Care Plan

Student: Sherwin Llevares Date: 03/22/20

Course: NSG-320CC Instructor: Karina Mondragon

Clincial Site: Banner Boswell Client Identifier: R.S Age: 82

Reason for Admission: Fall resulting in a Fracture of left femoral neck

Client was admitted from the Emergency Department on March 22, 2020. Upon arrival in the ER R.S. presented with left forehead abrasion, left
shoulder bruised, and is in pain. R.S presented to the ED due to experiencing a fall at home which she has falled multiple times in the past few
months.

Medical Diagnoses: (Include Pathophysiology and Risk Factors): Current clinical manifestations:
- Femoral Neck Fracture - Weakness
- Severe pain
Pathophysiology:
- bruising
A femoral Neck fracture is located in the area of the upper portion of the - swelling in multiple areas of the body
femur just right underneath the ball part (femoral head) of the ball-and-
socket joint (Mayo Clinic, 2018b).
Potential clinical manifestation are:
- severe pain in the hip and the groin area
Risk Factors: - inability to put weight in the affected area where the injury
- Age related to the persons bone density and muscle mass. As well is
as older people have problems with eye vision and balance which - stiffness
increase the risk for fall. - bruising
- Physical inactivity: weight-bearing exercise can help strengthen - swelling
bone and muscles making it less likely to break something upon - shorter leg on the injured side
fall making it a higher risk for fractures when a person is inactive. - turning outward of the leg that was injured
- Poor nutrition: person who is not taking enough vitamin D and

© 2018. Grand Canyon University. All Rights Reserved. Rev 2.17.18

 calcium can increase risk for fractures (Mayo Clinic, 2018b). - the inability to move after the fall
- (Mayo Clinic, 2018b).

Assessment Data
Subjective Data: R.S. reports that she came to the ED because she had fallen at home and is in pain.
VS: 03/22/20 Q4h Labs: 03/22/20 Diagnostics:
(2000) WBC: 5.2 WNL
Vitals not available but stable
Normal: 4.0-11.0 Completed:

(2400) RBC: 4.5 WNL  MRI (03/22/2020)

Vitals not available but stable o Reason: Rule Out Fracture
Normal: 3.70-5.40 o Findings: Complete Fracture of Left
Femoral Neck
(0400) HgB: 10.8 WNL
 X-ray Left Shoulder (03/22/2020)
Vitals not available but stable Normal: 10.0-16.0 o Reason: Rule Out Fracture
g/dL o Findings: No Fracture Identified
Hct: 22.7 Low HCT is due to
either anemia or fluid Scheduled:
Normal: 39-50%
overload (Billett,
1990). No pending diagnostics

Platelets: 300,000 WNL

Normal: 130,000-
400,000 μL
Na+: 140 WNL
Normal: 135-145

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K+: 3.4 Low potassium levels
is due to the patients
Normal: 3.5-5.0
chronic kidney
mmol/L
disease (Mayo Clinic,
2018)

Phosphorus: 3.5 WNL

Normal: 2.7-4.5

Magnesium: 1.7 WNL

Normal: 1.5-2.5

BUN: 7 WNL
Normal: 7-20 mg/dL

Cr: 1.4 WNL

Normal: 0.6-
1.4mg/dL

Glucose: 111 WNL

Normal: 70-130
mg/dL

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Assessment: Orders:
PMH: Coronary Artery Disease, hypertension, chronic kidney disease,
and osteoarthritis.
 Vital Signs: Q4H
 Ice 15 min: Q4H PRN
 Hip Precautions: No flexion past 90 degrees, No adduction
past midline.
Neuro: A/Ox4. Speech is clear. Pupils are Equal, round, regular and  Vascular Check: Q2H Bilateral Lower Extremities
approximately 3cm. Reactive to light, open spontaneously.  Nonweight bearing LLE until post op
Resp: Patient is in RA with stable vitals signs. The respiratory rate was  PT to get client out of bed day of surgery
stable. Lungs sounds are clear all throughout. The inspiratory effort are  Antiembolism stockings: 30 min off BID
unlabored, no cough or sputum.  SCD’s: while in bed
 Incentive Spirometry: Cough and Deep Breathe: Q4H, 2L O2
Cardiac: Heart rate was stable and regular rate and rythm. The blood
NC for saturation <93%
pressure is stable. Radial & pedal pulse were palpable bilaterrally and
 Dressing Change: BID L forehead: Nonstick telfa pad with
approximately 2+. No lower or upper edema noted bilaterally on the
paper tape
extremities. Cap refil are brisk <3 sec on both upper and lower
 Code Status: Full
extremities. Patient has a sinus rhythm.
GI: Abdomen is round, non-tender, and soft. Bowel sounds are
hypoactive. Last bowel movement was not stated. NPO since midnight
but diet is to be advanced as tolerated after surgery.
GU: Client has a foley catheter in place. Urine is clear and yellow with
no pain upon urination. No amount of urine output was recorded.
Skin: skin is warm, pink, dry and intact. The color of the skin is
appropriate to the patient. An abrasion is present on her left forehead
with a clean, dry, and intact dressing. Left shoulder is bruised and
slightly swollen. Bruise on the left hip.
MSK: Upper extremity motor response is equal and strong with
resistence bilaterally. Lower extremity motor response was not equal
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bilaterally. Left lower extremity is weak and is unable to move against
resistance. Right lower extremity moves against resistance. Fall
precautions. Hip precautions.
Hygeine: client has 2 pre op bath. Oral care and pericare were not
documented.
Monitoring Lines/IVs: Peripheral IVs location are in the right AC. No
pain, swelling, tenderness, and redness. 20 gauge is used on the right
forearm no inflamation or phlebitis noted. This IV site is running
normal saline at 75 mL per hour.
Pain: Patient has a controlled dull pain of 4/10. Patient states that her
pain does go to a sharp 8/10 pain rating with movement.
Weight: 54 kg Height: 162.5 cm

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6
 Medications
ALLERGIES:
Lisinopril (unknown reaction), Naproxen (unknown reaction)

Name Dose Route Frequency Indication/Therapeutic Adverse Effects Nursing Considerations

Effect

G: Bacitracin NA Topical BID to This medication is an anti- Rash, pseudomembradnous Nursing Assessment:
forehead infective. This patient is using colitis, nausea, vomiting, renal 1. Assess lesions prior to and
B: BACiiM this medication for treatment of failure, and pain at site periodically during therapy.
localized infections (Vallerand (Vallerand et al., 2017). 2. Monitor bowel function.
et al., 2017). Diarrhea, abdominal
cramping, fever, and bloody
stools should be reported to
health care provider due to
possible CDAD.
3. Monitor CBC periodically
during therapy. Monitor renal
function.
Patient Education:
1. Instruct patient to use only
as long as prescribed due to
possible overgrowth of
resistant organisms.
2. Caution patient to notify
health care professional if
fever and diarrhea occur.
3. Advise patient to only use
on minor cuts or burns. Do
not use on animal bites,
serious burns, or deep cuts
(Vallerand et al., 2017).

1-2 mg IV Push Q2H PRN This medication is an opioid Confusion, sedation, blurred Nursing Assessment:
G: Morphine Soln-Inj pain (3-5) analgesic. The patient is taking vision, respiratory depression, 1. Assess pain level, location,
1mg, pain (6- this to relieve pain (Vallerand hypotension, bradycardia, and type before and 20
B: MS Contin 8) 2mg, call et al., 2017). constipation, urinary retention, minutes following
for pain 9 or and physical dependence administration of this drug
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 >. (Vallerand et al., 2017). IV.
2. Assess LOC, BP, HR, and
RR before and during
administration, do not give is
RR is below 10.
3. Assess risk for
dependency, addiction,
abuse, or misuse of opioids
prior to therapy as this can
result in overdose and death.
Patient Education:
1. Educate patient on how
and when to ask to receive
this pain medication.
2. Educate patient on alcohol
consumption while taking
this medication, do not use
alcohol or other CNS
depressants with this
medication.
3. Explain to patient and
family how and when to
administer this medication as
well as signs and symptoms
of respiratory depression
(Vallerand et al., 2017).
G: Acetaminophen and 5/325 mg Oral Tab Q4H PRN This medication is an opioid Chills, loss of apetite, dizziness, Nursing Assessment:
Oxycodone for pain analgesic. This patient is taking nausea, headache, stomach 1. Assess type, location, and
this to relieve pain (Vallerand, pain, cough, fever, sore throat, intensity of pain prior to and
B: Percocet Sanoski & Deglin, 2017). and physical dependence one hour after administration.
(Vallerand et al., 2017). 2. Assess BP, pulse, and
respirations before and
periodically during
administration. Assess level
of sedation.
3. Assess risk for opioid
addiction, abuse, or misuse
prior to administration.
Patient Education:
1. Instruct patient and family

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on how to ask for and take
pain medication.
2. Medication may cause
drowsiness or dizziness.
Advise patient to call for
assistance when ambulating
or smoking.
3. Advise patient to make
position changes slowly to
minimize orthostatic
hypotension (Vallerand et al.,
2017).

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 5 mg IV Push Q4H PRN This medication is used to
G: Metoprolol For SBP decrease bp and heart rate by
>160 blocking the stimulation beta 1.
B: Lopressor This client is taking this
medication for regulating her
blood pressure and preventing
MI. Especially when
experiences A-fib recently
(Vallerand et al., 2017).
Bronchospasm, Bradycardia,
hypotension, constipation, and
heartburnds (Vallerand et al.,
2017).
Nursing assessment:
1) Monitor Blood pressure
before administering. Should
not be below 90/60 if so hold
it.
2) Monitor the heart rate if its
<60 then hold it
3) Monitor patient I&Os
Patient Education:
1) teach the patient to take
their own pulse and blood
pressure if they are taking it
at home
2) Remind the patient to get
up slowly because of the
orthostatic hypotension.
3) caution the patient that
taking this medication it can
increase the sensitvity to
cold.
(Vallerand et al., 2017).

G: Enoxaparin 70 mg SQ Q Daily for This medication is an Bleeding, anemia, vommiting, Nursing assessment:
antiembolism anticoagulant. It prevents the hyperkalemia, and rash 1) Asses signs of bleeding in
B: Lovenox formation of thrombus. The (Vallerand et al., 2017). the gums, nose bleed, etc.
patient is on this medication in 2) Monitor patient who have
order to prevent DVT and hypersensitivity of the drug.
clots. (chills, fever, and urticaria)
3) Monitor CBC, platelet
count, and stools for occult
blood for the remainder the
patient is on the drug.
Pateitn education:
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 1) Tell the patient to report
any signs bruising and
unusual bleeding.
2) advice patient to contact
health care provider for
dizziness, rash, fever,
swelling, and dificulty
breathing.
3) Advice patient to not take
contraindication drugs such
as aspirin or ibuprofen.
(Vallerand et al., 2017).

100mg/cap Oral BID Medication is used for Dehydration, electrolyte Nursing assessment:
G: Losartan Constipation. It softens the imbalnce, abdominal cramps, 1) assess for abdominal
stool in order to let it pass at and urine discolaration distention
B: Cozaar ease. Patient is taking this due (Vallerand et al., 2017). 2) the presence of bowel
to constipation (Vallerand et sound
al., 2017). 3) Assess the color,
consistency, and amount of
stool produced.
Patient education:
1) advise patient that laxative
are only used for short term.
2) Encourage patient to use
other forms of bowel
regulation.
3) using this in a long term
situation can cuase
electrolyte imbalnces
(Vallerand et al., 2017).
Nursing Diagnoses and Plan of Care
Goal Expected Outcome Intervention(s) Rationale Evaluation
Client or family focused. Measurable, time-specific, Nursing or interprofessional Provide reason why interventionWas goal met? Revise the
reasonable, and attainable. interventions. is indicated/therapeutic. plan of care according the
Provide references. client’s response to current
plan of care.
Priority Nursing Diagnosis: The primary diagnosis for this patient is the acute pain that she has. This would be the main priority because many factory can arrise when she
is immobile and lays in bed all day.
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Acute pain related to surgury as evident by her telling us that upon movement her pain level rises to an 8/10.
The client will be able to tolerate
pain levels
Secondary Nursing Diagnosis:
Self-care deficit related to physical limitations as evidenced by inability to perform ADL’s on own due to hip surgery.
Client will demonstrate
performing ADL on his own
In the end of the shift the client
will verbalize that she will be in
her acceptable pain goal of
1/10.
The patient will be able to
perform three activites of any
ADLs at an optimal level by the
the end of shift.
1) Client teaching on how to
evauluate pain through PQRST.
2) Be caution when handling the
client affected extremities as it
can cause severe pain.
3) Be able to implement
alternative pain therapies like
hot/cold therapy.
(Phelps et al., 2017)
1. Consider the patient’s need
for assistive devices.
2. Start an effective exercises
routine.
3. Instruct significant others
how to assist the patient during
1) Patient will be able to
describe her pain effectively to
the nurse
2) Being able to identify which
limp and manipulate it in order
to not cause pain to the client.
3) Client is able to utilize
alternative pain therapies.
(Phelps et al., 2017)
(Phelps, Ralph & Taylor, 2017)
1. Assistive devices improve
confidence in performance of
ADLs.
2. Increased strength and
endurance contributes to
autonomy in self-care.
(Phelps, Ralph & Taylor, 2017)
1) The goal was met patient
was able to describe the pain
specifally to PQRST
2) The goal was met. Upon
manipulation of the limp no
pain showed.
3) Met. Patient did not want
pain meds but rather a warm
blanket
(Phelps et al., 2017)
1. Met. Patient was given a a
fracture bed pan which she can
do on her own if she wanted to.
2. Not met. Pending on the
orders on when the PT can
intiate the exercises
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self-care activities. 3. Involving significant others
can decrease the need for skilled
(Phelps et al., 2017) home services while also being
able to reinforce health care
instructions that were given.
(Phelps et al., 2017)
References
3. Met. Family memebers
understood on their roles of
helping the patient with the
ADLs
(Phelps et al., 2017)
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 Billett, H. H. (1990). Chapter 151 Hemoglobin and Hematocrit. Retrieved from NCBI:

https://www.ncbi.nlm.nih.gov/books/NBK259/

Mayo Clinic. (2018b). Hip fracture. Retrieved from: https://www.mayoclinic.org/diseases-conditions/hip-fracture/symptoms-

causes/syc-20373468

Mayo Clinic. (2018c). Low potassium (hypokalemia). Retrieved from: https://www.mayoclinic.org/symptoms/low-

potassium/basics/causes/sym-20050632

Phelps, L., Ralph, S., & Taylor, C. (2017). Sparks & Taylors nursing diagnosis reference manual (10th ed.). Philadelphia, PA:

Wolters Kluwer.

Vallerand, A., Sanoski, C., and Deglin, J. (2017). Davis’s Drug Guide for Nurses (15th ed.) Philadelphia, 

PA: F.A. Davis

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