Question

Mrs. Toms, 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 work-up she was taken to surgery for an open reduction with internal fixation (ORIF) of her right hip. On her first post-op day, her right hip dressing has a small amount of dried dark red drainage. She has an IV of D5/0.45 NS at 75 mL/hr, O2 at 2L/NC, clear liquid diet and circulation, movement, sensation, and temperature (CMST) neurovascular check q4h to the right leg for the first 24 hr. The following medications are ordered: PCA with morphine sulfate delivering 1 mg/hr continuously, FeSO4 325 mg po tid with meals (start hen on regular diet), Colace 100mg po daily. She is very restless and confused this morning.

Prioritize the five nursing interventions as you would do them to take care of Mrs. Toms. Write in the number in the box to identify the order of your interventions (#1=first intervention, #2=second intervention, etc.) and state an evidence-based rational for each intervention (cite your source)

INTERVENTIONS PRIORITY #                             RATIONALE

Assess surgical dressing
Take vital signs
Assess pain level
Check O2 saturation level
Check neuro status of right leg (CMS)

During the follow-up assessment for the first post-op day you note the following:

1. Pedal pulse present: weak in the right foot, stronger in the left foot
2. Hgb 10.5g and Hct 32%
3. Bowel sounds hypoactive in all quadrants
4. Crackles in the lower bases of the lung

All of the following nursing diagnosis may apply to Mrs. Toms

Acute pain, Risk for infection, Risk for impaired skin integrity, Impaired urinary elimination Impaired gas exchange, Fatigue, Impaired physical mobility, Ineffective tissue perfusion

1. Select the ONE nursing diagnosis above that is of priority at this time
2. Provide a rationale for your selection
3. List three nursing interventions that meet the needs of Mr. Jackson

On the second post-op day Mrs. Toms is still very confused and is trying to get out of bed. She has bilateral scattered crackles in the lungs, SOB on exertion, R. 32 and a nonproductive cough.

Based of the situation above, identify and write the priority problem in the box below. Then, starting with the small box labeled #1, prioritize the nursing intervention for this situation and identify your follow-up action plan for Mrs. Toms. What is new action plan?

Priority Problem # 1   # 2 # 3 # 4 # 5 # 6     New Action Plan

Nursing Interventions

1. Take the vital signs
2. Check O2 saturation
3. Stay with patient
4. Call physician
5. Do hourly incentive spirometer
6. Encourage fluids

Answer 1

1.Intervention priorities Rational

1. check oxygen saturation level 1. oxygen is very important for survival. Low oxygengen saturation can cause confusion and restlessness   

2.Check the vital signs 2. vitals are the important indicator of the health status of a patient. Its give the nurse the data needed for care planning. If infection is present a patient temperature will increase

3.Assess surgical dressing 3. surgical dressing is assessed to evaluate signs of infection .

4. Assess the pain level 4. knowledge the level of pain will help the nurse to plan forbetter care and to adjust the anasgesic dose base upon the pain level

5. Check neuro status of right leg 5. to gain information about any development of neurological complications eg(nerve injury)

2. Ineffective gas exchange: The patient crackles can be heard due to infection in the lungs which has impaired the gas exchage. impairment in gas exchange leads to lack of oxygen in the blood and more of carbondioxide. this increase the complications and deteriorates the patient health. therefore improving the gas exchange is the first priority care