Day 1, 0700:
72-year-old client was admitted to preoperative holding for right hip total arthroplasty. Client has a history of hypertension and COPD. Client had left hip total arthroplasty 4 years ago. Client has smoked half a pack of cigarettes per day for 50 years. Denies alcohol or illicit drug use.
Day 1, 0700:
Client is sitting quietly in no distress. S1 and S2 auscultated; no murmur, gallop, or rub noted. Breath sounds noted to have faint wheezing bilaterally. Client has a barrel chest. Client moves all extremities well.
1400:
Client admitted to the medical-surgical unit following the procedure. Client reports pain as 7 on a scale of 0 to 10. Operative leg supported with pillows. Abduction device secured.
Day 2, 0700:
Client states, "l feel pretty good, considering." Client requests a cup of ice for dry mouth. Reports pain as 4 on a scale of 0 to 10. Instructed client regarding coughing and deep breathing exercises. Encouraged client to continue to use incentive spirometer.
1000:
Nurse called to the client's room. Client's family reports that client became short of breath "out of nowhere." Client noted to be diaphoretic and agitated. Tachycardia noted. Breath sounds noted to have faint wheezing with crackles bilaterally. Equal chest expansion, barrel chest. Right leg immobilized, 1+ edema to the right leg. Abduction device straps loose.
Day 1, 0700:
Temperature 370 C (98.60 F)
BP 158/78 mm Hg
Heart rate 95/min
Respiratory rate 18/min
Oxygen saturation 98% on room air
Weight 136 kg (299.8 lb)
Height 177.8 cm (70 inches)
BMI 43.2
Day 2, 1000:
Temperature 370 C (98.60 F)
BP 162/90 mm Hg
Heart rate 111/min
Respiratory rate 24/min
Oxygen saturation 91% on room air