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Nursing Care Plan

Submitted by:

Rachelle Ann A. Reyes BSN3-6

Submitted to:

Prof. Ederlyn Lumabi, RN, MAN

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

Injury to intertrochanteric right femur

Tissue swelling, bruising or hematoma mass at site of injury

Restricted or loss of function of affected part

Increase diameter of thigh

Hypertension (occasionally seen as a response to acute pain/anxiety)

Tachycardia (stress response)

Fatigue, weakness (e.g. affected extremity or generalized)

Gait and/ or mobility problems

Fracture closed complete displaced intertrochanteric right femur

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.

IV. Laboratory/ Diagnostic Result, Interpretation and Nursing Implication


Procedure/ Date Indications Normal Values/ Findings Hemoglobin Actual Findings and Interpretation Nursing Responsibilities Pre: 90 (indicates anemia, bone marrow problems, blood loss due to accidents/injuries) Hematocrit 0.37-0.52 0.28 (indicates anemia, bleeding, destruction of RBC) WBC 4.5-11 x 10^9/L 10.32 (indicates infection, inflammation or tissue injuries) Segmenters 0.40-0.74 0.77 (indicates infection/ inflammation) Lymphocytes 0.19-0.48 0.11 (indicates infection) Eosinophils 0.01-0.02 0.06 (indicates infection) Monocytes 0.03-0.09 Platelet count 150-450x10^9/L 266 0.06 Post: Dispose the needle properly Send the specimen to the laboratory after doing the procedure Check the doctors order Prepare the cleaned needed equipments

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

V. Medications and Treatment


BN/GN Dosage/ Frequency/ Route 50 mg/tab O.D. Oral Indication/CI S/E and AR Nursing Responsibilities

Cozaar (Losartan)

Treatment of hypertension alone or in combination with other antihypertensive agents

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

Dosage/ Frequency/ Route 500 mg/tab B.I.D. Oral

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

case hypoprothrombinemia occurs. -Discontinue if hypersensitivity reaction occurs.

BN/GN

Dosage/ Frequency/ Route 25 mg/tab O.D. Oral

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

Dosage/ Frequency/ Route 10 mg/tab O.D. A.C. Oral

Indication/CI

S/E and AR

Nursing Responsibilities

Norvasc (Amlodipine Besylate)

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.

VI. Nursing Priorities

Impaired Comfort Disturbed Sleep Pattern

VII. Nursing Care Plan

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

>Will establish rapport

> to gain the trust and cooperation of the patient

Short term goal: > Goal met,

>Will explain all the procedures to the patient

>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

>to obtain baseline data

>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

A2>Disturbed sleep pattern r/t environmental factors (e.g. climate, noise)

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

>this reduce stress & promotes sleep

>Over fatigue may cause insomnia

>Milk contains L-tryptophan which facilitates sleep

>these promote rest

>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

>to promote rest and/or conserve energy

>to allow for periods of uninterrupted rest of the pt.

VIII. Discharge Plan


Content 1. Compliance Medication The patient will continue the prescribed medications with proper dosage and frequency in order to hasten the recovery of the patient. >Informing the patient about the prescribed medications and its importance regarding to her condition. >Reminding and reviewing the patient about the drugs in order to make familiarity with the treatment. >Encouraging the patient and to avoid using non-prescription drug unless use is approved by the physician. >Encouraging the patient to follow the diet and fluid intake recommended to her. >Educating the patient to follow the diet and fluid intake recommended by the physician for her. >Educating the patient about foods that are healthy yet appropriate for her diet. Strategy

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.

Exercise Activity/Lifestyle Changes

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.