Question

Location: Orthopedic unit 1555

SBAR report from day shift nurse:

Situation: Mrs. Jacobson is an 85-year-old white female who was admitted last evening after falling and fracturing her hip. X-rays have been taken and show left intertrochanteric hip fracture. Mrs. Jacobson is scheduled for surgery tomorrow.

Background: Mrs. Jacobson has a 10-year history of osteoporosis, and her daughter reports that recently Mrs. Jacobson has been having dizzy spells.

Assessment: Mrs. Jacobson's vital signs are stable. Her pain is under control with morphine every 4 hours, and I medicated her at 1400. Her pain level was 2 after the morphine. The skin is intact; color and sensation around the hip area are within normal limits. A Morse Fall Scale assessment was completed on admission, and her score was 45. Fall precautions were implemented.

Recommendation: You will need to reposition Mrs. Jacobson as she needs to be turned every 2 hours. You should perform a focused musculoskeletal assessment, reinforce safety, and provide patient education on fall risk. Assess her pain level and medicate for pain if needed.

1.Assessment- 2 subjective data, 2 Objective data

2. 1 Nursing diagnosis

3. 2 long term goals, 2 short term goals

4. evaluation of goals, 3 evaluation of intervention

Answer 1

1:-Assessment

:-subjective data

Patient complains of pain on his hip

objective data :-Pain level reading ,facial expression

inability to do activities

:-nursing diagnosis -

acute pain related to fracture as evidenced by pain score reading and facial expression

long term Goal:-

patient will free from pain and improve activity level

Short term goal-get relax from pain

Planning:-asses the pain and pain scoring

-provide comfortable position

Assist in daily activities

Give diversions activities

Provide analgesics as per orders

Evaluation:-

Evaluate the client outcome after providing panning asses for any changes.client will achieve the goal.

2-assessment

Subjective date-inabilty to move

Objective data-pain score reading

Fracture

Nursing diagnosis:-

Risk for Impaired skin integrity related to long-term confinement in bed.

Goal-

Long term goal-

Improve skin integrity and free from bedsore

Short term goal-

Prevent any bed sore

Planning:-

Assess the ability to move and self care

- provide regular position changes

Monitor skin and special areas regularly

-provide back care and skin care to prevent skin erosion

-help them in range of motion exercise

-apply skin lotion and change diaper .

Evaluation:-

Patient will free from any bed sore and improved skin integrity.

3:-assesment

Subjective data-

Unable to perform activity

Objective data:-

Age,fracture of hip

Nursing diagnosis:-

Risk for fall related to fracture and age

Goal:-

Longterm-improve the activity level and do self care activities by self

Short term goal-prevent from fall and injury

Planning:-

Asses the patient activity level.

-monitor fall score

Help the patient in activities

Provide assistance when ever needed

Arrange all articles near to patient

Maintain safety including side rails

Maintain floor free from slippery or water.

Evaluation:-patient will improve activity level and will be go do self activities without fall risk