Patient Care Summary: Mrs. Sally Smith
Introduction
- Care team: Nicole, Jen, and Sam (nurses)
- Patient: Mrs. Sally Smith
- Date of Birth: 5/26/67
- Location: PMI Hospital
- Reason for Admission: Elective knee surgery
Initial Assessment
- Allergy band checked: Allergic to codeine
- Mental orientation confirmed: Correctly identified hospital, date, and reason for visit
- Code word for family information sharing: "Twinkle"
Vital Signs and Initial Checks
- Vitals: Blood pressure slightly elevated
- Medical history: Hypertension
- Medications ordered: Metoprolol (25 mg), Rocephin (antibiotic)
- Heart and lung assessment: Clear lungs, regular heart rate (sinus rhythm at 95)
- Abdominal assessment: Hypoactive bowel sounds (common post-surgery)
Pain and Medication Management
- Post-surgery knee pain: Rated 7/10, sharp and stabbing
- Tylenol administered but insufficient
- Physician called for stronger pain medication: Morphine 2 mg IV push
Additional Assessments
- Foley catheter: No infection, 300 ml clear yellow urine
- Lower limb pulses checked: Good capillary refill
Intervention and Education
- Oxygenation: Shortness of breath; adjusted nasal cannula from 2 to 3 liters
- Incentive spirometer introduced to prevent pneumonia
- Instructions: Use 10 times every hour
Morphine Administration
- Educated on morphine effects: May cause drowsiness, respiratory depression
- Continuous monitoring required
Follow-up and Case Management
- Case management to provide rehab resources
- Pain level improved post-morphine: Reduced to 3/10, no sharp pain
- Blood pressure improved: 130/78
Final Instructions
- Call light and tray table provided
- Hourly rounds scheduled
- Encouraged to call nurses if needed
Physician Collaboration
- Sam communicated with Dr. Palacios
- Discussed pain management and medication adjustments
- Morphine agreed for pain control every two hours as needed
These notes summarize the important care activities, patient assessments, and interventions provided to Mrs. Sally Smith post knee replacement surgery, including pain management and patient education to ensure recovery and comfort during her hospital stay.