I have no idea where to start! I am suppose to put together intervention priorites and I don't know what is priority. I'll give the entire scenario:
Mrs. T, 72 years old, fell at home and was admitted to the hospital with a fracture of the right hip. She was alert and oriented on admission. After the initial workup, she was taken to the surgery for an open reduction with internal fixation (ORIF) of her right hip. On her first postop day, her righ thip dressing has a small amount of dried, dark red drainage (is this significant?) She has an IV of D5/0.45 NS at 75 mL/hr., oxygen at 2 L/nasal cannula, clear liquid diet, and circulation, movement, sensation and temperature (CMST) neurovascular checks qfh to the right leg for the first 24 hours. The following medications are ordered: PCA with morphine sulfate delivering 1 mg/ hr continuously, FeSO4 325 mg po tid with meals (start when on regular diet), Colace 100 mg po daily, She is very restless and confused this morning.
I am given the following intervention and need to prioritize them
-assess surgical dressing -take VS -assess pain level -check oxygen saturation level -check neurovascular status of right leg (CMST)
then give rationale for them all after puting them in order
During the follow-up assessment for the first postop day, the nurse notes the following:
1. Pedal pulse present; weak in the right foot, stronger in the left foot
2. Hemoglobin 10.5 g/dL and hematocrit 32%
3. Bowel sounds hypoactive in all quadrants
4. Crackles in the lower bases of the lungs
Which of the following nursing diagnoses may apply to Mrs. T: acute pain, risk for infection, risk for impaired skin integrity, impaired urinary elimination, impaired gas exchange, fatigue, impaired physical mobility, ineffective tissue perfusion
-- of these what would be the Nursing diagnosis? then the rationale? then the nursing interventions?
On the second postop day Mrs. T is still very confused and is trying to get out of bed. She has bilateral scattered crackles in the lungs, shortness of breath on exertion, R 32 (what does this mean) and a non productive cough.
-then based on the situation above what is the priority problem of the following: take VS, check oxygen saturation, stay with patient, encourage incentive spirometer hourly, call physician, or encourage fluids. Once the priority problem is identified then these need to be put in priority order as well.
Then what would be your plan for follow-up care for Mrs. T.???
I've never done something like this and don't even know where to start