Question

F.J. is a 70-year-old white woman admitted to the hospital because of a fall at home during the night. She is scheduled for an open reduction with internal fixation (ORIF) of the right hip at 8:00 AM this morning. She has a history of type 2 diabetes mellitus that is well managed with metformin (Glucophage) 5 mg twice daily.

Subjective Data

• States pain is a level 7 on a scale of 1 to 10
• Last dose of metformin was at 6:00 PM the previous evening

Objective Data

Physical Examination

• Blood pressure 120/54, pulse 101, temperature 98° F, respirations 20
• Alert and oriented to person, place, and time
• Lungs clear to auscultation
• Heart rate and rhythm regular, no murmurs
• Height 5’2”, weight 150 pounds
• Bowel sounds active and present in all four quadrants
• Circulation and sensation to bilateral lower extremities intact
• Strength left lower extremity 5/5, right lower extremities not tested because of pain

Diagnostic Studies

• X-Ray reveals a break in the right hip
• Morning blood glucose level was 280 mg/dL

Preoperative Orders

• NPO after midnight
• Type and crossmatch 2 units of packed red blood cells
• Start an IV of lactated Ringer's at 75 mL/hr
• Place in Buck’s traction
• Ensure that surgical consent form is signed and placed in the chart
• Administer ceftriaxone sodium (Rocephin) 1 gram IV when called to OR

1.Name 3 nursing diagnosis, 3 interventions for each diagnosis and patient education

Answer 1

• ANSWER•

•Nursing diagnosis,

1• Acute pain related to movement of bone fragment and immobilty device as evidenced by report of pain.

•Nursing Intervention,

1.Assess pain by pain rating scale and record level of the pain .

2•Protect the immobilization of  affected part by cast ,splint and traction.

3• Provide the sentimental support to the patient.

4• Educate the patient regarding stress managament technique.

2. Risk for impaired blood sugar related to Diabetes mallitus as evidenced by blood sugar monitoring.

Nursing Intervention;

1.Check the blood sugar level before administration of medicine .

2.Monitor  for sign and symptom increased blood sugar like polyurea,polyphagia

3.Educate the patient regarding diabetic diet.

4.Assess the patient for Low blood sugar level

3.Risk for impaired skin integrity related to immobilty as evidenced by immobile patient due to traction.

•Nursing Intervention;

1.Educate the patient regarding the use of emollient cream to decrease dryness of the skin.

2. Educate the patient to take plenty of fluid to rehydrate the body .

3.Provide the nutritional diet to fulfill the nutritional need of body.

4. Change the position of patient frequently if possible

5. Give the back care to the patient to  increase the circulation.