nursing 0700 Handoff Report Mrs. T, 72 years old, had an open reduction with int
ID: 139328 • Letter: N
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nursing
0700 Handoff Report Mrs. T, 72 years old, had an open reduction with internal fixation (ORIF) of her right hip yesterday This is her first postop day. Her right hip dressing has a small amount of dried dark red drainage. She has an IV of D5/0.45% NaCl at 75 mL/hr, oxygen at 2 L/min/nasal cannula, and is on a clear liquid diet. The right leg is warm, pedal pulse present, capillary refill around 2 seconds. IV PCA with mor- phine sulfate delivering 1 mg/hr continuous infusion. The following medications are ordered: FeSO4 325 mg po tid with meals, docusate sodium 100 mg po daily. The urinary catheter is draining clear urine and is to be discontinued today 0600 vital signs are P 80, R 18, BP1 10/84, pulse ox 96%, pain level difficult to assess since she is restless and confused this morning Mrs. T fell at home and sustained a fracture of the right hip. She was brought to the ER by ambulance. She was alert and oriented on admission. After the initial workup, she was taken to surgery A Restless, grabbing linens and moaning. Confused to time and place this morning. Skin warm, IV site R The following nursing interventions are recommended patent, O2 at 2 L/NC. Side rails up Prioritize the following five recommended nursing interventions according to Mrs. T's current needs. Write a number in the box to identify the order ofyour interventions (#1-first intervention, #2 econd intervention, etc.), and state a rationale for each intervention. INTERVENTIONS PRIORITY# RATIONALE Assess surgical dressing . Take VS, assess pain level, check pulse ox Assess neuro status . Assess right leg position and body alignment . Check neurovascular status of right leg (CMST) KEY POINTS TO CONSIDERExplanation / Answer
Nursing interventions priority wise:
-Take VS, assess pain level, check pulse ox.
-Assess neuro status
-Assess right leg position and body alignment
-Check neurovascular status of right leg (CMST)
-Assess surgical dressing
Rationale:
-Failuretorescue is a critical proportion of healing facility quality. Understanding crumbling is frequently gone before by changes in crucial signs. Be that as it may, persistent multiparameter imperative sign checking may diminish quiet security with a bounty of superfluous cautions.
-A neurological examination is the appraisal of tangible neuron and engine reactions, particularly reflexes, to decide if the sensory system is disabled.
-The body and the muscles and joints of the body work best when the body is in a specific arrangement entire moving. These perfect positions encourage the muscles and joints to deliver and lessen drive in the best way.
-The capacity to recognize a traded off appendage through cautious perception empowers incite referral and ensuing treatment, which may some way or another outcome in a lasting deficiency.
-The fundamental motivations behind a careful dressing when used to cover an injury mending by essential aim are to control any postoperative dying, assimilate exudate.
First day:
Nursing diagnosis:
-Impaired physical immobility
-Impaired gas exchange
-Acute pain
-Fatigue
-Risk for infection
Nursing interventions:
-Impaired Physical Mobility is portrayed by the accompanying signs and side effects: Inability to move deliberately inside physical condition, including bed portability, exchanges, and ambulation. Failure to perform activity as trained.
-The hypoxic quiet has restricted stores; unseemly action can expand hypoxia. Evaluate the home condition for aggravations that impede gas trade.
-The characterizing trademark for a nursing care plan for intense torment is that the patient must report or show indications of inconvenience.
-A staggering supported feeling of depletion and diminished limit with regards to physical and mental work at normal level.
-An adjusted admission of omega 3 and omega 6 unsaturated fats, protein, vitamins A, C and E, zinc and iron is basic in diminishing danger of contamination.
Rationale:
-Failure to move deliberately inside physical condition, including bed portability, exchanges, and ambulation.
-Debilitated gas trade is an overabundance or shortfall in oxygenation as well as carbon dioxide disposal at the alveolar-fine layer. Dispersion is the procedure by which O2 and CO2 are traded at the air-blood interface.
-Repulsive tangible and fervent knowledge emerging from real or possible tissue destruction or portrayed regarding such harm.
-A mind-boggling managed feeling of weariness and diminished limit with respect to physical and mental work at regular level.
-Understanding stays free of disease, as prove by ordinary essential signs and nonappearance of symbols besides side effects of contamination. Early acknowledgment of disease to yield into version provoke treatment.
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