Question

CASE SCENARIO:

An 80 year-old woman fell in her home. She is evaluated in the emergency room and is found to have a hip fracture. She was recently started with hydrocholorothiazide to treat her hypertension. She has been on an SSRI for depression following the loss of her husband and is taking NSAIDs for pain associated with osteoarthritis. Her vitals are stable. She is lethargic and disoriented but otherwise appears well. Laboratory works reveals Na – 105 mEq/L, K – 3.2 mEq/L, BUN – 32 mg/dL, Creatinine – 1.0 mg/dL.

1. Develop a Nursing care plan (ADPIRE, Assessment, Diagnosis, Planning-short term and long term goal, Intervention-Rationale, Evaluation) for this patient based on the scenario

Answer 1

1. Acute pain related to movement of bone fragments as evidenced by reports of pain.

ASSESSMENT	DIAGNOSIS	GOAL	INTERVENTION	RATIONALE	EVALUATION
Subjective data:- The patient has complaints that she is having pain in the hip Objective data:- The patient looks tired and facial expression alike pain	Acute pain related to movement of bone as evidenced by reports of pain	Long term goal:- 5 day after the nursing care the patient will be free from pain and back to the early satge Short term goal:- After 3 hours of nursing care the patient pain will reduce	Assess the base line data Check the level of pain by using th epain scale Provide comfortable position to the patient Provide diversional therapy Place the patinet on the orthropedic bed Suppot the fracture site with comfort devices Administer the anagesics as per the doctor's order	To know the current condition of the patient To know the intensity of pain To reduce the pain To divert the patient mind from pain Helps to provide traction properly Improve the comfortness and reduce the pain To reduce the pain	Goal met The patient's pain has been reduced as evidenced by the pain scale meassurement

2. Impaired physical activity related to arthritis as evidenced by the inability to move.

ASSESSMENT	DIGNOSIS	GOAL	INTERVENTION	RATIONALE	EVALUATION
Subjective data:- The patient is always asking for the help and compaints about the joint pain Objective data:- The patient is having Inability to move Pain while moving	Impaired physical activity related to arthritis as evidenced by the inability to move	Long term goal:- After one week of nursing interventions the patient will be able to move without any help and perform the activities of daily living independantly Short term goal: After 3 hours of nursing interventions the patinet will be reduced the inability to move and will be back to the early life	Assess the general condition of the patient Check the factors which interfere with movement Provide support to the patinet Teach some exercise Administer antibiotics as per the doctors order	To know the baseline data To reduce the interfering factors related to easy movements To do the ADL by own To improve the early recovery To reduce the arthritis	Goal met The patinet is able to do the ADL by her own as evidenced by the patient is not calling for the help always.

3. Risk for decreased cardiac output related to hypertension.

ASSESSMENT	DIAGNOSIS	GOAL	INTERVENTION	RATIONALE	EVALUATION
Subjective data:- The patinet complains that shre is very tired and feeling palpitation always Objective data:- Increased BP Disorientation Lethargy	Risk for decreased cardiac output related to hypertension	Long term goal:- After 5 days of nursing interventions the patient's blood pressure will become normal ane she will go back to the early stage of life Short term goal:- After 3 hours of the nursng interventions the BP will be back to the normal stage	Assess the baseline data Check the creatinine level Check the vital sings Auscultate the heart sound Provide a calm and quite environment Teach the yoga and exercices Administer the antihypertensive drugs	To know the general condition of the patient Increased creatinine level indicates a sign of hypertension To know the funtions of the vital organs To know the heart disturbances To provide the relaxation Induce relaxation To reduce the blood pressure	Goal met The patinet hypertention is reduced as evidenced by the blood pressure monitor

4. Risk for bedsore related to hip fracture as evidenced by impaired skin integrity.

ASSESSMENT	DIAGNOSIS	GOAL	INTERVENTIONS	RATIONALE	EVALUATION
Subjective data:- The patient compaints about irritationa nd pain in the boney prominences Objective data:- Redness Pain Cyanosis	Risk for the bedsore related to hip fracture as evidenced by impaired skin integrity	Long term goal:- After 7 days of nursing interventions the risk fore bed sore will be reduced and the patient will be back to the early stage Short term goal:- After 2 hours of nursing care the risk factors for bed sore will be removed and the patient will be back to the normal stage	Assess the baseline data Inspect the skin for any sign of bedsore Boney prominence for the risk of bedsore Change the position of the patient freequently Provide the skin care Provide wrinkle free bed	To know the general condition of the patient and skin integrity To findout the bedsore before its occurance and prevevt it To reduce the presure and friction at the boney prominences To prevent the bedsore To inmprove the circulation To prevent the friction	Goal met The risk for bed sore is prevented as evidenced by the healthy skin integrity.