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DE LA SALLE HEALTH SCIENCES INSTITUTE COLLEGE OF NURSING AND SCHOOL OF MIDWIFERY LEVEL III NURSING CARE PLAN
Patient Name: J.C.J. Age: 73 Sex: Female CS: Widowed Medical Diagnosis: Fracture closed complete displaced intertrochanteric right femur Attending Physician: Dr. Boyles I. Chief Complaint/ Other Complaints Right Hip Pain Swelling on the right thigh
II. Nursing History Few hours prior to consultation patient was walking on a street near their house when after crushing by a passing vehicle she stepped on uneven ground, lost a balance and fall with her right hip. III. Pathophysiology (pathophysiological events) and Explanation
Fall
The combination of increased fragility of bone and a traumatic event such as a motor vehicle accident or fall may result in either a direct impact or generation of a torsional force transmitted through the leg to the intertrochanteric area. When such forces are greater than the strength of the bone in the intertrochanteric area, a fracture occurs. An intertrochanteric hip fracture occurs lower than a femoral neck fracture. Intertrochanteric hip fractures have a different treatment because they do not have the issues with damage to blood flow to bone seen with the femoral neck fractures. Because the bone blood flow is usually intact, these fractures can usually be repaired, and do not require the hip replacement procedure.
Hematology
(4-22-13)
Used to evaluate anemia, leukemia, reaction to inflammation and infections, peripheral blood cellular characters, state of hydration and dehydration, polycythemia, haemolytic disease of the newborn, to manage chemotheraphy decisions
120-160 g/L
Intra: Explain all the procedures to the patient and its purpose Clean the site for extraction of blood with cotton soaked in alcohol and then dry Assist the patient while doing the procedure
Cozaar (Losartan)
Headache, dizziness, syncope, insomnia, Hypotension, Rash, urticaria, pruritus, alopecia, dry skin, Diarrhea, abdominal pain, nausea, constipation, dry mouth, URI symptoms, cough, sinus disorders, Cancer in preclinical studies, back pain, fever, gout, muscle weakness
-Administer without regard to meals. -Alert surgeon and mark patient's chart with notice that losartan is being taken. The blockage of the reninangiotensin system following surgery can produce problems. Hypotension may be reversed with volume expansion. -Monitor patient closely in any situation that may lead to a decrease in blood pressure secondary to reduction in fluid volume-excessive perspiration, dehydration, vomiting, diarrhea--excessive hypotension can occur.
BN/GN
Indication/CI
S/E and AR
Nursing Responsibilities
Ceftin (Cefuroxime)
Treatment of Upper and Lower Respiratory Tract Infections and Skin Infections
Headache, dizziness, lethargy, paresthesias, Nausea, vomiting, diarrhea, anorexia, abdominal pain, flatulence, liver toxicity, Nephrotoxicity, bone marrow depression, decreased WBC, decreased platelets, decreased Hct, serum sickness reaction, pain
-Culture infection, arrange for sensitivity tests before and during therapy if expected response is not seen. -Give oral drug with food to decrease GI upset and enhance absorption. -Have vitamin K available in
BN/GN
Indication/CI
S/E and AR
Nursing Responsibilities
Capoten (Captopril)
Treatment of hypertension
Tachycardia, angina pectoris, MI, CHF, hypotension in salt/volume depleted patients, Rash, pruritus, scalded mouth sensation, photosensitivity, alopecia, Gastric irritation, aphthous ulcers, peptic ulcers, hepatocellular injury, anorexia, constipation, proteinuria, polyuria, oliguria, urinary frequency, neutropenia, agranulocytosis, thrombocytopenia, hemolytic anemia, pancytopenia, cough, malaise, dry mouth, lymphadenopathy
-Administer 1 hr before or 2 hr after meals. -Alert surgeon and mark patient's chart with notice that captopril is being taken; the angiotensin II formation subsequent to compensatory renin release during surgery will be blocked; hypotension may be reversed with volume expansion. -Monitor patient closely for fall in BP secondary to reduction in fluid volume (excessive perspiration and dehydration, vomiting, diarrhea); excessive hypotension may occur. -Reduce dosage in patients with impaired renal function.
BN/GN
Indication/CI
S/E and AR
Nursing Responsibilities
Treatment of: -Chronic stable angina, alone or in combination with other agents -Essential hypertension alone or in combination with other antihypertensives
Dizziness, light-headedness, headache, asthenia, fatigue, lethargy, peripheral edema, arrhythmias, flushing, rash, nausea, abdominal discomfort
-Monitor patient carefully (BP, cardiac rhythm, and output) while adjusting drug to therapeutic dose -Monitor BP very carefully if patient is also on nitrates. -Monitor cardiac rhythm regularly during stabilization of dosage and periodically during long-term therapy. -Administer drug without regard to meals.
CUES
NURSING DIAGNOSIS
LONG TERM
SHORT TERM
INTERVENTION
RATIONALE
EVALUATION
S>medyo nangangalay na namamanhid ang pakiramdam ko lalo na sa mga binti ko O>Received pt. lying on bed in supine position, awake, conscious, coherent and communicative >V/S of: T = 35.6 C P = 63 bpm R = 20 cpm BP= 130/70 mmHg >(+) numbness on lower extremities >(+) facial grimace >(+) guarding behaviour
o
A1>Impaired comfort r/t tissue trauma and reflex muscle spasm o 2 fractures
> After a week my patient will not be able to experience pain and/or spasms on lower extremities
> Within my 4 hours span of care my patient will be able to: a. reports decrease feeling of spasm on lower extremities after the given interventions
>for the patient to be aware to the different procedures that will be done to him and to also lessen his anxiety
Patient reported decrease feeling of spasm on lower extremities after the given interventions
>Will assess V/S and record >Will evaluate clients ability to provide selfcare
>Self-care places and important part in maintaining integrity of the skin >to prevent dehydration
>Will encourage the pt. to increase fluids >Will help and encourage the pt. to do ROM exercise
> to maintain muscle and bone integrity and to prevent muscle atrophy on both lower and upper extremities
CUES
NURSING DIAGNOSIS
LONG TERM
SHORT TERM
INTERVENTION >Will encourage the pt. to maintain a cool environment >Will instruct the pt. to follow as consistent a daily schedule for retiring & arising as possible >Will instruct the pt. to avoid heavy meals, caffeine, before retiring >Will instruct the pt. to reduce large fluid intake before bedtime >Will encourage to increase daytime physical activities as indicated like simple ROM exercise >Will instruct to avoid strenuous activities before bedtime >Will encourage use of soporifics such as milk as indicated >Will provide nursing aids (e.g. back rub, bedtime care, pain relief, comfortable position, relaxation techniques)
RATIONALE
EVALUATION
S>minsan naiistorbo ang pagtulog ko gawa nga ng sobrang init at minsan ang ingay pa
After a week my patient a. Will regularly fall asleep without difficulty as measured by clients verbalization of ease of falling asleep consistently b. Will wake less frequently throughout the night as measured by verbalization of less frequent awakening
Within my 4 hours span of care my patient will be able to: > understand the purposes of the given measures in increasing or promoting sleep
>hot environment will cause the pt. to perspire too much and this will make him feel uncomfortable >this promotes regulation of the circadian rhythm, & reduces the energy required for adaptation to changes >though hunger can also keep one awake, gastric digestion & stimulation from caffeine can disturb sleep >because this will induce frequent urination @ night
Short term Goal: >Goal met, The patient understood the purposes of the given measures in increasing or promoting sleep
O>(+) restlessness
>Will encourage to wear loose fitting clothes >Will encourage to open the window if possible >Will encourage the pt. & family to limit the number of visitors and their length of stay >Will organize nursing care
>this will promotes sleep and increase pt.s feeling of comfort >to promote air ventilation
Diet
Advised the patient to only eat foods that she can tolerate, drink plenty of water, drink warm or cool liquids and avoid drinking alcohol Patient will know and follow patients restrictions in foods and proper eating of healthy foods.
The patient will be engaged in doing simple ROM exercises in order to maintain muscle and bones integrity as well as maintaining a good body circulation. Be sure to get enough rest and sleep on a daily basis.
>Educate the patient about how to do simple ROM exercises like flexion of upper and lower extremities or walking for a short distance. >Educating the patient about the importance of exercise, rest and sleep in the body and its benefits to once health.