NURSING CARE PREPARATION

Student Name:

Diana Millan

Date of care: 12/05/13

Age: 89
Gender: Female
Eriksons Developmental Level: Stage 8
Integrity versus Despair

Date of Care: 12/05/13

Date of Admission: 11/26/2013
Ethnic/Cultural Preferences: Unknown
Allergies: Gluten, Vicodin
Code Status: DNR

Primary Diagnosis:
Aftercare for healing traumatic fracture of left hip
Co-morbidities:
Aftercare following surgery injury and trauma
Difficulty in walking
Muscle weakness (generalized)
Closed fracture unspecified part neck femur
Cervicalgia
Pernicious anemia
Depressive disorder not elsewhere classified
Anxiety state, unspecified
Unspecified osteoporosis
Barretts esophagus
Other & Unspecified noninfectious gastroenteritis and colitis
Osteorarthrosis unspecified whether generalized or localized unspecified site
Discharge Plan (add day of clinical):
2-3 weeks, patient will return to her house which is located right next to her daughters
house.
Preliminary Integrated Pathophysiology primary diagnosis (what is going on with your client at
the cellular level for the health condition, verbal at beginning of shift and final is to be typed 1-3 pages
with APA formatting). Explain how your clients primary diagnosis, co-morbidities, medications and labs
interrelate. See pathophysiology document

Data Collection (Record exactly what is written on the personal information sheet [aka Kardex]. Any
assessment/elaboration should be made on the assessment sheet):
IV (Fluid type, rate, access type):
CBG (Yes/No, frequency): No

Diet (Type): Regular, gluten free

I&O (MD order/Nursing Order/Frequency): None
ordered
Fall Risk/Safety Precautions (Yes/No): Yes, use
gait belt; hip precautions
Wound Care (Yes/No): Surgical wound on left
hip; Aquacel Dressing
Drains (Yes/No, Type): No

No

Activity (What is ordered): OT and PT; No PT

that causes pain
Oxygen (Yes/No, Delivery method, how much): No
Last BM: None from 0700-1100; Patient was

gone the last half of the day

Other Tubes: N/A
ASSESSMENTS
(Include Subjective & Objective Data)

Integumentary:
Head and Neck:
Skin is pink, warm, and dry
Head: round, soft, nontender; hair is thin, no
Decreased skin turgor
hair loss
No bruising
Patient diagnosed with cervicalgia, No pain
Surgical wound covered with Aquacel
during assessment; stated neck pain was
dressing on left hip; Patient stated she would only felt during some movements. Neck
have the staples from the surgery removed pillow helps a lot with the pain
today
No palpable masses

Ear/Nose/Throat:
Thorax/Lungs:
Ear: No pain, tenderness, stated she had
Symmetrical chest
some hearing difficulties
Clear lung sounds
Eyes: PEARRLA
Equal chest rise and fall
Nose: symmetrical, no discharge
RR of 16, normal pattern and depth
Throat: No problems swallowing, tongue pink
and moist

Cardiac:
S1 & S2 present
HR: 78 radial pulse assessed, strong and
regular equally bilateral
Capillary refill: 2 seconds on upper
extremities; 3 seconds on lower extremities
Skin is pink, warm, and dry
No edema

Musculoskeletal:
Patient able to stand and walk with a cane
and one person assist
Takes slow, small, careful steps due to an
increase in pain with certain movements
Enjoys walking, being active
Foot strength: 5 (scale 0-5)
Right and left arm strength 5 ( scale 0-5)
Left Leg strength 4 (scale 0-5)
Right Leg strength 5 (scale 0-5)
Full ROM for flexion of the upper extremities,
abduction, adduction, dorsiflexion and
extension of lower extremities

Genitourinary:
Bladder incontinent

Gastrointestinal:
Bowel incontinent

No burning or stinging with urination

Abdomen: no pain, tenderness, masses, or

pain
No bruits heard on auscultation
Normal bowel sounds, not hypoactive or
hyperactive

Neurological:
Awake, alert and oriented X4
Depression scale: 1; scores more than five
points suggest depression
Patient stated she is happy and satisfied
with her life, Ive had a wonderful life

Other (Include vital signs, weight):

P: 78, radial pulse strong and regular,
equally bilaterally
BP: 118/72 right brachial
RR: 16 normal depth and pattern
Sp02 room air: 99%
Temperature (temporal): 98.4F
Pain (chronic or acute):
Patient rated pain a 0 on a scale of 0-10
during assessment but stated she did
sometimes have pain in the neck and lower
left extremity and was managed with
medications; Chronic (Cervicalgia); Acute (r/t
fracture) occurs with some movements of
the leg
Pain management:
Neck pain is reduced when neck pillow is
used for support
Oxycodone for pain r/t to fracture

CURRENT MEDICATIONS
List ALL regularly scheduled and prn medications scheduled on your client.
(Due morning of clinical)
Generic &
Trade Name

Classification

Tylenol PM
Extra
strength

Nonnarcotic
analgesic;
antipyretic

Albuterol Bronchodilator
sulfate
nebulizatio
n solution
Alprazolam
Bisacodyl

ButalbitalAPAPCaffeine
tablet

Antianxiety;
sedativehypnotic
Stimulant
laxative
Analgesic

Supplement

Calcium

Cetirizine
HCl

Dose/Route/
Rate if IV

Onset/Peak

Intended
Adverse reactions
Action/Therapeu (1 major side effect)
tic use. Why is
this client
taking med?

Two tablets Onset: 10- Headache Hepatotoxicity

of 325 mg 30 min
PO
Peak: 1-2H
2.5
mg/3mL
Inhaled

Onset: 515 min

Peak: 0.52H

SOB

Tremors

0.25 m PO Onset: 30
Anxiety
Syncope
min
Peak: 1-2H
5 mg, give Onset: 15- Constipatio
Fluid and
2 tablets
60 min
n
electrolyte
PO
Peak:
disturbances
Varies
50-325-40 Onset: 15- Headache Arrhythmias
mg; give
30 min
one tab PO Peak: 1-2
H
600 mg PO

Onset:
R/t after
Constipation
Unknown care healing
Peak:
for
Unknown traumatic
fracture of
hip
Antihistamine 10 mg; one Onset: 30 Prophylaxis Depression
tab PO
min

Nursing Implications for this client. (No

more than one)

Monitor for S&S of

hepatotoxicity (rash, fever,
nausea, abdominal pain)
Monitor for effectiveness
(decreased SOB, normal
breathing pattern and rate)
Monitor for S&S of drowsiness
and sedation
Evaluate patients need for
continued use of drug (bowel
movements)
Monitor for effectiveness of
pain relief

Monitor if side effects

(constipation and upset
stomach) persist or worsen

Monitor for sedation

Peak: 1 H
Chlorphenir Antihistamine
amine-DM
Cholecalcif
erol

Vitamin D
analog

Clonazepa Anticonvulsant
m
Glycerin
Hyperosmotic
suppository
laxative;
antiglaucoma
House
enema

Laxative

Escitalopra Antidepressant
m oxalate
(Lexapro)
Mag-Al Plus

Antacid

1-5
mg/5mL; 2
Ml PO
1000 unit
tab; 2 tab
PO

Onset: 6 H Cough
Drowsiness/se Monitor for CNS depression and
Peak: 2-6
dation
sedation
H
Onset:2-6 Prophylaxis- Constipation
Monitor for signs of
H
increases
hypercalcemia (constipation,
Peak: 10- Vitamin D
dehydration, polyuria)
12H
stores
0.5 mg tab Onset: 60 Prophylaxis Respiratory
Monitor for signs of suicidal
PO
min
depression
ideation in depressive
Peak: 1-2
individuals
H
1
Onset: 15- Constipatio Hyperglycemia
Monitor for dehydration
suppository 30 min
n
rectally
Peak:
Unknown
1 dose
Onset: Constipatio
Diarrhea
Monitor for effectiveness of drug
rectally
Unknown
n
(daily bowel movements)
Peak:
Unknown
10 mg, one Onset: 1 Depression
Insomnia
Observe for worsening of
tab PO
wk.
depression or emergence of
Peak: 3 H
suicidality

200-200-20 Onset: Indigestion

mg/5mL;
Varies
give 30 ml
Peak:
PO
Varies
Milk of
Saline cathartic; 30 ml PO Onset: 3- Constipatio
magnesia
antacid
6H
n
Peak:
Unknown

Diarrhea

Monitor more effectiveness (if

acid problems persist or worsen
in one week)

Hypotension

Evaluate patients continued

need for drug. Prolonged and
frequent use of laxative doses
may lead to dependence

Oxycodone Narcotic (opiate 5mg tablet Onset: 10HCl

agonist),
PO
15 min
analgesic
Peak: 3060 min

Pain

SOB

Monitor for effectiveness (pain

level)

Pregablin Anticonvulsant;
25 mg
Onset:
Pain
Ataxia
Gaba analog; capsule PO Unknown
analgesic/miscel
Peak: 1.5
laneous;
H
Anxiolytic
Promethazi Antihistamine;
12.5 mg Onset: 20
Nausea
Respiratory
ne HCl
antiemetic;
tablet PO
min
depression
antivertigo
Peak:
Unknown
Rivaroxaba Anticoagulant;
15 mg
Onset: 30 Prophylaxis
Bleeding
n
antithrombotic tablet PO
min
complications
Peak: 2-4
H
Valium

Monitor for and report mental

status or behavior changes
(anxiety, panic attacks,
restlessness, irritability,
depression, suicidal thoughts)
Supervise ambulation,
promethazine sometimes
produces marked sedation and
dizziness
Monitor vital signs closely and
report immediately S&S of
bleeding and internal
hemorrhage (intracranial
bleeding, epidural hematoma,
retinal hemorrhage, GI bleeding)
Benzodiazepine 5 mg tablet Onset: 30Muscle
Hypotension Monitor for and report signs of
anticonvulsant,
PO
60 min spasms/anx
suicidal ideation, especially in
antianxiety
Peak: 1-2
iety
those treated for anxiety states
H
accompanied by depression

Wilson, B. A., Shannon, M. T., & Shields, K. M. (2014). Pearson nurse's drug guide 2014. Upper Saddle River, N.J.: Pearson Education.

DIAGNOSTIC TESTING
Include pertinent labs [ABGs, INRs, cultures, etc] & other diagnostic reports [X-rays, CT, MRI,
U/S, etc.]

NOTE: Adult values indicated. If client is newborn or elder, normal value range may be
different.
Date

Lab Test
Normal Values Patient Values/
Date of care

Sodium
135 145 mEq/L
Potassium
3.5 5.0 mEq/L
Chloride
97-107 mEq/L
Co2
23-29 mEq/L
11/14 Glucose
75 110 mg/dL

116

/13

BUN
8-21 mg/dL
Creatinine
0.5 1.2 mg/dL
Uric Acid Plasma
4.4-7.6 mg/dL
11/14 Calcium
8.2-10.2 mg/dL

Interpretation as related to
Pathophysiology cite reference &
pg #

Patient is not diabetic though glucose

levels are high; may be r/t to stress,
injury, or surgery
Corbett, J. V., & Banks, A. D. (2013).
Laboratory tests and diagnostic
procedures: With nursing
diagnoses (pp. 190-191). New
Jersey: Pearson.

8.4

/13

Phosphorus
2.5-4.5 mg/dL
Total Bilirubin
0.3-1.2 mg/dL
Total Protein
6.0-8.0 gm/dL
Albumin
3.4-4.8gm/dL
Cholesterol
<200-240 mg/dL
Alk Phos
25-142 IU/L
SGOT or AST
10 48 IU/L
LDH
70-185 IU/L
CPK
38-174 IU/L
WBC
4.5 11.0
RBC
male: 4.7-5.14 x
10
female: 4.2-4.87 x
10

11/14 HGB

11.6

May be related to injury and blood

/13

loss of fracture resulting in low RBC

and low Hgb; anemia
Corbett, J. V., & Banks, A. D. (2013).
Laboratory tests and diagnostic
procedures: With nursing
diagnoses (pp. 32). New Jersey:
Pearson.

male: 12.6-17.4
g/dL
female: 11.7-16.1
g/dL

11/14 HCT
male: 43-49%
/13 female: 38-44%

35.2

May be related to injury and blood

loss of fracture resulting in low RBC
and low HCT; anemia
Corbett, J. V., & Banks, A. D. (2013).
Laboratory tests and diagnostic
procedures: With nursing
diagnoses (pp. 28). New Jersey:
Pearson.

MCV
85-95 fL
MCH
28 32 Pg
MCHC
33-35 g/dL
RDW
11.6-14.8%
Platelet
150-450

DIAGNOSTIC TESTING
Date

UA

Normal
Range

Interpretation as related to
Pathophysiology
cite reference & pg
Results
#

Normal
Range

Interpretation as related to
Results Pathophysiology cite reference & pg
#

Color/Appearanc
e
pH
Spec Gravity
Protein
Glucose
Ketones
Blood
Date

Other

(PT, PTT, INR,

ABGs, Cultures,
etc)

Date

Radiology

11/14/1 X-Rays
3

Results

Interpretation as related to
Pathophysiology cite reference & pg
#

Chest- 1 view: Mildly May be related to anemia, the heart

enlarged heart; must pump more blood to make up for
calcification is
lack of oxygen in the blood.
present in thoracic Mayo Clinic. (2011, July 21). Enlarged
aortic arch. Hilar
Heart. Retrieved December 5,
vessels are mildly
2013, from
congested. No
http://www.mayoclinic.com/healt
infiltrate or pleural
h/enlargedeffusion. NO
heart/ds01129/dsection=causes
parenchymal
masses or nodules

Scans
EKG-12 lead
Telemetry
Other

DAR NURSING PROGRESS NOTE

Include the same note that was written in the client record for the priority nursing
diagnostic statement. Include the date/time/signature.
Patients major concern was impaired mobility related to femoral neck fracture. Prior to the fracture, she
had been very active and independent. She was worried that she would not be able to do things on her own or be
as happy as she was prior to the fracture. She believes she has lived a wonderful life and was not expecting a
fracture to occur, stated the pain when she fell was worse than childbirth. Actively listened to the patient and
encouraged her to express her concerns. Explained to the patient that she may gain some strength and mobility
with physical therapy. Patient was very informed of her diagnosis and knew a lot about her signs and symptoms
as well as what caused them. Ensured patient was comfortable with sufficient pillows to support left lower
extremity and a neck pillow for support and comfort. Patient had a scheduled doctors appointment at 1100 and
was gone for the rest of the day with her daughter. 12/05/13 @ 1500 D. Millan,
SN-----------------------------------------------------------------------------------------------------------------------------------------------------------------------

PATIENT CARE PLAN

Patient Information:
89 year old female
Traumatic hip fracture
Allergies: Gluten, Vicodin
Code Status: DNR
Nursing Diagnosis should include Nanda Nursing Diagnostic statement, related to (R/T), as evidenced by
(AEB).

Problem #1 Impaired physical mobility r/t weakness in left lower extremity AEB difficulty
standing and initiating gait
Desired Outcome: Will walk to the nurses station from her room and back by December
13, 2013
Nursing Interventions
Client Response to Intervention
1. Assist with sit-to-stand exercises to
1.
improve leg strength
Patient able to stand on her own using a
cane
2.
2. Assist with ROM exercises for increased
Patient able to perform flexion,
mobility and strength
extension, and dorsiflexion of lower
extremities
3. Assist with and encourage patient to walk 3.
Patient enjoys walking and staying
active
Evaluation (evaluate goal & interventions, what worked/what didnt, what would you adapt if needed):
Goals were all met. The patient was given more than a week to meet the above goals
because of the expectation that she would not want to walk or that weakness and pain
were increased. On the contrary, the patients pain was being managed and she was able
to walk with the assistance of a cane support her own weight.
Problem #2 Impaired comfort r/t illness related symptoms AEB pain
Desired Outcome: Patient discomfort will decrease and will be maintained at a
manageable level throughout the day
Nursing Interventions
Client Response to Intervention

1. Assess/question the patient about what

comfort measures she usually takes

2. Provide patient with comfort measures

such as extra pillows or blankets for both
emotional and physical support
3. Teach patient about alternate methods of
pain management

1.
Patient stated a neck pillow provided her
support, comfort, and pain relief. Extra
pillows under the left extremity provided
support and comfort.
2.
Extra pillows provided comfort &
support for left lower extremity
3.
Patient is able to use distraction to
forget about pain or discomfort ; stated
she liked animals and her cat & Furry
Friends are able to make her forget
about her pain

Evaluation:
Goals were all met, the most important pain relief for this patient is support of the neck
for cervicalgia and support of the left lower extremity. Support from extra pillows provide
comfort and reduced pain caused by the fracture. Also, distraction in the form of animals
is therapeutic and distracts her from her worries and pain.
Problem #3
Desired Outcome:
Nursing Interventions
1.

Client Response to Intervention

1.

2.

2.

3.

3.

Evaluation: