Making a decision - nursing care plan

[Aus_nurse_Brissy]

hi

i have the following q for an assignment. i think i have the right ides but would appreciate some guidance.

thanks in advance

case scenario

stan smith is an 82-year-old male admitted to hospital via the emergency department. he

tripped and fell on the pavement outside his home. he has a history of type 2 diabetes and has a 60 pack-years (1 pack per day for 60 years) smoking history. he lives alone but has a daughter in the next suburb and a son who lives interstate.

on admission to the emergency department mr smith presented as follows:

- glasgow coma scale 15

- heart rate 108/minute and regular

- blood pressure 166/94 mmhg

- respiratory rate 24/minute, shallow, slightly laboured

- spo2 97% on 3l oxygen/minute via nasal prongs

- temperature 36.9c

- haematocrit 0.30%

- haemoglobin 130 g/l

- wbc 10 109/l

- prescribed oral metformin for his type 2 diabetes

neurovascular assessment findings:

right leg left leg

- colour pale pink

- temperature cool warm

- capillary refill > 2 secs

- distal pulses present present

- oedema yes, to hip nil

- sensation decreased full

mr smith complained of excruciating pain in his right leg and hip and was given ivi morphine with effect. there was some bruising and skin discoloration to his right upper thigh. his right leg was externally rotated and slightly shorter than the left.

he was diagnosed with a subtrochanteric fracture of the right hip and has just returned to the ward post operatively following an open reduction and internal fixation (orif) with

compression plate and bone screws of the right femur.

on return to the ward:

- vital signs are stable

- bsl within normal limits

- on supplemental oxygen to maintain his oxygen saturations above 95%

- iv infusion - patient controlled analgesia (pca) for pain management using morphine

1mg bolus dose with a 5 minute lockout

- ivt d/saline running 8 hourly

- ordered low molecular weight heparin

- order for low-dose haloperidol as a prn order for post operative delirium if needed

- fluid balance chart

- ted stockings in situ on both legs

- bellovac drain insitu - to be removed in 24 hours

- mobilise in 24 hours with physio

question 1

explain the underlying pathophysiology of subtrochanteric hip fracture and bone healing following orif. use current literature to support/justify.

all good with this one :-)

question 2

discuss the immediate prioritised post operative care for mr smith using current evidence and literature to support/justify your reasoning:

a. identify nursing problem/diagnosis - priority 1

i decided on this -

acute pain related to tissue and bone trauma, disruption of skin integrity through and surgical incision and oedema.

o identify four (4) key pieces of assessment data to support this problem

1. patient states he has pain

2. iv infusion - patient controlled analgesia (pca) for pain management using morphine 1mg bolus dose with a 5 minute lockout.

3. open reduction and internal fixation (orif)

4. age

5 use body systems assessment framework

6 briefly outline the underlying pathophysiology for each assessment data

7 discuss two (2) relevant interventions and justify your clinical reasoning

not sure about these.......

8 outline two (2) specific evaluation criteria that would indicate that the

interventions were successful

....or these.....

b. identify nursing problem/diagnosis - priority 2

i chose - impaired tissue integrity related to surgical intervention and physical immobility.

o identify four (4) key pieces of assessment data to support this problem

1. smoker

2. diabetes

3. age

5. immobility/wound site

6 use body systems assessment framework

7 briefly outline the underlying pathophysiology for each assessment data

o discuss two (2) relevant interventions and justify your clinical reasoning

not sure about these....

o outline two (2) specific evaluation criteria that would indicate that the

interventions were successful

(approximately 1200 words - ie 600 words per problem).

question 3

briefly discuss the two (2) most likely complications that mr smith may develop post

operatively. use current literature to support. (approximately 400 words).

i have chosen dvt and infection but am not sure how to write them as nursing diagnosis......

[nurseprnRN, BSN, RN]

use body systems assessment framework

briefly outline the underlying pathophysiology for each assessment data (does this mean for admission to the er? i don't see any postoperative assessment data)

o discuss two (2) relevant interventions and justify your clinical reasoning

not sure about these.......

o outline two (2) specific evaluation criteria that would indicate that the

interventions were successful

....or these.....

this means, look at your assessment data and what physiology was involved to make the findings what they are. what physiology, for example, is involved in pain? edema? having a pale, cool leg? leg rotated and shortened? having a low-ish body temp?

what are two things you would do about each of them? why?

how will you know that each of your interventions worked?

i used to suggest that my students make a grid to figure these out. wide columns across the page, with an assessment datum in each at the top. yours would then divide those columns in half, and the labels on rows would say, "interventions." since you need two for each, you'd divide that in half, too, so you have two interventions per finding. below that you have your success criteria-- how do you know they worked?

as a brief example (not fully fleshed out), take the shortened, rotated leg. physiology: femur is no longer intact; weight of foot rotates leg to the side, muscle spasm shortens the limb since femur isn't whole. interventions: blanket roll or sandbags along outer leg to immobilize in neutral position (physician may have to establish position before immobilization), pain med to decrease spasms. evals: well, what do you think?