Assessment Map

Oxygenation: #1 -BP-115/64, P-64, R-25, SPo2-97% on 4 liters of O2 -Breath sounds noted with rhonchi heard throughout and respirations unlabored and shallow -cough noted with thick yellow sputum present -Chest symmetry is equal with no accessory muscle use noted -Skin is pink and warm -Nail beds pink with capillary refill of less than 3 seconds -Spirometer reading is 500 and accapella competed at this time -HR is regular with normal heart tones noted -Myocardial Infarction was experienced while hospitalized for ORIF -JVD is positive and EKG reading of sinus rhythm with premature atria complexes, right bundle branch block, T-wave abnormalities are noted -Pedal pulses are weak and +1 edema is noted in lower left extremity -Has history of smoking 2 packs of cigarettes a day, but denies use at this time Lab values are as follows: Hgb-8.9, Troponin-1.81, PT-13.8, INR-1.3, PTT26.2, RBC count-2.89, CPK-71, CK MB2.5, ABGs: pH-7.457, Po2-84.7, PCo2-32 Nursing Implications: Monitor for s/s or reoccurring MI. Monitor troponin levels for increase of decrease. Monitor for signs of bleeding. Medications: Nitro patch, Aspirin, Lopressor, Lovenox, Klor-con, prinivil, multivitamin with iron Nursing Dx.: *Ineffective airway clearance R/T thick mucous secretions AEB patient unable to clear mucous from throat effectively. *Activity Intolerance R/T impaired oxygen transport AEB Hgb level of 8.9 Collaborative Problems: Pneumonia, DVT, Anemia, Dysrhythmias, Recurrent myocardial infarction Activity and Rest: #4 -Patient is non-weight bearing on left hip and requires assistance with transfers -PT/OT to help restore strength and build muscle as well as rebuild ability to walk on left leg due to hip ORIF Nutrition: #6 -Weight is 179 pound and height is 5 feet 11 inches -Decreased RBC and Hgb levels noted -Appetite is good. Currently on diabetic cardiac diet which was implemented recently -Has no difficulty chewing or swallowing -No known allergies to food noted -No nausea, vomiting, heartburn, or loss of appetite noted -Mucous membranes are pink and moist, breath is odorous, Mouth swabs used to clean oral mucousa -No recent gain or loss in weight noted Lab values: Hgb-8.9, Blood sugar-213, Sodium-137, Magnesium-1.9 Nursing Implications: Iron rich diet to increase Hgb level Medications: Klor-con, multivitamin with iron, Protonix Nursing Dx.: *Readiness for enhanced nutrition R/T newly being placed on a diabetic cardiac diet AEB patient requesting information on what foods he can or cant have on a diabetic cardiac Collaborative Problems: Bleeding, Cardiac Failure, hypoglycemia, Infection Elimination: #5 -Urine is clear light amber in color with no odor noted -Currently has catheter in place that is to be discontinued upon discharge to nursing home facility. -Urinary output for 8 hours is 300ml -No complaints of nocturia, hematuria, frequency or pain/burning with urination noted now or prior to catheter insertion -Bowel Sounds are active in all four quadrants -Abdomen is soft and non-distended -Last BM was on 3-21-12 and was loose, brown and incontinent -No reports of constipation, diarrhea, or hemorrhoids noted Lab values: Urinalysis results and occult stool samples are negative Medications: Senna, Morphine, Tylenol with codeine Nursing Dx.: *Risk for infection R/T catheter placement *Risk for constipation R/T immobility and use of narcotic medications Collaborative Problems: Perforated bowels, Hemorrhoids

Assessment: Client is an 81 year old male who was admitted to the telemetry unit on 3-1712 following a myocardial infarction after have a left hip ORIF. He lived with his daughter in her home and has a code status of DNR-No vent. He requires assistance with ADLs and is a two assist

Protection: #2 -T-99.6 -Skin is warm, dry, and pink -Skin turgor is brisk -IV site noted to left hand and is free from s/s of infection, infiltration, or phlebitis

-Active ROM in all extremities except lower left extremity -Energy level is low and patient remains mostly in bed or bedside chair -Patient is turned at least every two hours to prevent pressure ulcers from inactivity -Complaints of pain noted upon movement of left hip -Sleep and rest periods are within normal limits for patient and no complaints of fatigue or sleepiness noted -uses one pillow for sleep and follows same habitual sleep patter as at home Lab Values: X-ray confirmed left ORIF Medications: Morphine, Tylenol with Codeine Nursing Dx.: * Impaired physical mobility R/T left hip surgery AEB patient requiring assistance with mobility and pain with movement of lower left extremity *Activity Intolerance R/T pain in left hip AEB patient stating that his hip only hurts when he moves it *Risk for constipation R/T decreased mobility and narcotic use Collaborative Problems: Pain, DVT, Infection, Constipation

with transfers and non-weight bearing on left hip. He has a dressing to his left hip surgical site that is cleaned, painted with betadine, and covered with telfa dressing. He is currently on oxygen running at 4 liters and hour to keep his O2 sats above 90%. He has a catheter, which will be taken out this afternoon for discharge to nursing home rehab facility. Admitting Dx: MI, ORIF History Dx.: Anemia, diabetes, hypercholesterolemia, HTN, CVA, aortic aneurysm, hernia repair, prostate cancer, Parkinsons disease Allergies include: PCN, Cephalosporin, Carbap Lab values: PTT-26.2 (anticoagulant therapy) PT-13.8 (anticoagulant therapy) INR- 1.3 (anticoagulant therapy) K-3.9 (WNL) CK MB-2.5 (WNL) WBC-7.9 (WNL) RBC-2.89 (Surgical blood loss/anemia) Hgb-8.9 (Surgical blood loss/anemia) CL-102 (WNL) CPK-71 (WNL) Mg-1.9 (WNL) ALT-90 (WNL) AST-111 (WNL) Triponin-1.81 (MI) AGBs: pH-7.457 (WNL) Po2-84.7 (WNL) PCo2-32.0 (Shallow breathing and mucous) Current Medication list includes: Nitro Patch, Asacol, asprin, Lopressor, Lovenox, Multivitamin with iron, protonix, senna, morphine, Phenergan, hydroduril, prinivil, Tylenol with codeine, Zofran, Lasix, Klor-con, and 0.9% NS IV running at 50ml/hr Fluid and Electrolytes: #3 -Mucous membranes pink and moist -Skin turgor brisk -+1 non-pitting edema noted in lower left extremity -Alert and oriented to person, place and time -I&O are equal and WNL Labs: Potassium-3.9, Sodium-137, Chloride-102, ABGs: pH-7.457, Po284.7, PCo2-32 Medications: Klor-con, Multivitamin with iron, Lasix, hydrodiuril, 0.9% NS running at 50ml/hr in left hand

-Two surgical wound sites noted to left hip area with staples in place -Surgical site is free from s/s of infections such as redness, warmth, drainage, odor, or swelling -Surgical site is cleaned, painted with betadine, and covered with a telfa island dressing -Capillary refill is less than three seconds and pedal pulses are noted bilaterally -Pain is noted at surgical site upon movement Labs: WBC-7.9 Medications: Betadine, Multivitamin with iron, Morphine, Tylenol with codeine Nursing Dx.: *Impaired skin integrity R/T surgical wound AEB wound being noted by nurse in left hip with staples in place *Risk for dehydration R/T increased body temperature *Risk for infection R/T surgical wound Collaborative Problems: Infection, Dehydration, Pain

Senses: #7 -Currently wears glasses and has a history of having cataracts for which he had cataracts surgery to try and correct -Hearing and speech are WNL -Complaints of pain are noted with movement of left hip. Alleviating factors for pain are resting and non-movement of affected area Labs: None noted for this category Medications: Morphine, Tylenol with codeine Nursing Dx.: *Pain R/T left hip surgery AEB patient

Neurological: #9 -Alert and oriented to person, place and time -PERRLA noted in both eyes -Speech is normal and easily understood -No tremors or decreased motor coordination noted -Able to follow commands -No memory loss noted Labs-None noted for this category Medication: None noted for this category Nursing Dx.: *None indicated

stating that he has pain with movement of left hip Collaborative Problems: Pressure Ulcers, DVT Endocrine: #8 -Capillary blood sugar is 213 -Urine sugar is negative -Currently on a diabetic cardiac diet -Hair is evenly distributed and full thickness is noted -Thyroid is not visible noted and no thyroid disturbances are noted Labs: None noted for this category Medication: None noted for this category Nursing Dx.: *Risk for injury R/T hypo and hyperglycemia episodes Collaborative Problems: Hypoglycemia, Ketoacidosis, Infections

Nursing Dx.: *Risk for fluid volume imbalance R/T IV fluid replacement Collaborative Problems: Hypervolemia Self-Concept: #10 Personal self-image: -States that he thinks that his physical attributes are fine -He believes that his physical functioning is good and states that he has no issues with sexuality -His appearance and grooming habits appear good -He has a flat affect and a monotone voice -When asked about his wellness-illness state, he stated Things will happen and there is nothing you can do about it. Sense of Loss: -He states that he has a sense of loss for his mother -His feelings on grief are that it is a fact of life and everyone has to go through it -He does not feel a sense of loss for objects or body parts Personal Self: -Values honesty and family and believes that these are his most important values in life -His religious beliefs are Baptist and he believes that his needs are being met at the hospital for his religion -He is able to express his feelings freely and his personality traits are easily observed -Denies anxiety at this time and is motivated to get stronger and back to an independent state of mobility -Does not appear defensive of questions and does not try to focus all of the attention onto himself Ideal Self: -His ideal self would be to be independent again and this is also what he expects himself to be -Claims he feels successful from his career as a bus and semi-truck driver and feels that he wants to spend the rest of his life being with family and friends

Collaborative Problems: None indicated

Role Function: #11 -Level of education is high school Eriksons stage: Integrity vs. Despair Havighurst stage: Older Adult -adjusts to physiological changes -manages retirement years in satisfying manor -Satisfactory living and income arrangements -Participates in social and leisure activities -Has social network of friends and support people -Views life as worthwhile -Has high self esteem -Secured appropriate help to care for self -Adapted to diminishing energy and ability -Gains support from spiritual belief -Accepts death (Lemone, pg.25) -Primary role in life is a father, secondary is grandfather, and these roles are considered most important to him -Believes that he functions in these roles well and doesnt believe that his health state has interfered with them -No cultural or financial concerns are noted at this time Interdependence: #12 -His support system at this time is his daughter with whom he resides -He feels that he functions independently in everything except mobility at this time, but feels he will heal and get stronger -All verbal and non-verbal behaviors are congruent

Priority Map
Assessment: Client is an 81 year old male who was admitted to the telemetry unit on 3-17-12 following a myocardial infarction after have a left hip ORIF. He lived with his daughter in her home and has a code status of DNR-No vent. He requires assistance with ADLs and is a two assist with transfers and non-weight bearing on left hip. He has a dressing to his left hip surgical site that is cleaned, painted with betadine, and covered with telfa dressing. He is currently on oxygen running at 4 liters and hour to keep his O2 sats above 90%. He has a catheter, which will be taken out this afternoon for discharge to nursing home rehab facility. Admitting Dx: MI, ORIF History Dx.: Anemia, diabetes, hypercholesterolemia, HTN, CVA, aortic aneurysm, hernia repair, prostate cancer, Parkinsons disease Allergies include: PCN, Cephalosporin, Carbap Current Medication list includes: Nitro Patch, Asacol, asprin, Lopressor, Lovenox, Multivitamin with iron, protonix, senna, morphine, Phenergan, hydroduril, prinivil, Tylenol with codeine, Zofran, Lasix, Klor-con, and 0.9% NS IV running at 50ml/hr Priority Concerns: Infection, Skin Integrity, Oxygen, Pain, Nutrition Ineffective airway clearance R/T thick Collaborative Problem: DVT Impaired physical mobility R/T left hip mucous secretions AEB patient unable surgery AEB patient requiring assistance to clear mucous from throat effectively with mobility and pain with movement of lower left extremity Client will have effective airway The nurse will manage and minimize Client will have improved physical clearance AEB: occurrence of DVT through nursing mobility AEB: 1. Thinner mucous secretions measures and medication 1. Participating in PT/OT at ordered by 2. Decreased mucous secretions administration as ordered. physician 3. Decreased rhonchi noted upon 2. Walking short distances with minimal auscultation assistance 4. Respiration rate will be below 20 3. Transferring with minimal assistance breaths per minute 4. Moving from side to side in bed with 5. Respiration depth and quality even minimal assistance and deep 5. Having no pain with movement of lower left extremity Nurse will: Nurse will: Nurse will: 1. Administer medications daily as 1. Administer prophylactic anticoagulant 1. Administer pain medication daily as prescribed to thin and decrease mucous medications daily as ordered to prevent prescribed to minimized discomfort any secretions DVT help promote mobility 2. Monitor oxygen saturation twice per 2. Monitor that compression boots are 2. Perform passive range of motion to each shift and as needed to make sure in place every shift daily while client is in all extremities three times daily at 0900, levels are above 90% bed 1400, and 1900 3. Administer oxygen per physicians 3. Monitor that anti-embolic stockings 3. Assist client in ambulating to and orders daily are in place every shift daily from the bathroom and for short 4. Check oxygen flow and tubing every 4. Take anti-embolic stockings off each distances in the hallways three times shift daily to make sure that the oxygen shift daily to check skin integrity and daily at 0900, 1400, and 1900. is flowing adequately and tubing is apply lotion as needed 4. Educate client on importance of intact 5. Monitor for bleeding every shift daily building muscle strength and keeping st 5. Change oxygen tubing on the 1 of due to anticoagulant therapy active daily with walks at 0900, 1400, every month at 1500 or as needed for 6. Assess for calf tenderness and and 1900 defective tubing warmth and positive Homans sign 5. Assist client with bed mobility daily as 6. Assist client in using incentive every shift daily needed and teach client ways to spirometer and accapella four times independently turn himself in bed daily at 0800, 1200, 1600, 1800 and as needed for secretions 7. Instruct client to do cough and deep breathing exercises four times daily at 0800, 1200, 1600, 1800, and as needed for secretions Medications administered as prescribed. Medications administered as prescribed. Medications administered as prescribed. Pulse oximetry reading of 97% noted on No bleeding tendencies noted. AntiPassive range of motion performed 4 liters of oxygen. Nasal cannula tubing embolic stocking and compression boots except in left lower extremity due to is intact with no kinks and is flowing are in place. Skin integrity is warm, dry, discomfort. Assisted with transfers from freely. Oxygen tubing to be changed on and intact under stockings. Negative bed to bedside chair. Unable to

April 1 at 1500. Incentive spirometer measured 500ml at most and 300 at least. Accapella effectively used at this time. Cough and deep breathing exercises ineffective as client refused to cough stating No. Client educated on importance of coughing and deep breathing as well as proper technique, but still refused Modify: Consult respiratory therapy to educated client on coughing and deep breathing to prevent complications

st

Homans sign noted and no tenderness or warmth noted in calf. Client has not experienced DVT. Continue to monitor.

ambulate at this time due to non-weight bearing status. Client assisted with positioning in bed and educated on independent turning in bed. Client educated on muscle building and strength training exercises and the importance or rebuilding muscle and strength Modify: Ambulation orders on hold until cleared by physician. Consult with PT/OT about independent strength and muscle building exercises that the client can perform on his own

Pathophysiology Map
Common Medical Management: Treatment for this diagnosis are as follows: -open reduction and internal fixation surgery -Pain medication -Anti-coagulant therapy -Stool Softeners -Prophylactic antibiotics -Anti-inflammatory medications -anti-ulcer medications -Surgical wound care Medical Diagnosis: Closed left hip fracture Pathophysiology: A fracture occurs when the bone is subjected to more kinetic energy than is can absorb. Fractures may result from a direct blow, a crushing force, a sudden twisting motion, a sever muscle contraction, or disease that has weakened the bone. Two basic mechanisms produce fractures: direct force and indirect force. With direct force, the kinetic energy is applied at or near the site of the fracture. The bone cannot withstand the force. With indirect force, the kinetic energy is transmitted from the point of impact to a site where the bone is weaker. The fracture occurs at the weaker point (Lemone, pg.1401). Typical behaviors of a hip fracture include pain, swelling, inability to ambulate, and shortening and external rotation of the affected side. The prognosis for a hip fracture depends on the persons age. The risk of complications and death increases with every ten years of life and are greatest in people with osteoporosis such as post-menopausal women. Very few people will regain the mobility that they had prior to the fracture (Olsson, pg.124) and most older adults will need to be place in a nursing home setting where they can receive assistance with ADLs. Compared client diagnosis and treatment with textbook presentation: According to the book, all of the common medical management pertains to the treatment that the client is currently on. The client diagnosis was right on with what the book describes as a hip fracture. I didnt find any discrepancies between the care that the client received and the textbook material on how this diagnosis is diagnoses, treated, and common nursing management of hip fractures. Actual Complications: -Pain -Decreased mobility -Inability to bear weight on left extremity -Myocardial infarction

Common Nursing Management: -Maintain skin integrity -Monitor vital signs -Prevent infection -Control Pain -Maintain circulation -Monitor pedal pulses -Increase mobility -Turn and reposition at least every two hours while in bed -Monitor for edema -Monitor for calf tenderness and positive Homans sign -Monitor for loss of sensation in affected extremity -monitor surgical site for gaping and bleeding -Monitor surgical site for redness, warmth, edema, odor and purulent drainage -RICE therapy Reference: (Lemone, pg.1401-17)

Potential Complications: -Compartment syndrome -DVT -Infection -Delayed Union of bone -Non-union of bone -Reflex Sympathetic Dystrophy

Interconnections:
1. Patient has an Hgb of 8.9 and his energy level is low. The low Hgb is causing the decreased energy level, because adequate oxygen is not being supplies to the tissues because the hemoglobin is what carries oxygen in the blood so when it is low the oxygen is low to. Patient requires oxygen supplementation and has low Hgb. The low Hgb is causing the need for supplemental oxygen use, because the body is not getting adequate oxygen to the tissues. Hgb carries oxygen to tissues and when it is low, the bodys oxygen supply is not sufficient enough. Patients blood sugar is 213 and has a surgical wound on his hip. When a patient has high blood sugars, wound healing is slower and there is a greater risk for infection. Patient is complaining of pain in his left hip and has decreased mobility. The pain in the hip causes him to keep the effected leg immobile and therefor decreases his mobility. Patient is on narcotic medication for pain management and requires stool softeners to avoid constipation. Narcotic drugs slow the motility of the GI tract and cause the waste to harden in the bowel causing constipation. By giving the client stool softener, the waste will be kept soft, allowing the patient to move their bowels easily.

2.

3. 4. 5.

Abnormal Lab Results PTT-26.2 PT-13.8 INR- 1.3 RBC-2.89 Hgb-8.9 Triponin-1.81 PCo2-32.0

Stimuli anticoagulant therapy anticoagulant therapy anticoagulant therapy Surgical blood loss/anemia Surgical blood loss/anemia Myocardial Infarction Shallow breathing and mucous secretions

Implications for Nursing Bleeding Precautions Bleeding Precautions Bleeding Precautions Monitor labs for further decrease in RBC and notify physician if levels decrease Increase in iron rich foods Give prescribed iron supplements Monitor for reoccurring MI. Monitor values daily for increase or decrease. Encourage cough and deep breathing exercises. Monitor patient for C02 toxicity s/s.

Long Term Goal: Client will have increased mobility and return to a state of health similar to before ORIF surgery. Discharge planning: Client will be discharged to Vancrest Healthcare rehabilitation unit in Van Wert,OH. OT/PT to evaluate and treat. Non-weight bearing on lower left extremity until cleared by physician. Continue medications as prescribed by physician. Health Promotion Teaching: Health promotion teaching on how to prevent falls and how to make the home environment safe from obstructions while walking needed. Also, teaching on the diabetic cardiac diet is needed to help control the clients diabetes and prevent further heart complications.

Works Cited LeMone, Priscilla, and Karen M. Burke. Medical-surgical Nursing: Critical Thinking in Client Care. Upper

Saddle River, NJ: Pearson/Prentice Hall, 2008. Print.

Olsson, Lars-Eric, Jn Karlsson, and Inger Ekman. "Effects of Nursing Interventions within an Integrated

Care Pathway for Patients with Hip Fracture." Journal of Advanced Nursing 58.2 (2007): 116-25.

Web. 27 Mar. 2012.