[Solved]: NUR 114 Clinical Judgement Mapping Activity for…

NUR 114 Clinical Judgement Mapping Activity for SimulationClient: Michael Martin Age: 70 BD: 8/25/19xxNurses note: Client is a 70-year-old male currently on the rehab unit for Physical Therapy (PT) after undergoing a left knee replacement 1 week ago to treat osteoarthritis. Client complains of pain in left knee and has been taking Percocet 2 3x a day. He is ambulating with walker and is attending PT twice a day. He is eating well and consumes 100% of his meals. Client states he has noted a change in his bowel movements since surgery. He complains of constipation.Last evening, he was complaining of suprapubic pain, dribbling of urine and incomplete emptying of the bladder. A bladder ultrasound showed a volume of 700 mL. He was diagnosed with acute urinary retention. A 16F (10 mL balloon) indwelling urinary catheter was inserted to gravity drainage as per health care provider orders. A urinalysis sent to the lab.Client reported early this morning that he was looking forward to a better quality of life with decreased pain and increased activity after his surgery. He stated: I was looking forward to going home soon. Now I have this tube in my bladder. How do I manage this? How can I go to PT today? Patient education to be provided.Social history: He currently lives with his wife of 45 years and attends Sunday services regularly at the local Methodist church when he is home.Medical HistoryMedicationL knee replacementAcute urinary retentionOsteoarthritisHTNHyperlipidemiaBPH Hydrochlorothiazide 25 mg po once daily Losartan 50 mg po once daily Finasteride 5 mg po once daily Atorvastatin10 mg po once daily in the evening Acetaminophen 650 mg po every 4-6 hours for pain level 5 or less. Do not exceed 3 g/24 hours Percocet 5/325 give 1 tablet po every 6 hours as needed for pain level 6 or greater. Milk of Magnesia Suspension (400 mg/5 mL) Give 30 mL po at bedtime if no BM in 3 days. Bisacodyl Suppository 10 mg. Insert one suppository rectally as needed for constipation not relieved 8 hours after administration of Milk of Magnesia UrinalysisNitrite: negativeColor: yellowRBC: traceClarity: clearWBC: 0-3/hpfSpecific Gravity: 1.015Bacteria: negativeProtein: NegativeEpithelial: negative Vital signsPain assessmentTemp: 97.5 FP changing position; standing up, movingApical 72 – regularQ throbbingRadial 72 – regularR L kneeResp – 18S 7/10 BP: 124/72 L armT especially after Physical Therapy; Taking Percocet helps the pain. Physical AssessmentGeneral SurveyAOx3, wears glasses. Weight: 94 kgCirculation/PerfusionApical and radial 72, HR regular, cap refill <3 sec, negative edema, no tenting, +2 peripheral pulses bilaterally both upper and lower extremities.RespiratoryClear breath sounds, no cough, O2 saturation 97% on room air, Denies SOB/DOE and orthopneaNeurologicalMusculoskeletalFull weight bearing, ambulates with use of walker+5 BUE, +5 RLE, +3 LLE, requires rest after PTGILow fat, low salt diet, hypoactive +BSx4, + flatus, small hard BM 3 days ago, occasional LLQ tendernessGU16 F (10 mL balloon) Indwelling urinary catheter to gravity drainage; Change to leg bag during daytime hours. Initial output on catheterization 800 mL yellow urine. Output 400 mL from 11 pm 7 am.IntegumentaryIncision on left knee, dry and intact Based on the Case Study for Michael Martin, identify 3 priority problems based on the assessment data. Include one client outcome and the interventions that help you to reach this outcome. Identify risk for nursing problems. Client problem #1 Outcome: Assessment data Interventions:Client problem #2 Outcome: Assessment dataInterventionsClient problem #3 Outcome: Assessment data:Interventions Safety and Risk reduction: What problems can you anticipate that could further complicate the clients recovery. Risk for: