Care plan help with elderly man with fractured acetabulum

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My patient is an 88 year old very independent (takes care of wife, who is basically healthy, but with dementia) male who fell and fractured his left acetabulum. He has a history of HTN, hyperlipidemia, calcification of iliac, carotid and vertebral arteries, hearing impaired (wears hearing aids), dm (oral) for 20 years, with a prostatectomy due to cancer. He sounds in awful shape but his labs and assessment were very normal except for some anemia, thrombcytopenia that the doc attributed to trauma of the fall. His creatinine was a little high, at 151. He had 92% O2 when I took it, we were having problems with the ox pulsometer. He was not on O2. Alert, jovial, memory intact. The doc said to put no weight on the leg for 24 days. I only had 5 hours with him as this was our first day of clinicals so I am limited to my followup info. I really struggling with a priority diagnosis. The docs were all over him about his cardiovasc but he refused treatment, these were unspecified, or I did not find them on his chart. He is on the traditional meds you would expect, ACE inhib, betablockers, antiarhythmics, antianginal, antilipidemic, oxycodon for pain. His rhythm and rate were ok, skin intact, pedal pulses a bit weak, he did say he had neuropathy in his feet. VS: BP 114/69 37.0 pulse 74 resp 14

I chose ineffective tissue perfusion r/t calcification in his peripheral arteries, aeb O2 was a bit low, and weak pedal pulses. Secondary nursing diagnosis is impaired physical mobility r/t pain and musculoskeletal impairment aeb left acetabulum fracture, opioid pain meds, and history of falls.

When I saw him, I knew his history but he was not presenting any signs or symptoms of these besides the ones I mentioned. Am I on the right track? As far as evaluations, any ideas? Thanks!!

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Specializes in med/surg, telemetry, IV therapy, mgmt.

ok, first off think of your care plan as capturing this patient's nursing problems at one moment in time--like a photograph captures a picture of something happening and preserving that one moment in history. so, don't be concerned about followup info. your care plan is about this 88-year old's nursing problems and what you're gonna do about them as of that point in time where you entered his life. our job as nurses is to assist patients in responding to their diseases and conditions and helping them achieve their activities of daily living. in putting together the care plan we begin by collecting data and then sifting out the data that is abnormal. that abnormal data is what becomes the basis for the care plan. the data we are most interested in concerns the following:

  • prior health history (review of systems) - this is an 88-year old man who fell (what was he doing that brought on the fall?) and fractured his left acetabulum (part of the pelvic bone that articulates with the head of the femur). he also has been a diabetic for 20 years and has a history of htn, hyperlipidemia, calcification of iliac, carotid and vertebral arteries, and had cancer of the prostate. he is hard of hearing and needs hearing aids to hear. his wife has dementia and he is her primary caretaker.
  • physical signs and symptoms of disease or illness - i can't believe that in the 5 hours you spent care for this man that you didn't learn anything about his current condition other than he had weak pedal pulses. broken bones produce pain because of muscle spasm at the site of the break. you mention he is on oxycodon for pain but there is no assessment of pain. assessment and description of pain includes the following:
    • where the pain is located
    • how long it lasts
    • how often it occurs
      • a description of it (sharp, dull, stabbing, aching, burning, throbbing)

      [*]have the patient rank the pain on a scale of 0 to 10 with 0 being no pain and 10 being the worst pain

      [*]what triggers the pain

      [*]what relieves the pain

      [*]observe their physical responses

      • behavioral: changing body position, moaning, sighing, grimacing, withdrawal, crying, restlessness, muscle twitching, irritability, immobility
      • sympathetic response: pallor, elevated b/p, dilated pupils, skeletal muscle tension, dyspnea, tachycardia, diaphoresis
      • parasympathetic response: pallor, decreased b/p, bradycardia, nausea and vomiting, weakness, dizziness, loss of consciousness

you mention the doctor's concern about this patient's heart and i see he is on a number of heart medications. did he have any edema in the affected leg? what does "his rhythm and rate were ok" mean? did you talk with him about his heart problems? he doesn't think he has a heart problem and his vital signs seem to indicate that his medications are controlling his heart rate and blood pressure. if the doctors aren't stating he has an immediate heart problem i wouldn't force one on him. they are probably worried that his fall came about as a result of syncope which could be related to a heart condition which is why they are bugging him about checking out his cardiac status. what about his prostate and urination? what's this he says about having neuropathy in his feet? is this a complication of his diabetes? i'm curious about how he came to fall and wonder if this neuropathy in his feet had anything to do with his falling.

  • assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - this is big for someone who is ordered to have no weight bearing on the affected leg for 24 days. imagine not being able to stand on one of your legs for 3 weeks and you are 88 years old. how will you get up from a sitting position? how will you get up and down stairs? how will you stand and keep your balance? how would you put on and take off a pair of pants? another question i have is how will his wife get cared for while he is on restricted weight bearing? did you talk about this with him?
  • reviewing the pathophysiology, signs and symptoms and complications of their medical condition - you need this information to formulate the etiologies for some of your nursing diagnostic statements. i will tell you now that "calcification in his peripheral arteries" is not the same as calcification of iliac, carotid and vertebral arteries. peripheral vascular disease wasn't even mentioned as one of his medical diagnoses! calcification of iliac, carotid and vertebral arteries is something that was seen on an x-ray and means nothing without physical examination correlation and symptoms to accompany them. see:

    [*]reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking - ace inhibitor, betablockers, antiarhythmics, antianginal (chest pain is indicative of coronary artery disease), antilipidemic (indicative of high cholesterol), oxycodon for pain (where's the pain?), and, again, why the order for no weight bearing on the affected leg for 24 days?

after collecting information i am ready to diagnose. based on what you have (and haven't) posted. . .

  • impaired physical mobility r/t pain and order for no weight bearing on injured leg aeb [need evidence]
  • acute pain r/t trauma and muscle spasm aeb [description of pain]
  • deficient knowledge, fracture, treatment and discharge needs r/t lack of information aeb [need evidence]
  • risk for ineffective tissue perfusion, peripheral r/t immobilization of affected limb
  • risk for falls r/t history of previous fall, age of 88, need to use assistive device to ambulate, anemia, hard of hearing, neuropathy in feet, risk of blood sugar changes, and taking the following medications: ace inhibitors and narcotics for pain.

- - - - - - - - - - - - - - -

the problems with your diagnoses are as follows:

ineffective tissue perfusion r/t calcification in his peripheral arteries aeb o2 was a bit low and weak pedal pulses.

  • the place or organ of the
    ineffective tissue perfusion
    needs to be identified in the title. i presume you meant
    ineffective tissue perfusion, peripheral.
    this diagnosis specifically refers to the tissues not getting enough oxygen.

  • the
    r/t
    , or etiology, must tell the most rational reason why the tissues aren't getting enough oxygen. do we know? what is preventing the oxygen from getting to the tissues? how does
    calcification in his peripheral arteries
    have anything to do with oxygen getting to the tissues? i'm not getting the connection. blood is the substance that carries oxygen and how the oxygen gets transported to the cells of the body. calcium has no connection with it.

  • the
    aeb
    items are your evidence of the
    ineffective tissue perfusion, peripheral.
    think of them as your proof that the
    ineffective tissue perfusion, peripheral
    exists. if the tissues of the feet and legs are not getting enough oxygen what will you see? pale, cyanotic or other skin discolorations, temperature changes in the skin, weak pulses, bruits over the arteries if you listen to them with your stethoscope, edema, there may be no hair or shiny skin. however,
    o2 was a bit low
    is a measure of the patient's respiratory status and has nothing to do with the oxygenation of the tissues.

impaired physical mobility r/t pain and musculoskeletal impairment aeb left acetabulum fracture, opioid pain meds, and history of falls.

  • as i mentioned above, the
    aeb
    items are your evidence of his
    impaired physical mobility
    (limitation in independent, purposeful physical movement of the body or of one or more extremities).
    all of your
    aeb
    items fail as evidence that would support or prove
    impaired physical mobility.

    • left acetabulum fracture
      is a medical diagnosis and does not even come anywhere near describing physical movement.

    • opioid pain meds
      are a medical treatment for pain ordered by the physician.

    • history of falls
      is an anticipated (potential) nursing problem that has its own risk factors (a total of 9 for this patent) and needs to stand as it's own diagnosis with goals and nursing interventions. it cannot be a symptom of another nursing diagnosis,
      impaired physical mobility.

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