Question

So, I had a patient who is a 85 year old, no past medical or surgical history who came in after fall from 3rd floor of building during a suicide attempt. He contained multiple trauma, and hip fracture. Chest CT-scan showed right ninth rib fracture. Right wrist xray shows avulsion fracture noted at the dorsal carpus. Vital signs were stable, afebrile and room air. He has abdominal incision, staples were removed, dry, intact, no redness. Wound on the right elbow. PICC line was removed. Blood glucose was high 231. Pt is on diabetic diet, nutrition is decreasing, ate 15-25% of of brekafast and lunch. On foley catheter collecting light amber urine. No bowel movement since the 23rd. Physical therapy came in but refused to get up complaining of pain to hip and elbow. Foam boots to low extremities, incentive spirometer every 1 hr, SCD while in bed, turn and position every 2 hr.

Medications:

1. Novolog Flx Pen 100 unit/mL 3mL Pen. Inj.
2. Saline Lock Flush 10mL IV
3. Colace capsule 100mg PO BID
4. Cymbalta capsule 20mg PO daily
5. Lovenox Inj. 40mg SQ Q24hr
6. Norvasc tab 10mg PO daily
7. Protonix Inj. 40mg IV daily SCH
8. Miralax Packet 17gm PO BID PRN

Lab Tests:

Hemoglobin: 9.5L

Hematocrit: 29.1L

WBC 11.8H

Platelet 581 H

Sodium: 134

Chloride: 100

Potassium 4.0

Carbon dioxide 25

Creatinine 0.79L

BUN 25 H

INR 1.01

PTT 32

PT 12.7

QUESTIONS:

- What are the nursing diagnosis?

- What are the three top problems for this patient? Include "related to" and "as evidenced by".

- What are the goals presented for priority problems are listed with measurable outcomes?

- What are the interventions (at least one education intervention) Relationships apparent between interventions and each goal/outcome and problem. Be concise and clear, achievable, relates to the stated diagnosis and client outcome.

- Evaluation: States how client outcome was met, what might have helped or hinder attainment of the outcome, analyzes the care given. If needed, revisions in the care plan done; interventions, assessment, state if should have done something differently in retrospect.

- Labs: (discussed how the labs relates to the patient’s specific condition).

Answer 1

NURSING DIAGNOSIS

1.A cute pain related to movement of bone fracture and injury to soft tissues as evidenced by facial mask of pain,verbalization

2. Impaired physical mobility related to pain as evidenced by inability to move purposefully within the physical environment

3. constipation related disease process as evidenced by infrequent passage of stool

4. altered glucose metabolism related to decreased insulin production as evidenced by blood glucose:231

5. Imbalanced nutritional status:less than body requirements related to diabetic mellitus as evidenced by weakness

_Three top problems

1. pain related to movement of bone fracture and injury to soft tissues as evidenced by facial mask of pain,verbalization

2. Impaired physical mobility related to pain as evidenced by inability to move purposefully within the physical environment

3. constipation related disease process as evidenced by infrequent passage of stool

_GOALS

1.patient gets to be relief from pain

2. patient gets to be maintain normal physical mobility.

3. patient gets to be maintain normal bowel movement

4. Patient gets to be maintain normal glucose metabolism

5. Patient gets to be maintain normal nutritional status.

_INTERVENTIONS

Diagnosis/problem	goal	interventions
Acute pain related to movement of bone fracture and injury to soft tissues as evidenced by facial mask of pain,verbalization	patient gets to be relief from pain	Seeds the characteristics of pain Provide comfort devices Provide diversions therapy Administer analgesics as prescribed
Impaired physical mobility related to pain as evidenced by inability to move purposefully within the physical environment	patient gets to be maintain normal physical mobility	Assess the level of movement Encourage the patient to do active and passive exercise Instruct the patient to take more rest Administer analgesics as prescribed
constipation related disease process as evidenced by infrequent passage of stool	Patient gets to be maintain normal bowel movement	Assess the condition of the patient Encourage the patient to take fruits and vegetables Instruct the patient to take 2 litre water per day Administer laxative as prescribed
altered glucose metabolism related to decreased insulin production as evidenced by blood glucose:231	Patient gets to be maintain normal glucose meyabolism	Assess the condition of patient Instruct to avoid carbohydrate rich food Instruct to take more and more water Encourage to take bitterguard juice once in a day
Imbalanced nutritional status:less than body requirements related to diabetic mellitus as evidenced by weakness	Patient gets to be maintain normal nutritional status	Assess the nutritional status of patient Provide iv fluid if needed Instruct to take more vegetables Refer to a dietician

_EVALUATIION

1 patient got relief from pain as evidenced by pleasant face

2patient maintained normal physical mobility as evidenced by ability to move purposefully

3 patient got relief from constipation as evidenced by frequent passage of stool

4 patient maintained normal glucose metabolism as evidenced by decreased blood glucose level

5 patient maintained normal nutritional status as evidenced by pleasant face and verbalisation

_LAB

1 hemoglobin; here hemoglobin is decreased ,this may due to loss of blood while injure and low nutritional intake.

2.the hemocrit is low and the reason may be same as the above

3platelet level is increased this may be due to the necessary if platelets for clotting in injury

4.chloride is low ,this may be due to low intake of dietary chlorine,lubg disease,heart disease