Intervention to a patient with a hip fracture

  1. 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
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    About mmgaff22

    Joined: May '09; Posts: 2


  3. by   Navidea
    ABC = airway, breathing circulation. Remember, no O2, no healing. So what would come first?
  4. by   daveintexas8
    OK. I'm just a student still, but I'm 3 semesters in, so here's where I'd start:

    You always start with ABCs. I am curious though, how the book would list the interventions, as I would consider the O2 sat % to be done with vitals. I guess technically, I would have to say VS, then O2 sat.

    I don't think the wound drainage is significant, as a small amount of drainage would be expected on post op day 1.

    Anytime you see a lab value, you wanna make sure you know if it's normal. The Hgb and HCT are low, which could indicate a bleed. However, I think that many times they are low post op because of bleeding during the procedure, so not necessarily a big deal. They do seem pretty low, though.

    One concern to me would be the diminished pedal pulse (especially on the same side as the surgical procedure). That makes me think possible circulatory problem.

    My biggest concern would be the lung sounds. One of the biggest concerns post op is the risk for blood clots. Post op (especially something like a hip fracture, and anything concerning the lower extremities) you're worried about the pt. thrombosing.

    The shortness of breath, confusion, and crackles in the lungs (think pulmonary edema) are hallmark signs of a pumonary embolism.

    That's probably gonna be your priority.
  5. by   Daytonite
    i have no idea where to start! i am suppose to put together intervention priorites and i don't know what is priority. i've never done something like this and don't even know where to start.
    i read every word of your post carefully. in order to complete this assignment you need to know the steps of the nursing process and what goes on in each of the steps. if you follow those steps in the sequence that they occur, you will be able to start and finish this assignment. you are pretty much having to put together a care plan for this patient although this scenario gives you some of the information that the care plan will have and is directing the course they want this care plan to take. in other words, it is as if it has given you a care plan with blanks, filled in some of the blanks and you have to fill the rest of them in with the information supplied from the scenario.

    this is how the steps of the nursing process are used to care plan:
    1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology) [font=arial unicode ms]
      • a physical assessment of the patient
      • assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
      • data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians (
      • knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed/ordered on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.
      • reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking
    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). it helps to have a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.
      • your instructors might have given it to you.
      • you can purchase it directly from nanda. nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international. cost is $24.95
      • many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information. this information will usually be found immediately below the title of a nursing diagnosis.
      • the nanda taxonomy and a medical disease cross reference is in the appendix of both taber's cyclopedic medical dictionary and mosby's medical, nursing, & allied health dictionary
      • there are also two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:
      • always sequence actual nursing problems before potential (risk for) or anticipated problems
      • use maslow's hierarchy of needs to sequence the diagnoses in order of priority of importance
    3. planning (write measurable goals/outcomes and nursing interventions)
      • goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing. they have the following overall effect on the problem:
        • improve the problem or remedy/cure it
        • stabilize it
        • support its deterioration
      • how to write goal statements: see post #157 on thread CAREPLANS HELP PLEASE! (with the R\T and AEB)
      • interventions are of four types
        • assess/monitor/evaluate/observe (to evaluate the patient's condition)
          • note: be clear that this is assessment as an intervention and not assessment done as part of the initial data collection during step 1.
        • care/perform/provide/assist (performing actual patient care)
        • teach/educate/instruct/supervise (educating patient or caregiver)
        • manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)
    4. implementation (initiate the care plan)
    5. evaluation (determine if goals/outcomes have been met) - this is an assessment. you will specifically look for the defining characteristics that supported your nursing diagnoses to see if, or how, they have changed (improved, stabilized or gotten worse) as well as for the evidence of any new nursing problems.
    i am given the following intervention and need to prioritize them. . .then give rationale for them all after puting them in order
    i gave you the link above to a website that breaks down maslow's hierarchy of needs. i have also posted the pyramid a number of times on the student forums and you can see it here: prioritizing nursing dx for pt. with ulcerative colitis. reading the information on the wikipedia site about the hierarchy will provide you with the rationale for the prioritizing.
    which of the following nursing diagnoses may apply to mrs. t? . .of these what would be the nursing diagnosis? then the rationale? then the nursing interventions?
    this is why you will need to follow the steps of the nursing process and develop and plan of care for this patient. this question is pretty much asking you to do that. it is the only way you are going to know which of those diagnoses (which are actually nursing problems) apply to this patient. begin with step #1 of the nursing process. go to the beginning information and list all the abnormal assessment data (step #1 is assessment) that the case scenario starts you off with. that abnormal data is what will become the defining characteristics (signs and symptoms) of this patient's eventual nursing diagnoses (nursing problems). if that still confuses you, take each nursing diagnose that the question lists (acute pain, risk for infection, risk for impaired skin integrity, impaired urinary elimination, impaired gas exchange, fatigue, impaired physical mobility, ineffective tissue perfusion) and look up the defining characteristics of each of them in a nursing diagnosis reference. i listed several places where you can find this kind of information above both online for free and in the appendix of a medical dictionary if you own one. you are going to find some of those postop day #1 defining characteristics staring at you from several of those nursing diagnoses. you will need to determine the order of priority to list the diagnoses.

    once you determine which nursing diagnosis to treat, the signs and symptoms that prove and support the existence of each diagnosis are what we treat as nurses. those are the things you will develop nursing interventions for. you should be able to find them by looking for them in the index of your nursing textbook. the rationale (reason) for doing them should be there also.
    what would be your plan for follow-up care for mrs. t.?
    this point of the assignment has given you some more data about the patient and is asking you to revise your plan of care to include this new information. how is this new information going to change what you have already laid out to be done for this patient? that is what this question is asking. this is merely step #5 (evaluation) of the nursing process.
    if you need to see how the nursing process is used to make a care plan there are a number of examples of them on this sticky thread:
    - help with care plans

    to help you, you need to remember that post op patients who have undergone general anesthesia must be monitored for these potential complications:

    • breathing problems (atelectasis, hypoxia, pneumonia, pulmonary embolism)
    • hypotension (shock, hemorrhage)
    • thrombophlebitis in the lower extremity
    • elevated or depressed temperature
    • any number of problems with the incision/wound (dehiscence, evisceration, infection)
    • fluid and electrolyte imbalances
    • urinary retention
    • constipation
    • surgical pain
    • nausea/vomiting (paralytic ileus)
    and, you can read a bit about orif surgery here:
  6. by   tnortham
    Daytonite has it covered...but to answer your question about R 32. It means respirations are 32 a minute. You will need to know this because it is an abnormal finding.
  7. by   Enkoeyez
    Lmao!!! Sheila??? Hahahahahaha I knw it's somebody lol I'm lookn for some answers too email me if u find anything
  8. by   xtxrn
    Quote from Enkoeyez
    Lmao!!! Sheila??? Hahahahahaha I knw it's somebody lol I'm lookn for some answers too email me if u find anything
    This thread is 2 1/2 years old.

    Who is Sheila? Look at what Daytonite wrote- you can't get better than her posts.