State College of Florida

Associate Degree Program

Nursing Process Worksheet

Pt. Initials:__GM____ Admit Date:_03/17/2011___ Sex m/f:___F___ Rm#:__228 A____ Age:__92__ Student Name:_Briana Kilgore________ Date of Care:_03/18/2011 Reason for Admission:_____L Femur Fx_______________________________________________Include Pathophysiology and Nursing Care of Diagnosis Surgery:_Scheduled for Hip Surgery today_______________________ Significant Medical hx:_O2 use at home, musculoskeletal weakness, renal insufficiency, poor appetite, pacemaker, hypertension Current Orders from Chart/Kardex:__Sodium, potassium, glucose, BUN,_creatinine____CodeStatus:_DNR__________________________________ Oxygen:__N/A_____ Foley Catheter:_Indwelling internal catheter intact/normal_____ Activity:_BR/Immobile____________ Diet:_Soft______ TedHose/SCDs:_N/A_____ Accuchecks:Coverage:__N/a______DressingChange/Treatments:__N/A____________________________________________________________________________________ IV/Adaptor Site:____left forearm_________ Date Inserted:__03/17/2011__ Site Appearance:__No infiltration/no phlebitis/clean______________________________________ IV Fluids/Additive:___Dextrose 5% NS_____________ Rate:_70 mls/hr________ Tubing Change due________________________________________________________ Temperature:_____99.1 F__________ Pulse:____72__ Respirations:_ 20/min_________ Blood Pressure:_152/75_________ O2 SAT:____98%_________________________ Assessment Nursing Diagnosis Nursing Care Plan Short Term/Long Term Goal Interventions Evaluation

A&O x1, responds to simple commands Reacts slowly to light with no accommodation Mouth very dry, pink Full set of dentures, not currently using Pain level at 6, scale 0-10 Skin is warm, normal to dry in appearance and intact Cap refill > 3 sec Pt. held my hand and had a very weak grip Overall, lung sounds clear but heard faint crackles in left lung, ICS 6

Acute pain related to tissue inflammation and bone injury AEB pt grimacing, wincing, and vocalizing level 6 on pain scale Deficient fluid volume AEB pts dry mouth, poor skin turgor, low output volume, slow cap refill, and proclaiming thirst

By end of shift: The pt. will have a reduced pain level <3, demonstrate a relaxed appearance, and have vital signs within normal limits

Reposition pt. to a more comfortable position Rationale: To promote nonpharmacological pain management (Doenges, 2010, pg 589)

Goal not met: Repositioned pt. to a more upright position which alleviated some pain; pain level 4 out of 10 as expressed by pt. Goal met: Administered oxycodone by mouth @ 0800. Pt. slept and appeared relaxed, pain at level 2 by end of shift. Goal partially met or undetermined: Pt. intake PO @ 1000 hrs 300 ml had some difficulty with straw due to dry mouth at first

Administer analgesics as ordered Rationale: to maintain acceptable level of pain (Doenges, 2010, pg 590) Pt. will maintain fluid volume at a functional level, >2000 ml/day, as evidenced by individually adequate urinary output, stable vital signs, moist mucous membranes, good skin turgor Pt. will not have skin breakdown or pressure ulcers Administer fluids and electrolytes as indicated by IV or mouth to rehydrate Rationale: steady rehydration over time prevents peaks and valleys in fluid level (Doenges, 2010, pg 370) Observe urinary output, color, and measure amount and specific gravity

Risk for impaired skin integrity r/t physical immobility AEB pt bedfast as a result of fractured left femur

Goal met: Pt. output at 220 ml by 1000, color yellow and clear

Bowel sounds in all 4 quadrants Radial pulse moderate x2 Skin turgor poor, skin remained elevated Intake: 70 ml/D5 NS/Hr Output @ 100 ml @ 0800

Rationale: to more accurately determine replacement needs (Doenges, 2010, pg 369) Assess skin and bony prominences for pressure signs Q8H Rationale: that may indicate particular vulnerability (Doenges, 2010, pg 764) Goal met: Gave a thorough skin assessment at 0800, no evidence of skin breakdown

Reposition the pt. to alleviate pressure effects Rationale: reduces likelihood of progression to skin breakdown (Doenges, 2010, pg 765)

Goal not met: Did not reposition the client to alleviate pressure at this time due to going to OR for hip surgery