Essay about Nursing Instructor

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Nursing Instructor

PHYSICAL HISTORY:

My clinical rotation was at St. Francis Hospital on the orthopedic/medical-surgical floor, 5-1. I was assigned JB for a patient 10/7 and 10/8. He was one day post-op from an elective bilateral knee arthroplasty.

JB is a 69 year old Caucasian male who stands 6 feet tall and weighs 251 pounds. He has a history of hypertension, benign prostatic hyperplasia, degenerative joint disease, and renal calculi. Medications taken at home: Nifedipine 60 mg. QD to manage his hypertension and nonsteriodal anti-inflammatories for the DJD.

JB's major problem is the degenerative joint disease (DJD) also referred to as osteoarthritis. According to Colodny, more than 50 million Americans suffer from
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JB was admitted to St. Francis on 10/6, the day of surgery. On post-op day one 10/7 his vital signs were: Pulse-84, Respirations-20, Blood Pressure-130/70, and Temperature 101.5 F. on 10/8 they were 86, 20, 135/74, and 102.0 respectively. All vital signs except for the temperature were within normal limits for this patient. He received Tylenol 650 mg. pm every 4 hours for elevated temperature. Laboratory results showed a low hemoglobin of 8.6g/dl (normal 12-16g/dl) and a low hematocrit of 25.2% (normal 36-41%). JB received 1 unit (500 cc) of RBCs on 10/7 and 10/8. All other laboratory values were within normal limits. The primary nurse felt the transfusions contributed to or caused the elevated temperature because JB showed no other signs of infection through physical assessment or laboratory values.

JB had clear lung sounds bilaterally. He had palpable pedal pulses and was positive for color, motion, and sensation in both affected extremities. Capillary refill was less than 2 seconds. His skin was warm and clean. He was diaphoretic due to an increased temperature. He had a quarter size reddened area on his coccyx that was being monitored and protective nursing interventions were instituted to prevent skin breakdown.
JB was oriented to time, person, and place.

SOCIAL HISTORY:

JB was born and raised in Connecticut. He and his wife have been married
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