NURSING CARE PREPARATION

Student Name: Diana Millan

Unit/Room Number: PSU 369

Age: 85
Gender: Female
Eriksons Developmental Level: Ego integrity vs.
Despair

Date of Care: 02/25/14

Date of Admission: 2/22/14

Ethnic/Cultural Preferences: American Indian/Alaska
native
Allergies: Penicillin, Keflex
Code Status: Full Code

Primary Diagnosis:
Left hip fracture

Co-morbidities:
Hyponatremia, hypokalemia, pulmonary fibrosis

Discharge Plan (add day of clinical):

Unknown

Preliminary Integrated Pathophysiology primary diagnosis (what is going on with your client at the cellular
level for the health condition). Explain how your clients primary diagnosis, co-morbidities, medications and
labs interrelate. 1-3 page APA formatted.

Data Collection (Record exactly what is written on the personal information sheet [aka Kardex]. Any
assessment/elaboration should be made on the assessment sheet):
Diet (Type): 500 mL fluid restriction
IV (Fluid type, rate, access type): Peripheral IV right
forearm, 20 ga, continuous pump FS-NaCl 0.9% (1052
mL @ 100 mL/hour over 10.5 H
I&O (MD order/Nursing Order/Frequency):
CBG (Yes/No, frequency): NO
500 mL fluid restriction
Fall Risk/Safety Precautions (Yes/No):
YES
Wound Care (Yes/No):
NO
Drains (Yes/No, Type): Urinary catheter (indwelling)
Other Tubes:

Activity (What is the patient activity level): Bed rest;

poor activity tolerance
Oxygen (Yes/No, Delivery method, how much): N/C 3
Lpm to keep O2 90-92 %
Last BM: 2/23

ASSESSMENTS
(Include Subjective & Objective Data)
Integumentary:

Head and Neck:

Skin pink, warm, dry, cracked

Large Bruise over left brachial artery
Large bruise on left arm r/t fall
Clubbing of fingernails and toenails
Peripheral IV on right forearm- flowing, clean, dry,
intact, no signs of swelling or inflammation

Head is round, soft, no pain

No alopecia
Neck: no masses, no tenderness on palpation, trachea
midline

Eyes/Ear/Nose/Throat:

Thorax/Lungs:

Eyes, ears, nose, symmetrical, no drainage or

discharge
No lesions or redness
No difficulty hearing
No difficulty swallowing
Tongue is cracked, pt. states tongue does not feel dry
Oral mucosa pink, moist
Non-productive cough

Hx of pulmonary fibrosis, edema

Symmetrical chest expansion
Inspiratory and expiratory crackles all lung fields
Non-productive cough
RR: 17; 18
SaO2: 92%; 97% 4 Lpm
No SOB present

Cardiac:

Musculoskeletal:

S1, S2
Skin pink, warm, dry
Capillary refill less than 3 seconds on upper and lower
extremities
Weak pedal pulses
Radial pulse regular, weak, equally bilateral
No edema, no JVD
Clubbing of fingernails and toenails
BP: 105/76; 107/76
HR: 100; 87

Bedrest; does not ambulate

Left Hip and knee ROM less than 100%
Right hip and knee contracted
Dorsi/plantar flexion greater on right foot than left foot
Pain at fracture site
Full ROM in upper extremities

Genitourinary:

Gastrointestinal:

Incontinent
Urinary catheter (indwelling): patent, draining
No pain, burning sensation
Urine: yellow, clear
Output: 290 mL
Intake: 354 mL (500 mL fluid restriction)

Abdomen: distended, firm, no masses

Slight tenderness, pt. stated some tenderness but not
so much you have to call the doctor
Pt. states normal bowel habits are 1 BM Q4 days
Hyperactive bowel sounds LLQ & RLQ
No nausea, vomiting, or diarrhea
Ate 75% of breakfast
No BM during shift

Neurological/Psychosocial

Other (Include vital signs, weight):

Awake, Alert, oriented X4

Clear, appropriate speech
Difficulty rating pain level and describing pain
Pupils: equal, round, sluggish reaction to light, pupil
size 2mm bilaterally
No tingling or numbness sensation
Strong bilateral grips
Dorsi/plantar flexion stronger on right foot
No dizziness or vertigo

Height: 63.5 in
Weight: 53.1
BMI 20.41
Pulse: 100; 87 radial, weak, equally bilateral
BP: 105/86; 107/75 left arm, laying down
RR: 17; 18, deep, regular
Temp: 98.0 F; 97.5 F Oral
SaO2: 92%; 97% 4 Lpm
Pain (chronic or acute) Acute
Pain management: narcotic opiate agonist analgesics

CURRENT MEDICATIONS
List ALL regularly scheduled and prn medications scheduled on your client.
(Due morning of clinical)
Generic &
Trade Name

Furosemide
(Lasix)

Levofloxaci
n
(Levaquin)

Polyethylen
e glycol
(Miralax
powder)

Potassium
chloride
(Klor-con
M20 SA)
Senna/docus
ate
(Senokot)

Classification

Dose/Route/
Rate if IV

Onset/Peak

Intended
Action/Therapeutic
use. Why is this
client taking med?
Imbalanced fluid
and electrolytes

Adverse
reactions (1
major side
effect)
Hypokalemia

Antibiotic

Tendinitis

Onset:
Unknown
Peak: 2-4
days

Constipation

Diarrhea

Onset: 15
min
Peak: 1-2 H

Hypokalemia

Cardiac
arrhythmias

Monitor potassium levels; observe for

signs and symptoms of hyperkalemia
(bradycardia, fatigue, general muscle
weakness, SOB, confusion, diarrhea)

Onset: 6-10
H
Peak:
Unknown

Constipation

Loss stools; loss

of water and
electrolytes

Monitor BM; Hold for loose stools

Electrolyti 40 mg=1 tab Onset: 30-60

c and
PO BIDmin
water
Meals
Peak: 60-70
balance
min
agent; loop
diuretic;
antihyperte
nsive
Quinolone
750
Onset:
antibiotic
mg/D5W
Unknown
(150 mL)
Peak: 1-2 H
IV Premix
Osmotic
laxative

17 gm=1
packet PO
daily
Mix with
juice or
water
Electrolyte 20 meg=1
replaceme tab PO BIDnt solution
Meals

Stimulant
laxative

8.6/50 mg
tab PO BID

Nursing Implications for this client.

(No more than one)

Monitor S&S of hypokalemia (fatigue,

paresthesias, depressed reflexes,
muscle weakness, cramps, rapid,
irregular pulse, arrhythmias,
hypotension, confusion )

Report onset of loose stools or

diarrhea. Pseudomembranous colitis
should be ruled out as the cause of
diarrhea during and after antibiotic
therapy
Monitor for effectiveness of
medication, monitor BM

Acetaminop
hen
(Tylenol)

Nonnarcoti 650 mg=2

Onset: 0.5-1
c analgesic tab PO Q4H
H
PRN Temp Peak: 1-2 H
>101 F
Hydrocodon Narcotic
5/325
Onset: 10-20
e/APAP
(opiate
mg=1-2 tab
min
5/325
agonist),
PO Q4 H
Peak: 30-60
(NORCO)
analgesic,
PRN Pain
min
antitussive for 10 days
Magnesium
Saline
30 mL= PO Onset: 3-6 H
hydroxide
cathartic;
BID PRN
Peak:
(Milk of
antacid
Unknown
magnesium)
Morphine
sulfate

Analgesic,
narcotic
(opiate
agonist)

Ondansetro
n (Zofran)

5-HT3
antagonist;
antiemetic
Laxative

Phophates
enema
(Fleet
enema)

2 mg/mL
syringe 1-2
mg IV Q1H
PRN pain
for 7 days
8 mg=4 mL
IV Q6 H
PRN
1 enema
rectal daily
PRN

Fever- temp above

101 F

Pain

Rash; negligible
with
recommended
dosage
Respiratory
depression

Monitor patient temperature

Monitor for effectiveness of pain

relief/monitor respirations

Constipation

Diarrhea

Evaluate PTs continued need for

drug. Monitor BM. Prolonged and
frequent use may lead to dependence

Onset:
Rapid
Peak: 20
min

Pain

Respiratory
depression

Monitor respirations following

administration; record relief of pain
and duration of analgesia

Onset: rapid
Peak: 1-1.5
H
Onset:
unknown
Peak:
unknown

Nausea/vomiting

Diarrhea

Monitor fluid and electrolyte status

Constipation

Diarrhea

Monitor for effectiveness and

continued need of medication; monitor
BM

DIAGNOSTIC TESTING
Include pertinent labs [ABGs, INRs, cultures, etc] & other diagnostic reports [X-rays, CT, MRI, U/S, etc.]
NOTE: Adult values indicated. If client is newborn or elder, normal value range may be different.
Date
Lab Test
Patient Values/
Interpretation as related to Pathophysiology cite
Normal Values
Date of care
reference & pg #
2/24 Sodium
126
May be related to diuretic use
/14 135 145 mEq/L
Corbett, J. V., & Banks, A. D. (2013).
Laboratory tests and diagnostic
procedures: With nursing diagnoses (pp.
111). New Jersey: Pearson.
Potassium
4.2
3.5 5.0 mEq/L
Chloride
97-107 mEq/L

88

Co2
23-29 mEq/L

35

Glucose
75 110 mg/dL
BUN
8-21 mg/dL
Creatinine
0.5 1.2 mg/dL
Uric Acid Plasma
4.4-7.6 mg/dL
Calcium
8.2-10.2 mg/dL
Phosphorus
2.5-4.5 mg/dL
Total Bilirubin
0.3-1.2 mg/dL

Total Protein
6.0-8.0 gm/dL
Albumin
3.4-4.8gm/dL

Cholesterol
<200-240 mg/dL
Alk Phos
25-142 IU/L
SGOT or AST
10 48 IU/L
LDH
70-185 IU/L
CPK

May be related to diuretic use

Corbett, J. V., & Banks, A. D. (2013).
Laboratory tests and diagnostic
procedures: With nursing diagnoses (pp.
122). New Jersey: Pearson.
May be related to chronic lung disease
Corbett, J. V., & Banks, A. D. (2013).
Laboratory tests and diagnostic
procedures: With nursing diagnoses (pp.
136). New Jersey: Pearson.

107
13
0.52

8.7

1.4

May be related to recent fracture or liver

dysfunction
Corbett, J. V., & Banks, A. D. (2013).
Laboratory tests and diagnostic
procedures: With nursing diagnoses (pp.
262). New Jersey: Pearson.

6.7
2.9

65
23

May be nutritional-inadequate intake of protein

or liver dysfunction
Corbett, J. V., & Banks, A. D. (2013).
Laboratory tests and diagnostic
procedures: With nursing diagnoses (pp.
232-233). New Jersey: Pearson.

38-174 IU/L
WBC
4.5 11.0
RBC
male: 4.7-5.14 x 10
female: 4.2-4.87 x 10
HGB
male: 12.6-17.4 g/dL
female: 11.7-16.1 g/dL
HCT
male: 43-49%
female: 38-44%
MCV
85-95 fL

9.5
5.01
14.2
42.2
84

MCH
28 32 Pg
MCHC
33-35 g/dL
RDW
11.6-14.8%

28.4

Platelet
150-450
Other:

184

May be related to blood acute blood loss during

fracture which may cause anemia; may be
nutritional
Corbett, J. V., & Banks, A. D. (2013).
Laboratory tests and diagnostic
procedures: With nursing diagnoses (pp.
34). New Jersey: Pearson.

33.7
18.1

May be related to blood acute blood loss during

fracture which may cause anemia; may be
nutritional also leading to anemia
Corbett, J. V., & Banks, A. D. (2013).
Laboratory tests and diagnostic
procedures: With nursing diagnoses (pp.
35). New Jersey: Pearson.

DIAGNOSTIC TESTING
Date

2/22/14

Date

UA

Normal
Range

Color/Appearance
pH
Spec Gravity
Protein
Glucose
Ketones
Blood
Other
(PT, PTT, INR,
ABGs, Cultures,
etc)

Results

Interpretation as related to
Pathophysiology cite reference & pg
#

Yellow clear
6.0
1.010
Neg
Neg
Neg
Neg

Normal
Range

Results

Interpretation as related to
Pathophysiology cite reference & pg
#

Date
Radiology

Results

2/22/14

X-Rays chest

2/22/14

X-ray hip

Intertrochanteric left hip

fracture with mile impaction
and lateral angulation. Soft
tissue swelling

2/23/14

Scans CT Chest

Extensive Pulmonary fibrosis

present in both lungs

2/22/14

EKG-12 lead

Telemetry
Other

Cardiomegaly, pulmonary
fibrosis

Possible left atrial abnormality,

inferior and anterior T wave
changes may be due to
hypertrophy or ischemia

Interpretation as related to
Pathophysiology cite reference & pg
#
Enlargement of the heart/lung tissue
damage
Corbett, J. V., & Banks, A. D. (2013).
Laboratory tests and
diagnostic procedures: With
nursing diagnoses (pp. 517).
New Jersey: Pearson.
Fracture
Corbett, J. V., & Banks, A. D. (2013).
Laboratory tests and
diagnostic procedures: With
nursing diagnoses (pp. 517).
New Jersey: Pearson.
R/t chronic lung disease
Corbett, J. V., & Banks, A. D. (2013).
Laboratory tests and
diagnostic procedures: With
nursing diagnoses (pp. 542).
New Jersey: Pearson.
Affected atria r/t hypertrophy of heart
Corbett, J. V., & Banks, A. D. (2013).
Laboratory tests and
diagnostic procedures: With
nursing diagnoses (pp. 604).
New Jersey: Pearson.

DAR NURSING PROGRESS NOTE

Include the same note that was written in the client record for the priority nursing diagnostic statement.
Include the date/time/signature.

Assessed lungs/oxygenation. SaO2 at 92%, pulse 100 bpm, RR 17. Instructed patient to do some deep breathing
and coughing exercises. Raised HOB 30 to ease breathing. Ensured oxygen was being delivered. Reassessed,
SaO2: 97%, pulse 87, RR 18. Pt. resting, bed in lowest position, bed alarm on, call light in reach. ---------------------------------------------------------------------------------------------------------------02/25/14 @ 1300 D. Millan, SN

PATIENT CARE PLAN

Patient Information:
85 year old female admitted for left hip fracture; hx of pulmonary fibrosis
Allergies: Penicillin, Keflex
Code Status: Full Code
Nursing Diagnosis should include Nanda Nursing Diagnostic statement, related to (R/T), as evidenced by
(AEB).
Problem #1 Acute pain r/t injury to soft tissue AEB discomfort, irritability, reports of pain
Desired Outcome: Pain level will remain at acceptable level to patient during shift
Nursing Interventions
Client Response to Intervention
1.
1.
Assess for subjective and objective signs of pain
Pt. reported pain, unable to rate and describe her
pain
2.
2.
Teach patient about taking alternative pain control and
Pt. states distraction and sleep help relieve pain
comfort measures
sometimes
3.
3.
Assist patient with repositioning to support injured
Pt. unable to reposition due to hip fracture.
extremity and administered pain medications if needed
Refuses to move.
Evaluation (evaluate goal & interventions, what worked/what didnt, what would you adapt if needed):
Pain level remained at manageable level. Pt did have difficulty describing and rating her pain. When asked, she
stated I dont know. And when asked to describe it she stated I just hurt all over. Upon reassessment of pain
following morphine administration, Pt. stated I guess its less. For future situations, printing out different pain
scales with faces or pictures may help. Number and color pain scales did not work for this patient.

Problem #2 Impaired gas exchange r/t pulmonary lung disease and edema AEB crackles and SOB
Desired Outcome: Respiratory function will be maintained at patient baseline level; no exacerbations during
shift
Nursing Interventions
Client Response to Intervention
1.
1.
Thoroughly assess respiratory function
Inspiratory and expiratory crackles, clubbing of
fingernails; hx pulmonary fibrosis, edema
2.
2.
Instruct and assist patient with deep breathing exercises;
Pt. performed deep breathing exercises and
assist with incentive spirometer if ordered following surgery coughing throughout the day
3.
3.
Ensure SaO2 remains above 90%. Administer supplemental SaO2 at increased from 93% to 97%
oxygen
Evaluation:
Interventions somewhat successful. Pt. able to do some deep breathing and coughing. SaO2 increased to 97% Pt
is not able to move, has been laying on her back for her whole stay at the hospital. Has not had surgery to repair
her hip. A better nursing diagnosis would be risk for impaired skin integrity. An air mattress was ordered today
to decrease her risk of developing pressure ulcers and at the same time will help the patient reposition easier.
Problem #3 Risk for electrolyte imbalance r/t medication side effects AEB decreased sodium and chloride
Desired Outcome: Pt. will learn how to avoid hypokalemia with diuretic use

Nursing Interventions
1.
Assess pt. knowledge/understanding/ assess latest serum
potassium levels
2.
Teach patient about potassium rich foods
3.
Administer potassium supplement; ondansetron if vomiting
is present; hold stool softeners for loose stools

Client Response to Intervention

1.
Pt. is very knowledgeable about electrolyte
imbalances. Pt. potassium levels normal, still
hyponatremic
2.
Pt. aware of foods high in potassium
3.
Pt. not experiencing vomiting, or loose stools.
Potassium supplement effective treatment for
hypokalemia

Evaluation:
Though patient does have electrolyte imbalances, mainly Hyponatremia, I will need to research more on
preventing such low sodium levels. It is difficult to balance everything out in this patient. Lasix must be given
because the physician believes she has CHF and fluid needs to be excreted. Salt is also being restricted.
Potassium levels are being maintained at normal levels due to potassium supplements. Also, all diuretics will
decrease sodium levels but with decreased sodium levels, there cannot be a surgery.

Running head: HIP FRACTURE

Hip Fracture
Diana Millan
Southwestern Oregon Community College
02/25/14

HIP FRACTURE

Hip Fracture
Eighty-five year old female was admitted to Bay Area Hospital for a left hip fracture
following a fall. The patient believes she may have fainted but does not remember much. The
physician notes state she has some sort of chronic lung disease but is unsure of what it is. She
does have pulmonary fibrosis, bilateral crackles and according to an X-ray, bilateral pulmonary
edema. She has electrolyte imbalances, hyponatremia and hypokalemia with no volume
depletion. She lives with her husband who called the ambulance when she fractured her hip.
Hip fractures are common in older adults and can lead to prolonged immobility or death
(Ignatavicius & Workman, 2013). Osteoporosis is a major and common risk factor for hip
fractures in older adults, which weakens the bones and leads to falls (Ignatavicius & Workman,
2013). The periosteum and blood vessels in the cortex, marrow, and surrounding tissue are
disrupted during a fracture (Huether & McCance, 2012). A clot forms in the medullary canal and
adjacent bone tissue dies, thus stimulating the inflammatory response. In about forty-eight hours
following the injury, blood flow increases to the site of fracture (Huether & McCance, 2012).
The healing process continues as bone-forming cells produce callus along the broken ends of the
bone (Huether & McCance, 2012). Healing occurs indirectly or directly. In direct healing, no
callus formation occurs and the fracture is usually repaired by surgery (Ignatavicius & Workman,
2013). In indirect healing, callus forms and the fracture is treated with a cast and no surgery
(Ignatavicius & Workman, 2013). The signs and symptoms associated with a fracture include
deformity, swelling, muscle spasms, tenderness, pain, impaired sensation, and decreased
mobility (Huether & McCance, 2012). The reatment of choice is open reduction internal fixation
which may include intramedullary rod, pins, prosthesis, or a compression screw (Ignatavicius &
Workman, 2013).

HIP FRACTURE

Hyponatremia increases the risks for falls and fractures in the elderly population. Low
sodium levels cause cognitive impairment which leads to unsteady gait and therefore, falls
(Ayus, Negri, Kalantar-Zadeh, & Moritz, 2012). Hyponatremia also contributes to osteoporosis
by increasing bone resorption to mobilize sodium (Ayus, Negri, Kalantar-Zadeh, & Moritz,
2012). This patient is scheduled to have surgery but due to hypokalemia, the surgery is being
delayed. There are studies that show a significant risk of developing hypokalemia after an
orthopedic surgery, especially in elderly patients (Yousef, Pagoti, & Bolton, 2008).
The patients medications include furosemide, a loop diuretic that causes a loss of both
sodium and potassium in the urine (Kee, Hayes, & McCuistion, 2012). Though not manifested in
this patient, hypocalcemia may also result from use of loop diuretics, increasing the risk for
osteoporosis and falls (Kee, Hayes, & McCuistion, 2012). Side effects include postural
hypotension, syncope, and nocturia, common causes of falls in the elderly (Kee, Hayes, &
McCuistion, 2012). It is important to monitor this patients electrolyte status closely, not only
because of the use of furosemide, but also laxatives which may cause diarrhea leading to fluid
and electrolyte imbalances. Another important medication for this patient is potassium chloride
which according to her lab values, it has helped maintain her potassium levels in normal range.
Sodium and chloride values are still low which may be related to the diuretic. CO2 levels are
increased and may be due to pulmonary fibrosis causing shortness of breath and decreased
respiratory rate (National Library of Medicine, 2014). It is important to keep this patients
oxygen levels up because oxygen diffusion is impaired in pulmonary fibrosis and may prolong
healing time in a fracture due to decreased oxygenated blood reaching the tissues. MCV and
RDW are also decreased and may be related to inadequate nutrition leading to anemia or acute
blood loss during fracture, also a cause anemia

HIP FRACTURE

References
Ayus, J. C., Negri, A. L., Kalantar-Zadeh, K., & Moritz, M. L. (2012). Is chronic hyponatremia a
novel risk factor for hip fracture in the elderly? Medscape, 3725-3731.
Huether, S. E., & McCance, K. L. (2012). Understanding pathophysiology (5th ed.). St. Louis,
MO: Mosby/Elsevier.
Ignatavicius, D. D., & Workman, M. L. (2013). Medical-surgical nursing: patient-centered
collaborative care (7th ed.). St. Louis, Mo.: Saunders/Elsevier.
Kee, J. L., Hayes, E. R., & McCuistion, L. E. (2012). Pharmacology: a nursing process
approach (7th ed.). St. Louis, MO: Elsevier Saunders.
National Library of Medicine. (2014). Pulmonary fibrosis . Retrieved from MedlinePlus:
http://www.nlm.nih.gov/medlineplus/pulmonaryfibrosis.html
Yousef, A., Pagoti, R. K., & Bolton, P. (2008). Postoperative hypokalemia: Its incidence, causes,
and implications for elderly patients with fracture neck of femur. Orthopaedic
Proceedings.

HIP FRACTURE