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62-years-old male patient, Group members, Suwanna Sinlapee ID:61010173,…
62-years-old male patient
Treatment/Medication
Medication
Current medication
Cefazolin 2 gm to OR 28/03 11:05
Ultracet 1 tab po prn every 8 hours 28/03 14:50
Tramal 1 amp IV prn every 8 hours 28/03 20:40
Home medication
OMG caltinum 2 x po pc
ultracet 1 tab bid pc
Previous medication
Enalapril 5mg 2 tab OD PC breakfast
Glipizide 5mg 1 tab bid ac breakfast and dinner
Simvastatin 40mg 1 tab od bedtime
manidipine 20mg 1 tab od pc breakfast
metformin 500mg 1 tab od pc
myonal 50mg 1 tab tid pc breakfast/lunch/dinner
Ultracet 1 tab bid pc
-ASA 2*po pc
Doctor order
27/03/2022
DTX bid ac keep DTX (80-180) 16:45
5% D/N/2 1000ml rate 80ml/hr 17：40
28/03/2022
Cefazolin 2 gm to OR 11：05
Check and record v/s every 15min in the first hour after operation,every 30min in the second hour after operation
continue order
Regular diet
-Cefazolin
Ultracet 1 tab bid pc
-lift the right leg
Bed rest
Tramal 1 amp IV prn every 8 hours
29/03/2022
At 10:00 or in the afternoon , make appointment with physical therapy teach use cruthes or walker (Rt leg without weight bearing)
-Can discharge in the afternoon
Home Medication
OMG caltinum 2 x po pc
ultracet 1 tab bid pc
Operation
OR Repair Achilles tendon with heel spur removel with ancher screw 28/3/2022 10：30
Nursing Diagnosis
Discomfort due to post operative pain
Subjective data: Pain score=7/10
Objective data:
The patient has surgical wound at right leg
Evaluation Criteria:
Pain score=0 or decrease
Normal vital signs: T=36.5-37,5 C BP=90/60-120/80mmHg, HR=60-100 bpm, RR=12-20 bpm
Patient can sleep well
Patient’s face brightened, refreshed, and showed no pain.
Nursing Goals: relieve pain
Evaluation:
pain score=3/10
Normal vital signs: T=36.5 C BP=139/93mmHg, HR=84bpm, RR=18 bpm, SpO2=98%
Patient can sleep well
Patient’s face brightened, refreshed, and showed no pain.
Nursing Intervention
Assess V/S and pain score every 4 hrs
Administer medication follow doctor order ( Tramol 1amp IV prn q 8 hrs, Ultracet 1 tab po prn every 8 hours)and observe side effects of medication such as nausea and vomiting, dry mouth, dizziness
Teach the patient to perform non- pharmacological pain relief methods such as deep breathing exercise, reading a book, etc.
Adjust comfortable position to reduce pain
Promote bedrest by organize nursing activities to stay at the same time / do not disturb the patient while resting / sleeping
Assess pain score again after provide nursing care
Risk for side effects of anti coagulant drug
Nursing Goal: To prevent bleeding
Nursing Intervention
Observe and assess sign & symptoms of bleeding such as petechiae on skin or blood in stool, to be prevented from the beginning if bleeding.
Assess vital sign every 4 hour for observing abnormal sign.
Before 3 days the day of appointment advice the patient stopASA follow doctor order
Monitor Hct and Hb counts periodically to assess bleeding tendencies.
After injection has to press the injection area for 5-10min stop bleeding
Evaluation:
Hb=14.9g/dl
Hct= 44.8%
no bleeding, no black stool and petechiae
Evaluation Criteria:
Laboratory results normal range
Hb 12-16 g/dl
Hct= 38-47%
There was no gastrointestinal bleeding, hematemesis , no black stool
There is no bleeding on skin or petechiae
Subjective data: U/D heart disease
Objective data: The patient receive ASA
OR: Repair achilies tendon
Pre/Intra/Post operation care
Evaluation criteria
The patient knows how to prepare himself during Pre/intra/post operative periods.
The patient can answer the questions
The patient can practice all pre/intra/post
operative care
The patient has no abnormal signs and symptoms of operation(Massive bleeding,infection)
Intervention
Intra-operation
Monitor the patient's vital signs, respiration, blood pressure and pulse during the operation
Perform Cefazolin 2 gm to OR at 11:05,28th,March,2022
Post-operation
Assess vital signs every 15 min 4 times/hr and then 30 min 2 times/hr and 1 hr until stable and then check every 4 hr.
Assess the patient blood loss
Remind patient keep supine position 6 hours after surgery.
Assess pain score and administer pain killer follow doctor order Tramal 1 amp IV prn every 8 hours and obeserve the side effect such as sleepiness.headache.nervousness.uncontrollable shaking of a part of the body.muscle tightness.changes in mood.heartburn or indigestion.dry mouth.
Ask patient to raise his Right leg above the heart level for most of the 48-72 hours after surgery. For example, putting a pillow under the patient's lower leg will reduce swelling and pain.
Teach about early ambulation for post-operation and consult physiotherapist for teaching how to walk with walker(Non weight bearing right leg)
Wound care dressing day 3 after surgery, always keep the wound dry.
Tell the patient 10-12 days after the operation
At the first postoperative appointment, the splint will be removed. Check whether the wound is healed and remove the suture at this time.
Tell the patient that the second postoperative appointment will be made 2-3 weeks after the first postoperative appointment 4-5 weeks after the operation. Ankle movement will be examined and tendon healing assessed
Pre-operation
Pre-operation
Assess vital sign every 4 hours and assess vital sign before going to the operation room
Blood exam such as CBC, BUN, Cr, Electrolyte and chest x-ray, EKG, for prepare surgery
Tell the patient surgical site at heel
Provide an inform consent to the patient
Clean antiseptic solution and prep skin at Rt heel to prepare surgery.
NPO at 0：00（28th,March,2022）
Tell a patient common side effects of spinal block:low blood pressure. This can make dizzy or uncomfortable. can be
Controled through infusion and Administration;itching. Drugs can alleviate this symptom;headache. As the spinal block decreases Back off, may have a headache at the beginning of the activity)
Tell patient about diet,the patient need to eat 6-8 hours after operation. need to eat a small amount of light to promote gastrointestinal peristalsis
Tell the patient that if he wants to get out of bed, inform the nurse or medical staff at the first time to prevent falling
Prepare himself before going to the operation room such as take off necessary or valuables, denture, under wear, cleansing his face and cut his nails etc.
Keep a patient’s necessary or valuables in a safe place
Give the patient and talk with a patient for psychological support
Goals
Prepare the patient for Pre/intra/post operative care
The patient will gain knowledge about pre/intra/post operative care
Evaluation
The patient can cooperate during pre operation/Intra operation /post operation
The patient has stable vital sign
The patient Estimate blood loss less than 50ml
The patient is free from any complication from operation，no massive bleeding,no wound infection.
Supportive data
S:The patient said:I have no history of surgery
O:The doctor made an appointment for an operation at 10:30 on the 28th
Risk to falling
Nursing Intervention
Explain the bed settings to the patient including how bed remote controls works.
lift both side rails
Avoid wet floors
Ensure the availability of a call bell when in the toilet.
Provide adequate lighting
Provide proper shoes or slippers
Bed at the lowest level
Set personal stuff near the patient bed
Take care this patient closely
Nursing Goals
To prevent patient falling
Evaluation criteria
The patient doesn't has any injuries on his body
The patient doesn't fall from bed, doesn't slip and falls
Evaluation
No falling
Objective data : The patient received repair achilles tendon with heel spur removal with ancher screw under spinal block on 28th,March 2022
Discharge planning
Nursing Goals
Patient has knowledge about taking care himself
Patient is able to take care himself at home
Developing the patient's self-care potential
Evaluation Criteria
Cooperate in conducting and taking care of himself properly.
Nursing Intervention
Preparing the patient before discharge followed D-METHOD.
D Diagnosis : Rupture of achilles tendon with right heel spur
M Medication : Omg caltinum = Calcium for to treat bone
Ultracet = Observe sign and symptoms of medicine such as Nausea, vomiting, constipation, lightheadedness, dizziness, drowsiness and sweating.
ASA: Observe sign and symptoms allergic reactions like skin rash, itching or hives, swelling of the face, lips, or tongue, confusion, pain or swelling.
E Environment : The floor should not be too slippery to prevent slipping.
Economics: He can pay by himself, no health insurance
T Treatment : Avoid forceful active and passive range of motion of the Achilles for 10 - 12 weeks, no running, jumping, or ballistic activities for 6 months.
H Health : Advice on physical exercise for recovery after surgery and avoid wound contact with water, eat less salt, eat more fruit and vegetables, eat low sugar food.
O Outpatient referral : Should see a doctor immediately when there are abnormal symptoms as follows: Severe pain and not able to walk or put on weight, fever, red, swollen wounds or having discharge, etc.
Patient comes to check by appointment every time.(29/06/2022)
D Diet : Eat 5 foods group and eat foods high protein to help recovery wound, avoid to eat fat food, eat low sugar food and eat less red processed meat.
Evaluation
Patient cooperates in conducting and taking care of herself properly
Patient’s information
Thai male patient age 62 years old ID: 55448069
BW:74 Kg Height: 171 cm BMI=25.3
Admission Date: 27/03/2022
Admission Dx. Rupture of achilles tendon with right heel spur
CC: According to appointment for surgery
PI: 5 days PTA the patient fell down then right ankle swelling, redness, severe pain and can’t walk with weight, so he decided to come to hospital. Physician recommend him to surgery.
V/S= T36.5C Pulse88bpm BP133/95 mmHg RR18time/min SpO2 98%
PH: Underlying disease: DM,HT,DLP,Heart disease(Treat at Sirirat Hospital)
Refuse of drug and food allergy history.
Refuse of accident and surgery history.
Abnormal Laboratory
27/03/2022
Creatinine 1.37 mg/dL (High)
28/03/2022
Blood sugar 183 mg/dL (High)
Keep DTX 80-180 mg/dL
Abnormal Physical Examination
Extremities : Rupture of achilles tendon with right heel spur
Diagnosis
Pre-op diagnosis: Rupture of achilis tendon Rt with heel spur
Post-op diagnosis: Rupture of achilis tendon Rt with heel spur
Operation: Repair achilis tendon Rt with heel spur removal with anchor suture
Group members
Suwanna Sinlapee ID:61010173
Chonlada Wonganan ID:61010242
Yanyun Yang ID:61010311