Nursing Care Plan Help Please!!!

[lopez123]

Can someone please help me?! I've been working on this nursing diagnosis care plan for hours and keep second guessing myself. My teacher gave us a scenario and wants us to write 2 care plans, 1 about a physical diagnosis, and another about a psychosocial diagnosis, with a long term goal and short term goal, etc. I keep wanting to aim towards Impaired physical mobility but I don't know if that's right. any help would be greatly appreciated!! Here is the scenario:

"L.R is a 78 year old Caucasian female. She is widowed and lives in an assisted nursing facility. Her daughter has medical and financial power of attorney and lives in town. LR is Roman Catholic. She has no known allergies. She is a full code

LR was admitted to the hospital due to a fall that the doctors suspect is secondary to several days complaints of light headedness. Her BP on admission was 80/60. Additional medical diagnosis include: history of hypertension, falls, osteoporosis and osteoarthritis in the rt. knee. On admission the patient showed the doctors the medications she took today (this am). Patient took 50 mg hydrochlorothiazide, 10 mg alendronate, and 600 mg calcium carbonate at home this morning. Patient reports that she might have inadvertently taken 2 tabs (100 mg) of hydrochlorothiazide. She is complaining of pain in her rt hip8/10. Rt hip is red, edematous and warm with limited ability to bear weight and bed mobility due to pain, x-ray indicates no fracture. She has an order for 0.2mg hydromorphone IV push every 6 hours. She has an IV in her rt. antecubital site infusing .09% NS at 75 mL/hr. She is on a 3 gm sodium diet. She is alert and oriented X 3. Speech is appropriate and follows conversation. Mucus membranes pink, moist, skin turgor over sternum

therapy/occupational/nursing evaluate and treat for home safety. Monitor skin integrity/prevent pressure ulcers, manage/teach constipation"

[windsurfer8, BSN, RN]

Are you going to trust your homework to someone online who may or may not even be a nurse? On this site are RNs, LPNS, CNAs, APRNs, etc,,,and a ton of students..and probably bored people who have nothing to do with nursing.

[lopez123]

I'm only looking for other perspectives, not copying and pasting people's answers. just wanted a better insight on the topic, I'm sure I'd be able to tell if it was wrong.

[Julius Seizure]

This has lots of possibilities that I see. Sounds like her two big issues are #1 that she was injured from a fall, yeah? And #2 sounds like she has a preexisting condition that she's being treated for.

So you could go in a few directions.

-what are you worried about with issue #1? What can be done to help her in the short term? What might have caused issue #1 and how can it be prevented from happening again so that she can have the best level of health she can have at home (what can help in the long term?)

-what is going on with issue #2 and do you think her current treatments are working okay? Anything that you think needs to be worked on to get her to the best level of health that she can have?

[lopez123]

Thank you for your input! I ended up using this diagnosis statement, Impaired physical mobility r/t falling aeb pain in rt. Hip 8/10. I'm sure there are plenty of diagnosis I could have used. now I have to figure out a psychosocial diagnosis, I was thinking ineffective health maintenance..