NSG 110 Patient Inda Butler Nursing Care Map Discussion
INDA BUTLER IS 60 YO AND WORKS FULL TIME AS A RECEPTIONIST FROR 25 YEARS. sHE HAS HEALTH INSURANCE BUT MANAGED CARE, sHE HAD SURGERY YESTERDAY TO REPAIr A RUPTURED DISC.
She has a history of chronic lower back pain, hypertension, and stress urinary incontinence She has severe pain after her surgery with a small back incision. She has been on bed rest and has requested pain meds. Her husband is a paraplegic and is wheelchair-bound. She is the only wage-earner as her husband is on fixed disability and needs to return to work as soon as possible. she is the primary caregiver for her husband but may need rehabilitation and physical therapy upon her return home. Her orders are as follows: Vital signs per routine
Pt may have clear l liquid diet to start and then advance as tolerated
BRP WITH HELP
IV D5.45 NS at 50 ml /hr
Cefazolin I gm iv every 8 hours.
Change dressing as necessary after first change by surgeon
Use incentive spirometry 10x/hr while awake
Morphine 5 mg iv every 4-6 hours for pain
When tolerating PO . Percocet 1-2 tabs PO every 4-6 hours for pain
Physical therapy consult
Pt to use a walker while up
Medications – Amlodipine 10 mg PO daily for HTN
Oxybutinin 5 mg extended release for sui
Discharge planning for PT