Care plan help for hip fracture

  1. 0
    I am having a hard time coming up with 3 nursing dx for my patient(2 physical, 1 psychosocial) and possible interventions. Here is the background information:
    Patient admitted for R hip fracture due to fall. Patient came from the nursing home and is alert and oriented x1, agitated. Hx of Alzheimer's. When admitted, patient also had pnuemonia, which put a hold on surgery. The patient's pneumonia got worse each day, so they decided to make the patient comfort care and not perform the surgery. Vitals were WNL. Patient on 2 L O2, foley, wears a brief, wearing mitts due to agitation, q2h turn, +3 edema in right lower leg. The problem is that the patient will not tell you if he is having any pain. He just keeps saying "I'm fine". On my last day with this patient, we were also concerned of a DVT in the right lower leg, but didn't look into it any further due to him being on comfort care at the time. The patient's heparin was d/c 2 days prior due to an elevated INR.

    So far, I am thinking
    Nursing dx 1: Right Hip Fracture r/t musculoskeletal impairment
    Interventions: q2h turn, monitor for skin breakdown, not sure about others

    Nursing dx 2: I am having a hard time coming up for this one related to the pneumonia. The patient's CXR showed a large area of infiltrate in the right upper lobe, left lower lobe consolidation, and bilateral pleural effusion. I am thinking Ineffective breathing pattern r/t fluid accumulation and inflammation?
    Nursing Interventions: Monitor rate, depth, and ease of respirations, Monitor for signs of hyperventilation, Monitor O2 sats

    Nursing dx 3: Chronic confusion r/t alzheimer's disease. I don't really like this one but I can't think of a bettter dx for symptoms of alzheimer's, agitation, confusion, etc...


    Any help is greatly appreciated.
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  4. 1
    Welcome to AN! The largest online nursing community!

    What semester are you? Is this your first care plan? Right hip fracture is NOT an approved NANDA I diagnosis. What care plan reference do yo use?

    You gave a lot of descriptions of her medical condition and medical diagnosis...but no assessment of the patient.

    Care plans are all about the assessment...of the patient. Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

    The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first. From what you posted I do not have the information necessary to make a nursing diagnosis.

    Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

    Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

    Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly.

    Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics. From a very wise an contributor daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.


    Here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan: ADPIE
    from our Daytonite

    1. Assessment (collect data from medical record, do a physical assessment of the patient, assess ADLS, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
    2. Determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
    3. Planning (write measurable goals/outcomes and nursing interventions)
    4. Implementation (initiate the care plan)
    5. Evaluation (determine if goals/outcomes have been met)

    Care plan reality: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be the medical disease, a physical condition, a failure to perform ADLS (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the nursing process.

    Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers (interview skills). Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

    A nursing diagnosis standing by itself means nothing. The meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient......in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are. Although your patient isn't real you do have information available.

    What I would suggest you do is to work the nursing process from step #1.

    Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLS (because that's what we nurses shine at). The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you.

    What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient.

    Did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list.

    This is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

    Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

    Another member GrnTea say this best......
    A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(nursing diagnosis)_____ . I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics) ________________. He has this because he has ___(related factor(s))__."


    "Related to" means "caused by," not something else.


    Last edit by Esme12 on May 18
    RunBabyRN likes this.
  5. 0
    Hip fracture is not a nursing diagnosis. Do you have a copy of the NANDA nursing diagnosis manual? This should be required for every nursing student.
    Esme's advice on this is always great, and I'm sure GrnTea will be along soon to post hers! They have really helpful info. Ultimately, you'll need to look this up and think through it. Look beyond the medical diagnosis.
  6. 1
    Quote from Esme12
    Welcome to AN! The largest online nursing community!

    What semester are you? Is this your first care plan? Right hip fracture is NOT an papproved NANDA I diagnosis. What care plan reference do yo use?

    You gave a lot of descriptions of her medical condition and medical diagnosis...but no assessment of the patient.

    Care plans are all about the assessment...of the patient. Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

    The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first. From what you posted I do not have the information necessary to make a nursing diagnosis.

    Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

    Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

    Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly.

    Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics. From a very wise an contributor daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

    Here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan: ADPIE from our Daytonite

    1. Assessment (collect data from medical record, do a physical assessment of the patient, assess ADLS, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
    2. Determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
    3. Planning (write measurable goals/outcomes and nursing interventions)
    4. Implementation (initiate the care plan)
    5. Evaluation (determine if goals/outcomes have been met)

    Care plan reality: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be the medical disease, a physical condition, a failure to perform ADLS (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the nursing process.

    Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers (interview skills). Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

    A nursing diagnosis standing by itself means nothing. The meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient......in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are. Although your patient isn't real you do have information available.

    What I would suggest you do is to work the nursing process from step #1.

    Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLS (because that's what we nurses shine at). The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you.

    What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient.

    Did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list.

    This is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

    Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

    Another member GrnTea say this best......
    Sorry Esme, What I meant to put for the first dx was activity intolerance r/t musculoskeletal impairment. This is my first care plan and it is my second semester. Some more assessment data is diminished breath sounds in the left lower lobe, use of accessory muscles, O2 92% on 3L O2, HR 85, BP 136/78, Temp 99.0 F, Pain 0, RR 24, bowel sounds hyperactive x4, foley, wears briefs, radial pulses equal bilaterally, bilateral grips weak, cap refill brisk, good skin turgor, stage 2 pressure ulcer right gluteal fold, several abrasions due to recent fall, 3+ pitting edema right lower leg, pedal pulse absent in R lower limb and thready in Left lower limb. possible DVT right lower extremity.

    My problem is the patient reports no pain, only responds to pain when we turn him q2h, does not help with ADL's. He is on comfort care, so I don't know how much I should do for him with the nursing dx if that makes sense.

    Activity Intolerance r/t musculoskeletal impairment and Ineffective breathing patterns r/t fluid accumulation and inflammation aeb RR 24 and diminished breath sounds Left lower lobe. How much do you really perform in your nursing interventions when someone is on comfort care? Obviously q2h turns are important to make the patient comfortable... Thanks for your help
    Esme12 likes this.
  7. 1
    I do have a nursing diagnosis book. I have to put 3 medical diagnosis on my care plan so I had a brain fart when I put that! Lol
    Esme12 likes this.
  8. 1
    Quote from bgeorge90
    Sorry Esme, What I meant to put for the first dx was activity intolerance r/t musculoskeletal impairment. This is my first care plan and it is my second semester. Some more assessment data is diminished breath sounds in the left lower lobe, use of accessory muscles, O2 92% on 3L O2, HR 85, BP 136/78, Temp 99.0 F, Pain 0, RR 24, bowel sounds hyperactive x4, foley, wears briefs, radial pulses equal bilaterally, bilateral grips weak, cap refill brisk, good skin turgor, stage 2 pressure ulcer right gluteal fold, several abrasions due to recent fall, 3+ pitting edema right lower leg, pedal pulse absent in R lower limb and thready in Left lower limb. possible DVT right lower extremity. My problem is the patient reports no pain, only responds to pain when we turn him q2h, does not help with ADL's. He is on comfort care, so I don't know how much I should do for him with the nursing dx if that makes sense. Activity Intolerance r/t musculoskeletal impairment and Ineffective breathing patterns r/t fluid accumulation and inflammation aeb RR 24 and diminished breath sounds Left lower lobe. How much do you really perform in your nursing interventions when someone is on comfort care? Obviously q2h turns are important to make the patient comfortable... Thanks for your help
    So lets look at this. Do you know what comfort care means? If not, do some reading on it. Maybe determine the facility's protocols for it. If this person is DNR/DNI, and your goal is to promote comfort, what does that mean? Do they discontinue life sustaining treatments? Or does it simply mean no extraordinary efforts? Are they looking into that DVT? Will they do anything about it? Knowing the answer to this might present a nursing diagnosis for you.

    Look at Maslow. If you look at physiologic needs for someone with Alzheimer's, pneumonia, and a hip fracture, what does this patient NEED? Consider ABCs. 92% with 3L. Why?

    I'm not a fan of activity intolerance for this patient, although my thinking on this may be incorrect. The thing is, this person is in bed with q2h turns. There is no activity to tolerate. Also, if the patient is not reporting pain, go with your gut on it - don't use it.

    For your psychosocial diagnosis, this person went into the hospital with a hip fracture, which should be an easy thing. (Well, not literally easy, but comparatively, in the grand scheme of reasons for hospitalization.) But instead of things going as planned, somewhere between the Alzheimer's and persistent pneumonia, his is now officially at the end of his life. Imagine the emotional response to that, maybe not just for him, but for his family as well. Also here, consider what comfort care means. What exactly is COMFORT? It's not only physical, but also emotional.

    The best way to determine nursing diagnoses, especially when you are first getting used to them, is to think to yourself, what does this person need? Put the whole situation together, thinking through how complicated it is, and imagine what this person needs. If they can't or don't tell you what it is that they need, imagine if it were you, or your family member. What would you need? Prioritize based on Maslow and ABC and you'll be good to go.
    Esme12 likes this.
  9. 1
    Looking in my NANDA-I 2012-2014, which you must have to make proper nursing diagnoses (and no, "care planning handbooks" do not have current info if they were published before 2012), I find the nursing diagnosis of "impaired comfort," which is a perfectly acceptable nursing diagnosis if your patient has at least one of the defining characteristics (I'll be he does, you just haven't given us your full nursing assessment because you focused on the medical diagnosis) and at least one related factor (I'd go with the first one, "Illness-related symptoms," since whether he c/o pain or not, a fractured hip is painful and I am sure he's uncomfortable being confined to bed and being on a turn schedule because he cannot put himself in a position of comfort whenever he wishes).

    Also, remember that the person in the bed is not the only person for whom you are learning to plan nursing care. Look at some of the psychosocial nursing diagnoses to see if any of their defining characteristics and related factors apply to his family or home caregivers. I'll bet they do. $29 and free two-day shipping for students from Amazon, and $25 and instant delivery to your Kindle or iPad. Do it now.
    Esme12 likes this.
  10. 0
    Also risk for infection from that foley. Was pt previously mobile? Risk for falls if he tries to get OOB. Constipation from immobility and opiates, fear, anxiety, maybe impaired sleep?
  11. 0
    You have been given some great responses

    A few diagnosis that pop in my head are

    Risk for falls
    Alteration in comfort
    Risk for infection (uti)
    Alteration in respiratory status

    Is family involved?
    Then you have more diagnosis related family caregiver
  12. 0
    Quote from bgeorge90
    Sorry Esme, What I meant to put for the first dx was activity intolerance r/t musculoskeletal impairment. This is my first care plan and it is my second semester. Some more assessment data is diminished breath sounds in the left lower lobe, use of accessory muscles, O2 92% on 3L O2, HR 85, BP 136/78, Temp 99.0 F, Pain 0, RR 24, bowel sounds hyperactive x4, foley, wears briefs, radial pulses equal bilaterally, bilateral grips weak, cap refill brisk, good skin turgor, stage 2 pressure ulcer right gluteal fold, several abrasions due to recent fall, 3+ pitting edema right lower leg, pedal pulse absent in R lower limb and thready in Left lower limb. possible DVT right lower extremity.

    My problem is the patient reports no pain, only responds to pain when we turn him q2h, does not help with ADL's. He is on comfort care, so I don't know how much I should do for him with the nursing dx if that makes sense.

    Activity Intolerance r/t musculoskeletal impairment and Ineffective breathing patterns r/t fluid accumulation and inflammation aeb RR 24 and diminished breath sounds Left lower lobe. How much do you really perform in your nursing interventions when someone is on comfort care? Obviously q2h turns are important to make the patient comfortable... Thanks for your help
    You are falling in to the trap that all students fall into. You see a diagnosis you like and try to retro fit the patient into it.

    What is most important or a priority to this patient? It is still the ABC's. Just by what you wrote here is what I see.....

    Ineffective Airway Clearance: does he have an effective cough?
    Ineffective Breathing Pattern: he has retractions, low O2 sat, and accessory muscle use, pneumonia
    Impaired Gas Exchange: low O2 sat, diminished breath sounds, pneumonia
    Ineffective peripheral Tissue Perfusion: diminished absent pulses, possDVT
    Impaired Tissue Integrity: stage 2? or absent pulses
    Impaired Skin Integrity: stage 2
    Acute Pain: he has a fractured/broken hip and grimaces with turning, B/P 136/78
    Impaired physical Mobility: he is bedridden and a fractured hip
    Hyperthermia: he has a fever
    Risk for compromised Human Dignity: Just because he is dying and needs to be cared for appropriately and with dignity. It shouldn't affect your nursing care. While the medical interventions might differ or be non existent we still give them appropriate nursing care for comfort.

    Now look these upin NANDA I or your care plan resource and tell me what you think applies. What part of your patients assessment fits the definition in the book.
    Last edit by Esme12 on Mar 14


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