Question

Mrs. C, is a 79-year-old woman is newly admitted to the geriatric rehabilitation unit on 11/06/2020 after having a hip replacement two days ago (11/4/2020).

Her medical history includes high blood pressure, type II diabetes and osteoporosis and mild dementia. She is complaining of 8/10 pain, poor appetite and states she is very nervous about physical therapy “breaking her new hip.” She is refusing her morning bath and ADL’s stating “my daughter will help me when she gets here”. Mrs. C. was noted to be dizzy when out of bed with physical therapy and nursing assistance yesterday (11/05/20). Upon examination you note the following: blood pressure is within normal limits, pulse 108 BPM. Respiratory rate is 22. It is 11:00am and she has not voided, she took only a few sips of water, refusing breakfast. She has had no visitors since her admission.

I. What additional information related to Mrs. C.’s condition & concerns should be included in your initial nursing history and assessment? (1 point)

II. Formulate three nursing diagnosis for Mrs. C. (1 point)

1. Physiological

2. Psychosocial

3. Safety

4. Patient education

III. Develop an ISBAR report addressing one of the patient concerns identified within the scenario as a communication report to a selected health care team member. (1 point)

IV. Identify members of the multidisciplinary team that you would want to include in caring for Mrs. C. (Provide rationale). (1 point)

Sample (I)SBAR Format (Refer to pages 474-477)

Identity/Introduction: Communicate who you are, where you are, and why you are communicating.

Situation or Problem: Communicate is going on with the patient. Brief summary

Answer 1

1) additional information like the intake and output should be included in the nursing assessment.

2) altered nutrition less than body requirement related to less intake

Disturbed thought process related to demensia

Risk of injury related to improper gait due to hip replacement surgery

3) isbar

I = identification. .i am the nursing officer from the plastic surgery ward, pts name is cc mrd is 1234

Situation= the pt with hip replacement surgery here is for rehabilitation, She is complaining of 8/10 pain, poor appetite and states she is very nervous about physical therapy. She is refusing her morning bath and ADL’s . Mrs. C. was noted to be dizzy when out of bed with physical therapy and nursing assistance yesterday, Upon examination noted the following: blood pressure is within normal limits, pulse 108 BPM. Respiratory rate is 22. It is 11:00am and she has not voided, she took only a few sips of water, refusing breakfast.

Background = pt was admitted on 11/06/2020 for hip replacement surgery and previous Her medical history includes high blood pressure, type II diabetes and osteoporosis and mild dementia

Assessment = the problem with the pt is emotional Instability, as she wants to wait her daughter to come and take care of her.

Recommendations = I think we should involve her family in care giving and assistance and the pt feels better that, and we should provide a good care and special attention to her

4) physical therapist, exercise trainer, nutritionist should b involved in the care of pt as these will improve the muscle strength, stamina and quick recovery for the pt