Question

Patient E.F. is an 85-year-old female who sustained a hip fracture after falling on her way out of the bathroom in her nursing home. She had surgery today to repair the hip fracture. According to reports from the staff of her nursing home, patient E.F. has a history of mild intermittent confusion. When she arrives on your unit from the recovery room, she is unable to tell you how she would rate her pain but she is groaning, grimacing, and appears uncomfortable when you reposition her. Since patient E.F. appears to be in pain, you give her the PRN oxycodone that is part of her postoperative orders. An hour later when you go to re-assess her pain, you note that E.F. has a respiratory rate of 8 breaths per minute. She is difficult to arouse and will not answer any questions verbally The reversal medication is effective in resolving patient E.F.’s lethargy, but she remains confused throughout that first night after surgery. She is not oriented to place or time, and does not understand that she had surgery. She wants to get out of bed, is calling out for family members who are not there, and pulls at her Foley catheter and IV line. The next morning, on the first day after surgery, the patient is seen again by the doctor. The doctor asks that you try to wean the patient off of her nasal cannula oxygen, since she does not wear oxygen normally. You attempt to wean the patient throughout the day, but have trouble obtaining oxygen saturations that are consistently above 90%. By the 2nd morning after surgery, the patient’s confusion has improved to what her family reports is her baseline mental status. However, she continues to require oxygen via the nasal cannula to keep her oxygen saturation above 90%. The provider is notified, and they order a chest xray. The patient’s lab values that night show the patient has an elevated white blood cell count and she has developed a cough. Her lung sounds are diminished with some crackles in the bases. please answer the following questions very briefly:

1) Priority Nursing Diagnosis:

2) Consultation that this patient needs:

3) Abnormal assessment findings currently exhibited

Answer 1

1. Priority Nursing Diagnoses include:

Based on her assessment findings her problems identified include:

Objective data: Abnormal findings

• WBC values are elevated suggesting of an infection
• Diminished lung sounds with crackles at the base suggesting that she might have developed pneumonia
• <90% oxygen saturation without oxygen
• General appearance: restlesness, lethargic, anxious and confused

Nursing diagnosis :

1. Impaired gas exchange related to fluid and exudate accumulation at the capillary alveolar membrane as evidenced by crackles at the base of lung
2. Ineffective breathing pattern related to inflammation and pain
3. Anxiety related to difficulty in breathing, perceived or actual loss of control and unfamiliar environment
4. Altered level of consciousness related to aging and impaired cognition
5. Interrupted family process related to health crisis
6. Risk for injury related to decreased level of consciousness
7. Risk for impaired skin integrity related to immobility

Nursing interventions

• Maintaining airway
• remove accumulated secretion to remove the danger of aspiration
• elevate the head end of bed to 30 degress to eliminate aspiration
• Positioning the client every 2-3 hours to lateral unoperated side to eliminate secretions
• Suctioning and oral hygiene of posterior pharynx and upper trachea
• Hyperoxygenated and hyperventillation to the client before suctioning to prevent hypoxia
• Chest physiotherapy and postural drainage to promote pulmonary hygiene
• Auscultate the chest atleast every 8hrs to detect adventitious breath sounds
• Provide frequent oral care
• Monitor ABG values

Protecting the patient

• Padded side rails and raised at all times
• Prevent injury from invasive lines and equipments
• Protecting the patient's dignity during altered LOC as providing and speaking to the patient during nursing care activities to preserve the patient,s humanity
• No negative speaking about patient,s condition or prognosis in her presence
• Maintain skin integrity and join integrity
• Regular shedule of turning to prevent skin necrosis
• Provide passive exercise to the extremities
• Trochantor rolls supporting the hip joints keeps the legs in proper allignment

2. Consultation that this patient needs include:

1. Pulmonology and respiratory therapist- for providing chest physiotherapy to clear out accumulated fluids and exudates
2. Psychologyist counselling- to reduce and anxiety and stress due to unfamiliar environment
3. Physiotherapist

3. Abnormal assessment findings currently exhibited include:

1. Elevated WBC count
2. Cough and diminished breath sounds and crackles on auscultation