Gordie Howe

1. Patient Info

1.1. Carpal Tunnel/Arthritis

1.2. 09/21/1971

1.3. Full Code

1.4. History:broken wrist,brain trauma

1.5. Allergies:NKDA

1.6. 52,White,Male

2. Nursing intervention

2.1. Chronic Pain: 1.Teach and implement non pharmacological interventions 2.Assess pain in client using self report on scale of 1-10 3.Splint Wrist at night to relieve sleep disturbances due to pain

2.2. Impaired physical Activity: 1.Assist patient in Active ROM. 2.Teach finger and wrist extension exercises.

2.3. Self Care Deficit: 1.Encourage patient to perform ADL's to patient's capability. 2. Assist patient with bathing

3. Patient Education

3.1. Teach client relaxation techniques to use during activities.

3.2. Provide Written material on pain relief

3.3. Reinforce the importance of taking pain medication to keep pain under control

3.4. Encourage client to avoid or limit repeptive strains on joints such as contact sports

3.5. Teach patient how to properly splint and elevate wrist

3.6. Make sure patient understands how to correctly do wrist exercises to reduce entrapment of nerve.

4. Multidisciplinary Care

4.1. LPN

4.2. Care Tech

4.3. Pharmacist

4.4. Orthopedic surgeon

4.5. Physical Therapist

4.6. Primary physician

5. Core Measures

5.1. SCIP

6. Goals

6.1. After 3 hours of care pt's pain will be reduced from 8/10 to 4/10.

6.2. Patient will be able to fully extend fingers for period of 2 minutes.

6.3. Patient sleeps appropriately to his normal schedule without waking due to pain.

7. Risk Factors

7.1. Repetitive Sports Injury to wrists

7.2. Arthiritis

7.3. Advancing Age: 52

7.4. BMI of 28

8. Lab/Diagnostic Data

8.1. MRI: Reveals bone erosion in carpals of pt's right wrist X-Ray: Reveals cartilage loss to right carpals EMG: Test revealed poor nerve function in distal phalanges Carpal Compression Test Ultrasonography: Reveals erosion of bone and evidenced of thickening of joint space due to inflammation

9. Potential Complications

9.1. Continued degeneration of join

9.2. Potential for deformed joints due to arthiritis

9.3. Daily tasks become more and more difficult

10. Top 3 Client Problems

10.1. Chronic Pain r/t unrelieved pressure on median nerve

10.2. Impaired Physical Mobility r/t chronic pain and joint stiffness

10.3. Self Care Deficit r/t pain upon movement

11. Medications

11.1. NSAIDS: ibuprofen, aspirin, and acetaminophen. Corticosteroids: prednisone, hydrocortisone, and prednisolone.

12. Objective Data

12.1. HR 110

12.2. BP 138/98

12.3. RR 21

12.4. Swelling and erythema of right wrist

12.5. Capillary refill of right fingers < 3 seconds

13. Subjective Date

13.1. Pt. stated pain at 7/10 .Aggravating factors are movement of wrist.Pt. stated immobility and pain medication as calming factors. Pt reports numbness and tingling of distal phalanges.