Tenosynovitis
by Kathleen Slaven
1. Labs:
1.1. Na: 142
1.2. Cl: 101
1.3. BUN: 18
1.4. K: 3.9
1.5. Creatinine: 0.9
1.6. Glucose: 145
1.7. WBC: 8.9
1.8. HGB: 12.4
1.9. HCT: 37.6
1.10. Plt: 213
2. Medications:
2.1. bupivacaine: local anesthesia
2.2. ceftTRIAXone: treatment of infection
2.3. cholestyramine: management of hypercholesterol
2.4. cloNIDine: mild-moderate HTN
2.5. colesevelam: reduction of LDL
2.6. enoxaprin: prevention of DVT / PE
2.7. hhydeochlorothiazide: mild-moderate HTN
2.8. indomethacin: OA & pain
2.9. levothyroxine: hypothyroidism
2.10. nebivolol: HTN
2.11. ordansteron: prevention of nausea & vomit
2.12. pantoprazole: GERD
2.13. rosuvastatin: hypercholestermia
2.14. vancomycin: treatment of infection
3. Medical Hx:
3.1. Hypertension
3.2. NIDDM (type 2 diabetes)
3.3. Hyperlipidemia
3.4. Hyptohyroid
3.5. Osteoarthritis of hands and multiple joints
4. Nursing Diagnosis #1: Acute pain
4.1. Intervention #1: Administer pain medication when needed
4.2. Intervention #2: Use heating compress
4.3. Intervention #3: Adjust hand to ensure proper placement in molding / brace
5. Nursing Diagnosis #2: Risk for Infection
5.1. Intervention #1: Ensure clean or sterile technique when cleaning wound
5.2. Intervention #2: Follow surgeon orders in regards to cleaning method
5.3. Intervention #3: Give pt. vancomycin for infection
6. Nursing Diagnosis #3: Impaired skin integrity
6.1. Intervention #1: Ensure proper wound drainage is taken care of
6.2. Intervention #2: Have pt. move every 2 hours
6.3. Intervention #3: Put on medication cream if skin becomes raw
7. Subjective assessment: Pt has no history of smoking, no stated family history of any cancer, pt. stated having a knee replacement surgery
8. Objective assessment:
8.1. Vitals:
8.1.1. 98.1 oral termperature
8.1.2. 50 BPM
8.1.3. 135/62 HR
8.1.4. 16BPM
8.1.5. Pain: 6/10