I am taking an Rn refresher course and I have to write a careplan for the following pt. Male 69 yo with admitting DX of dehydration and pressure ulcer over a fractured R hip. He reported that he fell at home where he remained on the for for 30+ hours before he was discovered and admitted to the hospital.
Admission nursing assessment T 36.5; BP 80/50; pulse 98;respirations 24: wt 116 height 5' 8".
Clothes are dirty with urine . Pt grasps your arms and pulls at the bedrails yelling," Let me up, my cat is out there!" he cannot tell you where he is or why his hip hurts. When you ask him to tell you today's date, he again wants to get up and feed the cat that is in the other room.
Acute confusion R/t unknown causes manifested by fluctuation in cognition and psychomotor activity
Pain r/t tissue trauma manifested by report of pain and restless behavior
Increase risk of Infection r/t tissue injury ( Not sure of how to word the manifested by part)
Nutrition less than body requirements r/t inadequate intake manifested by ,10% IBW
I am really having trouble with this one ---especially inerventions as he is in such a confused state and he may be pre-op NPO so not sure what to do here for goals or interventions.
not sure what to do with his psychosocial dx Social isolation??
What i really am struggling with is that there is this patient is a bit of a puzzle--it is sort of a chicken and the egg question. Did the fracture, pain, fluid /food status, cause his confusion or is his confusion the cause of his pathophysiology. Not knowing this is making the interventions and diagnosis, goals and interventions difficult. I have been out of Nursing so long and this is becoming so frustrating----any help would be appreciated.
