Case NURSING NR325

Max Boardman is a 52-year-old male who was admitted for a possible deep joint infection following a total left knee arthroplasty two weeks ago. The patient experienced swelling and redness in his knees for the past four days prior to admission. Past medical history consists of hypertension, coronary artery disease, rheumatoid arthritis to the left knee and bilateral wrists. He is allergic to penicillin and is a full code. His home medications are atenolol 25mg PO once daily and chlorthalidone 25mg PO once daily. He is single and reports being a social drinker and does minimal exercise. His current set of vital signs include a temperature of 38.8 C; pulse of 102; respirations of 20 and unlabored; blood pressure of 140/86; an SpO2 of 98%; and he is alert and oriented to person, place, time, and situation. His skin is warm and diaphoretic. IV site is intact. Surgical site is red, warm, and slightly swollen with no drainage. Nails are without ridging, pitting, or peeling. Skin rapidly returns with skin turgor assessment. Capillary refill of fingers and toes is less than 3 seconds. Head is normocephalic with no massess or deformities. Facial features are symmetric. Conjunctiva is pink and sclera is white. No signs of ptosis, edema, or swelling. Pupils are equal, round, reactive to light, and accommodating. Ears without edema or discharge. Tympanic membrane is translucent with no scarring noted. Nose is without drainage or polyps. No tenderness to the frontal and maxillary sinuses. Gag reflux intact. No swelling or ulcerations of the mouth. Tongue is pink. Neck has no scars or lesions present. Trachea is midline. Thyroid firm and with no nodules. No enlarged lymph nodes. Chest anterior posterior to transverse is appropriate. No tactile fremitus. Appropriate lung sounds anteriorly and posteriorly. Heart sounds are appropriate. Abdomen with no scars, lesions, or striae. Bowel sounds active in all four quadrants. No pain, masses, or pulsations of the abdomen. No rebound tenderness. Spleen is not palpable. Right knee hurts upon palpation. Full range of motion to upper extremities. Limited movement to bilateral wrists. Full range of motion to right lower extremity. Limited range of motion to left lower extremity due to pain. Cranial nerves II-XII intact.