Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬

King Saud Bin Abdul-Aziz ‫جامعة الملك سعود بن عبدالعزيز لعلوم‬

University for Health sciences ‫الصحية‬
Collage of Nursing ‫كلية التمريض‬

Nursing Care Plan

Adult II
NURS 316
Spring 2021

Course Instructors:
Dr. Sharifah Alsayed
Dr. Seham El gamal

Student’s Name: Fatema Alsayari

ID: 391220607
Section: B
Submitted on: 28/11/2021
 Medical diagnosis: right hip dislocation.

Subjective Data:

Mr. T is 39 years old, male, married, Muslim, speaks Arabic from Saudi Arabia, doesn’t work. In 18\9\2021 he came to the emergency
room with his son with a chief complaint of dislocation of hip joint and severe pain and went through right acetabulum open reduction
and internal fix. The patient previous history was DM, HTN post RTA (Renal Tubular Acidosis) and previous healed pressure ulcer stage
2 from home. No know allergy, normal sleep pattern 7-8 hours a day, doesn’t smoke and doesn’t consume alcohol.

Objective Data:

The patient GCS 15\15, braden scale was 20\23, his vital signs as follows BP 124\74, HR 88, RR 20, Temp 37.0, spO2 98%. His wight is
130kg, his height is 173cm. the BMI is 43.44 which is considered as obese stage 3. The patient has a PICC line in right arm with dextrose
5% in water. His appetite is good. Patient with round head with no lumps. His eyes are symmetrical with both pupils that have the same
shape, size, and react equally to light. The conjunctiva is pink. The nose appeared symmetrical. He has normal lung sound and breathing
pattern. The patient has no clubbing and normal capillary refill within 2 second. good upper and lower limbs strength. Good sensation and
good blood circulation. Patient dressing intact and dry with no backflow. Ambulatory with assistance.

History:
Past surgical Hx: 20\9 irrigation and
debridement right hip wound.
4\10 irrigation and debridement right hip
wound.
10\10 post right superior gluteal arteries
embolization
19\10 debridement of right hip blood
loss 50mls
1\11 irrigation and debridement right hip
wound with VAC
15\11 irrigation right acetabulum. VAC
change with possible implant removal
 Diagnostic procedure:
Date The procedure Findings
18/09/2021 Covid swap Negative
17\9\2021 X-Ray Posterior dislocation of right
hip

Lap results:
Test Patient value Normal value Interpretation Nursing intervention
ESR 76 1 – 13 mm\hr high related to infection assess and monitor for any signs of infection,
monitor skin color, encourage fluid intake.
PLATELET 621 150 – 450 high because of blood loss monitor patients for risk of spontaneous
bleeding, monitor fluid imbalance.

Hgb 10.1 13 – 18 g\d low related to deficient in manage fatigue balance between activity and
iron, vitamin B-12, or folate, rest, maintain adequate nutrition encourage a
substantial blood loss. healthy diet that is packed with essential
nutrients.
RBC 3.8 4.50 – 6.50 low because of bleeding encourage the patient to eat foods that are
high in protein and iron, such as liver, egg
yolk, beef, and dried fruits such as prunes and
apricots.
Hct 31.4 40 – 54 % low because of Decreased Increase iron and protein intake.
production of red blood cells,
bleeding
26.9 27 – 32 pg low caused by iron deficiency encourage the patient to maintain a healthy
MCH diet, reduce fatigue
 Eos 0.87 0.1 – 0.7 High related to infection assess the skin if there are any rashes, itching,
and asthma, encourage fluid intake.

Medications Action Dosage Frequency Route Contraindication Side effects Nursing

responsibility
Ciprofloxacin antibiotic used 250 mg every 12 Oral diarrhea from an infection nausea, monitor for
to treat several hrs. with Clostridium difficile vomiting, symptoms of
bacterial bacteria, diabetes, low blood stomach pain, tendinitis, altered
infections sugar, glucose-6-phosphate heartburn, mental status,
dehydrogenase (G6PD) diarrhea, pale complete blood
deficiency, low amount of skin, unusual count, and renal and
magnesium in the blood, low tiredness, hepatic function in
amount of potassium in the sleepiness prolonged therapy.
blood, a low seizure
threshold, pseudotumor
cerebri, a condition with
high fluid pressure in the
brain, a painful condition
that affects the nerves in the
legs and arms called
peripheral neuropathy,
myasthenia gravis, a skeletal
muscle disorder
Diphenhydra used for 25 mg three times Oral overactive thyroid gland, dry mouth, nose, Monitor respiratory
mine insomnia, a day increased pressure in the and throat, function at rest and
symptoms of eye, closed angle glaucoma, drowsiness, during exercise.
the common high blood pressure, dizziness,
cold, tremor in stenosing peptic ulcer, nausea,
parkinsonism, blockage of the urinary vomiting, loss of
and nausea bladder, enlarged prostate, appetite,
an inability to completely constipation,
empty the bladder, chronic increased chest
idiopathic constipation congestion,
headache,
muscle
 weakness,
nervousness.
dextrose antimicrobial 100 ml every 8 hrs. Injecti Stop using dextrose 5% in high blood sugar Clinical evaluation
therapy over 30 min on water and call your doctor at (hyperglycemia) and periodic
once if you have a fever, , Low blood laboratory
cough, wheezing, increased potassium determinations are
thirst or urination, confusion, (hypokalemia), necessary to monitor
hallucinations, extreme Fluid retention changes in fluid
thirst, muscle weakness, (edema), High balance, electrolyte
weak or shallow breathing, or low blood concentrations, and
fainting, or severe irritation volume acid base balance
or signs of infection around (hyper/hypovole during prolonged
the IV needle. mia), fever, parenteral therapy or
dehydration, whenever the
Mental condition of the
confusion, patient warrants such
Unconsciousnes evaluation.
s, Ketones in
urine
(ketonuria),
Glucose in urine
(glycosuria),
Excessive
urination,
excessive thirst,
diarrhea.
Enoxaparin sodium is an 30 mg twice a day injecti Known hypersensitivity to Mild irritation, Assess for signs of
anticoagulant, on enoxaparin (urticaria, pain, bruising, bleeding and
It is used to anaphylactic reactions) or redness, and hemorrhage,
treat and any heparin products, Active swelling at the including bleeding
prevent deep major bleeding such as injection site gums, nosebleeds,
vein gastrointestinal bleed, may occur, unusual bruising,
thrombosis History of heparin-induced Fatigue or fever black/tarry stools,
and pulmonary thrombocytopenia within the may also occur. hematuria, and a fall
embolism past 100 days, Active gastric in hematocrit or
or duodenal ulcers, blood pressure.
Hemorrhagic
cerebrovascular accident.
Nursing Care Plan:

Nursing Goal Nursing intervention Rational Evaluation

Diagnosis
Acute pain client verbalizes - apply ice packs as - promotes vasoconstriction patient reported
indicated. in surgical area, which pain 4/10 after
related to hip relief of pain.
- resting in bed in a supine or reduces bleeding and reassessment goal
dislocation as side lying position several reduces pain perception. not met, care to be
times a day, promotes - reduces muscle tension, continued.
evidence by
healthy posture and teaches refocuses attention,
patient reporting proper body mechanics. develops a sense of control,
- A firm mattress is and may improve coping
5/10 pain
recommended. skills in the management of
- as patient’s pain subsides, discomfort or pain that lasts
he gradually resumes a long time.
normal activities. - Morphine is pain relieving
- administer prescribed pain painkiller.
relievers medication ex:
morphine
Impaired Patient moves - Guidance or support for
patients with active and
physical mobility independently
passive ROM exercises in
related to affected and unaffected
limbs.
decrease strength
- Encourage the use of
of hip dislocation isometric exercise, starting
with unaffected limbs.
as evidence by X-
- Support through self-care
ray showing activities (bathing,
shaving).
posterior
- Providing and supporting
dislocation of the mobility aids such as
wheelchairs, walkers,
right hip.
crutches, and canes
- It increases blood flow to Goal not met as
muscles and bones, improves
patient is unable to
muscle tension, maintains
joint mobility, prevents move right hip
contractures and atrophy, and
(passive ROM),
prevents calcium absorption
when not in use. care to be
- The isometric diagram helps
continued.
maintain muscle strength and
mass by contracting muscles
without bending joints or
moving limbs. These
exercises are contraindicated
for acute bleeding.
- Improves strength and blood
circulation, improves patient
condition management, and
promotes voluntary well-
being.
- Early mobility reduces resting
complications (phlebitis) and
promotes healing and
normalization of organ
function. Learning how to use
AIDS correctly is important
for maintaining optimal
mobility and patient safety.
deficient Client will - Discuss nutritional - This will aid in the healing Patient showed
requirements, including a low- as well as general well-
knowledge verbalize interest in
fat, high-protein, calcium-rich being.
related to lack understanding diet. - Infection risk will be learning more
- Cleaning the external fixator reduced because of this.
for exposure/ of the about his case
on a regular basis is - Immediate intervention can
recall evidence condition, recommended, as is keeping reduce the severity of
the device free of dust and complications such as
by question prognosis, and pollutants. infections and cardiovascular
request for potential - Instruct patients and other problems. However, this
caregivers to identify signs needs to be resolved with
information. complication and symptoms that may rest and elevation.
require medical evaluation.
These symptoms include
severe pain, fever, chills, foul
odors, altered sensations,
swelling, burning sensation,
numbness, and tingling.

Risk for The client achieves - Provide sterile wound care - Prevents mutual Patient showed
according to the protocol contamination and the
infection related timely wound signs of
and practice careful hand possibility of infection.
to invasive healing, is free of washing. - This helps avoid mutual infection, care
- Start the prescribed pollution.
procedure or purulent discharge to be
quarantine procedure. The - There are many steps that can
environmental and erythema, and presence of purulent be taken to treat local continued.
drainage requires attention infections
exposure. has a fever
to wounds and chains. - Wide-spectrum antibiotics
- Procedure support may be used prophylactically
(incision and drainage, or may be geared toward a
drainage placement, specific microorganism.
hyperbaric oxygen - prompt intervention may
therapy). reduce the severity of
- Administer medications, complications.
 as indicated: Ex; IV and
topical antibiotics
- Note presence for signs
and symptoms of infection
fever, chills, foul odors,
altered sensations,
swelling, burning
sensation.
Risk for fall Patient will not - Examine any factors that - By using assessment tools, the no fall
might put you at a higher level of risk and subsequent observed care
related to joint sustain fall
risk of falling. fall precautions can be to be continued
integrity - provide a sign near the determined. until discharge.
patient’s bed to remind the - To maximize patient’s safety.
healthcare provider to take - Items too far from the patient
precautions against falls. can contribute to falls.
- Bring items used by
patients to an easily
accessible location.
References:

- Shirley, Wood, A., Alin, Amadou, martinez, E., Naluwu, J. M., SA, J., Rachel, & Jonathan. (2021, February 11).
Coronavirus disease (COVID-19) Study Guide. Nurseslabs. Retrieved November 27, 2021, from
https://nurseslabs.com/coronavirus-disease-covid-19/.

- U.S. National Library of Medicine. (n.d.). Ciprofloxacin: Medlineplus Drug Information. MedlinePlus. Retrieved November 27,
2021, from https://medlineplus.gov/druginfo/meds/a688016.html.

- RxList. (2021, September 2). Dextrose: Generic, uses, side effects, dosages, interactions, warnings. RxList. Retrieved November
27, 2021, from https://www.rxlist.com/consumer_dextrose/drugs-condition.htm.

- WebMD. (n.d.). Common and rare side effects for diphenhydramine oral. WebMD. Retrieved November 28, 2021, from
https://www.webmd.com/drugs/2/drug-1428/diphenhydramine-oral/details/list-contraindications.