nursing. 2 pages. please read the directions. these are interested to be brief.
ID: 139705 • Letter: N
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nursing. 2 pages. please read the directions. these are interested to be brief. not to elaborate. thanks I like seeing others perspectives
2-21 THE PATIENT WITH A HIP FRACTURE 0700 Handoff Report: S 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 1/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: FeSO 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, BP 110/84, pulse ox 96%, pain level difficult to assess since she is restless and confused this morning B Mrs. T fell at home and sustained a fracture of the right hip. She was brought to the ER by ambulance. A Restless, grabbing linens and moaning, Confused to time and place this morning. Skin warm, IV site R The following nursing interventions are recommended She was alert and oriented on admission. After the initial workup, she was taken to surgery 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 (#)-first intervention, #2 : second 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
#1. RECOMMENDED NURSING INTERVENTIONS:
FIRST INTERVENTION is monitor vital signs, assess the pain level and check pulse oxymetry. RATIONALE: Inadequate circulating volume compromises systemic tissue perfusion.
SECOND INTERVENTION: Assess the neurological status of the patient.
RATIONALE: To prevent or minimize complications related to anaesthesia and the surgical procedure.
THIRD INTERVENTION: check neurovascular status of the right leg.
RATIONALE: decreased or absent of pulse may reflect vascular injury and necessiates immediate evaluation of circulatory status and impaired feeling, numbness results in nerve damage.
FOURTH INTERVENTION: assess the surgical dressing site. RATIONALE: To promote healing and to prevent infection.
FIFTH INTERVENTION: assess right leg position and body alignment.
RATIONALE: It rovides stability, reduces possibility of disturbing alignment and muscle spasms which enhance healing.
#2. In the first post-operative day, crackles in the base of the lung indicates pulmonary edema which is a hallmark sign of pulmonary embolism. It should be treated as early as possible. Pedal pulse is checked every 2 to 4 hours after the surgery inorder to assess the circulation to prevent from nerve damage or cyanosis. It is usually weak in the right foot ( surgical limb) than the other. Next hemoglobin level is checked because of increase in blood loss during the surgery. Hypoactive bowel sounds are normal after surgery.
#3. NURSING DIAGNOSIS: ACUTE PAIN RELATED TO MOVEMENT OF BONE FRAGMENTS, EDEMA AND INJURY TO THE SOFT TISSUE.
Nursing Interventions and Rationale:
a) Maintain immobilization of affected part by means of bed rest, cast, splint or traction which helps to relieve pain and prevents bone from displacement and tissue injury. b) Elevate and support injured extremity to promote venous return, decrease edema and may reduce pain c) Evaluate and record the reports of pain, location and characteristics of pain including intensity to influences effectiveness of interventions. d) Medication can be given before pain becomes severe to promote muscle relaxation and enhance participation of the patient e) Provide emotional support and encourage use of stress management techniques such as relaxation, deep-breathing exercises to promote sense of control and to reduce the stress of injury and pain.
#4. NURSING INTERVENTIONS: 1. Call physician 2. Administer oxygen per nasal canula 3. Monitor vital signs every 5 minutes 4. Monitor oxygen saturation level continuously 5. Stay with the patient and 6. Prepare to transfer patient.
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