Please help me with care map

[littletown]

Hi friends:

I am working on my client care map. I need help with it, two many concerns, i don't know if the following is right or not. i did not use up all my abnornal data that i have assessed. any input are appreciated.

My client: John is 85 years old male. He is admitted on: fracture ankle (with cast on left ankle, and dressing on left ankle) and delirium (very mild, can not keep tract of time), the medications he is taking: potassium chloride; vitamin D; thyroxine; resedronate sodium; irbesartan; hydrochlorothiazide; fluticasone; Acetaminophen; dabigatran, ventolin (puffer) and atrovent

My assessment is as follows:

- Used to smoke and exposure to pollute environment and drink*

- RLL -crackles,

- Lost 7 lb at the first week of admission*

- Needs extra blanket when he sleeps

- One of his granddaughter visits and helps him every day, his son and step daughter have not shown up since he is in hospitial

- Joint between humerus and clavicle was hurt in the past*

- Unable to keep track of time, date and month and has mild short memory*

- He cannot function critical thinking, such as he cannot calculate simple addition and subtraction

- A little difficulty related to hearing (he uses hearing aid)*; unable to hear well if more than 2 persons at the same time to communicate; dentures

- Pain on left ankle, pain level is 5 out of 10 for half an hour with movement

- Left ankle unable to move due to the cast and fracture*

- Left ankle: swelling and stiff, the pain level is 2-3 out of 10 at rest and 5-6 out 10 with movement*

- Left lower limb does not move well because of a cast and fracture, one small incision on ankle with no swelling, no discharge and it is dry, no redness

- Muscle weakness and sore with movement on left ankle*

- Edema found on left foot*

- Toes on left foot are purple and cold* he can wiggle and feel them; feels tired after exercise; SOB on exertion*

- Needs one person to transfer, with commode or wheelchair*; cannot bath his back; needs moderate help in dressing pants; upper extremities move well, with minor assistant in feeding

I need to identify four priority nursing diagnosis, for each diagnosis, identify client short term and one long term goal; identify interventions that address these four nursing diagnosis, and provide rationale to support the interventions, evaluate the impact these interventions

Nursing diagnosis:

1. Impaired physical mobility

r/t fracture left ankle

AEB: report pain on movement; left ankle unable to move due to the cast and fracture

Left foot is stiff and swelling, the toes of foot are purple, cold and swelling ; muscle

Weakness

Client short-term goal: client will participate in ADLS and desired activities every day

Long-term goal: client will increase strength and function of left ankle in two weeks

Intervention:

- Teach the client appropriate wheelchair use and techniques Rationale:

- Instruct client regarding fracture healing process, diagnostic procedures, treatment and its complications, home care, daily activities, diet, restrictions and follow-up Rationale:

2. Risk for falls

R/T wheelchair use, 85years old, fracture ankle with cast on it, delirium

Goals:

Short-term: client will understand of risk factors and free of injury in hospital

Long-term: client will be able to protect him from injuring.

Interventions:

- I will do pain assessment regularly and observe his gross motor coordination Rationale:

- Make sure environment hazards in care setting Rationale:

- Assess client's cognitive status, coping abilities. Rationale:

3. Anxiety

R/T: stress, sick role function, change health status,

AEB: lost 7 lb since in hospital, impaired attention, and diminished ability to problem solve,

Goals:

Short-term: client will appear relaxed in two weeks

Long-term: client will find sound ways to deal with anxiety

Interventions:

- Identify client's anxiety factors and observe client's behaviours

- Help client identify feelings and begin to deal with problems, isten and talk to the client Rationale:

- Provide comfort measures, such as, quiet environment, lighting, warm environment. Rationale:

- Provide emotional support to client, explain all procedures to decrease anxiety and to obtain cooperation. Rationale:

-

4. Impaired memory

R/T: delirium

AEB: cannot keep track of time, experience of forgetting (he said 'did I have my medication?' after he took half an hour, but not always forgetting); always asked 'what do we do next?; I don't know, ask nurses'; cannot do simple calculations

Goals:

Short-terms: client will maintain orientation to time in short period of time

Long-term: client will demonstrate accurate what he did

Interventions:

- Decrease the amount of stimuli in client's environment, such as, low noise level, few people. rationale: this decreases the possibility of forming inaccurate sensory perception.

- Correct client's description of inaccurate perception. Rationale: participation in real situation interferes with ability to respond to reality.

- Provide a feeling of safety in client's environment by asking same personnel on a regular basis to provide cares