 mg IV PRN pain

Indication: Pain

Name: Cefazolin 1 gram IV q8h for 24 hours

Indication: Prophylaxis against infection

Name: Docusate Sodium 50 mg PO once daily

Indication: Constipation

Name: Acetaminophen 650 mg PO q6 hours as needed for pain

Indication: Pain

Name:

Indication:

Review of Systems

Vital signs:    Temp:98.6     BP: 120/80   HR:78   RR: 19   O2 Sat: 97%RA   Pain: 1 left knee (0-10)

CNS/Neurologic:    LOC:a&0x3      Confused:     Drowsiness:     Fatigue:   Numbness:    Tingling:

CVD:  SOB: denies   Edema:0  Palpitation: all pulses present and equal 2+

Pulmonary: B/L CTA   SOB:Denies    Wheezing:       Cough:Denies

Labs

Cholesterol:   Total:  185   HDL:50    LDL:100    Triglycerides: 125

Liver:   AST:  23   ALT:   30

CoagulationStudies:   PT:   PTT:   aPTT;    INR:

Other:

Medical Orders (include medications, diagnostic tests,etc.)

PAT CXR: Lungs and pleural spaces are clear. Cardiomediastinalcontour is normal. Normal chest x-ray.

PAT EKG: Sinus rhythm occurs at about 78 beats per minute, withminor variations in the RR intervals. The PR interval, QRSduration, and QTc are all normal.

Nursing Assessment  

Plan of Care: (Include nursing interventions andteaching)