School Name Student: Student Name, SN School

Date(s) of Care: 11-09-2010

NURSING PROCESS RECORD
Initials: H.L. Room: 919A Age: 95 Sex: Female Admission Date: 11-07-2010

Chief Complaint (What brought you into the hospital): “I tripped on blanket at home and was unable to bear weight on left leg.”

Diagnosis: Fractured Femur (Closed) – Left side at surgical neck Surgery / Date: Cardiac complications delay; Pt unwilling

BACKGROUND RESEARCH
Pathophysiological Explanation of Diagnosis: A fracture is a break in bone continuity affecting mobility and sensation.
Fractures are described by extent of break: complete or incomplete; type of break: nondisplaced, compound, comminuted,
displaced, oblique, spiral, impacted, greenstick; extent of soft-tissue damage: open (compound - skin surface disrupted
into open wound), closed (simple, no open wound); type of tissue damage: Grade I (minimal skin damage), II (open, skin
& muscle contusions), or III (damage to skin, muscle, nerves, & blood vessels); and cause: pathologic, fatigue, or
compression. Bone heals in 5 stages: hematoma formation, granulation tissue, callus formation, osteoblastic proliferation,
and bone remodeling. Long-bone fracture patients must be monitored closely first 48 hours for fat emboli. Hip fracture
(upper femur) is most common in older adults. Hip fractures have a high mortality rate as a result of multiple complications
r/t surgery and immobility, including blood clots, pneumonia, and infection.

Etiology: Primary cause is trauma from either direct blow to bone or indirect force from muscle contractions or pulling
forces on the bone. Fractures in the elderly often result from falls. Contributing factors include sports, vigorous exercise,
and malnutrition. Some genetic factors as well as osteoporosis (particularly in older adults) and other bone diseases
increase the risk for fractures. Fractures may be pathological (spontaneous) occurring in weakened bone after minimal
trauma or normal forces.

Signs and Symptoms: bone alignment changes manifesting as deformity, shortening of extremity or change in bone shape;
decreased range of motion; crepitus; ecchymotic skin over fracture site; hematoma; subcutaneous emphysema over
fracture site; swelling over fracture site; neurovascular compromise of affected limb; moderate to severe pain at site of
fracture or adjacent or distal area(s)

Common Complications: hypovolemic shock, fat emoblism syndrome, venous thromboembolism, pneumonia (geriatric),
infection, ischemic necrosis, delayed union, acute compartment syndrome (rare), crush syndrome (rare)

Other Medical Problems: Idiopathic hypertrophic subaortic stenosis, atrial fibrillation, paroxysmal supraventricular
tachycardia, sick sinus syndrome, angina pectoris, hypertension, peripheral vascular disease, hyperlipidemia,
hyponatremia, thrombocytopenia, osteopenia, osteoporosis, elevated liver enzymes, gastroesophageal reflux disease,
recurrent urinary tract infection

Allergies: Sulfas, amiodarones

Code Status: DNR

ASSESSMENT – STEP I
Physical Assessment:
Appearance on first sight: Smiling, lying in low-Fowler’s position, weakly extending a greeting.

Neurological assessment: Alert & oriented to person, place, and time, PERRLA, weak bilateral grips, but no unilateral deficit.

Skin Assessment: pink, cool (T=96.9°F axillary), dry and intact. Xerosis and flaking on distal upper and lower extremities.
Poor turgor, skin tenting. Petechiae on finger tips and toes. Multiple ecchymotic areas on dorsal surface of hands (Pt
states IV attempts), 15 score on Braden Scale for predicting pressure ulcer risk (17-23 no risk); no signs of erythema,
tearing, or shearing. Padding of bony prominences with pillows and foam-pressure relieving devices on feet/heels.
Condition of hair: Grey, clean, well kept Nails: Normal nail beds, moderate vertical ridging, clean, trimmed
Mouth: No lesions, mucosa pink and moist, no noticeable caries

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Cardiovascular assessment: S1, S2, S3, and S4 audible, AP 94 irregularly irregular, BP: 147/78 (RA, lying), cap refill 5 sec.,
pitting edema (3+) bilateral lower extremities, pedal pulses equal bilat (1+); Sequential compression devices applied
bilaterally to lower extremities Parenteral fluids: I/V right-antecubital capped; dressing clean/dry/intact; no signs of
infiltration, hematoma, or visual phlebitis

Nursing Process Record / Page 2

Respiratory assessment: Lungs clear in upper lobes bilaterally; diminished in lower lobes. R-19. SpO2 92% NC 2L.

Gastrointestinal assessment: Normal bowel sounds in all quadrants. Patient anorexic, freely consuming fluids.
Diet: Cardiac Date of last BM: 11/7 in morning, prior to fall

Musculoskeletal assessment: Strict bed rest. Non-weight bearing. Fractured left femur affecting movement, but CSM intact.

Genitourinary assessment: Indwelling Foley catheter draining to gravity – 150mL/16 hours clear, yellow urine – physician
notified. Intake estimated at 800mL for 16 hour time period.

Assessment of sleep: States adequate sleep during hospital stay; denies need for sedative/hypnotics.

Comfort/Pain assessment: 9/10 numeric scale (0-10). Nurse notified, morphine IV push administered. Patient feels cool to
touch, turned up heat in response and provided a second blanket. Water, glasses, and hearing aids within reach.

Environment/Safety: Bed in low position, side rails up x3 (support for fractured hip); call light and phone in reach. Floor clear
and dry. Strict bedrest.

Lab Data:
DATE TEST DEFINITION NORMALS PATIENT’S REASONS
(KOMC values) DATA (see index)
11/07/2010 urinalysis (UA) Multiple tests on urine specimen
hemoglobin Amount of blood in urine negative trace ↑ (1)
protein Level of protein in urine 0-8 mg/dL 100 mg/dL ↑ (2)
11/08/2010 Blood Sodium (Na+) Amount of Na+ in blood sample 136-145 mEq/L 133 mEq/L ↓ (3)
Blood Carbon Dioxide (CO2) Measure of CO2 in blood sample 22-30 mEq/L 21 mEq/L ↓ (4)
Blood glucose (non-fasting) Level of glucose in blood sample <200 mg/dL 279 mg/dL ↑ (5)
Brain Natriuretic Peptide (BNP) Measure of BNP hormone in blood (cardiac func.) 0-100 pg/mL 1146 pg/mL ↑ (6)
Aspartate Aminotransferase (AST) Measure of AST enzyme in blood (liver function) 14-36 U/L 167 U/L ↑ (7)
Alanine Aminotransferase (ALT) Measure of ALT enzyme in blood (liver function) 11-66 U/L 2367 U/L ↑ (7)
Red Blood Cell Count (RBC) Amount of RBCs per microliter of blood sample 2.94 M/μL 4.1-5.7 M/μL ↓ (8)
Red Blood Cell Distribution Width Variation in size of red blood cells sample 11.9-14.3% 15.6% ↑ (9)
Platelet Distribution (PLT) Amount an d size of thrombocytes in blood sample normal (subjective) decreased; giant (10)
Absolute Neutrophil Count (ANC) Measure of neutrophils in blood sample 2.1-7.7 K/μL 9.1 K/μL ↑ (11)
Lymphocytes Percentage of lymphocytes of white blood cells 20-40% 9% ↓ (12)
UA
granular casts Amount of cellular disintegration casts in urine 0-0/LPF 0-2/LPF ↑ (13)
hemoglobin negative small ↑ (1)
RBC Amount of red blood cells and casts in urine 0-3/HPF 10/HPF ↑ (14)
Bacteria Indicates presence of bacteria in urine sample none 1+ ↑ (15)
hyaline casts Amount of protein casts in urine sample 0-0/LPF 10-25/LPF ↑ (16)
protein 0-8 mg/dL 200 mg/dL ↑ (2)
WBC Amount of white blood cells and casts in urine 0-5/HPF 95/HPF ↑ (17)
squamous cell sediment Amount of microscopic epithelial cells in urine 0-5/LPF 6/LPF ↑ (18)
Serum Creatinine Amount of creatinine in blood sample 0.5-1.1 mg/dL 1.68 mg/dL ↑ (19)
BNP 0-100 pg/mL 1540 pg/mL ↑ (6)
11/09/2010 Blood Phosphate (PO4-3) Measure of PO4-3 in blood sample 2.5-4.5 mg/dL 6.4 mg/dL ↑ (20)
Blood Magnesium (Mg2+) Measure of Mg2+ in blood sample 1.6-2.3 mg/dL 1.5 mg/dL ↓ (21)
Blood Urea Nitrogen (BUN) Measure of urea in blood sample 10-20 mg/dL 29 mg/dL ↑ (22)
Blood Potassium (K+) Measure of K+ in blood sample 3.5-5.0 mEq/L 6.0 mg/dL ↑ (23)

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 Blood Na+ 136-145 mEq/L 135 mEq/L ↓ (3)
Reasons Index: (1) Hematuria likely related to collecting system damage in kidneys (H.L. has Stage 3 Kidney Disease). (2)
Proteinuria indicates renal disease (H.L. has Stage 3 Kidney Disease). (3) Decrease due to increased sodium loss – in
H.L. related to chronic renal insufficiency. (4) Decrease likely indicative of chronic renal failure in H.L. (5) Elevated level
likely indicative of chronic renal failure and/or acute stress response. (6) Elevated levels indicative of congestive heart
failure and systemic hypertension in H.L. (7) Significant elevation indicative of hepatic ischemia or other liver disease

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Nursing Process Record / Page 3

process. (8) Decreased levels suggest anemia which could be related to trauma to bone marrow, dietary insufficiency, or
acute stress in H.L. (9) Increased RDW suggests iron-deficiency anemia. (10) Decreased platelet distribution width and
giant size are indicative of H.L.’s thrombocytopenia. (11) Increased ANC is indicative of a left-shift suggesting severe
inflammation (fractured femur) and/or infection (urinary tract infection). (12) Decrease lymphocytes indicative of a left-shift
suggesting severe inflammation (fractured femur) and/or infection (urinary tract infection). (13) Presence is indicative of
renal failure and/or muscular trauma. (14) RBCs in urine suggest glomerulonephritis related to H.L.’s kidney disease. (15)
Presence indicates urinary tract infection. (16) Presence is indicative of proteinuria likely caused by H.L.’s renal disease.
(17) Presence indicates urinary tract infection. (18) Suggestive of glomerulonephritis related to H.L.’s kidney disease. (19)
Elevated levels are indicative of renal disease. (20) In H.L.’s case likely indicative of impaired phosphate excretion due to
severely decreased glomerular filtration rate due to severe kidney disease. (21) Decrease likely due to excessive urinary
loss related to H.L.’s kidney disase. (22) H.L.’s elevated BUN is indicative of her congestive heart failure, renal disease,
and hepatic impairment. (23) H.L’s hyperkalemia is likely due to stress and renal tubular dysfunction.

Diagnostic Studies: Pelvis X-ray 11/7/2010: findings indicate impacted fracture of left femur at surgical neck. Chest X-ray
11/8/2010: findings indicate moderate to large pleural effusions in Right lobes and small pleural effusions in left lobe, most
likely reflecting fluid overload, however pneumonia cannot be ruled out.

Scheduled Medications:
DRUG/DOSE/ROUTE/FREQUENCY
azithromycin (Zithromax) 500 mg IVPB q24h
ceftriaxone (Rocephin) 2 g IVPB q24h
docusate sodium (Colace) 250 mg PO BID
furosemide (Lasix) 40 mg IVPush once
metoprolol (Lopressor) 50 mg PO BID
nitroglycerin (Nitro-Dur) 0.6 mg/hr 1 patch
TD every day
sennosides (Senokot) 8.6 mg PO BID
simvastatin (Zocor) 80 mg PO every bedtime
DRUG CLASS
(therapeutic / pharmacological)
Antiinfectives / Macrolides
Antiinfectives / 3rd Generation Cephalosporins
Laxatives / Stool Softeners
Diuretics / Loop Diuretics
Antianginals, Antihypertensives / β-blockers
Antianginals / Nitrates
Laxatives / Stimulant Laxatives
Lipid-lowering Agents / HMG-CoA Inhibitors
REASON
Urinary tract infection (UTI)
Prevent osteomyelitis/Treat UTI
Prevent constipation
Promote urination/Reduce edema
Decrease BP; prevent angina
Prevent/Treat angina pectoris
Promote defecation/Treat const.
Treat hyperlipidemia

As Needed (PRN) Medications:

DRUG/DOSE/ROUTE/FREQUENCY
acetaminophen (Tylenol) 650 mg PO q4h
atropine (Ansyrl) 0.5 mg IVPush
metoclopramide (Reglan) 10 mg PO QID
morphine (Duramorph) 2-10 mg IVPush q4h
hydrocodone/acetaminophen (Norco)
5mg/325mg 1 to 2 tablets q4hr
ondanestron (Zofran) 32 mg IVPush q8h
DRUG CLASS
REASON
(therapeutic / pharmacological)
Antipyretics, Analgesics Mild pain (1-3/10); temp >100.4°F
Antiarrhythmics / Anticholinergics Bradycardia
Antiemetics GERD exacerbation; N/V
Opioid Analgesics / Opioid Agonists Moderate to severe pain
Opioid Analgesics / Opiod/NonOpioid Combo Moderate to severe pain
Antiemetics / 5 HT3 antagonists Nausea/vomiting

Psychosocial Assessment:
Culture and its implications for care: Caucasian female of European American ancestry. With regard to the death process,
European Americans should have accommodations made to include family to stay with person at all times. Health care
workers are expected to care for family as well. Heroics are implied so European Americans need to state their wishes in
writing to not have life-saving measures performed. European Americans expect full disclosure of health status and
should be allowed to disclose that information to their family themselves. H.L. immediately sought treatment after her fall
(self-reliance). H.L. requested family presence. H.L. has been under health care for long-term management of
hypertension, multiple cardiac issues, and renal failure. H.L. is a retired homemaker.

Spiritual practices: Was raised protestant, but not currently practicing. Believes in “God, The Almighty”; enjoyed her
chaplain visitation. Does not pray or go to services on a regular basis. Her family is not “religious”.

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Developmental assessment: According to Loevinger, H.L. is in the integrated stage of development. She evidences this by 1)
her ability to transcend conflicts in her life, 2) her sense of self-awareness where she notes and is able to discuss
discrepancies between normal conventions and her own behavior, 3) her self-identity is fully worked out. H.L. discussed
her life with me and her readiness to “sleep forever” now. She has accomplished all she wished to in her life.

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Nursing Process Record / Page 4

Effects of illness/hospitalization on sexuality: H.L.’s husband passed “many, many, many years ago”. No other comments.

Body image: H.L. was not concerned with her body image. However, she verbalized wish to “sleep forever”.

Family structure: Widowed, 4 children, many grand and great-grand children. Lives with great-grandson; cared for by a
granddaughter who also has power of attorney.

Patient’s understanding of illness: Fully understands the implications that she will likely not recover. Readily accepts that
death is a close inevitability given her situation.

Ethical issues: H.L. discussed her desire for euthanasia by asking me to provide her with more morphine. I explained that it
was illegal for me to do so and that she needed to discuss her wishes with her physicians and family.

How do you feel about caring for this patient? I really enjoyed caring for this patient, although I found it to be an emotional
experience due to the implications of near death and moving a patient into comfort care through the palliative care team. I
totally respect and understand her wishes.

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Nursing Process Record / Page 5
NURSING GOAL
DIAGNOSIS
1) Acute Pain related to Medication Response: By
disruption in bone 11/9 1400, H.L. will report
continuity as evidenced relief of symptoms to at least
by verbalization of pain tolerable level or to complete
words relief via analgesics using
numeric scale 0-10 with 1
indicating no discomfort and
10 indicating worse
discomfort imaginable.
INTERVENTION – NURSING
ORDERS
a) Pain Management: Perform a
comprehensive assessment of pain
to include location, characteristics,
onset, duration, frequency, quality,
intensity or severity and
precipitating factors of pain.
b) Pain Management: Evaluate
effectiveness of analgesics at
regular, frequent intervals after
each administration and especially
after initial doses, also observing
for signs and symptoms of
untoward effects bearing in mind
geriatric implications of analgesic
administration (respiratory
depression, nausea/vomiting, dry
mouth, and constipation).
c) Pain Management: Provide H.L.
with optimal pain relief through
prescribed analgesics.
d) Analgesic Administration:
Determine analgesic selection
(opioid or nonopioid) based on
H.L.’s type and severity of pain.
e) Analgesic Administration:
Implement actions to decrease
untoward analgesic effects (e.g.,
constipation) in H.L. Assess for
overall GI functioning as well as
for constipation.
RATIONALE EVALUATION
a) Pain is a subjective experience Goal/outcome only partially met.
and must be described by the The client verbalizes pain and
client in order to plan effective discomfort and requests analgesics
treatment at onset of pain. Client states
“pain at 6” out of 10, 30 minutes
after oral pain medication. Client
b) The analgesic dose may be then states “no pain” 20 minutes
adequate to raise the client’s pain after parenteral analgesic
threshold or may be causing administration. Prior to each
intolerable or dangerous side administration client states “pain
effects or both. Ongoing at 9 or 10”.
evaluation will assist in making
necessary adjustments for
effective pain management.
c) Each client has a right to expect
maximum pain relief. Optimal
pain relief using analgesics
includes determining the
preferred route, drug, dosage,
and frequency for each
individual. Medications ordered
on a prn basis should be offered
to the client at the interval when
the next dose is available.
d) Various types of pain require
different analgesic approaches.
Some types of pain respond to
nonopioid drugs alone, others to
a combination of low-dose
opioid with non-opioid, and
others to opioids only.
e) Constipation is a common side
effect of opioid narcotics, and a
treatment plan to prevent
occurrence should be instituted
at the beginning of analgesic
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therapy.

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Nursing Process Record / Page 6
NURSING GOAL
DIAGNOSIS
2) Risk for Peripheral Tissue Perfusion: Peripheral:
Neurovascular By 11/9 1400, H.L. will
Dysfunction R/T have usual or improved
disruption in bone peripheral neurovascular
continuity function as evidenced by
palpable peripheral pulses,
capillary refill time of 5 or
less seconds, extremities
warm and usual color,
ability to flex and extend
feet and toes, usual or
improved reflexes, muscle
tone, and sensation in
extremities, and no new or
increased pain in
extremities.
INTERVENTION – NURSING
ORDERS
a) Pain Management: Pain: Assess
severity (on a scale of 1 to 10),
quality, radiation, and relief by
medications.
b) Peripheral Sensation Management:
Pulses: Check the pulses distal to
the injury. Check the uninjured
side first to establish a baseline for
a bilateral comparison.
c) Peripheral Sensation
Management: Pallor /
Poikilothermia: Check color and
temperature changes above and
below the injury site. Check
capillary refill.
d) Peripheral Sensation Management:
Paresthesia: Check sensation by
lightly touching the skin proximal
and distal to the injury. Ask if the
H.L. has any unusual sensations
such as hypersensitivity, tingling,
prickling, decreased feeling, or
numbness.
e) Peripheral Sensation Management:
Paralysis: Ask the client to
perform appropriate range-of-
motion exercises in the unaffected
and then the affected extremity.
RATIONALE EVALUATION
a) Diffuse pain that is aggravated by Goal/outcome only partially met.
passive movement and is Client was able to maintain
unrelieved by medication can be circulation to usual level. Client
an early symptom of fat or blood was not able to perform active or
emboli, compartment syndrome, passive range of motion.
or limb ischemia.
b) An intact pulse generally
indicates a good blood supply to
the extremity, although fat
emboli and compartment
syndrome may be present even if
the pulse is intact.
c) If pallor is present, record the
coldness carefully. A cold, pale,
or bluish extremity indicates
arterial insufficiency or arterial
damage, and a physician should
be notified. A reddened, warm
extremity may indicate infection.
Norma capillary refill time in
elderly patients is 5 seconds or
less.
d) Changes in sensation are
indicative of nerve compression
and damage and can also indicate
compartment syndrome.
e) Paralysis is a late and ominous
symptom of compartment
syndrome or limb ischemia.
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Nursing Process Record / Page 7
NURSING GOAL
DIAGNOSIS
3) Impaired Physical Immobility Consequences:
Mobility related to Physiological: Ongoing,
disruption in bone daily goal, H.L. will
continuity as evidenced maintain position of
by pain and inability to function and skin integrity
ambulate as evidenced by absence of
contractures, footdrop, or
decubitus in lower
extremities.
INTERVENTION – NURSING
ORDERS
a) Prevention of Complications:
Perform and encourage regular
skin examination and care.
b) Prevention of Complications:
Support affected body parts and
joints using padding, positioning
devices, and pressure-relieving
mattresses.
c) Promotion of Mobility: Encourage
client’s participation in self-care
activities, physical or occupational
therapies as well as diversional
and recreational activities.
d) Promotion of Mobility: Assist with
and encourage H.L. to reposition
self on a regular schedule as
dictated by inability to move
lower left limb.
e) Promotion of Wellness: Involve
client and her family in her care,
assisting them in learning ways of
managing problems of immobility,
especially because impairment is
expected to be long-term.
RATIONALE EVALUATION
a) Regular skin examination helps Goal/outcome only met. Client
to reduce pressure on sensitive participated in skin inspection and
areas and to prevent repositioning and verbalized
development of problems with feelings of discomfort or pressure.
skin integrity as well as quickly Complete absence of contractures,
identifies early development of footdrop, and decubitus. Palliative,
skin impairment. discharge, surgery, and social
b) Use of pressure-relieving devises work care team met with client
reduces tissue pressure, prevents and family to discuss long-term
stress on tissue, reduces potential outcomes and immobility.
for disuse complications, and
aids in maximizing cellular
perfusion to prevent skin injury.
c) Client participation reduces
sensory deprivation, enhances
self-concept and sense of
independence, and improves
body strength and function.
d) Positional changes enhance
tissue circulation reducing risk of
tissue ischemia.
e) To maintain effective coping
mechanisms, client needs to be
able to manage immobility to
reduce sensory deprivation, and
enhance self-concept and
independence. Client may need
referral for support and
community services to provide
care, supervision,
companionship, respite services,
nutritional and ADL assistance,
adaptive devices or changes to
living environment, financial
assistance, etc…
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Deglin, J. H. & Vallerand, A. H. (Eds.). (2007). Davis’s Drug Guide for Nurses (11th ed.). Philadelphia, PA: F. A. Davis.

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DRUG CARDS – SCHEDULED MEDS

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DRUG CARDS – PRN MEDS

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